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Vo l u m e x X I X , N o . 10 J a n u a r y 2 016

The Compassionate Care Act Giving Minnesotans a choice By Sen. Chris Eaton, RN, and Rebecca Thoman, MD

“W

Medical ethics and the unconscious mind

ill you take me to Oregon?” was Dave’s plea to his son. At 95 years of age, Dave was slowly dying from end-stage cancer. His lungs, heart, and bowels were on a slow, steady decline that could take months, but his mind remained sharp. He had had a long, active life, playing golf and enjoying his grandchildren to the ripe old age of 93, when the diagnosis of melanoma was made. Since then his life had slowly declined to little more than eating, sleeping, and toileting, all of which required help. His weakness led to recurrent falls and injuries that resulted in trips to the emergency room. Dave dreaded visits to his many specialists who recommended another treatment or medication, and he hinted about his thoughts by asking his primary physician if he “knew Jack Kevorkian.” The response was a prescription for antidepressants. Dave didn’t want to die confined to his bed, gasping for air and suffering from

The Compassionate Care Act to page 18

A conflict of interests By Robert S. Emmons, MD

M

y patient “George,” aged 55, developed gastroparesis after 45 years of living with Type I diabetes. Because his gut cannot absorb iron, it was necessary to treat intermittent bouts of severe anemia with IV iron infusions. During one of our visits, George informed me that he had been

feeling cold, tired, and down—all telltale symptoms of anemia. I had treated George for recurrent major depression for 20 years, but now treating him meant sending him back to his hematologist, “Dr. Winston.” Medical ethics and the unconscious mind to page 16


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January 2016 • Volume XXIX, Number 10

Features Medical ethics and the unconscious mind  A conflict of interests

1

Minnesota’s

By Robert S. Emmons, MD

The Compassionate Care Act  Giving Minnesotans a choice By Sen. Chris Eaton, RN, and Rebecca Thoman, MD

Most Influential

1

HEALTH CARE LEADERS

Minnesota Health care Roundtable Behavioral health integration 22 By M  PP Staff

DEPARTMENTS CAPSULES MEDICUS 

10 Practice 13 Management 

INTERVIEW 

14

A commitment to the underserved Jim Eppel UCare

Women physician leaders By Heather Awad, MD

20

Health Care Policy  31 The 2016 Minnesota legislative session By Nate Mussell, JD

Neurosurgery 

Oblique Lateral Lumbar Interbody Fusion By Hamid R. Abbasi, MD, PhD, FACS, FAANS

Request for nomination In our August 2016 edition, Minnesota Physician will profile 100 of our state’s most influential health care leaders. In a format featuring photos, bios, and quotes, we will highlight the men and women most responsible for making Minnesota a global model for health care delivery. These individuals will represent every aspect of the industry: physicians, business executives, political leaders, policy analysts, etc. We invite you, our readers, to participate in this recognition process. If you know anyone within your organization you feel should be considered, please fill out the form below and return it by mail, fax, or email prior to May 27, 2016. We welcome your input and participation in making this list as comprehensive and meaningful as possible.

100 Most Influential Health Care Leaders Nomination Form 32

i would like to nominate the following individual(s): Name and location of nominee’s employer or practice:

Nominee’s contact info:

Professional Update: Pediatrics Pediatric atopic dermatitis  By Sheilagh Maguiness, MD; Ingrid Polcari, MD; and Kristen Hook, MD

1 O

34 Brief description of the nominee’s work and influence:

www.mppub.com

Publisher Mike Starnes | mstarnes@mppub.com Editor Lisa McGowan | lmcgowan@mppub.com Associate Editor Richard Ericson | rericson@mppub.com Acquisitions Editor Patricia Mata Starnes | tmata@mppub.com Art Director Joe Pfahl | joe@mppub.com Office Administrator Amanda Marlow | amarlow@mppub.com

Nomination submitted by:

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Name:

Account Executive Kylie Engle | kengle@mppub.com

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

City, State, Zip: Phone #: Email:

January 2016 Minnesota Physician

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4

Minnesota Physician January 2016


It clicked when my doctor and I discussed Trulicity 速1,2

Trulicity is a GLP-1 RA therapy that offers proven glycemic control, once-weekly dosing, and the Trulicity pen.*1 If you have patients who struggle with the idea of adding an injectable, consider Trulicity as an option for the next step in their care.1,3 Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg for additional A1C reduction. * In clinical studies, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose; the percentage of patients achieving A1C <7% ranged from 37% to 69% for 0.75 mg and 53% to 78% for 1.5 mg.1,4-7

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

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

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, on next page and accompanying Brief Summary of Prescribing Information. Please see Instructions for Use included with the pen.

Learn about proven glycemic control with fewer injections at Trulicity.com

January 2016 Minnesota Physician

5


Trulicity® is an injectable option that may click with your patients

1,2

A GLP-1 RA therapy that offers:

Proven glycemic control*1

Once-weekly dosing

The Trulicity pen

* In clinical studies, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose; the percentage of patients achieving A1C <7% ranged from 37% to 69% for 0.75 mg and 53% to 78% for 1.5 mg.1,4-7 Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg.

Once-weekly Trulicity delivered results across clinical trials A1C from baseline A1Creduction reduction from baseline Add-on to metformin (26 weeks)

Add-on to metformin (52 weeks)

Add-on to metformin and Actos® (26 weeks)

Add-on to metformin and Amaryl® (52 weeks)

Compared to Victoza®4

Compared to Januvia®1,8,9

Compared to Byetta®1,10

Compared to Lantus®1,6,11,12

MeanA1C A1Cchange change from from baseline Mean baseline(%) (%)

0.0 -0.2 -0.4

-0.39

-0.6

-0.46

-1.0

-0.87

-1.2

-0.99

-1.10

-1.4

-1.08 -1.51

Victoza (1.8 mg) (n=300; Baseline A1C: 8.1%)

Januvia (100 mg) (n=273; Baseline A1C: 8.0%)

Placebo (n=141; Baseline A1C: 8.1%)

Trulicity® (1.5 mg) (n=299; Baseline A1C: 8.1%)

Trulicity® (0.75 mg) (n=281; Baseline A1C: 8.2%)

Byetta (10 mcg BID) (n=276; Baseline A1C: 8.1%)

Trulicity (0.75 mg) (n=272; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=279; Baseline A1C: 8.1%)

Trulicity (0.75 mg) (n=280; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=273; Baseline A1C: 8.2%)

26-week, randomized, open-label comparator phase 3 study

104-week, randomized, placebo-controlled, double-blind

• 104-week, randomized, placebo-controlled, 26-week, randomized, open-label phase 3 study of adult patients with type 2 diabetes treated of adult patients with type 2 diabetes treated with metformin with metformin mg/dayof adult patients mg/day comparator≥1500 phase 3 study of adult double-blind phase≥1500 3 study • Primary objective was to demonstrate noninferiority of • Primary objective was to demonstrate noninferiority of patients with type 2 diabetes treated with type 2 diabetes treated with metformin Trulicity 1.5 mg vs Januvia on A1C change from baseline at Trulicity 1.5 mg vs Victoza 1.8 mg on A1C change from baseline with metformin ≥1500 52 weeks (-1.1% vs -0.4%, respectively; difference of -0.7%; at 26 weeks (-1.42% mg/day vs -1.36%, respectively; difference of ≥1500 -0.06%; mg/day 95% CI [-0.19, 0.07]; 2-sided alpha level of 0.05 for noninferiority

95% CI [-0.9, -0.5]; multiplicity-adjusted 1-sided alpha level

52-week, randomized, placebo-controlled phase 3 study

5. Wysham C, Blevins T, Arakaki R, et al. Efficacy and safety of dulaglutide added onto pioglitazone and metformin versus exenatide in type 2 diabetes in a randomized controlled trial (AWARD-1)

endpoint of[published superiority was notin met correction appears Diabetes Care. 2014;37:2895]. Diabetes Care. 2014;37:2159-2167.

6. Giorgino F, Benroubi M, Sun JH, et al. Efficacy and safety of once-weekly dulaglutide versus insulin glargine in patients with type 2 diabetes on metformin and glimepiride (AWARD-2) [published online ahead of print June 18, 2015]. Diabetes Care. doi:10.2337/dc14-1625. 7. Data on file, Lilly USA, LLC. TRU20140912A. 8. Data on file, Lilly USA, LLC. TRU20150313A.

78-week, randomized, open-label comparator phase 3 study

• 78-week, randomized, open-label comparator 52-week, randomized, placebo-controlled (open-label assignment to Byetta or blinded assignment to (double-blind with respect to Trulicity dose assignment) of adult Trulicity or adult patients with type 2 diabetes to patientsphase with type3 2 diabetes with maximally tolerated phase 3 placebo) studyof(open-label assignment studytreated (double-blind with respect to treated with maximally tolerated metformin (≥1500 mg/day) metformin (≥1500 mg/day) and Amaryl (≥4 mg/day) Byetta assignment to Trulicity or Trulicity dose assignment) of adult patients and Actosor (upblinded to 45 mg/day) • Lantus titration was based on self-measured fasting plasma of adult typeof2 diabetes glucosewith 2 diabetes treated with24% maximally •placebo) Primary objective was topatients demonstratewith superiority utilizingtype an algorithm with a target of <100 mg/dL; Trulicity 1.5with mg vsmaximally placebo on change in A1C from metformin baseline of patients were titratedmetformin to goal at the 52-week primarymg/day) endpoint and treated tolerated tolerated (≥1500 at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; objective was to demonstrate (≥1500 mg/day) and Actos1-sided (up toalpha 45level mg/day)• Primary Amaryl (≥4 mg/day)noninferiority of Trulicity 95% CI [-1.2, -0.9]; multiplicity-adjusted 1.5 mg vs Lantus titrated to target on A1C change from baseline at

• Primaryofobjective Primary objective was to model demonstrate was towith demonstrate 0.025 for noninferiority 0.25% margin; analysis of margin 0.4%; mixed repeated measures analysis) covariance of using last observation [LOCF]); noninferiority ofobjective Trulicity 1.5 mg for vsA1C reduction wasnoninferiority Trulicity 1.5 carried mg vsforward Januvia • Primary of noninferiority met; primary objective met of 0.025; analysis of covariance using LOCF); primary of superiority was not met • Primary Victoza 1.8secondary mg onendpoint A1C change from on A1C change from baseline at 52 weeks objective was to demonstrate objective met baseline at 26 weeks (-1.42% vs -1.36%, (-1.1% vs -0.4%, respectively; difference of superiority of Trulicity 1.5 mg vs placebo on respectively; difference of -0.06%; 95% CI -0.7%; 95% CI [-0.9, -0.5]; multiplicitychange in A1C from baseline at 26 weeks References [-0.19, 0.07]; 2-sided alphaST,level ofal.0.05 adjusted 1-sided of 0.025 for -0.5%,a respectively; difference 1. Dungan KM, Povedano Forst T, et Once-weekly dulaglutide versus once-dailyalpha liraglutidelevel in metformin-treated patients with type (-1.5% 2 diabetesvs (AWARD-6): randomised, open-label, phase 3, non-inferiority trial [published 2014;384:1348]. Lancet. for noninferiority margin 0.4%;correction mixedappears in Lancet. noninferiority with 2014;384:1349-1357. 0.25% margin; analysis of -1.1%; 95% CI [-1.2, -0.9]; multiplicity2. Trulicity [Prescribing Information]. Indianapolis, IN: Lillyof USA, LLC; 2015. model repeated measures analysis) covariance using last observation carried adjusted 1-sided alpha level of 0.025; 3. Data on file, Lilly USA, LLC. TRU20150203A. forward [LOCF]); primary objective met analysis of covariance using LOCF); primary • Primary objective of noninferiority for 4. Data on file, Lilly USA, LLC. TRU20150203B. objective met A1C reduction was met; secondary •

Lantus (n=262; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=279; Baseline A1C: 8.1%)

Data represent least-squares mean ± standard error.

-0.76

-1.30

-1.36 -1.42

-1.6 -1.8

-0.63

-0.8

52 weeks (-1.1% vs -0.6%, respectively; 1-sided • Lantus titration wasmultiplicity-adjusted based on self-measured alpha level of 0.025 for noninferiority with 0.4% margin; analysis of fasting plasma covariance using LOCF); primaryglucose objective metutilizing an

algorithm with a target of <100 mg/dL; 24% of patients were titrated to goal at the 52-week primary endpoint

• Primary objective was to demonstrate

noninferiority of Trulicity 1.5 mg vs Lantus titrated to target on A1C change from baseline at 52 weeks (-1.1% vs -0.6%, respectively; multiplicity-adjusted 1-sided alpha level of 0.025 for noninferiority with 0.4% margin; analysis of covariance using LOCF); primary objective met

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

6

Minnesota Physician January 2016


Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS

In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components. Risk of Thyroid C-cell Tumors: Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist (GLP-1 RA), have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 RA use in humans. If serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging, the patient should be further evaluated. Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected, discontinue Trulicity promptly. Do not restart if pancreatitis is confirmed. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia. Hypersensitivity Reactions: Systemic reactions were observed in patients receiving Trulicity in clinical trials. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 RAs, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug.

0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%). Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree. Pregnancy: There are no adequate and well-controlled studies of Trulicity in pregnant women. Use only if potential benefit outweighs potential risk to fetus. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. A decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age. Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen. DG HCP ISI 20APR2015 Trulicity® is a registered trademark owned or licensed by Eli Lilly and Company, its subsidiaries, or affiliates. Trulicity is available by prescription only. Actos® is a registered trademark of Takeda Pharmaceutical Company Limited. Byetta® is a registered trademark of the AstraZeneca group of companies. Amaryl® and Lantus® are registered trademarks of Sanofi-Aventis. Januvia® is a registered trademark of Merck & Co., Inc. Victoza® is a registered trademark of Novo Nordisk A/S. Other product/company names mentioned herein are the trademarks of their respective owners. References 1. Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC; 2015. 2. Trulicity [Instructions for Use]. Indianapolis, IN: Lilly USA, LLC; 2014. 3. Polonsky WH, Hajos TR, Dain MP, Snoek FJ. Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population. Curr Med Res Opin. 2011;27(6):1169-74. doi: 10.1185/03007995.2011.573623. Epub Apr 6, 2011. 4. Dungan KM, Povedano ST, Forst T, et al. Once-weekly dulaglutide versus once-daily liraglutide in metformin-treated patients with type 2 diabetes (AWARD-6): a randomised, open-label, phase 3, non-inferiority trial [published correction appears in Lancet. 2014;384:1348]. Lancet. 2014;384:1349-1357. 5. Umpierrez G, Tofé Povedano S, Pérez Manghi F, et al. Efficacy and safety of dulaglutide monotherapy versus metformin in type 2 diabetes in a randomized controlled trial (AWARD-3). Diabetes Care. 2014;37:2168-2176. 6. Giorgino F, Benroubi M, Sun JH, et al. Efficacy and safety of once-weekly dulaglutide versus insulin glargine in patients with type 2 diabetes on metformin and glimepiride (AWARD-2) [published online ahead of print June 18, 2015]. Diabetes Care. doi:10.2337/dc14-1625. 7. Blonde L, Jendle J, Gross J, et al. Once-weekly dulaglutide versus bedtime insulin glargine, both in combination with prandial insulin lispro, in patients with type 2 diabetes (AWARD-4): a randomised, open-label, phase 3, non-inferiority study. Lancet. 2015;385:2057-2066. 8. Data on file, Lilly USA, LLC. TRU20150203A. 9. Data on file, Lilly USA, LLC. TRU20150203B. 10. Wysham C, Blevins T, Arakaki R, et al. Efficacy and safety of dulaglutide added onto pioglitazone and metformin versus exenatide in type 2 diabetes in a randomized controlled trial (AWARD-1) [published correction appears in Diabetes Care. 2014;37:2895]. Diabetes Care. 2014;37:2159-2167. 11. Data on file, Lilly USA, LLC. TRU20140912A. 12. Data on file, Lilly USA, LLC. TRU20150313A.

The most common adverse reactions reported in ≥5% of Trulicitytreated patients in placebo-controlled trials (placebo, Trulicity

PP-DG-US-0359

10/2015 PRINTED IN USA

©Lilly USA, LLC 2015. All rights reserved.

January 2016 Minnesota Physician

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

insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia in this setting. Hypersensitivity Reactions: Systemic hypersensitivity reactions were observed in patients receiving Trulicity in clinical trials. If a hypersensitivity reaction occurs, the patient should discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. ADVERSE REACTIONS

INDICATIONS AND USAGE Trulicity™ is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

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

Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg): nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions: In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 42% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and active-controlled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia: Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials: Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), Trulicity 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5  mg: 5.0%; Severe: all 0. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. Documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented symptomatic hypoglycemia occurred in 85% and 80% of patients when Trulicity 0.75 mg

TrulicityTM (dulaglutide)

TrulicityTM (dulaglutide)

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

Trulicity DG HCP BS 20APR2015 Brief Summary 7 x 9.75

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DG HCP BS 20APR2015

DG HCP BS 20APR2015

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and 1.5 mg, respectively, was co-administered with prandial insulin. Severe hypoglycemia occurred in 2.4% and 3.4% of patients when Trulicity 0.75 mg, and 1.5 mg, respectively, was co-administered with prandial insulin. Heart Rate Increase and Tachycardia Related Adverse Reactions: Trulicity 0.75 mg and 1.5 mg resulted in a mean increase in heart rate (HR) of 2-4 beats per minute (bpm). The long-term clinical effects of the increase in HR have not been established. Adverse reactions of sinus tachycardia were reported more frequently in patients exposed to Trulicity. Sinus tachycardia was reported in 3.0%, 2.8%, and 5.6% of patients treated with placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively. Persistence of sinus tachycardia (reported at more than 2 visits) was reported in 0.2%, 0.4%, and 1.6% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Episodes of sinus tachycardia, associated with a concomitant increase from baseline in heart rate of ≥15 beats per minute, were reported in 0.7%, 1.3%, and 2.2% of patients treated with placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively. Immunogenicity : Across four Phase 2 and five Phase 3 clinical studies, 64 (1.6%) Trulicitytreated patients developed anti-drug antibodies (ADAs) to the active ingredient in Trulicity (ie, dulaglutide). Of the 64 dulaglutide-treated patients that developed dulaglutide ADAs, 34 patients (0.9% of the overall population) had dulaglutide-neutralizing antibodies, and 36 patients (0.9% of the overall population) developed antibodies against native GLP-1. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, the incidence of antibodies to dulaglutide cannot be directly compared with the incidence of antibodies of other products. Hypersensitivity : Systemic hypersensitivity adverse reactions sometimes severe (eg, severe urticaria, systemic rash, facial edema, lip swelling) occurred in 0.5% of patients on Trulicity in the four Phase 2 and Phase 3 studies. Injection-site Reactions: In the placebo-controlled studies, injection-site reactions (eg, injection-site rash, erythema) were reported in 0.5% of Trulicity-treated patients and in 0.0% of placebo-treated patients. PR Interval Prolongation and Adverse Reactions of First Degree Atrioventricular (AV) Block: A mean increase from baseline in PR interval of 2-3 milliseconds was observed in Trulicity-treated patients in contrast to a mean decrease of 0.9 millisecond in placebo-treated patients. The adverse reaction of first degree AV block occurred more frequently in patients treated with Trulicity than placebo (0.9%, 1.7%, and 2.3% for placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively). On electrocardiograms, a PR interval increase to at least 220 milliseconds was observed in 0.7%, 2.5%, and 3.2% of patients treated with placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively. Amylase and Lipase Increase: Patients exposed to Trulicity had mean increases from baseline in lipase and/or pancreatic amylase of 14% to 20%, while placebotreated patients had mean increases of up to 3%. DRUG INTERACTIONS Trulicity slows gastric emptying and thus has the potential to reduce the rate of absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are concomitantly administered with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to any clinically relevant degree. USE IN SPECIFIC POPULATIONS Pregnancy - Pregnancy Category C: There are no adequate and well-controlled studies of Trulicity in pregnant women. The risk of birth defects, loss, or other adverse outcomes is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes to maintain good metabolic control before conception and throughout pregnancy. Trulicity should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In rats and rabbits, dulaglutide administered during the major period of organogenesis produced fetal growth reductions and/or skeletal anomalies and ossification deficits in association with decreased maternal weight and food consumption attributed to the pharmacology of dulaglutide. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for clinical adverse reactions from Trulicity in nursing infants, a decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established in pediatric patients. Trulicity is not recommended for use in pediatric patients younger than 18 years. Geriatric Use: In the pool of placebo- and active-controlled trials, 620 (18.6%) Trulicity-treated patients were 65 years of age and over and 65 Trulicity-treated patients (1.9%) were 75 years of age and over. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Hepatic Impairment: There is limited clinical experience in patients with mild, moderate, or severe hepatic impairment. Therefore, Trulicity should be used with caution in these patient populations. In a clinical pharmacology study in subjects with varying degrees of hepatic impairment, no clinically relevant change in dulaglutide pharmacokinetics (PK) was observed. Renal Impairment: In the four Phase 2 and five Phase 3 randomized clinical studies, at baseline, 50 (1.2%) Trulicity-treated patients had mild renal impairment (eGFR ≥60 but <90 mL/min/1.73 m2), 171 (4.3%) Trulicitytreated patients had moderate renal impairment (eGFR ≥30 but <60 mL/min/1.73 m2) and no Trulicity-treated patients had severe renal impairment (eGFR <30 mL/min/1.73 m2). TrulicityTM (dulaglutide)

Trulicity DG HCP BS 20APR2015 Brief Summary 7 x 9.75

DG HCP BS 20APR2015

No overall differences in safety or effectiveness were observed relative to patients with normal renal function, though conclusions are limited due to small numbers. In a clinical pharmacology study in subjects with renal impairment including end-stage renal disease (ESRD), no clinically relevant change in dulaglutide PK was observed. There is limited clinical experience in patients with severe renal impairment or ESRD. Trulicity should be used with caution, and if these patients experience adverse gastrointestinal side effects, renal function should be closely monitored. Gastroparesis: Dulaglutide slows gastric emptying. Trulicity has not been studied in patients with pre-existing gastroparesis. OVERDOSAGE Overdoses have been reported in clinical studies. Effects associated with these overdoses were primarily mild or moderate gastrointestinal events (eg, nausea, vomiting) and nonsevere hypoglycemia. In the event of overdose, appropriate supportive care (including frequent plasma glucose monitoring) should be initiated according to the patient’s clinical signs and symptoms. PATIENT COUNSELING INFORMATION See FDA-approved Medication Guide • Inform patients that Trulicity causes benign and malignant thyroid C-cell tumors in rats and that the human relevance of this finding has not been determined. Counsel patients to report symptoms of thyroid tumors (eg, a lump in the neck, persistent hoarseness, dysphagia, or dyspnea) to their physician. • Inform patients that persistent severe abdominal pain, that may radiate to the back and which may (or may not) be accompanied by vomiting, is the hallmark symptom of acute pancreatitis. Instruct patients to discontinue Trulicity promptly, and to contact their physician, if persistent severe abdominal pain occurs. • The risk of hypoglycemia may be increased when Trulicity is used in combination with a medicine that can cause hypoglycemia, such as a sulfonylurea or insulin. Review and reinforce instructions for hypoglycemia management when initiating Trulicity therapy, particularly when concomitantly administered with a sulfonylurea or insulin. • Patients treated with Trulicity should be advised of the potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid fluid depletion. Inform patients treated with Trulicity of the potential risk for worsening renal function and explain the associated signs and symptoms of renal impairment, as well as the possibility of dialysis as a medical intervention if renal failure occurs. • Inform patients that serious hypersensitivity reactions have been reported during postmarketing use of GLP-1 receptor agonists. If symptoms of hypersensitivity reactions occur, patients must stop taking Trulicity and seek medical advice promptly. • Advise patients to inform their healthcare provider if they are pregnant or intend to become pregnant. • Prior to initiation of Trulicity, train patients on proper injection technique to ensure a full dose is delivered. Refer to the accompanying Instructions for Use for complete administration instructions with illustrations. • Inform patients of the potential risks and benefits of Trulicity and of alternative modes of therapy. Inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and advise patients to seek medical advice promptly. • Each weekly dose of Trulicity can be administered at any time of day, with or without food. The day of once-weekly administration can be changed if necessary, as long as the last dose was administered 3 or more days before. If a dose is missed and there are at least 3 days (72 hours) until the next scheduled dose, it should be administered as soon as possible. Thereafter, patients can resume their usual once-weekly dosing schedule. If a dose is missed and the next regularly scheduled dose is due in 1 or 2 days, the patient should not administer the missed dose and instead resume Trulicity with the next regularly scheduled dose. • Advise patients treated with Trulicity of the potential risk of gastrointestinal side effects. • Instruct patients to read the Medication Guide and the Instructions for Use before starting Trulicity therapy and review them each time the prescription is refilled. • Instruct patients to inform their doctor or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens. • Inform patients that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and HbA1c levels, with a goal of decreasing these levels towards the normal range. HbA1c is especially useful for evaluating long-term glycemic control.

Eli Lilly and Company, Indianapolis, IN 46285, USA US License Number 1891 Copyright © 2014, 2015, Eli Lilly and Company. All rights reserved. Additional information can be found at www.trulicity.com DG HCP BS 20APR2015 TrulicityTM (dulaglutide)

DG HCP BS 20APR2015

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Mayo Clinic Finds Diabetes Patients are Tested Excessively Researchers at Mayo Clinic have completed a study that shows a national trend toward overtesting glycated hemoglobin (HbA1C) levels in adults with type 2 diabetes. They say the overtesting causes redundancy and waste and that it adds unnecessary medical costs and a time burden for patients and providers. In addition, they note that overtesting can lead to overtreatment with medication, adding even more cost and potential health complications. While protocols for monitoring and testing in patients with type 2 diabetes are not well defined, there is a consensus that testing once or twice a year would suffice for adult patients who are not using insulin, have stable glycemic control within recommended targets, and have no history of severe hypoglycemia or hyperglycemia. However, the researchers say that this study provides definitive evidence that there is a much higher prevalence of testing in practice.

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“Our findings are concerning, especially as we focus more on improving the value of care we deliver to our patients—not only ensuring maximum benefit, but also being mindful of waste, patient burden, and health care costs,” said Rozalina McCoy, MD, primary care physician and endocrinologist at Mayo Clinic and lead investigator of the study. “As providers, we must be ever vigilant to provide the right testing and treatment to our patients at the right times—both for their well-being and to ensure the best value in the health care we provide.” Researchers studied a group of 31,545 nonpregnant adults with controlled noninsulin-treated type 2 diabetes. They found that about 55 percent achieved and maintained the recommended HbA1C level and were tested three or four times a year, while 6 percent were tested five or more times. “Potential reasons for more frequent testing include clinical uncertainty: misunderstanding of the nature of the test—that is, not realizing that HbA1C represents a three-month average of glycemic control; or a desire for diagnostic and management thoroughness,” McCoy said. “Other times, it may

Minnesota Physician January 2016

be the result of fragmentation of care (more than one unconnected provider); the need to fulfill regulatory demands, such as public reporting of performance metrics; or internal tracking of performance.”

Pilot Program Shows Pharmacists Can Help Improve Hypertension A pilot program at HealthPartners has shown the potential of community pharmacists to improve hypertension in patients. The six-month pilot program enrolled 270 HealthPartners members who have hypertension and a prescription for medication to lower their blood pressure at a Sterling Pharmacy, the company that partnered with HealthPartners on the program. These patients received a SmartCard so they could routinely measure and track their blood pressure inside the pharmacies. That data transfers automatically to the Sterling Pharmacy clinical system so the pharmacists can view the results

and recommend any changes in dosage or different medications to the patient’s provider. “One of the key findings of the pilot program is the importance of personal interaction between the patient and the pharmacist,” said Tim Gallagher, president of Astrup Drug, Inc., which owns and operates Sterling Pharmacies. “Pharmacists have the opportunity to extend the care team and optimize therapy to positively impact patient outcomes.” Almost half of the participants had uncontrolled blood pressure at the start of the program, and about one-third experienced improved blood pressure over the course of the pilot program. “It is well understood that the pharmacist can play a key role in supporting medication adherence,” said Richard Bruzek, vice president of HealthPartners pharmacy services. “This pilot shows that community pharmacists can add even more value by confirming that the prescribed medication is doing what it is supposed to do.” HealthPartners is looking into expanding the program in 2016 due to the positive results of the pilot.


Minnesota Gets High Marks on State Health System Scorecard Minnesota has ranked first on the 2015 state scorecard on state health system performance from the Commonwealth Fund. It tied with Vermont for first, followed by Hawaii, Massachusetts, and a tie for fifth among Connecticut, New Hampshire, and Rhode Island. This is the fourth such scorecard, with previous versions published in 2007, 2009, and 2014. Minnesota also ranked first in 2014. To create the scorecard, researchers analyzed the most recent data available for 42 indicators grouped into five domains— access and affordability, prevention and treatment, avoidable hospital use and cost, healthy lives, and equity. Minnesota is the only state to score in the top quartile on all five measures. Mississippi was the lowest performing state, followed by Oklahoma, Arkansas, Louisiana, and Alabama. Overall, however, the scorecard shows that more states improved than worsened on the majority of the 42 indicators. “Gains reported by the scorecard likely reflect the influence of public policy—most noticeably, the role of the Affordable Care Act in expanding health insurance coverage—as well as public and private initiatives at the national, state, and community levels,” according to the report. “States have many opportunities to widen these gains in various ways—purchasing health care for low-income Medicaid populations and state employees, establishing rules that guide health care and insurance markets, setting strategy for health information technology and exchange, supporting public health, and acting as conveners and collaborators in improvement with other health care stakeholders.” Minnesota did well overall, but there were some categories in which it ranked very low. For example, the state ranked 45th in “home health patients who get better at walking or moving around” and 47th in “home health patients whose wounds improved or healed after an operation.” It also ranked low in “children with a medical and dental preventive visit in the past year,” dropping to 48th when the

category applied to children in families with low income. According to the authors, if Minnesota were to improve to the level of the best performing state in each category, 97,174 more adults would be insured, 82,453 fewer adults would go without needed health care because of the cost, and 13,286 fewer emergency department visits would occur among Minnesotans with Medicare.

Summit Orthopedics Announces Major Expansion in Woodbury Summit Orthopedics has announced finalized plans to expand into Woodbury’s Bielenberg Sports Center after submitting the proposal to the Woodbury City Council in a meeting in November. The city council approved a lease agreement with Summit Orthopedics at a meeting on Dec. 9. The plan includes a two-story, 14,450-square-foot clinic and wellness center space in the building in which it will offer physician appointments, physical therapy, and sports performance services, as well as wellness educational classes on topics such as yoga and nutrition. The city’s original plans for the Bielenberg Sports Center included a large space for a restaurant and for the Minnesota United Football Club, the state’s professional men’s soccer team, when the $22 million sports facility was built. However, the restaurant and soccer team canceled those plans for different reasons and now Summit Orthopedics will occupy the space they have left vacant. Construction will begin immediately and it is expected to open by late spring 2016.

Request for

Community Caregivers Recognizing Minnesota physician volunteers Nomination Closing: February 15, 2016 Publication Date: April 2016 Minnesota Physician Publishing announces our annual Community Caregivers feature. We are seeking nominations of Minnesota physicians who have volunteered medical services in communities in Minnesota, in the U.S., or abroad. The nominees selected for recognition will be featured in the April 2016 edition of Minnesota Physician, the region’s most widely-read medical publication. To qualify, nominees should be physicians practicing in Minnesota who have performed medical services, either locally or abroad, during 2015. Both teams and individual physicians may be nominated; if the nomination is for a team, please designate one or two physicians who could fill out a questionnaire if selected for the feature. To nominate a physician or team of physicians, please fill out the nomination form below and submit it by mail or fax by Feb. 15. Send to Minnesota Physician Publishing, Community Caregivers, 2812 East 26th Street, Minneapolis, MN 55406. Fax to 612.728.8601 For more information, call 612.728.8600.

Community Caregivers Nomination Form I would like to nominate the following physician(s): Name and location of physician’s practice:

Physician’s contact info (email and phone):

Brief description of the physician’s medical volunteer service:

State of Minnesota Sued Over Ban on Transition-Related Surgery Coverage

Nomination submitted by:

The American Civil Liberties Union (ACLU) and its Minnesota chapter have filed a lawsuit against the state of Minnesota

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challenging the coverage ban on transition-related surgeries for transgender people covered by Medical Assistance and MinnesotaCare. The suit was filed on behalf of coplaintiffs OutFront Minnesota, the state’s LGBTQ rights group, and Evan Thomas, a Minnesotan currently on Medical Assistance who is diagnosed with gender dysphoria. Thomas has begun hormone therapy and legally changed his gender and name earlier this year after struggling with ongoing depression, but has been denied coverage for his gender transition surgery. “For many transgender people, transition-related surgery is a medical necessity and can sometimes be a matter of life and death. Transgender Minnesotans—like everyone else—should be able to receive adequate health care based on medical standards of care,” said Joshua Block, a staff attorney with the national ACLU’s Lesbian Gay Bisexual Transgender & AIDS Project. “Every major medical organization has recognized that policies

banning coverage for medically necessary transition care have no basis in modern medical science. Minnesota’s statute is a historical relic based purely on disapproval of transgender people.” The ACLU says Medical Assistance “provides coverage for medically necessary care for virtually every type of medical condition,” but that there is a “sweeping and categorical exclusion of all transition-related surgical care without any regard to whether the treatment is medically necessary for an individual recipient.” A spokesperson at the Minnesota Department of Human Services said that they have received the lawsuit and are reviewing it. “When a law makes state financial assistance available for medically necessary surgery in some instances, but denies state assistance for that same or substantially equivalent surgery when the objective is to treat gender dysphoria, such a law is perceived as a state-sanctioned badge of inferiority, and further fuels the stigma affecting the transgender community,” the lawsuit says.

At the federal level, Medicare reversed its ban on coverage for gender transition related surgeries last year. Ten states and the District of Columbia currently cover transition-related surgical care. “The statute that we’re challenging is six words long,” said Phil Duran, legal director for OutFront Minnesota. “It says: ‘Sex reassignment surgery is not covered.’ They want to add the phrase, ‘unless medically necessary.’”

Otter Tail County Collaborative Funded to Demonstrate Personal Health Records The Otter Tail Personal Health Record Collaborative has received $1 million in funding from the Minnesota Department of Human Services (DHS) as part of a federally funded demonstra­ tion to better understand and expand the use of personal

health records for older adults and people with disabilities who receive Medicaid-funded longterm services and supports. The collaborative will use the funds to demonstrate the use of personal health records in the state’s long-term services and supports system and will work with DHS and the federal government to test a standard for sharing service plans and other information related to community-based long-term services and supports. The funds will be used through March 2018. “The goal of this initiative is to develop a system in which data related to an individual’s long-term services and supports follows the person and is shared with appropriate parties, including the individual, to promote better overall quality of care,” said Loren Colman, assistant commissioner of the DHS Continuing Care for Older Adults Administration. “This system will also help to capture and report, with appropriate permissions, data related to quality and outcomes to improve the overall long-term services and supports system.”

ME E T I NG OF THE

MINDS DE M E NT IA CONFE R E N C E 2016

3.19.16

St. Paul RiverCentre

engage.connect.learn. KEYNOTE SPEAKERS Mary Mittelman, D.P. H.

Research Professor of Psychiatry and Rehabilitative Medicine, NYU School of Medicine

Donald Warne, M.D., MPH

Director of the Master of Public Health Program, North Dakota State University; Senior Policy Advisor, Great Plains Tribal Chairmen’s Health Board

Learn more and register at

alz.org/mnnd #ALZminds

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Minnesota Physician January 2016


Medicus Brian Sick, MD, internist and pediatrician at the University of Minnesota Medical Center’s Primary Care Center, has received the Early Distinguished Career Alumni Award for his accomplishments. Since 2007, Sick has served as medical director of the Phillips Neighborhood Clinic, a free, student-run clinic where students of medicine, dentistry, nursing, pharmacy, Brian Sick, MD physical therapy, public health, and social work provide care to more than 1,100 underserved patients per year. He is also an assistant professor at the Medical School where he is responsible for the Academic Health Center’s interprofessional education curriculum. Sick earned his medical degree at the University of Rochester School of Medicine in New York and completed a dual residency in internal medicine and pediatrics at the University of Minnesota. Marilyn Peitso, MD, pediatrician with CentraCare Health in St. Cloud, has received the 2015 Betty Hubbard Maternal and Child Health Leadership Award from Minnesota’s Maternal and Child Health Advisory Task Force and the Minnesota Department of Health for her leadership and advocacy on behalf of mothers and children in Minnesota. Peitso is a longtime member of Marilyn Peitso, the Minnesota Medical Association (MMA) and MD currently serves on its board of trustees and the MMA Foundation’s board of directors. She is also on the state’s Health Care Financing Task Force and she previously served as president of the Minnesota Chapter of the American Academy of Pediatrics. She earned her medical degree at the University of Minnesota Medical School and completed her internship and residency at University of Iowa Hospitals and Clinics. James Standefer, MD, adjunct professor of ophthalmology at the University of Minnesota, has received the 2015 International Blindness Prevention Award from the American Academy of Ophthalmology (AAO) in recognition of his work helping to prevent blindness on a global scale. He has been a member of the AAO for 45 years and was chairman of its International EducaJames Standefer, tional Development Committee for eight years. MD After 25 years of treating patients at a private practice, Standefer left to volunteer full time. He has performed cataract surgery and worked as a clinical and surgical ophthalmologist at several locations across the world. His most significant contributions were made in developing and teaching two-week training courses to educate practitioners in developing countries about glaucoma diagnosis and treatment. Standefer earned his medical degree at Weill Cornell University Medical College in New York City and completed his residency at Washington University in St. Louis, Mo. Kenneth Ripp, MD, family medicine physician at Raiter Clinic in Cloquet, has received the 2015 Physician of the Year Award from the Lake Superior Medical Society Alliance for his consistent demonstration of “qualities that patients and physicians recognize as defining medical excellence in medical care delivery.” Candidates are nominated by their peers and patients. Kenneth Ripp, MD Ripp earned his medical degree from the State University of New York Upstate Medical University at Syracuse and completed his internship and residency at St. Joseph’s Hospital Health Center.

Osmo Vänskä /// Music Director

Ladysmith Black Mambazo Fri Mar 4 8pm

Paul Simon’s Graceland made them famous. This South African ensemble sings in English and Zulu, accompanied by tongue clicks, snaps, whistles, kicks, hops and waves.

Rajaton: Best of the Beatles with the Minnesota Orchestra

Sat Mar 12 8pm / Sun Mar 13 2pm Hear this Finnish a capella vocal group’s take on the complete Sgt. Pepper’s Lonely Hearts Club Band album. After intermission, it’s the Beatles greatest hits.

Schumann, Ravel and de Falla

Fri Mar 18 8pm / Sat Mar 19 8pm

Jesús López-Cobos, conductor / Andreas Haefliger, piano Here’s one of the season’s most anticipated programs——the Orchestra Hall debut of the Spanish-born conductor Jesús López-Cobos with a pianist of deep lyrical insight——the extraordinary Andreas Haefliger.

minnesotaorchestra.org 612.371.5656 / Orchestra Hall PHOTOS: Ladysmith; Shane Doyle. Rajaton; Ville Paul Paasima. López-Cobos; Javier del Real

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January 2016 Minnesota Physician

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INTERVIEW

A commitment to the underserved

Jim Eppel UCare Mr. Eppel became president and CEO of UCare in June 2015. He leads the health plan and its nine health coverage products from offices in Northeast Minneapolis. He has been a top Minnesota health care executive for more than 35 years. Before UCare, he was senior vice president of OptumInsight where he oversaw Optum’s operational review of MNsure in late 2013. Previous positions include COO at Blue Cross Blue Shield of Minnesota and senior-level positions at Allina Health, UnitedHealth Group, Medica, and MedCenters Health Care. Mr. Eppel serves on the boards of RespirTech and 360 Communities. He also has been a board member of Memorial Blood Centers, the University of St. Thomas Alumni Association, and CaringBridge. He was named to Minnesota Physician magazine’s 2012 list of “100 Influential Health Care Leaders.” Twin Cities Business Magazine also named Mr. Eppel one of “100 People to Know in 2016.”

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M  any of our readers may not be familiar with the history of UCare. How was it started and what was its original mission? UCare has a rich history of quality, service, and innovation. Physicians with the Department of Family Medicine at the University of Minnesota Medical School created it in 1984 as a demonstration project for 100 Medical Assistance recipients in Hennepin County. Today’s UCare offers nine plans that serve people of all ages and in all states of health, individuals and families, adults with disabilities, and every multicultural community. Of particular note is our commitment to underserved populations and our focus on individual consumers and their families. The expertise, understanding, and experience we have gained have served our members well. Our mission to “improve the health of our members through innovative services and partnerships across communities” was developed by senior leadership in 1995 and has served UCare well. U  Care is frequently recognized as one of the best places to work in the Twin Cities. Can you share some of the secrets to creating this kind of corporate culture? We have been honored every year in the Star Tribune’s Top Workplaces listing since it began in 2010. I believe it is because we have built a culture in which people want to work and grow. For our part, we promote listening, open and frequent two-way communication, and transparency wherever possible. Employees respect and support one another. They know our mission and commitment to service. They have a sense of ownership and are proud of the positive impact their work has on others. Our employees share valuable feedback through our employee engagement surveys, and their ideas are used to strengthen our organization. When all is said and done, employees want to know they make a difference and they want to be treated with respect.  W  hat can you tell us about UCare’s experiences with MNSure? In 2013, we developed our first commercial products—UCare Choices and Fairview UCare Choices— for MNsure. We are definitely finding our stride for these products and they are experiencing steady growth. Overall, we are pleased with our MNsure experiences this year and look forward to refinements that will strengthen the user experience.

Of course, there has been considerable pricing volatility in MNsure’s first two years. The health plans are working to deliver products that cover members’ costs and deliver value to consumers. Considerable collaboration between the various stakeholders still is needed to build stability in this marketplace.  Recently, UCare was in the news about state contracts. What can you share about this story? It has been a tough time, but we moved through it. Shortly after I became CEO, we learned that we lost Medicaid and MinnesotaCare state public program contracts for 2016 following a statewide competitive bidding process by the Department of Human Services. It was a blow on many fronts. Our loss of approximately 350,000 members led to a workforce cut of 29 percent for 2016. During this time we were gratified by the outpouring of support we received from diverse communities, provider partners, nonprofit agencies, and even other health plans. Letters and phone calls on our behalf affirmed the quality and value we have delivered for three decades to our members and Minnesota. In the end, we retained Medicaid and MinnesotaCare service in Olmsted County for 2016. We have spent late 2015 planning for our new reality. We are focused on growing our membership, strengthening our operations, and stabilizing our financial performance. The UCare of Jan. 1, 2016, will be a reconfigured, leaner, and energized organization with a clear eye on our future—a future about which we are excited.  UCare and Essentia Health recently announced an exciting new joint venture. Please tell us about this alliance. It is called EssentiaCare and is an innovative Medicare Advantage PPO partnership we believe is a model for future health plan/care system collaborations. It is a remarkable and affordable product that offers patient-centered, cost-effective care to Medicare beneficiaries in 10 north-central counties within Essentia Health’s service area. It improves member experience, reduces health care costs, and ensures better health outcomes.

What really sets EssentiaCare apart and makes it especially effective is our 50/50 co-ownership structure, which is quite uncommon in health care. Certainly there were “hiccups” during MNWe share equally in its administration, risk, and sure’s first year. Although the MNsure team worked results. This new care model engages older patients very hard—there are many complex processes in taking an active role in their health. Plan meminvolved—the health plans experienced technical isbers use the broad Essentia Health network and sues. Still, we worked with MNsure to resolve issues enjoy a seamless customer service experience. knowing we all have a stake in MNsure’s success and will benefit from a smoothly operating system.

Minnesota Physician January 2016


 What vision do you have for the future of UCare? Time and time again, UCare has demonstrated its ability to connect with, engage, and serve the individual consumer and his or her family. We will build on this distinctive competency as we partner with other key health care players to serve a variety of individual consumers through our existing product portfolio, as well as new products and services. We will continue to be an “integrator” within the health care community, to the benefit of consumers and providers of health care services.

 What trends do you see that are shaping the future of our health care delivery system? Here are my top five trends: 1) continued consolidation; 2) greater collaboration and/ or integration of health care delivery and financing; 3) greater transparency of cost and quality data to aid decision-making; 4) continued efforts to redesign the delivery system and take care of the consumer; and 5) expanded incentives focused on the consumer/ patient role in maintaining good health.

 What are your thoughts on the Affordable Care Act (ACA)? It is well intended, but perhaps a bit off the mark in practice. For many, the impact of the ACA is felt as the redistribution of cost and risk. It shifts costs from older consumers to younger consumers, from the less healthy to the healthier consumer, from providers of care to the insurance system. Some have benefitted from the ACA and will continue to do so; others have been disappointed. The reality is that at a minimum, many refinements of the law are needed. We all have to commit to doing our part to work with it and make the changes necessary to have it come closer to achieving its intended goals.

UCare has a rich history of quality, service, and innovation. In addition, one of the most important trends results from a realization that, to date, the health care system has not truly acted like a “system.” In response to this recognition, we are seeing continued efforts to align the motivations and incentives of the various constituents—providers, payers, purchasers, patients, etc. There is great promise in continued alignment, integration, and collaboration.

 I f you had to change one thing about how the health care delivery system works today, what would it be? Actually, I will give you two: 1) The health care delivery system was largely developed for the convenience of those who work in the system, as opposed to those who use the system. This is already changing, and the most successful providers will focus on ease of use for the consumer. 2) While we all understand the benefits of competition, at times it gets in the way of “doing the right thing” in health care. We need to be intentional about competition vs. collaboration. There are major issues affecting the health of our communities that would benefit by a more collaborative approach by all players.  What reasons for optimism can you share with our readers about the future of health care? More and more, I see evidence of the alignment of incentives between providers, insurers, purchasers, and patients. There is a shared acknowledgement that the “health care system” needs to act more like a system, as I noted earlier, and that we need to return the patient to the center of that system. Watching this happen gives me great hope for the future of health care.

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Medical ethics and the unconscious mind from cover

At our next visit, I was surprised to learn that Dr. Winston was not planning to give George an iron infusion. The reason? His hemoglobin level was 10.8 and his insurance plan determined that this treatment is not medically necessary until levels fall below 10. George was accustomed to paying out of pocket for psychotherapy in my direct-pay practice, and was willing to do the same to get his iron infusion. I phoned the hematologist to recommend this solution, but he reluctantly refused. Network physicians like Dr. Winston are prohibited from billing patients out of pocket for covered services deemed not medically necessary by the plan; coverage provisions like this cannot be appealed. George continued to suffer with untreated anemia for months.

Dr. Winston honored his contract with the insurance plan, but what was his ethical responsibility to his patient? Consider the Principles of

contractual obligation that directly conflicts with patient welfare. In a situation of moral ambiguity, Dr. Winston defaulted to contractual compliance.

Clinical decisions and ethical choices are more unconscious than we would like to imagine.

Medical Ethics of the American Medical Association. Principle 8 asserts, “A physician shall, while caring for a patient, regard responsibility to the patient as paramount,” but this influential code gives no more than oblique guidance to the clinician who faces a

Codes of medical ethics will continue to leave broad swaths of moral uncertainty, until the field develops a systematic theory to guide physicians in managing the intimate communications between their own unconscious minds and third-party payers. For that, we can look to the discipline of behavioral economics and specifically Daniel Kahneman’s popular book, “Thinking, Fast and Slow.” Unconscious decisions A physician’s clinical decisions and ethical choices are more unconscious than we would like to imagine. Adapting a two-system model from Kahneman’s book, I have personified the different parts of a physician’s decision-making process into three characters: Scientist, Sage, and Homunculus. The Scientist’s job is to allocate limited psychic energy to attention-demanding mental activities. As she works through a problem, she pulls up memories and holds several intermediate steps in her mind at the same time. When the Scientist is engaged, muscles tense, pupils dilate, the heart rate goes up, and she is relatively blind to other things going on around her. She is easily fatigued, so peripheral activities deplete the energy needed for core tasks.

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Minnesota Physician January 2016

The next character in this inner drama is the Sage. When training to become a physician, the acquisition of skills requires an emotionally supportive, consistent environment; timely, accurate feedback about the effects of clinical interventions; and lots of practice. A marker of proficiency is the ability to deal with large amounts of clinical information quickly and efficiently. The Sage operates automatically and unconsciously, recognizing patterns and accurately matching experience with well-known categories. As clinicians know, medical practice regularly presents them with decisions where they can call on relatively less prior experience and no hard science for guidance. What now? If the doctor is not careful, yet another part of the mind, the Homunculus, might take over. Like the Sage, the Homunculus also operates automatically and unconsciously, quickly placing experience into preexisting categories. But unlike the Sage, the categories used by the Homunculus are not empirical. He is quick to stereotype and terrible at estimating probabilities. The Homunculus is quite risk averse, easily motivated by short-range gains, and he cannot follow rules. Worst of all, he has supreme confidence and no self-control. When working in fields of true proficiency, it is eminently logical for the physician to trust clinical experience as a guide, but in the Age of Science, the Scientist feels obliged to keep the Sage mostly hidden. When the doctor is pushed into areas of ambiguity, decision-making gets even dicier. The Scientist still articulates choices, but she is quite apt to take up and rationalize ideas and feelings that were whispered in her ear by the Homunculus. The Scientist can easily recognize


Homunculus at work in the minds of colleagues, but she is almost completely blind to her own susceptibility to his blandishments. Dr. Winston’s dilemma illustrates that the Homunculus can be engaged to drive decisions even in the presence of both science and proficiency. Dr. Winston was knowledgable and experienced with IV iron infusions. If no third-party agendas had been attached to payment, the Sage would have driven the obvious decision to give George a previously effective treatment. The Scientist would have realized that the literature on iron infusion does not provide evidence that supports specific laboratory parameters as cutoffs for treatment and remembered her old professor intoning, “Treat the patient, not the labs!” Because Dr. Winston signed a contract with an insurance plan, the anonymous author of the iron infusion coverage advisory had an opening to make a direct appeal to Homunculus, who automatically overruled the Scientist and the Sage. It was risk-averse Homunculus who conjured up images of punishing insurance plan audits and contract terminations. If she needed an after the fact rationalization, the Scientist could look to some medical ethicists in the employ of managed care plans who argue that physicians are responsible to be good stewards of society’s limited resources. The real decision not to treat George was made by Homunculus in Dr. Winston’s unconscious mind, a place not reached by codes of ethics. Payers exploiting unconscious motivations Physicians like to imagine that the Scientist is in charge at all times, but health care administrators understand and exploit the central role of Homunculus.

In systems of care driven by third-party reimbursement, doctors are subjected to a complex mix of incentives, financial, legal, and otherwise,

A global budget is an extremely blunt instrument. Executives driven by performance incentives are in charge of devising performance

Slogans such as “total quality improvement,” “payment for value,” “population-based care,” and “distributive justice” all represent values that are not truly intrinsic to the relationship between an individual patient and her physician. The “choice architects” who design new systems of payment for care use these catchphrases in public discourse to appeal to the Scientist, all the while expanding and refining the program of incentives that will covertly bend Homunculus to third-party economic and political agendas.

incentives to drive physician employees. If George is treated by Dr. Winston in an ACO, an imaginary contractual straitjacket will be replaced by monetary carrots and sticks. Either way, Homunculus makes the clinical decisions.

Physician, know thyself

Knowledge of our unconscious minds will improve the quality of our ethical decision-making.

all designed to put Homunculus in the driver’s seat. As an example, an electronic medical record presents a physician with treatment algorithms, with the preferred choices (usually less expensive) marked with green traffic light symbols, and the alternatives (usually more expensive) marked with red traffic light icons. This crudely simple device of color coding will induce Homunculus to act as if he is driving toward a traffic light rather than treating a patient.

Direct-pay and fee-for-service are not just payment mechanisms, they also represent an ethical stance. In my private psychiatric practice, patients Medical ethics and the unconscious mind to page 42

When behavioral economics migrates to the halls of power, it is turned to purposes not envisioned in the academy where it originated. The authors of the Affordable Care Act (ACA) subscribe to a theory of “soft paternalism,” which holds that it is morally valid to arrange “choice architecture” so that choices are presented to individuals in ways that “nudge” them toward “healthy” decisions. The central feature of the Accountable Care Organization (ACO) model is a global budget set by actuaries. If the target number is exceeded, then the organization is penalized financially, and physicians are expected to share the pain— “shared savings”—in order to motivate them toward “best practices.” January 2016 Minnesota Physician

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The Compassionate Care Act from cover

bleeding bedsores and constipation. His son, who relayed this heartbreaking story, could do little to help. Dave lingered in hospice for more than a year. While palliative care relieved some of the pain, much of Dave’s misery could not be alleviated. The family felt traumatized. Sadly, Dave’s story is neither new nor unique.

Cruzan legal battle culminated in the Patient Self-Determination Act, which affirmed the rights of Americans to refuse unwanted medical treatment and established the primacy of patient authority in medical decision-making. In the 1980s and 90s, states codified the

and was prosecuted and acquitted five times before being found guilty of murder. His renegade approach and blatant disregard for the rule of law caused a backlash in the public arena, where some came to see his actions as more murderous than compassionate.

Most Americans support authorizing aid in dying at the end of life.

control should her symptoms become too much to endure. Like Brittany and her family, most Americans support authorizing aid in dying at the end of life. For the past two decades, Gallup polls show that seven out of 10 Americans have indicated strong support for the idea. With the recent passage of the End of Life Option Act in California, 16 percent of the U.S. population now has access to aid in dying in five states.

The history of aid in dying

The long road to acceptance

Medical breakthroughs of the past century have raised questions about what constitutes quality of life. It wasn’t so long ago that removing life support, even in clear cases of medical futility, was considered murder. The landmark case of Karen Ann Quinlan in 1976 settled the debate about whether life support could legally be withdrawn from patients in a vegetative state. A decade later, the Nancy

The medical community has been slow to accept aid in dying, but several leading professional organizations have endorsed the option, including the American Medical Women’s Association, the National Physicians Alliance, and the American Public Health Association. Earlier this year, the California Medical Association (CMA) withdrew its opposition to the End of Life Option Act, adopting a stance of neutrality and sanctioning aid in dying as a legitimate option. CMA former president Luther Cobb, MD said, “CMA’s focus has historically been on improving end-of-life options and enhancing palliative care and hospice for patients who are terminally ill. Ultimately, however, it’s up to the patient and their physician to choose the course of treatment best suited for the situation—and CMA’s new position on physician aid in dying allows for that.”

role of health care agents and instituted legal protections for physicians when hastening death was an unintended side effect of treatment. The impact of these high profile cases notwithstanding, it was Dr. Jack Kevorkian whose actions provoked the widest public discourse. He assisted more than 130 dying patients

In 1997, Oregon voters supported the groundbreaking Death with Dignity Act that authorizes terminally ill adults of sound mind to obtain medication that they may self-administer if and when their suffering becomes unbearable. By 2005, Washington voters had embraced a nearly identical law. Current thought The American Medical Association’s (AMA) current position in opposition to “physician assisted suicide”—established in 1993—references Dr. Kevorkian and early failed attempts to authorize aid in dying. The AMA’s Council on Ethical and Judicial Affairs has not rendered an opinion on the subject of medical aid in dying in recent years despite dramatic changes to the legal, social, and scientific environments. More recently, Brittany Maynard’s widely publicized story has sparked renewed public interest in access to aid in dying nationwide. The 29-year-old moved her family to Oregon in order to access medical aid to end her suffering from stage 4 brain cancer. Rather than face unrelenting headaches, seizures that left her unable to speak, and a gradual decline into paralysis, blindness, and dementia, she was able to live her final months enjoying what she loved most— her family and the great outdoors — knowing she was in

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Minnesota Physician January 2016

The physician’s role Patient-centered care now demands that physicians relinquish the old doctor-knows-best role and instead engage with patients as partners, exploring their goals of treatment and helping meet their needs. In his best-selling book, “Being Mortal,” Dr. Atul Gawande describes our predicament: However miserable the old system has been, we are experts at it…. You agree to become a patient, and I, the clinician, agree to try to fix you, whatever


MINNESOTA HEALTH CARE ROUNDTABLE the improbability, the misery, the damage, or the cost. With this new way, in which we together try to figure out how to face mortality and preserve the fiber of a meaningful life … we are plodding novices. It is our responsibility as physicians to understand that aid in dying is a medical practice defined by accepted standards of care. The public will look to us as a trusted resource as the discussion intensifies, and we have a responsibility to help moderate this vital conversation, so that it is addressed with honesty and humility rather than specious arguments based on misinformation, speculation, or hyperbole. The Oregon Public Health Division prepares annual reports on the Death with Dignity Act that refute claims that aid in dying leads to widespread abuse.

No one will be required to participate in this law.

Minnesota’s Compassionate Care Act is modeled after the highly successful Death with Dignity Act (DWDA) in Oregon. To qualify, a patient must be an adult resident of the state, terminally ill, and of sound mind. A request for aid in dying must be made in writing twice, at least 15 days apart and signed in the presence of two witnesses. Two physicians must determine that a patient meets the criteria and is free from coercion. Any doubt or disagreement between physicians necessitates a third evaluation. Patients are repeatedly provided information about hospice, palliative medicine, and other treatment options. They are also given the opportunity to rescind their request at any time. Nearly 200 physicians in Oregon and Washington have followed this protocol successfully for more than 15 years.

Some argue that better hospice care would make aid in dying unnecessary, but more than 90 percent of Oregon patients who used the DWDA were enrolled in hospice at the time. The Center to Advance Palliative Care and National Palliative Care Research Center gave all four states with Death with Dignity laws an “A” rating in 2015. In their 2015 analysis of geographic variation in hospice use patterns, Shi-Yi Wang et al. noted that Oregon was the only state in the highest quartile of hospice use and the lowest quartile of potentially concerning patterns of hospice use. The authors suggested that could be attributed to its Death with Dignity Act. There are some who oppose aid in dying for religious reasons. To them, end-of-life suffering is God’s will and medical intervention to shorten the dying process is wrong. We respect this view. Freedom of religion is a foundation of our democracy. No one will be required to participate in this law, whether patient, caretaker, or physician. In the final analysis, we hope physicians will support our view that patients should have access to a full range of options at the end of life, including aid in dying. For some patients, prolonging the dying process is not the same as extending life. Whatever our personal beliefs, as medical professionals, we have a duty to respect our patients’ values and goals as they make difficult choices at the end of life.

Sen. Chris Eaton, RN (DFL), rep-

resents Minnesota Senate District 40, which includes Brooklyn Center and Brooklyn Park. She serves as the DFL majority whip and as vice chair for the State and Local Government Committee. Rebecca Thoman, MD, leads Doctors for Dignity, an initiative of Compassion & Choices.

FORTY-FIFTH SESSION

Medical Innovation vs. Medical Economics When payment policies limit quality of life Thursday, April 21, 2016 • 1:00-4:00 PM Downtown Minneapolis Hilton and Towers Background and Focus: The pace of innovation in medical science is rapidly escalating. From more accurate diagnostic equipment, to the use of genomic data, to better surgical techniques and medical devices, to new and more efficacious pharmaceuticals, breakthroughs occur nearly every day. These advances face many challenges when incorporated into medical practice. Several significant factors limit this adoption, including the economic models around how patient use of new science will be utilized. Twentieth century health insurance, medical risk management, and reimbursement models are controlling 21st century medical care and patients are the losers. Objectives: We will review examples of recent scientific advances and the difficulties they face when becoming part of best medical practice, despite their clear superiority over existing norms. We will look at prevailing thinking behind economic models that govern how health care is paid for today. Our panel of industry experts will explore potential solutions to these problems. We will look at ways to create balance between payment models, new technology, and increased quality of life. Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub. com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAx Card #  Check enclosed  Bill me

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January 2016 Minnesota Physician

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Practice Management

P

enny Wheeler, MD, president and CEO of Allina Health, recalls choosing an advisor while in medical school at the University of Minnesota. “I remember thinking I was so smart for choosing Dr. Val Ulstad as my advisor—then 35 other students chose her too.” Dr. Ulstad, the winner of many teaching awards, would likely inspire any medical student, but she was one of a small percentage of academic women leaders in the early 1980s. It has been clearly demonstrated that women leaders increase the profitability of their organizations, and their flexible, collaborative style is valued. With so few women physicians to choose as a mentor, perhaps it should have come as no surprise that close to a quarter of Dr. Wheeler’s classmates would also choose Ulstad. According to the American Medical Association’s 2012 figures, women represent 31

Women physician leaders Addressing societal barriers By Heather Awad, MD

percent of all physicians in the U.S., and the Association of American Medical Colleges (AAMC) reports that women make up almost half of today’s medical school population. However, the AAMC, and the Rock Health white paper tell us that the percentages are much smaller at the top, where women represent less than 20 percent of division chiefs, medical school deans, and department chairs. Only 4 percent of health care CEOs are women, and not all are physicians. This incongruity shows room for important improvements in private practice.

This year, we’re taking a more inclusive, outsidein approach to value, mindful that the health of all our patients and communities is the reason for the care we provide.

Learn more and register at www.icsi.org Early bird discounts end April 8, 2016

Keynote Speakers Gary L. Cunningham, Metropolitan Economic Development Association (MEDA), Minneapolis —Creating a New Narrative for Community Engagement in Health Care

Tiffany Christensen, North Carolina Quality Center—Is Partnership Possible? A Hybrid Patient Perspective

Pre-Conference Workshop Turning Surviving Into Thriving with Allina Health’s Corey Martin, MD Practical, proven tools based on principles of adaptive leadership to develop the resilience needed to succeed in this complex and challenging environment. > Three flexible tracks: Systems/Payment Models, Clinicians/ Resilience, Community/Patient Engagement > 26 sessions with a mix of local and national speakers > Compelling presentations of value to meet all interests and needs

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Minnesota Physician January 2016

Why do we need more women leaders? Profits improve and a feminine leadership style is currently admired. According to Forbes, “Research suggests that women at the helm of companies…tend to outperform their male counterparts.” McKinsey & Company’s “Women Matter” research notably shows “that higher participation of women in management [grew] the company’s bottom line,” and multiple studies agree. Also, according to Gerzema and D’Antonio’s research in “The Athena Doctrine,” “traditionally feminine leadership [is] now more popular than the macho paradigm of the past.” The approach is recognized as “flexible, collaborative and nurturing.” Women lead their teams in a cooperative style to greater profitability. Many private practices in Minnesota have groomed and recruited women physicians as leaders, but there isn’t a lot of data available that is specific to our state. However, a look at the careers of three Minnesota physicians, along with the 2015 Medscape Women as Physician Leaders Report, will shed light on the topic and show opportunities for more women to end up in the leader’s chair. President of Southdale Pediatrics Vicki Oster, MD, president of Southdale Pediatrics for the past 12 years, was not involved with leadership until her residency, when she was inspired by the teaching aspects of her work as well as patient care. This led to her becoming chief resident, where she saw herself as a mentor and supporter of

those she was leading. Early in her career, she was asked to serve on committees at the University of Minnesota, Children’s Hospital, and at her practice. She went on to chair many of these committees, was named medical director of her practice, and was eventually asked to be president. Early in her career she didn’t imagine herself as a leader at the level she has attained, but she realized that she learned important leadership skills by serving on committees over the years. “I think many women sell themselves short and don’t think they can be a leader, when in fact, anyone can do it!” Like many other women physicians who end up in leadership roles, Dr. Oster felt that it is most important to be a leader in her own practice. In the 2015 Medscape Women as Physician Leaders Report, leaders maintained the importance of leadership in their own practice slightly above that of leadership in a professional organization. The majority identified themselves as medical directors or practice owners. In sharp contrast, nearly half of the non-leaders view attaining leadership in their practice as very or somewhat important, versus only 20 percent reporting the same for a professional organization. This can present a challenge when professional organizations seek women leaders. President of the Minnesota Academy of Ophthalmology Janice Sinclair, MD, president of the Minnesota Academy of Ophthalmology (MAO) has always been a leader, starting with middle school student council in St. Paul. She continued her interest in leading when attending the University of Minnesota Medical School by co-leading the medical school talent show among other activities. She is past president of Northwest Eye Physicians, and the first female partner in that practice. “I always wanted to be involved in everything,”


she says. Dr. Sinclair is proud to have had a hand in furthering her specialty in Minnesota through her work as president of the MAO and loves leading a group that “is greater than the sum of its parts.” She notes that even though she has “a fantastic husband” who takes a primary role at home after work, she still wants “to be more involved at [her kids’] school.” When offered the presidency of MAO, she decided this would be a good time rather than some years down the road, considering the age of her children and her plans to attend future school activities. A discussion of women leaders must also address both open and subtle gender bias. Dr. Sinclair is an ophthalmologist, a specialty whose roles are more than half male. In the Medscape report, 40 percent of non-leaders anticipate that overt gender bias will be a problem in leadership positions, while a smaller yet significant number (24 percent) have experienced this challenge in the leader group. Dr. Sinclair has not experienced overt gender bias in her leadership trajectory in ophthalmology. She does, however, describe the awkwardness of being a trailblazer. “I was the first woman partner in my group, and they didn’t have a maternity leave when I joined.” More female physicians have followed in Dr. Sinclair’s footsteps at Northwest Eye since then. There are multiple studies showing gender bias in hiring women leaders. One by Moss-Racusin et al. in the Proceedings of the National Academy of Sciences of the United States of America (2012) shows that male and female researchers reviewed identical applicant dossiers for a laboratory manager position, some with the name “John,” and some with the name “Jennifer.” Women and men chose the male candidate over the female with exactly the same CV and offered “John” a higher starting salary. In the McKinsey

“Women Matter” studies, they report that “most executives recognize the impact of gender diversity on financial performance,” but surveys show only 62 percent of men believe it at the C-level position, compared to 90 percent of women at that position. Middle managers lagged farther. Only 50 percent of men believed the research on the positive financial impact of women leaders, compared to 80 percent of women at that level. Bias is still a barrier for increasing women leaders in medical companies.

Support is key Support from their families and their practice is a common theme voiced by these three physicians when discussing their leadership success. The Medscape Women as Physician Leaders Report also shows that one-third of female physicians, leaders and non-leaders, state that family support is very important when taking a leadership position. The survey found that no meaningful correlation existed between the age of women’s children and their interest in leadership.

Women lead their teams in a cooperative style to greater profitability.

President and CEO of Allina Health Penny Wheeler comes to medical leadership after a well-established career as an obstetrician/gynecologist, although she notes that doctors show “everyday leadership by the way we model compassionate care” in our work with patients. It was a defining moment when she was offered the chief clinical officer position at Allina Health, which moved her away from daily patient care. One of the many supportive influences that helped, was having a partner at home who pointed out that the stack of journals that used to feature subjects like “placenta previa,” suddenly centered around journals discussing “quality improvement.” Her partner’s insights aided Dr. Wheeler’s evolution in viewing herself as a different kind of doctor than she had been in the past. She became a full-time leader with a passion for working towards achieving quality that would improve the health of an even greater number of patients than she could see personally.

Dr. Wheeler and Dr. Sinclair also highlight that structural

support from their practices has been key. Women’s Health Consultants allowed Dr. Wheeler to take time away from the practice to be president of the Hospital Medical Staff at Abbott Northwestern in 2000 and 2001. Northwest Eye offers their physicians a reduced call schedule once they become president of the practice, plus a small stipend. “The time is what makes it worth it,” Dr. Sinclair insists, “and that has really encouraged” most of the partners to take a turn at president. All of the women in the Medscape report are concerned with not having enough time to get everything done, as well as work getting in the way of their personal life. Time management is the most commonly cited reason for turning down a leadership position. Women know they need the support of their families, and acknowledge the paramount importance of the structural components Women physician leaders to page 40

Your Link to Mental Health Resources

January 2016 Minnesota Physician

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Minnesota health care roundtable

Mr. Starnes: Conservative estimates suggest that one in five people have some form of behavioral health concern. In Minnesota, that means that over 1 million people could use professional assistance. Every element of the health care delivery system finally recognizes the role that behavioral health care can play in improving the quality of life and lowering overall costs of health care. How can recognizing and treating behavioral health issues before they manifest in negative ways address these issues? Dr. Sulik: A recent report found that, on average, the cost of treating a medical condition will triple if the individual has a co-occurring behavioral health condition. Data also show that an adult with a serious mental illness will die 25 years sooner than an adult without a mental illness. This is an extraordinary statistic, but it has not triggered the level of alarm that it should. These individuals are not dying as a result of their behavioral health conditions, they are dying as a result of medical conditions that their mental illness impedes access in care for. Dr. Gibbs: I recently read about an individual in St. Cloud who had a serious mental illness that had not been fully diagnosed. While they were waiting to get a formal diagnosis and treatment plan in place, a police officer was killed, and the patient ultimately died as well. It was a very bad outcome, because of the lack of access to care and because they could not get the right assessment at the right time. Judge Meyer: I have yet to meet a person in my professional career that we have reached before things got out of control. By definition, people appear in front of me after they have been charged with a crime. I have seen how treatment and taking a holistic approach to their physical health, behavioral health, housing, medication, employment, and education can turn lives around so that people do not remain in crisis. That means fewer emergency room beds, fewer jail beds, and fewer crimes. Their whole quality of life improves. Ms. Lantz: For a lot of the population, particularly on the high end of the need spectrum, access to behavioral health care opens up access to primary care and physical health care. That population has a much

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About the Roundtable Minnesota Physician Publishing’s forty-fourth Minnesota Health Care Roundtable examined the topic of Behavioral health integration: New pathways to care. Eight panelists and our moderator met on Nov. 12, 2015, to discuss this topic. The next roundtable, on April 21, 2016, will address Medical innovation vs. medical economics: When payment policies limit quality of life.

generalized anxiety. There is a shame associated with that, and so to make that bridge or to have that openness within primary care to say, “Yes, this is also my struggle,” is a barrier that we need to overcome. Dr. Schiff: We often face folks who have already hit the criminal justice system or are already seriously mentally ill, but people move up and down a continuum of mental well-being. Finding folks earlier—before their illness gets out of control and also earlier on in their lives—should be the focus for resources and effective treatment. Mr. Starnes: What obstacles or barriers to access do patients face in seeking care for behavioral health concerns? Dr. Gibbs: Beds are very limited. It is a huge problem, starting with the waiting list to get acute patients into the hospital. The other problem—getting patients out of those beds and into an appropriate aftercare setting—jams up the whole system. It has been a serious problem in Minnesota for the last five or six years, and it usually gets worse in the winter.

Behavioral health integration New pathways to care higher incidence of asthma, of cardiovascular disease, of pulmonary disease, and of preventable disease. So, as folks come in to the mental health system, we need to look at physical health indicators and figure out how to get people into primary care as well. Dr. Pederson: We sometimes forget that behavioral health and medical conditions are linked together, especially in the older population, where you may have some cognitive impairment that makes it harder to distinguish the two. We need to work together so that primary care is not just going down its path, or mental health is not just going down its path, with neither one seeing how they could link together better. Ms. Anderson: Another important perspective is the stigma for clients of even being offered resources, whether it is a serious and persistent mental illness or a

Ms. Anderson: Prior authorization also creates significant obstacles, especially with some third-party companies that are paid to scrutinize and make decisions without ever meeting the client or speaking to the treatment team. If a client does not fall within this box at this time or into an average length of stay or treatment, their coverage is denied and their access is limited. Dr. Beecher: I helped my patients deal with prior authorizations and reimbursement limitations as a solo practitioner. For five years, as a medical director for a PPO [preferred provider organization], I was on the other side of those issues. I left that position because my style was to call and find out what the assessment and the plan was, to speak with some professional who knew what was going on. I would usually approve it and I do not think that was thought of too highly by some of the people that were hiring me, so I finally decided to stay in my office practice. It is a real tension, and the thing that makes one angry about it is that there are human beings involved here. Ms. Lantz: I’d like to say a word about Medicaid reimbursement rates. I do not think there is a provider out there that thinks the


Minnesota health care roundtable Medicaid rates cover the cost of care or allow for uniqueness in innovation, and that is part of the issue. Medicaid might cover much of the cost of a specific service, but when you are dealing with people, the work that you do is much broader than that, and the payment does not allow flexibility to do innovation, to be unique. It does not allow for, say, a case manager to go to a doctor’s appointment to explain what is happening. There are a lot of limitations on what Medicaid rates will allow, and they are a pretty marginal rate to begin with. Dr. Pederson: One of the things that we will do next year is to work with clinics to help them examine their screening processes for getting folks in to see providers if they are in the hospital, and to make changes in that work flow. It is a very complicated piece, but unless we study those steps and processes, there is no amount of money that we can throw at it that will make it work. Dr. Sulik: Mental illnesses cause impediments in the ability to organize and follow through. For example, if a primary care physician or advanced practice provider identifies a patient who needs mental health treatment, they will initiate a referral, but 50 percent of those patients will not be able to follow through successfully to that first appointment. If it is for a substance abuse issue, we lose 75 percent of the people. As a system, we penalize those individuals for exhibiting the symptoms related to their illness and we create additional barriers, and if somebody misses two appointments or if they do not show up for that first appointment, they cannot reschedule.

“We need to make it okay for people to talk.”  artha Lantz, MSW, M LICSW, MBA

Mr. Starnes: What changes do we need to make within the delivery system to address these issues? Dr. Schiff: Behavioral Health Homes should, with federal approval, get launched in July. The whole idea is to integrate physical health, behavioral health, and community partnerships. Basically, they are care coordination, family and patient support, education, and integrated transition. For those who are not already in a targeted case management situation, we will provide a continuity of care, with a core team delivering services. That team will involve either a nurse on the mental health side or a behavioral health provider on the physical health side, along with community health workers or peer support specialists or recovery coaches. All of those people will provide, for the first time, an integrated service. Dr. Pederson: In health care, we are not producing a product; we are producing a service. It is not the health care organization producing it and giving it to the person, it really needs to be the patient and the health care team working together. As I think more about Behavioral Health Homes and all of what we need to do regarding reimbursement, it is this joint production of health care services that we need to consider, not just a product that we are producing. Ms. Lantz: Behavioral health plans should not just be client centered, but also client driven. Consumers should

Sarah Anderson, MSW, LICSW, is CEO of Psych Recovery, Inc., where she currently practices clinically. She is the author and program director of Solveig IOP as well as the CEO of the outpatient clinic. She is also the CEO of The Professional Matrix Inc., a company that assists Minnesota social workers in receiving and providing supervision. Lee Beecher, MD, DLFAPA, FASAM, is president of the Minnesota Physician-Patient Alliance (MPPA), a nonprofit organization committed to improving health care. Now retired, Dr. Beecher maintained a solo practice in adult and addiction psychiatry in St. Louis Park for more than four decades. Timothy P. Gibbs, MD, FAPA, DFAACAP, is chief medical officer for Natalis Counseling and Psychology Solutions. A child and adolescent psychiatrist, he is a fellow in the American Psychiatrist Association and a distinguished fellow in the American Academy of Child and Adolescent Psychiatry. Martha Lantz, MSW, LICSW, MBA, is executive director of Touchstone Mental Health and treasurer of the Minnesota Community Healthcare Network. She is a licensed independent clinical social worker and holds a masters degree in business administration from the Carlson School of Management at the University of Minnesota. Judge Kerry W. Meyer is a judge in Minnesota’s 4th Judicial District, serving in the Hennepin County Criminal Mental Health Court. She has presided over cases involving adult criminal, juvenile delinquency and child protection, and civil litigation. Her current assignment, starting in 2013, is in Problem Solving Treatment Courts. Jane C. Pederson, MD, MS, is chief medical quality officer for Stratis Health, providing leadership and clinical guidance for health care quality and safety initiatives. Pederson is boardcertified in both internal medicine and geriatrics, and maintains a clinical practice providing primary care for residents in the assisted living setting. Jeff Schiff, MD, MBA, is medical director for Minnesota health care programs at the Minnesota Department of Human Services, where he focuses on the development and implementation of evidence-based benefit policy, the advancement of improved care delivery models, and the improvement of clinical quality. L. Read Sulik, MD, is chief integration officer and executive director at PrairieCare Institute. A pediatrician and child, adolescent, and adult psychiatrist, he has spent his career addressing the barriers that behavioral health needs create, as well as how these barriers contribute to negative and costly outcomes in chronic health conditions.

About the Moderator Mike Starnes has been the publisher at Minnesota Physician Publishing since 1986. His duties include the production of MedFax, Minnesota Physician, Employee Benefits Planner, and Minnesota Health Care News; directing the Minnesota Health Care Consumer Association; and hosting the Minnesota Health Care Roundtable.

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Minnesota health care roundtable be the creators of their plan and drive that plan. Regardless of their level of mental health condition, people still know what they want in their life. It might not be what anyone else wants for them, but they know what they want. If we can have an opportunity to be innovative or to help them meet their needs, there is that potential to open up the doors and let it be client driven, not just client centered. Dr. Beecher: There also has to be a demand on the part of the person for these services. When I was in my residency at the University of Chicago many years ago, a behavioral psychologist, Israel Goldiamond, took me down to Manteno State Hospital, and he told me he was going to take an unusual approach. During a group therapy session, he pulled the patient aside and asked, “How did you get to the hospital?” She said, “I’m a schizophrenic.” He said, “No, how did you get to the hospital?” She said, “Well, I threw a brick through a squad car window in Grant Park and the police picked me up and then I ended up here at the hospital.” So, in other words, there is a behavioral chain that needs to be identified and personalized for each client patient. Unless the team does that, we are not going to be able to motivate them.

Dr. Gibbs: We talked earlier about reimbursement being too low, but part of the issue is that reimbursement pays for the wrong things. It pays for procedures and things that are easy to put into codes, but it does not pay for things like establishing a relationship. It does not pay for sitting down and talking to the patient’s other care team. Behavioral Health Homes will pay for those things, and will allow care managers to establish a relationship with the patient and to coordinate the care. Dr. Pederson: The goal should not be following protocols, but designing protocols to help us do what we want to do for that patient. We are talking about patients who are at different places when they enter the health care system. Before we start developing the health care plan, we need protocols to help us determine where this person is. Are they at a point where we need to provide a lot of structure? Are they at a point where they can provide input into their plan? Our goal is to get them there. Ms. Lantz: There are all kinds of opportunities for technology as well, such as telemedicine in rural areas or for people who do not want to leave their homes. We also need systems that talk to each other. Primary care doctors and behavioral health providers should have access to each other’s electronic health records, with client consent. There may be not just one, but three, four, or five care plans out there, and everybody who is working with the patient may or may not know about the others. One of the greatest movements is creating those health information exchanges and figuring out a way that we can communicate between all the providers.

“We now treat the electronic health record rather than the patient.” Lee Beecher, MD, DLFAPA, FASAM

Mr. Starnes: Another significant obstacle is the coordination of care between health care professionals who see the same patient, whether this is between a primary care physician and a mental health care professional or between different kinds of mental health care professionals. How can we incentivize this coordination? Dr. Sulik: All of our professional organizations are doing major work to set standards of communication and integration between behavioral health providers and medical providers. There has traditionally been somewhat of a black hole when a primary care physician sends a patient to a behavioral health clinician. They just automatically send the patient there and never hear much back. Even in integrated systems, there still could be barriers because of misconceptions that mental health records have to be kept completely separate. HIPAA does not prevent communication and coordination of care. The system has to incentivize providers to be able to communicate and collaborate effectively between themselves and individual patients and their families. Dr. Schiff: There was some commentary in professional journals recently about patients with mental health diagnoses having access to their own records. In the physical health world, we have made a lot of progress in this area. Some mental health patients are a little more reluctant to do that, but I think that that sort of transparency is necessary. Dr. Beecher: We also need to protect privacy. At the Minnesota Psychological Association convention last year, we had a good debate about electronic health records and whether there should be a mandate for psychologists to have access to the records. One woman working in a state system said that her clients would not come to the clinic if they had an electronic record and they knew that their information was going to be put into that record. Ms. Anderson: For people receiving mental health services, there is a lot of very personal information that they do not want shared with other professionals or to appear within their medical record. I give my patients reassurances of how I document and share information with primary care or other professionals. I tell them that I’m not going to share and document every single detail

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Minnesota health care roundtable that we talk about, but some information needs to be shared to best serve them. We are not jeopardizing their privacy by doing this, but a lot of clients get really nervous about electronic health records. Everybody has different opinions or fears about people hacking into mental health records. There could be details that some of their closest family members do not know about. We need to assure clients that data is safely protected, tell them what information we share, and the purpose behind it.

have some“People move up and body who is down a continuum of in multiple mental well-being.” systems, to share Jeff Schiff, MD, MBA relevant information. Just having snippets of information is not the same as having a conversation about the client’s real concerns and fears, but it is still better than having no communication.

Judge Meyer: On this discussion about giving everyone access to their records, I believe that the tenor and detail of forensic evaluations would change if the professionals knew that the subject of the evaluation was going to see it. That is why, in my world, I would not want patients to see all the evaluations that are done, because I think I would not get as much detail, as a judge, to help me plan their services and the community bases I want them involved in. The psychologists are very open with me about information, but patients do not want to see their trauma written down anywhere. I need to see it in general information from the providers, but I do not think that the patients want to see it again.

Ms. Anderson: We already spend a significant amount of our time on documentation. We see clients for an hour, then we document later, on our time. Some of the documentation requirements, frankly, are ridiculous. Adding even more documentation is very concerning because there simply is not the time, and it is either going to result in lower actual reimbursement, because you do not have time to see as many clients, or you may get sloppy.

Dr. Beecher: I agree that there are special occasions where details of exams should not be shown to the patient, such as when a patient is in a court situation or forensic situation. However, why can’t we use the phone? One of the reasons I stayed in private practice and solo practice is because I could use the phone. I would call people, clinics, primary care. I was down the hall from a primary care clinic, and I would walk my patients down there. I would even do home visits occasionally if I felt that was necessary. That has vanished. We now treat the electronic health record rather than the patient, in my opinion. Mr. Starnes: Is there a way the electronic health record could be improved to allow better compatibility with behavioral health issues? Ms. Lantz: Yes, we are working on it, but it is not an easy task. There are competing thoughts about who wants what information, how that information can be shared, what information should be shared, and who has the authority to see different levels of detail. The electronic health record is not the only answer, but it is one way, when you

Dr. Sulik: One of the biggest mistakes is that people are still documenting in the exact same way they documented before the electronic health record, and it does not work that way. Also, the requirements for people providing therapeutic services do not exist in other areas of health care. There is no physician that needs to complete a 90-day treatment plan. Nobody in primary care has to do that. We treat behavioral health conditions and behavioral health providers as somehow different than the rest of health care, as if they need to be treated and regulated differently. This is health that we are talking about. Mr. Starnes: Substance abuse issues are a significant element of behavioral health. An enormous industry, disconnected in many ways from the rest of health care delivery, has grown up around substance abuse. How can this industry, which operates under very different levels of reporting and accountability, become better aligned with the rest of health care delivery? Dr. Schiff: The whole concept of a dual diagnosis for somebody who has a mental

health disorder and a chemical dependency

disorder seems almost ironic, because the two are so interrelated. People self-medicate their mental illness, for example. We need to figure out a much better way of integrating this care so people are not told, well, you can only get your behavioral health services once you have done CD [chemical dependency treatment], or vice versa. They need to be treated at the same time. Judge Meyer: Most of the people who come to me [in court] will start getting consistent mental health treatment through a substance use disorder clinic. I send almost all of them into a dual diagnosis MI/CD [mental illness/chemical dependency] program. It is incredible what we have available in our community in these areas, as well as for serious and persistent mental illness and in dealing with self-medication. It is amazing to watch the lights come on for people when I say to them, “You can’t use marijuana anymore,” and they ask, “What are you talking about?” I tell them that I know that drugs make them feel good, but that we are going to try legal drugs, so that I know exactly what they are getting every day, and have them check in with the doctor. That way we are going to get the right amount so you do not have to take this illegal substance anymore that is unpredictable. They are okay with that. They agree to try that. We start through the detox process

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Minnesota health care roundtable “We have to keep hammering away at reducing stigma.” Timothy P. Gibbs, MD, FAPA, DFAACAP

in a CD treatment facility and they just do a great job of having mental health providers, psychiatrists for medication, and therapists to start talking about the underlying trauma that led to the substance use in the first place, and then they integrate the physical care as well. Mr. Starnes: Are patients with substance abuse disorder viewed as “less sick” than patients with other types of behavioral health care issues, and are there issues around pulling this type of data into the medical records? Dr. Gibbs: I believe that the issue of stigma has come up for some patients. Somehow substance abuse disorder is seen as something that is behavioral, rather than as an underlying illness. Patients may want their records kept separately, because they think that substance abuse diagnoses will affect their ability to get insurance or a job later on, and the mental health professionals are complacent with that and say that these records are somehow special, they need to be kept in a special place. I think it is a bad system and a bad split that has grown up and we just need to say that this is all part of health treatment, it should all be treated equally. Ms. Lantz: I believe that most mental health folks feel as if mental health has been siloed from the system, and some believe that chemical dependency has been siloed from the mental health community even further. Mental health funding has really shifted

over the last 15 to 20 years. It has become more of a Medicaid-reimbursable service, and been added to the state Medicaid plan. Chemical health did not follow that route. There is a state-funded consolidated treatment fund that covers most chemical dependency services and has not been embedded into categorical funding, and so it creates systems where you are not sure how much and what is going to be funded every year. You are creating a system that is more driven by the Legislature and how much money can be added to that consolidated treatment fund. Medicaid is not the be-all, end-all for everything, but at least there is a susceptibility model there and at least there is a predictability around that, so I think those funding models really have hampered some progress that chemical dependency could have had. Mr. Starnes: Let us talk about the negative social perception or stigma that is associated with mental illness. What impact does this have on individuals with mental illness and what can we do to change it? Ms. Anderson: A large part of that starts with the legislation and with our government. The Department of Human Services is given a budget by the Legislature and the governor. When have they heard your voice? It is amazing that a lot of times we get caught up in our professional world, and we do not follow through with macro-level advocacy. It is sad, because we could have quite an impact if they did hear our voice. If we shaped policies and law based on how to best treat people and what we want for our community, versus waiting for something terrible to happen and then reacting to it, it would be a great start. Dr. Pederson: Words are always important. We think about mental illness being

in this bucket and physical illness being in that bucket. We have to start putting them together into that holistic piece. Also, we need to quit thinking about health care as a product, and thinking that we always have to do something. It is much easier to do something about blood pressure, for example. It’s a little harder for me to get my head around what I am doing if you are suffering from anxiety. I can give you a pill, but that might work, or it might not. We have to change our thinking about how these all come together. Ms. Lantz: Some of the new approaches are putting behavioral health into a public health model. It could be funding more education programs, embedding language about emotional health in schools, and using a public health approach to educate a community. We need to make it okay for people to talk about feeling sad, having depression, being anxious, all those things. Dr. Schiff: Where you cross from being well to being ill is really a vague thing. There is no magic number at which my risk is incremental as I go further up the line. The other thing about stigma is that we are trying to determine where mental health issues can be addressed. If we could address a lot of them in primary care, there would be less suffering, because people would have access where they would not necessarily have it otherwise, because of culture or gender or generation. Not everyone wants to run off and talk to a psychiatrist or a therapist, so we need to find the right balance and create improved access across the board. Mr. Starnes: What are the best ways to measure outcomes in behavioral health? Dr. Gibbs: The ideal would be to interview the patient four years or six years after treatment and ask how things turned out and have the patient say, “Well, I still have this problem,” or “No, that problem is completely gone and everything is good in my life.” We do not have the time or the tools to do that now, but we can do other kinds of measurements that will show us how patients are doing in the short term. Sometimes those tools show us things that the patient cannot or will not tell us in our face-to-face interviews. At our clinic we are developing our own outcomes measure using a 50-question, patient-administered questionnaire on an iPad or other electronic device. It gives a color-coded visual result

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Minnesota health care roundtable that you can view immediately in the medical record, and we share it with the patient. We also share it with the other providers to enhance coordination of care. Dr. Sulik: You need standardizations in what is measured and how it is measured. More than anything, we need a standard to measure how patients envision their ideal state and how treatment is improving their pursuit and achievement of that ideal state. We also need to be more efficient in providing behavioral health care and in making it less costly than it is today. If we do that well, we can also impact that individual’s total cost of medical care. Outcome measurements must be value-added, and they must be clinically relevant. I should not be measuring anything if I am not engaging the patient in that measurement, and I should not be reporting anything about an outcome if the patient has not already been engaged in that measurement. Dr. Pederson: We have outcome measures for accountability and outcome measures for quality, and we try to use them in the same way. We have a lot of measures created for accountability, but they really are not useful when we look at quality. We need to examine those measures to determine whether that provider/patient team could actually make an improvement in this measure, if they work together, if they use best practices. Mr. Starnes: Are you talking about the difference between measures of process versus measures of function? Dr. Pederson: No, not necessarily. Measures of process help us determine whether we are following the process in the way that we intend to follow it. Sometimes we can improve outcomes without ever changing the process, just because we are paying closer attention. The outcomes, then, are the actual output of that process that we can review over time. If it is not where we want it to be, we need to go back and look at how we changed that process of care. Those measures can be really helpful to the providers, as opposed to chasing down all these various measures that they are not necessarily linked to.

that we finally voted that sexual orientation was no longer a pathology. Can you imagine arranging process and outcome measures based on homosexuality and treatment? Well, there were people who were doing things like that even though we did not have it all systematized and did not have computers going at the time. We have got to be very careful about defining what a mental disorder or a mental illness is, and about what these things are called. Mr. Starnes: What issues do we need to address to better integrate families into the care team for individuals with behavioral health issues? Dr. Schiff: We need to ensure that we are using tax dollars wisely, but without prescribing too much detail to providers. And we must engage families. We have spent some time talking about privacy issues, but people do not get better in isolation or in isolation with their mental health providers. They get better in their communities and with their families. Behavioral Health Homes can support that reintegration into families and communities. Dr. Sulik: That is a great example of something that is not treatment but that supports the healing process. We have to change our way of thinking and our way of reimbursing to support individuals and their healing processes. Community and family support is critical, but there is no current mechanism of reimbursement. The idea that a Behavioral Health Home can reimburse for patient and family support is an innovation.

on building a supportive network around somebody. Different studies have shown that if people have two authentic relationships that are supportive of their well-being, then their odds of improving their life are far more significant. Having this supportive environment of people is the correct focus. There are a lot of clients who do not have family or who have families that do not want to be involved. Dr. Beecher: Dr. Marc Galanter [New York University School of Medicine] has a book on network therapy in which he goes through the steps of sitting with patients and identifying their significant others and supportive people. He asks patients who their friends are, who they can trust, stuff like that. Then he sets up contracts with the patient so that he can get hold of somebody to help if neccesary, or somebody could call him if the patient slips. Judge Meyer: For many of the people I talk with and work with, their families are the source of their trauma. It may not be the cause of their mental illness, but it is certainly an underlying trauma that has kept them from dealing with it appropriately. Their families, frankly, are clueless about mental illness and symptoms. They either say, “Oh you might be doing fine right now, but I know you are going to slip later,”

Ms. Anderson: We make a lot of assumptions when we use the word “families” with regard to our clients. A lot of times, those assumptions are not going to be helpful. Instead, I would focus

“Behavioral health and medical conditions are linked together.” J ane C. Pederson, MD, MS

Dr. Beecher: I want to talk about diagnoses in this context. Until 1973, homosexuality was a disease, according to the American Psychiatric Association. I was on the assembly of district branches at the time

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Minnesota health care roundtable or they say, “There is nothing wrong with you, you have a learning disability, that is all. We do not have mental illness in this family.” There’s so much denial and it really counteracts what we are trying to do. So if there is a supportive family, awesome, right, they really care. But in the case of other family members, we just cannot possibly pull them along far enough to be helpful to the recovery process.

their understanding that we can create an ability within them to undergo that change. We have really failed to invest our time and efforts to make certain that our patients fully understand what we are thinking and what we believe may be impacting them, and helping to make sure, before they leave us, that they have achieved an improvement in their thinking and understanding about themselves.

Mr. Starnes: Ultimately, success with therapy comes down to choices that need to be made by the individual patient. How can this individual be best educated and engaged and empowered to make the choices that will be most beneficial?

Ms. Lantz: Even after they understand what they need to do, figuring out where to go for that particular help is very difficult. Even for people who have been in the field for a long time, understanding the mental health system and the chemical dependency system, how to access it, what kind of funding is needed, what criteria you have to meet— it really takes some kind of navigator within the system to understand it all.

Dr. Sulik: In all of health care, we have probably done an okay job of telling people what might be wrong and what they need to do to fix it. We do not do a good job at all, in behavioral health as a whole, but also more broadly in health care, in really developing that individual’s insight into what is truly going on and why. We don’t explain the full impact on them, how they can prepare to undergo the change they need to make, and how to find the right type of structure and support to undergo that change. It is really through education and improving

Ms. Anderson: If I ever told somebody that I knew what was best for them, I would lose them. The better path to success is to start where the client is at, offer them choices, and have them make the decision. Dr. Pederson: We have a son who is a French horn player and when he was going through his auditions we realized he had pretty significant performance anxiety. Me being the physician, I told him, “I have diagnosed your performance anxiety, and you need to see a mental health professional.” He did that, but said it did not help, and I thought, this system just does not work at all. Really, what he needed to do most was to talk to his friends. They said, “Hey, we all have performance anxiety.”

“We need to assure clients that data is safely protected.”  arah Anderson, MSW, S LICSW

The answer is to figure out how you can get people the tools, the techniques, to deal with some of these things. I was coming at it from the wrong perspective. I was coming at it by saying, “I diagnosed this, I am giving you the treatment, why aren’t you taking this from me?” We need to change our perspectives. Dr. Schiff: This is an interesting point: when is it a diagnosis, and when are you somewhere else on the continuum? I have a similar story with my son, who was sad at one point. I chose not to take him in because I knew he would have a diagnosis. I thought, okay, we are going to deal with this, and we dealt with him in a number of different ways, and actually he did go in for a while and then he left. He said, “All I need is my dogs, my friends, and my music.” He has recovered with support. One of the challenges is that we are all in this business. Diagnosis does not mean something bad for us, because we are past the stigma, but sometimes we have to figure out what are we going to do for mental well-being that is not diagnosis-related. Dr. Beecher: It has got to be a mutual thing between patients and providers. I might ask, “Why did you come today and what would you like to take away?” If I am a psychiatrist and I am supposed to do the meds or whatever, I will try to tell you what I think my role is in the system and then I will say, “Well, you know, I am supposed to help with the meds today, what do you think about that and where are we at?” And then I can say, “I am frustrated, too, with this crazy quilt system. Let’s see if I can help you and we get through this thing together.” Dr. Gibbs: I have a group of patients who have complete insight into their problem and still cannot change. So education is not the only thing. But if we use these outcome tools to share with the patient, helping the patient to see if they are getting better or not, that could be very helpful for patients to improve over time. Ms. Lantz: We have not spoken much about how we promote wellness—not just diagnosing and managing disease, but actually promoting wellness. Part of the conversation could be about what makes you happy, what motivates you, what made you get out of the car and come into the office today. We could promote talking about whether

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Minnesota Physician January 2016


Minnesota health care roundtable it feels good to walk for 10 minutes when you are really mad at your dad or whatever. Those are the things that are lost in the system right now. Dr. Schiff: I’d like to ask my mental health colleagues about the relationship of stigma to the ability to recover. I believe that some people acquire that stigma regarding mental illness, and they believe that once you have it, you have it forever. Dr. Sulik: I have had many opportunities to watch patients tell stories of recovery. That’s never done often enough. People will stand up and celebrate that they are a breast cancer survivor, but you do not see enough people having the forums and the platforms and the opportunities to openly share their stories of recovering from trauma, depression, or living with bipolar disorder and being able to make it day to day and still hold a job or live independently. Dr. Beecher: I think we have to be sensitive to that personal story. Some patients will be traumatized by something and others will not be. It is not a clear thing as to what causes what. We have to start from the standpoint of how this factor has influenced this individual. Dr. Pederson: We tend to say, “They have depression,” as if they are just going to have depression forever and that is going to be how they are defined. Patients hear that as well. But if you have an infection, we say, “We are going to treat your infection, it will get better.” I do not know if they necessarily hear, from those of us in primary care, that you can recover from depression, that it is not necessarily something that will define you for the rest of your life. Judge Meyer: I have people who come back to court over and over again, and everyone around them has similar diagnoses. They see other people with that label who have succeeded and who may want to talk about what they are doing correctly. I understand that group work does not work very well in general for mental illness, but in some situations it really can, especially when you can be around people and talk openly about it. Talking about stigma, how about getting somebody to volunteer to come into a place called “Mental Health Court”? They ask me, “What is wrong with you, lady?” So I make them watch it and we do not talk so much about what it is called, but they have to watch before they say yes or no. Almost

everybody says yes because “The system has they get to see other people to incentivize succeed. I do not know providers.“ how that plays out in real life or in a psychiatrist’s L. Read Sulik, MD office, but it has been really powerful for people to be able to brag about their successes, and, when they graduate the program, to talk about some of their life history and how far they have come in recovery. They are going to have that diagnosis and label forever, but they really get to see how their circumstances could change. Ms. Anderson: I agree with what people are saying, but I would like to point out personality disorder. If you are a client who does not have a lot of experience within mental health and you are told that you have a personality disorder, that sends a far different message than, “You have depression,” or “You have bipolar disorder.” “Personality disorder” insinuates something is wrong with them and with who they are. So I do think there are a lot of terms that actually contribute to the stigma. Mr. Starnes: What have we seen that has worked in terms of coordinated care teams and behavioral health? Judge Meyer: We have a psychiatrist available who can do a diagnosis, because we need people who can also write emergency prescriptions. We have a therapist who is excellent with people who have never been to therapy before. They may be scared of it, they have probably missed a bunch of appointments, but she is right there in court. We have a nurse who dispenses the medication for them, keeping it safe in her office. She can do the eyeball check and see if they look as if they took their medication yesterday, the day we took off, and watch them take their medication today. We have social workers who can hook up our individuals with the community providers we work with. We also address housing, education, employment, and doctor appointments. We teach them that you do not have to use the

emergency room for everything that ails you, and that is a cost savings for everyone. We surround them with a team. Now of course, you all know that I have a big hammer over their head, but all we are looking for is to get them set up in the community and into recovery mode. So that is what works for us. My hammer. Dr. Gibbs: Even for experienced clinicians, studies show over and over again that having some kind of objective measure works better than just clinical judgment. Outcomes measurements or other kinds of measurements definitely help people. Ms. Lantz: A team is really about who has the relationship and understanding of the consumer. We have teams in our agency that include occupational therapists, pharmacists, long-term care workers, peer specialists, and health coaches. But it still comes down to who holds the relationship with the consumer. The information should be funneled through that go-to person. You could have a team that revolves around one person, regardless of what facility they are in, whether they are in their home, whether they are in their school, who can intervene at times when needed. Dr. Beecher: Developing the holding relationship is critical. The patient must trust you. The patient will appreciate the fact

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Minnesota health care roundtable that you are a person trying to help. You are bringing the patient in and I think this holding relationship idea is really a very wonderful concept. Dr. Sulik: I had an opportunity to visit the Southcentral Foundation of the Alaska Native Medical Center. Their Nuka System of Care integrates primary health care, behavioral health care, and traditional healing practices for Alaskan natives. They do not have “patients,” they have “customer owners,” and their entire philosophy centers on serving those customer owners. Their health system is owned by the people they serve. That got me thinking about the silliness of how we continue to separate services. Imagine going into a restaurant and ordering your food and then having to find your own beverages at some other restaurant that serves only beverages, with no coordination between the two. Separating mental health care and primary care is just as silly. We need to integrate these two

separate worlds, because they are all part of health and well-being. Mr. Starnes: Final question. What is the most important thing that needs to be done to better integrate behavioral health access with the rest of health care delivery? Dr. Pederson: It is truly just communication. We have different modes of communication. We talked earlier about the electronic health records and how we need to improve them. Minnesota is creating an ehealth road map to better utilize our electronic services. I think we have to also bring in some of the things that were talked about on the panel today. We cannot totally rely on electronic communication for a lot of these complex issues. We have to figure out how to integrate and how to allow providers to actually talk to each other. Dr. Gibbs: We have to keep hammering away at reducing stigma and thinking about mental health as part of health. The more we can integrate the whole system into one system that takes care of people’s overall health, the better off we are. Ms. Anderson: The client-centered vote. The most important variable is to give clients options, communicate with them, and make them the decision-makers. Dr. Schiff: The one thing we have not talked about as much is social risk factors. We need to think about access, not just in terms of integrating

“They are going to have that diagnosis and label forever.” Judge Kerry W. Meyer

behavioral health and physical health, but in terms of identifying and thinking about the entire new year in which people are living, and what that new year and those stresses might do to their physical and mental health. Ms. Lantz: I would love to see us refocus our health care system on talking about quality of life and wellness. How do we really just start talking about wellness, and what is wellness to you? What does that mean? How do we talk about quality of life? So then you do not get into this paradigm split about what is mental health, what is chemical health, and what is physical health. It is really about your highest quality of life that you want to attain, and how this system could help you achieve it. Dr. Sulik: That requires change in our current thinking and in our current way of being, and I think what is most needed is intentional change management across that process of change. We have to prepare ourselves for this change and structure ourselves to undergo this change successfully so that it is sustained. Judge Meyer: You are going to be able to tell that I am the outsider. I need services available to send people to. It is hard enough to figure out where to go, but when you call and they say it will be three months before they have an opening, it’s even harder. Right now it’s a three to four month wait for every psychiatrist in the metro area. We have a work-force crisis and so I need more trained professionals. If people can get services, then we can integrate the rest of it. But if services are not available, it does no good for me to order someone to go to a psychiatrist who does not exist. Dr. Beecher: A corollary question would be, who owns health? My answer would be that it is the client/patient/person who owns it. So then why don’t we empower that client/person to shape a care delivery system that would serve his or her needs? There may be questions about poverty and welfare and medical assistance, but I think we have not looked enough at giving people choices and power to actually put together these teams that we are talking about. The Alaska Native Medical Center talks about the customer owner. I think the customer owner is the patient.

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Minnesota Physician January 2016


Health Care Policy

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short 12-week session, a large budget surplus, and an election in the fall could lead to a potentially wild legislative session in 2016. The Legislature returns on Mar. 8 this year and will likely begin at a furious pace to try and get bills heard and through committee by early April. Generally, the second year of the legislative biennium has been devoted to policy bills and bonding given that the budget was completed in the first year. Recent history doesn’t seem to allow much escape from the budget however, with either an additional surplus or additional deficit to deal with before the election. Fortunately the Legislature will be dealing with a surplus, but even that can be quite challenging as 2015 demonstrated. The November economic forecast projected a $1.8 billion budget surplus for the upcoming year, which—after using $600 million to replenish the state’s budget reserves—leaves a projected $1.2 billion on the table. This number could be revised up or down in February when the final economic forecast for the budget year comes out, but expect a number of politically-driven spending ideas to emerge with the election looming in the fall as the Legislature moves through a fast-paced session. Many expect the budget to focus on a tax and transportation bill—two items that were left off the table at the end of last year’s special session. The prospects of a significant investment in transportation were made stronger following the release of the November forecast when the Governor publicly took an increase in the gas tax off the table. The House Republicans are likely to put their priorities squarely behind significant tax relief, while Senate Democrats have talked about increasing local government aid and transportation funding for roads, bridges, and transit. Outside of transportation and taxes, it is unclear how much investment will be made in other areas of the budget, including Health and Human Services. The first hints at next year’s budget will come when

The 2016 Minnesota legislative session An election year preview By Nate Mussell, JD the Governor releases his supplemental budget recommendations in early 2016. An election year The budget surplus and subsequent posturing over taxes and transportation will be a preview of what promises to be an interesting year with every member of the House and Senate up for re-election in the fall of 2016. Recently, election years have brought many surprises before, during, and following the legislative sessions. With so many members up for re-election, much of the interest over the coming months will be on which members will choose to forgo re-election in November. To date, seven legislators have already said they won’t seek re-election including longtime Health and Human Services Committee chair Senator Kathy Sheran, and this comes on top of the four special elections that will take place before the session begins in March. If recent history is any indicator, the number of retirements is likely to double by early summer. The Department of Human Services During the coming session and over the next year it will be interesting to watch Gov. Dayton’s former general counsel, Emily Johnson Piper, transition into her new role as commissioner of the Department of Human Services (DHS). Previous DHS commissioner Lucinda Jesson had been with DHS since the Governor’s first election in 2012, but many were not surprised that Jesson moved over to the Judicial Branch when Dayton appointed her to the Minnesota Court of Appeals in November. Overseeing and managing one of the state’s largest agencies is no small task. In the past year, Jesson and DHS came under scrutiny

on issues including the sex offender program, the state’s security hospitals, and the handling of a statewide competitive bid for public health programs. Johnson Piper will certainly have her hands full over the coming months. Since Dayton appointed Johnson Piper in early December, legislators— most notably House Minority Leader Paul Thissen—have come forward with potential plans to reform DHS including plans to break up the large agency into a series of smaller agencies. It will be intriguing to see if any of these reform ideas gain momentum during an otherwise quiet session for Health and Human Services.

The provider tax and MinnesotaCare Looking back at the budget negotiations from last session, one of the major points of discussion centered on the state’s MinnesotaCare program—funded in large part by the provider tax. While there was ultimately a stalemate over the future of MinnesotaCare, it certainly highlighted the stark differences between the Senate and House majorities about where to go with MinnesotaCare and the provider tax in the near future. Looking ahead, the provider tax is still scheduled to sunset at the end of 2019—taking almost half a billion dollars off the table in the Health Care Access Fund. The Legislature formed a Health Care Financing Task Force this past year to try to address this issue and others facing the state in the coming years. Although the task force has been meeting throughout the fall months, very few people are holding The 2016 Minnesota legislative session to page 39

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Neurosurgery

T

Oblique Lateral Lumbar Interbody Fusion

he likelihood of Minnesota Vikings center John Sullivan returning to the field this season dropped to close to zero recently following a second surgery on his lower back. Sullivan initially was treated via a lumbar discectomy in September of this year to repair a herniated disc. The Vikings were hoping he would be healed by midseason, but a recent weightlifting injury will keep him on injured reserve. This is not just a problem football players face. The

A new minimally invasive procedure By Hamid R. Abbasi, MD, PhD, FACS, FAANS probability that a person will suffer from lower back pain is high: approximately 80 percent

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Minnesota Physician January 2016

of all people suffer from this affliction at some point during their lifetime. Lower back pain is one of the most expensive and prevalent health conditions in the Western world, one of the most common causes of health care utilization, one of the leading causes of activity-limitation for people under 45, and the third most common cause of surgical procedures in the U.S. In numerous cases, low back pain is associated with spondylosis, the general degeneration of the spine associated with natural wear and tear that occurs in the joints, discs, and bones of the spine as people age. The vast majority of low back pain is mechanical in nature. Some examples of the mechanical causes of low back pain include intervertebral disc degeneration, herniated or ruptured discs, sciatica, skeletal irregularities such as scoliosis, spondylolisthesis, and traumatic injury. In recent years, the rate of disability due to lower back pain has increased dramatically and consequently health care costs have skyrocketed; particularly in patients with the above-mentioned disc disorders. In light of these issues, improvements in surgical treatments of disk disorders could benefit hundreds of thousands of patients annually and contribute to lower health care costs. The evolution of interbody fusion for lower back pain Following failure of conservative pain management, such as steroid injections, surgical procedures to alleviate back pain are often performed to fuse spinal discs together, thereby reestablishing correct disc height

and stopping disc movement. If a condition requires emergency care, conservative management may be passed up for surgical intervention. The standard treatment for lower back pain, Posterior Lumbar Interbody Fusion (PLIF), often leads to surgical morbidity as it is an invasive procedure that requires the stripping of muscles and soft tissue. Open Transforaminal Lumbar Interbody Fusion (TLIF) is a standard alternative to PLIF because it has been shown to cause less surgical morbidity leading to a quicker recovery. However, during the TLIF procedure, muscles are still detached and denervated and this may cause further injury. Minimally invasive (MI) TLIF was developed to address these issues. Relative to open TLIF, MI TLIF decreases blood loss and complication rates; but, surgery times are similar or may be longer. However, post-operative recovery is reduced in MI TLIF and long-term outcomes are generally as good, but not better, than for open TLIF. Oblique Lateral Lumbar Interbody Fusion (OLLIF) is a new minimally invasive surgical procedure developed at our practice that is performed to achieve spinal fusion of the lumbar vertebrae. Unlike other procedures, it can often be performed as an outpatient surgery.

Lower back pain is one of the most expensive and prevalent health conditions in the Western world. OLLIF is less invasive OLLIF is the first minimally invasive fusion procedure that is faster than open surgery. It is a state-of-the-art technique that is indicated for severe degenerative disk disease, listhesis, discogenic stenosis, and disk reherniation. With some experience, OLLIF can also correct for scoliosis and other deformities. Bony obstruction,


significant spinal canal stenosis, large facet hypertrophy, grade II spondylolisthesis, and other gross deformities are relative contraindications for this procedure. OLLIF has a more straightforward approach than any of the previous techniques described in this article and allows for fusion of the lumbar spine through a single 10–15 mm incision. Since the procedure is performed via a small 15 mm incision on the patient’s side (see Figure 1), the surgeon does not need to move, remove, or alter major muscles, healthy bone structures, or nerve bundles. As such, the use of this procedure overcomes the complications seen with open surgeries. Unlike most other spinal fusion approaches, the OLLIF procedure can be used to effectively treat all lumbar levels of the spine. It further eliminates the need for direct visual reference during the surgery with the help of electrophysiological monitoring. OLLIF’s major improvement is to perform spinal fusion via

Figure 1. The OLLIF incision point

Figure 2. K  ambin’s triangle and surrounding anatomy

Incision Point Disk Height marked from midline Disk Height determined in lateral view

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ing

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oo

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Superior Articular Process

Superior Endplate of Inferior Vertebral Body Source: Dr. Hamid Abbasi

Source: Dr. Hamid Abbasi

Kambin’s triangle (see Figure 2). Kambin’s triangle is composed of the exiting nerve (hypotenuse), the superior border of the caudal vertebra (base), and the traversing nerve root or the superior articular process (height). Because the triangle is an electrophysiologically silent window, OLLIF requires no direct visualization. The surgical approach is guided solely through electrophysiological monitoring and biplanar fluoroscopy. Following removal of

Positive outcomes Our practice retrospectively assessed the perioperative outcome data from 69 consecutive OLLIF patients and compared them to a control group of 55 consecutive open TLIF patients. All of the surgeries were performed by the same surgeon. The data show that, compared to open TLIF, OLLIF is a straightforward procedure that significantly reduced surgery time, patient blood loss, and hospital stay. For a single level

the disk material, a biocompatible polymer implant, along with bone graft material, is positioned into the empty space left by the removed disc. This implant material maintains proper spacing of the vertebrae while the fusion takes place. Typically, a posterior fixation with pedicle or facet screws also accompanies this procedure. Once the adjacent vertebrae are joined together by a solid “bridge” of new bone mass, the fusion process is complete.

OLLIF to page 38

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Professional Update: Pediatrics

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topic dermatitis (AD) is the most common inflammatory skin condition in the pediatric population with between 10 to 20 percent of children affected. About 30 percent of these cases can persist into adulthood. The social and economic burden of this disease is substantial, costing the U.S. health care system over $1 billion annually. The quality-of-life impact on children and their families has been found to equal that of asthma and type I diabetes. Thus, there is an urgent need to provide better care and counseling for this patient population. Though the etiology of AD is multifactorial and involves a complex interplay between the skin, the environment, and subsequent immune dysregulation, the past decade has brought about many advances in our understanding of this condition and better care for patients. In the following sections we will discuss the importance of the skin barrier and the role that infection plays in AD. We will present a summary

Pediatric atopic dermatitis Exciting treatment improvements By Sheilagh Maguiness, MD; Ingrid Polcari, MD; and Kristen Hook, MD

of the recently published and exhaustive guidelines for care in atopic dermatitis. Finally, we will review the role for systemic therapies and discuss future areas of innovation. Itâ&#x20AC;&#x2122;s all about the barrier When approaching a child with AD, start by assessing the integrity of the skin barrier. In children with very dry skin, it is likely that they have a genetic predisposition to developing AD. Alan Irvine, MD, and colleagues first published the link between filaggrin mutations, atopic dermatitis, and allergic diseases in 2007. Since then,

our understanding of the role of skin barrier function in AD has been transformed. We now know that genetic variants in stratum corneum proteins such as filaggrin, predispose patients to dry skin and increased transepidermal water loss (TEWL), setting them up for the development of AD. When the skin barrier is xerotic and compromised, there are many downstream consequences that give rise to the clinical signs and symptoms that predominate in this disease, namely; dry skin, itch, inflammation, and infection/col-

Reducing infection Almost all children and infants with AD are colonized with staphylococcus aureus, so the role of infection in AD cannot be overemphasized. Over the past decade, there has been strong data published in support of the role of dilute bleach baths in the management of infection and colonization in the setting of AD. Jennifer Huang, MD, and colleagues first demonstrated their efficacy in reducing infection and disease severity in children with AD in 2009. However the molecular mechanism regarding how sodium hypochlorite works has recently been studied in mouse models: dilute bleach baths are not only antimicrobial, but also anti-inflammatory (and perhaps even anti-aging). We recommend regular use of dilute bleach baths for infants and children with moderate to severe AD, though even those with mild disease may benefit. (See Sidebar 2 for details on dilute hypochlorite baths.)

Sidebar 1. Gentle skin care for newborns and infants Bathing: A tub/soaking bath daily is recommended, but must be followed by application of bland emollient.

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Cleanser: Gentle non-soap cleansers (synthetic detergents) are best. Limit use to 2â&#x20AC;&#x201C;3 times weekly if possible. Examples include Cetaphil cleanser, unscented Dove, Vanicream cleanser, and baby Aquaphor wash. Emollient: 1â&#x20AC;&#x201C;2x daily application of a bland emollient, either ointment (Vaseline, Aquaphor) or cream (Cetaphil, CeraVe, Eucerin, Vanicream, etc.) is recommended, and is most useful when applied in the first few minutes after bathing. Avoid lotions, as these often contain fragrances and alcohols which may be irritating to sensitive skin.

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Minnesota Physician January 2016

onization. Addressing skin barrier integrity is one of the most helpful things primary care providers and pediatricians can do, and may also have a preventive effect. Two recent randomized studies have demonstrated that early emollient application at least once daily in infants at risk for developing eczema reduced the signs of atopic dermatitis by 30 to 50 percent at age 6 months. Larger trials are currently in progress to validate these findings, however, it is simple, safe, and cost effective to recommend application of emollients and optimize gentle skin care practices in newborns and infants. (See Sidebar 1 on gentle skin care recommendations for newborns and infants.)

Intensive topical therapies for infantile AD Our pediatric dermatology team at the University of Minnesota routinely treats patients with severe atopic dermatitis. Management of patients with AD can often comprise 30 to 40 percent of our clinical practice. Many infants with severe atopic dermatitis are followed in our practice. Infants usually present around three months of age with diffuse xerosis and eczematous plaques throughout the body, in particular on the face and extensor surfaces with associated seborrheic dermatitis (cradle cap) of the scalp. In these patients, intensive topical therapies can lead to excellent improvement.


At the first visit, if there is crusting or overt signs of infection, bacterial cultures are obtained and typically grow out moderate or heavy staph aureus indicating colonization/infection. Infants improve rapidly with appropriate bathing and gentle skin care techniques to address all the clinical features of the disease: dry skin, itch, inflammation, and infection. Our approach to severe infantile AD consists of the following regimen: Daily dilute bleach baths, mild to mid-strength topical steroids on affected areas, petrolatum-based emollients twice daily head to toe, and damp pajama wraps are administered for a duration of two weeks. This intensive course requires an investment of time and education for the families on the initial visit, and handouts are very helpful. With good adherence to topical therapies, infants improve dramatically over the course of two weeks with marked improvement in all symptoms (infection, itch, dryness, and actively inflamed areas). Following improvement at the two week follow up visit, therapies are tapered.

eczematous skin lesions (often in age-specific distribution), and a chronic and relapsing history. On occasion, skin biopsy specimens or other tests may be helpful to distinguish it from other disorders. There are no reliable biomarkers to confirm the diagnosis or assess disease severity, so IgE levels should not be obtained for this purpose.

enough. Proactive, intermittent use of topical corticosteroids as maintenance therapy (for example one to two times per week) on areas that commonly flare has been shown to be effective and is recommended. Wet wrap-therapy with or without a topical corticosteroid can be recommended for patients with moderate to severe AD.

Addressing skin barrier integrity is one of the most helpful things. Best evidence practice The highest level of evidence from the recent guidelines mentioned earlier supported the following interventions: • The use of regular emollients at least once daily • The use of topical corticosteroids and topical calcineurin inhibitors as anti-inflammatory agents • The use of oral antibiotics in overtly infected eczema

Topical calcineurin inhibitors (TCI) including tacrolimus and pimecrolimus are recommended and effective for treatment of both adults and children with AD. TCI are particularly useful when a steroid-sparing agent is desired, for example when there is a need for treatment of sensitive areas such as the face, anogenital skin or skin folds. For patients with AD less than 2 years of age with mild to severe

disease, off-label use of 0.03 percent tacrolimus or 1 percent pimecrolimus ointment can be recommended. Adjunctive and complementary interventions While there are many alternative treatments available for AD, many of these treatments either have insufficient or inconsistent evidence to support their use. Therefore, the following interventions are not recommended at this time: probiotics/prebiotics, fish oils, evening primrose oil, borage oil, multivitamin supplements, zinc, vitamin D, vitamin E, and vitamins B12 and B6; routine use of house dust mite covers; the use of specific laundering techniques, such as double rinsing, detergents, or other laundry products (lack of clinical studies); general use of sublingual immunotherapy and injection immunotherapy; Chinese herbal therapy and massage therapy; aromatherapy, naturopathy, hypnotherapy, Pediatric atopic dermatitis to page 36

There is no evidence for the following interventions:

Sidebar 2. Bleach bath “how to” Dilute hypochlorite baths are similar in concentration to a chlorinated swimming pool. The recommended dilution is 2 tsp. of plain bleach per gallon of water.

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For a full bathtub: ½ cup plain bleach (~6% sodium hypochlorite) or ¼ cup concentrated bleach (~8 % sodium hypochlorite) For an infant tub: 1–2 tablespoons Guidelines for care In 2014, a large group of AD experts published a four-part series of evidence-based guidelines that address important clinical questions that arise in the management and care of AD. These were published in the Journal of the American Academy of Dermatology by leading pediatric dermatologists Lawrence Eichenfield, MD; Robert Sidbury, MD; and many expert co-authors. Here is a brief summary of several of these recommendations. Diagnosing AD The diagnosis should be made clinically, using criteria such as the presence of itch, typical

• The use of non-sedating antihistamines for pruritus • Food elimination based solely on RAST testing without corresponding clinical symptoms Prescription medications Topical corticosteroids are recommended in patients who have failed to respond to good skin care and regular use of emollients alone. Consider several factors to choose the appropriate topical steroid, including patient age, areas of the body affected, patient preference, and cost. Twice-daily application of corticosteroids is generally recommended for the treatment of AD, but in some cases once-daily application may be

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Pediatric atopic dermatitis from page 35

acupressure, or autologous blood injections. Systemic therapies and future directions Topical therapies are the first line and considered the optimal treatment approach for AD. As discussed earlier, many exciting advances have demonstrated the importance of emollients in barrier repair, which, if initiated early in infancy, may have a preventive effect on the development of AD. The recent guidelines support the safety and efficacy of topical corticosteroids and calcineurin inhibitors as anti-inflammatory agents, and most patients (even those with moderate and severe disease) can be managed with topical therapies. However, occasionally, systemic therapy is indicated. Adequate control of disease is necessary to alleviate chronic itch and sleep deprivation, which have been linked to mental health disorders (ADHD, OCD, depression)

and have significant impact on quality of life. Children with atopic dermatitis refractory to conventional therapy or who lack adequate social support to perform topical treatment may require systemic immunosuppression. Oral prednisolone is not generally utilized in the management of AD, as rebound flares and side effects limit its use and may lead to worsening of disease severity over time.

There is an urgent need to provide better care and counseling for this patient population. Systemic immunosuppressive agents for AD include cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil. The Pediatric Dermatology Research Alliance (PeDRA), a national multicenter work group, is currently creating guidelines for systemic therapy of AD. Current evidence supports use of all of these

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agents in refractory cases, though randomized controlled trials are lacking. Dupilumab is the newest agent reported in the treatment of patients with AD, and shows great promise. Dupilumab is a fully human monoclonal antibody that blocks IL-4 and IL-13 signaling. Atopic dermatitis is a Th2 cell-driven inflammatory disease, thus IL-4 and IL-13 are thought to be key drivers of in-

Minnesota Physician January 2016

flammation in AD. Phase I and II RCTs in adults have shown considerable benefit in pruritus and inflammation, with excellent improvement in disease severity. The results of the initial trial by Lisa Beck, MD, and colleagues were published in the New England Journal of Medicine and a larger phase II trial was recently reported in

the Lancet, supporting the initial positive results. Dupilumab represents the first biologic agent with demonstrated safety and efficacy in this condition, though studies in children are still needed. Atopic dermatitis is a chronic skin disease and management can be challenging and time consuming. However, the last few years have shown tremendous progress in our understanding of the pathogenesis of the disease, leading to improvements in treatment and exciting new ways to help patients. Sheilagh Maguiness, MD; Ingrid Polcari, MD; and Kristen Hook, MD, are assistant professors in

the Department of Dermatology at the University of Minnesota Medical School. They sub-specialize in pediatric dermatology and are the only board-certified pediatric dermatologists in and around the Twin Cities. They practice at the University of Minnesota Health Pediatric Dermatology Clinic at the Masonic Children’s Hospital.


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Neurology OB/GYN Orthopedic Surgery Pain Medicine Pediatrics Psychiatry Sports Medicine Urology Vascular Surgery

To learn more, visit fairview.org/physicians, call 800-842-6469 or email recruit1@ fairview.org fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer

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Sioux Falls VA Health Care System

MAYO CLINIC CLINIC HEALTH HEALTH SYSTEM SYSTEM is is aa family family of of clinics, clinics, MAYO MAYO CLINIC HEALTH SYSTEM is a family of clinics, hospitals, and other health care facilities serving more than than 60 60 hospitals, and other health care facilities serving more MAYO CLINIC HEALTH SYSTEM is a Wisconsin. family of clinics, hospitals, andinother health care facilities serving more than 60 communities Minnesota, Iowa, and Mayo Clinic communities Minnesota, Iowa, and Wisconsin. Mayo Clinic hospitals, andin health care facilities serving more than 60 communities inother Minnesota, Iowa, and Wisconsin. Mayo Clinic Health System System links the expertise expertise of Mayo Mayo Clinic in practice, Health links the of Clinic in practice, communities in Minnesota, Iowa, and Wisconsin. Mayo Clinic Health System links the expertise of Mayo Clinicsystems in practice, education and research research with the the health-delivery health-delivery of our our education and with Health System the expertise of Mayo Clinic insystems practice,of education and links research with the health-delivery systems of our local communities. local communities. education and research with the health-delivery systems of our local communities. local communities. The Northwest Wisconsin Region Region opportunities opportunities include: include: The Northwest Wisconsin The Northwest Wisconsin Region opportunities include: Dermatology Occupational Medicine Dermatology Occupational Medicine include: The Northwest Wisconsin Region opportunities Dermatology Medicine Emergency Medicine Medicine Occupational Ophthalmology (General & & Glaucoma) Glaucoma) Emergency Ophthalmology (General Dermatology Medicine Emergency Medicine Occupational Ophthalmology (General & Glaucoma) Family Medicine Orthopedics Family Medicine Orthopedics (General & Glaucoma) Emergency Medicine Ophthalmology Family Medicine Orthopedics General Surgery Psychiatry (Adult (Adult & & Child) Child) General Surgery Psychiatry Family Medicine Orthopedics General Surgery Psychiatry (Adult & Care Child) Hospitalist Pulmonary/Critical Hospitalist Pulmonary/Critical Care General Surgery Psychiatry (Adult & Child) Hospitalist Pulmonary/Critical Care Infectious Disease Disease Urgent Care Care Hospitalist Pulmonary/Critical Care Infectious Urgent Infectious Disease Urgent Care Internal Medicine Urology Infectious Disease Urgent Care Internal Medicine Urology Internal Medicine Urology Neurology Internal Medicine Urology Neurology Neurology Neurology Mayo Foundation Foundation is is an an affirmative affirmative action action and and equal equal opportunity opportunity Mayo Mayo Foundation isan anaffirmative affirmativeaction actionand andequal equalopportunity opportunity employer and educator. Mayo Foundation is employer and educator. employer and andeducator. educator. employer If you wish to learn more or or to to express express interest interest in in these these positions, positions, If you wish to learn more you wish wish to to learn more or to express interest in these positions, please contact us at 800-573-2580; email IfIf you learn more or to express interest in these positions, please contact us at 800-573-2580; email pleasecontact contactus usatat800-573-2580; 800-573-2580;email euphysicianrecruitment@mayo.edu; oremail apply at at please euphysicianrecruitment@mayo.edu; or apply euphysicianrecruitment@mayo.edu; or apply at http://www.mayoclinic.org/jobs/physicians-scientists euphysicianrecruitment@mayo.edu; or apply at http://www.mayoclinic.org/jobs/physicians-scientists http://www.mayoclinic.org/jobs/physicians-scientists http://www.mayoclinic.org/jobs/physicians-scientists

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

Sioux Falls VA HCS, SD Cardiologist

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(605) 333-6852 www.siouxfalls.va.gov Applicants can apply online at www.USAJOBS.gov January 2016 Minnesota Physician

37


OLLIF from page 33

fusion OLLIF, mean surgery time was 69 minutes (min) and blood loss was 29 ml. Surgery time was approximately twice as fast as open TLIF (mean 135 min) and blood loss was reduced by over 80 percent compared to open TLIF (mean 355 ml). Typically, patients return home following an OLLIF procedure within a few hours after surgery. Since the OLLIF procedure is designed to avoid any major muscles and preserve healthy, natural structures, the procedure may result in less pain and trauma to the back, and recovery is faster. Typically, OLLIF patients experience recovery and a return to normal recreational activities in a few weeks. The data suggest that OLLIF overcomes the difficulties of traditional open fusions described previously, thereby making it a safe and technically less challenging surgery. While these and other data show that minimally invasive spine surgery reduces

morbidity, hospital stay, and accelerates a patient’s rehabilitation time, data regarding cost effectiveness of MI techniques are limited.

TLIF population (42 percent for surgical/operating room time and 58 percent for hospital length of stay). Mean blood loss was also reduced in the OLLIF

OLLIF is the first minimally invasive fusion procedure that is faster than open surgery. OLLIF is cost effective Prior to the July 30, 2015 issue of Cureus, differences in resource consumption between open TLIF and OLLIF were not documented. In the report found in this issue, our group additionally monetized quantifiable differences in resource utilization between these two procedures. Using the case series mentioned previously of 69 consecutive OLLIF surgeries and 55 consecutive open TLIF controls, the use of two key hospital resources were decreased in the OLLIF population by approximately one-half over the

population with the differential blood loss between the OLLIF and TLIF procedures being approximately one unit of blood per patient. Discussion OLLIF is the first minimally invasive lumbar fusion procedure that is faster than open surgery. Data suggest that OLLIF overcomes difficulties of traditional open fusions, thereby making it a safe and technically less challenging surgery than open or minimally invasive TLIF. Further, the cost reductions and faster recovery

times associated with this technique make it an attractive alternative to the conventional open fusions presented for patient and insurance providers. The drop in the use of essential hospital resources suggests that hospitals that are limited by operating room or hospital bed accessibility might be able to achieve greater throughput efficiency by boosting the overall percentage of patients receiving OLLIF. Further study of the OLLIF technique is justified as it has the ability to significantly improve the outcomes of patients needing lumbar fusions. Hamid R. Abbasi, MD, PhD, FACS, FAANS, is board-certified in neurolog-

ical surgery. He specializes in brain and spine disease and is among a few surgeons with the highest number of revolutionary OLLIF procedures performed. He practices at Tristate Brain and Spine Institute and at Fairview Health System, Douglas County Hospital, and Riverview Health.

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The 2016 Minnesota legislative session from page 31

their breath while waiting to see if any of these major decisions around the MinnesotaCare program and the provider tax are going to be solved by a task force. This is particularly true given the history of the multitude of task forces that have tried to address health reform and other issues over the past half-decade and failed to find solutions to difficult issues. The future of the provider tax and MinnesotaCare are likely to be at the forefront of the budget discussions in the 2017 legislative session, but until then differing views remain and it’s difficult to predict how things will pan out then. A quiet policy year? Outside of the possible budget discussions around a tax and transportation bill, and a potential bonding bill, there doesn’t appear to be a big appetite to take on any significant health care policy issues next session. The one issue that

went unresolved last session, but saw a large push from the physician community, was prior authorization policy reforms. The issue moved through mul-

electronic submission is almost assuredly not going to resolve the underlying tension between the physicians and the payers over prior authorization.

The provider tax is still scheduled to sunset at the end of 2019. tiple committees in the Senate, but did not get a hearing in the House due to the strong opposition from the pharmacy benefit management organizations and the health plans. The Minnesota Medical Association has made fixing prior authorization their top priority for the upcoming session. Beginning Jan. 1, 2016, providers and payers are required to submit all claims for prior authorization electronically—a requirement instituted as part of Minnesota’s Electronic Prescription Drug Program law. The new e-requirements may eliminate some of the burdens, but the

Another issue that remains front and center even after significant investments were made in the 2015 session is that of mental health. The House, Senate, and Governor’s office in conjunction with the Department of Human Services made mental health funding and policy reforms a priority in the 2015 session, but despite those changes there seems to be a long way to go in addressing some of the significant mental health issues facing the state. While it is unclear what potential reforms might arise for consideration in the upcoming session, one can expect that

there will be considerable discussion about these issues even in a short session. Always a surprise Even though the budget will likely be this session’s main focus, every legislative session throws out a number of surprises, and these issues often become significant, particularly in short legislative sessions. It is important for physicians to remain engaged and up to date on what is going on at the Legislature. Legislators always point out that they are not experts when it comes to health care issues. They rely on physicians and other providers to help them make informed decisions about finances and policies that impact health care practice throughout Minnesota.

Nate Mussell, JD, is with the Minneapolis law firm of Lockridge Grindal Nauen PLLP. The firm provides legal and government relations services to a variety of health care providers.

Family Medicine Minnesota and Wisconsin Physician Opportunities At Essentia Health, we believe in collaborative care that values the perspective of patients and their families. Backed by the resources of a large, integrated health system, our physicians provide quality care across the large and small communities we serve. A physician-led organization, we offer access to research initiatives, clinical device and medication trials, NIH studies, and independent research.

Open positions include: • • • • • • •

Cardiology Dermatology Endocrinology Family Medicine Geriatrics General Surgery Neurology

• Outpatient Internal Medicine • OB/GYN • Rheumatology • Pediatric Specialties • Urgent Care

We are actively recruiting exceptional board-certified family medicine physicians to join our primary care teams in the Twin Cities (Minneapolis-St Paul) and Central Minnesota/Sartell, as well as western Wisconsin: Amery, Osceola and New Richmond. All of these positions are full-time working a 4 or 4.5 day, Monday – Friday clinic schedule. Our Minnesota opportunities are family medicine, no OB, outpatient and based in a large metropolitan area and surrounding suburbs. Our Wisconsin opportunities offer with or without obstetrics options, and include hospital call and rounding responsibilities. These positions are based in beautiful growing rural communities offering you a more traditional practice, and all are within an hours’ drive of the Twin Cities and a major airport. HealthPartners continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefits package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com, 952-883-5453, toll-free: 800-472-4695. EOE

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Women physician leaders from page 21

of their practices that allow time for leadership. What leads to success? Another major difference between leaders and non-leaders in the Medscape report was worth noting. Seventy-two percent of women leaders said that doing well in their job was the factor that helped them attain a leadership position. Non-leaders agreed with this to a lesser extent, but also felt that building alliances, and finding the support of mentors and peers would be important in helping them become leaders. Drs. Wheeler, Oster, and Sinclair list many academic and community mentors, both female and male. However, the Medscape report highlights that non-leaders rate inspiration from female physicians (38 percent) as possibly being more helpful than inspiration from male doctors (13 percent).

Each of the three Minnesota doctors that I interviewed, took the time to ask me about my career, and to offer encouragement. The Minnesota doctors featured here have benefited greatly from mentorship, and practice it in their daily interactions. The Medscape report highlights mentorship as a key component to embolden women doctors to become leaders.

Wheeler, Oster, and Sinclair have all been physician leaders in private practice, hospitals, and in organizations outside of their practices. Dr. Wheeler, in particular, is in a tiny cohort of women physicians as CEO of a large health care company. All three describe the benefits of mentors who have connected them, encouraged them, and inspired them by example. They are all bolstered by support

Mentorship [is] a key component to embolden women doctors to become leaders.

Given the wealth of research showing the positive impact of women leaders on organizations and their profits, Minnesota medical groups should try to increase female leadership percentages. Drs.

from their families and their practices, particularly by allowing time off from clinical duties to allow for leadership roles. The McKinsey group’s research shows, “When gender diversity

is at the top of the strategic agenda, there are more actions taken and more women at the C-level.” This advice is important to translate for professional organizations, since women physicians who are not already leaders are viewing positions outside their own practices as less vital to their careers. Remember that women of all age groups believe leadership is important, but they need sponsors and mentors. Practices should make structural changes that give women the time to see their patients as well as sit in the leader’s chair. Minnesota health organizations need to address gender bias, and take mindful action if they wish to reap the benefits of having women leaders.

Heather Awad, MD, is a family physician, writer, and practice owner/ physician at Medical Acupuncture in Falcon Heights, Minnesota.

Olmsted Medical Center, a 220-clinician 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: Anesthesiologist Hospital

ENT

Rochester Southeast Clinic

Family Medicine Rochester Clinics

General Surgery Hospital

Plastic Surgery

OMC Hospital – Women’s Health Pavilion

Psychiatrist

Rochester Southeast Clinic

Psychiatrist – Child & Adolescence

Sleep Medicine

Rochester Southeast Clinic

Rochester Northwest Clinic

Psychology–Adult

Urology

Rochester Southeast Clinic

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

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

www.olmstedmedicalcenter.org 40

Minnesota Physician January 2016

Hospital


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

A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

Opportunities for full-time and part-time staff are available in the following positions:

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Medical ethics and the unconscious mind from page 17

pay the full fee at the time of each visit. I do not participate in any insurance networks, but my patients can submit claims and many do get reimbursed. Cutting out the billing overhead reduces my fees by 50 percent and frees up time to take new patients into treatment. More importantly, the direct-pay model prevents third parties from tweaking the payment setup to make Homunculus serve their interests. Many physicians choose to practice in systems of care driven by third-party payment because they believe they will not otherwise have access to enough patients to make a living. Physicians who make that business decision have to constantly guard against the influence of the Payer/ Homunculus alliance. If Dr. Winston had systematically examined his unconscious

motivations, he might have had the detachment to recognize a way out of his dilemma in treating George. A referral to an out-of-network hematologist would have kept Dr. Winston in contractual compliance, while the colleague, unfettered by a patient-unfriendly contract, would have been free to accept payment from George for the treatment he needed. Knowledge of our unconscious minds will improve the quality of our ethical decision-making. Our own experience of right and wrong in clinical practice, exemplified by the Sage, really is sufficient most of the time to ensure that we do the right things for our patients in everyday practice. An ethical dilemma results when individual clinical circumstances give rise to valid but conflicting moral considerations; a doctor then needs the Scientist to logically weigh it all out, always tempered by empathy for the

patient. Here, codes of medical ethics, provided that they are written by clinicians, give us access to the collective wisdom gained through generations of practice. And remember, Homunculus lacks the capacity to follow ethical rules. The Scientist needs all her energy to ride herd on Homunculus, so she cannot afford to be diverted by any non-clinical tasks when ethical problems arise. When the physician has incentive to align with the interests of a third-party payer ahead of patient welfare, it is not a true ethical dilemma. It is simply a conflict of interest. Doctors are not trained to be ethically proficient in saying “No” to third-party interests that undermine quality of care; rather, compliance with authority is widely modeled and regularly reinforced. Fear of punishment or loss of group approval are strictly Homunculus concerns.

A Diverse and Vital Health Service

Courses of ethical training and codes of ethics that speak only to the Scientist leave physicians relatively defenseless to keep Homunculus in check, all the while third-party payers are refining the sophistication of their communications with him. Programs designed to systematically incentivize physician behavior are programs that intentionally degrade the mental ecosystems in which physicians make ethical choices. We can reduce the power of the choice architects by recognizing their methods as morally compromising and by knowing our own unconscious minds. George is counting on us.

Robert S. Emmons, MD, has maintained a private practice in Burlington, Vermont for 26 years, and is the founder and staff physician for the Franciscan Free Psychiatric Clinic in Moretown,Boynton Vermont. He is Service also a diHealth rector of the Association of American Physicians and Surgeons.

Boynton Health Service

Welcome to Boynton Health Service Located in the heart of the Twin Cities East Bank campus, Boynton Health Service is a vital part of the University of Minnesota community, providing ambulatory care, health education, and public health services to the University for nearly 100 years. It’s our mission to create a healthy community by working with students, staff, and faculty to achieve physical, emotional, and social well-being. Boynton’s outstanding staff of 400 includes board certified physicians, nurse practitioners, registered nurses, CMAs/LPNs, physician assistants, dentists, dental hygienists, optometrists, physical and massage therapists, registered dietitians, pharmacists, psychiatrists, psychologists, and social workers. Our multidisciplinary health service has been continuously accredited by AAAHC since 1979, and was the first college health service to have earned this distinction. Attending to over 100,000 patient visits each year, Boynton Health Service takes pride in meeting the health care needs of U of M students, staff, and faculty with compassion and professionalism.

Gynecologist/Clinical Supervisor Boynton Health Service is seeking a gynecologist or primary care physician with extensive experience in women’s health to serve as Assistant Director of Primary Care in charge of the Women’s Clinic. The Assistant Director will provide clinical services, ensure staff adherence to relevant regulations, assure the highest professional and ethical standards, and work with the Director of Primary Care and Chief Medical Officer to formulate long range planning and policies. This position offers a competitive salary and a generous academic status retirement plan. Professional liability coverage is provided. Apply online at www1.umn.edu/ohr/employment, select “External Applicants” and then search for keyword: Gynecologist. Job ID#: 300363 To learn more, please contact Hosea Ojwang, Human Resources Director 612-626-1184, hojwang@bhs.umn.edu. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer

410 Church Street SE • Minneapolis, MN 55455 • 612-625-8400 • www.bhs.umn.edu

42

Minnesota Physician January 2016


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November 2015 Minnesota Physician

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rehabilitate a body, we start T owith the mind and soul. If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. Thatâ&#x20AC;&#x2122;s our approach. Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.

To make a referral or for more information, call us at (888) GSS-CARE or visit 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. Š 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553

MN Physician Jan 2016  

Medical ethics & the physician’s unconscious mind- A conflict of interests By Robert Emmons,MD | The Compassionate Care Act- Giving Minne...

MN Physician Jan 2016  

Medical ethics & the physician’s unconscious mind- A conflict of interests By Robert Emmons,MD | The Compassionate Care Act- Giving Minne...