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November 2011 • Volume 9 Number 10

Pre-existing condition insurance Jackie Garner

Chronic venous insufficiency John Martin, MD, FASC

Medicare open enrollment Michele Kimball


You call it “reminding mom to take her pills.�

We call it caregiving.

You or someone you know may be a caregiver. WhatIsACaregiver.org


CONTENTS

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NOVEMBER 2011 • Volume 9 Number 10

16

NEWS

18

PERSPECTIVE

Emily Gunderson MOFAS

10 QUESTIONS

The Natural Path to Health

HEALTH CARE REFORM Making headway in mental health By Sue Abderholden, MPH

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20 22

CALENDAR National family caregivers month

T H I R T Y- S E V E N T H

SESSION

PAIN MANAGEMENT Palliative care By Michele Fedderly, EdD

HOME CARE There’s no place like home By Amy Nelson

Kristin Becker, ND

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MINNESOTA HEALTH CARE ROUNDTABLE

By John D. Martin, MD, FACS

PEOPLE

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VASCULAR MEDICINE Chronic venous insufficiency

MEDICARE Navigating Medicare open enrollment

24

ONCOLOGY Lymphoma

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INSURANCE Health insurance for people who can’t get it By Jackie Garner

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Specialty pharmacy

From the Lymphoma Research Foundation

HOLISTIC HEALTH Medicine and the arts By Gary A.-H. Christenson, MD

By Michele Kimball

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Mary Scarbrough Hunt mshunt@mppub.com

Controlling the cost of care Thursday, April 19, 2012 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access. Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care.

ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name

ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com

Company

ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

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Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans.

City, State, Zip

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

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NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

3


NEWS

UCare, CaringBridge Form Partnership Minneapolis-based UCare has announced it will begin working with CaringBridge, an online service that allows people with serious medical conditions to update friends and families through a personalized website. CaringBridge websites are free and not only allow patients and their families to get information out about health conditions, but also provide a place for people to leave messages of support. It also lessens some of the stress in clinical situations, when in the past medical staff might have to help notify loved ones. According to Jeri Peters, clinical services director for UCare, the new partnership will allow CaringBridge officials to train UCare support staff in how to talk to patients during difficult health situations and help them explore various options for informing others or seeking support. “It will be one more resource for us when we have members

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who are challenged with a very serious health condition,” Peters says. “CaringBridge removes some of the burden of primary caregivers from communicating with a long list of individuals. It also helps ensure that accurate information and the same information is given. And people don’t have the cost of all of those phone calls.” With the announcement, UCare becomes the third insurance company to establish an official partnership with CaringBridge. Minnetonka-based Medica is another insurance partner with CaringBridge, and there is a long list of health systems and hospitals that work with the group in Minnesota as well.

State Ranks No. 1 in Long-Term Care A new report lists Minnesota as No. 1 in the U.S. for delivery of long-term care services and support to state residents. The report, Raising Expectations: A State Scorecard on

MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, was released by the AARP, the Commonwealth Fund, and the SCAN Foundation in September. The analysis finds wide variation in the quality of services and support delivered to seniors and families. It examines four key elements of long-term care delivery performance: affordability and access; choice of setting and provider; quality of life and quality of care; and support for family caregivers. The report assesses states’ performances on those larger goals by looking at 25 individual indicators. Officials say that some of the long-term care indicators were measured in the study for the first time. “This report will help states make and sustain targeted improvements so that people can live and age with dignity in their own homes and communities,” says Susan Reinhard, AARP senior vice president for public policy. “Achieving a high-performing, long-term support and services

system will require a concerted effort from both the public and private sectors.” Minnesota, Washington, and Oregon were found to be the top three states in delivering longterm care services and support. However, officials say, even the top states need to do more work to create higher-performing systems of services and support for seniors. “All states need to vastly improve in areas including home care, assisted living, nursing home care, and support for family caregivers, and more efficiently spend the substantial funds they currently allocate to longterm services and support,” the groups say in a statement. Minnesota ranked fourth nationally in affordability and access to long-term care services and support; third in choice of setting and providers; fourth in quality of life and quality of care; and fourth in support for family caregivers.


Grant Will Help State Monitor Increases in Insurance Premiums Minnesota will get nearly $4 million from the federal government to establish a system to monitor insurance premium increases. The funding was announced last week as part of $109 million in grants to 28 states, a move that federal officials say will hold down premium increases and improve transparency. The new program is part of the Affordable Care Act (ACA), and requires health insurers seeking to increase their rates by 10 percent or more in the individual and small group markets to undergo an evaluation to determine if the rate increases are reasonable. Prior to this announcement, the U.S. Department of Health and Human Services (HHS) had already given $48 million to 42 states to help set up rate review systems. “We’re committed to fighting unreasonable premium increases and we know rate review works,� said Secretary Sebelius. “States continue to have the primary responsibility for reviewing insurance rates, and these grants give them more resources to hold insurance companies accountable.�

Hennepin Healthcare, HFA Discuss Merger Hennepin Faculty Associates (HFA), the independent medical group that contracts with Hennepin County Medical Center (HCMC), is discussing a merger with the health system that owns HCMC. HFA has nearly 400 provider members. It provides medical services at HCMC’s hospital and clinics, and owns the Minneapolis Medical Research Foundation. In 2007 Hennepin Healthcare System took over day-to-day governance of HCMC and its clinics from Hennepin County, which continues to own the health system and its assets. In a statement released Sept. 22, Gina Flak, manager of HFA

corporate communication and marketing, said, “Hennepin Faculty Associates is exploring with Hennepin Healthcare System, Inc. the possibility of integrating HFA into Hennepin Healthcare System. At this stage ‌ a confidentiality agreement is in place that prohibits us from releasing additional details.â€?

U of M Researcher To Develop Tools for Medic Training A University of Minnesota researcher will lead a new consortium to develop new training tools and methods for combat medics. University of Minnesota urologic surgeon and simulation expert Robert M. Sweet, MD, FACS, will be the principal investigator on a three-year $11 million grant program to analyze future needs in medic training and to develop simulation tools to improve that training. “New training capabilities may potentially save the lives of service members as training shifts to state-of-the-art approaches to combat medicine,� says Sweet, who also directs the U of M Medical School’s Simulation Programs. “With our military partners, we plan on providing means of skills assessment and recommendations on revising training curricula for some of the most critical injuries and trauma routinely seen on the battlefield: massive bleeding (hemorrhage) and airway management.� Officials say simulation technology, which has become commonplace for training in aviation and aerospace, is still underdeveloped in the health care field. The new consortium will seek to create a unique combination of medical education and realistic simulation for medics-intraining. “It’s one thing to effectively and safely perform these skills in a controlled setting; it’s another to do it under the duress of battle,� says Sweet. “Our facilities

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News to page 6 NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

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News from page 5 will simulate the sights, sounds, and smells of the battlefield and our human factors team will be monitoring medics’ stress responses to the situation as they perform these life-saving maneuvers. We want them to feel like it’s real so that they don’t freeze up the first time they have to perform these skills in combat.”

Communities Join “do” Campaign Three metro-area communities will partner with Blue Cross and Blue Shield of Minnesota in an 18-month project to improve health through good nutrition and active living choices. The project is part of Blue Cross’ ongoing “do” campaign, and will be called “do.town.” The mayors of Bloomington, Edina, and Richfield announced the creation of do.town on Sept. 27 along with officials from Blue Cross and other community leaders. They say the goal of the ini-

tiative is to make their communities places where the healthy choice is the easy choice by giving residents more opportunities to eat right and be physically active, and by creating healthier homes, schools, and workplaces. “We believe healthy communities are strong communities, but barriers to healthy living are everywhere,” said Edina Mayor James B. Hovland. “To help our residents succeed in being active and eating well, we needed a partner with proven expertise in helping people by making their surroundings—where they live, work and play—healthier.” Blue Cross’s “do” campaign has been part of a high-visibility effort to promote active lifestyles through a range of strategies. With the do.town initiative, city officials will conduct outreach and listening sessions in each community to better understand what barriers currently exist, then help community members make healthier choices. Officials say the campaign may take steps such as working

to make biking or walking to school safer; helping improve access to healthy foods at work, school and in faith organizations; or allowing more community gardens to serve people with low incomes. The initiative’s website is www.do-town.org.

UHG Study Finds Confusion about Medicare In September, Minnetonka-based UnitedHealthcare (UHC) released a study that finds a large percentage of Medicare recipients and boomer-age Americans do not have a good understanding of Medicare benefits and the changes to the program that will occur under the Affordable Care Act (ACA). UHG and the National Council on Aging surveyed 1,000 seniors and found that more than half of the respondents found Medicare confusing or did not understand it at all. Nineteen percent of those enrolled in the

program said they did not know what type of Medicare coverage they have. Confusion over ACA changes is common as well. Only 12 percent of seniors said they had a good understanding of what changes would come to Medicare under the new health reform law. “Without a solid grasp of the basics of Medicare, older adults are not well positioned to understand their options and find the coverage that best meets their needs,” says Jim Firman, president and CEO of the National Council on Aging. “These findings show that Medicare beneficiaries either are not getting the information they need to understand the program or that the information currently available isn’t resonating with them. Both scenarios are worrisome today but also of great concern given the significant growth on the horizon for Medicare as boomers age.”

Supporting Our Patients. Supporting Our Partners. SupportingYou. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2011


PEOPLE Judith Buchanan, DMD, PhD, a professor and

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associate dean for academic affairs in the University of Minnesota School of Dentistry, has been appointed interim dean of the school. Buchanan came to the University of Minnesota in 2005, after serving as academic dean of the School of Dentistry at the University of Pennsylvania School of Dental Medicine from Judith Buchanan, DMD, PhD

1997 to 2005. Buchanan received a doctorate in

biochemistry from the University of Texas in 1977, and her DMD in 1980 from the University of Florida, College of Dentistry. She served for 22 years in the military (in the National Guard and Army reserves) and attained the rank of lieutenant colonel in the National Guard. In 2003, she was deployed to run dental clinics in Bosnia and Germany. Nick Brown received the 2011 Judd Jacobson Memorial Award from Courage Center at an award ceremony in October. The award recognizes the pursuit or achievement of a business entrepreneurial endeavor by a person with a physical disability or sensory impairment. The 18-year-old Brown, who owns Nick’s Lawn Service in Shakopee, has cerebral palsy and speech challenges, and uses a power wheelchair to get around. He received $5,000 to advance his business.

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o you know of family members, friends or neighbors who have difficulty using their telephone? Do they have trouble hearing, speaking or have a physical disability that prevents them from using a standard telephone? The Minnesota Telephone Equipment Distribution Program can provide special telephone equipment at NO CHARGE to Minnesota residents of all ages!! The equipment includes amplified (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment. To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663, (888) 206-6555 TTY. Eligibility requirements do apply.

Caleb H. Creswell, MD, has joined DermaThe Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge.

tology Specialists, PA, and is seeing patients at the practice’s Edina and Eden Prairie locations. Creswell graduated from the University of Wisconsin Medical School and served as chief resident at the University of Minnesota Department of Dermatology. Creswell is a clinical assistant professor of dermatology at the

Caleb H. Creswell, MD

University of Minnesota and is a member of the American Academy of Dermatology and the Minnesota Dermatological Society. His special interests include medical, surgical, cosmetic, and pediatric

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dermatology. Jonathan Nash, DDS, has joined Piedmont Heights Dental Associates in Duluth in the practice of general dentistry. Nash is a

Palliative care is designed to improve the quality of life at the time when an individual’s disease is not responsive to curative treatment.

graduate of the University of Minnesota—Duluth and the University of Minnesota School of Dentistry. He is a member of the Minnesota Dental Association and the American Dental Association. Chris Cintron, JD, MPA, has joined Hennepin County Medical

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Center as the new chief clinic officer. Cintron has a broad background in ambulatory leadership, most recently serving as vice president of Ambulatory Care Services at Grady Health System in Atlanta, where he led a division that included nine community-based, multispecialty practices and 42 hospital-based practices. He had similar roles at Bronx-Lebanon Hospital Center in New York and at New York Methodist Hospital. Kimberly Talbot has joined Orthopaedic Associates of Duluth as a physical therapist. She specializes in orthopedic, sports medicine, and manual techniques of the shoulder, hip, knee, foot, and spine. Talbot has been working as a physical therapist in the area for the past six years. She earned a master’s degree in physical therapy from the College of St. Scholastica in Duluth, and is pursuing a

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NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

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PERSPECTIVE

How much alcohol during pregnancy is too much? “None for nine”

A

Emily Gunderson MOFAS

Emily Gunderson is communications director of the Minnesota Organization on Fetal Alcohol Syndrome (MOFAS). The organization provides education to professionals, parents, and other caregivers, and works to ensure that all women know there is no safe level of alcohol consumption during pregnancy. For more information, please visit www.mofas.org.

study released earlier this year in a well respected medical journal attracted a lot of national and local media when it suggested that “light drinking” (defined as one to two drinks per week) during pregnancy is not only safe, but could actually be beneficial to the cognitive development of a child. Naturally, this made headlines in many newspapers and on television stations across the country. Unfortunately, these conclusions are not supported by research and are just plain misleading for a number of reasons. The U.S. Surgeon General has stated quite emphatically that there is no safe amount or safe time to consume alcohol during pregnancy, and studies have confirmed this.

Here in Minnesota, as many as 8,500 babies are born every year with prenatal alcohol exposure. Nationally, FASD affects one in every 100 live births. That’s more common than autism and Down syndrome combined, and it is 100 percent preventable. The Minnesota Organization on Fetal Alcohol Syndrome believes that we need to empower women with information so they can make healthy choices while they are pregnant— particularly when it comes to alcohol.

It is not illegal for a pregnant woman to drink alcohol; alcohol is the most common substance consumed in our society today, and a woman does have the right to make her own choices. So, getting back to the question, “How much is However, it is unfair to put her in that position too much?”—the answer is: We don’t know. without making sure that she has accurate, facEveryone probably knows tual information with which someone who drank during to make her decision—espepregnancy whose baby cially when the media says “turned out just fine.” This that it is safe for a woman to Nationally, does not mean alcohol is drink “lightly.” Alcohol has safe, however. There is fetal alcohol syndrome been widely documented as absolutely no way of knowa teratogen, which is an ing how any amount of alcodisorders affect one in agent that can disturb the hol will affect your particular development of an embryo baby. Every baby is different, every 100 live births. or fetus—i.e., it can cause just as every adult is differbirth defects or halt the pregent. Since the unborn infant’s nancy altogether. More brain continues to develop specifically, alcohol has been proven to cause a throughout pregnancy, it is always vulnerable to range of developmental disabilities called fetal the harmful effects of alcohol. So whether it’s you, alcohol spectrum disorders (FASD). your daughter, granddaughter, friend, or a patient So, why is it so important to correct these misinterpretations? Because prenatal alcohol exposure is the leading cause of preventable intellectual disabilities and behavioral difficulties in the United States. Because biological, foster, and adoptive families raising children permanently harmed by prenatal alcohol exposure can tell you countless stories about how “a little alcohol” has caused endless heartbreak for the children and their families. The combination of amount of alcohol consumed, timing of consumption (i.e., the month of pregnancy), and frequency (how often alcohol is

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consumed) will determine the degree of prenatal alcohol exposure, but any combination of these can cause permanent brain damage in the developing fetus, so why take a risk? Studies have consistently shown that alcohol use during pregnancy poses a grave risk, so it is puzzling why some physicians are still unwilling to issue a clear “No Safe Amount” message to their patients.

MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

who is pregnant, please remember that no amount of alcohol is safe during pregnancy. If you can remember just three simple numbers: 0, 4, and 9—“Zero Alcohol For Nine Months”—you have the power to save countless lives. Please ask others to spread the word, and together we can save a whole generation. There are very few things in this world that one actually can change, but FASD is one of them. We can prevent the next generation from being affected by the many health disparities associated with prenatal alcohol consumption.


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10 QUESTIONS

& Kristin Becker, ND Kristin Becker, ND, is founder of The Natural Path to Health in St Paul. She is also vice president of MNANP, the Minnesota Association of Naturopathic Practitioners. How (and when) did naturopathic medicine begin? Nature-based medicine is the foundation of modern medicine. But as pharmaceuticals developed and treatments such as bloodletting were used, nature-based practitioners began to distinguish themselves by using herbs and emphasizing diet and hygiene. The term “naturopathy” was adopted in the early 20th century to describe these practices. Around 1920, there were a number of naturopathic medical schools in the U.S. (including one in Minneapolis), with thousands of naturopathic doctors and patients using naturopathic therapies. The discovery of miracle drugs like penicillin, and the formation of a large medical system primarily based on pharmaceuticals, were associated with the temporary decline of naturopathic medicine. In the 1970s, however, the consumer “wellness” movement led to the rebirth of naturopathic medicine in the U.S. What kind of training does a naturopathic doctor receive? Naturopathic Doctors (NDs) have a four-year undergraduate degree in “pre-med” coursework prior to attending a U.S. Department of Education-accredited four-year residential naturopathic medical school. This education is similar to any other medical school’s education in terms of basic sciences and clinical courses. The training is based on general practice, with additional coursework in clinical and physical diagnosis, physical examinations, laboratory testing, pharmacology, and minor surgery, as well as herbal medicine, clinical nutrition, nutritional supplementation, lifestyle counseling, homeopathy, and physical medicine. How does naturopathy differ from medical doctors and homeopaths? NDs are experts in holistic and natural medicines. Medical doctors are experts in pharmaceuticals and surgery. Both forms of medicine work well together because they “speak the same language,” as they are both trained in Western medicine and use scientific research to support their clinical practices. NDs are like primary care physicians or general practitioners, in that they don’t specialize in just one system of the body. NDs emphasize prevention and promote wellness. Although the focus is on diet and lifestyle changes, natural therapeutic supplements and modalities, NDs are also trained in pharmaceuticals and minor surgery. Although NDs cannot prescribe pharmaceuticals in Minnesota, this expertise is vital to understanding drug-nutraceutical interactions. Homeopathy is a unique medicine that is used to stimulate the body’s own healing process. Naturopathic medical schools include training in homeopathy, which NDs may use as one of their treatment methods. What kinds of interactions do you have with doctors from other branches of medicine? Most NDs work in private practice and regularly consult with other practitioners, sometimes referring patients to specialists when deemed necessary. As experts in drug-nutraceutical interactions, we are often consulted by other doctors to ensure that it is safe for a patient to combine their medications with supplements. Some NDs work in integrative clinics with other conventional and holistic practitioners. Photo credit: Bruce Silcox

What kinds of medical conditions do you see most commonly? As general practitioners, NDs see patients with all kinds of ailments, from acute infections to chronic diseases such as rheumatoid arthritis or diabetes. Naturopathic medicine has effective treatments for numerous conditions, including cardiovascular, autoimmune, lung, and digestive

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2011


We treat the cause and not just the symptoms of disease while doing no harm.

diseases, endocrine disorders, chronic pain, and allergies. Because we treat the underlying cause of the disease, we can succeed with hard-to-treat conditions such as fibromyalgia, chronic fatigue, migraines, skin disorders, ADHD, and syndromes that cannot be easily diagnosed. What kinds of treatments do you use? My treatment plans address diet, nutrition, and lifestyle issues, supported with nutritional supplements and herbal remedies. I also offer visceral manipulation and craniosacral massage therapy, and recommend hydrotherapy home treatments. But each ND is unique, guided by our philosophies and not just our modalities. Some NDs may use more homeopathy, Ayurvedic, or Chinese medicine. What is meant by saying naturopathy is defined by philosophies, not treatment methods? NDs believe in the body’s ability to prevent and combat disease, if obstacles to health are removed. We spend a lot of time educating patients Our focus is optimal wellness and prevention, not just the removal of disease. We treat the cause and not just the symptoms of disease while doing no harm. NDs treat each individual by considering physical, mental, emotional, genetic, environmental, and social factors. These philosophies define our profession, not the treatment methods we choose. NDs prefer to use the least invasive therapies first. Depending on the urgency of the situation, a pharmaceutical prescription may actually cause the least harm.

NDs are regulated by the Minnesota Board of Medical Practice. How do they differ from naturopaths? Naturopathic Doctors must graduate from a nationally accredited, doctorate-level naturopathic medical school whose program includes an internship in a naturopathic health clinic under physician observation. NDs must also pass rigorous medical boards, continue their education yearly, and be registered by the state. Minnesota allows other individuals to use the title “naturopath,” provided they do not use the term “Naturopathic Doctor.” They can have various education backgrounds and there is no minimal educational requirement.

What do you see in the future for naturopathic medicine? Increasing integration between various health practitioners and increased use of NDs as primary care doctors. A common complaint from patients is that they have been told to make lifestyle changes but are not told how to begin. NDs are highly trained in this area. Can you describe a typical office appointment? NDs are unique in the amount of time we spend with patients: one to two hours per appointment. This allows time to listen to patients’ health concerns, understand their health goals, and thoroughly explain why the prescribed changes need to be made. We conduct physical examinations and nutritional analyses, and use diagnostic tools such as lab work and imaging. We use the latest scientific research to develop a customized treatment plan with and for each patient.

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HEALTH CARE REFORM

Making headway in mental health Ending insurance discrimination By Sue Abderholden, MPH The National Alliance on Mental Illness (NAMI) has long supported strong health care reform legislation that expands coverage to the millions of Americans who live with mental illness. No other group of illnesses has had such a long history of being discriminated against, by society and by health insurance companies, many of which have refused to fully cover treatment or to issue policies at all to those with mental illness. Recent legislation Three important federal laws address discrimination against mental health care: the WellstoneDomenici Mental Health Parity and Addiction Act of 2008 (hereafter referred to as the WellstoneDomenici Act); and the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, together referred to as the ACA. The Wellstone-Domenici Act will affect all health plans, including self-insured plans. [Most

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

Minnesotans are covered under self-insured plans, to which Minnesota’s 1995 parity law did not apply.] The Wellstone-Domenici Act does not mandate that insurance companies offer mental health coverage, however; it only states that plans already covering mental health cannot apply different financial requirements or treatment limitations for mental health care than for physical health care. This applies to copays, deductibles, and out-of-pocket limits, treatment limits (number of visits, length of stays), and nonquantified limits (prior authorization and medical necessity criteria). The Affordable Care Act By expanding eligibility for health insurance, the ACA has improved access to mental health treatment. It also assures eligibility for health coverage by prohibiting the practice of excluding people with preexisting conditions. This took effect right away for children under the age of 19, and will expand to everyone in 2014. NAMI has learned that some people are being denied coverage for non-severe forms of anxiety and depression, even if they had never been hospitalized. For people with more serious forms of mental illness, having coverage for treatment provides hope for recovery. Using Minnesota’s option for those denied coverage—the Minnesota Comprehensive Health Association—was not feasible for many because of its high deductibles, premiums, and copays. One ACA provision is for the establishment of health care “exchanges”—i.e., marketplaces to purchase health insurance for those who must buy their own policies. Under these exchanges, all insurance plans must cover mental health services—a first—and the services must be covered in the same way as other health care conditions. This will make mental health care accessible to those who must buy individual policies, including those employed at small businesses. NAMI will be advocating for a full continuum of mental health services (in-home, day treatment, residential services, etc.) to be included in the essential benefit set. One of the ACA’s most significant contributions is the simplification of federal Medicaid eligibility (called Medical Assistance (MA) in Minnesota). In 2014, people with incomes below 133 percent of the


Those living with a serious and persistent mental illness die on average 25 years earlier than their peers. federal poverty level will automatically qualify for Medicaid. Because Minnesota already had General Assistance Medical Care (GAMC)— insurance for low-income residents with incomes at 75 percent of the federal poverty level, or $8,168—it has taken advantage of early “opt-in” of Medicaid, allowing people who were on GAMC to be eligible for MA. The ACA also offers a chance to introduce innovations in Medicaid, such as expanding home- and community-based services for the disabled (including those with a serious mental illness) as alternatives to institutional care and coordinating care for people with multiple chronic health conditions (including serious mental illnesses). Minnesota is looking at several of these as alternatives to more costly institutional care, and to prevent hospitalizations. Young adults will now have greater access to health insurance. Unmarried and married young adults can continue to be covered under a parent’s plan until they are 26 years old. [Minnesota law provides coverage to age 25, but not for self-insured plans or state employee plans.] The 18–26 age group is one of the largest uninsured groups—the one when mental illness strikes most often. More young adults with a mental illness are now attending college, many parttime. Part-time status used to disqualify them from being covered by their parent’s plan and purchasing an individual plan was too expensive—plus it limited mental health coverage and often covered only generic medications. Having coverage will result in improved access to appropriate and timely mental health treatment during the years when there is a significant risk of developing a mental illness. Insurance eligibility will be based on income rather than disability status, too, which will streamline enrollment and foster earlier intervention. The process for certifying a disability is long and arduous, especially for people with a mental illness. For young adults, perhaps experiencing their first psychiatric hospitalization, the early opt-in will enable them to get treatment without having to prove to the Social Security Administration that their illness is so disabling that they cannot work. Now they will be able to qualify for MA, obtain care, and begin to work as they recover. Depression often co-occurs with other health conditions such as cancer, heart disease, and diabetes. More than 500 people die by suicide in Minnesota every year, most as a result of an untreated mental illness, particularly depression. Earlier intervention and access to effective treatment can help prevent these deaths. The ACA mandates that health plans—and Medicare, in the future—cover preventive health services, which include depression screenings. It has also authorized funding to support research on depression, including postpartum depression. Those living with a serious and persistent mental illness die on average 25 years earlier than their peers—the same life expectancy as people living in Bangladesh. Minnesota has launched the “10 x 10” campaign to increase life expectancy by 10 years in 10 years. It will promote the integration of physical and mental health care with funding earmarked by the ACA for colocating primary and specialty care in community-based mental health settings. Colocated care means coordinated care for those with mental and physical illnesses— especially important for those with chronic conditions.

Challenges remain Much of the funding that was cut this year in Minnesota’s legislative session was state grant money to counties for mental health care for the uninsured or underinsured, e.g., those with high-deductible plans or those with insurance plans that don’t cover mental health care. Now people will have to “wait in line” for care that they need— meaning they might not get care at all if the funds dry up first. The more we can move toward universal coverage and toward full coverage of mental health care, the less we will have to rely on grants and the less people will have to wait for care that they need and deserve. Minnesota has a severe shortage of mental health professionals— especially in racially and ethnically diverse communities, rural areas, and in certain career fields (psychiatrists and clinical nurse specialists). This is particularly true for children’s mental health services. The ACA has authorized grants for colleges and universities to recruit and train students in social work and interdisciplinary psychology programs, provided students complete an internship in child and adolescent mental health care. NAMI is looking forward to implementation of the ACA. Wider access to mental health care and treatment will enable all people to function better in school, work, home, and the community. The time of discriminating against mental illness is thankfully coming to an end. Sue Abderholden, MPH, is the executive director of NAMI Minnesota.

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MEDICARE

I

t is that time of year again, Medicare’s open enrollment period—only this year it is occurring a few weeks early. The 2011 open enrollment period actually began on Oct. 15 and ends on Dec. 7. This means that seniors only have a few weeks left to make changes to their basic Medicare plan, Medicare Part D Plan, or Medicare Advantage Plan. Enrollees have until Dec. 7 to make changes, which will go into effect on Jan. 1, 2012. Need to review each year

Navigating Medicare open enrollment By Michele Kimball

AARP recommends that all those enrolled in Medicare review their plan each year to make sure it is still the right choice for them. People’s needs often change from year to year, and so can their Medicare plan. A plan that may have met someone’s needs in 2011 might not cover a new medication needed in 2012. “Plan X” might have been the most affordable option two years ago, but subsequent improvements to competing plans may make one of them a better choice today. While this might be seen as a complicated and confusing process, resources do exist to help seniors navigate the open enrollment season. The Medicare website www.medicare.gov/find-a-plan offers a tool that can compare national plans side by side. The Minnesota Board on Aging offers a free, statewide service called Senior LinkAge that offers assistance by phone at (800) 333-2433. It is important for seniors to explore their options each year and to understand that there are resources out there to help. First, the basics

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Before considering the details of various Medicare plans, it might be helpful to review the basics. Medicare is a government-sponsored health care plan for individuals 65 and older (or any age with certain disabilities). Medicare is separated into four separate tiers, or parts. Parts A and B are considered “traditional Medicare” and cover the costs of most inpatient and outpatient acute care needs such as doctor visits and hospital stays. Medicare Part D consists of private plans that cover a portion of an enrollee’s prescription drugs. Part C plans—also called Medicare Advantage Plans—combine traditional Medicare with Part D so seniors can get both acute and prescription benefits through one single private plan. Each year individual Medicare plans can change. Certain benefits may be added and others dropped. Premiums and/or copays can also change from year to year. It is up to each individual to evaluate these changes during the open enrollment period. During open enrollment, anyone enrolled in traditional Medicare, Medicare Advantage, or Medicare Part D is eligible to switch plans. This means a senior can switch from one Part D plan to another, or can switch from Part D or traditional Medicare to a Medicare Advantage Plan. In order to do so, however, the changes must be made by Dec. 7, 2011. Knowing when to switch Knowing how and when to switch is the easy part; knowing whether to switch, and what plan to switch to, is a bit more complicated. Each year, Medicare enrollees will receive a “Notice of Change” letter. This letter will document what is covered under your current plan and what parts of the plan will be changing for the upcoming year. Because plans often change, it is important to review this letter carefully and learn what options are available in your geographic

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2011


area, such as other traditional Medicare, Part D, or Medicare Advantage Plans. In 2011, 99.7 percent of Minnesotans on Medicare will have access to at least one plan that is consistent with their previous plan. This means if a plan is changed significantly or even dropped, seniors will have the security of knowing that other plans should be available that offer comparable benefits. In addition to reviewing changes in certain health plans, Medicare enrollees should also carefully consider changes in their own health status. If they’ve started new medications, been diagnosed with a new condition, or moved to a new location, a change in Medicare plans may be necessary.

No one can put a price tag on having the right health care plan. While saving money on copays and deductibles is important, having a plan that actually meets your needs is critical. Michele Kimball is state director for AARP Minnesota and works in St. Paul. AARP Minnesota, which has nearly 700,000 members statewide, is a leading advocate on health care, long-term care, and economic security issues for Minnesotans over the age of 50.

What to consider when switching plans Once you’ve made the decision to switch Medicare plans, there are certain key questions to ask yourself in order to choose the right plan for your particular medical needs and budget: • How will I have to pay for premiums, deductibles, copayments, doctor visits, and hospital stays? • Does my doctor accept this coverage? If not, are there other doctors nearby who will? • Do I still have a choice of health care providers and hospitals in a particular network?

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your daughter’s daughter ghter’s esophagus us isn’t connected, you think it’s the hardest news you’ll ever have to swallow.

• Are referrals necessary to see a specialist?

The 2011 Medicare open enrollment period began on Oct. 15 and ends on December 7.

• Is there a yearly limit on out-ofpocket costs? • Are my medications included on the plan’s covered drug list? • What will the prescriptions cost? • Is my local pharmacy included in the network? Is it possible to get prescriptions by mail? • What happens if I get sick when outside my home state? • Does the plan have a 24-hour assistance line?

• Does the plan have a good quality rating? It is important for seniors to know that, in addition to family, friends, and financial advisors, there are resources out there to help with the decision-making process. Where to find plans Seniors who have access to the Internet should look at www. medicare.gov/find-a-plan. This website offers a simple, easy-to-use tool to find other plans in a particular geographic area, and to compare cost and benefits with one’s current plan. For Minnesotans without Internet access, Senior LinkAge is an excellent resource. Its staff is dedicated to helping seniors navigate complicated issues like Medicare. Senior LinkAge can be reached at (800) 333-2433.

For Ir Ireland’s eland’s parents, parents, s, that news came after r surgery, sur gery, when they w were eree told infection w was as threatening her life life.. W Wee told them w wee could c contin continue ue infusion therapy and beat the infection — at home home.. And because w wee focus exclusively ex clusively on pediatric care care, re, w we’ve ee’vve pro proven ven that w wee can reduce uce hospital and emerg emergency ency de department partment admissions admissions,, helping kids ids likee Ireland thri lik thrive. ve. Meet Ireland and lear learn n more re at MeetTheMiracle.com m

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Reviewing options is worth the time One of the most common criticisms of Medicare—especially Part D— is that it is too complicated. It’s true that it can be. But if you want to save money and find the best plan for you—i.e., get the most out of Medicare—you need to take the time to do your research. NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

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VA S C U L A R M E D I C I N E

Chronic venous insufficiency: Don’t ignore leg discomfort

Chronic venous insufficiency ealthy, fully functioning veins are an essential is a serious condition part of the circulatory system. Arteries carry Varicose veins usually are located on blood away from the heart, and veins carry the inside of the calf or thigh and can blood back to the heart after oxygen has been extracted at continue to enlarge over time, often the tissue level. A critical element of vein function is the netBy John D. Martin, becoming twisted, pouched, and thickwork of tiny, one-way valves inside the veins that allow forMD, FACS ened. They frequently occur in women ward blood flow while preventing backward flow. For many during pregnancy, even in women as people, those valves may not be working as well as they used to, young as their 20s. If these veins are left untreated, additional veins and over time the veins may become swollen and purple, appearing may dilate and the person may develop a condition called chronic as varicose veins. In fact, according to the U.S. Vascular Disease venous insufficiency (CVI), which is characterized by chronic Foundation, nearly 40 percent of women and 20 percent of men swelling, pain, and the skin changes mentioned above. have significant leg vein problems by the age of 50. CVI is extremely common and affects millions of people in the U.S. It is different from other conditions that affect blood circulation in the legs such as peripheral artery disease (PAD), because CVI occurs in the veins rather than the arteries. It does not result from hardening of the arteries (atherosclerosis). Some factors leading to the development of varicose veins and CVI can be prevented; others, unfortunately, are unavoidable. Risk factors include a family history of vein problems, age over 30, a history of blood clots or deep venous thrombosis (DVT), previous leg injuries, multiple pregnancies, and daily activities that involve long periods of standing or sitting. Sitting or standing for a long time can exacerbate the increased venous pressure from CVI and stretch the thin vein walls. Over time, this can weaken the walls of additional veins, leading to the development of additional varicose veins.

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Preventing CVI There are a few simple, preventive measures that can decrease one’s risk for developing CVI. These include regular exercise, taking frequent breaks to avoid standing or sitting for long periods of time, and maintaining a normal healthy weight. If visible changes occur in the legs—e.g., bulging veins or increased swelling—patients should see a physician. Symptoms

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

Diseases like CVI often go unnoticed and can lead to more serious problems like DVT. Many people with CVI don’t feel any symptoms at first, but as the disease worsens, swelling, pain, or ulcers may develop in or on the legs that can make walking and other everyday tasks difficult. In addition to pain and swelling, other common CVI symptoms include varicose veins, skin changes, and a feeling of heaviness in the legs.


Tests for CVI, like the probe-based test pictured left, can be simple and pain-free. A probe, or small device used for testing, can measure the blood flow in your veins in a matter of minutes (below).

Early detection is key Many people are unaware that minimally invasive testing is available. People often dismiss leg vein problems as a normal part of getting older. But early detection is key to being able to resolve problems, because the sooner it is diagnosed, the more treatment options one has. Anyone experiencing prolonged leg discomfort (or any of the other symptoms previously mentioned) should contact a physician. “In my experience, I have seen that chronic venous insufficiency can be an extremely disabling disease that affects quality of life. At our facilities, we emphasize that early detection and treatment can prevent many complications,� says Dr. Maria Gomes, an interventional radiologist at Minneapolis Vascular Physicians and medical director at the Minneapolis Vein Center.

sure in smaller veins. The procedure usually takes less than an hour and can provide immediate relief of symptoms. It involves only a tiny nick in the skin about the size of a pen tip, and most patients are able to return quickly to normal activity with little or no pain. “The newest technologies available make the treatment of chronic venous insufficiency easier and more tolerable,� says Dr. Gomes. “Since most treatments can be done as an outpatient procedure, there is little to no downtime, and the procedure may be covered by the patient’s insurance carrier. We are fortunate to have these technologies to help CVI patients.� “As confirmed by several clinical studies, patients undergoing treatment for varicose veins using the latest, advanced closure procedures experience less pain and bruising when compared to treatments that have been used in the past,� says Brian Verrier, vice president and general manager of Vascular Therapies at Covidien, one of the largest developers of CVI treatment technology. “Seeking treatment is important, as it can prevent disease progression and improve the quality of life.� Today’s most advanced treatments are highly effective and result in little to no scarring, so one should not be afraid to see a doctor about leg vein concerns. John Martin, MD, FACS, is medical director for BioMedix, a Minnesotabased manufacturer of health care devices, hardware, software, and online services designed to detect PAD and CVI. Martin is a board-certified vascular surgeon and CEO of Cardiology Associates, LLC, with offices in Washington, D.C., and throughout Maryland.

Testing is easy and quick If a patient needs to be tested for CVI, the primary care physician may be able to conduct the test in the office. With this option, the primary care physician uploads the results to a secure website where a specialist downloads the data for interpretation, then uploads the final report for the primary care physician—saving the patient the time and trouble of scheduling an additional appointment. Tests for CVI are usually quick and painless, and help your doctor decide whether other medical or surgical treatments are necessary. With today’s technologies, some tests for CVI can be completed in fewer than 20 minutes. One type of test, for example, uses a small probe to measure the venous refill time in the lower limbs; if the veins refill too quickly, that could be a sign of CVI. Treatment options While prevention and early detection of CVI are ideal, there are a number of treatment options for people who have already developed CVI. Graduated-compression stockings are an important part of treatment. They come in a variety of sizes and colors, and most pharmacies located within clinics and hospitals will have them for sale. (The prescribing physician will probably know which pharmacies carry them.) These stockings are snug, but help reduce swelling and pain. Most importantly, they decrease the risk of blood clots forming. There are also medications—even some herbal supplements—that are used to treat swelling and other CVI symptoms. For patients with significant vein dilation, there is a minimally invasive treatment called vein ablation. This treatment closes off abnormal veins using radiofrequency or laser, which reduces pres-

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November Calendar 8

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Lyme Disease Seminar and Support Dr. Maloney will present on the proper use of lab testing in Lyme disease. The discussion includes the performance of two tests (Enzyme-linked immunosorbent assay (ELISA) and Western Blot), and the limitations surrounding their use in the diagnosis of Lyme. Email questions to lyme@mnlyme.com. Tuesday, Nov. 8, 6:30–7:30 p.m., First Lutheran Church of White Bear Lake, 4000 Linden St., White Bear Lake Food Allergy Resource Fair This free event brings many food allergyfriendly vendors together to share their latest products and information. Stop by to try samples, check out new products, talk with vendors, or have one-on-one time with an allergist at our Ask the Doctor booth. For more information, email info@FoodAllergySupportMN.org. Saturday, Nov. 12, 9 a.m.–noon, Eisenhower Community Ctr., 1001 Hwy. 7, Hopkins Relationships after Stroke The discussion will include how stroke can affect relationship roles and dynamics, communication, and intimacy in relationships. The educational seminar is for stroke survivors and their care partners. For more information, contact Sue Newman at 612863-4996. Tuesday, Nov. 15, 2–3:30 p.m., Abbott Northwestern Hospital, 800 E. 28th St., Rm. E1220, Minneapolis Nurtured Heart Approach Are you the caregiver of a child with high energy and high intensity? Come and learn four effective strategies to help see your child’s behavior as a gift instead of a challenge. Cost: $30 per individual or $50 per couple. To register, call 612-798-8331 or email workshops@fraser.org. Wednesday, Nov. 16, 1:30–3:30 p.m., Fraser, 6344 Penn Ave. S., Richfield

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Understanding the Grieving Process The presenter will discuss various aspects and experiences of grief and explore ways of coping with changes brought on by grief. Rev. Tom Davis, is an ordained pastor who has served in congregational ministry for 21 years, disaster response/ recovery for six years, and hospital/hospice chaplaincy for five years. Call 651298-5493 to register. Friday, Nov. 18, 10:15–11:30 a.m., West 7th Community Ctr., 265 Oneida St., St. Paul

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Pulmonary Hypertension (PH) Support Group The Pulmonary Hypertension Association announces the formation of a new support group in the Twin Cities for PH patients, families, and caregivers. The group will focus on PH education and related topics. For more information, call Sean Warren at 763-607-9276. Saturday, Nov. 19, 1–3 p.m., St. Louis Park Recreation Ctr., 3700 Monterey Dr., St. Louis Park

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Blood Pressure Checks Fairview Lakes Community Health Outreach is offering free blood pressure checks. The screenings are held every Tuesday at this location. For questions, call 612-672-7272. Tuesday, Nov. 29, 9–11 a.m., Walmart, 200 12th St. S.W., Forest Lake

National Family Caregivers Month A caregiver is a relative, friend, or neighbor who provides care for an older or disabled adult. Caregiving is important work and it can be rewarding, but it can also be overwhelming. You may also be filling the dual roles of employee and caregiver. You are not alone. About 25 million Americans struggle to manage the stress of work responsibilities while caring for an elderly relative. If you are a caregiver, it is important for you to realize that it is okay to ask for help. • Call the Senior LinkAge Line, at 1-800333-2433 and ask for a referral to a caregiver consultant. A trained professional can help you assess your situation and create a plan to help you reduce stress while balancing work and caregiving responsibilities. • The Minnesota Board on Aging has seven regional Area Agencies on Aging that are dedicated to addressing the needs of older adults and their families. To locate services and resources in your local community, visit www.mnaging.org. • The MinnesotaHelp.info website is an online directory of services designed to help people in Minnesota find information and referrals. It is especially rich in resources for seniors and their caregivers, and for people with disabilities and their caregivers. 17 Caregiver Support Group Join us! We meet to discuss concerns, share knowledge, and provide mutual support in our roles as caregivers. Meetings are held the first and third Thursdays of the month. Call 952-888-7121 for more information. Thursday, Nov. 17, 10–11:45 a.m., Gideon Pond, 10030 Newton Ave. S., Bloomington

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

America's leading source of health information online 18

MINNESOTA HEALTH CARE NEWS NOVEMBER 2011


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PA I N M A N A G E M E N T

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ncreasingly, when we answer our toll-free helpline at the Minnesota Network of Hospice & Palliative Care, callers start the conversation with, “The doctor says my family member does not need hospice care yet, but suggested palliative care. What is that?” People attending our educational sessions on advance care planning, hospice, and palliative care often ask for more information about palliative care. This need for clarification is not surprising, since palliative care is a relatively new medical service. Palliative care supports people with serious health conditions, no matter what their age. Palliative care helps with pain and other symptoms caused by a serious illness or resulting from aggressive, curative treatment such as chemotherapy. With an overall goal to improve the quality of life for patients and their families, palliative care is appropriate at any time during a serious illness and can be provided together with curative treatment. Palliative care can be provided in homes, hospitals, nursing homes, and assisted living facilities. Research published in the 1999 Journal of the American Medical Association stated that people with a serious illness have three primary concerns: They want to control their pain and symptoms, have a good quality of life, and not be a burden to their families.

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Additional information on palliative care The palliative team is made up of the primary can be found on the following websites: physician, specialist(s), nurse, social worker, and chap• Center to Advance Palliative Care (CAPC) has a lain, who work together to provide medical, emotional, Palliative Care Provider Directory and a list of more and spiritual support to the patient and the family. The specific palliative care resources: team may also help the patient and family navigate the www.getpalliativecare.org health care system to ensure that they receive the care • American Academy of Hospice & Palliative they need. Medicine: www.palliativedoctors.org Lyn Ceronsky, director of Palliative Care for • Minnesota Network of Hospice & Palliative Care: Fairview Health System in Minneapolis, encourages www.mnhpc.org patients with serious illnesses and their families to “ask • Veterans Administration: www.va.gov their doctors about palliative care, or request that a palliative care team be involved in their care.” Palliative care teams work to decrease physical symptoms and stress and help Questions to ask palliative care providers the patient make important decisions. Palliative care makes a huge difference in the quality of life for someone who is seriously ill. When someone is considering palliative The New England Journal of Medicine reported on the effeccare, asking the following questions can tiveness of palliative care in a 2010 study of lung cancer patients. help with decision-making: The researchers found that “early palliative care led to significant 1. Who is part of the palliative care team? improvements in both quality of life and mood. As compared with 2. How will palliative care help me and patients receiving standard care, patients receiving early palliative my family? care had less aggressive care at the end of life but longer survival.” 3. How will the palliative care team work The patients lived almost three months longer that those who did with my current physician(s)? not receive palliative care. 4. What is the process to address pain and control symptoms in an emergency? Lack of knowledge among consumers There is a lack of knowledge about palliative care as shown in a survey of Minnesotans conducted in June 2010 for the Minnesota Network of Hospice & Palliative Care. The survey found that 68 percent of survey participants had never heard of palliative care. This percentage closely matches the findings of a national study commissioned and conducted in 2011 by the Center to Advance Palliative Care (CAPC). When the researchers defined palliative care, 62 percent said they would be “very likely” to consider it for a loved one who had a serious illness.

Early palliative care led to significant improvements in both quality of life and mood.

What is the difference between palliative care and hospice care?

Palliative care to page 34

Read us online wherever you are!

People are often confused by these two terms and wonder how they differ. The primary difference is that each serves a different group of patients. Palliative care is medical care for patients with any serious— but not terminal—illness, at any time during the illness, and may coincide with curative treatment. Hospices serve only the terminally ill and work to ensure that the patient is as comfortable as possible during his or her final days. Health insurance plans usually require separate coverage for hospice care, as does Medicare. The Veterans Administration covers both hospice and palliative care for veterans. The care continuum Palliative care is considered part of a continuum of care; patients can receive palliative care for a serious illness while getting treatment. If their illness become terminal, they can choose to receive palliative care through hospice care.

www.mppub.com NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

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HOME CARE

There’s no place like home By Amy Nelson

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s health care reform becomes a reality, there is a building momentum toward keeping patients in their homes whenever possible. Home care meets health care reform mandates—such as reducing rehospitalization rates—by allowing care recipients to avoid expensive, institutional alternatives like hospitals and nursing homes. Patient-preferred and cost-effective, home care is becoming an integral part of the health care continuum as it bridges the clinic-based model and the actual world patients live in.

For all ages and many conditions The primary population creating the demand for home care is seniors. As 78 million baby boomers approach retirement age, U.S. demographics are shifting significantly. Seniors will soon constitute 20 percent of the population. It’s estimated that by the year 2020, 12 million older Americans will need long-term care. A recent consumer survey by AARP showed that home care is the preferred care choice for 95 percent of seniors and retiring baby boomers. Both groups are interested in staying out of what is commonly known as the “broken hip revolving door” of hospitals,

rehab centers, and short-term nursing home placements. Home care serves people of all ages, not just seniors. Many health conditions can be managed at home. Clients include those recovering from temporary health challenges as well as those who are permanently disabled, chronically ill, or in need of end-of-life care. Their needs may be medical, nursing, therapeutic, or just assistance with everyday life activities. Two growing service niches are pediatric care (including premature babies) and young,

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disabled adults. Children who years ago would have been institutionalized or hospitalized long-term, or who would not have survived at all, are now being cared for successfully at home. Advances in medical technology have increased the number of patients now treated at home. Chronic patient needs being handled by home care nurses include tracheotomies, ventilators, gastrostomy tubes, IV therapies, and many cardiac conditions. Cancer and transplant patients are also able to recuperate at home. Skilled, private-duty nurses and case managers working in the home regularly meet complex medical needs. All such nursing activities are signed off by MDs, and patient care plans are recertified at a minimum of every 60 days. Additional technologies that improve home care service levels include telehealth service management, electronic medical records, and a variety of assistive technologies such as home sensors. A nurse using telehealth equipment, for instance, can potentially make up to 15 visits a day rather than the standard five. John McNamara, MD, medical director of Children’s Home Care and Hospice Program at Children’s Hospitals and Clinics of Minnesota, stated, “We have sent over 400 children home with trachs and vents, and find home care to be a very good alternative, with fewer infections and low readmission rates. Even acute illnesses have been successfully cared for at home.”

Home care serves people of all ages, not just seniors.

A cost-effective alternative

Home care is anywhere from five to 20 times less expensive than inpatient facility care. A 2009 study, published by Avalere Health, estimated that early home care use was associated with a $1.71 billion reduction in Medicare post-hospitalization spending over a one-year period. Home care is one viable solution that legislators and medical professionals can leverage to maximize care capacities while minimizing costs. In 2009, for example, national charges by Medicare were $135 per home care visit, $622 per day for skilled nursing facilities, and $6,200 per day for inpatient hospital care. The numbers speak for themselves. Types of home care There are five basic home-care service options: 1. Personal care assistants provide assistance with activities of daily living such as dressing, bathing, feeding, getting to doctor appointments, etc., and are not licensed by the state. This type of care is typically paid for by Medical Assistance, Minnesota’s Medicaid program. 2. Private-duty care—basically private-pay care—provides assistance with nonmedical needs such as shopping, cooking, transportation, and companionship, and involves household management services but no hands-on medical care. Some long-term care

policies will cover such home care, but reimbursement terms and exclusion criteria vary. 3. Licensed home care agencies employ a variety of home health care professionals, including skilled nurses, therapists, and home health aides. This type of care is typically paid for by private insurance, Medicare, and Medicaid. 4. Medicare-certified, skilled home care is typically received on an acute, intermittent basis, i.e., following an illness, injury, or change in disease status. Such services are physician-driven, and reimbursement is contingent on the individual demonstrating progressive improvement while being homebound. 5. Extended-hour nursing offers high-level one-on-one care, from four to 24 hours per day for those with medically complex needs. Home care ranges from a one-hour weekly visit to 24-hour livein care. It provides a one-on-one focus, which is difficult to obtain in hospitals or group facilities. Home care also respects cultural differences and ethnic diversities by assigning staff members not only by skill set but also by language (from Spanish to Somali to sign) and behavioral criteria, such as not smoking or not consuming pork. In hospital settings, there is no choice as to who provides the individual care. Home care allows the patient to select the service provider upfront and provides care in a controlled setting. Who pays for home care? Funding for home care is increasing as more people recognize its cost competitiveness. Many insurance companies now cover There’s no place like home to page 27

Complete Home Health Services LLC Caring for your home health needs... and more Providing a full range of physician-directed services for you and those close to you We offer: • PCA/Home Health Aide/Homemaker — will provide care to the clients by following a care plan set by the Registered Nurse (RN) • Nutritional Counseling, Diabetes Education, Asthma Education • Home Assessment— caters specifically to the individual client • Skilled Nursing Care—Administering IV drugs and wound-ostomy care • Companion/Respite Care—We provide caregivers to relieve someone who is already caring for a family member For more information contact: Complete Home Health Services Silver Lake Plaza Building 4001 Stinson BLVD NE, Suite LL32 St. Anthony MN, 55421

612-PUT-CARE • www.bchhs.com NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

23


ONCOLOGY

become tender. For example, if a person has a sore throat, the lymph nodes under the jaw and in the neck may swell. Most swollen nodes are a reaction to infection, however, and are not cancerous. Lymphoma develops when a genetic error, or mutation, occurs in the way lymphocytes are produced. There are two types of lymphocytes: B lymphocytes (or B-cells; “B” because B-lymphocytes come from the bone marrow), and T lymphocytes (or TThe lymphatic system cells; “T” because T-lymphocytes norThe lymphatic system is one of the most mally spend part of their lifespan in important parts of the immune system the thymus gland, a small organ in because it protects the body from disthe chest). B-lymphocytes develop ease and infection. It is a separate into cells called plasma cells that circulatory system made up of a series make antibodies, which attack From the Lymphoma Research of thin tubes called lymph vessels that toxins, bacteria, and some cancer cells Foundation carry lymph, a transparent fluid that contains that the body then removes. T-lymphowhite blood cells called lymphocytes, which are cytes also help the body fight viral infections made in the bone marrow, spleen, and lymph nodes. and destroy abnormal or cancerous cells. Like There are thousands of lymph nodes throughout the normal lymphocytes, cancerous lymphocytes can body. Lymph flows through lymph nodes and the spleen, grow in many parts of the body, including the lymph tonsils, bone marrow, and thymus gland. Lymph nodes nodes, spleen, bone marrow, blood, or other organs. filter lymph, removing bacteria, viruses, and other foreign Hodgkin lymphoma substances. If a large number of bacteria are filtered Hodgkin lymphoma is named after Thomas through a node or series of nodes, they may swell and Hodgkin, the British physician who first identified the disease in 1832. Also known as Hodgkin disease, HL is not as common as non-Hodgkin lymphoma. In fact, HL is relatively rare, accounting for less than 1 percent of all cancer cases in the United States. According to the American Cancer Society, approxiDo your legs hurt when you walk? mately 8,500 new cases of HL are projected each year. Although it Does it go away when you rest? can occur in both children and adults, it is most commonly diagnosed in young adults between the ages of 15 and 35 and in adults Or, have you been diagnosed with PAD? over age 50. Nearly 10 to 15 percent of all Hodgkin lymphomas are You may have claudication, caused by lack diagnosed in children and teenagers. The disease is more common in of blood supply to the leg muscles men than in women although, according to the American Cancer The University of Minnesota is seeking volunteers Society, incidence rates have decreased in men over the last 30 years to take part in an exercise-training program, and slightly increased in women. funded by the National Institutes of Health

L

ymphoma is the most common blood cancer in adults and the third most common cancer overall in children. The overall term “lymphoma” is used for more than 67 subtypes of the two main forms: Hodgkin lymphoma (HL) (formerly referred to as Hodgkin’s lymphoma) and non-Hodgkin lymphoma (NHL). There are six primary types of Hodgkin lymphoma and at least 61 types of non-Hodgkin lymphoma.

Lymphoma: an overview

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Types of Hodgkin lymphoma Hodgkin lymphomas are different from non-Hodgkin lymphomas in the way they develop, spread, and are treated. Hodgkin lymphoma has been divided into two main classifications, classical Hodgkin lymphoma (which accounts for approximately 95 percent of all HL cases) and lymphocyte predominant HL. The type of HL one has may affect treatment choices. Within classical Hodgkin lymphoma, there are four subtypes: nodular sclerosis (60 to 80 percent of all HL cases), mixed cellularity (15 to 30 percent of HL cases), lymphocyte depletion (<5 percent), and lymphocyte-rich (<5 percent). The two subtypes within lymphocyte predominant Hodgkin lymphoma are nodular lymphocyte predominant (5 to 10 percent of all HL cases) and diffuse lymphocyte predominant (extremely rare).


Symptoms of HL

Risk for developing lymphoma may be higher in individuals who: Well over 80 percent of Hodgkin lymphoma usually starts in • Have a family history of NHL (though no the lymph nodes and may be noticed patients with Hodgkin hereditary pattern has been well established) first in the neck, above the collarbone, lymphoma are cured. • Are affected by an autoimmune disease under the arms, or in the groin. • Have received an organ transplant Because lymph tissues are connected • Have been exposed to chemicals such as all over the body, abnormal lymphopesticides, fertilizers or organic solvents for a long period cytes can circulate, causing the lymphoma to spread from one • Have been infected with viruses such as Epstein-Barr, human lymph node to another. T-lymphotropic virus type 1 (HTLV-1), HIV/AIDS, hepatitis C, Risk factors or certain bacteria. Although the exact causes of Hodgkin lymphoma are unknown, Stages research shows that certain risk factors may play a role in the Non-Hodgkin lymphoma is divided into four stages based on how development of the disease: far the disease has spread: • Family history of Hodgkin lymphoma (though no hereditary pattern has been well established) • Epstein-Barr virus infection (which causes mononucleosis) • HIV infection • Weakened immune system caused by either an inherited condition or the use of immunosuppressants to prevent organ transplant rejection. Even if you have one or more of these risk factors, it does not mean that you will get Hodgkin lymphoma; most people with risk factors never develop the disease. Hodgkin lymphoma has been studied more than any other type of lymphoma, and the result of those studies has led to rapid advances in the diagnosis and treatment of the disease. Well over 80 percent of patients with Hodgkin lymphoma are cured. Non-Hodgkin lymphoma Non-Hodgkin lymphoma, like Hodgkin lymphoma, is a cancer of the lymphocytes. B-cell lymphomas account for 85 percent of all NHLs; T-cell lymphomas account for the remaining 15 percent. Because there are so many different forms of NHL, they are often grouped according to their clinical behavior and whether they are slow-growing/low-grade or aggressive/high-grade. Slow-growing lymphomas are usually chronic and not curable. Aggressive lymphomas, while potentially life threatening, can often be cured. NonHodgkin lymphoma has grown from being a relatively uncommon disease to being the fifth most common cancer in the U.S., nearly doubling in incidence since the early 1970s and increasing among women since 1991. Risk factors Although the exact causes of non-Hodgkin lymphoma remain unknown, some common factors appear to have an impact on risk. For example, NHL incidence increases with age. Approximately 70 percent of people diagnosed with NHL are 50 years of age or older; they are more likely to be men than women; and they are more likely to be Caucasian than African-American. The disease is also more common among people with depressed immune systems and those exposed to environmental carcinogens, pesticides, herbicides, viruses, and certain bacteria.

• Stage I (early disease): The cancer is found only in a single lymph node or in one organ or area outside the lymph node. • Stage II (locally advanced disease): The cancer is found in two or more lymph node regions on one side of the diaphragm. • Stage III (advanced disease): The cancer involves lymph nodes both above and below the diaphragm. • Stage IV (widespread disease): The cancer is found in several parts of one or more organs or tissues (in addition to the lymph nodes); or it is in the liver, blood, or bone marrow. Lymphoma to page 26

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• Radiation therapy

Lymphoma from page 25

• Stem cell transplantation

Common types of NHL Because there are so many different types of NHL and because new subtypes are continually being identified, classifying lymphoma is complicated, and has evolved over the years. The most common types of NHL currently include: • Diffuse large B-cell lymphoma (DLBCL): 31 percent • Follicular lymphoma: 22 percent • Mantle cell lymphoma (MCL): 6 percent • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): 6 percen

• Novel targeted agents • Newer versions of established agents. The form of treatment chosen depends on the type of lymphoma and the stage of the disease, as well as factors such as age, prior therapies received, and the patient’s overall health. Before starting treatment, patients should discuss all available treatment options with their physician. Participating in clinical trials

• Mucosa-associated lymphoid tissue (MALT) lymphoma: 5 percent • Peripheral T-cell lymphoma (PTCL): 6 percent • Anaplastic large cell lymphoma (ALCL): 2 percent • Lymphoblastic lymphoma (LL): 2 percent • Burkitt-like lymphoma: 2 percent • Lymphoplasmacytic lymphoma (LPL): 1 percent Treatment options

Patients interested in participating in a clinical trial should talk to their physician. Contact the Lymphoma Research Foundation’s Helpline for an individualized clinical trial search by calling 1-800-500-9976 or emailing helpline@ lymphoma.org. Resources For more information on HL and NHL, please visit the Lymphoma Research Foundation’s website, www.lymphoma.org.

Many effective treatment options exist for NHL patients, including: • Watchful waiting • Chemotherapy

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

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There’s no place like home from page 23

extended-hour nursing and care visits. A tracheotomy patient, for example, can be approved for 24-hours-per-day care for one month, then be weaned onto family care. Managed care companies such as Medica, Health Partners, UCare, and Blue Cross Blue Shield Association have come to understand that home care is safe, efficient, and provides the same level of care at a cost-effective rate. Payment options for home care include self-pay, Medicare, Medicaid, Veterans Administration, CHAMPUS, workers’ compensation, commercial health insurance companies, managed care organizations, and community organizations. Bringing it home Home care is a critical component of collaborative care that is increasingly moving from the periphery to the mainstream. The types of care now being handled at home are drastically different from care models even 10 years ago, and they will continue to evolve as technologies advance. Home is where families want their loved ones to be, because it’s where the highest quality of life can be had. Amy Nelson is founder, president, and CEO of Accurate Home Care, a provider of both pediatric and adult home care services in Minnesota.

A diagnosis of

Cancer is overwhelming news.

Matching patient needs with home-care provider skill sets is a primary consideration for consumers. The following questions can help consumers find the best home-care provider for their needs: 1. What process do you use to match your staff with clients? 2. What type of training is given to your staff members? 3. Does your agency have licensed social workers on staff to address the emotional needs of clients and families? 4. How closely do your supervisors evaluate the quality of care provided? 5. How are problems addressed and resolved? 6. How do you manage scheduling? Is care available around the clock if needed? 7. What are the credentials of your employees who will be in my home? Can they provide individual references? 8. What procedures are in place in case of an emergency, such as a power failure or inclement weather? 9. Are all of your caregivers licensed in their fields? 10. Can you provide references from doctors, hospital discharge planners, and clients? 11. How do you handle expenses and billing? Has your company ever been accused of fraud? 12. Will I receive a written care plan before service begins?

It raises many questions few of us are prepared to answer, such as: • How can I take time off from work? • Can I get help paying bills? • What is the difference between a health care directive and a power of attorney? • Can I keep my health insurance even if I lose my job? • And many others. If you or a loved one is facing cancer, we are here to help.

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Finding the right match

We provide free cancer related legal information on a wide range of topics.

Please visit our web site to find out more: www.cancerlegalline.org

Living with gout? Keep enjoying life’s simple pleasures.

Gout is the most common form of inflammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another. Learn more about managing this chronic illness at www.goutliving.org

educate.inform.empower NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

27


INSURANCE

Health insurance for people who can’t get it By Jackie Garner

I

f you’ve been turned down for health insurance because of a pre-existing condition, or offered coverage only at an unaffordable price, you may have another option: the Pre-Existing Condition Insurance Plan, or PCIP. PCIP is available to children and adults who have been locked out of the health insurance market because they have cancer, heart disease, diabetes, HIV/AIDS, asthma, or some other pre-existing medical condition. With PCIP, you can be insured for a wide range of benefits, including primary and specialty physicians’ services, hospital care, and prescription drugs. You won’t be charged a higher premium because of your medical condition, and your eligibility isn’t based on your income. Like commercial insurance plans, PCIP requires you to pay a monthly premium, a deductible, and some cost-sharing expenses (copays). Minnesotans enrolled in PCIP have access to a provider network that includes 22,264 doctors, 1,120 pharmacies, and 129 hospitals throughout the state. To qualify for PCIP, you must be a U.S. citizen or legal resident. You also must have a pre-existing condition or have been denied health coverage because of your health status. In addition, you must

In the next issue.. • Vaccination • Sinus congestion • Insomnia 28

MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

have been without health insurance for at least six months before you apply for PCIP. PCIP offers three coverage options: Standard, Extended, and a Health Savings Account. With a Health Savings Account, you can use pre-tax earnings to pay for PCIP. Premiums are based on the amount a subscriber would pay if he or she had no pre-existing condition and was able to purchase individual insurance in the open market. Each plan covers the same benefits but has different premiums, different medical and prescription drug deductibles (i.e., the amount you pay before your insurance company begins to pay benefits), and different prescription drug copays. You can select any qualified network provider for your care. Choose the plan that best meets your needs and know that you’re getting comprehensive, affordable health coverage. PCIP premiums were recently lowered 38 percent in Minnesota. The current premium for the Standard option for a Minnesota resident 35–44 years of age is $174 per month. The Standard option premium for a child 18 years old or younger is $96 per month. A Minnesotan 55 years old or older would pay $307 per month for the Standard option. (For ages between 44 and 55, cost varies by year; for details, go to “Find Your State” on the PCIP website, www.pcip.gov.) In addition to a monthly premium, you’ll pay other costs. In 2011, you’ll pay a deductible that ranges from $1,000 to $3,000— depending on which option you pick—for covered medical benefits before PCIP starts to pay. Prescription drugs may have separate deductibles. Preventive-care services, such as cancer screenings and flu shots, are covered 100 percent, with no deductible. After you pay the deductible, you’ll pay a $25 copay for doctor visits, $4 to $40 for most prescription drugs, and 20 percent of the costs of any other covered benefits you receive. Your out-of-pocket costs cannot exceed $5,950 per year if you stay in the PCIP network, and there’s no lifetime cap on the amount that PCIP pays for your care. Coverage always begins on the 1st day of the month. Generally, a completed enrollment application received on or before the 15th of the month will go into effect the 1st day of the next month. If it’s received after the 15th but on or before the last day of the month, your coverage will start no later than the 1st day of the second month. The Pre-Existing Condition Insurance Plan was created under the Affordable Care Act. It’s a transitional program until 2014, when all Americans—regardless of health status—will have access to affordable health insurance as the nation shifts to a new marketplace. PCIP is operated by the U.S. Department of Health and Human Services. Insurance is provided through GEHA, a nonprofit organization that covers federal employees and retirees.


You can apply online, by phone, or by mail. You must complete an application and provide a copy of one of the documents noted below, which must be dated within the past 12 months from the date of your application. • A letter from a doctor, physician assistant, or nurse practitioner stating that you have or had a medical condition, disability, or illness. This letter must include your name and medical condition, disability, or illness and the name, license number, state of licensure, and signature of the provider.

With PCIP, you can be insured for a wide range of benefits. • A denial letter from an insurance company for individual insurance coverage or a letter from an insurance agent or broker that shows you aren’t eligible for coverage from one or more insurance companies because of your medical condition. • An offer of individual insurance coverage that you did not accept from an insurance company. This offer of coverage has a rider that

says your medical condition won’t be covered if you accept the offer. • If you are under age 19 (or if you live in Massachusetts or Vermont), an offer of individual insurance coverage that you did not accept from an insurance company. This offer of coverage must show a premium that is at least twice as much as the PreExisting Condition Insurance Plan premium for the Standard Option in Minnesota. PCIP is already changing the lives of Americans who don’t have health care coverage and need medical care. James H., who lives in Texas, was diagnosed with brain cancer in 2010. Shortly after his diagnosis, James’ insurance company rescinded his coverage, claiming that his cancer was a pre-existing condition. James knew his lack of coverage was a death sentence. Fortunately, he was able to join PCIP in Texas and is now receiving the treatment he needs. For more information about required documents, go to “Learn More” at www.pcip.gov. You can also go to “Find Your State” at www.pcip.gov to find out how PCIP works in your state. For more information, go to www.pcip.gov or call (866) 717-5826 toll-free (TTY (866) 561-1604). The phones are open Monday through Friday from 8 a.m. to 11 p.m. Eastern Standard Time. Jackie Garner is consortium administrator at the Centers for Medicare & Medicaid Services (CMS), with oversight of the 10 Medicaid divisions in CMS’s Regional Offices. She served as acting deputy director for the Centers for Medicaid and State Operations in 2009 during the transition between federal administrations. Garner has more than 20 years of experience in health and human services at the state and national level, and received the Senior Executive Service Meritorious Executive Award in 2007.

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29


HOLISTIC HEALTH

Medicine By Gary A.-H. Christenson, MD

Arts and the

Hospitals and clinics are by nature frightening and brutal places. Patients would avoid them if they could. The experience could easily be characterized as a constellation of interrogations, physical and social isolation, invasion of privacy, and assaults upon the body. The truth is that some mental and physical discomfort is characteristic of the struggle to get better. However, physicians have both an interest and obligation to keep these discomforts to a minimum. Healing deals as much with the delivery as with the treatment. The challenges facing patients are but a subset of the challenges of life itself. We all deal with daily obstacles, uncertainty, and discomfort, not only in our individual lives but also as members of society. So how do we manage these discomforts? What makes life palatable? I would argue that a good deal of our individual and societal ability to cope with the myriad challenges of life comes through the arts. We arrange and design our living spaces, decorate our walls, listen to music, read, write, dance, recite stories, joke, delve into creative hobbies and pastimes, adorn our bodies

with styles that we find fashionable, and prepare our food in creative ways. The arts are not confined to museums, concert halls, and coffee books, however. They are woven into the very fabric of what it is to be human. And if they are essential to human nature, then physicians need to recognize the arts as an additional adjunct avenue for healing, just as worthy as diet, exercise, pharmaceuticals, and surgery. But how can the arts benefit health care? The arts in the health care environment Until fairly recently, health care environmental design has emphasized efficiency, practicality, and technology—i.e., from the perspective of health care providers and administrators, with less attention to the patient and family experience. The aesthetic sterility of the hospital ward nearly matched the necessary clinical sterility. In this context, patients, captive and immo-

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

(651) 603-0720 • (800) 511-3696 30

MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

©2007 National Down Syndrome Congress


bile, not only were constantly reminded where they were and what they faced, but were also forced to sacrifice their sense of control. Increased patient fear and anxiety were natural outcomes. Studies have demonstrated that the use of design and visual art not only improves the patient experience, but can also positively influence both clinical outcomes and medical expenditures. Several studies have revealed that rooms designed with views of nature decrease anxiety, physical discomfort, and the requirement for pain medications, compared to rooms without such elements. Other studies have suggested that artwork depicting nature can achieve similar results, although many have argued that soothing abstract art can be equally effective. Recognizing the subjective nature of art appreciation, more and more hospitals are offering art carts that allow patients to personally select the art to grace their rooms. Art is also being installed in procedure rooms, particularly on ceilings, to provide a more soothing, less threatening environment and/or serve as a pleasant distraction. Similarly, live music is being used in procedure rooms as well as at the bedside. Music is not just an acoustic pleasantry. One study demonstrated remarkable financial savings when music was played when children underwent diagnostic procedures; cost reductions related to a decreased need for nursing support, decreased need for sedation, and the greater success of the diagnostic procedure itself. Active participation in the arts has also proved useful for patients and families enduring the long confinement of dialysis and other lengthy medical treatments. And applications of the arts are not confined to the interior of medical facilities: Meditative and healing gardens, labyrinths, and sculpture gardens are increasingly being recognized as valuable for providing a welcomed respite for patients, families, and staff alike.

The arts ... are woven into the very fabric of what it is to be human.

The arts and medical treatments The arts also play a role in the active treatment of medical conditions. Dance and movement therapies are being used to increase the mobility of patients with Parkinson’s disease and other conditions that diminish movement. Singing allows patients with aphasia (loss of ability to understand or express speech) an avenue towards speech recovery. Museum visits and art-making are being used as adjunctive approaches to the treatment of patients with Alzheimer’s disease. Art, music, dance, drama, and poetry therapies have all been used to help patients express, reflect

on, and respond to their experiences. Although these creative arts therapies were initially applied as variants of psychotherapy, their use has expanded to treatment of numerous medical conditions. This should come as no surprise; what patient who is dealing with chronic disease is immune from the psychological challenges that derive from physical, social, and occupational impairments? The arts and prevention The field of medicine has increasingly emphasized the importance of efforts aimed at disease prevention, and the arts have a tremendous ability to address this goal. Dancing has been recognized as one of the best ways to fend off cognitive decline and has been proposed as one approach to increase exercise and address the growing obesity epidemic. An interesting variation on the theme, called Conductorcise, is a particularly enjoyable way to combine music appreciation and exercise in a group format. In England, the Get Healthy, Get Singing program uses song and dance to improve selfesteem, combat bullying, and promote healthy eating and exercise in schools. In Africa, art murals educate about disease prevention, and here in Minnesota, painted sidewalks have emphasized safe sex and HIV prevention. Medicine and the arts to page 32

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31


Medicine and the arts from page 31

Clearly, these efforts have great potential to help individuals and communities alike. But art is not limited to addressing the physical needs of the population. Disease trends are often associated with a lack of social cohesion and community health. The arts have a tremendous ability to pull communities together, as exemplified by beaded doll-making in AIDs-ridden villages in Africa and lantern-making in the north of England. The arts and physicians Most physicians entered medical school with some arts experience, such as participation in choirs, orchestras, garage bands, theater, dance, art classes, poetry, or story writing. Medical school matriculation often meant an abrupt end to these creative endeavors in the face of new demands for rigorous study. However, the sacrifice of these creative pursuits may reflect the sacrifice of skills that made these students good candidates for medicine in the first place. Indeed, further exposure to the arts may produce better physicians. For example, training in observational skills and art appreciation has been demonstrated to improve clinical observational skills. Instruction in music appreciation has been shown to improve a physician’s ability to listen through a stethoscope. Narrative medicine is being used to improve the ability of medical students to better understand, appreciate, and articulate their patients’ stories. Theatrical skills are being used to improve communication, empathy, and resilience in medical students. Locally, the University of Minnesota offers a program that encourages medical students to continue in previous creative endeavors or explore new artistic

avenues, in recognition of the value that the arts play in producing well-rounded physicians. The personal costs of burnout, compassion fatigue, and decision fatigue are gaining increasing attention, and discussions of what can help physicians stay resilient are becoming more relevant. The arts provide a way to reflect, engage one’s creativity, and find respite from challenging, hectic lives. There is value for both physicians and patients in reconnecting with their artistic roots and/or developing new creative interests. The arts are a valuable adjunct to patient care as well as self-care. Physicians should be encouraged to learn more about the multifaceted arts in health care movement, which recognizes the power that the arts can play in healing. Two useful resources are the Society for the Arts in Healthcare (www.thesah.org), the largest international organization representing the interests of all who share an interest in arts and health care approaches, and the local Midwest Arts and Healthcare Network (www.maihn.org). Gary A.-H. Christenson, MD, is mental health director for the University of Minnesota’s Boynton Health Service and an adjunct associate professor of psychiatry at the University of Minnesota Medical School. Dr. Christenson is also a Distinguished Fellow of the American Psychiatric Association, president of the Society for the Arts and Healthcare, and former co-chair of the Midwest Arts in Healthcare Network.

Minnesota

Health Care Consumer October survey results... Association

1. Have you, or a member of your family ever had any type of medical device (artificial joint, stent, pacemaker, etc.) surgically implanted?

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

80

50

61.9%

60 50 38.1%

40 30 20

Yes

14.3%

0.0% Very satisfied

Satisfied

14.3% 9.5%

10

0.0% Very satisfied

Does not Unsatisfied Very apply unsatisfied

MINNESOTA HEALTH CARE NEWS NOVEMBER 2011

Does not Unsatisfied Very apply unsatisfied

50 42.9%

40 30 23.8% 20

16.7%

14.3%

10

40 30

28.6% 21.4%

20 10

7.1%

2.4% 0

Satisfied

5. How satisfied have you been with the performance of this device?

Percentage of total responses

Percentage of total responses

Percentage of total responses

32

26.2%

10 0

20

42.9%

40

16.7%

31.0% 30

0

No

50 42.9%

20

45.2%

40

10

4. How would you rate the follow-up care associated with this procedure?

50

30

Percentage of total responses

Percentage of total responses

70

0

3. How satisfied were you with the procedure itself?

2. How satisfied were you with the medical advice leading up to the procedure?

Very satisfied

Satisfied

Does not Unsatisfied Very apply unsatisfied

0

0.0% Very satisfied

Satisfied

Does not Unsatisfied Very apply unsatisfied


Minnesota

Health Care Consumer Association

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

SM

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

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? NOVEMBER 2011 MINNESOTA HEALTH CARE NEWS

33


Palliative care from page 21

care providers, resulting in palliative care services being developed in rural areas of Minnesota. Rural communities currently building palliative care programs include Bemidji, New Ulm, Olivia, Red Wing, Roseau, Staples, Waconia, Wadena, Willmar, and Winona. For more information about palliative care services available in

5. What happens if the pain and symptoms cannot be controlled at home? 6. If my diagnosis or condition changes, will the palliative care team still work with me? 7. What part of the palliative care services will be covered by my insurance? 8. What services will we as a family have to pay for?

Palliative care is medical care for patients with any serious—but not terminal— illness, at any time during the illness. Hospices serve only the terminally ill.

9. Are there any services I am currently receiving that will not be covered under palliative care? Palliative care programs statewide There are palliative care programs available now in many areas of Minnesota. Most larger health systems have in-hospital palliative care programs. More recently, community palliative care programs have been created. Palliative care programs are more readily available in metropolitan areas of Minnesota, such as Minneapolis-St. Paul, Duluth, Rochester, and St. Cloud. Several rural Minnesota communities have begun offering palliative care services as well. Stratis Health and Fairview Health Services’ Palliative Care Program provides assistance to rural health

REGENCY

rural Minnesota communities, visit www.stratishealth.org/expertise/ longterm/palliative.html. With the increasing availability of palliative care programs in Minnesota, patients facing a serious illness should request palliative care because it can help them live better—and possibly longer. Michele Fedderly, EdD, is the executive director of the Minnesota Network of Hospice & Palliative Care, in North St. Paul.

H OSPITAL

OF

M IN N EAPOLI S

Giving People Their Lives Back Regency Hospital of Minneapolis is an intensive critical care hospital serving the needs of medically complex patients that require acute level care for a longer period of time than traditional hospitals are set up to provide. We are a national network of hospitals with a different way of thinking, a different way of caring, and a different way of treating, and it shows in everything we do.

R E G E NC Y PRO G R A M S A N D SE RV IC E S Pulmonary/ventilator program Medically complex/multi-system failure program Wound care program (stage III and IV decubitus) Low-tolerance rehabilitation services Regency Hospital of Minneapolis 1300 Hidden Lakes Parkway Golden Valley, Minnesota 55422 Main: 763.588.2750 Referral: 763.302.8340

34

MINNESOTA HEALTH CARE NEWS NOVEMBER 2011


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Minnesota Health care News November 2011