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MINNESOTA

DECEMBER 2017

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXI, No. 9

Climate change What every physician should know BY MACARAN BAIRD, MD, MS; SHANDA DEMOREST, DNP, RN; RACHEL KERR, RN, OCN; MICHAEL MENZEL, MD; TEDDIE POTTER, PHD, RN, FAAN; PHILLIP PETERSON, MD; WILLIAM O. ROBERTS, MD, MS, FACSM; AND BRUCE D. SNYDER, MD, FAAN

C Empowering patients, protecting choice A legislative response to consolidation in Connecticut BY CHRISTOPHER “KIT” CRANCER

A

sk an elected official or peruse the marketing material of a large health care system or insurer this year, and you will find that the term du jour is “patient empowerment.” A decade ago, when the Affordable Care Act was being debated, it was “patient engagement.” Whatever you call it, the patient (aka, health care consumer) cannot engage easily and certainly is not empowered unless she or he has “choice” in personal health care decisions regarding both clinician preference and costs incurred. While an ambulance ride following an accident does not allow the patient the time for Empowering patients, protecting choice to page 164

hanges in Minnesota’s climate are affecting the health and well-being of everyone living, working, and playing in our state. Climate-related extreme storms, multiple thousandyear flash floods, excessive heat, and drought, disproportionately impact the very young, the elderly, the chronically ill, the impoverished, communities of color, and outdoor workers. Climate change in all its manifestations is a major social determinant of health. What are the responsibilities of Minnesota physicians in the face of this challenge to the health of our patients and their communities? In Climate change to page 184


ANNOUNCEMENT

I CAN DO ADVENTURE The approaching holiday season is about hope, magic and miracles. So too, is Diveheart. The Downers Grove-based not for profit organization provides hope, magic, and even miracles, to individuals with disabilities. Diveheart offers children, veterans and others with disabilities the opportunity to escape gravity through Scuba Therapy. Diveheart participants include individuals with virtually any type of disability including Down syndrome, autism, cerebral palsy, paraplegia, blindness, deafness, spinal cord injuries, traumatic brain injury, post-traumatic stress disorder and more.

HOPE The Diveheart vision is to unleash the unrealized human potential that often exists in individuals with disabilities. The confidence, independence and self-esteem realized by Diveheart participants is tremendous. Diveheart helps individuals focus on what they can do, rather than what they can’t do. MAGIC Diveheart Scuba Therapy helps participants focus on their abilities, rather than their disabilities. This helps them to take on challenges that they may never have taken on before. Furthermore the forgiving, weightless environment of underwater offers buoyancy and balance to individuals who might struggle on land. They’re often able to move in ways that are impossible before joining a Diveheart program. Zero gravity is the great equalizer. MIRACLES Diveheart participants have experienced improved range of motion, ability to focus, pain relief and more. The aspect of pressure while diving provides benefits for people with autism and chronic pain due to spinal cord injuries. Some tell us that after diving, they’re pain free for up to three weeks, often for the first time since their injury. Every one is able to help perpetuate hope, magic and miracles during the holiday season. Your donation helps to make it possible for individuals with disabilities to experience Scuba Therapy, and the resulting benefits so that they might “Imagine the Possibilities” in their lives. Please visit www.diveheart.org/donate/ to learn more about how you can help promote the hope, magic and miracles of Diveheart. Diveheart donations are also accepted at 900 Ogden Ave #274 Downers Grove, Illinois 60515. Jim Elliott Founder & President Diveheart

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DECEMBER 2017 MINNESOTA PHYSICIAN


Do you have patients who struggle with the idea of adding an injectable?

TrulicityÂŽ (dulaglutide) is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe only if potential benefits outweigh potential risks. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease.

Select Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity.

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages and accompanying Brief Summary of Prescribing Information. Please see Instructions for Use included with the 2017 pen. MINNESOTA PHYSICIAN 4 OCTOBER

MINNESOTA PHYSICIAN DECEMBER 2017

3


Preparation2 •

Check the pen to be sure it is not expired, damaged, cloudy, discolored, or has particles in it

Choose an area for injection (abdomen or thigh), being sure to choose a different site (even within area) each week

The key administration steps

Disposal2

2

1

2

3

Uncap the pen

Place and unlock

Press and hold

Dispose of the pen in a closable punctureresistant container and not in household trash

Please review the full Instructions for Use with your patients to ensure they understand how to properly administer Trulicity. Select Important Safety Information •

Trulicity is contraindicated in patients with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2, and in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components.

Cases of medullary thyroid carcinoma (MTC) in patients treated with liraglutide, another GLP-1 RA, have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 RA use in humans. If serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging, the patient should be further evaluated.

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DECEMBER 2017 MINNESOTA PHYSICIAN


Your patients may find the Trulicity Pen easy to use 1

In a study, 99% of patients reported that overall, the Trulicity Pen was easy or very easy to use1

Patients with type 2 diabetes who were naïve to self-injection and injecting others (n=214) participated in a phase 3b, multicenter, open-label, single-arm, outpatient study on the safe and effective use of the Trulicity single-dose pen

The primary objective was to achieve a final injection success rate (proportion of patients who successfully complete injection) significantly greater than 80%

Patients were trained at baseline on proper self-injection technique with the pen

Final injection (4th weekly injection) success was observed in 99.1% [95% CI: 96.6% to 99.7%] (n=209) of patients (primary objective met). Success determined by evaluation of patients’ ability to accurately complete each step in the sequence of drug administration

After the final self-injection, patients completed a 12-item ease of use module (secondary endpoint). 209 (99%) out of 210 patients reported that overall, the single dose pen was “easy” or “very easy” to use

For more information on Trulicity’s simple approach to a patient’s first injection1 visit Trulicity.com/easy

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages and accompanying Brief Summary of Prescribing Information. Please see Instructions for Use included with the pen. MINNESOTA PHYSICIAN DECEMBER 2017

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Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatmentduration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutideinduced rodent thyroid C-cell tumors has not been determined. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components. Risk of Thyroid C-cell Tumors: Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist (GLP-1 RA), have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 RA use in humans. If serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging, the patient should be further evaluated. Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected, discontinue Trulicity promptly. Do not restart if pancreatitis is confirmed. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia. Hypersensitivity Reactions: There have been postmarketing reports of serious hypersensitivity reactions (eg, anaphylactic reactions and angioedema) in patients treated with Trulicity. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice. Use caution in a patient with a history of angioedema or anaphylaxis with another GLP-1 receptor agonist as it is unknown whether they will be predisposed to anaphylaxis with Trulicity. Renal Impairment: In patients treated with GLP-1 RAs, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions.

PP-DG-US-1092

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DECEMBER 2017 MINNESOTA PHYSICIAN

09/2017

Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity. The most common adverse reactions (excluding hypoglycemia) reported in ≥5% of Trulicity-treated patients in placebo-controlled trials (placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%). Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree. Pregnancy: Limited data with Trulicity in pregnant women are not sufficient to determine a drug-associated risk for major birth defects and miscarriage. Based on animal reproduction studies, there may be risks to the fetus from exposure to dulaglutide. Use only if potential benefit justifies the potential risk to the fetus. Lactation: There are no data on the presence of dulaglutide in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Trulicity and any potential adverse effects on the breastfed infant from Trulicity or from the underlying maternal condition. Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age. Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen. DG HCP ISI 06FEB2017 Trulicity® is a registered trademark owned or licensed by Eli Lilly and Company, its subsidiaries, or affiliates. Trulicity is available by prescription only. Other product/company names mentioned herein are the trademarks of their respective owners. References 1. Matfin G, Van Brunt K, Zimmermann AG, et al. Safe and effective use of the once weekly dulaglutide single-dose pen in injection-naïve patients with type 2 diabetes. J Diabetes Sci Technol. 2015;9(5):1071-1079. 2. Trulicity [Instructions for Use]. Indianapolis, IN: Lilly USA, LLC.

©Lilly USA, LLC 2017. All rights reserved.


Trulicity® (dulaglutide) Brief Summary: Consult the package insert for complete prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS • In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. • Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity.

Trulicity and other suspected medications and promptly seek medical advice. Use caution in a patient with a history of angioedema or anaphylaxis with another GLP-1 receptor agonist because it is unknown whether such patients will be predisposed to anaphylaxis with Trulicity. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity. ADVERSE REACTIONS

Risk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. Glucagon-like peptide (GLP-1) receptor agonists have induced thyroid C-cell adenomas and carcinomas in mice and rats at clinically relevant exposures. It is unknown whether Trulicity will cause thyroid C-cell tumors, including MTC, in humans, as the human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. One case of MTC was reported in a patient treated with Trulicity. This patient had pretreatment calcitonin levels approximately 8 times the upper limit of normal (ULN). Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist, have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 receptor agonist use in humans. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the potential risk for MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Such monitoring may increase the risk of unnecessary procedures, due to the low test specificity for serum calcitonin and a high background incidence of thyroid disease. Significantly elevated serum calcitonin value may indicate MTC and patients with MTC usually have calcitonin values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be further evaluated. Patients with thyroid nodules noted on physical examination or neck imaging should also be further evaluated. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitis-related adverse reactions were reported in patients exposed to Trulicity versus 3 in non-incretin comparators (2.7 cases per 1000 patient years). An analysis of adjudicated events revealed 5 cases of confirmed pancreatitis in patients exposed to Trulicity (1.4 cases per 1000 patient years) versus 1 case in non-incretin comparators (0.88 cases per 1000 patient years). After initiation of Trulicity, observe patients carefully for signs and symptoms of pancreatitis, including persistent severe abdominal pain. If pancreatitis is suspected, promptly discontinue Trulicity. If pancreatitis is confirmed, Trulicity should not be restarted. Trulicity has not been evaluated in patients with a prior history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia with Concomitant Use of Insulin Secretagogues or Insulin: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia in this setting. Hypersensitivity Reactions: There have been postmarketing reports of serious hypersensitivity reactions (e.g., anaphylactic reactions and angioedema) in patients treated with Trulicity. If a hypersensitivity reaction occurs, the patient should discontinue

Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg): nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions: In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 42% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and active-controlled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia: Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials: Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), Trulicity 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5 mg: 5.0%; Severe: all 0. Add-on to Glimepiride at 24 weeks, Placebo (N=60), Trulicity 1.5 mg (N=239), Documented symptomatic: Placebo: 1.7%, 1.5 mg: 11.3%; Severe: all 0. Add-on to Insulin Glargine with or without Metformin at 28 weeks, Placebo (N=150), Trulicity 1.5 mg (N=150), Documented symptomatic: Placebo: 30.0% 1.5 mg: 35.3%; Severe: Placebo: 0% 1.5 mg: 0.7%. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. In a 78-week clinical trial documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented

Trulicity® (dulaglutide)

Trulicity® (dulaglutide)

INDICATIONS AND USAGE Trulicity® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe Trulicity only to patients for whom the potential benefits outweigh the potential risk. Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not recommended in patients with pre-existing severe gastrointestinal disease. CONTRAINDICATIONS Do not use in patients with a personal or family history of MTC or in patients with MEN 2. Do not use in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components. WARNINGS AND PRECAUTIONS

DG HCP BS 10FEB2017 7 x 9.5

Trulicity, DG HCP BS 10FEB2017 7 x 9.75

DG HCP BS 10FEB2017 7 x 9.5

PRINTER VERSION 1 OF 2 MINNESOTA PHYSICIAN DECEMBER 2017

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Trulicity® (dulaglutide) Brief Summary: Consult the package insert for complete prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS • In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. • Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity.

ADVERSE REACTIONS

Risk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. Glucagon-like peptide (GLP-1) receptor agonists have induced thyroid C-cell adenomas and carcinomas in mice and rats at clinically relevant exposures. It is unknown whether Trulicity will cause thyroid C-cell tumors, including MTC, in humans, as the human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. One case of MTC was reported in a patient treated with Trulicity. This patient had pretreatment calcitonin levels approximately 8 times the upper limit of normal (ULN). Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist, have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 receptor agonist use in humans. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the potential risk for MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Such monitoring may increase the risk of unnecessary procedures, due to the low test specificity for serum calcitonin and a high background incidence of thyroid disease. Significantly elevated serum calcitonin value may indicate MTC and patients with MTC usually have calcitonin values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be further evaluated. Patients with thyroid nodules noted on physical examination or neck imaging should also be further evaluated. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitis-related adverse reactions were reported in patients exposed to Trulicity versus 3 in non-incretin comparators (2.7 cases per 1000 patient years). An analysis of adjudicated events revealed 5 cases of confirmed pancreatitis in patients exposed to Trulicity (1.4 cases per 1000 patient years) versus 1 case in non-incretin comparators (0.88 cases per 1000 patient years). After initiation of Trulicity, observe patients carefully for signs and symptoms of pancreatitis, including persistent severe abdominal pain. If pancreatitis is suspected, promptly discontinue Trulicity. If pancreatitis is confirmed, Trulicity should not be restarted. Trulicity has not been evaluated in patients with a prior history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia with Concomitant Use of Insulin Secretagogues or Insulin: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia in this setting. Hypersensitivity Reactions: There have been postmarketing reports of serious hypersensitivity reactions (e.g., anaphylactic reactions and angioedema) in patients treated with Trulicity. If a hypersensitivity reaction occurs, the patient should discontinue

Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg): nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions: In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 42% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and active-controlled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia: Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials: Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), Trulicity 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5 mg: 5.0%; Severe: all 0. Add-on to Glimepiride at 24 weeks, Placebo (N=60), Trulicity 1.5 mg (N=239), Documented symptomatic: Placebo: 1.7%, 1.5 mg: 11.3%; Severe: all 0. Add-on to Insulin Glargine with or without Metformin at 28 weeks, Placebo (N=150), Trulicity 1.5 mg (N=150), Documented symptomatic: Placebo: 30.0% 1.5 mg: 35.3%; Severe: Placebo: 0% 1.5 mg: 0.7%. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. In a 78-week clinical trial documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented

Trulicity® (dulaglutide)

Trulicity® (dulaglutide)

INDICATIONS AND USAGE Trulicity® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe Trulicity only to patients for whom the potential benefits outweigh the potential risk. Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not recommended in patients with pre-existing severe gastrointestinal disease. CONTRAINDICATIONS Do not use in patients with a personal or family history of MTC or in patients with MEN 2. Do not use in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components. WARNINGS AND PRECAUTIONS

DG HCP BS 10FEB2017 7 x 9.5

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Trulicity and other suspected medications and promptly seek medical advice. Use caution in a patient with a history of angioedema or anaphylaxis with another GLP-1 receptor agonist because it is unknown whether such patients will be predisposed to anaphylaxis with Trulicity. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity.

DECEMBER 2017 MINNESOTA PHYSICIAN

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PRINTER VERSION 1 OF 2


TH 49 SESSION DECEMBER 2017

|

THE OPIOID EPIDEMIC:

Volume XXXI, Number 9

COVER FEATURES Empowering patients, protecting choice A legislative response to consolidation in Connecticut

Climate change What every physician should know

Complex problems, complex solutions

By Macaran Baird, MD, MS; Shanda Demorest, DNP, RN; Rachel Kerr, RN, OCN; Michael Menzel, MD; Teddie Potter, PhD, RN, FAAN; Phillip Peterson, MD; William O. Roberts, MD, MS, FACSM; and Bruce D. Snyder, MD, FAAN

By Christopher “Kit” Crancer

DEPARTMENTS CAPSULES

10

MEDICUS

13

INTERVIEW

14

Caring for high-risk patients

Marc Manley, MD, MPH, Hennepin Health

WELLNESS AND PREVENTION

32

Racial disparities in nursing homes Findings and implications By Tetyana Pylypiv Shippee, PhD

22

The Aging Mastery Program

24

A playbook for living well By Hayoung Kye, MSW; Emily McDonald, MSW; and Zane Bail, MA

26

Minnesota Senior Health Options Better health outcomes for low-income seniors By Lauren Siegel, MSW, MPP; Sue Kvendru, BS; Kathy Albrecht, MSW, LISW; Heather A. Goodwin, BA; and Susan Oestreich, RN, BSN, CCM

Ensuring patient preference in a skilled nursing facility By Emily Black, RN, MSN, CNP, FNP-BC, and Ashley Kimeu, RN, MSN, CNP, ANP-C, GNP-C, ACHPN

PROFESSIONAL UPDATE: NEUROLOGY The EyeBOX A new way to assess neurologic function By Uzma Samadani, MD, PhD, FACS, FAANS

We will examine how the opioid epidemic began. We will discuss the elements of mistrust, blame, and miscommunication within the health care delivery system that were responsible for the staggering levels of destruction we face today. Meeting every definition of an epidemic, we will look at how this issue reaches into all parts of society. We will lay out a strategy that can address the central problems in bringing the opioid epidemic under control.

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WWW.MPPUB.COM ______________________________________________________________

Medicine is a field that changes slowly, but in the case of prescribing opioid-based pain medications, the speed of change was unprecedented. It has produced tragic outcomes. Two examples are the number of Americans now suffering from opioid-related substance abuse disorder (over 2 million) and the number of opioid-related deaths (over 50,000 annually, and growing). We are facing a complex problem, created by conflicting industry incentives and one that will demand unified stakeholder participation to solve.

Objectives: 28

Advanced care planning

The Gallery, Downtown Minneapolis Hilton and Towers

Background and focus:

SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

PUBLISHER

Thursday, April 26th, 2018, 1-4 pm

Medicare wellness visits The value to the patient, public, and provider By Kathleen Y. Keller, MAN, RN, CNE, and David P. Ingham, DO

Mike Starnes, mstarnes@mppub.com

EDITOR________________________________________________ Lisa McGowan, lmcgowan@mppub.com ASSOCIATE EDITOR_____________________________ Richard Ericson, rericson@mppub.com ART DIRECTOR_______________________________________________Scotty Town, stown@mppub.com OFFICE ADMINISTRATOR______________ Amanda Marlow, amarlow@mppub.com ACCOUNT EXECUTIVE_______________________________ Shawn Boyd, sboyd@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; email mpp@mppub.com; phone 612.728.8600; fax 612.728.8601. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub.com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX Card #  Check enclosed  Bill me

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Health Licensing Boards Implement Criminal Background Check Program The Minnesota Health Licensing Boards have cooperatively established the Criminal Background Check Program to help new applicants for licensure efficiently complete the mandatory fingerprint-based criminal background check now required by Minnesota law. Mandatory criminal background checks for professionals regulated by the Minnesota Board of Medical Practice will be implemented in phases—on Nov. 10 for acupuncturists, traditional midwives, and respiratory therapists; on Nov. 17 for physician assistants; and Dec. 1 for physicians, surgeons, and genetic counselors. After applicants have applied for licensure and paid all the required fees, they will be mailed a packet

containing additional information from the Criminal Background Check Program. It is then their responsibility to have their fingerprints taken and to complete all required paperwork.

Three Organizations Partner to Form Carris Health ACMC Health, CentraCare Health, and Rice Memorial Hospital are collaborating to create a new entity called Carris Health that will serve as a health care hub serving West Central and Southwest Minnesota.

Initial discussions about the partnership began in May, when the organizations signed a letter of intent to join forces. After months of discussion, strategy meetings, and town hall meetings, the Willmar city council voted unanimously to approve plans for the city-owned Rice Memorial Hospital to join the new health care system on Nov. 20 and

ACMC Health’s board of directors and its 89 physician shareholders also voted to proceed with the integration with a final decision made at a shareholder’s meeting, also on Nov. 20. Carris Health will be a subsidiary of CentraCare Health. According to the agreement, Rice Memorial Hospital will retain its name and its assets will continue to be owned by the City of Willmar. Carris Health will lease it for a total of 60 years and the 100-bed hospital’s more than 1,300 staff and physicians will become employees of Carris Health. The new entity will make a capital investment of at least $32 million in Rice Memorial Hospital during the first decade of the lease. The 174 employees of Willmar Medical Services, a joint venture between the hospital and ACMC Health, also will become employees of Carris Health. Through its separate agreement, ACMC Health will become part of

Carris Health. Operations at its 10 clinics and two ambulatory surgery centers will continue and its 955 employees will become employees of Carris Health. The organizations intend to finalize the agreements in 2018, when the formation of Carris Health will begin. Integration will take place over the next several months.

MHA Study Projects Physician Shortage A new study conducted by the Minnesota Hospital Association (MHA) has confirmed that a shortage of primary care physicians will develop in the state over the next decade. MHA collects health care workforce data from most Minnesota hospitals each year and this year, for the first time, MHA called on Towers Watson, a global professional services company, to conduct a

invites you to:

The Importance of Independent Physician Practice

Thursday, January 18, 2018 · 1:00 – 4:00 p.m · Radisson Roseville ·2540 Cleveland Ave, Roseville, MN

(35 W at County Road C)

We invite physicians and their managers, elected officials and their staff, employer/purchasers and others interested in the effects of over consolidation on patients and their physicians. 1:00-1:30 – Opening remarks: The Joys and Challenes of Independent Practice Eric Becken, MD – Midwest ENT, Chairman-Collaborative Care Cooperative

1:30 – 2:30: Connecticut’s Journey to reform its consolidated delivery system How over consolidation of a healthcare marketplace reached a tipping point and has required multiple legislative afforts to correct Dina Berlyn, J.D. – Counsel to Connecticut State

2:30-3:00: The challenges of payer contracting as an independent physician Properctives from Greater Minnesota line for speaker (s) IntegrityHealth network 3:00 – 3:45: Panel discussion: What can be done in Minnesota to improve the environment for independent providers key elected officials and physician leaders and Connecticut guests 3:45 – 4:00: Concluding remarks: Moving forward Eric Becken, MD – Midwest ENT, Chairman-Collaborative Care Cooperative

Senate Preident Pro Tempore

Jennifer Macierowski, J.D. – Chief Counsel and Director of Research, Senate Republican Office

10

DECEMBER 2017 MINNESOTA PHYSICIAN

Registration is required: Contact Annatiese.Minette@cdirad.com 952.738.4693 to register.


CAPSULES

comprehensive review of the state of the primary care physician and registered nurse workforces in Minnesota. The company used publicly available data from the Bureau of Labor Statistics and the state of Minnesota in addition to the hospital workforce data provided to MHA. “The current pipeline of graduates appears adequate to replace retirements as they occur. That, coupled with projected increases in demand because of an aging population, will result in a significant talent gap for physicians,” the review concluded. Specifically, a cumulative shortfall of nearly 850 primary care physicians is projected for the Minnesota workforce by 2024 due to the lack of annual growth in Minnesota’s graduate medical education programs, including residency or clinical training positions. The study showed that the number of openings for residency programs has been frozen since 1996. However, the supply of registered nurses will likely meet the demand, assuming that education programs continue to grow at their expected rate. In response to the findings, MHA is urging federal and state policy makers to lift the 17-year freeze on the number of physician residency positions available under Medicare funding; oppose cuts to federal Graduate Medical Education Funding; develop a statewide health care workforce plan; seek ways to increase funding of Minnesota’s Medical Education and Research Costs program; and support development of new primary care models, including telehealth technology. In addition, MHA is encouraging the Minnesota Department of Human Services to implement temporary payment increases for primary care services delivered to Medicaid patients as called for under federal law. “Many of our hospitals, especially those in greater Minnesota, already have difficulty attracting physicians,” said Lawrence J. Massa, president and

SINCE 1894 tradition of caring CEO of MHA. “I hope this new inforenrichingLIFE SINCE 1894 mation will provide an impetus to polibuildingCOMMUNITY feel atHOME cy makers to make the urgent decisions The STRENGTHEN enrichingLIFE needed on both the state and federal Transitional levels to give our health professional HEART ENGAGE buildingCOMMUNITY students access to the clinical training SINCE 1894buildingCOMMUNIT and residency experience they need to tradition of CARING HEART atHOME become licensed to practice.” enrichingLIFE feelatCenter

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Allina Health, HealthPartners Partnership Improves Care, Lowers Costs

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An analysis of the Metro Alliance, an accountable care organization (ACO) partnership between Allina Health and HealthPartners, has shown that health care costs in Anoka and southern Sherburne counties are increasing at a slower pace than the metro area average. The ACO serves a community of about 600,000 people who receive care at Allina Health and HealthPartners clinics and Mercy Hospital. An executive summary of the first seven years of the partnership shows that costs rose on average by less than 3 percent per year, compared to a more than 8 percent increase in the year before it began. The health care systems attribute the reduction in annual cost increases to care improvements such as reducing hospital readmissions, increased use of generic medications, and expanded access to outpatient mental health care. Since the partnership began, the rate of preventable readmissions decreased by more than 25 percent, saving about $11,220 to $13,000 per readmission, and prescriptions for generic medications have increased from 75 percent to 91 percent, saving an estimated $3.4 million per year in drug costs. The Alliance also opened a short-term residential facility for mental health with 16 beds and expanded Mercy Hospital’s partial hospital day-treatment mental health program to serve more than 4,500 patients per year,

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MINNESOTA PHYSICIAN DECEMBER 2017

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CAPSULES

helping offset the more than 5,000 visits to the Mercy Hospital emergency department each year. The Alliance continues through 2019, with an opportunity to extend the partnership.

University of Minnesota Launches Team to Address Health Disparities The University of Minnesota Medical School has opened its new Memory Keepers Medical Discovery Team (MDT), a space designed to research health disparities affecting Native American and rural communities, particularly the prevalence of dementia and diabetes among Native Americans. The team is based at the University of Minnesota’s Duluth campus, but is located in the city’s medical district due to space constraints on the campus.

The state-funded initiative is the first project launched by the Medical School after an investment by the state Legislature in 2014 to increase the prestige of the medical school. It aims to develop interventions and research to meet the challenges of health disparities among people who live in rural areas, and is focused specifically on vascular dementia in tribal communities and preserving brain health by the improved understanding of dementia and diabetes. Because rural populations are also plagued by dementia and diabetes, the team will develop interventions and research to meet the challenges of health disparities among people living far from the resources of urban population centers. The name was chosen because in Native American culture, memory keepers are traditionally elders of the tribe who preserve sacred songs and stories. By preventing

and helping people manage diabetes, the risk of vascular and other dementias that rob people of their memory can be reduced. It also features culturally related items and symbolism, including a medicine wheel table and a separately ventilated ceremonial room where sage can be burned safely. “We’re not finished,” said Neil Henderson, PhD, executive director of Memory Keepers MDT and a member of the Choctaw Nation of Oklahoma. “This is just the start, and we look forward to developing connections with the native populations here through this unique opportunity to improve rural health.”

Opioid Prescription Limits Recommended for Physicians Minnesota’s Opioid Prescribing Work Group adopted a new rule on

Nov. 16 that limits opioid prescriptions for doctors who participate in the state’s Medicare program. It requires approval by Minnesota human services commissioner Emily Piper before it will take effect. The rule states that nonsurgical physicians and dentists can have no more than half of their opioid prescriptions exceed 100 morphine milligram equivalents, which is about 20 five-milligram Vicodin or Percocet pills. Surgeons can have no more than 200 morphine milligram equivalents per outpatient prescription. The limits only apply to out-patient prescriptions meant to manage shortterm or acute pain. Those who exceed the new limits for more than half of their patients will receive warnings and go through training to help them get on track. If they don’t reduce their dosage amounts, they could face being removed from the Medicaid program.

V PTSD is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year • Intractable Pain • Post-Traumatic Stress Disorder

• Severe and persistent muscle spasms, including those characteristic of MS

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS

(651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

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DECEMBER 2017 MINNESOTA PHYSICIAN

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis


MEDICUS

Anne Bantle, MD, an assistant professor of medicine in the division of endocrinology, diabetes, and metabolism at the University of Minnesota Medical School, has received the 2017 Early Investigators Award from the Endocrine Society in recognition of having conducted outstanding endocrine research early in her career. She is one of 22 award recipients across the U.S. Bantle’s research focuses on therapies for the management of type 2 diabetes and the effect of the gut microbiome on human metabolism. Bantle earned her medical degree from the University of Minnesota Medical School and completed residency training and chief residency in Internal Medicine at the University of Vermont. She returned to the University of Minnesota for fellowship training in 2016.

– Jan 1 Nov 25 A Minnesota Orchestra Christmas: Home for the Holidays

Leif Solberg, MD, senior research investigator and senior adviser at HealthPartners Institute, is one of 80 new members that have been elected to the National Academy of Medicine in recognition of their outstanding professional achievement and commitment to service. He is the only new member from Minnesota. Solberg’s research focuses on quality measurement and improvement and organizational change, especially for chronic disease care and clinical preventive services delivery, as well as primary care redesign/medical home. He has been the principal investigator or co-principal investigator on many large National Institutes of Health/Agency for Healthcare Research and Qualityfunded research grants, and has published more than 240 research papers as well as 32 books and book chapters. He earned his medical degree at the University of Minnesota Medical School. Patrick Flynn, MD, director of research for Minnesota Oncology, has received the 2017 Harry Hynes Award from the Metro-Minnesota chapter of the National Cancer Institute Community Oncology Research Program (NCORP), a National Cancer Institute (NCI) supported network that brings cancer prevention clinical trials and cancer care delivery research to people in their communities. NCORP describes him as a visionary investigator who built a practice with more than 140 researchers and 50 research staff. He began the discussion about insurance coverage years ago and successfully engaged insurers in his community to support clinical trials. Flynn also serves as medical director for autologous bone marrow and stem cell transplants at Abbott Northwestern Hospital and is a principal investigator for the NCI grant-funded Metro-Minnesota Community Oncology Research Consortium. He earned his medical degree at the University of Minnesota Medical School. Scott Bartley, MD, a board-certified nuclear medicine physician, has been appointed as chief of staff at the St. Cloud VA Health Care System. He has been serving as the acting chief of staff since mid-June. Before stepping into that role, he served as associate chief of staff/education and chief of imaging. Bartley’s previous experience includes acting chief of staff and deputy chief of staff at the VA Tennessee Valley Health Care System and a detail to the assistant deputy undersecretary for health operations and management, clinical operations in Washington DC. He earned his medical degree from St. George’s University School of Medicine in Grenada, West Indies. He remains an active professional member of the Society of Nuclear Medicine and Molecular Imaging, the American College of Nuclear Medicine, and the AMA CPT and RUC Committees.

Merry and Bright

A New Year Celebration: Tchaikovsky Piano Concerto No. 1 An Evening with George Winston

Rufus Wainwright with the Minnesota Orchestra

A Christmas Oratorio

612-371-5656 / minnesotaorchestra.org / Orchestra Hall HARRY POTTER characters, names and related indicia are © & ™ Warner Bros. Entertainment Inc. J.K. ROWLING`S WIZARDING WORLD™ J.K. Rowling and Warner Bros. Entertainment Inc. Publishing Rights © JKR. (s17). The Little Mermaid: Presentation licensed by Disney Concerts © All Rights Reserved. Photo credits available online.

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MINNESOTA PHYSICIAN DECEMBER 2017

13


INTERVIEW

Caring for high-risk patients Marc Manley, MD, MPH, Hennepin Health

Metropolitan Health Plan was established in 1984 by Hennepin County as a licensed Managed Care Organization. In 2011, the plan joined with three other county health organizations to launch Hennepin Health. Those partners are Hennepin County Medical Center (HCMC), NorthPoint Health and Wellness Center, and the Hennepin County Department of Human Services and Public Health. The partnership brought together the expertise of health care delivery systems, a health care finance organization, and a public health and human services organization. Together, these organizations launched an accountable care organization that focused specifically on Hennepin County residents newly eligible for Medicaid under the Affordable Care Act. Originally this organization was designated a demonstration project and enrolled only adults without children, but in 2016 we were successful in winning a contract with DHS as one of four health plans offering a Medicaid product in Hennepin County. With that award, we expanded our membership to include low-income families with children. Hennepin Health has focused most on high-risk patients by addressing their medical, behavioral health, and social service issues. Many people may not understand the wide range of health care that Hennepin Health provides. Could you provide more details?

Hennepin Health provides the full array of health and dental services to people who receive Medicaid benefits. Many of our members receive care for mental health issues and chemical dependency. In addition, we help people get connected to a variety of social services, including housing, food, transportation, job training, and income support. Hennepin Health offers three basic products: PMAP, MNCare, and SNBC. How do they differ?

These are three of the products offered through the Minnesota Department of Human Services. PMAP provides health benefits for people with a household income below 133 percent of the federal poverty level (the cut-off value for household income is somewhat higher for children and

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DECEMBER 2017 MINNESOTA PHYSICIAN

pregnant women). Minnesota Care is for people with an income between 133 percent and 200 percent of poverty. SNBC provides benefits for lowincome adults with disabilities.

or substance abuse disorders, as well as physical illnesses. This kind of patient population needs help from a diverse team of professionals who are willing to work through big challenges every day. Coordinating the care for their diverse needs requires strong communication between different types of care providers. And it requires our health care system to be effective at addressing patients’ non-medical issues, such as housing and food, as essential to their survival and health. Another challenge we face is the uncertainty about funding for health care in general and Medicaid specifically. Continued attacks on Medicaid at the federal level create uncertainty for our organization and fear among our members. Here in Minnesota, funding for Medicaid continues to be tightly managed, and the limitations on our resources are apparent every day. How can physicians help support the work you are doing?

Health care for low-income, “...” high-risk individuals can be provided economically and effectively.

“...”

Please tell us about the history of Hennepin Health, from its original mission and work as Metropolitan Health Plan (MHP) to today.

How do you interact with other Minnesota counties and other states with programs serving the same population you serve?

Because of our unique approach to this complex group of patients, Hennepin Health has received recognition at the state and national level. There has been extensive interest in our approach from organizations around the state and the country. We’ve conducted site visits so that others can learn from us, published papers about our work, and maintained contact with a variety of other groups. We also are a member of a national organization of Medicaid plans, which includes a wide variety of organizations and plan types. This allows us to learn from other organizations that face similar challenges. What are the biggest challenges you face improving an increasingly diversified benefit set to an increasingly large population?

Some of the challenges we face exist because we serve a complex group of people. Many of our members are homeless or have mental illnesses

Physicians can help in many ways. One way is by simply accepting Medicaid patients into your practice. Another way to support our work is to speak up to support and protect the public resources that fund health and social services for low-income people. For many, their very lives depend on services related to housing, food, safety, and health care. What are the biggest problems you have communicating with the population you serve?

In general, our population is very challenging to reach. Because many of them have unstable housing, mail often doesn’t reach them. For financial or other reasons, they may not have access to a phone either. When we need to reach specific individuals, we sometimes have to go and find them, and that can be a challenge in itself. We do see many of our members in our own downtown Minneapolis office. Each month we have over 1,000 member visits in-person to our office because people seek help directly from us. Please share some of the success stories the programs you oversee have generated.

In the early years of Hennepin Health, great strides were made in developing a common


platform for communications in EPIC. Through EPIC, medical staff can communicate with social services staff and the health plan about the needs and progress of patients. Another early development was a multi-disciplinary open access clinic only for Hennepin Health members that addressed their needs, whether they’re medical, behavioral, or social. Another critical area of work was the linking of care coordinators across the system, to make sure high-risk patients got the care they needed. Hennepin Health also addresses social determinants of health that impact health and health care costs. Housing is a critically important issue for many of our members. Hennepin Health social service navigators have worked tirelessly to find housing for our high-risk members and documented the value of providing housing for this population. Every year Hennepin Health also supports innovative projects to address the needs of our members. Funds are set aside to test new ideas for improving care and to make needed changes to the functions of our ACO. One project that proved very successful was a program to better address the health care needs of people staying in a large shelter for homeless people in Minneapolis. We discovered that this population was receiving fragmented care for routine medical problems by using emergency departments

as their source of care. Hennepin County Medical Center community paramedics were placed onsite in the shelter during evening and night hours. The community paramedics were able to help with basic medical needs onsite. As a result, far fewer shelter users had to be hospitalized or required emergency care. What are the most important things you want people to know about Hennepin Health?

There are a number of important lessons to take away from the experiences of Hennepin Health in its first five years. First and foremost, we’ve shown that health care for low-income, highrisk individuals can be provided economically and effectively. We’ve also shown that certain social issues (the so-called social determinants of health) can also be addressed through Medicaid, and in fact they must be addressed in order to improve health. We’ve also shown that with the right players at the table and the right infrastructure to support communication between the players, social and behavioral care can be integrated into medical care, with improved results for patients. What does the future hold for Hennepin Health?

and sometimes we see people pushing for changes they don’t necessarily understand. I spent many years working in Washington—long enough to see both informed and competent legislation and some disasters. I always remain optimistic that our leaders will eventually get it right, even if there are a few wrong turns along the way. For Hennepin Health, our ability to provide care depends on a commitment to adequate funding for health care and social services for low-income populations. The Affordable Care Act provided that funding, and so far it has survived. If that funding continues under any name, I’m confident that Hennepin Health will continue to provide the care people need and be a laboratory for testing new ways to provide that care for people with complex needs. Marc Manley, MD, MPH, is the chief medical officer at Hennepin Health. He has also held leadership roles at the National Cancer Institute and Blue Cross Blue Shield of Minnesota. Dr. Manley received his medical degree from the University of Washington and his master’s degree from Johns Hopkins University.

It’s a scary time to predict the future. Health care has become a partisan political issue in Washington,

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3Empowering patients, protecting choice from cover

hospitals, and out-of-state experts. Among other things, the roundtable identified rapid change in the state’s delivery system: hospitals were consolidating and purchasing physician practices resulting in large health much choice, the vast majority of other health care services can and should systems with increasing market power. In fact, it was found that one system in be ones where the patient is empowered to make reasonable decisions. Connecticut was receiving nearly one-third of all hospital revenue and almost Thinking and working together on a bipartisan basis, the Connecticut 40 percent of all industry profits. As a result, lower cost General Assembly identified the “choice in care” providers, including community hospitals, were being issue as key to rebalancing a health care delivery squeezed out of the market or acquired by large health system (see the sidebar, “A healthy health care systems, which often reduced community services. In marketplace”) that they judged to be significantly addition, the Connecticut roundtable identified that imbalanced. More than any other state in the past The primary motivation consumers lacked the provider transparency tools few years, Connecticut has purposely not waited for behind consolidation required for them to make value-based decisions with Washington, D.C. to deliver solutions. Instead, key and physician practice respect to their health care, and providers lacked the policymakers have collectively plowed ahead with acquisitions was monetary. interoperability to exchange records thereby “fencing” small and large reforms. Connecticut has borrowed patients into one system. The consequence of these and built on ideas from Minnesota and other states changes is that patients are denied viable choices and and would like to share its efforts with those states are far from being empowered. experiencing cost increases caused by the changing health care landscape. This article provides a Motivation behind provider consolidation summary of those significant efforts. The roundtable found that the primary motivation behind consolidation

Studying the health care landscape In the face of skyrocketing health care costs and a potential and troubling incursion by for-profit hospitals, Connecticut State Senate President Pro Tempore Martin Looney (Democrat) and Senate Republican President Pro Tempore Len Fasano (Republican) established a bipartisan roundtable in 2014 to study the causes of cost increases and consider potential reforms. The roundtable included policymakers and a variety of health care providers,

Creating rural healthcare leaders

Policymakers take action The result of these hearings was SB 811 (Public Act 15-146) that enacted broad reforms of Connecticut’s health care system in 2015. The bill, which passed with wide bipartisan support, contained the following reforms:

Rural Healthcare MBA

• Disclosed facility fees on patient statements including requiring a statement that patients might have paid less if the services were provided at a facility not owned by a hospital;

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• Notified patients when hospitals purchase a physician practice or medical facility if the purchase is likely to result in charging facility fees;

• Online, accelerated eight-week terms

• Defined interference in the electronic and secure transfer of health records (“health information blocking”) as an unfair trade practice;

• Complete in 2 years

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16

and physician practice acquisitions was monetary—driven by reimbursement policies and a desire to enhance bargaining power. Between facility fees and higher reimbursement rates, when a physician practice is acquired by a hospital, costs for the very same care, provided in the same location, go up dramatically. For example, it was found that a consumer undergoing chemotherapy saw the charge for a routine injection go from $2,500 to almost $12,000 after the practice was purchased by a hospital, with a corresponding increase in his out-of-pocket costs. Additionally, the group’s study found examples where electronic health record systems, often built with the help of federal funds, were frequently being used by health systems as a means to gain leverage over potential acquisitions and increase market share.

DECEMBER 2017 MINNESOTA PHYSICIAN

• Banned facility fees for many outpatient visits; • Established new rules for the approval of hospital sales and increased scrutiny for hospitals that could potentially be purchased by for-profit companies or large health systems;

• Created the foundation for a statewide health information exchange. The exchange, although still under development, is intended to act as a resource for all providers to securely share relevant patient records and pertinent health information. Unlike health exchanges in other states, the Legislature intends to compel large systems to participate in the exchange and share information with other providers that they may not normally be willing to connect with;


COMMUNITY C AREGIVERS

A healthy health care marketplace The Minnesota Department of Health recently reported that the number of hospital-employed physicians has been steadily increasing in Minnesota and nationally—and so have health care costs. The correlation between hospital physician employment and cost increases was documented in a recent study from Avalere Health. The study shows that the 49 percent increase in hospital-employed physicians between 2012 and 2015 has led to a $3.1 billion increase in Medicare costs for four common procedures in cardiology, orthopedics, and gastroenterology. While the primary role of physicians is to provide high-quality care they must also be involved in containing costs and providing high-value care. Continued consolidation of health care providers may make the health care delivery system less patient focused and unable to respond to changing patient needs. In a patient-centered health care delivery system patients need to be empowered to select clinicians based on both quality and cost factors as defined by the patient and, their insurer. As most hospital employees are financially or otherwise incented to “keep” patients within the hospital system, it sometimes causes a tug-of-war for the patient who wants to see a non-hospital physician. The reasons for seeking an outside provider are varied and include access, quality, past patient-physician relationships, cost difference, geographic convenience, or even free parking. Health policy leaders have promised a great deal about engaging and empowering patients. However, nothing could be further from reality when a patient is fenced in “electronically” because a hospital employee says that health records won’t be complete if the patient doesn’t accept the in-hospital system referral or the hospital-employed provider refuses to provide a referral to a non-hospitalbut-patient-preferred and qualified physician. A healthy health care marketplace must include a mix of independent, group, and hospital-based physicians to foster an environment where innovation, customer service, and cost containment reign and electronic medical record administrators seek secure interoperability with other federally certified electronic platforms. Independent practicing physicians understand that both state and federal regulations continue to push for more consolidation, which contradicts policy leaders’ quest for patient engagement and cost containment. A failure to empower patients has consequences that harm our patients and our communities. The Collaborative Care Cooperative, whose members are independent medical specialty groups, has wrestled with how to affect public policy and inform influencers, while protecting our patients. We have invited two legislative attorneys from Connecticut to speak to physician and legislative influencers in Minnesota regarding that state’s struggles to give more empowerment to their citizens, while implementing cost containment strategies. Connecticut’s efforts are both fascinating and revealing. The event, “The Importance of Independent Physician Practice” will be on Thursday, January 18 from 1–4 p.m., at the Radisson in Roseville. More information is available by calling (952) 738-4693.

REQUEST FOR NOMINATION Publication Date: March 2018

Recognizing Minnesota physician volunteers Minnesota Physician Publishing announces our annual Community Caregivers feature. We are seeking nominations of Minnesota physicians who have volunteered medical services in communities in Minnesota, in the U.S., or abroad. The nominees selected for recognition will be featured in the March 2018 edition of Minnesota Physician, the region’s most widely read medical publication. To qualify, nominees should be physicians practicing in Minnesota who have performed medical services, either locally or abroad, during 2017. Both teams and individual physicians may be nominated; if the nomination is for a team, please designate one or two physicians who could fill out a questionnaire if selected for the feature. To nominate a physician or team of physicians, please fill out the nomination form at mppub.com/community-caregivers.html or mail the form below by January 10, 2018.

I would like to nominate the following physician(s): Name and location of physician’s practice: Physician’s contact info (email and phone): What country/state/city did the volunteer service take place?

Brief description of the physician’s medical volunteer service:

Nomination submitted by: Phone #: Email: Send to: Minnesota Physician Publishing Community Caregivers,

Eric Becken, MD, ear nose and throat physician at Midwest ENT Specialists

2812 East 26th Street,Minneapolis, MN 55406

and chairman of the Collaborative Care Cooperative.

Online form: www.mppub.com/community-caregivers.html Fax: 612.728.8601 Email: lmcgowan@mppub.com For more information, call 612.728.8600

www.mppub.com

Empowering patients, protecting choice to page 424 MINNESOTA PHYSICIAN DECEMBER 2017

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3Climate change from cover

Extreme heat

Global warming appears to be associated with more frequent “heat waves” its Principles of the Ethical Practice of Public Health, the American Public driving local temperatures well above the area averages for the season. Minnesota Health Association states that “People and their physical environment are is projected to experience five to 15 more days with temperatures over 95°F and interdependent,” that “Knowledge [in this case regarding climate change] higher nighttime low temperatures. This combination is not morally neutral and often demands action,” will increase the prevalence of heat stroke requiring and “In many instances, action is required in the more extensive health care interventions and absence of all the information one would like.” As community adaptations. As each year becomes the practitioners, researchers, and leaders of health “hottest on record” heat stroke will become more care organizations do we accept that the ethics of frequent along with the associated health impact. Climate change has played a public health apply to the threat of climate change? key role in many of the most During heat waves, populations that are not And if so what are we prepared to do about it? devastating epidemics. acclimatized will be at greater risk of both classic Climate change is driven by greenhouse and exertional heat stroke. Those at greatest risk are gas emissions from fossil fuels, however there the elderly and families living in crowded conditions is another aspect to consider. Fossil fuels are with no air conditioning. Also at risk are individuals who work outdoors in activities that require high the primary source of air and water pollution intensity exercise, as hot humid conditions suppress normal heat loss pathways. (particulate matter, ozone, volatile organic compounds, mercury, etc.) that During the Chicago heat wave of the mid 1990s, the difference between life have important health implications. Certain groups of Minnesotans are and death was as little as 30 minutes exposure to air conditioning at a local store particularly vulnerable to climate change and fossil fuel pollution. Examples or restaurant. With global warming, both classic and exertional heatstroke will are the isolated elderly with limited ability to deal with weather extremes; increase in prevalence, along with the associated morbidity and mortality. low-income communities with higher burdens of chronic disease often located in areas with more pollution; and asthmatics or those with chronic Air pollution lung disease at increased risk of exacerbations from higher ozone and pollen Climate change is also projected to harm human health by increasing levels. Minnesota physicians must recognize the implications of climate and ground-level ozone and/or particulate matter air pollution. The impacts of pollution-related factors not only for the patients coming to our offices but climate change add to the cumulative stresses currently faced by vulnerable also for the communities they come from. populations including children, the elderly, the poor, some communities of color, and people with chronic illnesses. Evidence shows that exposure to air pollution, including ozone, particulate matter, and pollen, is associated with the development and progression of diseases such as asthma, COPD, allergies, and cardiovascular diseases such as heart attacks, strokes, and Your Link to Mental Health Resources arrhythmias. The cardiovascular and respiratory impacts are worse for individuals with these pre-existing diseases. According to the Minnesota Department of Health (MDH), climate change is responsible for over $2 billion annually in added health care and related costs in Minnesota. Studies have documented that the warming of Minnesota’s climate has extended our pollen season by about three weeks over the past 20 years, while more frequent extreme rain and flood events trigger the growth of allergenic molds. Increasing carbon dioxide levels also promotes the growth of plants that release airborne allergens. Allergy specialists attest that higher pollen concentrations and longer pollen seasons are increasing allergic sensitization, asthma episodes, hay fever, and allergic rhinitis.

Epidemics Together with human travel spreading disease, climate change has played a key role in many of the most devastating epidemics. Global warming promotes vector-borne diseases by increasing the breeding season and habitat of ticks and mosquitoes. Minnesota physicians have witnessed a remarkable increase in diseases transmitted via infectious agents harbored in the tick Ixodes scapularis—Lyme disease, human granulocytic anaplasmosis (first recognized in Minnesota), babesiosis, and Powassan virus encephalitis (most frequently seen in Minnesota). Harbored in many bird species, West Nile virus is now the most common cause of mosquito-borne encephalitis in Minnesota. Fortunately, Minnesota is too cold (so far) for Aedes aegypti and Aedes albopictus, the mosquito species that transmit viruses that cause dengue, chikungunya, and Zika virus disease. But physicians need to

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DECEMBER 2017 MINNESOTA PHYSICIAN


caution their patients traveling to warmer climates about the risk of these infections. Travelers may also need to be warned about cholera, a waterborne infection that is linked to climate change.

Natural disasters Climate change also impacts people psychologically. For instance victims of Hurricanes Sandy and Katrina had high rates of PTSD, depression, and anxiety up to a year later. Floods and tornadoes can similarly affect Minnesotans. Minnesota has welcomed sizeable groups of refugees fleeing conditions related at least in part to climate change including historic famines and related conflict. Many Minnesotans are experiencing a sense of loss as our environment changes. Decreased snow pack limits winter recreation, while coal-fired power plants have contaminated our lakes and rivers with mercury meaning fish consumption can be dangerous especially for pregnant women. Altered forest ecology threatens iconic species such as the moose, which are familiar symbols of our state and our identity. Furthermore, forestry experts predict the Boundary Waters Canoe Area will transition from pines to maple and oak within a few decades. It is not uncommon to experience a sense of loss and grief, termed solastalgia, when things we have treasured about our environment are altered and begin to disappear.

leaders in health settings, health professionals have the opportunity to reduce the carbon footprint of their organizations. Organizations can develop an interdisciplinary sustainability or “green team” to identify opportunities for energy savings and waste reduction. Enrolling in Xcel Energy’s Windsource, optimizing indoor temperatures with programmable thermostats, and installing electricity timers are great options for energy savings in clinics and hospitals. Partnering with city waste management to implement recycling and composting and purchasing environmentally preferable supplies can reduce waste in health settings. For more information, Practice Greenhealth (https://practicegreenhealth.org) is a national resource for health care organizations seeking to reduce energy and waste. Physicians can also teach patients about the health dangers of climate change and how to adapt to or mitigate these effects. Patients can be empowered to follow similar green energy and waste-saving practices at home. Including patients in the conversation motivates them to implement protective measures against climate change for their own family’s health.

What can we do? First of all, Minnesota physicians can increase their knowledge about health-related impacts of climate change. The MDH offers preparedness toolkits and the Climate and Health report that describes climate change-related health impacts and up-to-date public health data.

A growing understanding of systems and complexity suggests that interdisciplinary research, interprofessional collaborative practice, and patient and family-centered care are essential for sustainable solutions. These partnerships are evident in the best practice strategies of Health Care Without Harm (https://noharm.org), a global non-profit organization that works to “transform health care worldwide so that it reduces its environmental footprint, becomes a community anchor for sustainability, and a leader in the global movement for environmental health and justice.”

Second, it is important to recognize that the U.S. health care sector contributes to approximately 8 percent of the nation’s carbon footprint. As

Climate change to page 404

What should physicians do?

MINNESOTA PHYSICIAN DECEMBER 2017

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PROFESSIONAL UPDATE: NEUROLOGY

The EyeBOX A new way to assess neurologic function BY UZMA SAMADANI, MD, PHD, FACS, FAANS

D

espite increasing media attention and awareness, there is still no FDA approved diagnostic for concussion. This means that physicians have no way to assess whether a patient has a concussion and when they have recovered. The lack of measures for patients entering and completing clinical trials for concussion and other forms of traumatic brain injury (TBI) contributes to the failure of such trials for therapeutics and prophylactics. This comes at great expense to the research and development community and those it hopes to serve, including athletes, students, and hapless victims of trauma. The mission of the Brain Injury Research Laboratory at Hennepin County Medical Center is to prevent, classify, and treat brain injury. We developed an automated eye-tracking algorithm called the EyeBOX to classify brain injury while a patient watches a short film clip or video. The underlying premise of this technology is that normal healthy people have eye movements that are tightly synchronized, while those with neurologic injury have impairments traceable to the pathway in the brain responsible for that particular movement.

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The technique consists of stabilizing a subject with a chin and forehead rest, while they view a monitor where a short film clip plays continuously inside an aperture that moves around the perimeter of the screen. Typical videos in our lab are clips of Disney movies, football highlights, and music videos. The patient’s pupils are tracked for over 220 seconds for comparison of each pupil’s position and also to a database of control subjects. The technique does not require a trained examiner and is fully automated.

Our results To date, our laboratory has published five peer-reviewed papers on this technology, with others under review. We have shown that this methodology enables direct assessment of the physiologic function of cranial nerves III and VI. We found that recording a subject’s eye movements while they watch a video allows rapid detection of cranial nerve palsies and that these can be tracked through their resolution. Cranial nerve palsies are commonly found in numerous diseases including trauma, vascular lesions, tumors, diabetes and other endocrinopathies, and infectious and inflammatory pathology among others. The EyeBOX allows quantitative assessment of any pathologic process impacting the functioning of these cranial nerves and creates a new mechanism for assessing physiologic function of the central nervous system by conferring the potential of eye tracking in a clinical context. This technology is additionally useful for those unable to participate in calibration, such as young children, neurologically impaired individuals, and research animals capable of watching videos.

Elevated ICP One of the hallmarks of brain injury is elevated intracranial pressure (ICP). Elevated ICP is known to cause decreased function of cranial nerves, among its many other impacts. We recently found that higher ICP was associated with decreased cranial nerve function detectable by eye tracking, and that as ICP returned to normal, function returned to normal as well. Regardless of whether elevated ICP occurs during a concussion, it is known to impact eye movements. We have, however, demonstrated that 1) eye tracking can detect and quantitate the severity of abnormal eye movements within a few hours after concussion, 2) the severity of abnormal eye movements correlates to the severity of concussion symptoms using two different measures with Spearman’s correlation, and 3) post-concussion eye tracking initially worsens then improves toward normal within one month in most patients.

Ease of use The EyeBOX is a passive form of examination that limits the impact of volitional factors such as attention and compliance with instructions, which are components of fatigue. When a subject closes his/her eyes or turns away from the screen, such data (or lack thereof ) does not affect the analysis of results since they are only based on the data actually captured. Since the task is relatively passive—the patient is told nothing at all or told to “watch the TV”—there is no requirement that the patient be literate in any particular language.

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The concept of disconjugate gaze as a marker for brain injury has its laboratory group and collaborators. It will be determined by other researchers origins in the oldest known surgical treatise. Textbooks and chapters on and clinicians who will, upon replication of our results, agree that brain injury is more vast than visible on conventional imaging, ultimately validating the brain injury have been dedicated to the assessment of eye movements, and a fears and concerns of the previously undiagnosed and untreated afflicted. pubmed search of brain injury and eye movements yields nearly a thousand Replication of our results will also enable the testing of therapeutics and citations. Assessment of binocular gaze conjugacy in primates for research prophylactics for brain injury, perhaps changing purposes has been performed for many years with the game for many more potential sufferers. the magnetic search coil technique requiring that Accurate stratification of patients entering coils be implanted into the bulbar conjunctiva. clinical trials for brain injury, and quantitative This technique was first described by Fuchs and Eye tracking can detect and outcome assessments have been elusive, leading Robinson in 1966 and can also be performed in quantitate the severity of to the failure of 30 consecutive human trials. The humans fitted with scleral search coils designed abnormal eye movements within need for another outcome measure here is not specifically for tracking eye movements. a few hours after concussion. optional—it is an urgent imperative, necessary to The advantage of our technique over wellprevent further exercises in futility. established and rigorous methodologies is that our algorithm can be automated, and performed simply, remotely, and noninvasively, in the absence of a trained technician.

How eye tracking works Eye tracking is a technology that has been around for at least 30 years. My laboratory took the concept of eye tracking and developed it to assess central nervous system integrity. Rather than assess what someone chooses to look at, as had been done in the past, the EyeBOX measures how well the eyes are capable of moving. While previous forms of eye tracking involved spatial calibration, our algorithm assesses movement over time. The reason that calibration prevents detection of subtly abnormal eye movements is that if one eye has weakened movement in a particular direction, the camera will interpret the eye’s ability to move in the direction of that weakness as the full potential range of motion due to the calibration process. For example, if during calibration, a person is directed to look at a position but only moves halfway there, the calibration algorithm will mistakenly indicate that movement to the halfway point is actually full movement. Subsequent eye movements to the halfway point will be interpreted as occurring at the full range of normal motion. Thus, though only one eye makes it halfway to the target while the other eye fully reaches the target, the camera interprets both eyes as being together when in reality only one eye is. Nonspatially calibrated tracking assesses eye movement over time rather than space. Our methodology assesses physiologic functioning of the central nervous system and provides different information about the brain than imaging studies enabling visualization of anatomy or electrical studies of activity. The closest proxy for eye tracking is likely the “follow my finger” component of a physical examination that assesses sustained vergence, or the ability of both eyes to converge on a single moving focal point. Nonspatially calibrated ocular motility tracking assessment does not require that the subject explicitly consent to being tracked prior to assessment of their central nervous system functioning, and this raises ethical considerations as it can be deployed even remotely via webcam. The potential applications of the EyeBOX include improved diagnosis and detection of diseases ranging from internuclear ophthalmoplegia to strabismus, however its greatest potential is as an outcome measure or biomarker for brain injury and concussion.

Conclusion The ultimate utility of nonspatially calibrated eye tracking however, will not be established by my undoubtedly biased speculation, or the work of my

Our decision to commercialize the EyeBOX arose from the need to make this technology widely available, so we formed the company Oculogica Inc. Our mission is to change the way brain injury is diagnosed and defined—rapidly, algorithmically, non-invasively, and objectively. Uzma Samadani, MD, PhD, FACS, FAANS, is an associate professor of neurosurgery at the University of Minnesota; holds the Rockswold Kaplan Endowed Chair for Traumatic Brain Injury Research at Hennepin County Medical Center; and is a staff neurosurgeon at the Minneapolis VA Medical Center.

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SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

Racial disparities in nursing homes Findings and implications BY TETYANA PYLYPIV SHIPPEE, PHD

M

ost people do not want to live in a nursing home (NH), but estimates show almost 45 percent of Americans over age 65 can expect to spend some time in a nursing home. Almost one quarter will stay a year or longer, usually at the end of their lives. Most people enter nursing homes after a hospital stay, for post-acute rehabilitation, but a significant portion of those will go on to become long-stay residents. Different factors influence why people stay in a nursing home long-term, but mostly it’s due to multi-morbidity, lack of family support, or lack of available resources to stay at home. The need for long-term care is increasing dramatically as our population ages. About 1.5 million older adults receive nursing home care and this number is projected to increase to 3 million by 2030.

Why QOL matters for residents Traditionally, much of the research on nursing homes has focused on the quality of medical and nursing care. Quality of care typically assesses care processes and directly related medical outcomes, and is often measured via staff reports. However, quality of life (QOL) is an important consideration

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for everyone, and perhaps most acutely for nursing home residents. QOL is a set of patient-centered and patient-reported measures, capturing multiple aspects of resident well-being. Both quality of care and QOL are important, but one could argue that care processes and outcomes are only important insofar as they improve or maintain resident QOL. In fact, my early work, based on living in a retirement facility for two years during graduate school, highlighted the social aspects of residents’ QOL. My findings showed that social engagement, meaningful activities, and relationships in the lives of older adults play a vital role in long-term care settings. Many residents talked about medical care as an inevitable part of their life (and the reason why they needed institutional care) but was not something they wanted to dwell on. Instead, residents preferred talking about meaningful people in their lives, and their goals, interests, and aspirations. They did not want to be seen as “patients” in need of care. My experience of getting to know and learn from these residents motivated me to devote my energy toward improving QOL for older adults, rather than limiting my focus to quality of care.

Factors that influence QOL Quality of life is complex, and influenced by a wide range of structural and individual factors. Individual factors relate to residents’ demographic and social characteristics and health status. Structural factors include facility-level characteristics such as staffing, facility size, location, ownership, and other factors. Based on the work I’ve done in close collaboration with colleagues at the Minnesota Department of Human Services (DHS), we know resident health and expectations influence their QOL, but our findings also show that facility factors such as staffing have a considerable impact. One of our key findings has been the positive impact that direct-care hours by activity staff have on residents’ QOL. We also know that facility size, funding type (e.g., proportion of Medicare), and quality ratings, such as those captured in the Centers for Medicare and Medicaid Services Nursing Home Compare/5-Star Rating System, influence resident QOL.

Racial disparities in QOL Quality of life is not equally distributed in later life, with health disparities only increasing as people age. Non-white nursing home residents typically receive worse quality of care compared to their white peers, with disparities linked to racial and socioeconomic segregation of nursing home care. Yet, we historically knew much less about disparities in QOL. This was a major gap because the proportion of minority older adults in nursing homes has increased dramatically in the past decade, without much attention from policymakers or providers. Current estimates show that the proportion of non-white nursing home residents will surpass that of white residents by 2030. One reason for this increase is that white residents, who generally have more economic resources relative to their non-white peers, choose to live and receive services in other settings, including assisted living, continuing care retirement communities (which often require a considerable down payment), or home. Older non-white adults are more likely to lack economic resources for such services. They may also face


Black and American Indian residents were most disadvantaged (although Asian and Hispanic residents also reported lower scores), reporting lower satisfaction with most QOL domains compared to white residents. The key difference between our 2010 findings is that individual-level racial My work, in collaboration with the Minnesota DHS, found racial disparities remained significant, even when adjusted for health status and disparities in nursing home resident QOL, using other factors. Thus, health differences alone do information from a large sample of residents not explain the racial gap in residents’ QOL and across all Medicare/Medicaid-certified nursing likely include other factors such as racial bias and homes in Minnesota. Unlike most other states, other indicators we don’t capture in our models. Minnesota is unique in having validated measures Social engagement, meaningful Similar to 2010, we found significant differences of QOL (one of only two states to have such activities, and relationships in the on the facility level: NHs that have a higher measures). The measure includes 52 questions lives of older adults play a vital proportion of non-white residents have lower related to various aspects of QOL, grouped into role in long-term care settings. average QOL scores, compared to NHs with a 12 categories, such as comfort, environment, higher proportion of white residents. privacy, dignity, activities, food, autonomy, and relationships. The QOL tool is scientifically What causes the disparities? validated, and has been used in Minnesota What are some reasons for these disparities? since 2005. Overall, the QOL scores have been To answer this, we are currently interviewing residents and staff relatively high in Minnesota, with averages in the 80th percentile. in facilities that have a high proportion of minority residents, and other barriers, such as discrimination in housing and, thus, end up going to NHs in higher numbers because they are less likely to have access to other types of care.

In our work, we used 2010 Minnesota QOL interview data, linked with resident’s clinical data and facility characteristics, to examine whether there were disparities in QOL—and if so, whether these disparities were related to residents’ racial status or the facility’s racial makeup. Our sample for this analysis included 376 nursing homes in Minnesota, encompassing 10,929 residents.

What we found

holding community focus groups. Although our research is ongoing, we have interviewed approximately 50 minority NH residents, over 20 staff members, and conducted community focus groups with over 30 community and family members. Based on these interviews, we can share the following insights. Racial disparities in nursing homes to page 384

Our findings showed significant racial differences in QOL, with non-white residents reporting considerably lower QOL scores for most domains and for overall QOL score. However, when we accounted for resident health characteristics, the differences in most QOL domains became nonsignificant, indicating that much of the disparity was due to different health profiles for minority and white residents (except food enjoyment, where the difference remained significant). Indeed, when comparing health profiles of minority and white residents, we note that white residents tend to be on average 14 years older, more physically impaired, more likely to have dementia, while non-white residents are less physically impaired, more likely to have diagnoses of mental illness, and more likely to have Medicaid as a primary source of payment. The question then remains as to whether nursing homes are appropriate residences for some non-white residents with lower physical needs but a higher need for mental health services.

Helping Beautiful Things Emerge From Hard Places

In terms of racial status and facility makeup, we found, that higher proportions of non-white residents at the facility level is a significant predictor of lower QOL, even after accounting for resident and facility factors. Our findings indicated that facility proportion of minority residents predicted QOL more consistently than did individual-level race/ethnicity. This likely reflects stark inequality in facility factors among NHs serving minority vs. white residents and the resources available to these facilities. These findings laid the foundation for my current work, which is funded by the National Institute of Health (an ongoing, five year project that started in 2016). The project aims to assess predictors of NH QOL in Minnesota and nationally as well as to compare the structure, culture, and process factors influencing QOL in NHs with high, moderate, and low proportions of minority residents. In our work so far, we used 2015 data from Minnesota and found significant racial disparity both on the individual and facility levels.

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SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

The Aging Mastery Program A playbook for living well BY HAYOUNG KYE, MSW; EMILY MCDONALD, MSW; AND ZANE BAIL, MA

M

ore and more, the nation’s 76 million baby boomers are seeking solutions for aging well especially as life expectancy continues to increase. It’s no longer enough to recommend that people “exercise daily,” “eat well,” or “save more.” Boomers need specific, engaging opportunities that motivate and support them to take these actions.

Telephone Equipment Distribution (TED) Program

The National Council on Aging (NCOA) has a history of designing, developing, and implementing real-life solutions to address the challenges of aging that have made a difference in the lives of older adults for more than 65 years. NCOA’s signature programs and services look at the whole person, understanding that health issues, economic security, and social connectedness must all be addressed for individuals to live their lives to their fullest. In 2013, as NCOA’s president and CEO, Jim Firman entered his 60s, he realized that there was no comprehensive program for aging well that incorporated sound science, practical tips, and motivation to help people make the most of their lives. He set out to create such a program and

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

1-800-657-3663 ted.program@state.mn.us mn.gov/dhs/ted-program Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

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DECEMBER 2017 MINNESOTA PHYSICIAN

named it the Aging Mastery Program (AMP). AMP helps older adults and boomers build their own personal playbook for aging well. The program incorporates evidence-informed materials, expert speakers, group discussion, peer support, and small rewards to give participants the skills and tools they need to achieve measurable improvements in managing their health, remaining economically secure, and increasing societal participation. AMP guides individuals to create sustained changes in daily habits and behaviors. The advantage of changing habits is that once behaviors become automatic, participants no longer have to use energy or willpower to maintain positive decisions. AMP covers a range of behaviors that include nutrition and fitness, but also extend to sleep patterns, relationships, economic health, civic engagement, advance care planning, and other vital topics. The in-person, 10-part program is held at sites where older adults and baby boomers already gather in their communities, such as senior centers, churches, community centers, and hospitals. To offer the program, organizations are required to sign a license agreement and take an online training class. An online community space provides access to program materials and a chat room for asking questions and sharing best practices.

Bringing AMP to Minnesota In 2016, NCOA partnered with the Minnesota Recreation and Park Association (MRPA) and the Minnesota Association of Senior Services (MASS) to implement AMP in small towns and rural communities across Minnesota through a grant. A statewide advisory committee selected 14 community-based organizations as grantees spread across covering 19 communities in the state. These grantees received training, program materials, and funding to implement the program at least three times over an 18-month period. One of the state grantees was the Northland Foundation, a regional foundation serving northeastern Minnesota. The Northland Foundation engaged with community leaders in Lake and Aitkin Counties to run this pilot program. Both counties have aging population higher than state and national averages. “The Foundation has an extensive history of working in aging and intergenerational programming,” said Lynn Haglin, vice president of the Northland Foundation. “The grants for AMP presented an exciting opportunity to help two rural areas implement a new approach to support healthy aging.” To date, these two pilot sites have held six 10-week programs engaging 93 participants. Both sites have made excellent progress over the past 18 months with their efforts and are working on plans to sustain this opportunity into the future. “Older adults from our community have embraced the classes,” said Chris Langenbrunner, community education director for the Two Harbors School District and AGE to age coordinator. “In addition to the regular AMP courses, we have offered two elective classes that have been popular including ‘Intergenerational Connections’ through our AGE to age program and ‘Communicating with Your Doctor.’”Four additional classes for another 40–60 participants are planned this fall.


Evaluating the program Research and evaluation are key components of AMP and have enabled NCOA to refine and enhance the program. NCOA partnered with the Columbia Aging Center at the Columbia University Mailman School of Public Health, to lead the evaluation work for the Minnesota sites. Feedback from participants in Minnesota has shown a positive impact on overall well-being and quality of life including:

economics teacher Barb Hayes. “I also became aware of opportunities to be engaged in my community. As a result of the classes, I made positive changes to support my overall health including volunteering more.”

Nationally, preliminary results of more than 7,000 participants in more than 200 sites across the country show that AMP participants significantly increased their physical activity levels, healthy eating habits, use of advanced planning, social connectedness, and participation in evidence-based self-management • One hundred percent reported that AMP The nation’s 76 million baby programs after taking the core curriculum. A was fun. boomers are seeking solutions for recent quasi-experimental study conducted by • Ninety-eight percent felt that the program aging well. the State University of New York at Albany found was of excellent quality or good quality and significant increases in days walking, minutes 97 percent would recommend AMP to their walking, information planning, and care planning friends. actions for the intervention group as compared • Ninety-six percent reported that AMP has to the control group. These differences were helped them deal more effectively with sustained approximately three months later. The their health. findings suggest that AMP can help older adults build their self-management skills, consider critical issues to their current and future well-being, and • Ninety-six percent felt that AMP helped or helped a great deal in successfully maintain themselves where they would like to live. improving their quality of life other than health or personal finances. • Eighty-two percent or more reported learning something new.

What’s next for AMP?

• Seventy-eight percent reported that AMP has helped them deal more effectively with their personal finances.

Based on the positive feedback and outcomes of the program, there are plans to expand AMP classes in Minnesota and across the country. In addition,

“One of the best things that came from the classes is that I reconnected with an old friend,” said Lake County AMP participant and retired home

The Aging Mastery Program to page 344

CELEBRATE THE HOLIDAYS WITH THE SPCO

Join in an annual holiday tradition as the SPCO presents festive performances of some of classical music’s most treasured works. These performances sell out every year — order today to ensure you get seats!

Bach’s Brandenburg Concertos Thursday, December 7, 7:30pm Temple Israel, Minneapolis Friday, December 8, 8:00pm Saturday, December 9, 8:00pm Ordway Concert Hall, Saint Paul Sunday, December 10, 2:00pm Benson Great Hall, Arden Hills

Led by SPCO musicians and soloists Continuing our annual holiday tradition, the SPCO presents Bach’s most cherished set of orchestral works, the Brandenburg Concertos. The profound inventiveness and instrumental virtuosity of these enduring Baroque masterpieces are on full display as led by our own SPCO musicians and soloists.

Please note: Holiday concerts are not eligible for voucher or concert membership redemption.

Handel’s Messiah

Copresented with The Basilica of Saint Mary

Thursday, December 14, 7:30pm Friday, December 15, 8:00pm The Basilica of Saint Mary, Minneapolis Saturday, December 16, 8:00pm Sunday, December 17, 2:00pm Ordway Concert Hall, Saint Paul Jonathan Cohen, conductor; Amanda Forsythe, soprano John Holiday, countertenor; Isaiah Bell, tenor; William Berger, baritone The Singers – Minnesota Choral Artists; Matthew Culloton, Artistic Director Celebrate one of classical music’s most beloved traditions as the SPCO performs Handel’s Messiah. Artistic Partner Jonathan Cohen and the SPCO are joined by an all-star roster of vocal soloists with the renowned vocal ensemble The Singers — Minnesota Choral Artists in their SPCO debut.

Adult Tickets: $11 – $50 | Child Tickets: $5 MINNESOTA PHYSICIAN DECEMBER 2017

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SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

Minnesota Senior Health Options Better health outcomes for low-income seniors BY LAUREN SIEGEL, MSW, MPP; SUE KVENDRU, BS; KATHY ALBRECHT, MSW, LISW; HEATHER A. GOODWIN, BA; AND SUSAN OESTREICH, RN, BSN, CCM

I

n 2017, the Centers for Disease Control and Prevention found that nearly two-thirds of seniors have at least two chronic conditions, but lowincome status predicts having four or more chronic conditions. With each additional chronic condition comes the potential for fragmented care and more physician specialists, medications, and utilization of resources.

Low-income seniors accessing both Medicare and Medicaid— known as “dual-eligibles”—have some of the highest medical and social needs and are the costliest Medicare and Medicaid recipients. In 1997, Minnesota launched the Minnesota Senior Health Options (MSHO) program in an effort to provide better care in a more efficient way to dual-eligible seniors, age 65 and over. MSHO enrollees receive all Medicare and Medicaid benefits through one health plan in order to reduce fragmentation of care and simplify access and overall management of chronic conditions. MSHO played an important supporting role for late-1990s efforts to divert seniors away from nursing home placements

by providing supports and services for them to continue living at home and in their communities. A recent longitudinal data analysis conducted by the federal Department of Health and Human Services found that MSHO enrollees experience improved health and well-being outcomes compared to people eligible for the MSHO program but enrolled in the nonintegrated (Medicaid-only) program, Minnesota Senior Care Plus (MSC+). This article explores the components of the MSHO program that support better health outcomes among seniors.

The benefits of MSHO MSHO integrates Medicare and Medicaid into a single program for improved coordination of care and simplified access to health care and long-term care services. Minnesota’s Department of Human Services (DHS) contracts with seven managed care organizations to provide MSHO services throughout Minnesota. As of October 2017, 38,000 people were enrolled in MSHO out of the 51,548 eligible. The most common reasons seniors choose not to enroll in MSHO include: • Lack of knowledge about or understanding of the program • Lack of interest in changing their Medicare Part D plan • The effect MSHO enrollment would have on their retirement benefits People choose to enroll in MSHO for many reasons, such as wanting one ID card for all their health care services, receiving additional benefits including an assigned care coordinator, financial assistance toward a health club membership, and coverage of additional dental services.

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DECEMBER 2017 MINNESOTA PHYSICIAN

With MSHO, the managed care organization covers all services for the enrollee, which includes hospital stays, prescription drugs, and 180 days of nursing home room and board. The MSHO program includes elderly waiver services such as adult day care, homemakers, and personal emergency response systems in the managed care benefit set. Elderly waiver is a federal Medicaid program that helps fund home and community-based services for a person who requires the level of care provided in a nursing home but chooses to live in the community instead. Most important, the managed care organization provides a care coordinator to help the enrollee best utilize their Medicare and Medicaid benefits; navigate the health care system; and access primary, acute, rehabilitative, behavioral health, and long-term care services. MSHO’s care coordinators, who are registered nurses or licensed social workers, help enrollees receive the care they need and play a vital role in facilitating information sharing among the enrollee’s interdisciplinary care team. The care coordinator conducts a health risk assessment with enrollees within 30 days of their MSHO enrollment and annually thereafter. The assessment identifies clinical and social needs and provides an opportunity for the enrollee to communicate what is most important to them. Based on the assessment results, the enrollee and the care coordinator collaboratively build a care plan that establishes the enrollee’s goals, health care and longterm care needs, desired services, and safety plan. MSHO has been cited as a model for seamlessly integrating Medicare and Medicaid, and in turn, increasing access to care, delivering person-centered


care and promoting independence in the community. However before a federal Department of Health and Human Services study that used the natural experimental landscape afforded by MSHO and MSC+, Minnesota could only speculate that the MSHO program creates improved health outcomes for seniors. This study established that MSHO has clear benefits for its enrollees.

Study shows MSHO improves health outcomes The Assistant Secretary for Planning and Evaluation, a branch of the Department of Health and Human Services, partnered with RTI International and the Urban Institute to complete a longitudinal data analysis comparing service delivery patterns from 2010 through 2012 among dual-eligible seniors enrolled in the MSHO program and the MSC+ program. The study, released in March 2016, found MSHO enrollees were:

left alone to deal with his serious chronic health issues. Daily tasks were very difficult for him, and he was failing on his own. He ended up in the hospital very ill and went into a transitional care unit. They questioned his ability to care for himself, but he wanted to continue to live on his own.

Low-income seniors accessing both Medicare and Medicaid … have some of the highest medical and social needs.

• Older, female, and slightly more likely to live in rural areas of the state. • Likely to have more medical conditions and disabilities. • Forty-eight percent less likely to have a hospital stay; those hospitalized had 26 percent fewer hospital stays during the time period. • Six percent less likely to have an outpatient emergency department visit; those who visited an emergency department had 38 percent fewer visits during the time period.

“As his MSHO care coordinator, I became involved in the case and remember our first encounter and his pessimistic attitude that things wouldn’t get any better. I explained the MSHO program and the supports and services it could offer, but he appeared hopeless and kept saying he was so sad and alone. After two visits, I was able to get his permission to try using services and supports in order to help him remain independent in his home.

“In working together to create his individualized care plan, he agreed to work with a mental health therapist and use some elderly waiver services such as weekly homemaking and adult day care services. Once the supports and services were in place, Richard’s whole outlook on life changed and he felt his life turn around. He was able to live independently in the community, have people help and care about him, and make friends and feel less isolated.”—Nicole Lageson, manager of MSHO, HealthEast, a part of Fairview Health Services Minnesota Senior Health Options to page 354

• Thirteen percent more likely to have home and communitybased services (as opposed to living in an institutional setting) than in MSC+. • Nearly three times more likely to have a primary care visit; those who had a primary care visit had 36 percent fewer visits in the time period. Enrollment statistics in MSHO demonstrate enrollees’ high satisfaction with the program—very few MSHO enrollees ever switched to MSC+ during a year, but 12.8 percent of MSC+ enrollees switched to MSHO after the beginning of a year. These study findings led the Centers for Medicare & Medicaid Services to make an official comment stating that combining Medicare and Medicaid into one program seems to provide the necessary support and coordination needed for the greater health needs of people dually-eligible for Medicare and Medicaid. The study can be found on the Department of Health and Human Services website at https://aspe.hhs.gov/report/ minnesota-managed-care-longitudinal-data-analysis.

A case study We have outlined MSHO program components and outcomes, but it is prudent to share a specific case to really understand how the MSHO program supports improved outcome for dual-eligible seniors. In 2016, DHS asked MSHO care coordinators to submit case studies and success stories to articulate the work they do with MSHO enrollees. The following is one such story: “I have had the pleasure to work with many enrollees over the years, but there are always a few whom I’ll never forget. For me one of those enrollees was Richard, who had recently lost his wife. Although his children had promised to care for him, they quickly went out of the picture and he was MINNESOTA PHYSICIAN DECEMBER 2017

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SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

Advanced care planning Ensuring patient preference in a skilled nursing facility BY EMILY BLACK, RN, MSN, CNP, FNP-BC, AND ASHLEY KIMEU, RN, MSN, CNP, ANP-C, GNP-C, ACHPN

A

mericans are living longer. Illnesses once considered life limiting are now viewed as chronic conditions thanks to advances in medical management. These patient scenarios are increasingly complex in the setting of multiple medical comorbidities, polypharmacy, and advancing technologies. This often results in patients requiring a higher level of care in a longterm skilled setting. This level of care is needed when an illness or trauma limits the ability to carry out the activities of daily living. According to The Retirement Project, among those aged 65 and over, 69 percent will develop disabilities before they die, and 35 percent will eventually enter a nursing home. As reported by the Henry J. Kaiser Family Foundation in 2012, there were 1.4 million people in nursing homes nationally. The majority of people requiring long-term care are elderly. Rogers and Komisar report that approximately 63 percent of those in long-term care are people aged 65 and older (6.3 million); the remaining 37 percent are 64 years of age and younger (3.7 million). Providing aggressive medical interventions in this population that is often not within the patient’s goals

comes at a high cost. Open discussions exploring the patient and family’s goals for care are essential in preventing unwanted hospitalization and interventions that can be detrimental to quality of life as well as costly to the health care system.

Bridging the gap through advanced care planning How do we bridge the gap between the 80 percent of patients that want to avoid hospitalizations at the end of life and the 98 percent of patients that spend time in the hospital at the end of life? Advance care planning (ACP) is crucial. According to the Centers for Medicare & Medicaid Services, the key components of ACP include understanding the options available for care at the end of life; determining which types of care best fit the individual wishes of the patient; and sharing these wishes with care givers including family, friends, and medical providers. Establishing these wishes early can help ensure that the patient’s requests will be honored if he/she is no longer able to participate in such discussions. This can also include discussion and explanation of advance directives. These discussions help ensure that care providers meet the person’s goals and are not pursuing interventions that do not fit within these goals for care. These conversations need to go more in depth than, “Do you want us to

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do everything or nothing?” or “Do you want CPR or not?” The Harvard Serious Illness Conversation Guide suggests that within these conversations, certain components must be included: 1) assessing and understanding the current condition, 2) ensuring the person wants to know information, 3) asking what goals they have, 4) understanding their biggest fears and worries, and 5) being aware of how much they are willing to go through in order to gain more time.

the medical situation or appreciate the consequences of the treatment option. The surrogate decision makers are vitally important in these cases.

Although it’s never easy, an ACP can relieve some of the stress associated with enacting a patient’s wishes. In JAMA in 2008, Wright and colleagues conducted a U.S. multisite prospective, longitudinal cohort study of patients and their informal caregivers that showed that aggressive care is associated with worse patient quality of life and worse bereavement adjustment. Those An ACP can relieve some of the who did have an ACP did not show an increase stress associated with enacting a in major depressive disorder or worry, but end-ofpatient’s wishes. life discussions were associated with lower rates of ventilation, resuscitation, ICU admissions, and earlier hospice enrollment.

These conversations help ensure that the care team understands the values and preferences of the patient. It also helps clarify points that might not be apparent in an already existing advance directive document. This knowledge helps the health care team offer a treatment plan tailored to the wishes and needs of the patient. Advanced care planning also provides the designated health care power of attorney the information needed to make decisions based on knowledge pertaining to the wishes of that person. These discussions ideally take place on admission to a skilled nursing facility and as needed thereafter with changes in the patient’s condition. Physicians and nurse practitioners/physician assistants should be leading these conversations and providing guidance in decision-making. According to a review by Flo et al. (2016), clinicians are expected to recognize illness trajectories and provide individualized advanced care planning. In practice, the participation of this patient population in their own end-of-life treatment planning does have limitations. Allen et al. (2009) found that although most residents preserve the ability to express a treatment preference, many lack the capacity to understand

A case study It was just a normal day for Mr. HD when he arrived at the hemodialysis unit from his skilled nursing facility. He checked in at 7 a.m. and sat in his normal chair. He opened his book to pass the time during his dialysis run, which started without incident. Earlier that week, he had his biannual care conference with the care team at his skilled nursing facility. The discussion included his medical providers at the facility, a dietician, social worker, charge nurse, and his daughter, who was his only child. During that meeting, Mr. HD stated he was happy with his Advanced care planning to page 304

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3Advanced care planning from page 29

him to live to see his next grandchild born. As a result of this event, the nursing facility made changes to ensure that discussion and documentation initiated in the nursing home were also communicated to other members of the patient’s care teams.

current quality of life, but worried about what the future would hold. He had seen other patients at the dialysis center suffer during the end stages of renal disease. He did not want to suffer or be a burden to his daughter. He wanted to remain at the facility where he had resided for the past four years. He enjoyed the company, the meals, and the good care he received. However, if his condition worsened and he was burdened with increasing symptoms, he wanted to stop hemodialysis and focus Aggressive care is associated with on quality of life, allowing him to die comfortably in worse patient quality of life and his “home.” With this conversation, he requested to be worse bereavement adjustment. a Do Not Resuscitate/Do Not Intubate (DNR/DNI). Everyone present at the care conference understood and all were in support of his wishes.

Communication Once the end-of-life discussion has occurred, as in Mr. HD’s case, it is important to communicate those wishes to all invested parties involved in the patient’s care. This includes documentation of the patient’s wishes in the medical record, communication with the health care power of attorney to ensure he/she is aware of the patient’s wishes, and communication with staff who provide direct care. This often includes communication with other specialty areas, like a kidney dialysis clinic.

That day at hemodialysis was going smoothly and seemed like any other day when the nurse checked on Mr. HD near the end of the run. Soon after this, chaos ensued. His hemodialysis machine started alarming and the staff immediately responded. Mr. HD was unresponsive and without a pulse. Cardiopulmonary resuscitation was initiated and 911 called. EMS arrived and intubation took place. Within a matter of moments, he was in the ambulance on his way to the hospital where was admitted to the intensive care unit.

Who acts on a DNR order? At a dialysis center, it would likely be a physician or nurse practitioner since this setting is more likely to have a clinician in close proximity. Patients are allowed to die in dialysis centers and would not necessarily be transported to a hospital. At a skilled nursing facility, a nurse would most likely act on the orders for DNR/DNI when dealing with the previously discussed wishes of a pulseless patient.

Thankfully, Mr. HD did well after his pulseless arrest; one reason for this was the quick action by the staff at the hemodialysis unit. Mr. HD took the time to reflect on the incident and the positive outcome that allowed

The Physician Orders for Life Sustaining Treatment (POLST) form is an effective means of documenting the patient’s wishes in a concise manner. The POLST form is a widely recognized tool to document care goals for

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patients who are seriously ill or frail, and should be used for all patients in a long-term care setting. This form is a complement to the traditional Advanced Directive, both of which are legal documents. The POLST allows for designation of a Do Not Hospitalize (DNH) order. Completion of a POLST can be initiated by the patient/family/nursing home/social worker/ physician/nurse practitioner/physician assistant, but has to be signed by a physician/nurse practitioner/physician assistant to become an order. The decisions are made by patients and/or their surrogate decision maker. A study by Nakashima et al. found that long-term care patients with an established DNH order had significantly fewer hospital stays and emergency room visits than patients without DNH orders. This indicates that when a patient’s wishes are clearly established and properly communicated, the wishes are indeed upheld, which improves quality of life by avoiding unwanted interventions. It is appropriate to send a copy of the POLST form with the patient to all appointments as a way of communicating with other teams. This form is now widely recognized across all care settings. Recommendations to patients to obtain a DNR/DNI bracelet would also be helpful to signal to health care professionals the patient’s wishes regarding resuscitation.

includes using the POLST form, medical alert bracelet, and/or a phone call for a verbal handoff that will help ensure that everyone involved understands the patient’s wishes. Residents in skilled nursing facilities are at high risk for undergoing aggressive medical interventions that may not fall within the goals for care. Early ACP discussions can help bring the patient and family wishes to the forefront of care. By following the request of the patient, the care team can increase quality of life, reduce unwanted hospitalizations and ED visits, as well as decrease the anxiety and burden on the patient’s family. Emily Black, RN, MSN, CNP, FNP-BC, is a board-certified family nurse practitioner. She has worked at Mayo Clinic caring for geriatric patients in skilled nursing facilities and in hospice care for pediatric and adult patients in inpatient and outpatient settings. She holds dual appointments as instructor in medicine and nursing at the College of Medicine at Mayo Clinic.

Ashley Kimeu, RN, MSN, CNP, ANP-C, GNP-C, ACHPN, is double-

Conclusion

boarded as a geriatric and adult nurse practitioner. She worked at Mayo Clinic

Conversations related to goals of care happen at many levels through the continuum of care. As the population within skilled nursing facilities continues to grow more complex, it is imperative to have thoughtful conversations about the values and preferences of the patient. Thorough documentation and communication of these wishes with the entire health care team caring for the patient is imperative. An effective way to do this

consulting for the palliative care inpatient team and is currently working in aging and supportive care programs, taking care of the sickest patients in the care transitions, palliative care homebound, and nursing home practices. She is certified in hospice and palliative care and is an assistant professor of medicine at the College of Medicine at Mayo Clinic.

BEYOND DEMENTIA KEYNOTE SPEAKERS Allen Power, M.D.

Schlegel Chair in Aging and Dementia Innovation – Schlegel – U. Waterloo Research Institute for Aging

3.03.18

St. Paul RiverCentre

David Knopman, M.D.

Consultant in Neurology – Mayo Clinic; Chair, Medical and Scientific Advisory Council – Alzheimer’s Association

Learn more and register at

alz.org/mnnd

#ALZminds MINNESOTA PHYSICIAN DECEMBER 2017

31


WELLNESS AND PREVENTION

Medicare wellness visits The value to the patient, public, and provider BY KATHLEEN Y. KELLER, MAN, RN, CNE, AND DAVID P. INGHAM, DO

time to look at preventive measures unless flagged by the electronic medical record. So these wellness visits serve an important function and benefit the patient tremendously.

f you doubt the value of a preventive visit, just ask Earl’s family and friends for their opinion. If Earl were alive today, he would be happy to advocate for beneficiaries of Medicare to get their “free” annual wellness visit. Earl was a vibrant retired plant manager who enjoyed good health. Other than medications for rheumatoid arthritis, he had no other pertinent health history. Earl was married for 66 years, had eight children and many grandchildren which kept him busy. To remain active after retirement, Earl became a court mediator. One evening, he was taken by ambulance to the emergency room and admitted for emergency surgery for a ruptured abdominal aortic aneurysm. This was quite a traumatic event for Earl and his loved ones.

Medicare wellness visits are totally free to the beneficiary as long as they occur every 365 days. As a provider who gives these wellness exams, be sure to include these screenings, which are covered by Medicare Part B:

I

The purpose of the Medicare wellness visit Medicare wellness visits went into effect in January 2011 as part of the Affordable Care Act and its intent is to keep beneficiaries healthy, rather than pay for treatment when they become ill. It’s important to note that these “visits” are not “physicals” but more of a screening by a medical team. Providers often see patients for focused visits and don’t have the luxury of

• Abdominal aortic aneurysm screening (for prior smokers or family history) • Alcohol misuse screening and counseling • Bone mass measurements • Cardiovascular disease screening and behavioral therapy • Cognitive screening • Cervical and vaginal cancer screening • Colorectal cancer screening • Depression screening • Diabetes screening • Glaucoma testing • Lung cancer screening • Mammograms and obesity screening and counseling

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Those without MWV

Those with MWV

79%

94%

Colorectal Screen

80.6%

91.8%

Pneumonia Vaccine

34.5%

54.1%

Influenza Vaccine

30.2%

43.8%

Zostavax Vaccine

21.8%

36.3%

Mammogram

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Table 1. A comparison of patients who have had Medicare wellness visits versus those who have not. Source: Allina Health (from their Medicare population)

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DECEMBER 2017 MINNESOTA PHYSICIAN


While the Medicare wellness visit provides many screenings to detect a problem, there is value in questioning the beneficiary about sun exposure, social activities, nutrition, and all the other aspects of whole person care. Seven of the top 10 causes of death, according to the Centers for Disease Control in 2010, can be screened for in this visit. Any red flag answers present the opportunity to discuss the concern with the beneficiary, which is often not possible when the patient is in for other problems.

to a flowsheet in our EPIC system with any red flag answers automatically added to the provider notes as an alert.

Engaging patients in their care

patient’s age and specific medical history. For a patient in their late 60s, the conversation may center around cancer screening and prevention,

Value to the provider

Medicare wellness visits go a long way toward building and solidifying the relationship a patient has with their provider. For those patients who do not visit often, it’s an opportunity to connect with their provider and hopefully become comfortable discussing Preventive health screenings health issues. For patients who see their provider Preventive health screenings and vaccinations regularly, the wellness visit affords an opportunity have long been thought of as Patients who schedule a Medicare wellness visit for a holistic approach to the patient’s overall one of the most important health care strategies. are more likely to get the appropriate vaccines and health. Most follow-up visits deal with very screenings (see Table 1). There is no disputing the specific medical problems that may not affect a fact that influenza vaccinations have been shown patient with overt symptoms (such as in the case to effectively prevent hospitalizations and death of hypertension) so may feel more important to among people aged 65 and older as well as other the provider. A “big picture” wellness visit allows populations. According to the National Institutes of Health, preventive for more flexibility to address what is important to the patient and allows health screenings have long been thought of as one of the most important time to delve deeper when needed. health care strategies because they facilitate early diagnosis and treatment, There are core topics covered for every patient during a wellness improve quality of life, and prevent premature death. visit, but providers also tailor various aspects of the visit according to the Many seniors are already engaged in their care, particularly in the Midwest. Unfortunately, many are not aware of what a Medicare wellness visit is. While implementing the new MWV flowsheet, 30 Allina patients were asked why they scheduled a Medicare wellness visit. Two reported receiving a letter from Medicare while the rest said that a provider or member of the care team recommended the visit. Reminding patients of the value of medication reconciliation, advance care planning, and vaccines will generally also get them to schedule a wellness visit. Sometimes during a wellness visit a patient will bring up an issue or request a screening exam that is not covered under the specifics of the Medicare wellness visit. It’s encouraging that the patient is asking these questions, but it’s important that you explain the constraints of what Medicare covers during this visit. You can either have them schedule another appointment to address the issue or extend the time of the wellness visit to discuss the issue explaining that they will be billed separately for anything outside of the wellness visit parameters.

Scheduling and organizing wellness visits Despite Medicare’s attempt to notify patients of the “free” wellness visits, many patients do not schedule an appointment. What gets patients to schedule a wellness visit? If physicians, other health care providers, or office staff talk to patients about the benefits of these wellness visits when they come into the office this often spurs them to make an appointment. We found that sending a reminder letter resulted in 33 percent of patients scheduling an appointment. If this fails, then continued discussion about the benefits of wellness visits when patients come into the office can help. Medicare wellness visits often require more time in a provider’s schedule, so efficiency is important. It’s helpful if the provider has a team to assist with the rooming and to explain any information that the patient needs to understand before leaving. In addition, it is important to have a streamlined process for Medicare wellness visits and with that in mind we developed such a process earlier this year. We found that if some basic screening questions are asked of the patient 48 hours prior to their wellness visit, this gives us the ability to plan for the visit in advance. We added screening questions

Medicare wellness visits to page 364

Ruptured AAA

Preventive Visit

Ambulance

Medicare Wellness Visit

Emergency Room

Surger y

Surger y

ICU (6 weeks)

ICU (5-­10 days)

Ventilator-­B ethesda & to Northridge Care (8 months)

Hospitalizations for further complications yy Colostomy for Necrotic Bowel yy Sepsis yy Clots yy Abdominal wound & wound vac Rehab (6 months)

Rehab 2-­3 months

Table 2. The complications resulting from Earl’s ruptured AAA versus catching the issue at a wellness visit. Source: Allina Health

MINNESOTA PHYSICIAN DECEMBER 2017

33


3The Aging Mastery Program from page 25 AMP Core Classes • Navigating • Exercise

Longer Lives

and You

• Advance • Healthy

Planning

Relationships

• Sleep

• Medication

Management

• Healthy

• Community

Engagement

Eating and Hydration

• Financial

• Falls

Prevention

Fitness

NCOA is creating a self-guided version of the program that individuals can do at their own pace and at home, because the in-person program may not be available or accessible to every individual, especially the homebound. This product, called the Aging Mastery Starter Kit, distills the core themes and activities of the AMP classes into an in-home toolkit. The foundation of the kit is the AMP Playbook, which provides practical tips for aging well across six dimensions: 1) gratitude and mindfulness, 2) health and well-being, 3) finances and future planning, 4) creativity and learning, 5) connections and community, and 6) legacy and purpose. The kit also contains activity cards, a notepad for marking progress, and other materials that encourage people to take small steps toward positive behavior change. The Aging Mastery Starter Kit will be available for purchase in 2018.

Implications and opportunities There are many translational studies demonstrating what older people can and should do to be healthier, including exercising more, eating healthier, taking prescribed medications appropriately, preventing falls, and having effective advanced care plans. Unfortunately, many are not taking these actions. Only 28–34 percent of older adults exercise regularly, as many as 55 percent are non-adherent to their medication regimens, and only 33 percent have advanced care plans.

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With the fragmented nature of the health system and the demands and costs of care expected to double in the decades ahead, there is an urgent need for programs that engage people in adopting healthier behaviors. AMP is a promising and highly scalable approach to get millions of older adults to take small steps that will improve their health and well-being. Learn more about AMP at ncoa.org/AMP and learn more about the Northland Foundation’s intergenerational and aging programming at northlandfdn.org. The launch and growth of the Aging Mastery Program in Minnesota was made possible through funding provided by Margaret A. Cargill Philanthropies. Hayoung Kye, MSW, is a program specialist for the Aging Mastery Program at the National Council on Aging. She leads the multiple AMP grants and projects, while providing technical assistance and programmatic support. She also manages the AMP national database and oversees the online community platform.

Emily McDonald, MSW, is the director of Aging Mastery Program Community Partnerships at the National Council on Aging. She has 10+ years of experience working in multi-community, rapid-cycle innovation programs for older adults.

Zane Bail, MA, is director of development and special projects at the Northland Foundation. She designs programs, writes grant proposals, manages program implementation, and conducts evaluations. During her 20+ years she has provided leadership and support for several nationally 651-292-9292 | saintpaulhotel.com | 800-292-9292

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funded initiatives.


3Minnesota Senior Health Options from page 27 Developing a care plan Richard’s case demonstrates the interconnection of social, health, mental, and emotional challenges and the importance of addressing all these components to obtain a better quality of life. The health risk assessment is an important first step for an MSHO care coordinator to learn about the enrollee’s needs and what is most important to that individual. The assessment addresses the enrollee’s medical, cognitive, functional, psychosocial, and mental health needs and provides the person-centered approach needed to support their health and well-being. From a purely medical model, it may seem that Richard’s chronic health conditions should have been addressed first, but Richard’s loneliness was central to him at the time and addressing this simultaneously with his health issues resulted in improved outcomes. The health risk assessment guides the care coordinator in addressing very personal aspects of one’s health and well-being in a private and dignified manner and allows the enrollee to express what is most important to them. Managed care organizations work diligently to build a team of highly skilled care coordinators who can capture the art and science of conducting a successful health risk assessment. The Individualized Care Plan (ICP) is developed with the enrollee based on what is identified through the health risk assessment. This person-centered document uses a realistic strengths-based approach to establish obtainable health and wellness goals. Richard was in tune with his emotions enough to understand that he wanted social connection to others to be happier. The care plan is specific to each enrollee’s needs and guides the work of the enrollee, the care coordinator, and the interdisciplinary care team, who work together to achieve the enrollee’s identified goals and improve the enrollee’s quality of life. Richard’s story clearly illustrates the impact this work can have on an enrollee’s well-being. The care coordinator is at the heart of the care team, creating the best environment for the care plan to be communicated to all specialists and providers for the best outcomes. Richard had health care, long-term care, and mental health services, all of which contributed to positive outcomes for each of the other services. For example, his mental health services helped engender the hope he needed to be more social and happy at his adult day program, and his meal and homemaker services allowed him to stay safe and nourished in his home so that he could live independently and work on other aspects of his individualized care plan. MSHO enrollees across Minnesota have unique health disparities including lower socioeconomic status, poor health literacy, possible cognitive deficits, and multiple comorbidities. The MSHO program has allowed managed care organizations to proactively work with and experience success with some of the state’s most vulnerable citizens.

Conclusion Having a single-care delivery program such as MSHO in Minnesota has shown improved patterns of care for low-income seniors enrolled in the program. The case example demonstrates how the program positively impacts enrollees’ quality of life, improves health care outcomes, and shows the value of care coordination. Minnesota is proud to offer such a highquality program for the frailest residents of our state. As a physician, if you have a patient who is a senior on Medicaid and has a health plan (managed care organization) providing their coverage, tell them to call their health plan’s member services number on the back of their ID card to discuss the value of integrating their Medicare into their Medicaid coverage with the MSHO program.

Lauren Siegel, MSW, MPP, is the special needs purchasing policy coordinator at the Minnesota Department of Human Services.

Sue Kvendru, BS, is the coordinator of MSHO at the Minnesota Department of Human Services.

Kathy Albrecht, MSW, LISW, is the manager of regulatory oversight and improvement at Medica.

Heather A. Goodwin, BA, is senior health services manager at South Country Health Alliance.

Susan Oestreich, RN, BSN, CCM, is senior manager of MSHO/MSC+/ SNBC at HealthPartners.

Family Medicine Physician HealthPartners Medical Group – Hugo, Minnesota We are actively recruiting a family medicine physician to join our primary care team at our Hugo clinic. This is a part-time or full-time, outpatient-only family medicine (no OB) position. Our primary care team includes family medicine physicians, pediatricians, advanced practice providers and chiropractic services. This role offers potential for physician leadership and urgent care coverage at the clinic. We use the Epic medical record system in all of our primary care and specialty care clinics and admitting hospitals. Epic experience is helpful, but not required. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefits package, paid malpractice and a commitment to providing exceptional patient-centered care. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at 952-8835453; toll-free: 800-472-4695. Apply online at healthpartners.com/careers and search for Job ID 42519.

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

healthpartners.com MINNESOTA PHYSICIAN DECEMBER 2017

35


3Medicare wellness visits from page 33

visit. Instead, he had multiple complications and an extended recovery period resulting in more expense to Medicare and to Earl. Had Earl been a beneficiary of a Medicare wellness visit, he would have had a planned procedure, a better quality of life, and significantly lower costs. And Earl is just one example.

whereas for a patient in their early 90s, the focus may be on preventing falls and being safe in their home. Each patient is unique, and the topics covered and emphasis placed on various aspects of the visit will vary. Providers have noted that the time they have to spend with a patient to discuss prevention and planning during a wellness visit is refreshing. This is an exceptional opportunity for the physician to review preventive measures as well as provide Many [beneficiaries] are personalized health advice. not aware of what a

Medicare wellness visit is.

Value to the public

Looking ahead, net Medicare spending (that is, mandatory Medicare spending minus income from premiums and other offsetting receipts) is projected to increase from $590 billion in 2017 to $1.2 trillion in 2027, according to the Congressional Budget Office (CBO). Table 2 shows the difference in length of stay (in Earl’s case) for a ruptured abdominal aortic aneurism (AAA) compared to a planned surgical procedure caught at a Medicare wellness visit. Imagine the savings if this was multiplied by all the other patients with preventable problems! We all love stories with a happy ending. Earl was one of the 25 percent who survived his surgical procedure for AAA and was lucky enough to live another eight years. But, it is possible that his recovery would have been speedier had his aneurism been discovered during a Medicare wellness

Kathleen Y. Keller, MAN, RN, CNE, has been in the health care field for 43 years and is a certified nursing educator. She has been with Allina for 10 years, six as a nursing manager at Allina Health Northfield Clinic, and four in the Quality Department as a project management coordinator. Her most recent project included the redesign of the Allina Health Medicare wellness visit protocols to improve efficiency with the use of the electronic record. Keller is also an assistant professor of nursing at St. Catherine University.

David P. Ingham, DO, is an internal medicine physician with Allina Health’s Abbott Northwestern General Medicine Associates in Edina. He is passionate about making the electronic medical record simple, intuitive, and clinically relevant, so that medical providers can focus on what is important—the patient. Dr. Ingham serves on multiple committees and a recent large project included the redesign of Allina Health’s Medicare wellness visit.

With more than 25 specialties, Olmsted Medical Center continues to experience significant growth. We are known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: • Dermatology • Endocrinology • Family Medicine

• Internal Medicine • Gastroenterology • Occupational Health

• Ophthalmology Surgeon/ Refractive Surgeon

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

• Psychiatrist – Child & Adolescence • Psychologist– Adult • Urology

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: dcardille@olmmed.org • Phone: 507.529.6748 • Fax: 507.529.6622

www.olmstedmedicalcenter.org 36

DECEMBER 2017 MINNESOTA PHYSICIAN


Family Medicine & Emergency Medicine Physicians

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

Great Opportunities

• Immediate Openings • Casual weekend or evening shift coverage • Set your own hours • Competitive rates • Paid Malpractice

POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

Sioux Falls VA HEALTH CARE SYSTEM Cuyuna Regional Medical Center is seeking two full-time Family Medicine physicians for its Crosby Clinic. Located in the heart of the Cuyuna Lakes Area, CRMC’s Crosby clinic has recruited 22 New and dedicated, quality physicians & APC’s in the last 2 ½ years that, along with the required up-to-date technology, have developed CRMC into a regional resource for advanced diagnostic and therapeutic healthcare services. Our Family Medicine opportunity: • MD or DO • Board Certified/Eligble in Family Medicine, Internal Medicine or IM/Peds • Full-time position equaling 36 patient contact hours per week • Work 4.5 days a week. • 1 in 11 Peds call. (Majority of calls handled by phone consultation) • Practice supported by 14 FM colleagues, APC’s and over 35 multi-specialty physicians • Subspecialty providers—Internal Medicine, OB/GYN, Orthopedics, Urology, Surgery, Oncology, Pain Management and more • Competitive comp package, generous signing bonus, relocation and full benefits • New Residients are encouraged to apply

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.

The VAHCS is currently recruiting for the following positions: Cardiologist

Psychiatrist

Urologist (part-time)

Endocrinologist

Psycologist

ENT (part-time)

Orthopedic Surgeon

Pulmonologist

apply online at www.USAJOBS.gov

A physician-led organization, CRMC has grown by more than 40 percent in the past three years and is proudly offering some procedures that are not done elsewhere in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by an ever-increasing range of services offered.

Contact: Todd Bymark, tbymark@cuyunamed.org (218) 546-3023 | www.cuyunamed.org

(605) 333-6852 ·

www.siouxfalls.va.gov

MINNESOTA PHYSICIAN DECEMBER 2017

37


3Racial disparities in nursing homes from page 23

services for people living with mental illness. Our finding that much of the racial disparity exists at the facility level points to the need for more resources for facilities that have a high proportion of residents where Medicaid is the First, many minority residents have high social needs, in addition primary source of payment. We also saw a great need for more community to physical complexity. For many NH residents, family serves as a vital engagement with residents in high proportion minority facilities, some of form of support by visiting and calling the resident, bringing favorite which have no community volunteers. Too often, or familiar foods, even serving as advocates for we seem to think of nursing homes as “institutions,” the resident within the facility. We have found, separate from the communities in which they are however, that many minority residents lack family located. We need creative solutions that involve all supports. In some cases, residents may be alienated Non-white nursing home of us: community organizations having purposeful from family due to long-term homelessness or residents typically receive worse outreach and engagement, especially for minority mental health needs. quality of care compared nursing home residents; policy makers and advocates Second, many minority residents talk about to their white peers. who can change policies; and universities working to the lack of culturally competent care in the NH partner with facilities and benefit our students with and describe missing familiar foods and culturally more intergenerational connections. As one of the relevant activities. Through interviews we residents said, “Aging is not easy, but what choice conducted with a number of Hmong NH residents, do we have?” Indeed, many residents may not have many described life in the NH as being “without much choice but to take it a day at a time. However, the rest of us have a meaning,” and devoid of active engagement and a sense of social belonging. choice to step up and advocate for their needs, serve as family when family Some of these residents shared their experiences in the NH in bleak terms: is not present, and engage with residents on a meaningful level. As I have such as that their purpose was “just to live and wait to eat,” or one resident personally experienced, we will be the first to benefit from these relationships. said that he felt like a “caged pig.” For many of these residents, it seemed as though the meaning had been stripped from their lives. Tetyana Pylypiv Shippee, PhD, is a social gerontologist and an associate

Conclusion These findings have implications for policy and practice, including a clear need for affordable assisted living housing as well as the need for supportive

professor at the University of Minnesota Division of Health Policy and Management in the School of Public Health.

MASONIC CANCER CENTER A comprehensive cancer center designated by the National Cancer Institute

Medical Director, Minnesota Cancer Clinical Trials Network Masonic Cancer Center is seeking a physician with training and experience leading multi-center clinical trials in cancer to be the Medical Director of the newly formed Minnesota Cancer Clinical Trials Network (MNCCTN). The role is .5FTE. This individual will assume the leadership role in the implementation, conduct, and supervision of interventional (prevention, therapeutic, survivorship) clinical trials in new regional centers in the state of Minnesota. As Medical Director of the MNCCTN, the successful candidate will lead a new organization and direct clinicians involved in interventional cancer clinical trials to bring access to citizens in areas of the state with poor access to cancer clinical trials. Responsibilities include oversight of six (6) regional clinical trial sites (identification, feasibility assessment, and establishment); planning, implementation and execution of cost-effective and efficient clinical trial operations; working with the MNCCTN steering committee on vision, mission and direction of the network; representing the MNCCTN in discussions with other research partners across the state; and enrolling research subjects on prevention and therapeutic clinical trials. The Medical Director will partner with a full-time senior network manager who will lead the administrative operations of the MNCCTN. This position will work with the leadership of the Masonic Cancer Center, University of Minnesota, Mayo Clinic Cancer Center, and The Hormel Institute for efficient, shared trial support responsibility; and he/she will work with the Essentia NCI Community Oncology Research Program (NCORP), Sanford NCORP of the North Central Plains, and Metro Minnesota MMCORC on site identification and outreach. This position requires travel across the state of Minnesota to help establish cancer clinical research regional sites. This administrative appointment, depending upon qualifications, will be at the Associate or Professor compensation level, commensurate with experience. The qualified candidate will have a medical degree from an accredited medical school, board certification, current MD licensure in the state of Minnesota without restrictions or eligibility for state of MN license without restrictions, experience in oncology clinical trial execution and direction, and administrative experience in management of cancer clinical trials. Board certification in an oncology discipline is desired. Individuals may apply by going to the Employment System to search and apply for job opening 320440.

The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer.

38

DECEMBER 2017 MINNESOTA PHYSICIAN

Contact info: Dr. Douglas Yee, Director Masonic Cancer Center University of Minnesota jacob016@umn.edu

612-626- 5475


St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Opportunities for full-time and part-time staff are available in the following positions: • Internal Medicine/Family Practice

• Physician (Geriatric Evaluation & Management) • Physician (Hospice & Palliative Care)

• Physician (Pain Clinic/Outpatient Primary Care) • Psychiatrist

• Pulmonologist ( Primary & Specialty Medicine) Applicants must be BC/BE.

PRACTICE WHERE BEAUTY SURROUNDS YOU

Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.

WORK-LIFE BALANCE: •  Competitive salary •  Significant starting & residency bonuses •  4-day work weeks •  51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:

Visit www.USAJobs.gov or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

MINNESOTA PHYSICIAN DECEMBER 2017

39


3Climate change from page 19

duty to protect the public’s health and good health begins with and is dependent upon a healthy environment.

In Minnesota, Health Professionals for a Healthy Climate (HPHC) inspires and activates the health care community to address climate change through interprofessional education, clinical practice, and public advocacy. On April 20, 2018, Code Blue for Patient Earth: Responding to the Urgent Threat of Climate Change to One Health will be held at the Science Museum of Minnesota. This interprofessional conference is co-sponsored by HPHC; the Academic Health Center of the University of Minnesota; the University of Minnesota Institute on the Environment; the Abbott Northwestern Hospital Foundation; the Science Museum of Minnesota; Fresh Energy, and others. Minnesota physicians are positioned to advocate for policy changes to address climate change. Physicians can challenge the common conceptualization of climate change, as strictly an environmental issue and help lawmakers understand how climate change impacts health. Furthermore, physicians can testify about the health impacts of climate change at public hearings on infrastructure projects that have the potential to exacerbate or mitigate climate change. Cultivating a relationship with legislators can provide physicians with an open line of communication to use when pending legislation relates to climate change. Climate change can perhaps be best understood as a public health problem and therefore an issue of immediate concern to those of us in the caring professions. We made a commitment to serve the health of not only those in our direct care, but also of their families and communities and future generations. Whatever our specialty or focus, it is our fundamental

All of the authors are available for further discussion. Macaran Baird, MD, MS, is professor and head of the Department of Family Medicine & Community Health at the University of Minnesota Medical School in Minneapolis.

Shanda Demorest, DNP, RN, is an assistant professor at the University of Minnesota School of Nursing in Minneapolis.

Rachel Kerr, RN, OCN, is an experienced nurse and is currently pursuing a Doctor of Nursing Practice degree at the University of Minnesota.

Michael Menzel, MD, is an anesthesiologist and founder of Guatemala Surgery. Teddie Potter, PhD, RN, FAAN, is a clinical associate professor at the University of Minnesota School of Nursing in Minneapolis.

Phillip Peterson, MD, is professor of medicine emeritus at the University of Minnesota Medical School in Minneapolis.

William O. Roberts, MD, MS, FACSM, is a professor in the Department of Family Medicine & Community Health at the University of Minnesota Medical School in Minneapolis.

Bruce D. Snyder, MD, FAAN, is a retired neurologist and the coordinator of Health Professionals for a Healthy Climate.

Minneapolis VA Health Care System Opportunities are available in the following specialties:

• Associate Chief of Ambulatory Care • Chief of Internal Medicine • Chief of Nephrology • Director of Primary Care Pain Management • Internal Medicine/Family Practice • Outpatient Clinics: Maplewood, MN (Rover); Chippewa Falls, WI; Superior, WI

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Minneapolis VA Health Care System (MVAHCS)

is a teaching hospital providing a full range of patient care services with state-of-the-art technology, as well as education and research. Comprehensive health care is provided through primary care, tertiary care and longterm care in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics and extended care.

Possible Recruitment Incentive • Competitive Salary Excellent Benefits • Paid Malpractice Insurance

For more information on current opportunities, contact: Rick Pope: Richard.Pope@va.gov • 612-467-1264 or Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964

One Veterans Drive, Minneapolis, MN 55417

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DECEMBER 2017 MINNESOTA PHYSICIAN

www.minneapolis.va.gov


Ely Bloomenson Community Hospital is

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Helping physicians communicate with physicians for over 30 years. Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: •

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3Empowering patients, protecting choice from page 17

statutes to ensure that secure, patient record transfers included diagnostic imaging and that hospitals offer a bi-directional EHR exchange to other providers. Further, the duo sponsored legislation (recently featured on NBC Nightly News) that focused on regulating pharmaceutical benefit managers (PBMs) and banning gag orders placed on pharmacists by insurers. Under the bill, pharmacists will no longer be contractually prohibited from telling customers if there is an option for them to pay less for their medically necessary, and sometimes life-saving, prescription treatment options. Policyholders also can no longer be charged more than the negotiated price. (Prior to this law, PBMs would collect the entire co-pay even when it was higher than the cost of the drug.)

• Required the state’s insurance exchange to establish a site to compare provider cost information on common procedures; • Required hospitals to notify patients of their rights to request cost and quality information; • Required insurers to update provider directories and establish toll-free numbers for patients to ask about out-of-pocket costs and provider network status; • Defined a “surprise bill” that holds patients “harmless” in certain scenarios beyond their control, and established provider reimbursement protocols; and

LaserWave Communications

Throughout the country and certainly in the nation’s capital, there are political and marketplace headwinds created by some stakeholders, to • Required hospitals to annually disclose the salaries and benefits of maintain very limited outside access to proprietary electronic health record 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main their ten highest paid employees. systems, which shields the costs to consumers and builds enough bulk to Providers of Business Communication Solutions – www.laserwave.net curtail patient empowerment. However, the State of Connecticut is proof In 2016, Senators Looney and Fasano partnered up again and achieved that policymakers can work together to pass bipartisan, comprehensive health passage of high-impact health care legislation. This time, they established 160brings First Street SE, Suite 5,choice—to New Brighton, MN 651-383-1083-Main care policy clarity—and patients and consumers. 160 Suite First Street SE, Suite 5,MN New651-383-1083-Main Brighton, MN that 651-383-1083-Main reasonable limits on physician non-compete established 160 First Streetagreements, SE, 5, New Brighton,

Laser Hello Decision Makers …Wave Communications aser ave ommunications aser WLW ave CW ommunications LLaser LTechnology aser W ave L ave aser C ommunications C W ommunications aveCC ommunications

160 First 160 Street First Street SE, Suite 160 SE, First Suite 5, New Street 5, Brighton, New SE,Brighton, Suite MN 5, 651-383-1083-Main New MN 651-383-1083-Main Brighton, MN 651-383-1083-Main We are LaserWave Communications

Providers of Business Communication Solutions – www.laserwave.net Providers of BusinessSolutions Communication Solutions – www.laserwave.net Providers of Business Communication – www.laserwave.net

Providers Providers of Business of Business Communication Providers Communication of Business Solutions Communication Solutions – www.laserwave.net – www.laserwave.net Solutions – www.laserwave.net the office for a State Health Information Technology Officer to oversee HelloMakers Technology Decision Makers Hello Technology Decision Hello Technology Decision Makers Hello Hello Technology Technology Hello Technology Decision Decision Makers Decision Makers development of the state’s information exchange, and revised the Printer/Scanner is the director of State Legislative Policy for Christopher “Kit”Makers Crancer Wehealth market Digital Copier/Network Systems state’s medical foundation laws to make it easier for independent physicians Center for Diagnostic Imaging (CDI). He is a registered lobbyist in a number of & Wide-Format Printers to savvy business owners to access capital.

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We are LaserWave Communications We are Communications We are LaserWave Communications We We are are LaserWave We LaserWave areLaserWave LaserWave Communications Communications Communications statemarket capitols, including and manages CDI’s contract lobbyists and We DigitalHartford, Copier/Network Printer/Scanner Systems

We market Digital Copier/Network Printer/Scanner Systems WeWe market Digital Copier/Network Printer/Scanner Systems In 2017, Senators Throughout Looney and Fasano teamed upDigital once more with We market market Digital We Digital market Copier/Network Copier/Network Copier/Network Printer/Scanner Printer/Scanner Printer/Scanner Systems Systems Systems the Upper Midwest, and across North America. legislative priorities. Prior to joining CDI, Mr. Crancer served as chief of staff to additional first-in-nation health care reforms that were enacted by the & Wide-Format Printers to savvy business owners && Wide-Format Printers tomultiple savvy business owners aser ave ommunications Wide-Format Printers to savvy business owners &&Wide-Format & Wide-Format Wide-Format Printers Printers to savvy to Printers savvy business to business savvy owners business owners owners Missouri state senators and managed one of the state’s largest political Connecticut General Assembly and signed by the Governor. Included in this 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main Throughout the Upper Midwest, and across North America. Throughout Upper Midwest, and across North America. action committees. Providers of Midwest, Business Communication Solutions – America. www.laserwave.net year’s package was a provision aimed at broadening the the state’s inoperability Throughout thethe Upper Midwest, and across North America. Throughout Throughout Throughout the Upper Upper Midwest, the Midwest, Upper and and across across North and North across America. North America.

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We pick the brands and models with thecounts, features our customers demand Term, it is typically returned to the Leasing Company. Webrands purchaseand directly from those • Windows and out MAC • Low-meter • All units refurbished with We pick out the models with the features our customers demand  the We pick out theand brands and models the features our customers demand  We We pickpick out theWe brands and models with themodels features ourthe customers demand leasing companies!   pick We out  out brands the pick brands and out models the brands models with and with the features the features with our customers our features customers demand our demand customers demandClean ensuring manycounts years of service and Showroom Compatible We endeavor to find the most favorable meter Our Customers Typically Save 75%the or most More!!  We endeavor to find favorable meter counts with endeavor tomost find the most favorable meter counts We endeavor to find themost most favorable meter counts • All come warranty • the Dealer certified Working As counts New • Hundreds of satisfied customers  units We  endeavor We endeavor We to We find toendeavor find the the to favorable find favorable meter most meter favorable counts counts meter o ALL of our copiers have more than 90% of their useful life left to give…. o ALL of our copiers have more than 90% of their useful life left to give…. 

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The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. © 2017 University of Minnesota Physicians and University of Minnesota Medical Center

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Empowering patients, protecting choice A legislative response to consolidation in Connecticut By Christopher “Kit” Crancer Climate change W...