Vo l u m e x x v i i I , N o . 10 J a n u a r y 2 015
Confronting prescription opioid misuse Physicians play a pivotal role By Carol Falkowski
s the non-medical use of prescription opioid medications continues to escalate, the negative consequences are changing the American landscape. Few rural areas, suburban communities, or metropolitan hubs are untouched by this tragic and far-reaching public health crisis. Scope and impact According to the 2010 National Survey on Drug Use and Health, an estimated 35 million people (14 percent of the U.S. population age 12 and older) have used prescription pain relievers non-medically at least once in their lifetime, and 12 million in the past year. Nearly one-third of the 2.9 million Americans who used drugs recreationally for the first time in 2010 began by using a prescription drug non-medically.
Drug diversion Opioid theft in health care delivery By Joe Cappello, MA
n the last 20 years, pharmaceutical controlled substances have become the drug of choice for abuse in the United States only exceeded by marijuana. The “traditional” drugs of abuse, heroin, methamphetamine, and cocaine are a distant third. Pharmaceutical opiates, when prescribed and used legitimately, are an effective tool for pain management. However, when they are illegally prescribed and abused, they become pharmaceuti-
cal-grade heroin. Heroin and pharmaceutical opiates are now stand-ins for each other—when one is difficult to obtain, users switch to the other. A by-product of recent pain management models in the U.S. health care industry is that pharmaceutical opiates are ubiquitous in health care environments. Put simply, more medical professionals directly handle controlled substances, which means Drug diversion to page 10
Among adolescents, 7.1 percent of high school seniors in the U.S. reported non-medical use of narcotics other than heroin in the past year (Monitoring the Future Study, 2013). While this may seem relatively small, young people who misuse prescription opioids face a heightened risk of addiction and overdose, and also are more Confronting prescription opioid misuse to page 14
THE PAIN SPECIALIST TEAM YOU CAN TRUST Trust the care of your patients to the team at Medical Advanced Pain Specialists (MAPS). We are pleased to offer an inter-disciplinary approach to pain management, that may include: • Interventional Procedures • Physical Therapy • Behavior Health • Chronic Pain Program
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January 2015 • Volume XXVIII, No. 10
Features Drug diversion Opioid theft in health care delivery
MINNESOTA HEALTH CARE ROUNDTABLE
By Joe Cappello, MA
Confronting prescription opioid misuse Physicians play a pivotal role
By Carol Falkowski
The New Face of Health Care
Minnesota Health Care Roundtable Treating chronic illness
Is health care reform helping? By MPP staff
Expanding medical professional relationships
Ruth Martinez, MA Minnesota Board of Medical Practice
Living well with chronic conditions By Jean K. Wood, MSW, MAPA
Thursday April 23, 2015, 1:00-4:00 PM
legislative update 20 New faces, old issues By Nate Mussell, JD
Downtown Minneapolis Hilton and Towers
Colorectal cancer in Minnesota By Shelly Madigan, MPH; Matthew Flory, MPP; and Jim Chase, MHA
To be, or not to be? By Jennifer Reedstrom Bishop, JD, and Timothly A. Johnson, JD
Health Disparities 18 Advancing health equity By Peter Dehnel, MD
Background and Focus: With dramatic population growth, and as baby boomers become senior citizens, the demand for health care is exceeding the supply. Addressing the shortage of medical doctors involves creating new relationships between medical professionals. Training and licensure for Physician Assistants, Advanced Nurse Practitioners, Chiropractors, Respiratory Therapists, Physical Therapists, Home Care Providers, Dentists, and many other health care professions have become increasingly rigorous and provide expanded support to our health-care delivery system. Greater integration of these professions allows medical doctors to work to the top of their license but requires new pathways for communication and care coordination. Objectives: We will examine many of the new partnerships that are emerging between medical doctors and other medical professionals. We will look at the ways leveraging these new relationships can improve access to care while reducing costs and improving outcomes. We will consider points of resistance to forming these kinds of health care teams and what should be avoided in creating them. We will discuss what the proper oversight for these relationships should entail and how to maximize the coordination of care that they require. Sponsors Include:
Minneapolis Advanced Pain Specialists and Pediatric Home Service
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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.
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Please mail, call in, or fax your registration by 4/20/2015 January 2015 Minnesota Physician
Report Compares Medical Costs Across Minnesota Minnesota Community Measurement (MNCM) has released a report comparing the cost of medical care at providers throughout the state. This is the first time a total cost of care report has been issued. The group gathered data from 2013 claims from Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, and PreferredOne. Figures from more than 1.5 million patients were analyzed to determine average costs for 115 medical groups representing 1,052 clinics in Minnesota. The data included combined payments from consumers and insurers. Figures were risk-adjusted and outlier costs were removed to make the information as accurate as possible. The average monthly cost of care per patient was $435, but that figure ranged from $269
to $826 at individual medical groups. Eighty percent had an average range of costs, according to MNCM. Per adult, the average monthly cost was $514, while it was $216 for pediatric patients. “What’s striking is the difference between medical groups in the middle—a range of more than $1,500 per patient annually just between those considered average cost,” said Jim Chase, president of MNCM. The lowest monthly cost on the list came from Moorhead-based Seven Day Clinic, at $269. The highest-cost medical group was Mayo Clinic, which came in at a monthly cost of $826—20 percent higher than the average. Chase estimates that if every clinic cut spending by $12 per patient per month, the state would save $750 million in health care costs annually. “Medical groups can see where they stand on cost and to collaborate with others to learn what’s working to improve value
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of care,” said Chase. “This helps everyone improve and drives change.” The report is the result of a three-year effort involving many parties. The medical groups plan to use the information to improve the affordability of care. “Minnesota’s providers and health plans are to be commended for working together to increase transparency of the cost of care and for using that information to improve the value of care,” said Chase. “These conversations are not always easy, but the results are essential for our community.”
Essentia Health Recognized for Low Blood Pressure
Essentia Health has ranked in the 90th percentile for health care systems that have lowered patient blood pressure through a national program by the American Medical Group Association called
Measure Up/Pressure Down. “We have a higher prevalence of patients with high blood pressure in this area, so it’s very important for us to provide the best possible care,” said Cindy Ferrara, program manager of quality improvement at Essentia Health. The goal of the campaign is for health care providers to have 80 percent of patients with high blood pressure have their condition under control by 2016. According to the American Medical Group Association, high blood pressure contributes to almost 1,000 deaths every day in the U.S. There are 84 medical groups participating in the program. “We challenged our health care providers to raise the bar on high blood pressure treatment and control with a first-of-itskind campaign,” said Donald Fisher, CEO of the American Medical Group Association. “Our initial data confirm that we are making a dramatic difference in the health and well-being of our
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Minnesota Physician January 2015
patients with high blood pressure less than two years into our effort.”
Minnesota Ranking Falls on National Health Report
Minnesota has been ranked sixth among all 50 states in the 2014 edition of America’s Health Rankings that was issued Dec. 10 by the United Health Foundation in collaboration with the American Public Health Association and the Partnership for Prevention. The state ranked third in 2013 and 2012 before falling to sixth this year. Neighboring states Wisconsin and Iowa ranked 23rd and 34th respectively. Hawaii came in first, while Mississippi was ranked last. Minnesota did well on several measures. The state remained in first place for fewest cardiovascular deaths, at 184.7 deaths per 100,000. It came in second for lowest rate of prema-
ture death (which fell 5 percent in the last two years), fewest days of poor physical health, and fourth for health insurance coverage and fewest days of poor mental health. The state also showed some areas that need improvement. It had a high percentage of adults that engage in binge drinking and placed 46th for that measure. In addition, Minnesota showed persistent disparities in health status among racial groups, a high incidence of pertussis (in which it ranked 48th), and low per capita public health funding (in which it ranked 44th with an investment of $48 in state and federal funds per resident). “Minnesota continues to perform well in most measures of public health, but we’ve slipped in some key areas and we are still seeing significant racial disparities in health status,” said Ed Ehlinger, MD, Minnesota commissioner of health. “We need to continue our work to address health disparities as well as the
other issues highlighted in the report.” This is the 25th year that the report has been issued. Minnesota ranked first in 1990; sixth place is the lowest ranking it has received in any year.
More Testing Needed for Adults With Hypertension
About one in three, or 345,000, Minnesotans with hypertension reported that they have not been tested for diabetes in the last three years, according to an analysis from the Minnesota Department of Health (MDH). It is a U.S. Preventive Service Task Force recommendation to test blood glucose levels in patients with hypertension because research shows that there is a 50 percent reduction in cardiovascular events if people who are diagnosed with diabetes receive proper treatment. About 1.1 million adults in Minnesota have
hypertension. Researchers used data from the 2011 Minnesota Behavioral Risk Factor Surveillance System to determine how many of these patients also were being tested for diabetes. This is the first analysis of its kind from MDH. “We need health care providers to be aware of the need to screen people with hypertension for diabetes,” said Renee Kidney, PhD, lead author of the analysis and senior epidemiologist at MDH. “And, very importantly, we need people with hypertension to talk to their providers and ask for the screening.” There were adults from all age groups, gender, and weight categories who reported not having a diabetes screening. Overall results show adults with hypertension that were less likely to have been tested for diabetes were 18 to 44 years old; normal weight or overweight (not obese); not taking high blood pressure medication; had less than a college education; Capsules to page 6
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and had not been to a checkup in the last two years. Kidney added that the results show a lack of testing and a lack of recognition among respondents about tests they may have been given by their doctors already. “It may be that one is needed, or it also may be an issue of people not recognizing the name of a test that their provider has given them already,” she said.
New Brain Aneurysm Treatment Studied
Abbott Northwestern Hospital and Consulting Radiologists, Ltd. (CRL) are conducting a study to determine the safety and effectiveness of an investigational device called the WEB Aneurysm Embolization System. The device, created by Sequent Medical, based in Aliso Viejo, Calif., is made of a tiny wire mesh basket about the diameter of a pencil eraser. It is meant
to help patients with wide-neck bifurcation aneurysms, which are more challenging to treat with the traditional method of inserting tiny metal coils into the aneurysm. Instead, the device is placed inside the aneurysm through a catheter that is threaded through the arteries and into the brain. Researchers will investigate whether the WEB Aneurysm Embolization System is an effective alternative to reduce and eventually eliminate blood flow within the aneurysm. “If proven to be efficacious, this could be an exciting new technology that expands the horizon of endovascular brain aneurysm treatment, particularly of wide-neck bifurcation aneurysms, which until now, required stent assistance for treatment,” said Josser Delgado, MD, CRL interventional neuroradiologist at Abbott Northwestern. The device already has undergone several European trials. This study will determine FDA approval in the U.S.
Minnesota Physician January 2015
Genetic Testing Benefits Most TripleNegative Breast CA A study led by Mayo Clinic has found that most patients who have triple-negative breast cancer would benefit from genetic testing for mutations in known breast cancer predisposition genes, including BRCA1 and BRCA2. “Clinicians need to think hard about screening all their triple-negative patients for mutations because there is a lot of value in learning that information, both in terms of the risk of recurrence to the individual and the risk to family members,” said Fergus Couch, PhD, professor of laboratory medicine and pathology at Mayo Clinic and lead author of the study. “In addition, there may be very specific therapeutic benefits of knowing if you have a mutation in a particular gene.” Results from the study show that nearly 15 percent of triple-negative breast cancer
patients had harmful mutations in the predisposition genes, the majority of which appear in genes involved in DNA damage repair. Of those, 11 percent had mutations in the BRCA1 and BRCA2 genes. Researchers say the findings suggest that the origins of triple-negative breast cancer may differ from other forms of the disease. “Triple-negative breast cancers are different from all the other breast cancers,” said Couch. “Other studies have suggested that this form of the disease might be associated with some defect in DNA repair, and our study verifies that. Our findings generate a whole new set of hypotheses about how triple-negative breast cancer might be arising, which could give us better ideas for prevention or new therapies for this disease.” The results support genetic testing guidelines for triple-negative breast cancer patients who have a family history of cancer or a diagnosis before age 60.
Medicus Howard Epstein, MD, is the new executive vice president and chief medical officer of PreferredOne, Golden Valley. Board-certified in internal medicine, he completed medical school at Washington University, St. Louis, and a residency in internal medicine at the University of Minnesota. Previously, he served as chief health systems officer at the Institute for Clinical Systems Improvement, Bloomington. Peter Igarashi, MD, board-certified in nephrology, has assumed the position as Nesbitt Chair and head of the Department of Medicine at the University of Minnesota. He graduated from UCLA School of Medicine, and completed a residency in internal medicine at the University of California, Davis, and a nephrology fellowship at Yale University School of Medicine, New Haven, Conn. Igarashi previously served at the University of Texas Peter Igarashi, Southwestern Medical Center, Dallas, where he MD held the Robert Tucker Hayes Distinguished Chair in Nephrology; was a professor of internal medicine and pediatrics and chief of the Division of Nephrology; and directed the university’s O’Brien Kidney Research Core Center. Ronald Ronquist, MD, board-certified in orthopedic surgery, has joined the Essentia Health– Virginia Clinic. Ronquist earned a medical degree from the University of Michigan Medical School in Ann Arbor and completed a residency in orthopedic surgery at McLaren Health Care– Flint in Flint, Mich.
Penny Wheeler, MD
/// Music Director
Ronald Ronquist, MD
Riddell W. Scott, MD, board-certified in dermatology, has joined Ridgeview Specialty Clinic. She graduated from the University of Tennessee Health Sciences Center College of Medicine in Memphis, where she completed a residency in dermatology. Charles J. Snow, MD, board-certified in obstetrics and gynecology, has joined Western OB/GYN in Waconia and Chaska, a division of Ridgeview Clinics. Snow graduated from the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and served a residency in obstetrics and gynecology at the University of Minnesota Medical School.
Riddell W. Scott, MD
Penny Wheeler, MD, has assumed the position as CEO of Allina Health. Previously, she Charles J. Snow, served as Allina’s president and MD chief clinical officer, having joined the Allina Health executive leadership team in June 2006. Wheeler, an obstetrician-gynecologist, completed medical school, residency, and an obstetrics and gynecology fellowship at the University of Minnesota Medical School.
Chester B. Whitley, PhD, MD, director, PKU Clinic, Departments of Pediatrics and Experimental and Clinical Pharmacology at the University of Minnesota, has been named a 2014 RARE Champion of Hope–Medical Caregiver by Global Genes. Global Genes is a California-based nonprofit organization that advocates for patients with rare diseases, and honored Whitley for his work with PKU patients. Whitley is board-cerChester B. Whitley, tified in genetics, completed all his medical PhD, MD training at the University of Minnesota, and is principal investigator of the Lysosomal Disease Network, headquartered in the university’s pediatrics department.
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January 2015 Minnesota Physician
Upholding the integrity of health care delivery Y ou have a long history working with the Board of Medical Practice (BMP). Tell us about the journey that led to your current position as the Board’s executive director.
Ruth Martinez, MA Minnesota Board of Medical Practice Ms. Martinez is executive director of the Minnesota Board of Medical Practice. She has a long career in public service and has been with the Board since 1988, including 12 years as supervisor of the Board’s Complaint Review Unit. Ms. Martinez works closely with internal and external stakeholders in the healthcare delivery system, and frequently represents the Board by participating in work groups and coalitions. She has been actively involved with development and implementation of programs, procedures, and technological advancements that improve access to information, enhance patient safety, and increase process transparency.
W hat are your plans around increasing the role of the Board in public policy issues?
At any time, there may be state or federal policy issues that impact the Board. My plans include My career in public service has involved three state building relationships with policy-makers, actively agencies: the Department of Revenue; the Departengaging with internal and external stakeholders, ment of Commerce; and, since 1988, the Board of monitoring community practice standards, identiMedical Practice. My first position with the Board fying trends, and researching legislative initiatives. involved processing physician license applications. Because the Board may be asked to take a position Responsibilities over my career have spanned the on policy issues, it full spectrum of is essential that the the Board’s work I appreciate the considerable Board, through its in issuing credenPolicy & Planning tials, investigatfinancial and personal investment Committee, fully uning complaints, necessary to complete a medical degree. derstands the issues and monitoring and implications compliance with of taking a formal Board actions, position. My role is to assure that we have the inforallowing me to support the Board in carrying mation necessary to make an informed decision on out its mission to protect the public. Through the whether to support, oppose, or remain neutral on licensing process, I came to appreciate the considerany policy issue impacting medical practice or the able financial and personal investment necessary to Board’s regulatory authority. complete a medical degree and engage in residency training. For applicants, acquiring a medical license brings a sense of achievement along with great W hat would you like physicians to know responsibility. Newly licensed physicians express about how the Board works on maintegratitude for the opportunity to practice medicine nance of certification? and display a sincere commitment to the health, The Board has been and continues to be actively enwelfare, and safety of patients. gaged in discussions at both the local and national My positions in the complaint review unit enabled levels on the evolution and understanding of “mainme to interact with consumers and licensees, and tenance of certification.” The Board recognizes that support the Board’s efforts to assure that credenlifelong learning and self-assessment are important tialed providers practice medicine with reasonable to updating a provider’s knowledge and skills. The skill and safety to patients. I have been involved in Board has authority to accept certification or recera number of special projects and initiatives intification by a specialty board in lieu of compliance cluding assisting in implementation of the Health with continuing medical education requirements Professionals Services Program (HPSP), serving as during the cycle in which certification or recertificaa liaison to internal and external stakeholders in the tion is granted. New standards for maintenance of health-care delivery system, and representing the certification continue to evolve and the Board will Board on work groups and coalitions such as the certainly continue to monitor and engage in discusMinnesota Alliance for Patient Safety. I have also sions about how physicians can best demonstrate participated in advancing the Board’s use of techcontinued clinical competence. nology through development of an award-winning internal database, launch of the Board’s website, W hat can you tell us about the kinds of and implementation of online services. As executive complaints the Board receives in terms of director of the Board, since August 2014, I have had annual volume, variety, and percentage the privilege of sustaining my engagement in public that lead to action? service. On an annual basis, the Board receives approximately 800 to 850 complaints and takes approxiW hat have been some of the biggest mately 65 to 75 disciplinary actions. The Board also changes you have seen in the nature of the enters into approximately 10 to 15 public, non-diswork done by the Board? ciplinary, corrective action agreements each year, Notable changes during my career with the Board to remediate isolated practice deficits. The Board include: 1) implementation of the Health Professionis obligated to investigate all complaints that are als’ Services Program (HPSP), for providers with within its statutory jurisdiction. The investigation health conditions that may require confidential seeks factual findings to determine whether the monitoring to assure patient safety; 2) legislative aupractice act has been violated and whether discithority for use of nondisciplinary corrective action plinary or corrective action is necessary to protect agreements; 3) expanded use of educational conthe public. Disciplinary actions are often based on ferences to address practice concerns; 4) enhanced illness or addiction, inappropriate prescribing pracuse of technology for managing internal processes, tices, violation of state or federal laws relating to the providing external access to information, and offerpractice of medicine, substandard medical practice, ing online services; and 5) increased transparency or inadequate documentation. A complaint may be regarding Board processes. dismissed without action if the investigative process
Minnesota Physician January 2015
assures the Board that the respondent practitioner meets minimum practice standards and the public is not at risk by his or her continued practice.
T ell us about the Board’s role in registering physicians to practice telemedicine. Effective July 1, 2002, legislation was enacted to require that physicians practicing telemedicine who were not fully licensed in Minnesota, register annually with the Board. Eligibility for telemedicine registration requires that the physician be fully licensed in the state from which the telemedicine services will be provided, and shall not have been subject to revocation or restrictions of a license in any state or jurisdiction. The physician must also comply with state laws, the state judicial system, and the Board with respect to providing medical services to state residents.
H ow do you work with other state boards of medical practice? Board members and staff have established strong relationships with other state regulatory boards through active participation with the Federation of State Medical Boards (FSMB) and Administrators in Medicine (AIM). Board members and senior staff routinely attend annual meetings to hear presentations on relevant topics, interact with other
regulators, and share ideas for developing effective regulatory policies and procedures. In addition to its activities at the national level, the Board also has statutory authority to share public and non-public data with other state licensing boards, and may request public and non-public data from other states. Disciplinary actions are reported to a national practitioner data bank and to the FSMB for distribution to other jurisdictions in which the licensee may hold or seek licensure or employment, and for posting on the nationally accessible AIM website.
W hat are some of the biggest challenges facing the BMP? The Board is challenged to evaluate and understand the scope of its regulatory authority within an evolving team approach to health care delivery, in which a group of providers with different roles, responsibilities, and license types may collaboratively provide care to a patient. Another challenge involves regulating medical care and clinical oversight across state lines, as enhanced technology and new business models remove physical obstacles and expand opportunities to provide medical services across jurisdictional boundaries. The Board is also challenged to explore ways to expedite licensure and develop licensing requirements consistent with other states. Currently, the Board is researching and evaluating the regulatory implications
of an Interstate Medical Licensure Compact proposed by the FSMB. Another challenge is timely access to relevant patient medical records, which are essential for the Board to fairly and efficiently complete its regulatory investigative processes. Receipt of incomplete or heavily redacted medical records may delay a Board investigation or preclude the Board from accurately determining whether violations have occurred.
W hat do you want doctors to know about the BMP? Board members and staff are committed to the Board’s mission to protect the public and uphold the integrity of health care delivery in Minnesota. Both physician and public members of the Board make substantial contributions of their time and expertise to carry out the Board’s mission by serving on the Licensure, Policy & Planning, and Complaint Review Committees. In addition, Board members value relationships with their fellow Board members, Board staff, the Attorney General’s office, professional peers, and regulators in other jurisdictions to assure that they are fair and effective in issuing credentials and regulating licensed health care providers. I cannot recount the number of Board members who have described their service on the Board as one of their most important and rewarding endeavors.
University of Minnesota - Continuing Professional Development (formerly the Office of CME) Education is essential to achieving and sustaining quality healthcare. Through partnership with healthcare leaders, our educational activities help advance quality improvement and patient care initiatives.
2015 CPD Activities
(All courses in the Twin Cities unless noted)
LIVE COURSES Pediatric Dermatology Progress & Practices February 20, 2015 Fundamentals of Critical Care Support March, 2015 Integrated Behavioral Healthcare Conference: Building Partnerships & Teams for Better Care March 13, 2015 Cardiac Arrhythmias: An Interactive Update for Internal Medicine, Family Medicine & Pediatrics April 3, 2015 Psychiatry Update Spring 2015 April 9-10, 2015
Maintenance of Certification in Anesthesiology (MOCA) Training April 18, 2015 Live Global Health Training (weekly modules) May 4-29, 2015 Midwest Cardiovascular Forum Controversies in Cardiovascular Disease May 16-17, 2015
www.cmecourses.umn.edu ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Adolescent Vaccination • Nitrous Oxide for Pediatric Procedural Sedation • Preventing Chronic Pain • Global Health - To include Travel Medicine & Refugee Health - Family Medicine Specialty - Pediatric Specialty For a full activity listing, go to www.cmecourses.umn.edu
Bariatric Education Days: Advances in Bariatric Care May 27-28, 2015 Workshops in Clinical Hypnosis June 4-6, 2015 Topics & Advances in Pediatrics June 4-6, 2015
Office of Continuing Professional Development 612-626-7600 or 1-800-776-8636 • email: email@example.com
Promoting a lifetime of outstanding professional practice
January 2015 Minnesota Physician
Drug diversion from cover
more opportunities for abuse. If a medical professional steals or tampers with controlled substances in order to abuse them, the potential consequences are far reaching and catastrophic to their patients, their employers, their peers, and, ultimately, themselves. A tampering case As an example, in March 2011, the Drug Enforcement Administration (DEA) Minneapolis–St. Paul District Office was notified by a Central Minnesota hospital that a registered nurse employee stole hydromorphone, a Schedule II injectable narcotic, by tampering with its packaging, resulting in the bacterial infection of 25 postsurgical patients, one of whom died from related complications. During interviews with DEA, U.S. Food and Drug Administration (FDA), and Minnesota Department of Health (MDH) personnel, the nurse admitted
that he removed hydromorphone from IV drip bags and replaced it with saline solution. The nurse said that he stole the
Opiates are ubiquitous in health care environments. drugs for self-use. It is worth noting that the nurse tested negative for HIV, hepatitis B virus, and hepatitis C virus. Forensic analysis revealed that the bottle of saline the nurse kept in his personal work
MDH’s investigation summary, Outbreak of Gram-Negative Bacteremia at St. Cloud Hospital, (2012, June 13), stated, “Importantly, within 48 hours of symptom onset, six case-patients were transferred to an intensive care unit, three required unanticipated surgical procedures due to the unexplained nature of their symptoms, and one died. It is unclear whether case/ patient outcomes were a result of symptoms of bacteremia or symptoms of inadequate pain management since health care workers responding to the case/patient would have assumed that the patient was receiving the prescribed dosage of narcotic. While it is possible that coincidental events led to these outcomes, given the microbiologic and epidemiologic data, this is highly unlikely.” The nurse pleaded guilty to federal charges and was sentenced to 24 months incarceration in March 2013. In addition, the nurse was ordered to pay victim restitution in the amount of $340,000.
The problem and consequences Given the obvious short- and long-term catastrophic potential consequences of drug theft and tampering, it is helpful to understand the scope of the problem, how to respond to a theft, and ways to prevent and detect theft and tampering of controlled substances.
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The reasons for opioid abuse among medical professionals ranges from developing an addiction to controlled substances that are legitimately prescribed after an injury or for a condition, to experimental curiosity about the euphoric effect they see in patients when administering a controlled substance.
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space and used for tampering was contaminated with the genetically identical bacteria found in the infected patients.
Minnesota Physician January 2015
The intention of the substance abuse was not to betray
their patients, their oaths, their peers, and their employers. However, pretrial services, probation, prosecutors, and judges respond to these violators through the filter of the drug addiction that drove the violator’s behavior. The majority of medical professionals that divert controlled substances admit to stealing the drugs for self-use, while some distributed the drugs to others purely for profit; the latter operate in the same manner as common drug dealers. There are three important things for law enforcement and the employer to consider when dealing with possible drug tampering: 1. To triage the possible immediate and long-term consequences of bacterial and viral infectious agents harming or killing patients 2. T o identify and stop the violator 3. To rule out that the violator is carrying an infectious agent Many violators are frequently intoxicated while on the job and the possible consequences of this behavior are self-evident. The victims of diversion often experience little or no pain relief. The violator typically makes medical administration notations to hide the drug diversion. The next professional to review the chart might administer a larger dose in the belief that the patient is opiate tolerant and unwittingly overdose the patient. Tampering of pills or capsules often involves the violator substituting a look-alike non-controlled drug that can potentially harm a patient when administered. It is important that the employer attempt to audit all available data (i.e., Pyxis records, video, MARs, and key-card events) to understand the scope of the violator’s activity in order to identify likely victims. Who are the violators? The majority of thefts involve
nurses. However, investigations involve thefts by physicians, dentists, home health care workers, pharmacists, laboratory technicians, custodial staff members, and emergency medical technicians. No one category is immune from drug diversion. This is not to imply that nurses are more likely to commit these crimes, but rather nurses generally have frequent, legitimate, necessary, and routine access to controlled substances in their work environment versus other medical professionals. Drug diversion is about access and opportunity. There are two types of violators. Some work in a hospital or clinic and have an established, long-term career and are, quite often, highly regarded by their peers. In general, these violators seem to gravitate to injectable narcotics in Schedule II such as hydromorphone, fentanyl, and morphine. The other type of violators are transitional professionals who often move from one job location to another (i.e., home health care, nursing homes, hospice) in order to veil their theft or tampering. These violators seem to gravitate to tablets or capsules in Schedules II, III, and IV such as oxycodone, hydrocodone, and the benzodiazepines. The Coalition In May 2011, as a result of the bacterial infection in the Central Minnesota hospital, the Minnesota Hospital Association (MHA), and MDH convened the Minnesota Controlled Substance Diversion Prevention Coalition, a collaborative effort of a broad-based stakeholder group across a variety of care settings including hospitals, long-term care facilities, professional health care organizations and associations, home care, state licensing agencies, law enforcement, prosecution, and hospice. In March 2012, the Coalition published a comprehensive report of “Best Practice Principles” for pharmacies located
in hospitals and clinics. These guidelines are available at the MHA and MDH websites and can be adapted easily to fit every size and type of medical facility that stores, administers, and dispenses controlled substances.
Figure 1: N umber of reports of theft or loss to the DEA submitted via form DEA-106 per year and per month
Another product of the Coalition was the analysis of reported thefts/ losses of controlled substances to DEA from April 2005 to August 2013. DEA registrants are required to submit theft/loss reports of controlled substances to DEA. There is no federal requirement that nonDEA registrants such as nursing homes, hospice care, and home health care agencies report thefts or losses to DEA. As a result, there is little or no data concerning controlled substances thefts from those facilities.
percent. (Source: DEA theft/loss data analyzed by DeVries.) Recent DEA theft/loss data through September 2014, which has not been analyzed, suggests that the rise in reporting continues at the same rate as previously reported drug thefts.
Although it is difficult to determine cause and effect from this data, it suggests that registrants are getting better at detecting theft and reporting it more accurately. DeVries analyzed the DEA Drug diversion to page 12
The scope of theft and tampering To understand the scope of medical professional theft, the DEA theft/loss data, analyzed by Aaron DeVries, MD, MPH, medical director of the Infectious Disease Epidemiology, Prevention, and Control Division at MDH, included all reported thefts (see Figure 1 above) of controlled substances in the state of Minnesota. These thefts were denoted as “employee pilferage” or “other” from hospital/clinic pharmacies, retail pharmacies that are physically co-located in a clinic or hospital, and practitioners who store controlled substances for use by patients (i.e., outpatient surgery center). Narcotics are involved in these thefts about 80 percent of the time, benzodiazepines about 11 percent, and stimulants about 7 percent. Ketamine, testosterone, muscle relaxers, THC, and barbiturates comprise the remaining 2 January 2015 Minnesota Physician
Drug diversion from page 11
Figure 2: D iversion events per 100,000 population: 1/2009–8/2013
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Souce: DEA theft/loss data analyzed by Aaron DeVries, MD.
Figure 3: IV/IM diversion events per 100,000 population: 1/2009–8/2013
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Souce: DEA theft/loss data analyzed by Aaron DeVries, MD.
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Figure 4: P rescription painkillers sold in Minnesota
Grams per 10,000 people Up to 2,200 grams 2,201 to 2,800 2,801 to 3,300
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3,301 and up
Source: Automation of Reports and Consolidated Orders System (ARCOS), U.S. Drug Enforcement Administration, 2012. Prescription opiate analgesics (painkillers) include: codeine, morphine, fentanyl (brand names: Sublimaze, Actiq, etc.); hydrocodone (brand names: Vicodin, Lortab); hydromorphone (brand names: Dilaudid, Palladone); meperidine, pethidine (brand name: Demerol); and oxycodone (brand names: OxyContin, Percodan, Percocet). 2011 data. (Falkowski 2013)
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theft/loss data based on diversion events per 100,000 population and mapped it geographically in Figures 2 and 3 above.
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
Analysis of DEA’s ARCOS data by Minnesota ZIP code (see Figure 4 above) revealed
Minnesota Physician January 2015
regional variations in the population-based prescribing of opioid medications (Falkowski, Drug Abuse Trends in Minneapolis/St. Paul, Minnesota–January 2013 Update, Drug Abuse Dialogues, St. Paul, 2013).
employees who are aware that controlled substances are being diverted report this to the appropriate person in management.
There is a direct correspondence between increased availability of controlled substances and thefts of controlled substances. Ultimately, investigators want to prevent drug diversion rather than respond to it.
However, evidence that theft is occurring is, obviously,
Detecting theft or tampering Detecting the theft or tampering of controlled substances can be difficult. Management adopting the Best Practices Principles that were developed and published by the Minnesota Controlled Substance Diversion Prevention Coalition would go far toward preventing, detecting, and responding to thefts. Management should implement as many elements as possible. The Principles are based on the concept of “trust but verify” and are easily adapted to the retail pharmacy, hospice, nursing home, and physician and dental venues, among others. d
not limited to: slurred speech, lethargic or intoxicated behavior, increased irritability, change in work performance, social withdrawal, furtiveness, and clothing choices to hide injection sites.
Heroin and pharmaceutical opiates are now stand-ins for each other.
different from suspecting that theft is occurring. Interactions with many of these violators by employers and investigators reflect a common denominator: unexplained changes in the violator’s behavior before the thefts occur and continuing until they are caught. Some obvious signs include, but are
Federal law requires that
Although many Minnesota hospital systems have begun implementing the Best Practices Principles, drug theft and tampering are persistent and pernicious. Sadly, violators are very good at “gaming the system” and will exploit any systemic weakness to feed their addiction. It is vitally import-
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ant to have systems in place to guard against diversion and to promote early detection of theft when it does happen. Appropriately stated by Ms. Falkowksi, “Everyone working in a health care setting should learn to identify the behaviors that may indicate an emerging substance abuse problem and possible drug diversion in a coworker. If faced with suspected drug addiction or drug diversion by a coworker, the first step is to contact the appropriate person in their organization. Heightened awareness is no longer enough. Observant and concerned workers are essential eyes and ears on the ground. Without their willingness to become part of the solution, the problems associated with pharmaceutical drug diversion will only escalate—at everyone’s expense.” Joe Cappello, MA, has been a diversion investigator with the Drug Enforcement Administration since 1989.
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Confronting prescription opioid misuse from cover
likely to use other drugs. A 2013 study published in the Michigan News found that roughly one-third of the 18-year-olds who used prescription opioids non-medically continued the misuse into their twenties, and almost all used marijuana or other controlled substances at ages 23–24. An estimated 100 million Americans experience chronic pain (non-cancer, non-acute pain lasting more than 90 days), at an estimated annual cost ranging from $560 to $635 billion (Relieving Pain in America, a Blueprint for Transforming Prevention, Care, Education, and Research, 2011). This represents one-third of the U.S. population. The prevalence is expected to increase with the rise in diabetes, cardiovascular disease, obesity, and arthritis in the aging population. Since opioids are commonly prescribed in the treatment
of pain, it is no surprise that prescriptions have risen as well. The number of prescriptions for opioids dispensed by U.S. pharmacies grew 48 percent from 2000 to 2009 alone, from 174 million to 257 million (SDI, Vector One: National Years 2000–2009). Opioids can produce significant side effects such as respiratory depression, mental clouding, nausea, constipation, physical tolerance, and dependence. They have high abuse potential, high addictive potential, and high overdose potential. Some patients who exceed the prescribed amount will develop opioid addiction. Some of these will be people with no prior addiction history who were otherwise healthy individuals. Many opioid addicts, in turn, will switch to heroin use because it is readily available, is generally of high purity, and is more affordable than prescription opioids. Some patients will profit from the sale of their
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Figure 1: A dmission to Mpls./St. Paul addiction treatment programs by primary substance problem (excluding alcohol): 2007–2013
Minnesota Physician January 2015
Data used with permission from Minnesota Department of Human Services, 2014
diverted medications to opioid addicts. And some patients will develop hyperalgesia, an abnormal pain sensitivity, as the result of long-term treatment with opioids. Concomitant with the heightened availability of opioid medications is the dramatic and unprecedented influx of heroin into the U.S. from Mexico. Inasmuch as the magnitude of any drug epidemic is a function of both demand and supply, the supply of opiate drugs in this country has never been greater for both legal prescriptions and illegal heroin. The resultant opioid epidemic is one of many consequences that include hospitalizations, addiction, overdose, and death. Hospital emergency department episodes involving non-medical use of narcotic analgesics more than doubled from 2004 to 2011 (from 1,940 to 4,836) in the Twin Cities. Heroin-involved episodes nearly tripled during the same time period, rising from 1,189 to 3,493 (Falkowski, Drug Abuse Trends in Minneapolis/St. Paul, Minnesota, June 2013). From 2012 to 2013, heroin exposures reported to the Hennepin Regional Poison Center grew from 127 to 147, a 15.7 percent increase.
The number of people receiving treatment for opiate addiction is rising everywhere. Nationwide, 9.7 percent of total treatment admissions in 2012 were for opiates other than heroin, compared to only 1 percent in 1997, according to the 2013 Treatment Episode Data Set. In Minnesota, of the 49,814 addiction treatment admissions in 2012, 8.4 percent were for opiates other than heroin, and 8.2 percent were for heroin, according to the Minnesota Department of Human Services. In the Twin Cities in 2013, treatment admissions for these drug categories reached unprecedented levels; 9.5 percent of treatment admissions were for opiates other than heroin (compared with 1.4 percent in 2000), and 14 percent were for heroin (compared with 3.3 in 2000; see Figure 1 above). Treatment admissions for heroin and other opiates combined (23.5 percent) now are second only to treatment admissions for alcohol (43.9 percent). From 1999 through 2012, the age-adjusted drug-poisoning death rate in the U.S. more than doubled, from 6.1 per 100,000 population to 13.1, according to the CDC. During the same time period, the rates for deaths involving opioid analgesics more than tripled, from 1.4 per
Figure 2: D rug-related deaths in Hennepin and Ramsey counties: 2006–2013
Data used with permission from Hennepin County Medical Examiner, Ramsey County Medical Examiner, 2014.
100,000 to 5.1. Of 41,502 deaths due to drug poisoning in 2012, 16,007 involved opioid analgesics and 5,925 involved heroin. The CDC reports that the death rate from heroin overdose doubled from 2010 to 2012 alone. Drug-induced deaths now outnumber motor vehicle deaths. Prescription opioid overdose deaths outnumber deaths from heroin and cocaine combined (CDC Vital Signs, 2011). Opiate-related deaths in Hennepin and Ramsey Counties have significantly escalated in recent years as well (see Figure 2 above). Future considerations and solutions Addressing a drug epidemic in the United States historically involves: prevention in schools, homes, and communities; access to evidence-based addiction treatment; and action by law enforcement to curtail the supply. Yet, with this epidemic and the undeniable role of the medical community, it is equally important to scrutinize and change medical practices that contribute to and perpetuate it. To help ensure that pain was assessed as part of patient evaluations, the Joint Commission on the Accreditation of Healthcare Organizations declared pain to be the fifth vital sign in 1999. Has this created undue emphasis on it? Today, patient satisfaction metrics often are calculated into formulas used to determine a doctor’s compensation. Patient complaints are
to be avoided at all costs. Yet, addicted, doctor-shopping patients will never give satisfactory ratings unless their prescriptions are issued and repeatedly refilled. Could this be a possible institutionalized disincentive for doctors to address a patient’s addiction to opioids? It is probable that both of these practices have had unintended, but significant consequences that may have a chilling effect on changing medical practice to more effectively prevent, identify, and address opioid abuse and addiction.
Doctors also must acquire and maintain an up-to-date knowledge base about the range and efficacy of various addiction treatment options, particularly medication-assisted treatment for opioid addiction. Doctors often face a knowledge gap about the effects of long-term opioid therapy in the treatment of chronic pain and uncertainty about how best to proceed with patients who struggle. Add to this mix, an apparent lack of consensus among the medical community regarding the extent to which longterm treatment with opioids adequately reduces patients’ symptoms or improves patient functioning and quality of life. Medical students and doctors alike need to keep apprised of the emerging science about opioids and other, alternative methods of treating long-term, chronic pain. Federal regulations At the federal level, the U.S. Drug Enforcement Admin-
istration (DEA) is making it easier for people to dispose of unwanted, unused prescription medications by developing regulations that allow the transfer of pharmaceutical controlled substances to authorized collectors for the purpose of disposal. Certain DEA registrants (manufacturers, distributors, reverse distributors, narcotic treatment programs, retail pharmacies, and hospitals/clinics with an on-site pharmacy) can modify their DEA registration to become authorized collectors. The U.S. Food and Drug Administration (FDA) recently reclassified hydrocodone combination drugs such as Vicodin from Schedule III to Schedule II of the Controlled Substances Act. Under Schedule III doctors could prescribe a six-month supply as a 30-day prescription with up to five refills. Now, under Schedule II, they are limited to a three-month supply Confronting prescription opioid misuse to page 42
Insufficient physician training Long-standing inadequacies in medical training about addiction, pain management, and opioids also must be remedied. It is still the case that these topics are hardly covered in medical schools, yet are critical to the understanding of the dual epidemics of opioid addiction and chronic pain. When doctors are not adequately educated about the basics of addiction, it continues to go unnoticed, undiagnosed, and untreated. Screening for addiction needs to be integrated with primary care, as is routine screening for other chronic diseases with behavioral components such as diabetes, hypertension, and asthma. Practitioners needn’t wait until the disease has developed in order to initiate a dialogue with patients about high-risk drinking and drugging behaviors that if left unchecked, can progress into addiction.
January 2015 Minnesota Physician
eople with chronic conditions rarely spend more than 1 percent of their life at a health care provider’s facility. It is the other 99 percent of one’s life—when an individual is at home—that determines whether they return to full health or not.” Unknown In the United States, approximately one out of every two people have at least one chronic condition, and one in four have multiple chronic conditions. According to the Chronic Conditions among Medicare Beneficiaries Chartbook, 2012 edition (published by the Centers for Medicare & Medicaid Services), 63 percent of those aged 65 to 74 have had two or more chronic conditions. By age 85, 83 percent had two or more chronic conditions. According to the National Council on Aging (NCOA), direct health care expenditures associated with chronic conditions totaled more than $262 billion in 2009. Chronic health issues affect health care costs as well as a
Living well with chronic conditions How self-management programs can help By Jean K. Wood, MSW, MAPA person’s quality of life and ability to live independently. An individual’s health and well-being is heavily influenced by daily decisions about diet, exercise, medication, and when to seek medical care. Self-management education programs, such as the Stanford University Chronic Disease Self-Management Program (CDSMP), provide the tools needed to change and improve the lives of those living with ongoing health conditions. CDSMP is designed to help participants gain confidence (self-efficacy) and the skills to better manage their health issues. Action
planning, problem-solving, and decision-making techniques enhance a person’s ability to cope with ongoing health issues. The start of Stanford’s program The Stanford School of Medicine’s CDSMP was developed in the Family and Community Medicine division at Stanford University’s School of Medicine after receiving a five-year research grant. The purpose of the research was to develop and evaluate a community-based, self-management program that assisted people with chronic illness. The study was completed in 1996. Over 1,000 people with
various health conditions participated in a randomized, controlled test of the program, and were followed for up to three years. Those who participated in the program, as compared to the control group, demonstrated significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, and social/role activity limitations. In addition, they spent fewer days in the hospital and had fewer outpatient visits and hospitalizations. The workshop CDSMP is an evidence-based program that has been approved by the U.S. Administration for Community Living, U.S. Centers for Disease Control and Prevention, and the NCOA. CDSMP is a workshop for anyone 18 years of age or older, with an ongoing health condition. CDSMP is offered in 46 states and 19 countries and is known under various names,
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Minnesota Physician January 2015
for example: Healthier Living, Better Choices, Better Health, or Living Well. In Minnesota, CDSMP is called Living Well with Chronic Conditions. Living Well with Chronic Conditions is a six-week group workshop that meets for two and a half hours per week in community centers, churches, community education classrooms, clinics, and hospitals. Workshops are facilitated by two trained leaders, one or both of whom have chronic illnesses themselves. The workshop is designed so participants can build confidence in managing ongoing health conditions such as heart disease, diabetes, high blood pressure, and arthritis. Subjects covered during the workshop include appropriate exercise; communicating effectively with family, friends, and health professionals; nutrition; decision-making; and techniques to deal with problems such as frustration, fatigue, pain, and isolation. The workshops are designed to actively involve participants. Activities such as action planning, problem-solving, and decision-making let participants learn from each other, build on successes, and incorporate skills that help them manage their health issues. The interactive workshop gives participants the opportunity to experience a sense of confidence and success, to see things from a new perspective, and to connect with others who have similar issues. The way that CDSMP is taught is as important, if not more important, than the subject matter. Because CDSMP is a licensed, evidence-based program the leader manuals are scripted and that maintains program consistency regardless of where it is offered. Self-management skills There are three major skills that are key in the self-management component of a CDSMP workshop: action planning, problem-solving, and decision-making. Action planning. At each workshop, participants develop a weekly action plan. The
plan involves something that each participant wants to do, is achievable, and is action spe-
restaurant. John decided that he would invite a friend over for dinner and cook a healthy meal once or twice a week. Decision-making. People with chronic health issues often find themselves having to make many decisions in their dayto-day lives and when times are uncertain. This is a challenge even for those who are healthy. The workshop shows participants how to make decisions with confidence. Decision-making is broken down into a process that helps participants tackle what they need to decide on. They identify what they want, the options available, the pros and cons, and then ultimately apply the “gut test,” which makes them face how they really feel about a potential decision.
Approximately one out of every two people have at least one chronic condition. cific. Action plans help participants break a larger goal down into smaller, more realistic or achievable steps. Participants often are so overwhelmed by their health problems that they can’t see solutions to their everyday problems. Participants are encouraged to keep track of their plan during the week and report back on how it all went at the next meeting. Feedback is key to boosting participants’ confidence and ability to accomplish the tasks they set for themselves. Developing an action plan teaches them how to deal with problems and health issues so they can lead a more balanced life. For example, Mary wanted to walk to a nearby park to enjoy the flowers, but needed to build up her stamina. Her action plan involved walking in the hallway of her apartment for 10 minutes after breakfast three times a week. Each week she increased her walking time; after four weeks she was able to reach the park. Problem-solving. Everyone has problems, but when you are overwhelmed with chronic health issues, solving these problems can seem insurmountable. Learning the skill of problem-solving lets people see that there are many ways to solve a particular problem and often it’s liberating to realize this. For example, John liked to cook, but didn’t eat healthy because cooking for one was too hard. When he talked about this problem at the workshop he discovered that others faced the same issue. Suggestions ran the gamut from eating with a group, choosing a healthy frozen meal from the supermarket, having a friend over to share a homemade meal, or ordering healthy takeout meals from a
The results Randomized controlled trials and follow-up studies conducted over the last 10 to 15
years have shown the Stanford University CDSMP to be effective. Participants in the program have had very positive outcomes. They find that they are exercising more, managing their cognitive symptoms better, communicating more effectively with their doctors, feeling more energetic and less fatigued, and experiencing fewer bouts of fear or depression. Many of these benefits continued well beyond initial participation in a workshop. Between 2010 and 2012, Minnesota was one of 17 states to participate in a national follow-up study on how CDSMP changed health outcomes, lifestyle behaviors, and health care utilization. The overall results from Minnesota mirrored the positive results found nationwide. According to the NCOA fact sheet on the value of Stanford’s CDSMP, the positive effects of Living well with chronic conditions to page 40
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From the Courtroom to the Capitol.® January 2015 Minnesota Physician
onsider the following scenario. “Johnny” is born to a 24-year-old single mother at 29 weeks gestational age and has a very rocky NICU course. In spite of receiving optimal care, he has residual chronic lung disease and some moderate cognitive delays. His childhood is punctuated by frequent hospital and emergency room admissions for asthma largely due to his mother’s poverty-related stressors. She is unable to schedule follow-up appointments for her son or afford his expensive controller medications. Johnny’s biological father is not involved in his life at all. Because of his frequent school absences and residual cognitive delays, Johnny does not do well academically and ends up not graduating from high school. When he has a job, it tends to be temporary menial labor paying minimal wage. He begins smoking cigarettes, partly to help relieve his stress and depression. Due to a combina-
Advancing health equity How you can make an impact By Peter Dehnel, MD
300 to 350 range the few times it is measured. He has a hard time managing his blood pressure and a typical measurement for him is 170/110. His kidneys are on a rapid course to fail and his vision is deteriorating, but these quickly become moot considerations. He also has developed significant, but undiagnosed, Your patients likely will reflect coronary the manifestations of disparities. artery disease and suffers a massive myocardial infarction at age 47. The hemoglobin A1c level is frelast 10 days of his life are spent quently above 11. He does not in a cardiac ICU, intubated and have an identified primary care unconscious, on multiple vasoclinic. His cholesterol is in the pressors, antiarrhythmics, and even a left ventricular assist device (LVAD). All of these heroic interventions did not prevent his ultimate demise. This is the end of Johnny’s story, but it serves as the starting point of Presentations Include: our conversation about health • Creating Customized Reports for status disparities. Medical Practices • PAs and NPs: Partnering with Educators Health disparities in to Maximize the Productivity of these Minnesota Clinic-Critical Personnel In February 2014, a letter from • ICD-10: Ready, Set, Go Minnesota’s state commission• Physician Integration Strategies ers starts with the following: • Cyber Risk In Healthcare. What’s the Issue? • Mentorship - Effective Strategies to Develop, Support “Minnesota is a great place and Bring Out the Best in Emerging Leaders to live, with a strong economy, beautiful parks and recreation When: Tuesday, March 3 - Wednesday, March 4 areas, and some of the best Where: The Depot Renaissance, 225 3rd Ave S schools in the country. But we know that not all people Minneapolis, MN 55401 have the same opportunity to Cost: $275 MMGMA, HFMA, HRAM & MMA members be healthy. Stark inequalities $400 Nonmembers (After 2/5/15, $325 for Members persist in some parts of our and $450 for Nonmembers) society, and these inequalities have resulted in some groups Please join us at our semiannual conference as we discuss a having better health outcomes wide range of healthcare business topics. than others—even after factorFor registration or more information, ing in individual choices. For please visit: Minnesota to have the brightest http://www.mmgma.org future possible we need to eliminate these health disparities, or call 651-999-5359 especially those experienced by people of color and American Indians.” tion of heredity, easy access to convenience foods, and a lack of physical activity, Johnny attains a BMI of 44 by 23 years of age. Because of family and ethnic risk factors, he develops type 2 diabetes by the time he hits 28 years of age. He does not manage his diabetes well, so his
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Minnesota Physician January 2015
This letter is part of the 123-page report “Advancing Health Equity in Minnesota” that goes on to state: “Minnesota has these disparities in health outcomes because the opportunity to be healthy is not equally available everywhere or for everyone in the state.” The Minnesota Department of Health (MDH) is taking the lead on this and it is a priority for that agency. Minnesota is a very healthy state, being recently ranked third by the UnitedHealth Foundation on a composite of 30 core measures and 19 supplemental measures. The core measures range from cardiovascular deaths to the availability of dentists to immunization status to physical inactivity. The supplemental measures include hypertension, preterm births, the teen birth rate, and income disparity. This same survey methodology by the UnitedHealth Foundation places Minnesota as the healthiest state for seniors over 65 years of age. When it comes to disparities, there are some population groups that are consistently and predictably not doing as well as the rest of us. Solutions need to be discovered and implemented to give everyone an equal chance at good health. The physician’s role As a physician, what is your personal sense of urgency regarding the topic of health disparities in Minnesota? Is this in the category of a “burning platform” for you, your clinic, or your employer if you work for one of the major health systems in this state? What can you do to really have an impact on disparities, other than agree that “someone should do something about it?” What really could have been done to alter the downward trajectory of Johnny’s health? In all fairness, if you are a physician in practice you likely are focusing on the needs of the patients that you see in your office each day, and you do not have a lot of time or energy to focus on disparities of health outcomes for different popula-
tion groups. On the other hand, your patients likely will reflect the manifestations of these disparities on a regular basis. Where you practice also has a direct influence on the frequency of population-based disparities that you encounter as you work towards improving the outcome of patients with conditions such as asthma, diabetes, hypertension, and heart failure. Inequalities in health outcomes also will impact your ability to score well on measures that are published through the Minnesota Community Measurement program. To put the question another way: What, if anything, can engaged and motivated physicians do to address these disparities in health outcomes for different population groups? Johnny’s story highlighted many of the disadvantages and challenges to improved health status that many MDH disparity reports reflect. The likelihood of any individual physician having a significant impact is low, but that could change if doctors worked collaboratively to end health disparities. Recommendations for change A survey by the UnitedHealth Foundation found that Minnesota ranks 46th in public health funding. This is a sad commentary that contrasts with an otherwise stellar showing in health status outcomes. Without increased support for public health infrastructure, our national ranking likely will diminish over time. Physicians can and should encourage their legislators and local elected officials to boost this support. A physician can even go so far as to participate in a work group or community advisory group. Working with and supporting community groups that address the root causes of health disparities is another opportunity for physicians to actively bring about change. This involvement should not require a huge commitment of time. It often is surprising how much traction community groups can gain with the sup-
port and input of a physician. To make significant progress reducing health disparities will take a higher level of support and commitment. Physicians can have the biggest impact by working in conjunction with public health officials, hospital systems, the Legislature, and any other relevant groups. Getting to the modifiable root cause or causes of disparities should be a first step despite the lack of data and analysis that might help point to the issues. How does unmarried childbearing impact disparities? Getting back to Johnny’s story, he had many disadvantages that could easily overwhelm and discourage even the most committed champion for change. On the other hand, one of the critical events that shaped his entire life was his premature birth at 29 weeks and the complications that he experienced. One of the bigger modifiable risk factors for preterm births, low birth weight deliveries, and small-forgestational-age infants is being born to an unmarried mother (Maternal and Child Health Journal, 2011). This is a variable that is independent from poverty, but often is compounded by the lower socioeconomic status of unmarried women. Non-marital childbearing has increased from an average of 18 percent in 1980 to 40 percent in 2007. There are significant differences in ethnic groups for non-marital child bearing, with African American families at roughly 70 percent compared with whites at 25 percent. In addition, single-parent families are at increased risk of poverty with its associated health risks. Here, non-Hispanic black children are two and a half times more likely to be raised in a single-parent family than the average for the country (32 percent versus 13.6 percent according to the Family Structure and Children’s Health in the United States, Centers for Disease Control, 2010, Series 10, Number 246). Single mothers living in poverty and being at a higher risk for delivering a preterm baby is an area that
needs more investigation when it comes to health disparities. This risk factor does not seem to be actively discussed or included in many conversations about disparities, but will need to be thoroughly explored if the state wishes to make even more progress in this area. An opportunity for change At the end of the day, what can physicians do to help change the course of disparities in health outcomes? Becoming actively engaged in the conversation is a good first step. En-
couraging elected officials and public agencies to join in creating successful interventions is another option. Finally, ensuring that we are getting to the real root causes of health status disparities will be essential if we are going to make significant progress. That would be a great agenda for the physician community to champion. Peter Dehnel, MD, is a pediatrician and co-chair of the Twin Cities Medical Society’s Legislative and Public Policy Committee.
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New faces, old issues
ontrol of the Minnesota Legislature has gone from one party to the other over the past few sessions. The pendulum seems to have stopped in the middle as the Republicans regained control of the House this November leaving the Democrats in control of the Senate. The next couple of legislative sessions will certainly present challenges not only with two-party control of the House and Senate, but also logistically because the Capitol building is undergoing extensive renovations. Sections of
A 2015 Minnesota legislative preview By Nate Mussell, JD the Capitol will remain closed in 2015 with the entire building likely to close in 2016. These space limitations will have an impact on the timing of committee hearings and affect the scope of potential legislative agendas.
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Minnesota Physician January 2015
The primary focus of the upcoming session will center around the budget with a particular emphasis collectively from the House, Senate, and Governor’s office on transportation spending. The new House Republican majority also is likely to look at rolling back or eliminating some of the tax initiatives passed in the last biennium as part of its budget priorities. Before even getting to the meat of the budget discussion, a significant number of new legislators will be diving headfirst into a new world at the Capitol. More new faces The 2015 legislative session welcomes 24 new faces and two returning faces to the Capitol. Since 2010, the Legislature has seen almost half of its members newly elected. This constant turnover of new members often equates to steep learning curves for new members and new committee chairs. In addition to new faces, this November’s election cycle also saw the retirement of two of the leading voices on health care in the Minnesota House of Representatives: Rep. Tom Huntley (DFL–Duluth) and Rep. Jim Abeler (R–Anoka). Control of the Health and Human Services (HHS) Finance Committee in the House has been in the hands of both of these legislators going all the way back to 2008. To say that a lot has happened in health care since 2008 would be an understatement, but without either Huntley or Abeler at the helm, there is no question that their institutional knowledge will be missed. Legislative retirements can leave a void, but they also provide new opportunities for others. In late November, the newly elected House leadership announced the committee structure and committee chairs
for the next two years. Former House Majority Leader Rep. Matt Dean (R–Dellwood) will chair the HHS Finance Committee over the next two years and Rep. Tara Mack (R–Apple Valley) will chair the HHS Reform Committee. Both Dean and Mack have extensive backgrounds in health care having served on multiple health committees during their tenure. In an interesting move—likely signaling where some of their priorities will lie over the next two years—Republicans created a new Aging & Long-Term Care Policy Committee to be chaired by Rep. Joe Schomacker (R– Luverne). A budget year With the start of a new legislative biennium, the Legislature is again tasked with formulating a new state budget. Although the political makeup of the Legislature plays a large role in budget discussions, the base from which these discussions begins comes from the November and February economic forecasts. The preliminary budget forecast, released during the first week of December, showed a surplus of just over $1 billion dollars. Gov. Dayton will release his budget on Jan. 27 based on this surplus figure, but these priorities often change depending on the forecast, which is released during the first week of March. As indicated earlier, expect much of the budget discussion between the Governor, House, and Senate to center around tax policy as the Republicans look to reevaluate the increased tax revenues passed by the DFL-controlled Legislature in 2013. On the other hand, the Governor and Senate hope to maintain as much of that revenue as possible to fund their priorities. The HHS budget will again be a significant part of the discussion as the legislative session builds into April and May. One can expect to see more attention focused on reimbursement for different providers such as hospitals, physicians, dentists, and long-term care workers. The health-care access fund and the provider tax, also will
be a major part of the HHS budget negotiations. Provider tax looms One of the more interesting issues to watch in 2015 will be the fate of the current provider tax repeal. While the 2 percent provider tax has been on the books in Minnesota since 1998, a repeal of the tax was passed in 2011 as part of the overall budget agreement reached at the end of the special session. Rep. Dean, then serving in his role as House Majority leader, was instrumental in getting that repeal passed. In fact, a provider tax phaseout was one of only six bills that Dean authored that session. Two years later in 2013, Sen. Tony Lourey (DFL–Kerrick), current HHS finance chair in the Senate, moved an elimination of the provider tax repeal forward as part of his budget package. Although Lourey was later rebuffed in his move to eliminate the repeal in 2013, the looming repeal presents an interesting dichotomy in potential negotiations between the two chairs on the issue in the upcoming session. However, in spite of the repeal to come at the end of 2019, there remain many interested groups who feel the revenue could be used to further fund health care priorities beyond 2020. MNsure changes? Since its inception two years ago, MNsure, the state’s health insurance exchange has been a hot target politically. During its first year, MNsure was plagued with technology issues, giving many legislators the opportunity to criticize everything about the online exchange: the governing structure, the financing, and even the marketing campaigns. While no legislative changes were made to the exchange in the last session, the new Republican House majority is likely to take any opportunity it can get in the upcoming session to propose changes to MNsure. Although a full repeal of the state exchange is not going to happen, as some would like, watch for potential tweaks to the governing structure and the board.
Health care workforce Over the summer and fall months, the Legislature and governor’s office have focused on health-care workforce and health-care education issues. Both the Legislative Healthcare Workforce Commission and the Governor’s Blue Ribbon
sota Department of Health on nurse staffing in mid-January. Another new issue that could gain some momentum this year is the issue of an interstate physician licensure compact. We have seen a variation of this issue come forward in the past in bills around a nurse licensure
Much of what happens at the Capitol has an impact on your practice and patient care. Committee on the University of Minnesota Medical School will release preliminary reports in early 2015. While many of the recommendations likely are to be new topics, expect to see some effort put into passing legislation in 2015 to address some of the impending workforce issues facing physicians and other health care providers. Some of these recommendations might include additional dollars for loan forgiveness programs for physicians and non-physician providers, additional funding for clinical training sites or state education programs, and efforts to encourage science and math education in early school grades. Other issues to watch Every legislative session brings surprises as individual legislators bring forward their policy ideas or momentum builds behind certain constituent groups throughout the session, and 2015 will be no different. Some of the overall themes to watch in 2015 are likely to be care for the aging population; end-oflife care; veterans’ health care (in light of the ongoing federal issues with the VA); consumer access to health care information, including data privacy issues; and continued discussions of scope of practice. An issue that dominated much of the discussion in 2013, but that is unlikely to gain much traction in 2015 with the change in the majority, is the issue of nurse staffing levels. Despite the political change, there could be some focus on the issue with the pending report due out from the Minne-
compact, but there is a growing push nationally and by a number of state medical boards for a physician licensure compact. The initial push for the compact comes about as a result of the increased use of telehealth services, often occurring across state borders. Stay engaged It is nearly impossible for physicians to keep up with the ever-changing political and policy environment at the Capitol each legislative session.
But it remains important for physicians to stay involved in the legislative process because much of what happens at the Capitol has an impact on your practice and patient care. Legislators would be the first to tell you individually that they are not the experts, but that they rely on their constituents and others to educate them on many of the previously discussed issues. Take some time during next year’s legislative session to reach out to your legislator and tell him or her about your practice as a physician and help educate them about the issues that are of concern to you. Collectively, these efforts go a long way in impacting and bringing about change to the health care issues that affect you the most.
Nate Mussell, JD, is with the Minneapolis law firm of Lockridge Grindal Nauen PLLP. The firm provides legal and government relations services to a variety of health care providers.
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Minnesota health care roundtable
Mr. Starnes: According to the Centers for Disease Control and Prevention, as of 2012, about half of all American adults—over 117 million people—had at least one chronic illness. Seven of 10 deaths result from chronic illness, and 84 percent of all health care costs relate to chronic illness. With numbers like these, an important part of health care reform involves how we treat chronic illness. Today, our panel will examine current methods of treating chronic illness, how health care reform has improved treatment, and how it can improve further. What do we mean when we say “chronic illness?”
About the Roundtable Minnesota Physician Publishing’s forty-second Minnesota Health Care Roundtable examined the topic of treating chronic illness. Five panelists and our moderator met on Oct. 30, 2014, to discuss this topic. The next roundtable, on April 23, 2015, will address The New Face of Health Care: Expanding medical professional relationships.
Dr. Burns: Chronic illness is a long-lasting condition we cannot cure but can often control. Mr. Starnes: Can “illness” and “disease” be used interchangeably with “chronic?” Dr. Sulik: I prefer “condition” because we’re talking about illness requiring ongoing care and management. Dr. Twynham: I like “condition” because stigma’s associated with “disease” and “illness.” Ms. Taylor: I agree, “condition” is much less stigmatizing. Ms. Benson: Thinking about chronic conditions allows us to begin identifying the support needed. Mr. Starnes: Conditions that fit the standard definition of a chronic condition include diabetes, congestive heart failure, and asthma. Obesity and Alzheimer’s are not in that category. Do we limit access to care or increase the cost of care by limiting what we consider chronic? Dr. Twynham: Absolutely. Most of my morbidly obese patients represent only the tip of the iceberg of those who are morbidly obese. In our society they’re stigmatized and rejected by the medical profession, partly because we feel inept; we don’t have a magic cure. As a result, we’re uncomfortable taking care of them. These patients are attuned to caregivers’ emotional cues and when they’re told, if you just tried harder you could lose that weight, they don’t go to health care providers and their obesity escalates into type 2 diabetes, high blood pressure, pulmonary hypertension, sleep apnea, asthma, cancers, congestive heart failure, and they reenter the system when a lot could have been prevented by earlier
Minnesota Physician January 2015
Treating chronic illness Is health care reform helping?
intervention. This problem will increase dramatically as obese teenagers become morbidly obese 20-year-olds and start dying in their 30s and 40s. Mr. Starnes: The way patients are entered into the system affects their ability to obtain coverage. Is there benefit in expanding coding for chronic conditions? Dr. Sulik: Children with significant emotional behavioral disorders; adolescents, young adults, and adults suffering from recurrent depression and severe anxiety, trauma, post-traumatic stress disorder, trauma-related disorders: These conditions really do cause a chronic condition by creating significant chronic vulnerability for these individuals. Those most severely debilitated and faced with the stigma that their illness is not considered chronic are those with addictions. The only way we will ever overcome these illnesses is to treat them as chronic health conditions and provide the right type of financial and ongoing supports for them. The idea that we can separate mental health and mental illness from physical
illness has been proven wrong. Our future is realizing these complicated conditions involve multiple internal and external factors and physical components as well emotional, cognitive, and spiritual components. Dr. Twynham: I support that. Many of my patients, whether for cancer or morbid obesity, as they move through treatment of their physical condition, often develop emotional conditions that adversely impact their ability to comply with medications or other treatments. In health care reform, a lot of talk has been about the medical home, where spiritual, emotional, physical, psychiatric care, and social services are coordinated under one roof. That might be the model to move toward. Ms. Benson: If we included dementia among chronic conditions, we could take a more holistic approach to supporting people with dementia and their support network. Engaging each care team member in helping that individual manage their chronic conditions would produce significant positive outcomes, including compliance with medications and other treatment strategies. Mr. Starnes: Does anyone have examples of how health care reform has affected treating chronic conditions? Dr. Sulik: Health care reform emphasizing integrating health care and behavioral health care has finally achieved national recognition. Most accountable care organizations and payers are examining how to integrate effectively. The driving force behind that has been the emphasis on reducing total cost of care. In the last three to five years, data has shown that, regardless of your health condition, the cost of treating it will at least double or triple if you have a co-occurring behavioral health condition. The cost of treating diabetes or congestive heart failure doubles or triples if someone has depression, anxiety, or an addiction. If you have depression and diabetes, the cost of treating diabetes increases at least four-and-a-half times. If you have depression, a substance abuse disorder, and diabetes, the cost of treating your diabetes increases probably 11 times. Mr. Starnes: So, the Accountable Care Act encourages paying attention to behavioral health issues in order to reduce the cost of treatment.
Minnesota health care roundtable Dr. Sulik: We in health care are now charged with population health, a very different mindset and accountability than treating somebody with an illness. Population health requires a lot of education, support, engagement, different types of collaborations, and partnerships. Mr. Starnes: Is access to bariatric surgery or postoperative care for cancer patients improving as a result of health care reform? Dr. Twynham: Access to care for morbid obesity has continued to decline since 2007. Insurers increasingly restrict who is a candidate for bariatric therapy. A lot of barriers are deliberate hoops to jump through. Many patients don’t have the emotional or social resources to jump through those hoops and don’t get care. From the moment someone comes to one of my educational seminars interested in bariatric surgery to the day they have an operation averages nine to 15 months. What other chronic illness takes that long to get care? I do not see that improving under the Affordable Care Act because many insurers have exclusions for morbid obesity. In terms of cancer care, health care reform has opened doors. Especially for very-low-income people, who now can afford follow-up visits. Mr. Starnes: Health care reform was supposed to eliminate denial of coverage for preexisting conditions. Has anyone seen seniors with chronic conditions benefit from reform? Ms. Taylor: Diabetes is a long-term condition, so no exclusion for preexisting conditions is a major benefit of the Affordable Care Act. Ms. Benson: There are two outcomes of health care reform so far. Read, building on what you said about behavioral health, one outcome is that we are seeing social services for older adults with chronic conditions being more a part of the conversation. Things like providing home services to help older adults maintain independence. That’s positive. We hope to increase coordination between health care and community social services. The other benefit, although minimal so far compared to the need for it, is additional funding to continue building programs proven to help older adults manage their chronic conditions, like pain management, falls prevention, exercise. Ms. Taylor: Other things the Affordable Care Act has done for people with diabetes is that hospitalization, prescription medicine coverage, preventive
health services, and chronic disease management are included in the essential benefit set. It also has provided new funding to state health departments to work on obesity, diabetes, heart disease, and stroke. Those funds help state health departments partner with medical associations, businesses, and community organizations to make sure programs are in place that link with the health system and provide supportive care for people in communities. In Minnesota, as a result of the Affordable Care Act we received grant funding from the Centers for Medicare & Medicaid Services to study the impact of incentives on participation and weight loss among people who are on Medicaid and participate in the diabetes prevention program. It’s a yearlong program helping people learn to eat more healthfully and develop the habit of being more physically active in order to lose 5 percent to 7 percent of their weight. This helped us to work with 25 clinics in the Twin Cities area to develop infrastructure needed to work with community organizations, for the Y to offer a diabetes prevention program, and for us to learn how to work with a low-income, diverse, often immigrant population in diabetes prevention. Mr. Starnes: We’ve heard complaints that health plans essentially deny coverage for preexisting conditions by restricting access to medication for specific conditions, either by limiting formulary options or through excessive copays for certain medications. Has anyone seen this? Dr. Burns: Yes. Some of my patients have pulmonary hypertension and take a lot of expensive medications. Some patients say, “I can come and see you but I can’t handle six or seven different medications” that are critical to keep them out of the hospital. Dr. Twynham: Similarly, because bariatric patients eat a much smaller amount of food they often lack specific vitamins and minerals. If vitamin D3 is available over the counter it’s not reimbursed, and can cost upward of $100 a month. Mr. Starnes: What are the biggest obstacles to improving your patients’ outcomes? Dr. Burns: In chronic congestive heart failure, one of the biggest obstacles is patient compliance with medication regimen, follow-up. We try, especially early after a diagnosis, to see patients very frequently. Patients that comply with recommended appointments and the reinforcement that comes with
Kari Benson, MPA, is the planning coordinator for the Minnesota Board on Aging (MBA), housed at the Minnesota Department of Human Services. The MBA oversees Older Americans Act programs for the state and advocates on behalf of older adults and their families. Benson facilitates development of the State Plan on Aging by the Board on Aging; coordinates the annual Area Plan process by which regional Area Agencies on Aging are funded; and develops Board policy and guidance for the Area Agencies on Aging to implement the Older Americans Act. She also coordinates policy and strategic initiatives encompassing public, home, and community-based services programs that support older adults and people with disabilities. Durand E. Burns, MD, is a researcher at the Minneapolis Heart Institute Foundation and a clinical cardiologist practicing with Minneapolis Heart Institute at Abbott Northwestern Hospital. Board-certified in internal medicine and in cardiovascular disease, he completed medical school and a residency in internal medicine at the University of Minnesota Medical School, Minneapolis, and a fellowship in congestive heart failure and cardiac transplant at Rush–Presbyterian–St. Luke’s Medical Center in Chicago. Burns is particularly interested in congestive heart failure, pulmonary hypertension, and heart transplantation. L. Read Sulik, MD, FAAP, DFAACAP, is chief integration officer for PrairieCare, which provides inpatient psychiatric care to children and adolescents and outpatient care for all ages at five locations in the Minneapolis–St. Paul area. In this role he oversees integration of primary and behavioral health care. He has served in a similar capacity for Sanford Health System, as assistant commissioner for chemical and mental health services at the Minnesota Department of Human Services, and as medical director of child and adolescent psychiatry at St. Cloud Hospital. Board-certified in pediatrics, psychiatry, and child and adolescent psychiatry, Sulik is also a clinical associate professor at the University of North Dakota School of Medicine and Health Sciences and the University of Minnesota Medical School. Gretchen Taylor, MPH, RD, supervises the Minnesota Diabetes Program (MDP) at the Minnesota Department of Health. MDP aims to prevent type 2 diabetes, improve health outcomes for people living with diabetes, and reduce diabetes-related disparities across populations. Taylor is on the executive team for the Minnesota Diabetes Collective Impact Initiative, whose prevention goal is to make the National Diabetes Prevention Program available and accessible to all for whom it is indicated in Minnesota. She is also the principal investigator on the CMS–funded research study called Minnesota Medicaid Incentives to Prevent Diabetes, also known as “We Can Prevent Diabetes in Minnesota,” which is testing the effects of incentives for weight loss and attendance among Medicaid enrollees participating in the Diabetes Prevention Program in 25 metro area clinics. Crystal Twynham, MD, FACS, is in independent medical practice as Crystal Twynham, MD, PLC. Board-certified in surgery, Twynham graduated from the University of Minnesota Medical School; served a residency in surgery at Marshfield Clinic/St. Joseph’s Hospital in Marshfield, Wis.; and served as a fellow in bariatric, metabolic, and minimally invasive surgery at the University of Minnesota Medical School.
A bo u t th e Mo d e r ato r Mike Starnes has been the publisher at Minnesota Physician Publishing since 1986. His duties include the production of MedFax, Minnesota Physician, Employee Benefits Planner, and Minnesota Health Care News; directing the Minnesota Health Care Consumer Association; and hosting the Minnesota Health Care Roundtable.
January 2015 Minnesota Physician
Minnesota health care roundtable them often do quite well. But plenty of people miss that appointment and resume eating salty pizza. That’s one of the frustrating obstacles to caring for these patients. However, I’m very pleased that Twin Cities primary care physicians recognize that congestive heart failure is difficult to take care of—it requires a lot of appointments and follow-ups, and doesn’t happen in a 15-minute appointment—so in my experience, metropolitan-area cardiology programs have experienced much more primary care referral than one might expect. The Heart Institute, where I practice, and other programs have spent a great deal of time in the community educating patients and physicians about how to succeed with heart failure. I think that’s made an impact. Dr. Twynham: Among morbidly obese patients I see, less than 20 percent of them are referred by their primary provider. Eighty percent are self-referred. Dr. Sulik: None of us as physicians can truly care for someone with a chronic health condition. Movement in this country to team-based care is from improved understanding as well as necessity. I cringe when we talk about “compliance” because it implies patients choose to not follow through with instructions. But very often, individuals with chronic health conditions have an obstacle to being able to follow through. For example, adults in Sioux Falls see their Sanford internists about four to four-anda-half times in a year and a half. However, individuals with a known diagnosis of depression saw their internist 1.1 times over an 18-month period. We know that depression incapacitates someone’s motivation. Many individuals with chron-
ic health conditions have co-occurring conditions that interfere with the ability to follow through. What it takes to change human behavior is structure, support, education, and repetition in a supportive environment. Team-based care works. We must keep coming up with creative ways of funding that because honestly, that is what impacts total cost of care. Mr. Starnes: If only 20 percent of obese patients are referred by a physician, how can postponing seeking care turn a chronic condition into an acute crisis? Dr. Twynham: People don’t want to admit that they have a disease. They don’t care until they come to the ER and Dr. Burns has to admit them for acute heart failure and pulmonary hypertension, and I’m called to see them because they’re 540 pounds and will die without bariatric care. But, again, the barrier is often stigma. There is stigma to seeking treatment for obesity surgery. One-third of my patients won’t allow me to talk to family members after their operation and if I do, they ask me to say I removed their gallbladder and not mention I also did a gastric bypass. There are a lot of issues that interfere with seeking care. There is prejudice from primary care providers who think bariatric surgery doesn’t work. They have the 1950s attitude that somehow I am operating on patients’ brains and changing some psychological aspect. Maybe I am, because surgery changes certain hormones that affect the brain’s eating, appetite, and reward centers. But barriers are really societal, mostly from prejudice. Ms. Taylor: If we look further upstream at why people are overweight and have other chronic diseases as a result of being overweight, part of that is the obe-
Disparities persist in terms of available interventions. Kari Benson, MPA
sogenic environment, one that doesn’t make it easy to eat healthfully or be active. We don’t have to be active in order to work. We have a lot of access to high-calorie, highfat, high-sodium, high-sugar, cheap food. That’s part of the problem. Something we have going for us in Minnesota is that we have the statewide health improvement program that brings $47 million to the state health department, which grants it to local community health boards. Those boards work to reduce obesity and to reduce tobacco use and exposure in their communities by working on policy changes, systems changes, and environmental changes to make it easier to find healthy foods and increase physical activity. It is upstream so there is still a lot we need to do to identify people once they have the beginnings of chronic diseases like prediabetes, or even diabetes, since a third of people with diabetes are undiagnosed. Ms. Benson: Some obstacles for seniors are basic building blocks of daily life that can make it hard to take action to either prevent onset of a particular chronic condition or to better manage chronic conditions, overall health status. It is access to services like transportation. If they can’t make it to their doctor’s appointment or they can’t get to the pharmacy, trying to follow their doctor’s recommendations, trying to make sure they’ve got healthy food, is hard. The family caregiver role is key but not always identified and supported, so the entire family unit can struggle quite a bit. Plus, with limited or fixed incomes, there are trade-offs in terms of what older adults choose to spend their limited dollars on. Mr. Starnes: A point all of you mentioned was having a patient more engaged. You’d think that if they have congestive heart failure they’d stay off the pizza, but apparently not. Can anyone share what works to create a more engaged patient? Dr. Burns: Patients that, in my experience, do best are ones that comply with the multidisciplinary approach. I spend a lot of time reinforcing the principles, nonpharmacologic therapies, the importance of standing on the scale every day. It’s easy for someone to note that their weight went up three pounds today and three pounds yesterday. Those simple at-home steps are very important. But that is where I come back to saying, in the field of congestive heart failure, the importance of listening to what the multidisciplinary team is telling
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Minnesota Physician January 2015
Minnesota health care roundtable you, the reinforcement and the education piece, helps a great deal in having patients succeed. Granted, there are a lot of potential barriers for the elderly, the lack of family backup and transportation for many patients, the inability to afford any of the levels of care that we are talking about, those are definite barriers. The frequency,
pursuit of his or her own health is really important as we think about what’s needed to help them. There is good data on identifying those who are low on the engagement scale and targeting them to bring them in for more structured visits. They need more structure, education, and support for their engagement process. That process could be a meaningful opportunity to prepare this individual for changes he or she needs to make. Mr. Starnes: Let’s talk about the role an employer can play to improve the health of people with chronic conditions. Has anyone seen examples of employer-sponsored programs addressing this? Ms. Taylor: In Minnesota, there’s the diabetes prevention program. It’s relatively expensive for people to pay for on their own but if it’s in the insurance benefit an
One of the biggest obstacles is patient compliance with medication regimen. Durand E. Burns, MD
at least initially, of follow-up and time-consuming visits is really what prepares us to succeed in the specific case of congestive heart failure. We pay a great deal of attention to comorbidities and a fairly large number of my patients with congestive heart failure chronically have some degree of depression. A fair number of patients have comorbid conditions regarding their heart and other organ systems, and we try to pay attention to all of those. Those who succeed are usually those that get into it and say, I never knew how much better I could feel and I’m going to keep the ball rolling. Mr. Starnes: Work has been done regarding how the larger topic of behavioral health can be used to provide engagement strategies for chronic conditions. Can anyone discuss this? Dr. Sulik: How engaged an individual is in
employer selects and is available to people with prediabetes, it can do a lot to make changes that may prevent or delay onset of type 2 diabetes, and help them develop lifelong habits they need. Even if they do develop diabetes they will be healthier. Mr. Starnes: Let’s consider how health care disparities relate to chronic illness. Ms. Taylor: For many chronic diseases there are disparities in morbidity and mortality. People with diabetes who are non-Hispanic white often have better access to care, better ability to follow instructions or access medications. They may have higher health literacy, which is very important in following through. Nonwhite populations in Minnesota have higher mortality from diabetes and worse outcomes in diabetes management.
Ms. Benson: Disparities persist in terms of available interventions that are proven effective for particular populations. Older adults who identify themselves as other than non-Hispanic white often don’t have a health promotion program that works for them. That’s changing, but it’s definitely something we’re working on and see a great need for. Dr. Sulik: When I was assistant commissioner at the Department of Human Services, that department and the Department of Health both had initiatives targeting health disparities in Minnesota and promoting public education to improve access to care. Both showed some areas of improvement among ethnic populations except Native Americans and African Americans. The disparity in access to care and how care is provided in these two populations in Minnesota is astounding and needs to be addressed in a very significant manner. A culturally mindful approach to engaging individuals can help overcome some obstacles to feeling comfortable and safe in a health care setting and the desire to seek health care. Also, health disparity isn’t only defined by ethnicity. We don’t think of mental illness as creating a health disparity. People aren’t dying from mental illness, they’re dying from other chronic health conditions because mental illness impedes their ability to access and engage in care. So disparities can be thought of in a very broad sense. Dr. Twynham: I agree, we need to broaden our definition of disparities. We need to look at disparity in how people make health care a priority. That often reflects ethnic differences; some populations do not make their health a priority. Day-to-day living is a priority. There is great disparity in care provided by primary care providers trying to survive their day of 50 patients. Some are able to help people access the right care and others are too overwhelmed. Lastly, the way information is delivered is vital. Perhaps it’s best delivered by someone viewed as a leader and thought promoter, someone who can influence communities. Ms. Taylor: We had some interesting community conversations with Native American, African American, Latino, Hmong, and Somali populations to ask what concerns them about diabetes and prediabetes, and what messages might motivate them to visit a provider for testing or to take action in their own lives. There is a great deal of fatalism. How can we change that? Part of it is working within communities.
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Minnesota health care roundtable Ms. Benson: People make the most improvement if they participate in a program delivered by and in their community, with their peers and their culture. Increasingly, we are able to get those types of programs, such as a tai chi program that has been found to be adaptable for a wide range of populations in the Twin Cities metro. We need to do that more. Mr. Starnes: Let’s see how community-based chronic-condition self-management programs can help. Can anyone share information about them and how they can be utilized? Ms. Taylor: This is a big focus of work we do in partnership with the Minnesota Department of Health to address needs of people with prediabetes. An estimated 1.4 million adults in Minnesota have prediabetes, one in every three adults. Only 10 percent know they have prediabetes. There is a very effective evidence-based program called The Diabetes Prevention Program (DPP). It was tested through a nationwide randomized controlled trial with over 3,000 participants of all ethnicities. They tested the effects of this yearlong program of 16 weekly sessions and eight monthly sessions. The DPP worked with individuals one-on-one, but it’s been found to be just as effective in a group setting. The original research showed that people who increase their physical activity to 150 minutes a week and lose 5 percent to 7 percent of their body weight reduce their risk of developing diabetes by 58 percent over a three-year period. Even after 10 years, their incidence of diabetes was 34 percent lower than those who didn’t make these changes. This is a very, very effective program. It is starting to be avail-
able in Minnesota but the main barrier is reimbursement for it. That really needs to be covered. Also, as we heard from Kari with the Minnesota Board on Aging, there is a chronic-disease self-management program. It is a six-week program and can be peer led, but doesn’t have to be. Both programs have standard curricula and are proven effective. Ms. Benson: In Minnesota, the best-known chronic-disease self-management program is “Living Well with Chronic Conditions.” If someone is activated enough to attend the program, the investment is relatively doable. Participants meet weekly for six weeks with a group of peers. Classes occur in various settings in communities statewide. Participants share challenges, questions, concerns; see they aren’t the only one dealing with a chronic condition; and help each other. They do action planning and problem-solving. Participants learn skills, build the confidence to tackle health-related problems, and learn to communicate more effectively with health care providers.
up with this wonderful program.” A good example is the YMCA’s ABC program, which stands for “After Breast Cancer.” It provides a yearlong membership to the Y and rehabilitation of arm and chest muscles, restoring patients’ confidence in their body image and overall health. Patients are the best way to get the message to primary doctors. Mr. Starnes: As we look at improving care for patients with chronic conditions, we must address how to create a better understanding of the role of behavioral health.
Dr. Sulik: We’re horrible at identifying behavioral health conditions. We’re even worse, once we identify them, at getting people access to care. If I’m a family physician and identify a patient as depressed, and refer that patient to see a psychologist or psychiatrist, 50 percent of patients in that situation would not be able to follow through with the referral and would never make the first appointment. If an individual has a substance abuse disorder and I make Dr. Burns: The Heart of New Ulm project a referral, 75 percent will never be able to aims to eliminate heart disease of all forms follow through with that initial appointin New Ulm, Minn. Published data shows ment. Siloing across health care creates decreased incidence of myocardial infarcsuch a fragmented approach to care that we tion (heart attack). This project has potenlose many of our patients, even when we do tial for much wider application in other identify. We need to improve the ability to communities. recognize behavioral health needs. To me, that’s a transformative way of thinking. I’m Mr. Starnes: How can we encourage physicians not talking about only recognizing those to refer more patients to these types of comindividuals suffering from mental illness, munity programs? I’m talking about recognizing broad-based behavioral health needs. Then we need to Dr. Twynham: Engage patients so that they tell their primary doctor, “Hey, I got hooked consider, how do we engage that individual with resources we are bringing in a collaborative manner into the primary care clinic and the other specialty clinics? Because, honestThe idea that we can separate ly, even in a cardiology clinic you mental health and mental illness encounter the same thing. So we from physical illness has been need to think about ourselves as a broader team working effectively proven wrong. with that individual. As a team L. Read Sulik, MD, FAAP, DFAACAP in health care, we need to think together, train together, educate together, and we need to come together in a different way to work with patients, particularly those with behavioral health needs. Mr. Starnes: For example, the primary care doctor may see a patient with a chronic condition and recognize that this person needs the services of another type of medical professional that isn’t within that clinic. How do we get that care to that patient?
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Minnesota health care roundtable Dr. Sulik: That’s what I’ve been trying to do for the last 15 years: integrate behavioral health and primary health care. In the ideal world, I would have a triage behavioral health person who could do an initial assessment in the primary care clinic so the patient doesn’t have to go someplace else for assessment of behavioral health needs. Then, that behavioral health person or others would be able to provide ongoing coaching and training for engagement and needed behavioral changes, regardless of the patient’s chronic health condition. Those things have to occur in some manner that reaches patients where they are. Mr. Starnes: When patients first get a diagnosis of severe heart disease, there likely will be mental issues accompanying it but cardiologists are not psychiatrists. How can these patients be identified and advised? Dr. Burns: To Read’s point, I think none of us are as good as we should be about identifying mental health or behavioral health issues in our patients. Understand that in congestive heart failure, there are roughly 600,000 to 700,000 new presentations every year. The vast majority are via an emergency department and acute hospitalization. I think it is 5.6 days in the DRG for congestive heart failure hospitalization but the average length of stay is significantly longer. During that time, this newly diagnosed patient is a classic deer-in-the-headlights patient; almost nothing you convey to them in terms of what we need to do registers. Hence the importance of outpatient follow-up. Over time, the overlay of situational anxiety, depression, etc., may begin to come through. But I freely admit I’m not as effective as I should be at identifying those issues. Perhaps until the person’s family says, Dad’s been holed up in the house for the last two months not wanting to get out and do anything, that triggers me to say something else is going on at that point. It doesn’t hit my radar as much as it should. Dr. Sulik: Randy, I would want you to have the resources and help you need to meet your patient’s needs, particularly in those crisis situations. That’s one of the biggest hurdles. Early in my career, I did a lot of training of primary care physicians, which just raised their anxiety: “You need to understand depression and anxiety better so you can address it better in your primary care setting.” Well, they’re already so overwhelmed trying to address so much that my thinking started to evolve. We are not talking about just improving our own
abilities as physicians to recognize and deal with everything this patient is coming to us with, but we have to consider who else we need with us to meet this individual’s needs. Mr. Starnes: Most patients aren’t good at recognizing behavioral health problems themselves. How does this issue affect patients?
That depends on there being a certified diabetes educator available in their clinic or community. In many places, especially outstate Minnesota, it’s not available. Telemedicine helps provide access to diabetes education, but the other problem with diabetes education is that it doesn’t generate revenue for a clinic because reimbursement for it isn’t what it should be. So it’s an ongoing
We need to invest upstream throughout the chronic disease spectrum. Gretchen Taylor, MPH, RD
Ms. Benson: There is a lot of denial by older adults. They may be focused on near-term issues. The same can be said about early dementia. It’s not until you look back that you realize the individual probably had signs of dementia a long time ago. There is a need for tools that could be used easily but it’s more about bringing that care team together. Mr. Starnes: It is difficult to go from not having diabetes to having it and seeing this massive behavior change that is required. Accompanying depression is part of this. Ms. Taylor: When someone is diagnosed with diabetes, we hope they are referred for 10 hours of diabetes education by a certified diabetes educator and that they get personal counseling they need for medication management and behavioral changes they’ll need to make. Diabetes education is available two hours every year thereafter.
problem for people to get the education and support they need. When you’re first diagnosed with a disease that you know you’re going to have for the rest of your life, it is hard to hear, so you need ongoing support. Depression is a very common comorbidity and that can affect someone’s ability to act. Dr. Sulik: Something we’ve been trying to do in models of integrated health is to add screening for co-occurring behavioral health conditions and behavioral health needs to the patient visit via electronic health records and patient portals. Just asking one question on sadness and irritability and one question on anhedonia can be a profoundly important prescreen for the risk of depression. That can open the door to conversation about awareness of it. Screening is critical; some prescreening tools are in use.
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Minnesota health care roundtable Mr. Starnes: If you have one chronic condition, you probably have more than one. What can be done for patients with multiple issues? Dr. Burns: Coexisting significant multiorgan comorbidities are a significant problem in patients with congestive heart failure. Chronic renal insufficiency, COPD; many of my patients are former long-term smokers and have lung disease causing underlying symptoms. It makes it more difficult to manage, particularly patients with significant chronic renal insufficiency or renal failure. They are at much higher risk for hospitalization and morbidity. Comorbid-
chronic rejection they have received from the medical profession. Then you’re really in a pickle because you now have someone who clearly exhibits signs of early congestive heart failure, pulmonary hypertension. You can tell they have sleep apnea because they fall asleep while you’re talking to them. They have diabetes, hypertension, hypercholesterolemia, and none of it’s controlled. Much of the nine to 15 months I mentioned is spent preparing people to maximize their physiologic status before an operation. Often that means finding a cardiologist, internist, and endocrinologist. It’s staggering how much coordination of care
People don’t want to admit that they have a disease. Crystal Twynham, MD, FACS
ities also make it more difficult to treat some patients with a cocktail of indicated medications. No research studies showing medications like ACE inhibitors and beta-blockers to be beneficial included patients over 75. A large percentage of my congestive heart failure patients are 79 or 83, and have comorbidities that would have eliminated them from participation in the studies. Dr. Twynham: Coordination of care is definitely a problem. Just getting a doctor to the phone so you can talk with them for 30 seconds about the patient to facilitate their care is sometimes impossible. Nothing substitutes for that conversation with the primary provider. In patients with morbid obesity, one-third of them don’t have a primary provider because of stigma and
is required. Their physiology changes so greatly after bariatric surgery that I need to tell their primary doctor they shouldn’t take their antihypertensives or diabetic medications because their blood sugar is normal as a result of the surgery. Mr. Starnes: One key to treating chronic illness is the cost of medication and medication management. Are there problems with this? Dr. Sulik: The Minnesota Council of Health Plans in 2008 had data showing that 50 percent of antidepressant prescriptions in Minnesota are never refilled. There is no reason to use an antidepressant for only 30 days and never refill it. That shows how widespread the problem is, that individuals don’t fully understand the purpose of the
medication; how they need to give it time to achieve clinical effectiveness; what that effectiveness should be; how we monitor individuals regarding their understanding of the role of the medication and how it fits into the broader treatment plan; how we monitor them for medication effectiveness; and their adherence to the medication regimen. Monitoring is critical. Teaching, education, engagement, and coaching is another piece that historically, we have not been able to do well enough. When we look at health care cost in this country, much of it is associated with pharmaceutical waste. If we use genetic assays more to see if the patient has the right enzymes to metabolize these medicines to start with, we might save a lot of pharmaceutical waste, time, and adverse events associated with medications. All that can be accomplished with teaching, education, and monitoring right from the get-go with patients. Mr. Starnes: Medication cost can be a problem. Dr. Burns: Many medications can be prescribed as generics; Target or WalMart often have minimal $4 copays for one- or three-month supplies. There are exceptions. Pulmonary hypertension patients can qualify for administration of beneficial medications that aren’t generics and must be covered by some form of plan. These medications can cost $3,500 a month. Often, these patients take two or three different medications, each of which may cost that much. Nobody can pay that out of pocket. All clinics that care for a lot of these patients typically have staff that know how to jump through hoops to get patients their medications. By and large, we’re having much more luck than ever before getting patients medications. Some manufacturers have programs for patients that need meds, which is how we approach pulmonary hypertension medications. It doesn’t affect many patients, compared with the huge congestive heart failure population, but once we prove that a patient with that condition will potentially benefit from the medications, we can generally get them covered via sponsored programs. Mr. Starnes: Let’s talk about where the best support could come from for helping to treat chronic conditions. Ms. Benson: The family, if it’s nearby. They play a key role in helping the older adult remember all the day-to-day things to bet-
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Minnesota health care roundtable ter manage their chronic conditions. It can become a 24/7 job for the family caregiver. They may need support to maintain their own health and caregiving role. Providing caregiver respite, counseling, or peer support groups, training to better understand the chronic condition their loved one has, and what they can do to better manage those. Their role tends to become more critical as their loved one ages. Mr. Starnes: Certainly with psychiatric conditions there can be stigma. Does this affect the family caregiver who could provide more help but may want to distance themselves despite love for the family member? Dr. Sulik: Four things affect treatment of chronic conditions: stigma, misperception, misunderstanding, and misdiagnosing behavioral health conditions. So often, there is misunderstanding about how depression, anxiety, trauma, bipolar disorder, and schizophrenia manifest and affect individuals and those around them. If you’re a family member trying to help someone very anxious, they’ll trigger your own anxiety. Family caregivers need to be aware how support impacts them. Ms. Taylor: Someone with diabetes needs support to eat healthfully and be physically active, and it can be a fine line; the person with the illness needs to be responsible and doesn’t want to be nagged. Family members can be very supportive, as you said, Kari. An example from the Diabetes Prevention Program is an African American couple both diagnosed with prediabetes. They went to this year-long program together and said afterward, part of why we were so successful is that we did this together, we’re both on board to make changes, and we ended up successfully losing weight we needed to lose and maintaining that loss. Mr. Starnes: More improvement in treating chronic illness needs to be made. What can be done at a state and federal level? Dr. Burns: What we need to do in congestive heart failure is prevent hospitalizations, particularly rehospitalizations. That’s important on the federal as well as the individual hospital level. For a congestive heart failure patient that is hospitalized and then rehospitalized, Medicare and most private payers will not pay for rehospitalization if it occurs within 30 days. So one of the main goals for the federal government and individual hospitals, in terms of cost savings, is to prevent 30-day rehospital-
izations. One very important aspect of cardiovascular disease that has improved in this country and in western European countries is survival after an acute heart attack. Rapid response to patients having acute heart attacks has begun decreasing the incidence of fatal heart attacks. This involves the so-called level 1 heart attack program, in which patients are recognized in their community hospitals immediately as having a heart attack, and if too far away from appropriate care, helicoptered to a center that can perform angioplasty and put in stents. It has decreased mortality but created more patients with congestive heart failure. They survive their heart attack but end up with decreased heart function and enter the inexorable cycle of chronic congestive heart failure, perhaps requiring hospitalizations. What can the federal government and private payers do to further decrease expense, morbidity, and mortality in congestive heart failure? Continue funding more research. There hasn’t been too much new development in chronic heart failure management in many years, but a new medication that has been researched in Europe shows great promise. We haven’t done research in the United States on that medication yet, so the next step is to go through the FDA process. Mr. Starnes: To wrap up this discussion, what are the most important things that can be done in treating chronic conditions to achieve the Triple Aim of increased access to care, lower costs, and improved patient health? Dr. Burns: Improving access to care for people who have never carried insurance and have a preexisting condition that precludes them from getting insurance. I’ve started seeing patients who couldn’t afford office visits because they lacked insurance and now have it. As I understand it, 95 percent of Minnesotans now have some form of medical insurance. Giving patients the opportunity to establish with a primary care physician who can refer them to a specialist will reduce costs and, I strongly believe, improve outcomes. Ms. Benson: Supporting self-management by older adults. It is very important to have an ongoing funding stream/reimbursement for group education/self-management programs. These have been proven effective in decreasing unnecessary health care utilization up to three years after somebody goes through a six-week program, which is remarkable. They lead to improved out-
comes and improved access to care. That’s an important piece but we need other forms of self-management support that are more costly to provide but less costly than emergency room visits, hospitalization, and recovery. For example, providing someone with support they need in the way they need it given, whatever their level of engagement. Do they want to attend a group program? An online class? One-on-one intervention at home? Those are interventions and resources we would like to see but are more difficult to make widely available. Dr. Sulik: Now that we are accountable for population health, if we develop health care homes for individuals with chronic health conditions that are patient- and family-centered and engage patients and families fully and collaboratively, and integrate primary and behavioral health care teams, we can achieve significantly improved experiences of care and clinical and functional outcomes. It will save dollars, reduce hospitalizations and emergency room visits, and reduce complications of poorly integrated care. The Affordable Care Act gives us an opportunity but it’s what we do with it that matters. Dr. Twynham: We need to assess our population’s health and identify best practices for each chronic condition and how to deliver them. One delivery model may work in one community, but not in another. Most of our population is poorly educated about wellness. We need to completely revamp health education from prekindergarten up. We need to incentivize individuals to want to be healthy; if you want to take the stairs, you can’t even find them in some buildings. Ms. Taylor: To avoid a future in which one in three people have diabetes, we must prevent obesity. We have to continue investing in healthy communities to make it easier to make healthier choices. And I agree with Crystal, we need to educate everybody about food and physical activity. We need to continue to build on our own state health reform efforts to provide obesity prevention, early detection, and expanded treatment. We need funds at the state health department. We have no state funds for treating diabetes; all our funding depends upon federal money. We need to invest upstream throughout the chronic disease spectrum.
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an Minnesota meet the National Colorectal Cancer Roundtable’s challenge and achieve a statewide colorectal screening rate of “80 percent by 2018?” At the Minnesota Colorectal Cancer Roundtable held Oct. 10, 2014, Minnesota health care leaders including participants from health care systems, health plans, and public health agencies met to explore the opportunities and steps required to meet this national goal.
The majority of colorectal cancer (CRC) deaths are preventable through early detection. “More than 2,220 Minnesotans will be diagnosed with CRC in 2015 and 770 are expected to die,” said keynote speaker, John Allen, MD, MBA, AGAF, professor of medicine and clinical chief of digestive diseases at Yale University School of Medicine, president of the American Gastroenterological Association, and formerly with Minnesota Gastroenter-
Colorectal cancer in Minnesota Improving screening rates By Shelly Madigan, MPH; Matthew Flory, MPP; and Jim Chase, MHA
ology. This represents a substantial burden of pain, suffering, and financial devastation. That so many of these deaths and the very cancers themselves are avoidable makes this a critical priority for our state.
Unfortunately less than half of CRC cases diagnosed in
Less than half of CRC cases diagnosed in Minnesota are detected at the earliest stages. Current CRC and screening data in Minnesota The good news is that CRC incidence has been gradually declining in Minnesota (see Figure
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1 on page 31), with most of this change attributable to decreased incidence of regional disease (see Figure 2 on page 31).
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Minnesota are detected at the earliest stages, when the chance of cure is the greatest. The costs associated with treating a late-stage CRC case can exceed $250,000. “CRC screening may offer one of the highest returns on investment in medical care,” said Brian Rank, MD, medical director at HealthPartners Care Group, who kicked off the Minnesota CRC Roundtable. Minnesota Community Measurement (MNCM) data from 1,400 clinics statewide shows that CRC screening rates have increased by more than 1 percent each year since 2006 (see Figure 3 on page 32). Each percentage translates into an additional 10,000 people receiving screening, but the rate for 2013 was still only 69 percent, which is 11 percent below the 80 percent target. Minnesota needs to significantly accelerate current efforts to reach the goal of screening 80 percent of age-appropriate Minnesotans by 2018. Although screening rates for all populations continue to increase, significant racial and socioeconomic gaps persist. For example, a consistent 20 percent screening rate gap persists between people enrolled in commercial plans compared to government insurance pro-
grams (Medicaid and Medicare) over time (see Figure 4 on page 32). Eliminating disparities will still leave Minnesota far short of achieving the 80 percent screening goal, but it is a moral imperative to reduce disparities. Doing so helps us learn how to better engage all people and customize our recommendations for screening in order to decrease the disparities in CRC survival rates experienced by Medicaid recipients, people of color, and Native Americans. Is an 80 percent screening rate realistic? The short answer is, “Yes.” In fact, CentraCare Health System, based in St. Cloud, already has reached an 82 percent screening rate. It achieved this, according to George Morris, MD, CentraCare’s medical director, by implementing several system improvements: building clinical decision support tools into its EMRs; sending letters and reminders to patients; using chart messages; scheduling patients for screening appointments; and having patient navigators help patients obtain transportation and bowel preparation medications. Its gastroenterologists make it easy for primary care doctors who identify patients that need colonoscopies to get them done centrally as well as by providing care to patients in the small communities where they live. Finally, CentraCare publicly reports each provider’s CRC screening rate to not only increase peer pressure and/or competition, but to provide quality care for its patients. Although most of the increase in CRC screening statewide to date has been due to widespread use of colonoscopy, not all patients will get a colonoscopy. The key to getting patients screened and potentially reaching 80 percent screening compliance is to partner with patients to understand their preferences including options for other effective recommended CRC screening tests, such as FIT (Fecal Immunochemical Testing). Currently, only seven eastern
Figure 1. CRC incidence by summary stage
FIgure 2. C RC incidence by early vs. late summary stage
Note: Males & females combined; age standardized; classification method changed Jan. 1. Figure 1 and 2 Source: Minnesota Cancer Surveillance Data, 2014
states have higher CRC screening rates overall than Minnesota (Delaware, Maine, Rhode Island, Massachusetts, Connecticut, New Hampshire, and Maryland). Dr. Allen highlighted Minnesota’s colon cancer leadership, which is due to: • Clinical systems with sufficient capacity to screen 80 percent of Minnesota’s population • Organizations including ICSI and MNCM who can measure the results • A history of cooperation between competing health plans Allen told participants that what is needed to get beyond a 1 percent increase per year is, “a statewide initiative to address screening barriers with a dedicated group of stakeholders, a formal structure, a charter, key performance indicators, and a timeline specifically directed at the statewide level.” Moving toward 80 percent After reviewing the substantial progress made over the past five years, the 2014 CRC Roundta-
ble participants spent time in groups brainstorming one of six specific questions, which are listed here. They identified collaborative actions that can be tackled in the next 18 months to increase screening rates. 1. How can we communicate and promote the benefits of CRC screening to the newly insured? Actions: 1) Ask health plans to provide better profiles of newly insured clients to clinics; 2) Provide repeated, persistent messages to the newly insured about the importance of cancer screening; 3) Support communty-based awareness campaigns to ensure patients understand the positive impact screening may have on their lives. 2. What more can be done to address the financial barriers or disincentives for screening, particularly cost-sharing through copayments and changes in classification of tests from screening to diagnostic.
Actions: A three-step, interrelated process was recommended. 1) Colonoscopies that follow a positive FOBT (fecal occult blood test)/FIT should be defined as part of the comprehensive episode of preventive screening and not as a diagnostic procedure; 2) Redefine the payment mechanism so that when there is a positive CRC screening test of any type, the colonoscopy is still coded as a screening test; therefore, copayments and deductibles do not apply; 3) Educate patients so they understand what’s included in their insurance benefits. 3. How can we effectively engage and support providers in achieving the statewide goal for CRC screening? Actions: 1) Have systems publicly report screening data so that providers
know their screening rates; see how they compare with other providers; and understand the differences according to the populations they serve, including gender and other disparities; 2) Utilize a team approach within systems and adopt the philosophy of “Let it go,” to identify who on the team can best do the work; 3) Provide regional team training so the same messages and tools are utilized regionally. 4. How do we make sure that both providers and patients know that there are a variety of effective screening tests available? Actions: 1) Initiate community conversations that target at-risk populations about prevention and the multiple test options available; 2) Form a collaborative to share information Colorectal cancer in Minnesota to page 32
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on evidence-based testing and redesign messages and communication tools that present multiple options; 3) Have a subgroup around technology to collaboratively build the EMR engagement and decision support tools to properly code screening; 4) Need a Sage-like option for FIT testing. 5. How can we effectively address disparities in colorectal cancer screening? Actions: It was agreed that more time was needed to discuss this issue. 1) Need more patient-centeredness in care, more customization, and shared decision-making; 2) Address patient lack of trust and perceived discrimination and racism by being culturally responsive. Hire health care providers of the same ethnicity and
race as the patients in a particular delivery system; 3) Recognize that addressing disparities in housing, transportation, and justice, etc., may help eliminate the financial barriers that keep people from getting CRC screening. 6. How can we ensure that people who receive free screening have access to specialty follow-up care, including treatment, if needed? Actions: 1) Define the population volume that needs further evaluation and therapy (colonoscopy, imaging, treatment, etc.); 2) Identify a panel of providers that will accept patients without a payment source; 3) The state should organize hospitals, insurance groups, and health plans to say, “Yes, we’re going to commit to a specific amount of funds to support free screenings.”
Figure 3. C olorectal cancer screening statewide trend–Minnesota
Figure 4. CRC screening disparity patients enrolled in Minnesota health care programs (MHCP)
*Measure specifications changed for 2010 Report Year: Lowered upper age limit from 80 to 75.
CELEBRATE WITH THE SAINT PAUL CHAMBER ORCHESTRA Hear the SPCO perform its final concerts in the Ordway Music Theater. Then, join us for celebratory performances and be among the first to hear the SPCO in the new world-class Concert Hall, designed specifically for the artistry of The Saint Paul Chamber Orchestra. Special Ordway Music Theater Farewell Performances: Beethoven’s Ninth Symphony Thursday, February 12, 7:30pm Friday, February 13, 8:00pm Saturday, February 14, 8:00pm Ordway Music Theater, Saint Paul Lieberson: Neruda Songs Beethoven: Symphony No. 9
Special Performances: New Ordway Concert Hall Opening Celebration Thursday, March 5, 7:30pm Friday, March 6, 10:30am Friday, March 6, 8:00pm Ordway Concert Hall, Saint Paul Prokofiev: Symphony No. 1, Classical Tsontakis: Coraggio for String Orchestra Beethoven: Symphony No. 3, Eroica Concerts on March 5-6 are part of Rock the Ordway, a 22-day celebration of Minnesota’s newest world-class performance hall. Visit ordway.org/rocktheordway for details.
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Left to right: Andrew Manze, conductor Hyunah Yu, soprano Kelley O’Connor, mezzo-soprano Michael Colvin, tenor Andrew Foster-Williams, bass-baritone Not pictured: SPCO Chorale Dale Warland, artistic director
Figures 3 and 4 Source: Minnesota Community Measurement, October 2014
Colorectal cancer in Minnesota from page 31
Next steps Building on the efforts of the 2014 Minnesota CRC Roundtable, the Minnesota Cancer Alliance, American Cancer Society, and Minnesota Department of Health in partnership with participating care systems and health plans will convene a meeting to facilitate development and implement a plan based on these six issues. This open meeting will feature Richard Wender, MD, chair of the National Colorectal Cancer Roundtable and also will include breakout sessions to foster collaboration around the strategies. This meeting will take place on March 4, 2015. For more information about the 2015 Colorectal Cancer Meeting contact Matt Flory at the American Cancer Society (matt. email@example.com). Conclusion For the majority of people, a diagnosis of CRC is altogether avoidable as is dying from this disease. Early detection
Sioux Falls VA Health Care System
through routine screening is the key to more favorable outcomes. It was the consensus of this group of roundtable experts that implementation of the strategies outlined in this article should help accelerate an increase in screening and mitigate the human and economic toll of CRC in Minnesota. Contribute to reducing the burden of this disease by adopting any of these strategies that you believe might be effective in your practice, and join us and share your thoughts and experiences on March 4th. To register for the meeting go to: www.mncanceralliance.org/ about/meetings/colorectal-can cer-meeting
Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.
Sioux Falls VA HCS, SD Physician Assistant (Mental Health) Primary Care (Family Practice or Internal Medicine) Psychiatrist
Pulmonologist Optometrist (Aberdeen, SD) Part time Orthopedic Surgeon Urologist
(605) 333-6852 www.siouxfalls.va.gov
Shelly Madigan, MPH, is the Sage Programs section manager at the Minnesota Department of Health. Matthew Flory, MPP, is the Minnesota State Health Systems representative for the Minnesota Chapter of the American Cancer Society. Jim Chase, MHA, is the president of MN Community Measurement.
Applicants can apply online at www.USAJOBS.gov
You’ll love what you hear!
DID YOU KNOW? X 21% of diabetics have hearing loss – compared to 9% of non-diabetics X Hearing loss is tied to three-fold higher incidence of injury-causing falls, as well as more frequent and longer hospitalizations X Untreated hearing loss can affect cognitive brain function – and is associated with the early onset of dementia
As a physician with hearing loss since childhood, I have used a number of audiology services over the years. None has been more competent, friendly and home-like atmosphere than the offices of Dr. Paula Schwartz. Her office treats me the way I would hope my own office treats our patients. The recommendations and hearing devices have always been of excellent quality. Dr. James Rohde, Allina Health
Refer Your Patients to Audiologists that You can Trust! 6444 Xerxes Ave South Edina, MN 55423 (952) 831-4222
14050 Nicollet Ave South, Suite 200 Burnsville, MN 55337 (952) 303-5895
www.audiologyconcepts.com January 2015 Minnesota Physician
To be, or not to be?
ver the last 10 years, Minnesota, like the rest of the nation, has seen a significant increase in hospitals and health care systems buying physician practices and employing physicians. As hospitals and systems acquire more and more practices, it leaves fewer and fewer independent physicians throughout the state. This trend is a significant departure from the former system, comprised of mostly large and small independent practices. The justification for health systems buying practices and employing those physicians is obvious: physicians are a primary source of patient business and with changing reimbursement models that focus on cost containment and integrated care, having control over all segments of a patient experience is optimal. However, the motivations for why a physician group may opt for hospital or system employment are less clear and the right choice is far from obvious.
Examining options for medical practice By Jennifer Reedstrom Bishop, JD, and Timothy A. Johnson, JD While the practice of medicine is very similar for both independent and employed physicians, there are many issues unrelated to the delivery of patient care that vary significantly. Physician practice issues One main reason for the migration of independent practices to employed physician models is the evolving landscape of private practice. Four factors that influence where physicians elect to practice are: 1. Patient volume risk 2. Reimbursement risk 3. Increased practicemanagement complexities 4. Increased regulatory focus
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ealth care has been at the cente of federal r and state politics for decad the political es. No matter which way winds are care in Minn blowing, health esota and country has the rest of the been in a state several years . While much of change for tion recen of the attently has focus ed on the able Care AffordAct and the ever-changi ronment in which ng enviit continues there are to operate, a number of fundament that Minn esota will al issues face in the years. One coming issue that has garne cant attent red signifi ion recen tly is state will have the workf whether the meet the growing health orce in place to care dema There seem nds. sus in Minn s to be a general conse esota that nthe state a physician will face shortage in future as the very near more of retirement physicians reach the age and fewer and reside nts fill those new graduates the numb gaps. Altho ers vary based ugh analysis, on who does most peopl the e who have at the issue looked in recent years, includ the Minn esota Medi ing cal Assoc iation and The comin g physic ian shorta
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Minnesota Physician January 2015
Patient volume risk Now more than ever, physicians are faced with the increased risk of diminishing patient volume. With the enactment of the federal Affordable Care Act (ACA), and specifically its emphasis on Accountable Care Organizations (ACOs), there is an increased focus on delivery models where groups of providers, led predominantly by large health care systems, band together to treat a patient population. The goal of the ACO model is to hold these provider groups accountable for the “total cost of care” provided to their patients. To lower the total cost of care, ACOs need to ensure that patients are treated mainly by providers within the ACO provider network. Those physician practices that do not elect to participate in the ACO provider network are at risk of losing patients to providers within that network. This, in turn, places physicians that are employed by health care systems at an advantage. As patients select providers within the ACO network, employed providers may see an increase in patient referrals, whereas independent physicians may see a decrease. Regional health care plans have increased their introduction of health plan products that focus on using a “narrow network” of providers. Typically, these narrow networks are affiliated with a local hospital or large health system in the community. For those smaller independent groups that are not part of the hospital or health system, there is a risk of potentially losing patients, while physicians employed by these hospitals or health systems stand to benefit. Reimbursement risk With the introduction of various care delivery models by
health plans and the government, all providers are seeing a slow reduction in reimbursement. Additionally, with the overall increase in health care costs and the number of enrollees covered by health care plans, both employers and government programs (i.e., Medicare) are looking for ways to reduce provider reimbursement. Independent practices have taken a disproportionally greater share of reimbursement reductions resulting in reduced independent physician compensation. First, independent physician practices typically do not have the bargaining clout of hospitals and health care systems so a hospital or system may achieve greater reimbursement. Second, since hospitals and health care systems provide an array of services including inpatient and outpatient hospital services, ancillary services, physician services, etc., hospitals and systems have a broad base of revenue sources. These revenue streams permit health care systems to maintain their physicians’ compensation at higher levels than those typically received by independent practices. Third, large systems have the resources to participate in more creative delivery models such as ACOs, and they often receive enhanced reimbursement if the system can meet the delivery models’ goals and objectives. Practice-management complexities The business of operating a physician practice has become significantly more difficult and complex in recent years. In addition to the requirement that physician practices purchase and implement expensive electronic health records (EHR) systems, they also are required to keep up to date with complex coding and billing changes. This places a burden on independents to recruit and hire qualified personnel that are both expensive to retain and require frequent training. In addition, patients require more from their providers now, inTo be, or not to be? to page 36
Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact firstname.lastname@example.org or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • General Surgery • Geriatrician • Outpatient Internal Medicine
• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery
• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urgent Care
F O R M O R E I N F O R M AT I O N :
Kari Lenz, Physician Recruitment | email@example.com | (320) 231-6366
healthpar tners .com
© 2014 NAS (Media: delete copyright notice)
MN Physician Family or Internal 4" x 5.25" 4-colorMedicine Physician An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites.
Family Medicine & Emergency Medicine Physicians
• Immediate Openings • Casual weekend or evening shift coverage • Set your own hours • Competitive rates • Paid Malpractice
For more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to: firstname.lastname@example.org
763-682-5906 | 763-684-0243 email@example.com www.whitesellmedstaff.com January 2015 Minnesota Physician
dustries in the country. The nucluding better customer service, merous state and federal health care laws that place onerous modern clinic facilities, and regulatory requirements on cutting-edge technology. physicians and practices have Hospitals and health sysincreased significantly in tems are able to meet these recent years. Applicable laws demands, as they have the include the extensive Mediresources to purchase expensive care Program regulations; the technology, implement compreHealth Insurance Portability hensive EHR systems, and hire and Accountability Act of 1996 and retain qualified personnel. (HIPAA); Health Information Smaller independent practices, Technology for Economic and however, are not as fortunate. Clinical Health (HITECH) Act; the Clinical Laboratory Improvement Independent practices … Amendments of 1988 (CLIA); federal and can result in significantly state False Claims higher job satisfaction. Acts—among many others. Furthermore, since several of these With fewer physicians interlaws can penalize providers the ested in working in an inderegulatory risk to physicians for pendent practice, independent violating any of these laws, even practices are having trouble innocently, is a significant conrecruiting and retaining quality cern. Since health systems have physicians. significant resources, including knowledgeable billing personIncreased regulatory focus nel, sophisticated compliance The health care industry is one functions, and an experienced of the most highly regulated inTo be, or not to be? from page 34
legal department, they are able to successfully navigate these complex regulatory requirements. Without significant resources to rely on, physicians in independent practices are required to assume a greater role in understanding the various laws that impact their practices. Risk vs. reward But, all is not bleak for the independent physician. While physicians employed by health systems might face less patient volume and reimbursement risk, and have less day-to-day management responsibilities, their compensation may be capped by their employer. A physician employed by a hospital or system is typically paid under a base salary, with a possible production bonus for meeting certain service levels. Further, practicing within a larger enterprise may mean that the physicians are subject to policies and procedures that impact their daily practice without any mechanisms for
true input. Budgeting decisions made by administrators often interfere with the demands of the delivery of patient care, and can have a significant impact on the ability of a physician to treat patients in the manner desired by both the patient and physician. A physician or group examining whether to join a hospital or health system is therefore faced with a choice— give up control over certain aspects of practice in exchange for some reduction in risk associated with patient volume and protection from the impact of reducing reimbursement. In contrast, physicians operating in independent practices have direct control over elements of their practice, which can result in significantly higher job satisfaction and, perhaps, compensation. Compensation is generally tied to their production and the profitability of their practice. If they can operate their practices efficienTo be, or not to be? to page 38
Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.
Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258
Currently we are seeking to add the following specialists:
• Family Practice
• General Surgery
• Orthopedic Surgeon
• Internal Medicine
• Radiation Oncology
For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org
Minnesota Physician January 2015
Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:
Opportunities for full-time and part-time staff are available in the following positions:
• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.
• Dermatologist Please contact or fax CV to:
Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429
763-504-6600 Fax 763-504-6622
• Medical DirectorExtended Care & Rehab • Geriatrician/ Hospice/ (Geriatrics) Palliative Care • Ophthalmologist • Internal Medicine/ Family Practice
Applicants must be BE/BC.
It’s your life. Live it well.
Family Practice with OB Our independent, physician-owned clinic is seeking a BC/BE physician with OB for our family practice facility. 1:9 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental insurance, 401(k), CME and more. Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally performed plays, concerts and the arts; community festivals; dining and more.
Send CV to: firstname.lastname@example.org 218.879.1271 • www.raiterclinic.com 417 Skyline Blvd. • Cloquet, MN 55720
US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. 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 Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303
(320) 255-6301 January 2015 Minnesota Physician
To be, or not to be? from page 36
tly and effectively, independent physicians can experience high compensation levels. Also, independent physicians typically operate in a more entrepreneurial environment with the flexibility to provide ancillary services, such as imaging, physical therapy, and laboratory services. This can increase the profitability of their practice. Finally, while some independent practices have little clout when it comes time to negotiate payer contracts, if a group is in a specialty that is needed or in a group that is of some size, they may be able to negotiate higher professional fee reimbursement than a hospital or health system as hospitals and systems seek higher reimbursement for inpatient services while sacrificing outpatient practice. Hybrid options But wait, the choice might not be so dire. Independent physicians may have the opportunity to work with a hospital or
health care system in developing affiliate or contractual relationships which can give them the best of both worldsâ€”control over daily patient care and practice decisions with reduced patient volume and reimbursement risk. From recruitment support to entering into a Professional Services Agreement (PSA), Management Services Agreement (MSA), or Coverage Services Agreement (CSA), physician groups and hospitals or systems can develop contractual relationships that provide financial support to the practice if the physician group is providing clearly articulated services. For example, an ENT practice located near a hospital could sell its services to the hospital under a PSA for which the hospital then bills and collects for the services of the physicians at the hospital. The PSA financial terms must be at fair market value, but may include incentive compensation, both on an individual and group basis. Further, the purchased group can work
with the hospital to develop co-management models under which the physicians retain a significant voice in the care delivery and management decisions that impact their practice. While compliance with health care regulations is paramount in crafting these types of contractual relationships, physician groups and hospitals or systems that share similar visions for the delivery of care may benefit from working collaboratively. By giving up some control contractually, independent physicians will achieve reduced financial risks without becoming wholly employed by the hospital or system. A crystal ball Changes in the physician practice landscape have had profound impacts on Minnesotaâ€™s health care system. The last decade has seen a significant migration from independent practices to an employed physician model and that trend may continue, but we also are
seeing those groups that have remained independent interested in exploring hybrid options. Whether and when payer reimbursement models actually change will be the key to whether this integration trend continues, slows, or stops entirely. In the meantime, it is paramount that independent practices examine their goals and needs as a group and determine which elements of independence are important. With some introspection and strategic planning, a group can determine whether it is time to join forces with the local hospital or system in an employed model, whether there is an alternative model available that is worth exploring, or whether true independence is precisely the right model. Jennifer Reedstrom Bishop, JD, is a principal at Gray Plant Mooty and a chair of its Health & Nonprofit Organizations Practice Group. Timothy A. Johnson, JD, is a principal at Gray Plant Mooty and a member of its Health & Nonprofit Organizations Practice Group.
General Adult Psychiatry Be part of a broad-based mental health practice that is uniquely team-oriented! Hutchinson Health is seeking a sixth psychiatrist with a focus on general adult inpatient and outpatient care. Call responsibilities are 1 in 6. Compensation (salary plus productivity) and benefits are highly competitive. Our Mental Health services include a 12-bed inpatient unit and an outpatient clinic. The psychiatric staff includes two Fellowship-trained in child and adolescent, one Fellowship-trained in geriatrics, 10 other mental health professionals, and two chemical dependency professionals. Hutchinson Health, 50 miles west of the Twin Cities, includes a 66-bed acute care hospital, a 30-physician multi-specialty clinic, and several outpatient and specialty clinics. It serves 35,000 as the primary health care provider.
Hutchinson Health is an approved National Health Services site. Patient safety and evidence-based care are at the core of all clinical processes.
For further information, contact Hutchinson Health Human Resources (320) 484-4685 or email@example.com 38
Minnesota Physician January 2015
Fairview Health Services
Opportunities to fit your life
St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.
Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team. We currently have opportunities in the following areas: • Dermatology • Allergy/ • Immunology Emergency
• Hospitalist • Geriatric • Medicine Hospice
• Hospitalist • Internal Medicine
• Psychiatry • Orthopedic • Surgery Rheumatology
• Emergency • Medicine Family Medicine
• Med/Peds • Hospice
• Sports Medicine • Pain Medicine
• Family Medicine General Surgery • • General Surgery Geriatric •
Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.
• Pediatrics • Ob/Gyn
• Ob/Gyn • Urgent Care • Internal Medicine • Psychiatry • Orthopedic • Med/Peds
HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care.
• Vascular Surgery • Rheumatology
Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail firstname.lastname@example.org
Apply online at healthpartners.com/careers or contact email@example.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE
Sorry, no J1 opportunities.
fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer
healthpartners.com © 2014 NAS (Media: delete copyright notice)
MN Physician 4" x 5.25" 4-color
Olmsted Medical Center, a 160-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
Opportunities available in the following specialties: Pain Medicine Rochester Northwest Clinic Child Psychiatrist Rochester Southeast Clinic Family Medicine Pine Island Clinic Spring Valley Clinic General Surgery Call Only – Rochester Hospital General Surgeon Hospital
Send CV to: Olmsted Medical Center Administration/Clinician Recruitment
102 Elton Hills Drive NW, Rochester, MN 55901
email: firstname.lastname@example.org Phone: 507.529.6748 • Fax: 507.529.6622
www.olmstedmedicalcenter.org January 2015 Minnesota Physician
Living well with chronic conditions from page 17
participation in a Living Well with Chronic Conditions workshop include: • Engaging patients to become an active member of their health care team • Allowing participants to live a better quality of life despite their illness • Showing participants how to effectively manage their health concerns • Improving self-reported general health, reducing health distress, and increasing participation in social activities Getting the word out Since 2008, the Minnesota Board on Aging (MBA) and Minnesota Department of Health (MDH) have worked with many partners to introduce Living Well with Chronic Conditions to communities around the state. MBA and Area Agencies on Aging have trained and supported local providers of Living Well workshops. MDH
also has supported training and offered additional assistance to providers offering the workshops. Since 2009, these efforts have resulted in 2,522 people participating in 298 workshops across Minnesota. Testimonials Participant responses to the Living Well with Chronic Conditions workshop have been very positive. Comments from participants include: • “Living Well gave me a framework to take control of my life again. The action plans help me break things into manageable ‘bites’. I can do this.” • “I found out that I am not the only one who struggles with a chronic condition. I learned so much from the other class participants. We were able to encourage and motivate each other to make positive changes.” Physician involvement Physician referrals are encouraged and welcomed. Living Well with Chronic Conditions work-
shops are for anyone with an ongoing health condition/concern. The workshop is not disease specific, so it has a broad appeal to a larger population including those with multiple chronic health issues. The program encourages individuals to develop the knowledge, skills, and confidence to address or manage their health. Having patients that participate in a Living Well workshop can be a plus for health care practitioners. Studies have suggested that patient participation in a CDSMP workshop can be a useful adjunct to the self-management support provided in the clinical setting. CDSMP is a scripted workshop, therefore, participants receive consistent structure, information, skills, and support. The workshops do not conflict with existing programs or treatment and are designed to enhance treatment. The program is especially helpful for those who have more than one chronic condition, because it
lets them coordinate all the things needed to manage their health and to stay active. Helping people manage their ongoing health issues is critical given the level of chronic disease in the United States. By encouraging patients to manage their health with this program, physicians can help them remain active and independent as long as possible. Evidence-based programs, such as Living Well with Chronic Conditions, have successfully offered guidance to patients living with or at risk for ongoing health conditions. Workshops are provided in various settings across Minnesota. Physicians or patients can learn more at www.mnhealthy aging.org or by calling the Senior LinkAge Line at (800) 333-2433 to find a workshop. Jean K. Wood, MSW, MAPA, is executive director of the Minnesota Board on Aging and director of the Aging and Adult Services Division, Minnesota Department of Human Services.
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Minnesota Physician January 2015
Join the Leader in Correctional Health Care FEDERAL BUREAU OF PRISONS
Full-Time Psychiatrist – FMC Rochester, MN Full Time Clinical Director – FCI Sandstone, MN Learn more at: www.bop.gov
Here to care At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 12 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.
Make a difference. Join our award-winning team. Madalyn Dosch, Physician Recruitment Services Toll-free: 1-800-248-4921 Fax: 612-262-4163 Madalyn.Dosch@allina.com
allinahealth.org/careers 13273 0414 ©2014 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM
January 2015 Minnesota Physician 3.5x4.75_AD_MN_Medicine.indd 1
Confronting prescription opioid misuse from page 15
in 30-day increments that must be filled sequentially. State regulations More states, including Minnesota, have passed legislation that expands access to naloxone and removes barriers that may deter a bystander from seeking emergency assistance for the overdose victim (also known as “Good Samaritan” laws). Naloxone, when administered quickly and properly, immediately restores breathing to a victim in the throes of an opioid overdose. Twenty-one states, including Minnesota, have statutes that allow for “third-party” prescriptions of naloxone (i.e., the prescription can be written to a friend, relative, or person in a position to assist a person at risk of experiencing an opioid overdose). Minnesota law also allows prescriptions of naloxone to qualified first responders (e.g., law enforcement and EMTs).
Some states have moved expeditiously in tackling the prescription opioid/heroin problem head-on. For example, in 2013 the Wisconsin Department of Justice implemented a statewide heroin prevention campaign, called “The Fly Effect.” In 2014, Wisconsin Gov. Scott Walker signed seven bills collectively known as the Wisconsin H.O.P.E. (Heroin, Opiate, Prevention, and Education) Agenda, that in addition to Narcan/ Good Samaritan legislation, consists of bills that: 1) require individuals to show proper identification when picking up Schedule II or III narcotic/ opiate prescription medication in order to address prescription fraud and diversion, 2) expand Treatment Alternatives and Diversion (TAD) programs, and 3) create regional pilot programs to address opiate addiction in underserved areas. In 2012, prescription opiate and heroin abuse was identified as the top policy priority by
Minnesota’s first-ever Statewide Substance Abuse Strategy, a collaborative initiative developed by multiple Minnesota state agencies under the leadership of the Minnesota Department of Human Services. It called for mandatory continuing education units (CEUs) for Minnesota doctors regarding opioids, pain management, and addiction. Clearly this has not yet happened. It also called for accelerated efforts to increase participation by prescribers and pharmacists in the Prescription Monitoring Program and to examine alternate methods for law enforcement access. Enrollment in Minnesota’s PMP remains voluntary for prescribers, and the conditions under which law enforcement can access PMP data remain unchanged. Conclusion Moving forward we can all make positive changes. More parents need to tell their kids about the dangers of using
someone else’s prescription medications and keep medication out of harm’s way. They need to take seriously their child’s prescription drug abuse, rather than dismiss it as a “rite of passage.” More people need to realize that with opioids, just a little bit too much can kill you. More classrooms, families, and communities need to engage in realistic dialogue and factual education about drug abuse. Employees, especially health care workers, need to be vigilant about reporting suspected workplace drug impairment or suspected drug diversion. The bottom line is that doctors have a pivotal role in reversing this epidemic. Some have made improvements in practice. Still, if they simply continue business as usual, the body counts will continue to rise. Carol Falkowski is founder and CEO
of Drug Abuse Dialogues.
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Use your superpowers...
to conquer colorectal cancer. • Help your patients choose the best screening test for them. • Have your staff schedule your patient’s tests. • If your patients will incur significant out-of-pocket costs, call Sage Scopes: 1-888-643-2584.
The lives you save could make you a hero. 42
Minnesota Physician January 2015
GET READY FOR
STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •
Make a Plan—Look at the codes you use, develop a budget, and prepare your staff
Train Your Staff—Find options and resources to help your staff get ready for the transition
Update Your Processes—Review your policies, procedures, forms, and templates
Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services
Test Your Systems and Processes—Test within your practice and with your vendors and payers
Now is the time to get ready. www.cms.gov/ICD10
Official CMS Industry Resources for the ICD-10 Transition
5/28/14 1:52 PM
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