Vo l u m e x x v i i I , N o . 12 M a r c h 2 015
Hospital medical-staff bylaws A recent Minnesota Supreme Court ruling By Greg Myers, JD; David Asp, JD; and Elizabeth Snelson, JD
n Dec. 31, 2014, the Minnesota Supreme Court held that a hospital’s medical staff may have the capacity to sue, or be sued, as an unincorporated association, and that medical-staff bylaws could constitute an enforceable contract between the hospital and its medical staff.
Health exchange transparency Are we there yet? By Candace DeMatteis, JD, MPH
magine being required to purchase a box containing a year’s supply of food in advance. All you know is the cost of several boxes being offered, that these boxes contain some essentials like milk and bread, and the name of the store offering the boxes. How would you decide which
box to buy? Making matters more challenging, what if you or a family member have a health condition that requires a particular diet? If the food in the box that you chose does not meet your needs, you will end up having to buy different items Health exchange transparency to page 10
The decision, Med. Staff of Avera Marshall Reg’l Med. Ctr. v. Avera Marshall, No. A12-2117, 2014 WL 7448532 (Minn. Dec. 31, 2014), is significant for medical staffs that rely on bylaws to cover everything from credentialing applications to call coverage to disciplinary proceedings. It means that, as long as the terms of staff bylaws are sufficient to create a contract, a medical staff has the capacity to sue for enforcement. But the decision also underscores the need for any medical staff to be careful about what it agrees to in its bylaws. Hospital medical-staff bylaws to page 12
rehabilitation services from P ost-acute the Good Samaritan Society. Post-acute care is designed to heal and assist patients with care and support following a hospitalization from serious illness, injury or elective surgical procedure. Multiple in-patient and out-patient post-acute locations are located throughout the Twin Cities metro area and state of Minnesota. To learn more about our post-acute services, call us at 866-GSSCARE or visit www.good-sam.com/minnesota.
The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. ÂŠ 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G0066
March 2015 • Volume XXVIII, No. 12
MINNESOTA HEALTH CARE ROUNDTABLE Health exchange transparency Are we there yet?
By Candace DeMatteis, JD, MPH
Hospital medical-staff bylaws 1 A recent Minnesota Supreme Court ruling By G reg Myers, JD; David Asp, JD; and Elizabeth Snelson, JD
The New Face of Health Care
Addressing an epidemic By Elena Polukhin, MD, PhD
Expanding medical professional relationships
Mehul J. Desai, MD, MPH
Thursday April 23, 2015, 1:00-4:00 PM Downtown Minneapolis Hilton and Towers
Medical Advanced Pain Specialists
Professional Update: Radiology Stents 14 By Y asha Kadkhodayan, MD
2015 Community caregivers Making a difference in Minnesota and the world 20 By Lisa McGowan
Special Focus: Patient Compliance Following doctor’s orders 26 By S hawna L. Ehlers, PhD, ABPPCHP, and Mark J. Wilbur, MD
Diabetes education 30 By L aurel Reger, MBA, and Mary Beth Dahl, RN
Minimally disruptive 28 medicine 2.0 By Aaron Leppin, MD, and Victor Montori, 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. Panelists Include: • Mehul Desai, MD, Minneapolis Advanced Pain Specialists • Derek Hustvet, RRT-NPS, LRT, Director of Respiratory Service, Pediatric Home Service • John Gulon, DDS, President of Park Dental • Craig Johnson, PT, MBA, President MNPTA, Director of Clinical Integration Therapy Partners Sponsors Include: Minneapolis Advanced Pain Specialists, Park Dental, and Pediatric Home Service
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Please mail, call in, or fax your registration by 4/20/2015 March 2015 Minnesota Physician
Northwest Family Physicians Receives Quality Recognition Northwest Family Physicians, Crystal, has been named to a list of 11 primary care practices nationwide that provide higher quality care at below-average total annual cost. The recognition was announced by the Peterson Center on Healthcare, Washington, D.C., based on research funded by the Clinical Excellence Research Center of Stanford University, Stanford, Calif. Researchers looked for primary care practices that performed in the top 25 percent on nationally recognized measures of quality and the lowest 25 percent on health care costs per patient. Of 15,000 primary care practices considered, only 5 percent met these criteria. Of these, researchers conducted in-depth site visits to a sample of the highest performing sites, including Northwest Family Physicians. Researchers observed that the high-performing primary care practices differ in three distinct ways from practices with
average costs and quality scores. High-performing practices have deeper relationships with patients; their interactions with others in their local health care system are more coordinated; and, their practices are organized to foster teamwork.
Women Report Better Communication with Midwives Researchers at the University of Minnesota School of Public Health have found that pregnant women who are assigned a provider for prenatal care, versus choosing one themselves, have a better chance of receiving care from a midwife. Women who see a midwife for prenatal care report fewer communication problems than those who see other types of health care providers. According to researchers, this indicates that assigning a midwife to women with low-risk pregnancies by default could lead to better patient-clinician communication during prenatal care and childbirth.
Minnesota Physician March 2015
“Good communication and informed decision-making are cornerstones of high-quality, patient-centered care,” said Katy Kozhimannil, PhD, MPA, assistant professor at the School of Public Health and lead author of the study. “In this study, we found that women who saw a midwife for pregnancy reported that they were more likely to ask questions during their visits, had a better understanding of the medical words being used, and more often felt that their care provider spent enough time with them.” Researchers used data from the Listening to Mothers III survey, a report released in 2013 that summarizes the results of a poll of 2,400 mothers who gave birth in U.S. hospitals in 2011 and 2012. Results of the study show that women who were assigned a prenatal care provider were 63 percent more likely to receive care from a midwife. Pregnant women who expressed a strong preference for a female provider were twice as likely to be assigned a midwife. About 24 percent of women who received care from physi-
cians said they held back questions because they didn’t want to be difficult and about 30 percent said they did so because they felt rushed, compared to 14 percent and 24.3 percent of women respectively who saw midwives. Of those who saw physicians, 47.7 percent said they were not encouraged to voice all their questions and concerns, compared to 36.7 percent of those who saw midwives. And 53.6 percent of women treated by physicians said the provider used medical terminology they did not understand, compared to 24.3 percent of those who were treated by midwives. “Moving forward, one possibility suggested by these findings is greater use of a default midwifery option for pregnancy care for low-risk women, coupled with strong consultation and referral networks to ensure that women receive specialized care when complications arise,” said Kozhimannil. “Taken together with evidence on midwifery care’s quality and safety track record, our research implies that this kind of systems-level reform has potential to enhance communica-
tion and improve women’s birth experiences.”
State Sees Increase In High-Quality Asthma Care Minnesota Community Measurement (MNCM) has released its 2014 Health Care Quality Report. The report, in its 11th consecutive year, includes data submitted from more than 310 medical groups and 1,600 clinics in Minnesota on measures for 22 medical conditions. This year’s report also includes five new measures: cesarean delivery rates, total cost of care, and three measures for total knee replacement. The most notable improvement was in asthma care. More than 2,800 additional children and 4,400 additional adults had their asthma well controlled in 2014 compared with 2013. “Since asthma is not curable, managing and controlling it is essential to leading a normal, healthy life,” said Jim Chase, president of MNCM. “If asthma is not well controlled, it can be serious and even life threatening.” In addition, the rates of adults and children who received high-quality asthma care each increased by 7 percent from 2013 to 2014. Since 2011, the rate for children has gone up 32 percent and the rate for adults has gone up 31 percent. Both measures have shown the largest increase of any clinical quality measures from 2011 to 2014. Minnetonka-based Advancements in Allergy and Asthma Care was the highest performing medical group for the care of children with asthma, at 93 percent, and Willmar-based Allergy & Asthma Specialty Clinic was the highest performing clinic for adult allergy care, at 89 percent. Minnesota showed improvements in several other areas as well. All six measures related to patients diagnosed with major depression showed improvement, which resulted in 7,100 more of these patients receiving critical health care services in 2014 than in 2013. The rate of adolescents who received all recommended vaccinations by age 13 increased 3 percent from 2013 to 2014. The rate for two year olds with all recommended vaccinations remained the same as last year, at 78 percent, but has increased 7 percent since 2011.
The rate of appropriate treatment for bronchitis in adults increased 3 percent from 2013 to 2014, and increased from 20 percent in 2011 to 29 percent in 2014. It is one of the fastest improving measures tracked by MNCM.
Ultrasounds Can Reduce Unnecessary Lymph Node Surgeries Researchers at Mayo Clinic have found that ultrasounds can determine if women with lymph node-positive breast cancer need to have all of their underarm lymph nodes removed. Previously, when breast cancer spread to a patient’s underarm lymph nodes, it was routine for surgeons to remove the breast tumor as well as all of the lymph nodes to ensure the cancer did not spread. Results from the new study show that this is not necessary in some cases. Due to improvements in chemotherapy drugs and techniques, surgeons are seeing more women whose cancer is eradicated from the underarm lymph nodes after chemotherapy, according to Judy Boughey, MD, a breast surgeon at Mayo Clinic. Researchers determined that performing an ultrasound after chemotherapy can determine if these patients need all of the nodes removed, or if surgeons should only remove a few lymph nodes close to the tumor to test for cancer. Removing fewer lymph nodes when possible will reduce the number of women who experience complications and side effects after surgery. The research team studied more than 600 patients with node-positive cancer that received chemotherapy and then underwent ultrasound imaging. They classified the patients as having normal or suspicious lymph nodes based on the results and then tested to confirm if the classifications were accurate. Researchers found 181 patients whose ultrasound results indicated cancerous nodes, and 130 (about 72 percent) of those were confirmed node-positive with surgery. They found 430 patients whose ultrasound results indicated normal nodes, 243 of whom (about 57.5 percent) were found to be node-positive.
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Capsules to page 6 March 2015 Minnesota Physician
Letters To the editor: Capsules from page 5
Recommendations on Foreign-Trained Physicians Released Minnesota’s Task Force on Foreign-Trained Physicians has released a report saying that immigrant physicians are being underutilized as primary care providers, especially in rural and underserved areas of the state. The Minnesota Legislature authorized the formation of the 15-member task force, which began meeting in July 2014. Its goal was to develop strategies to integrate refugee, asylee, and other immigrant physicians living in Minnesota into the state’s health-care delivery system. Recommendations were submitted to the commissioner of health and the Legislature in January. The task force identified costs and barriers; alternative professions for those unable to practice as physicians in Minnesota; and possible funding sources. After meeting monthly from July through December, the task force reported its findings and recom-
mendations. Its analysis found that there are an estimated 250 to 400 unlicensed immigrant physicians in Minnesota, the majority of who are primary care providers and fluent in multiple languages. In addition, most of the state’s largest immigrant and refugee communities are underrepresented in the licensed physician workforce. For example, Minnesota’s Liberian community is the largest of any state in the U.S., but there only are eight Liberian-born physicians licensed in Minnesota. The task force also found that integrating these physicians into the health-care delivery system could save the state a substantial amount of money, in part by reducing expenses for preventable hospitalizations and chronic disease. It noted a study found that the state could save more than $63 million by integrating these physicians into underserved communities. The task force identified barriers that face immigrant physicians. The most prominent barrier was securing a medical residency, which they need in
order to meet physician licensing requirements. Most are disqualified because many residency programs require clinical experience in the U.S. and recent graduation from medical school. Recommendations to address the barriers include creating a statewide council to design, implement, and coordinate a comprehensive system for integrating immigrant physicians into the health care workforce; encouraging or requiring residency programs to revise requirements for medical school graduation dates; creating a standardized assessment and certification program to assess the clinical readiness of immigrant physicians; and developing dedicated residency positions for immigrant physicians. “This task force has thought creatively about this problem and brought us feasible and groundbreaking strategies that could fortify our physician workforce for years to come,” said Ed Ehlinger, MD, Minnesota Commissioner of Health. Ehlinger urged the chairs of several legislative committees to consider the task force’s recommendations in the next session.
Thank you for your February article titled, “Reporting child maltreatment and abuse.” Unfortunately, I fear that readers may misinterpret your statement on page 10 that “professionals who work with children...” are the only mandated reporters. The statute does not specify that only those who work with children are required to report abuse or neglect. In fact, the statute requires that “ a professional or professional’s delegate who is engaged in the practice of the healing arts, social services, hospital administration, psychological or psychiatric treatment...” is a mandatory reporter. All health care providers are mandated to report, whether they are seeing a possible victim, victimizer, or have otherwise learned of possible abuse/neglect. The statute does not allow us to exempt ourselves from reporting if we are seeing the possible perpetrator and not the child. Thank you again for highlighting this important issue. Shelley R. Stanton, MD Chief of Psychiatry FMC Rochester
Tell them there’s a better way! Get your patients screened for colorectal cancer.
Minnesota Physician March 2015
Medicus Peter J. Dehnel, MD, medical director for utilization management at Blue Cross Blue Shield of Minnesota, has received the 2014 First a Physician award from the Twin Cities Medical Society. The award recognizes a member of the Twin Cities Medical Society who has made a positive impact on organized medicine by giving time and energy to improve the public health, enPeter J. Dehnel, hance the medical community’s ability to pracMD tice quality medicine, and/or improve the lives of others in the community. Dehnel completed medical school and a pediatric residency at the University of Minnesota. Jennifer Gerckens, MD, board-certified in physical medicine and rehabilitation (PMR), has joined the PMR department at Hennepin County Medical Center (HCMC), Minneapolis. She completed medical school and a residency in PMR at Ohio State University Medical Center, Columbus. Also joining HCMC is Michael Hu, MD, board-certified in surgery and a Jennifer Gerckens, fellow of the American ColMD lege of Surgeons, who joins the surgery department. He completed medical school and a general surgery residency at the University of Minnesota; a vascular fellowship at Washington University, St. Louis, Mo.; and an endovascular mini-fellowship at Southern Illinois University, Springfield. Before joining HCMC, he practiced at Mercy and North MeMichael Hu, MD morial Medical Centers and with General and Vascular Surgery Consultants at Abbott Northwestern Hospital. Rick M. Odland, MD, PhD, FACS, has been named the new chief of HCMC’s Department of Otolaryngology, replacing Robert Maisel, MD, who has retired. Odland has been on staff at HCMC since 1995, has served as medical director of its Ear, Nose and Throat Clinic since 1997, and has been assistant chief of the department since 2013. Board-certified in otolarRick M. Odland, yngology and in the subspecialty of facial plastic MD, PhD, FACS surgery and reconstructive surgery, Odland graduated from Creighton University School of Medicine, Omaha, and completed an otolaryngology residency at the University of Minnesota. Erica Weiss, MD, board-certified in internal medicine, is now on staff in HCMC’s internal medicine department. Weiss completed medical school and an internal medicine residency at the University of Minnesota Medical School. Erica Weiss, MD Richard Lindstrom, MD, Minnesota Eye Consultants, has been invited by NASA to join a team of ophthalmologists working to prevent ocular degeneration in astronauts undergoing long-term space travel, in preparation for a mission to Mars slated for the 2030s. Ocular degeneration has been detected in astronauts who spent three to six months in space; the Mars mission will last 500 days.
Paula Termuhlen, MD, begins her tenure as regional campus dean of the University of Minnesota Duluth campus on March 31. She succeeds Alan Johns, MD, MEd, who will resume his role as a faculty member and Duluth’s assistant dean for medical education and curriculum. Termuhlen graduated from the St. Louis University School of Medicine, Missouri; completed surgical training at the University of Texas Health Science Center, Houston; and completed a surgical oncology fellowship at MD Anderson Cancer Center, Houston. She previously led the Community Medical Education Program at The Medical College of Wisconsin, Milwaukee.
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Song of the Earth: Mahler's Das Lied von der Erde Fri Apr 10 & Sat Apr 11 8pm
Mark Wigglesworth, conductor / Mihoko Fujimura, mezzo / Stuart Skelton, tenor To end Haydn's Farewell symphony, the musicians stop playing one by one, extinguish their lights and walk offstage. Fortunately they return for Mahler's magnificent The Song of the Earth.
Primal Paradise: Stravinsky's Rite of Spring Thu Apr 23 11am / Fri Apr 24 8pm
Michael Stern, conductor / Simon Trpčeski, piano A century after its debut caused riots in Paris, The Rite of Spring is as riveting as ever as is Rachmaninoff’s demanding Third Piano Concerto and Griffes’ The Pleasure Dome of Kubla-Khan.
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March 2015 Minnesota Physician
The mechanisms of pain
Mehul J. Desai, MD, MPH Medical Advanced Pain Specialists Dr. Desai is board-certified in pain medicine and physical medicine and rehabilitation, and practices at Medical Advanced Pain Specialists (MAPS) in Maple Grove. He completed his residency in physical medicine and rehabilitation at Georgetown University Hospital. During his residency, Desai spent six months completing a research fellowship at the National Institutes of Health conducting groundbreaking research into the mechanisms of muscle pain. After his residency, he completed a fellowship in pain medicine in the department of anesthesiology at Thomas Jefferson University Hospital in Philadelphia. Desai’s clinical interests include neuromodulation, specifically spinal cord stimulation and targeted drug delivery; discogenic pain and intradiscal therapies including biologic; complex spinal conditions; pelvic pain; outcomes-based research; and health care economics.
What recent regulatory changes have What can you share about how the field of affected prescribing pain medication? pain medicine began and how it has grown to where it is today? Over the past several years the Drug Enforcement Pain medicine is a relatively new specialty that Agency (DEA) has changed some of the classificagained prominence after World Wars I and II. The tions of frequently prescribed opioid painkillers. last 20 years have been a time of considerable The best example is hydrocodone, or Vicodin, evolution in the specialty. Initially considered a which is the most commonly prescribed medication subspecialty of anesthesiology, pain medicine has in the United States. The U.S. consumes 99 percent become a stand-alone specialty typically drawing of the world’s Vicodin supply. The DEA publishes providers with primary training and backgrounds an opioid classification schedule; and hydrocodone in anesthesiology; physical medicine and rehabiliwas recently reclassified as a Schedule II agent. tation; psychiatry; and neurology. With the advent Consequently, this medication can no longer be of improved imaging technology, we now can better called-in with multiple refills, but rather requires a define the source of pain and address it. The result signed script for each 30-day supply. is an explosive growth in pain medicine, leading to advances in diagnostic What can you tell us tools, therapeutic opabout the exciting tions, and an enhanced advances in treating The U.S. consumes 99 percent of chronic pain with interdisciplinary care the world’s Vicodin supply. implantable devices? model. Implantable devices have undergone a tremendous What are some of evolution over the past 10 the issues around the fine line between needing powerful opi- to 20 years. Rechargeable batteries have revolutionized the science of neuromodulation. Tremendous ate-based pain medications and becoming addicted to them? effort has gone into understanding the targets for This is a very important delineation to make. In the stimulation or drug delivery in order to improve acute setting (i.e., post surgery following trauma) outcomes. More recently, manufacturers have there is very good evidence to suggest that opioid developed stimulators that are magnetic resonance medications are both helpful and effective. Beyond imaging (MRI) compatible and sensors that can the acute setting there is very little data to guide us detect positional changes in the spinal cord and ador suggest improvement over the long term. Most of just the parameters to optimize coverage during difthe literature to date has been limited to follow-up ferent activities. There are new targets and parameintervals of 12 weeks or less. Furthermore, despite ters that may provide a more comfortable sensation some improvements in pain scores, many patients with spinal cord stimulation. Other developments do not show improvement in function with longfocus on novel pharmacological formulations and term opioid therapy. There are many cases where their delivery to spinal cord and brain targets. opioid medications are helpful and allow patients to retain or improve function over time. In these Tell us about some of the new work being situations, patients require frequent monitoring done involving an interdisciplinary and education. approach to pain management. It’s interesting that we are coming full circle with this idea. Historically, interdisciplinary or multi What are some potential solutions to the disciplinary treatments were the approaches of problems that arise because so many different kinds of doctors are able to prechoice. Because of time and financial constraints, scribe powerful pain medications? these options were essentially abandoned in most Several potential solutions exist to reduce the opiplaces outside of some specialty clinics and large oid epidemic currently affecting the United States. academic or federal organizations. With the advent Consideration might be given to ceiling doses for of the Accountable Care Act (ACA) and the concept non-pain board-certified providers or consultations of integrated care, value, and the medical home, with pain medicine providers on an annual or interdisciplinary care for a number of chronic semi-annual basis for those on chronic opioid therconditions have emerged. Pain is no different; apy. It is important to increase the amount of eduthe importance of a comprehensive multidimencation and support for non-pain providers through sional approach should be emphasized. The role of CME opportunities, compliance and dosing stratebehavioral health and physical therapy in conjuncgies, improved access to available resources, etc. It tion with medical treatment is being studied. This is equally importance to educate the patient as well dovetails into ACA-mandated improvements in as the general public. As with many issues, knowloutcomes and ultimately may improve outcomes edge and communication between stakeholders is a for pain and save health care dollars. clear key to success.
Minnesota Physician March 2015
Please talk about radiofrequency neurotomy. Who is a candidate for this procedure and what are the results? Radiofrequency (RF) neurotomy describes a group of procedures by which small peripheral sensory nerves are ablated to prevent the transmission of painful stimuli from their targets to the spinal cord and brain. RF technology works by placing an uninsulated probe adjacent to the target nerve. The probe then oscillates at a very high frequency and generates heat that subsequently ablates adjacent nervous tissues. In order to determine if a patient is a candidate for RF neurotomy, anywhere from one to two diagnostic blocks are undertaken with local anesthetic, selectively blocking the peripheral nerves. Typically, patients with axial spine pain that affects the central portion of the skeleton are the best candidates. These patients do not commonly have pain at rest; rather their pain comes with loading activities such as walking and sitting. Often, patients with prior whiplash injuries and persistent neck pain are also good candidates for RF as are those with mechanical low back pain. Newer iterations of RF neurotomy are successfully targeting intervertebral disc pain, sacroiliac joint pain, and pain from large peripheral joints such as the hip
and knee, particularly for patients that are not candidates for total joint replacement. Radiofrequency neurotomy falls into the evolving science of neuromodulation. What can you tell us about this field? What are some examples of how it is being used? Some of the most common examples of neuromodulation include spinal cord stimulation and targeted drug delivery. Other options include radiofrequency neurotomy. The future of neuromodulation might involve unique molecules that are specifically formulated for targeted delivery to treat pain. In addition, as technology continues to undergo miniaturization the ability to target specific anatomical areas and conditions will become more commonplace. This area of pain medicine has emerged in the past 10 years as one of the more cutting edge areas in the treatment of painful conditions. Examples of its use include pain related to malignancy, post-spine surgery pain, nerve pain, trigeminal neuralgia, and headaches. What advances in pain treatment do you foresee in the near future? As we continue to improve our understanding of neurochemistry and central nervous
system functioning, customized treatments to specific targets are likely to make their appearance. This may include medications tailored towards the epigenetics of pain. Miniaturization of technologies as well as the development of percutaneous techniques will likely allow less invasive approaches that allow faster recoveries and less postoperative pain. Portable technologies that may be worn on the body will also be applied to pain medicine to a greater extent. A recent Harvard Medical School study found that one in three Medicare patients are filling opioid prescriptions from multiple providers. What conclusions can be drawn from this data? It would appear that gaps in the coordination of care allow patients to obtain redundant or unnecessary prescriptions. Further, one might suggest that patients are able to manipulate the health care system to obtain multiple prescriptions. There appears to be a willingness from providers of multiple specialties to write prescriptions for controlled substances. Although in most cases this is done with altruistic intent, ultimately the results might be deleterious.
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952.837.8517 healthcare.cushwakenm.com March 2015 Minnesota Physician
Health exchange transparency from cover
out-of-pocket. Wouldnâ€™t you want more information before making that decision? Similar dilemmas confront consumers shopping for health insurance coverage in Minnesota. Though MNsure, the state health insurance exchange, has improved markedly over the last year, consumers need answers to important questions in order to make informed decisions about health insurance coverage and often struggle to find the information they need. The hunt for coverage options Consumers in Minneapolis shopping for coverage on MNsure have 65 health plans and 16 dental plans from which to choose the right coverage. For consumers browsing through coverage options, the exchange asks if having specific providers covered is important
and pledges to add a search option that narrows health plan choices for consumers if they want to keep a specific doctor in the future. In the meantime, to search for a list of covered providers in general or to find if a specific doctor is covered, the consumer has to locate a link to each health planâ€™s information. The exchange does not provide a link to a list of covered providers with the information that is readily available with each health plan. A consumer has to download a Summary of Benefits document where most health plans list a web page where consumers need to look to find a list of providers. The experiences on those web pages vary as each insurer presents the information differently.
Similarly, to find a link to a list of covered medicines, the consumer has to first download the Summary of Benefits
Affordable insurance premiums do not mean access to affordable care.
document. A quick check of several plans showed that some of the links to information on covered medicines open a document, some open to a search engine, and others just go to the health planâ€™s home page and require the consumer to hunt around the website for a list. For other services such as coverage for mental health services, physical therapy, or durable medical equipment, consumers have to check several different documents and websites to gather that information. Confusing terminology Having options is wonderful; not having readily available information to sort through presents significant challenges to consumers hoping to find coverage that meets their health care needs. The availability of information is half the battle. The other major need is for information that is presented in language a consumer can understand and use. When looking for information about covered medicines on the exchange, health plans often provide consumers with the same drug formularies they make available
Minnesota Physician March 2015
to medical professionals. Though clinicians would know to look at antineoplastics to determine which cancer medicines are covered or to look under antihyperlipidemics for cholesterol-lowering medicines, these terms are not understandable to people without a medical background. Similarly, tools that can locate covered providers may depend on the use of specific search terms, such as oncology instead of oncologist and may differentiate between hematology and oncology generally. Though accurate in the medical field, these details often are lost on consumers searching for doctors who treat cancer or any other number of chronic conditions. I thought I knew what I was getting! Without the tools to assist in sorting through their options, consumers make these important decisions with limited information. Making an uninformed choice can mean not being able to keep the same doctors, not having medicines used on formulary, and paying more out-of-pocket through deductibles, copayments, or coinsurance for needed care. Affordable insurance premiums do not mean access to affordable care if the benefits of the plan chosen do not match the needs of the patient. To make these important decisions, consumers need help understanding the trade-offs involved when it comes to costs, premiums, and the benefits offered and, the implications for them. For example, an analysis completed by the research firm Milliman in May 2014 found that Silver plans are almost four times more likely to use a single deductible that combines medical and pharmacy benefits than a typical employer-sponsored plan does. With a combined
deductible, medications and doctor visits are not covered until the deductible is reached. For Silver plans, the coverage level most often chosen by consumers, the deductible averaged $2,000 a year. For Bronze plans, the average deductible was nearly $5,000
selecting health care coverage is critically important. Understanding out-of-pocket costs There are tools available that would help. Consumers need tools that help them make
with affordable access to quality health care. Without the availability of consumerfriendly tools and information that let consumers see inside the “box” they are buying, we’re not there yet. Physicians witness the toll
Nothing currently is available to make out-of-pocket cost comparisons between health plan options.
a year. For most families, but particularly those with low incomes, having to incur thousands of dollars in medical costs before having a doctor’s visit covered or a prescription filled presents significant barriers to health improvement. Being able to estimate their costs under different plans can help consumers choose a plan that provides affordable access based on the care they need. The challenges and stakes are particularly acute for the almost one in two Minnesotans who live daily with a chronic condition, including a large number of people getting insurance for the first time. Research confirms that higher out-of-pocket costs can have a significant negative effect on rates of adherence to treatment regimens, particularly for taking medicines as prescribed (Goldman, Joyce, and Zheng; JAMA 2007). Improving medication adherence could save more than $105 billion per year by eliminating preventable hospitalization admissions, emergency department visits, outpatient visits, and avoidable pharmacy spending (IMS Institute for Healthcare Informatics, June 2013). Having insurance coverage does not necessarily mean having access to care, so making certain that Minnesotans have the information they need to make an informed choice when
sure the plan deductibles, charges for office visits, and costs for other services they need are affordable. Having a cost-calculator tool available on MNsure to estimate out-of-pocket costs, including premiums, could provide significant assistance. For example, California’s health care exchange offers consumers a cost calculator to help estimate out-of-pocket costs under each health plan depending on the consumer’s estimated use of health care services, including doctor’s visits, medications used, and anticipated medical procedures requiring hospitalization. Similarly, Medicare Part D provides beneficiaries with a cost calculator that allows them to estimate their costs under each plan offered to facilitate informed decision-making. MNsure provides a calculator that allows people to estimate how much premium assistance they may be entitled to receive, but nothing currently is available to allow out-of-pocket cost comparisons between health plan options. We’re not there yet Cutting the number of uninsured in Minnesota by more than 40 percent is a significant accomplishment and a good reason to celebrate. The ultimate goal, however, is providing Minnesotans
that a lack of affordable access to health care exacts on their patients’ health. It may be the patient who waits for an urgent problem to see her doctor because of a high deductible. It may be the patient who ends up in the emergency department from not taking her medicines
because of high copayments. It may be the patient for whom affordable access to recommended screenings or tests could have meant a better prognosis. As both trusted professionals and witnesses to the problems, physicians can help Minnesotans have better access to care. Making sure their patients know which health plans they accept is an important step, but physicians can have an even larger impact by working to assure that all Minnesotans have access to the useful tools and information they need to make informed decisions about health care coverage. Candace DeMatteis, JD, MPH, is the policy director for the Partnership to Fight Chronic Disease in Washington, D.C. and is committed to raising awareness of the significant impact of chronic disease in the U.S.
The Lawyers and Lobbyists that Doctors Trust Medicine is complicated. So are the laws that doctors, hospitals and insurance companies have to manage. Lockridge Grindal Nauen is one of Minnesota’s leading health care law firms. Our health care clients are so satisfied they’ll write us a referral.
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From the Courtroom to the Capitol.® March 2015 Minnesota Physician
Hospital medical-staff bylaws from cover
provision of the bylaws. For example, a hospital’s violation of the bylaws could support an argument against a peer-review action as arbitrary or motivated by bad faith.
of the bylaws themselves.
The question of whether medical-staff bylaws could be contractual had never been decided directly by the Minnesota Supreme Court, although a 1977 decision from the Court referred to The medical staff had the bylaws the capacity to sue. as creating a “contractual” right without any analysis Background on medicalof the issue. staff bylaws The question of whether Both Minnesota and federal law a medical staff may file suit The facts of the Avera require the governing body of for breach of the bylaws, Marshall decision a hospital to appoint a medical however, has been the subject of Avera, a South Dakota-based staff, and require the medical significant debate among courts hospital system, operates a staff to formulate bylaws, and lawyers across the country. medical center in Marshall, policies, and rules to govern its Many state courts have held Minn. The medical staff operations. that medical-staff bylaws are at the hospital adopted Even before the Minnesota contractual, and that members bylaws, including a provision Supreme Court’s decision in of the medical staff may sue requiring that the medical Avera Marshall, there were or be sued to enforce bylaw staff be required to approve potential legal consequences provisions, while others have any changes to the bylaws by whenever a hospital or medical used a case-by-case analysis two-thirds vote. Despite this staff violated a material depending on the specific terms provision, the hospital’s board repealed the existing bylaws and approved a set of revised ICSI 2015 bylaws in 2012 without the medical staff’s support. If not careful, a medical staff could expose itself to future liability by agreeing to bylaw provisions that it cannot follow. Or, in other cases, a hospital may ask a medical staff to agree to provisions that disavow the existence of a contract altogether, meaning the medical staff would voluntarily give up the very protections recognized in Avera Marshall.
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Minnesota Physician March 2015
The medical staff sued the hospital, arguing that the hospital board violated the bylaws. Among other relief, the medical staff sought a declaration that it had the legal capacity to file a lawsuit and that the medical-staff bylaws were enforceable against Avera Marshall. The district court dismissed the case, and the Minnesota Court of Appeals affirmed that decision. The Supreme Court’s decision The Minnesota Supreme Court reversed the lower court decisions, concluding that (1) the medical staff had the capacity to sue the hospital and (2) the medical-staff bylaws qualified as an enforceable contract under Minnesota law. Justice Alan Page, writing for a majority of justices on the Minnesota Supreme Court, first concluded that even though the medical staff had not created a formal legal entity (such as
a corporation), the medical staff satisfied Minnesota’s statutory requirements as an unincorporated association, with the legal capacity to sue and be sued. The medical staff was found to be an unincorporated association because it was “composed of two or more physicians who associate and act together for the purpose of ensuring proper patient care at the hospital under the common name ‘Medical Staff.’” As to the second issue, Justice Page wrote that Avera Marshall’s bylaws qualified as a contract under Minnesota law because the medical staff had consented to the bylaws by agreeing to provisions that exceeded the minimum standards required under state law—as a result, the bylaws were not merely the product of a preexisting legal obligation. Further, because the hospitalrequired medical staff members had to agree with the bylaws in order to be appointed to the medical staff, the hospital had formed a contractual relationship with each member of the medical staff upon appointment. Significance of the decision for medical staff Minnesota joins the majority of jurisdictions recognizing that medical-staff bylaws may be contractual, which is also a long-standing position of the American Medical Association. Members of a medical staff now have additional assurances that the requirements of the bylaws will be followed and, if the bylaws are not followed, medical staff now have a legal mechanism for enforcing the bylaws’ requirements. But this mechanism also could work the other way, when bylaws are enforced against the medical staff or one of its members. As a result, the decision is a warning for members of medical staff to be careful about what they agree to in their medical-staff bylaws. Although Avera Marshall likely means that, in general, staff bylaws constitute a
contract, the case does not establish that bylaws always will form a contract. In each case, the relationship between a hospital and medical staff will be determined by the facts of the situation and the terms of the bylaws. Medical staff may encounter situations where hospitals propose bylaw provisions that disavow the existence of a contract altogether. A footnote in Avera Marshall contemplates this practice by comparing medical-staff bylaws to employee handbooks, which also may constitute an enforceable contract depending on the language. If a hospital seeks to prevent bylaws from becoming contractual, it may seek to include a disclaimer that disavows the document is a contract, similar to disclaimers that frequently appear in employee handbooks. Where the terms of staff bylaws clearly create a contract, medical staff should be careful
not to agree to provisions that create burdensome or complicated obligations for staff members. If medical staff is unable to comply with the requirements of staff bylaws, the staff and its members may be exposed to potential liability for breaching the bylaws’ terms. The decision in Avera Marshall clarifies that a medical staff may have the legal ability and right to enforce staff bylaws. Yet as it recognized the new rights for medical staff, the Minnesota Supreme Court’s decision underscores that the obligation of medical staff to carefully review the bylaws before agreeing to them is just as important as it was before. Greg Myers, JD, and David Asp, JD, are partners with the law firm
Lockridge Grindal Nauen PLLP in Minneapolis specializing in health care compliance and litigation. Elizabeth Snelson, JD, serves as of counsel and specializes in legal issues related to credentialing, peer review, and bylaws.
Request foR nomination 2015 HealtH care arcHitecture & Design
Seeking Exceptionally Designed Health Facilities in Minnesota Nomination Closing: Friday, May 8, 2015 Publication Date: June 2015 We are seeking nominations of exceptionally designed health care facilities in Minnesota. the nominees selected for the honor roll will be featured in the June 2015 edition of Minnesota Physician, the region’s most widely read medical publication. eligible facilities include any construction designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. interiors, exteriors, expansions, renovations and new structures are all eligible. in order to qualify for the nomination, the facility must have been designed, built or renovated since January 1, 2014. it also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota or Iowa). color photographs are required at 300 dpi resolution (no more than eight) with caption of each to firstname.lastname@example.org. if you would like to nominate a facility, please fill out the form below and, a brief project description (150-250 words) by Friday, May 8, 2015. For more information, call (612) 728-8600.
Honor Roll nomination form
Facility name Type of facility Location Ownership organization Owner address, phone Architect/interior design firm Architect address, phone
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March 2015 Minnesota Physician
Professional Update: Radiology
ost people are familiar with stents because of their extensive use in opening up clogged arteries in the heart. There is, however, another important use of stents— treating brain aneurysms. Brain aneurysms are a focal weakening in the wall of a brain artery. At the site of weakening, the vessel wall balloons outward due to the constant stress of blood flow. While some aneurysms become symptomatic by enlarging and pressing on important parts of the brain, on their own, most brain aneurysms don’t cause any symptoms unless they rupture. A ruptured brain aneurysm usually results in a pattern of bleeding in the brain known as subarachnoid hemorrhage, which occurs under the membrane lining the brain. As one can imagine, a subarachnoid hemorrhage is a devastating event. Generally, one-third of
Not just for opening clogged arteries By Yasha Kadkhodayan, MD
patients don’t make it to the hospital, one-third of patients suffer substantial neurological injury, and one-third recover to lead normal lives. Symptoms and risk factors The symptoms of a ruptured brain aneurysm include the sudden onset of an acute headache, loss of consciousness, nausea and vomiting, neck stiffness, blurry or double vision, sudden weakness or numbness, sensitivity to light, seizure, or a drooping eyelid. Brain aneurysms are more common than most people think. According to the Brain Aneurysm Foundation, an
estimated 6 million people in the United States have an unruptured brain aneurysm, or one in 50 people. Aneurysms usually occur in people aged 35 to 60, but can occur in children as well. The median age at rupture is 50 years old, and there are typically no warning signs. In Minnesota, over 300 patients suffer from a subarachnoid hemorrhage every year (Minnesota Stroke Registry Program Report 2008–2012). Risk factors that may lead to the formation and rupture of brain aneurysms include smoking, high blood pressure, connective tissue disease, family history of brain aneurysms, and
Three patients. Who is at risk for diabetes?
stimulant drug use. Sometimes brain aneurysms are discovered incidentally when patients have their heads scanned for another reason, such as headaches, dizziness, visual changes, or stroke symptoms. When faced with an incidental aneurysm, physicians have to decide whether treatment is appropriate. This decision consists of weighing the unlikely but significant risks of treatment, which include stroke and death, against the small chance that the aneurysm may rupture on its own if nothing is done. This decision is often complicated. Treatment options Generally speaking, there are three ways to manage a brain aneurysm: open brain surgery, endovascular treatment, or surveillance. In some cases, the best treatment is no treatment. Aside from patient factors such as age and other medical conditions, aneurysms come in various shapes and sizes
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Minnesota Physician March 2015
and can have either narrow or wide necks. These factors often determine which treatment should be used to prevent rupture. Endovascular treatment In the past, the only treatment for brain aneurysms was open brain surgery, which usually involved physically excluding the aneurysm from the circulation with a surgical clip. Today, more and more aneurysms are treated endovascularly as large randomized trial data have shown not only safety, but also efficacy. If an aneurysm has a narrow neck, endovascular treatment with coils is often preferred. The femoral artery is generally accessed via a small incision made in the groin. Typically, endovascular treatment involves placing soft platinum coils directly into the aneurysm by way of the femoral artery to prevent it from rupturing (see Figure 1, on this page). A neurointerventional radiologist, who specializes in image-guided techniques, performs the procedure. Endovascular treatment with coils first became available in the mid-1990s, and physicians at Abbott Northwestern Hospital in Minneapolis were among the first in the country to perform this procedure. Some aneurysms, however, have wide necks that can make the coiling process difficult or even impossible as the coils can fall out of the aneurysm and occlude the parent artery. Balloon-assisted coiling Balloon-assisted coiling is one solution when faced with a wide-neck aneurysm. The procedure involves temporarily inflating a soft, compliant balloon across the aneurysm neck, which allows the coils to take the shape of the aneurysm. Once it is determined that the coils are staying securely inside the aneurysm, the balloon is completely deflated and removed. Sometimes, if an aneurysm has an especially wide neck, the balloon is not enough to keep the coil in place. That’s
where stent-assisted coiling comes into play.
Figure 1. Coiling of a brain aneurysm
Figure 2. Stent-assisted coiling of a brain aneurysm
Stent-assisted coiling The first stent system designed specifically for use in the brain was the Neuroform, which was introduced in 2002. The Neuroform—and Figures courtesy of Society of NeuroInterventional Surgery many subsequent devices—is vice. Flow diversion technology troduced. These stents, rather constructed of nitinol, which is represents a major evolution of than serving as a scaffold to a metal alloy containing nickel endovascular therapy of intrakeep coils in, are more accuand titanium in roughly equal cranial aneurysms, allowing us rately described as a mesh with proportions. Nitinol is known to treat aneurysms previously additional metal coverage that for its elasticity and shape serves to divert blood flow away deemed untreatable, or only memory, or ability to be detreatable by sacrificing the parfrom the aneurysm. With the formed at one temperature and ent artery. aneurysm’s blood flow reduced, recover its original shape upon it will shrink over time. The Pipeline embolization device heating. Since 2002, the Neuporous nature of the mesh, For large, wide-neck roform has undergone three however, does allow maintained aneurysms, the five-year cumumajor design changes, and blood flow to branch vessels lative risk of rupture can range several other stents have been that arise near the aneurysm developed. These include, more and may be covered by the deStents to page 19 recently low-profile stents capable of being delivered through smaller and smaller catheters, increasing the deliverability and safety of stent-assisted coiling. Stents can be used as a scaffold to keep coils inside a wideneck aneurysm (see Figure 2, on this page). Stent-assisted coiling, while carrying slightly more risk, allows doctors to treat more aneurysms from inside the blood vessels, avoiding the need for open brain surgery. Risks of the procedure include stroke due to a clot forming along the stent, or rupture of an artery in trying to place a complex device in the tortuous and delicate cerebral arteries. Stents that have an open cell design also can be placed inside each other, forming Y or even X configurations in order to treat aneurysms that occur at branch points and have necks that involve the walls of more than one artery. Flow diverters In the past few years, specialized stents known as flow diverters have been in-
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will never forget the conversation I had 15 years ago with my program director who was a world famous pain and addiction specialist. I was a resident in a New York City hospital at the time, but was born in Russia and attended medical school there. He was definitely not in a good mood, “Elena, you are so talented and I expect a lot from you. Your research is great, but lately I am disappointed with your clinical skills!” I was stunned and couldn’t understand why. “Your pain management for your patients is questionable. You aren’t prescribing enough pain medication and your patients are suffering.” He continued, “As you know this is the United States Bone and Joint Decade (2001-2010) and one of the mandates is to fight pain effectively. Remember, pain is the fifth vital sign and opioids don’t have a ceiling effect. The United States is a leader in innovative technology and Big Pharma offers a variety of effective ways to fight
Addressing an epidemic Moving toward responsible opioid prescribing By Elena Polukhin, MD, PhD pain. Forget the limitations you were under in Russia. Acupuncture, herbs, and massages are for poor countries, with underdeveloped technology. Besides, you are putting yourself and our department at risk of a lawsuit and jeopardizing your reputation and future. So, if you want to graduate, please revise your methods and start prescribing more effective pain meds.” I was speechless, upset, and fearful. Although I had mixed feelings, I started prescribing more pain medication out of respect for my boss, for fear of prosecution, and with the hope
of having a career in medicine. I have continued to follow my director’s advice to prescribe opioids. In the back of my mind I always doubted whether he was correct in thinking that opioids are the only way to control pain. Other teachers that I had outside of the United States used other methods when it came to treating pain such as Botox, prolotherapy, hypnosis, or acupuncture. The great opioid debate: PROP vs. PROMPT The Bone and Joint Decade is over and the U.S. is in the
middle of a pain epidemic with millions of patients addicted to opioids. Television and newspapers are full of terrifying stories about death from pain pills; pill mills in Florida; substance abuse and diversion; and doctors prosecuted for overprescribing pain medication. As physicians we wonder if we inadvertently harm our patients by prescribing opioids and put our careers at risk. The most important question remains, “What’s next when treating patients in chronic pain?” Should the reins be tightened on the use of long-term opioid therapy for patients with chronic noncancer pain? That question was at the heart of a controversy that boiled over in July 2012 when Dr. Andrew Kolodny from Brooklyn who founded PROP (Physicians for Responsible Opioid Prescribing) took a rather radical approach—limit/stop opioid use for most chronic, noncancer pain patients. Thir-
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ty-seven physicians issued a petition calling on the FDA to require opioid label changes and to limit opioid use solely for severe cancer pain—and then only for a maximum of 90 days at no more than the morphine equivalent dose of 100 mg. Pharmacists and physicians opposed to PROP’s proposed label restrictions were quick to respond. Jeffrey Fudin, MD, and 26 other physicians formed Professionals for Rational Opioid Monitoring and PharmacoTherapy (PROMPT). The group sent a letter to the FDA expressing their concerns about the safety of chronic opioid use, but suggested a different approach that emphasized “clinician education, proactive risk stratification, and appropriate therapeutic monitoring.” PROMPT’s approach was more gradual and practical than PROP’s. Fudin believed that the FDA’s risk evaluation and mitigation strategy (REMS) program for extended-release opioids “is a step in the right direction,” but that regulations “should go further and make education mandatory for all people who prescribe opioids.” Addressing opioid abuse in Minnesota Last spring, the Minnesota Department of Human Services formed the Universal Pharmacy Policy Workgroup to help address the state’s prescription opioid abuse epidemic. The workgroup’s recommendations included the following: • Preauthorizing Oxycontin use • Limiting opiate prescriptions to a maximum dose of 120 morphine equivalents per day • Excluding cough syrup with codeine • Limiting the use of Soma and Suboxone • Encouraging the use of the Prescription Monitoring Program (PMP) In general, this approach was closer to PROMPT’s goals and was supported by many physicians in the pain community.
Improving pain management There are some important, but basic, steps that we must take to improve and standardize pain management. I have given this
violent prosecution, multiple audits, and even disciplinary action. Physicians in private practice are at the biggest risk of prosecution. There are a
It is important to respect pain doctors and addiction specialists. a lot of thought and here are my suggestions. Rewarding adherence to pain standards Those who adhere to pain medicine policy should be rewarded. The Clinical Centers of Excellence Award given by the American Pain Society should be granted to pain and addiction clinics that practice pain and addiction medicine according to current best practices. Private practices should be recognized as well. Using medication-assisted treatment Expanding medication-assisted treatment for substance abuse disorders is our best chance to stem the tide of opioid addiction in Minnesota. Insurance companies must cover this type of treatment, which they generally don’t. Political support for and public education about medication-assisted treatment will eventually allow physicians to implement this plan of care. Educating others about pain management We need to educate the public, physicians, and legislators on the effective treatment of chronic pain and substance abuse, while separating truth from fiction with respect to “pill mill phobia.” Minnesota pain doctors are the first to support efforts to fight pill mills, end bad practices, and remove doctors that prescribe pain medication either illegally or unethically. At the same time we should be concerned that the anti-opioid movement will prevent physicians from doing their jobs effectively and saving lives. Many pain doctors and substance abuse practitioners have been hounded with false accusations,
lot of terrifying stories, but I was especially shocked by the four-year investigation in Utah of Lynn Webster, MD, for the overdose deaths of several patients. He was the former national president of the American Pain Management Association. Recently, federal prosecutors dropped all charges against Dr. Webster and closed the file. Despite being exonerated can you imagine his emotional and financial damage? Respecting physicians who treat pain It is important to respect pain doctors and addiction special-
ists. These physicians treat patients with chronic pain and chemical dependency and these often are the most challenging and difficult patients to treat. We are doing our best to offer effective, scientifically-based, realistic, affordable methods of treatment but pain physicians are still thought of as the “black sheep” of medicine, because their work is perceived to be unethical. People are quick to accuse us of wrongdoing and the authorities investigate what often are false accusations. My first job as a physician was at a chemical dependency hospital for drug addicts and alcoholics in southern Russia. I noticed that the patients there saw the world in a different light and were incredibly talented. They suffered because they were different and unable to find their way in a cruel world. Russia and many other countries respect pain and addiction physicians and do not Addressing an epidemic to page 18
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stigmatize addicted patients. The Russian Orthodox Church calls people who suffer from pain and addiction “red angels” or saints. It is thought that red angels absolve physical pain in other people through their suffering and that they are God’s healing hands. I first heard about red angels near Lake Baikal in Russia and was touched by the purity and deep sense of respect that these people were given. Perhaps this is why I became a pain management doctor. I sometimes think it was my destiny.
Reimbursing integrative treatment Insurance companies must reimburse integrative pain management treatment options including holistic methods, acupuncture, physical and occupational therapy, healing touch, physical modalities, herbs, stem cell therapy, prolotherapy, etc. PROMPT supporters feel that an integrative pain clinic should try alternate pain management methods before prescribing opioids. Unfortunately, these treatments are not covered by many health plans or have very limited coverage under the Affordable Care Act. Pain management physicians provide a lot of services pro bono as a result.
Revising pain policy As the opioid epidemic mounts, we need to consider how to bring about policy changes that will improve and set standards when managing chronic pain.
Improving the PMP The Minnesota Prescription Monitoring Program is a great program, but needs improvement. We need to gather meth-
Providing corporate grants Corporations in Minnesota should provide grants to develop and implement effective pain
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and addiction programs. Most of the “inner circle” concept of holistic pain management, mental health, and addiction control are not covered by most health plans and therefore are not available to most patients. The opioid addiction epidemic in Minnesota stems from our inability to provide a long-term solution to a long-term problem. Patients with chronic pain are given pain killers for a period of time and then simply sent away with little or no follow-up. These patients sometimes turn to buying their pain killers on the street in order to continue treatment. The future Am I optimistic about the future of pain management? Absolutely! We are going through a period of turmoil, an era of uncertainty and inconsistency not only in pain management, but in medicine in general. At the same time, with all the good and the bad, the U.S. is still the best country in the world with
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adone clinic data, eliminate the one-week delay in entering new data, and address the issue of having several providers work in the same clinic.
Addressing an epidemic from page 17
the best physicians’ armamentarium. I recently attended WHO meetings overseas and we had many debates about pain management and addiction. While there I realized that it will take time, but that with the support of providers, insurance companies, and the legislature we’ll be able to find the best way to treat patients in chronic pain. Physicians want to help their patients, these red angels, who put their trust in us to help them solve their problems. Elena Polukhin, MD, PhD, is board-certified in physical medicine and rehabilitation and practices at Rehabilitation Consultants PA in Bloomington. She is recognized in the U.S. and abroad for her expertise in integrative pain management, rehabilitation, and chemical dependency. Polukhin works with the International Society of Physical Medicine and Rehabilitation and the World Health Organization promoting innovative methods for pain management and chemical dependency. She has been a visiting professor at many universities in the U.S. and around the world.
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Stents from page 15
from 15 percent to 40 percent depending on the exact location. Furthermore, treatment of these failed or uncoilable aneurysms is risky and over half recur after treatment. A recent clinical trial known as PUFS (Pipeline for Uncoilable or Failed Aneurysms), published in Radiology in 2013, showed that wide-neck aneurysms can be treated safely and effectively using the pipeline embolization device. This is the only flow diverter currently approved by the FDA for use in the United States. Medication When inserting stents and flow diverters, the use of two antiplatelet or blood-thinning medications is required in order to reduce the risk of stroke during and after the procedure. Usually, this involves prescribing both aspirin and clopidogrel (Plavix) to be taken together. As such, we
typically avoid using stents or flow diverters to treat ruptured aneurysms where hemorrhage is already present.
tem. Midterm results from a retrospective study performed in 12 European centers were presented at the November 2013
Brain aneurysms are more common than most people think.
Stent devices awaiting FDA approval The application of stents and stent-like devices continues to expand. There are many new devices that are currently under evaluation for FDA approval in the U.S. Among these are devices that place the scaffold inside the aneurysm, a technique known as intra-aneurysmal or intra-saccular flow diversion. One such device is the WEB aneurysm embolization sys-
meeting of the World Federation of Interventional and Therapeutic Neuroradiology in Buenos Aires. The results were encouraging: There was a 93 percent rate of good clinical outcome and a 90 percent rate of aneurysm occlusion at follow-up more than one year later. There also are new devices specifically designed to be deployed at artery branch points. One is the pCONus, which has a
stent-like structure with distal “petals” that provide a bridging structure at the aneurysm neck. Aneurysms at branch points are difficult to treat given the high risk of compromising an important brain artery and causing a stroke. We will continue to see the exciting potential of stents and stent-like devices in image-guided radiological procedures for the treatment of complex neurovascular diseases. Who knew that the seemingly magical act of opening clogged arteries would be only the beginning? More information can be found at the Society of NeuroInterventional Surgery website (www.snisonline.org). Yasha Kadkhodayan, MD, is board-certified in radiology and is an interventional neuroradiologist with Consulting Radiologists, Ltd., at Abbott Northwestern Hospital in Minneapolis.
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2015 Community Caregivers
Making a difference in
Recognizing Minnesota’s Volunteer Physicians and Health Care Providers Each year, Minnesota Physician Publishing recognizes physicians and health care providers who have volunteered their medical services. Whether volunteering at home or overseas, these caregivers help people in need and come away with a revitalized sense of their work. Their compassion, commitment, and generous spirit reflect the deeply held values in Minnesota’s medical community. Written by Lisa McGowan
Minnesota Physician March 2015
Katie Klingberg, MD Apple Valley Medical Center
visited in the center of the city had dogs and cats roaming the hallways,” she noted. LAMA sends a medical team to Chimbote to provide basic medical, dental, and eye care, and ships donated medical supplies, home goods, and school supplies every autumn. In Peru, one does not receive medical care unless one has insurance or the cash to pay for it, leaving many with no hope of receiving good medical care or medication.
r. Katie Klingberg has been volunteering ever since she can remember. “Volunteering was an expectation—it was something I saw my parents do in our school and parish,” said Klingberg, a family physician at the Apple Valley Medical Center. She continued to volunteer while in college, traveling Volunteers set up to Appalachia, a makeshift clinic Atlanta, in an old church in Washington, D.C., for the Chimbote and the Pine Ridge week they are there. Reservation in Klingberg works with South Dakota. patients of all ages After graduation, and no one is turned she spent a year away. “If a patient volunteering as has a need we cannot a high school meet, we work very teacher in innerhard to help connect city Chicago, him or her with where many of doctors in Lima or her students had the United States,” been touched by she said. Klingberg gang violence, teen enjoys meeting pregnancy, and people from different poverty. It was an backgrounds, eye-opening and My volunteer work cultures, and life-changing year. circumstances on and advocacy will She continued the missions and to volunteer never be done. finding common throughout her ground with them, medical training, “I have repeatedly stopping only witnessed the power to marry and of compassion and gratitude that people raise three children. Klingberg’s oldest express just knowing that others care,” she daughter, Lindsey, joined her on a medical said. mission trip to Peru last year. On her last trip, Klingberg was asked Klingberg volunteered in 2012 and to visit a teenage boy with special needs 2014 with Los Amigos Medical Aid who was suffering from respiratory (LAMA)—a group founded in 2006 by distress. She found him in the hospital Dorothy and Tony Brama of Prior Lake, unconscious, unattended, and gasping for Minn. LAMA annually sends a medical air. She argued for better care for him, but team to Chimbote, an impoverished resources were scarce, and the staff was fishing port on the north coast of Peru. overstretched. Klingberg later found out Many residents of Chimbote lack even the that the boy had died. “I will never forget most basic necessities such as running that I could not save him in a system that water, beds, or electricity. Klingberg was is so broken. This boy’s plight reminds me shocked by the poverty she saw on her that my volunteer work and advocacy will first trip to Chimbote. “The hospital I never be done.”
Minnesota and the world Anne Tofte, MD Grand Itasca Clinic and Hospital
r. Anne Tofte volunteers at Project Care’s Free Clinic in Grand Rapids to help the uninsured in the Iron Range get much-needed medical care without incurring exorbitant debt. Project Care provides free health care and networks with community-based organizations to ensure that patients get continued treatment, screenings, and education. “What Project Care does very well is case management. This is something that larger organizations could learn a lot from,” said Tofte. Patients get help applying for insurance and finding affordable medication. A site coordinator from the clinic also makes follow-up phone calls to review lab results, check on patients’ progress, and answer any questions.
Tofte is a family physician and practices at Grand Itasca Clinic and Hospital in Grand Rapids, Minn. She feels very strongly that everyone deserves access to affordable medical care. “As a working physician and a Mom with an already busy schedule,
volunteering once a month at the Project Care Grand Rapids Clinic is something I feel very passionate about,” noted Tofte. The Grand Rapids Clinic is open on Tuesday evenings and is housed in an old office building with two exam rooms. Working at the clinic allows Tofte to get back to the basics of what she does as a physician,
physicians. Volunteering is an opportunity to reconnect with your original goals and ideas of what it means to be a physician.” She feels that the providers at the Project Care clinics provide exceptional care with limited resources. Individual clinics work very hard to find follow-up care that they don’t provide for patients and pride themselves on their success.
Tofte remembers working with Dr. Tim Rumsey at the Dorothy Day Homeless Shelter in Everyone St. Paul when she was a resident. He is committed to caring for the deserves underprivileged in his everyday access to work and in his work with the homeless. “Dr. Rumsey helped me affordable see that everybody has a story; medical care. they are all humans who deserve to be cared for. He also helped me understand that the factors that contribute to homelessness are often more complex than many people “It helps me remember why I went into realize,” said Tofte. Rumsey’s dedication to medicine and the patients are incredibly specializing in care for the homeless stayed grateful.” According to Tofte, “There are with Tofte and inspires her to help those in many forces at work in today’s medical need. climate that can suck the passion out of 2015 Community Caregivers to page 22
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March 2015 Minnesota Physician
Steven Kern, MD Specialists in General Surgery
wenty-six years ago Dr. Steven Kern began volunteering when he was in college because he hoped to save the world. He spent two summers in the Dominican Republic with the Institute for Latin American Concern sponsored by Creighton University. Although he quickly realized that he couldn’t save the world by himself, he got a tremendous amount of satisfaction from donating his time to those in need. Three years ago he went back to volunteering in the Dominican Republic and Haiti, this time as a surgeon. He credits his wife Anne, whom he met while volunteering in the Dominican Republic, for renewing his desire to volunteer overseas again. Kern is a general surgeon who practices with Specialists in General Surgery in Maple Grove. According to Kern, “Most of the patients have little or no access to surgical care or if they do they can’t afford it.” He volunteers with Hernia Repair for the Underserved, which is associated with the same organization he volunteered with in college. During a weeklong mission he and a team of doctors, nurses, and technicians typically
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from it too,” stated Kern. There are many organizations in need of medical expertise and the process of getting involved for most physicians requires very little effort. Locally he has seen some of his physician colleagues like Jack Graber, Paul Severson, Jeffry Twidwell, and Leslee Jaeger donate their time and medical skill overseas and he has taken their dedication to heart. On the He sincerely other side of the coin, hopes to inspire Kern has witnessed other physicians to colleagues leaving volunteer. Although medicine because The sense of goodwill his work has helped of burnout and feels many in Haiti and you will receive is that volunteering the Dominican intoxicating. mitigates this problem. Republic, he often His advice to other thinks that he gets physicians as far more from the as volunteering is, experience than the “Put aside a week and go! The sense of patients he helps. “I believe that we should accomplishment you will feel and goodwill help people less fortunate than ourselves you will receive is intoxicating. You will for many reasons, but in the end we benefit want to do it again.”
repair 70 to 80 hernias and hydroceles. Some of the operating facilities that they work in are quite modern, while others are very rudimentary. “We bring much of our own equipment,” said Kern. “One operating room in Haiti had insufficient lighting so I brought the brightest rock climbing head lamp I could find.”
Tim Jackson has been a dairyman most of his life. As the years passed, his knees wore out. “Two years ago they were getting so bad that I could hardly navigate anymore,” said Tim. He began to get depressed because it was too painful to continue his work and enjoy an active lifestyle. Tim sought help from providers and had some treatment before finding St. Croix Orthopaedics (SCO). His treatment journey with SCO helped him find the solution he was looking for. “It was a positive experience from the beginning,” said Tim. “He (the surgeon) painted a whole other picture for my life.”
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Minnesota Physician March 2015
Kelsy Kuehn, MS, PA-C Multicare Associates
elsy Kuehn, a physician assistant with Multicare Associates, recently returned to Minnesota after volunteering in Liberia for three months. Last November, the American Refugee Committee sent a team to Liberia, including Kuehn, to open a new Ebola treatment unit (ETU). Upon arrival, she was trained in the proper donning and doffing of personal protective equipment (PPE) so she wouldn’t become infected with the Ebola virus. Kuehn remembers thinking just before entering the “hot zone” for the first time, “I am not scared of Ebola because I have full faith in the PPE.” She worked briefly with Ebola patients during her training. Because construction of the new ETU was delayed, she was sent to work in the community clinic in Fish Town instead. Her work in Fish Town did not involve working with Ebola patients since the epidemic had not taken hold in River Gee County. Fish Town is a remote, rural community in southeastern Liberia without electricity or plumbing. Poverty there is rampant. It didn’t take long for Kuehn to note, “The health care problems run deep in Liberia.”
not stand up. “The The second civil clinic had no tests to war ended in run to see if there was 2003, but left the a disease causing the country and its child to waste away. We health care system had no supplements shattered. Liberia is on hand to give him chronically short of either,” said Kuehn. She health care workers, recommended that the equipment, and grandmother take him to drugs. According the closest hospital, but to Kuehn, “Health her advice was ignored. care providers Nothing had really can go for months prepared Kuehn for the without being paid lack of infrastructure and as a result often and for how some don’t show up for Liberians approach work. Corruption Humanitarian health care. People, is not uncommon, work is often very who have little reason with some health to trust authority, often care providers complicated. ignore medical advice. selling medication Liberians also tend to or charging for avoid hospitals and ETUs procedures that out of fear that their loved ones will be should be free.” It’s a frustrating system cremated and not buried according to their and ultimately it left Kuehn feeling helpless traditions. Despite all of this, Kuehn said at and wondering if her work really made the end of her sojourn, “This has not been a much of a difference in the long run. regrettable experience. Humanitarian work Kuehn saw patients who walked many is often very complicated.” miles to visit the clinic. One day, a woman brought her emaciated, two-year-old grandson in who was so weak he could
2015 Community Caregivers to page 24
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Daniel Sampson, DDS, MD OMS Specialists
reating homeless and underserved patients while he was a resident in San Francisco had a significant impact on Dr. Daniel Sampson. “My fellow residents and I would often box up our free dinners from the hospital and bring them out to the homeless on the hospital grounds.” Once Sampson returned to Minnesota, he started volunteering at local clinics while raising children and meeting the demands of a practice.
An oral and maxillofacial surgeon, Sampson practices at OMS Specialists and is the associate chief of surgery at Children’s Hospitals and Clinics. Sampson has been volunteering for 15 years both in Minnesota and Mexico. At home he works with Minnesota Mission of Mercy; Sharing and Caring Hands; Project Homeless Connect; and Special Olympics Special Smiles about six times a year to provide routine oral surgery care to homeless and indigent patients. He also serves on the board of directors for Apple Tree Dental, a nonprofit dental organization that serves nursing home
residents, people with disabilities, and lowincome families. Once a year, Sampson travels to Hermosillo in northwestern Mexico through Children’s Surgery International, an organization that provides specialized surgical and medical care to underprivileged children around the world. Sampson
Two years ago, Sampson was part of a team that repaired a 10-year-old boy’s cleft lip and palate. The young child was abandoned by his parents and left to fend for himself on the streets of Hermosillo. The boy was taken in by several mechanics The reward of a and allowed to live in parent smiling their shop. According to Sampson, “The when they see mechanics heard their child’s face about our surgical mission and brought after surgery is him to us for help. The immeasurable. fact that these guys took this child in was really touching.”
provides alveolar cleft bone grafting, closure of fistulas, and other cleft care working alongside surgeons who repair lips and palates. Parents often travel long distances to get care for their children. For many it’s their first exposure to modern medicine or surgical care. “Parents are often frightened about the procedures but they put their trust
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Sampson loves helping patients who are in pain and rebuilding faces that were incompletely formed. “The reward of a parent smiling when they see their child’s face after surgery is immeasurable,” said Sampson. “Hugs, handshakes, smiles, and tears of gratitude make it all worthwhile.”
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Minnesota Physician March 2015
Paula Schwartz, AuD Audiology Concepts
aula Schwartz never thought that her expertise as an audiologist had a place in volunteer missions overseas. “I was so envious of doctors who possessed the skills to really make a difference in the lives of the underprivileged,” Schwartz said. So she was thrilled when the opportunity recently arose for her to be part of a surgical team heading to Guatemala. She and colleague Kathy Wieser, who also works at Audiology Concepts, provided audiological and hearing aid services to people traveling many miles to seek help for their hearing challenges. The weeklong mission was organized by Faith in Practice an ecumenical Christian organization that seeks to improve the physical, spiritual, and economic conditions of the poor in Guatemala. Faith in Practice provides solarpowered body aids that enable people with profound hearing loss to hear. Schwartz and Wieser saw 150 patients in Guatemala with significant hearing loss due to the neglect of standard medical care in rural areas. Many of these patients have not been able to hear or communicate for much of their lives. Schwartz, who owns
Audiology Concepts said, “I believe that hearing is paramount to every aspect of our lives. To provide amplification from solarpowered body aids is certainly a gift.”
near normal. After retesting the teen on her 14th birthday, Schwartz had the honor of telling Flora that her hearing was normal and she no longer would be labeled “deaf.”
On the first day of clinic on Before traveling Schwartz’s recent to Guatemala, trip, a 14-year-old Schwartz girl named Flora volunteered on came in wearing several Rotary a body aid that International she received last Service trips over year. According the past four to Schwartz, years. Schwartz “Flora’s aid wasn’t was awarded the functioning, but International the fact that I could Service Award by still communicate her club in 2013. My passion lies in with her told me She volunteered international service. that something in India giving wasn’t right.” Last life-saving polio year’s audiogram drops to children showed that Flora and worked in had a profound the International hearing loss. Schwartz retested Flora and Village Clinic. She also raised money to identified a moderate conductive hearing support a girl’s school in northern India loss and sent Flora to the ENT for further and for a playground for abused and evaluation. The ENT scheduled surgery neglected children in Nepal. As a Rotarian, the next day and cleaned out a problematic Schwartz also volunteers locally but said, middle ear, which restored her hearing to “My passion lies in international service.”
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SPECIAL FOCUS: PATIENT COMPLIANCE
h no, there’s Mr. X on my schedule again [Sigh]. Why does he keep coming back? He doesn’t do anything I say! He doesn’t take his pills. He’s gaining weight. He says he quit smoking, but he smells like smoke. Maybe I should have a frank discussion with him. Maybe he needs a scare. Maybe I should suggest he see someone else. Obviously I’m not helping him. When is the weekend going to come? How can I help this patient who can’t seem to help himself? Setting attainable goals As a physician, you need to remember to have a healthy dose of empathy for your patients. Be honest; how long did you stick to your New Year’s resolutions or successfully make a big change in your life last year? Are you exercising
Following doctor’s orders
Learn from your experience and start again. You have to be able to run around the block first if you want to eventually run a marathon.
Getting patients to listen
Motivating your patients You can’t scare people into changing. If you use this tactic, your patients may stop coming to see you or lie to avoid conflict. Telling a patient that they will die unless they make changes to their lifestyle is not going to necessarily motivate them to change. Patients could become depressed if they have repeatedly tried to change without success. This is called learned helplessness. You should have frank, evidence-based discussions that assess patients’ risks, but you should also talk about the positive outcomes that go along with changing their behaviors. Spinning this discussion towards the positive instead of the negative is much more motivating.
By Shawna L. Ehlers, PhD, ABPP-CHP, and Mark J. Wilbur, MD aerobically 150 minutes a week, drinking less than two alcoholic drinks on every occasion, and eating five servings of fruits and vegetables every day?
Remember to have a healthy dose of empathy for your patients.
Is your BMI under 25? Do you smoke? Do you schedule regular medical appointments? Are
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you up to date on your screening exams and do you take your medicine exactly as prescribed, everyday? If you answered no to any of these questions then you
Minnesota Physician March 2015
are like 95 percent of Americans. Though humans are capable of change, we struggle with maintaining change. When striving to make changes to your life it’s always best to start with small, easily achievable goals. Consider increasing your physical activity and improving your energy by claiming that parking spot in the back of the lot or taking the stairs up to your office. This is a good way to set yourself up for success. Being physically active is one of the best ways to increase your lagging energy. Reassess these changes after adhering to them for a month. Do you want more energy? Then think about walking a fast lap during lunch. There are other easily attainable goals you could try. Stock your car with water and a piece of fruit every night before you commute to work or add five healthy granola bars for each day of the week in that extra cup holder. If you don’t seem to enjoy the things you used to and your partner thinks you are depressed, make an appointment to be evaluated. It is always best to start with one goal. And if you slack off it only proves that you’re human.
For example, what if a patient has to quit smoking? This is a large and difficult goal to attain. I’ve met two patients who were dependent on heroin. They both told me they would rather quit heroin again than try to stop smoking. What should you do to help a patient quit smoking? Be honest with your patients about the difficulty of quitting, but emphasize the positive and that they can seek help. You might say something like this, “Tobacco is the biggest risk to your health and happiness, and it may be the most difficult thing to change. However, if you quit you will find it easier to breathe and keep up with your grandchildren within the first month. In the long term you will live a longer, more active life and be able to do the things you want. This gives you more freedom. You might have to try to quit more than once, but we can brainstorm a plan together.” You also should encourage your patients to call the national hotline 1-800-QUIT-NOW to set up a personalized smoking quit
plan for free, which includes tips on how to problem-solve slips versus accepting failure. The scope of the problem In the United States nearly half of the actual causes of death are behavioral, leading with tobacco, poor diet, lack of physical activity, and alcohol misuse (Mokdad et al., JAMA 2004). In addition, misuse of opioid medication is a national epidemic resulting in addiction and sometimes death.
no reimbursement for this time spent, and the need to run a practice). In addition, medicine has a strong tradition of compliance versus collaboration, which is not exactly a recipe for success. I can’t think of many people who enjoy being told what to do without having the opportunity to discuss those changes with their doctors. This can result in reactance where patients disobey orders purely to establish the fact that they are in control of their lives. Careful communication can save you time in later visits.
only fall on the treatment team. Environmental and policy changes often are very effective, and can reach entire populations. School lunch programs, worksite wellness programs, health care systems that promote preventive care, government policies (e.g., cigarette taxes), and public environments (e.g., sidewalks, playground access, public transportation) have all improved the health of our nation. By aligning your medical advice with patient
life goals you will maximize adherence regardless of these environmental advantages. Shawna L. Ehlers, PhD, ABPPCHP, is an associate professor at Mayo Clinic College of Medicine; a clinical health psychology consultant at Mayo’s department of psychiatry and psychology; and the associate director of post-doctoral programs at the Center for Clinical and Translational Science. Mark J. Wilbur, MD, is department chair of family medicine at Olmsted Medical Center, and was twice nominated Minnesota Family Physician of the Year.
Collaborative care models promote patient adherence.
Much of polypharmacy results from poor adherence to initial prescriptions, which can lead to poor treatment effectiveness such as in the case of antibiotic resistant infections. Barriers to adherence among your patients can vary. Some common barriers are knowledge, literacy, cognitive ability, health beliefs/ myths (e.g., I can feel my blood pressure rising so I only take my medication when I feel the pressure), community norms, resources, and costs. Before you get the wrong idea, remember your New Year’s resolution success rate. Well-educated, wealthy people struggle with adherence as well. Other barriers to compliance are competing goals for determining what’s important now versus later; a lack of energy from fatigue, depression, or stress; and a lack of motivation. Strong social support and family systems can help patients motivate their commitment to change and maintain healthy change. Barriers can extend beyond patients and circle back to the physician. I don’t need to tell you that providers cite a lack of time and a lack of incentive as barriers (e.g., chronic failure in motivating patients to comply,
Inspiring your patients Collaborative care models promote patient adherence. I tell patients, “You are the most important member of your treatment team; you are the quarterback.” “What do you look forward to in life?” “Now, how can I help you get there?” Patients’ life goals almost always align nicely with their health goals. If a physician aligns those goals it may make the patient realize that changing will bring him or her what is really wanted. Having healthy, well-nourished hearts, lungs, muscles, and joints will help patients improve their golf game; let them walk their daughter down the aisle; or attend their grandchildren’s recitals and sporting events. They may finally have the energy and stamina to go on that big trip they’ve always dreamed about or to go shopping or hunting with a friend. Communication and empathy, trust and partnership, normalizing difficulty and preparing for slips, celebrating progress, and prioritizing a patient’s goals will help lead to patient adherence and success. For more information on human motivation, take a look at Miller and Rollnick’s book, Motivational Interviewing: Helping People Change. Finally, the responsibility for patient adherence does not
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Special Focus: Patient Compliance
n the April 2011 issue of Minnesota Physician, we showed how the structure of health care is organized to optimize quality markers that may have little relevance to patients and their lives. Particularly in patients with chronic disease, health care activities can occupy a large footprint and become an unnecessary burden. We showed how the workload of being a patient is added to the workload of being a person and that, in many cases, patients lack the resources and capacity to carry out this work. When workload and capacity are imbalanced, patients exhibit a clinical syndrome that can be thought of as “structurally induced nonadherence.” In the 2011 article, we used the example of a fictitious patient, John, who is fired from clinical practice because of an inability to meet quality markers for his diabetes. What appeared to John’s clinician as “noncompliance” was actually the result of
Minimally disruptive medicine 2.0 Avoiding structurally induced nonadherence By Aaron Leppin, MD, and Victor Montori, MD
a complex life and context that John was not supported to handle. John ultimately prioritized the parts of his life that were most meaningful and pressing to him—a family in crisis and a tenuous employment situation. Health care failed John because it was not sensitive to his context. Indeed, because of its rigid design, the only options it provided to him were maximum and infeasible care or no care at all. What John needed was a new and more appropriate form of care, something
we call minimally disruptive medicine. Minimally disruptive medicine (MDM) is an approach to care that is sensitive to the complex contexts in which patients exist. Providing MDM requires us to assess the workload imposed on patients (i.e., tests, treatments, self-management activities) and the capacity they have to carry it out (i.e., support, functional abilities, finances). When imbalances in these factors are found, clinicians must wisely respond by
reducing the workload and/ or by augmenting the capacity. This amounts to stopping or modifying treatments and enhancing the capabilities and resources patients and caregivers have to access and use heath care, and to enact necessary self-care. In 2011, MDM was primarily a concept to which we’d given much thought. But that was it. We have spent the last three years, in concert with outstanding stakeholder support and the input of numerous Minnesota physicians and health sytems, developing a method for making MDM a clinical reality. The objective of this article is to provide an update on our progress and answer some key questions of interest to Minnesota physicians. Does MDM work? For the practice of MDM to be of value, it must ultimately improve patient health and wellness and facilitate the
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Minnesota Physician March 2015
accomplishment of meaningful goals for life and health. To know whether this occurs, we first needed to develop a model that we could test and that describes the relationship between workload, capacity, and patient outcomes. We published this framework, termed the Cumulative Complexity Model, in the Journal of Clinical Epidemiology in 2011 (Shippee, et al.). We then used it in a proof-of-concept study to show how care oriented in a fashion consistent with MDM resulted in significant reductions in 30day readmission rates (Leppin, et al.; JAMA Internal Medicine, 2014). This care supported patients who were in a setting of acute capacity deficits. We also have empirically tested components of MDM, such as medication therapy management and shared decision-making and found value in these activities. How do you practice MDM? Clinically, the practice of MDM requires the assessment of constructs not currently evaluated in clinical practice. To address problems related to patient workload and capacity, we need methods and measures to identify them. Over the past year, we have developed a measure of treatment burden and have surveyed dialysis patients to understand the impact of the health care footprint in their lives. We also have used a user-centered design process to develop a tool for the clinical encounter that helps clinicians discuss key issues related to patient capacity with their patients. Finally, we developed structured strategies for connecting patients to the resources they need to be well and to flexibly implement necessary care into their lives. Our findings currently are being compiled into a 22-chapter implementation manual. The goal of this effort is to have available, within the next year, a resource that health systems and clinicians can use to guide implementation efforts. Is MDM available? The complete MDM model is not currently in operation anywhere, although we are pi-
loting aspects of it in the Mayo Clinic Health System, and we see evidence of its principles in the practices of colleagues at Hennepin County Medical Center and in state-of-the-art HIV clinics. Our research team is partnering with a number
to identify care activities that are commonly overused and to develop strategies for promoting a parsimonious culture of care. Systems themselves also can be redesigned to reduce interruptions and waste from the patient’s perspective (i.e.,
MDM implementation has the potential to transform how we think about health care delivery.
of Minnesota health systems to apply for funding to implement and test the model more completely. We are motivated to make MDM available to more patients and are at a point, conceptually and practically, where we can work with interested practices in their efforts to provide MDM-based care. Will MDM be reimbursed? There are many ways to provide MDM-based care that do not require changes in reimbursement. The most obvious of these is to focus efforts on enhancing patient and caregiver capacity. MDM, after all, is not minimalist or nihilist medicine—when care is needed and useful, it should be offered to patients. When useful resources exist, within or outside of the health system, they should be used. Related to this, CMS will soon begin reimbursing for MDMlike efforts to develop and document care plans based on patient goals and to coordinate care activities with community resources. Another simple method of practicing MDM-based care is to focus on removing waste. We realize that clinicians— especially those operating in pay-for-performance models— are held to quality standards for their reimbursement, but there are plenty of things done in routine clinical practice that are unlikely to achieve a quality target and will only add to patient workload. The Choosing Wisely Campaign is a resource that practices can use
sitting in waiting rooms, filling out forms, navigating the phone system, dealing with uncoordinated medication refills). Efforts to promote new models of care, such as accountable care organizations and patient-centered medical homes are most challenged when faced with the needs of complex patients. MDM can serve as the care philosophy backbone of proto-
cols of care coordination and clinic-community interactions that promote better outcomes by reducing the health care footprint on patient lives. For those clinical cases where patient-centered management decisions have the potential to result in penalization (i.e., because of a slight elevation in LDL cholesterol or HbA1c values), wisdom and holistic understanding of patient context is essential. We do not anticipate that MDM will necessarily result in the completion of all activities or the meeting of all targets required by guideline recommendations (these guidelines, after all, were not developed with sensitivity to patient context). At the same time, we would not promote a model that we did not believe had the potential to improve patient-important outcomes and improve overall health, function, and wellness. Our efforts to test Minimally disruptive medicine 2.0 to page 38
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special focus: Patient Compliance
n previous issues of Minnesota Physician, weâ€™ve written about evidence-based diabetes self-management education (DSME) as a means for improving patient health outcomes and also introduced the Everyone with Diabetes Counts (EDC) program that may benefit your Medicare patients with diabetes. In this article, we will offer tips to ensure that your patients with diabetes get the self-care education and support they need to manage their disease.
In November 2014, the Centers for Disease Control and Prevention (CDC) published a study of insured persons within one year of being newly diagnosed with diabetes and found that only 7 percent had participated in DSME. In an average primary care practice, the vast majority of patients with diabetes base their self-care practices on ambiguous information and are not getting educational support from a qualified professional for making positive behavior changes and following
Diabetes education Making it happen for your patients By Laurel Reger, MBA, and Mary Beth Dahl, RN treatment regimens correctly and confidentlyâ€”everything they would get from DSME services. Many physicians are doing their part quite wellâ€”diagnosing and making referrals to
ing long-term complications? The answer, of course, is complex. But, new studies and innovative practices reveal a number of relatively simple ways that primary care can help overcome the barriers and
The vast majority of patients with diabetes base their self-care practices on ambiguous information.
DSME. So why are people with this complex disease not getting the education that is proven to make a difference in bettering their day-to-day lives and avoid-
Minnesota Physician March 2015
improve community support for patients needing DSME services. You can probably guess the common barriers to diabetes
patients getting DSME. As outlined in the sidebar on page 32, the barriers include systems not having documentation in the medical record or automated referrals to DSME and clinicians not endorsing DSME with patients. Common patient barriers include financial concerns, no knowledge of DSME, and fear or denial of their diabetes diagnosis. Take on those system barriers The first systems barrier, lack of identification of diabetes diagnosis, refers not only to the number of undiagnosed patients, but also to those simply not documented as having diabetes. No documentation may come as a surprise in the age of sophisticated electronic health records (EHR), but it sometimes occurs when a patient is diagnosed elsewhere, such as in a hospital. Working to improve your overall care coordination and care transfers would likely Diabetes education from page 32
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March 2015 Minnesota Physician
Diabetes education from page 30
remedy this issue for your diabetes patients. You could also help address the high number of undiagnosed individuals (estimated to be nearly one-third of people with diabetes) by automatically screening all asymptomatic adults with risk factors. The American Diabetes Association’s Standards of Medical Care in Diabetes 2015 (found at http://care.diabetesjournals.org) recommends screening overweight or obese adults of any age and those with one or more additional risk factors, such as age 45 and older; a family history of diabetes; racial and ethnic minorities; and women who have had gestational diabetes. Routinely assess your patients’ risk factors for diabetes and screen them annually. You may be surprised by the high number of diabetes (and prediabetes) cases you uncover by systematically screening people at risk.
Patient preference may be another reason for lack of documented diagnosis. The second Diabetes Attitudes, Wishes and Needs (DAWN2) study revealed that fear of workplace discrimination is significant and widespread among diagnosed adults, and the reason why some resist documenting the diagnosis. DSME can help mitigate this concern. A diabetes educator can inform the patient of their rights in the workplace and direct them to resources and community support systems as needed. Automating referrals based on lab results and/or new diagnoses in the electronic health record is an innovation being tried in a number of Minnesota health systems. A new diagnosis is overwhelming—to both patient and provider. It’s easy to forget to make a referral, or to make the referral and not discuss it with the patient. For the patient, it’s easy to forget to make an appointment, or to not see the value in spend-
Barriers to diabetes patients receiving diabetes self-management education services Clinical system barriers
• Lack of identification of diabetes diagnosis • No automatic referrals to a DSME provider • No clinician endorsement to patients of the benefits of DSME • Inadequate follow-through with patients • Lack of effective partnerships with DSME providers
ing more time and money for “education.” In some systems with automated EHR referrals, the diabetes educator follows up with the patient to make the DSME appointment, promotes its value to the patient, and helps them overcome any barriers to participating in DSME. This automated referral mechanism can similarly be used to refer patients to community-based programs such as EDC for Medicare beneficiaries with diabetes or the National Dia-
• Financial: copays, deductibles, or no insurance coverage for DSME • Transportation and other logistical issues • Time needed for DSME (10 hours initially and two hours annually thereafter) during provider hours • Unawareness of DSME benefits and services • Fear/denial of their diagnosis
betes Prevention Program for people with prediabetes. Check with your IT staff to see if your EHR has a reminder or flag function that could be re-engineered as an automatic referral. Talk to your DSME partners to see who has such a system that might be replicated. Tout the benefits of DSME with patients Your advice matters to patients. We know from studies that Diabetes education to page 34
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 • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine
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Minnesota Physician March 2015
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At Allina Health, we’re here to care for the millions of patients we see each year throughout Minnesota and western Wisconsin. From rural to urban settings, you’ll find a practice and community that is right for you, with ideal staff support and the widest range of clinical practice options, physician leadership opportunities and competitive benefits. EOE/AA/Vet/Disabled Employer
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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.
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Currently we are seeking to add the following specialists:
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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
www.averamarshall.org March 2015 Minnesota Physician
Diabetes education from page 32
what a provider says or doesn’t say can make or break a particular behavior such as quitting tobacco or losing weight. If the patient does not hear about the benefits of DSME from you, chances are good that he/she will never attend. The challenge for primary care is to expand the delivery of diabetes knowledge, care, and support beyond their walls and into the community. Think about partnering with community and stakeholder organizations to offer several DSME options to your patients. Whenever you have a diabetes patient in your office, the American Association of Diabetes Educators recommends six things to be sure to tell that patient: 1. Diabetes is not the patient’s fault. Many factors contribute to the development of diabetes, including genetics and age as well as lifestyle choices.
Taking control of modifiable factors such as stress, weight, hypertension, and physical activity, can help the patient reduce the risk of complications and improve their quality of life.
that the focus will be on controlling carbohydrates, portion size, fat, and salt. They can apply what they learn to their usual meals. Diabetes can be the motivation to help the entire family eat and live healthier.
2. D on’t panic! Most people have horror stories about diabetes complications in a family member or have many misconceptions about the disease. Explain how the patient can lower their risk for complications and fit diabetes treatment regimens into their lifestyle. Also ask what they know about diabetes and help dispel any misunderstandings about the disease.
4. B eing active helps. Small increases in physical activity, such as walking further every day, can yield big rewards in controlling diabetes such as lowering blood pressure, managing weight, lessening depression, and strengthening heart, bones, and muscle. Activity helps the patient feel better and more energetic.
3. The patient does not need special foods. Many people believe they will never be able to eat sweets again, or will never be able to eat what their family is enjoying for meals. Let them know
5. The patient can master diabetes with DSME. With a certified diabetes education center, a diabetes educator will work with the patient to design a healthy living plan, tailor their treatment, and give them
Family Medicine with Clinic OB Physician-owned Gateway Clinic seeks a family medicine physician to join our new Hinckley clinic. 3 or 4-day week practice with shared hospital call. Full-scope primary care and clinic OB practice (prenatal and postpartum care in clinic, option for colleagues to cover OB call and deliveries). Generous salary with sign-on and retention bonus, outstanding benefit package, 15% retirement contribution. Shareholder opportunities available. Gateway Clinic has locations in Moose Lake, Sandstone and Hinckley. Centrally located between Mpls/St. Paul and Duluth, the area provides an excellent family focused, quality of life opportunity in a rural setting with good public schools and abundant with lakes, rivers, state parks, and ideal hunting - all within an hour to metropolitan conveniences.
For additional information, contact Dr. Kathy Brandli, President, at firstname.lastname@example.org or Eric Nielsen, Administrator, at email@example.com or 218.485.2000
the tools and support they need to manage diabetes day-to-day for a lifetime. The diabetes educator serves in this role as an extension of your health care team. With the EDC, patients learn from their peers about self-care, coping strategies, and community supportive resources guided by an evidence-based curriculum that augments what they’ve learned from attending a certified DSME program. 6. The patient is not alone. A diagnosis of diabetes is overwhelming, and your patients will need reassurance and encouragement. Remind them that they have a quality health care team on their side. Most diabetes clinical care and certified DSME programs are covered by insurance. There are support groups, Diabetes education to page 36
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Minnesota Physician March 2015
Family Medicine 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. 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. 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. Apply online at healthpartners.com/careers or contact firstname.lastname@example.org. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE
Opportunities for full-time and part-time staff are available in the following positions: • Associate Chief of Staff • Dermatologist
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• Geriatrician/Hospice & • Ophthalmologist Palliative Care • Physician (Pain Clinic)/ Panel Management • Internal Medicine/ Family Practice
Applicants must be BE/BC.
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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: email@example.com 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 March 2015 Minnesota Physician
Diabetes education from page 34
websites, a television channel, and even an annual Minneapolis expo focused on diabetes. A variety of effective treatment options are available, and most people with diabetes go on to enjoy long, healthy lives. Ultimately, your patients with diabetes, especially those newly diagnosed, can leave your office knowing that they can manage the disease—and even feel empowered and motivated to do just that. Rely on your DSME partners Here is a familiar scenario: A patient is given a diagnosis of type 2 diabetes, told to take their medications, monitor their blood glucose regularly, exercise, and lose weight. The provider has only a few minutes to describe the seriousness of the disease and the importance of following the complex treatment instructions. The dazed
patient nods but hears only a small part of what is said. Is it any wonder why one-quarter of patients do not take their insulin as prescribed, half do not monitor their blood glucose as told, and three-quarters do not follow their provider’s weight loss and exercise instructions? Your busy practice doesn’t allow you the luxury of educating patients, counseling on behavior change, or coaching them on self-management practices. But diabetes educators (both certified diabetes educators and trained community-based diabetes educators) do have that time and opportunity with the patient. A diabetes educator can take the hours necessary to work collaboratively with the patient to address the patient’s needs in depth, including cultural and social considerations. In a oneon-one or group setting, the diabetes educator strengthens diabetes knowledge, sustainable behavior changes, and positive health outcomes for the patient.
The diabetes educator works in partnership with you to best fit the patient’s clinical and lifestyle needs. For this educational relationship to work best, it is important that you not only refer your patients to a diabetes educator at the initial diagnosis, but follow up with the patient to be sure they continue their education by attending a certified diabetes education program annually and by taking advantage of community-based support programs such as EDC. Chances are, your practice is already being taxed by the demands of managing your diabetes patients. The predicted increase in the number of people with diabetes could completely overwhelm your best efforts. Now is the time to rely on your certified diabetes educators, local trained diabetes educators, and certified DSME centers to assume a great role in the care of diabetes patients.
Help your patients—and your practice—by referring your diabetes patients to a DSME program. This can be a certified program through your local health system as well as a community support program such as EDC. Here are links to find: • A certified DSME program anywhere in Minnesota, see www.tinyurl.com/ dsmeMN • A local diabetes educator, see www.diabeteseducator. org/find Laurel Reger, MBA, is a program planner with the Minnesota Department of Health Diabetes Program and co-chairs the Improving Patient Access to Diabetes Education group working to improve the use of DSME programs in Minnesota. Mary Beth Dahl, RN, is a program manager at Stratis Health. She leads the Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC) initiative by addressing barriers and improving access to education programs on diabetes self-management across Minnesota.
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 firstname.lastname@example.org 36
Minnesota Physician March 2015
Family Medicine & Emergency Medicine Physicians
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Family or Internal Medicine 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. 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: email@example.com
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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.
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: Family Medicine Spring Valley Clinic
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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 email@example.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
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
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Minimally disruptive medicine 2.0 from page 29
MDM in a randomized trial will help provide an evidence base to support its approach. In the meantime, efforts to “deprescribe” a treatment of low value or to avoid initiation of infeasible care can be documented in medical records when shared decision-making discussions occur. In the near future, this strategy can be used to attest to meaningful use of EMRs. It also can be used to document “patient refusal” and avoid penalization. The key point related to MDM and reimbursement, is that, when the patient’s needs are prioritized, there will always be an opportunity to do something. In those rare clinical situations where the infrastructure or resources simply do not exist to address patient capacity and the policy and reimbursement pressures completely preclude augmentation in patient care, there is always the
opportunity to acknowledge the patient’s context and situation. That, in and of itself, is of therapeutic value. Looking forward As 2015 begins, we are excited about the prospects of implementing and testing the value of MDM. An MDM implementation has the potential to transform how we think about health care delivery and how we define high-value care. This journey takes us from optimal evidence-based care defined mostly by adherence to guidelines and quality measures to optimally balancing the workload and capacity of patients and caregivers in order to advance their goals. We believe this is the next logical step for a state that has led the nation in taking the first steps toward reliable chronic care. Version 2.0 brings us back to the patient and to fully embracing the complexity of patient goals, patient preferences, and patient con-
text. We must bring to that task not just the tools we learned to use in version 1.0, many borrowed from manufacturing, but also the tools of interpersonal communication, of teamwork, and of collaboration. We are looking forward, excited and optimistic, to working with Minnesota practices and clinicians and funders and supporters to test MDM against the challenges of the frontlines of care, the only place where the model can prove its value and get better. We are publishing the insights we gather along the way and we welcome your insights too (see www.minimal
lydisruptivemedicine.org). Join our journey. Aaron Leppin, MD, and Victor Montori, MD, are physicians and health services researchers with the Knowledge and Evaluation Research Unit at Mayo Clinic. Their work focuses on the dissemination and implementation of patient-centered health care interventions. They are co-editing the implementation manual for MDM alongside their colleagues from the International MDM Collaborative, including, among others: Summer Allen, Kasey Boehmer, Kari Bunkers, David Eton, Katie Gallacher, Michael Gionfriddo, Ian Hargraves, Frances Mair, Carl May, Laura Odell, Nilay Shah, Nathan Shippee, and Kathy Yost.
MDM may reduce hospital readmissions “Our findings are consistent with the Cumulative Complexity Model” in showing that the most effective interventions reduced 30-day readmissions by almost 40 percent… These “used a consistent and complex strategy that emphasized the assessment and addressing of factors related to patient context and capacity for self-care (including the impact of comorbidities, functional status, caregiver capabilities, socioeconomic factors, potential for self-management, and patient and caregiver goals for care).” From Leppin, et al.; JAMA Internal Medicine, 2014.
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Minnesota Physician March 2015
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Health care infomation for Minnesota doctors Cover: Health exchange transparency by Candance DeMatteis, JD, MPH Hospital medical-staff byla...
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