Minnesota Physician • July 2022

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MINNESOTA

JULY 2022

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXVI, No. 04

PHYSICIAN Outstate Behavioral Health Care Meeting the challenges and needs BY THOMAS OTTEN, MA

A Optimum Medical Care The role of telemedicine BY WAYNE LIEBHARD, MD

s medical science and the delivery of health care continue to evolve, there is a growing understanding of the impact mental health has in every physician-patient encounter. From routine health screenings to care for chronic conditions to cancer treatment, the mental health of a patient can make a big difference in outcomes. So much so, in fact, that the time has come for quick and minimal mental health assessment tools to be part of every patient intake process, just like blood pressure and weight measurements. Simple mental health baseline data should be a part of every patient’s medical record. While it is unfortunate that this is not a universal best practice standard, it is even more unfortunate that the lack of access to mental health care has reached the full-blown crisis we face today. Outstate Behavioral Health Care to page 144

T

rying to determine what constitutes optimum medical care is a not an easy task. Nonetheless, this question needs to be posed, and an attempt needs to be made at an answer. Why? Because the entire endeavor of providing medical care–like so many other services–is geared toward providing not only what consumers desire, but also providing what is best for them–the optimum. Perhaps nowhere today, other than in the delivery of medical care, is the definition of “optimum” more divergent than it is between the providers and consumers of that care. Physicians have a moral and ethical duty to provide their patients with care that is both safe and appropriate, despite any outside pressures they may face. Given the current Optimum Medical Care to page 104


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55TH S ES SI O N

JULY 2022

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Publishing December 2022

Volume XXXVI, Number 04

COVER FEATURES Optimum Medical Care The role of telemedicine By Wayne Liebhard, MD

Outstate Behavioral Health Care Meeting the challenges and needs By Thomas Otten, MA

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Changing the Future of Health Care Kevin J. Mullaney, MD

RESEARCH.................................................................................. 16 The Efficacy of Medical Cannabis Removing the stigma, doing no harm

By Stephen Dahmer, MD DIVERSITY, EQUITY AND INCLUSION............................................ 18

CARE COORDINATION

Advancing health care equity

Improving Communication and Outcomes

How Minnesota’s health plans are leading the way

By Lucas Nesse, JD EMERGENCY MEDICINE............................................................... 22 Fluorescence Microangiography

BACKGROUND AND FOCUS: As health care faces rising costs, chronic workforce shortages and seemingly ever increasing administrative burdens, the pace of evo-

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lution is unparalleled. One example is the emergence of care teams;

By Thomas Masters, MD

many different licensed and unlicensed providers working together to the top of their training. While this offers benefits it also creates new challenges. The two most critical are ensuring every provider is aware of the care a patient receives and the patient is aware of, and adheres to, his or her individual treatment plan. The complexities of these task have given rise to a new part of the care team, the care coordinator.

OBJECTIVES: Our panel will examine the role of the care coordinator, how and why it is becoming an increasingly important part of health care delivery. When care coordination may be provided by clinic or health system staff, by third party payers, by private industry contracting out-of state employees, and even by state health agencies, utilization of this tool can present conflicts, confusion and frustration. We will look at the different aspects of care coordination and provide insight into how www.MPPUB.COM PUBLISHER

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they work best in various practice settings. Mike Starnes, mstarnes@mppub.com

ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com

JOIN THE DISCUSSION We invite you to participate in the conference development process.

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. 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.

If you have questions you would like to pose to the panel or have topics you would like the panel discuss, we welcome your input. Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

MINNESOTA PHYSICIAN JULY 2022

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CAPSULES

New Partnership Between Children’s Minnesota and PrairieCare Children’s Minnesota and PrairieCare recently announced a new partnership that will deliver high-quality psychiatric care to kids as young as six years old. Children’s Minnesota will open its first inpatient mental health unit this fall. PrairieCare will provide programmatic guidance and joint clinical leadership for the new unit, where Dr. Ryan Williams, PrairieCare’s physician executive, has been appointed as the medical director of inpatient psychiatry. “We’re excited to partner with PrairieCare to deliver the highest quality mental health services to kids in our community,” said Dr. Gigi Chawla, vice president and chief of general pediatrics at Children’s Minnesota. “Children’s Minnesota is committed to providing the full continuum of mental health services tailored

for kids in the region to improve access, equitable care and treatment throughout a child’s mental health journey.” Dr. Williams stated, “This partnership is a testament to the dedication of both PrairieCare and Children’s Minnesota to address the unmet mental health needs of our children.Kids and young adults need access to mental health resources designed for their specific, age-appropriate and medical needs, and we look forward to providing this personalized care to our community soon.” The new Children’s Minnesota inpatient mental health unit will care for approximately one thousand children and adolescents each year; it will provide a healing environment, which includes 22 dedicated inpatient psychiatric beds at the system’s St. Paul hospital, allowing parents to stay overnight with their child. It will be the first inpatient unit in

the east metro to treat kids under 12 years old. It will also be able to serve children with more complex medical needs, meeting the urgent mental health needs of the most vulnerable kids in Minnesota and the region. A dedicated, multi-disciplinary care team of psychiatrists, psychologists, program therapists, nurses, occupational therapists, child life and music therapists will provide individualized treatment tailored to meet each child’s needs.

Mayo and UnitedHealthcare Reach Medicare Advantage Agreement Mayo Clinic and UnitedHealthcare (UHC) have reached an agreement on a new multi-year network relationship. The agreement ensures members enrolled in UHC employer-sponsored and individual health plans have continued access to quality care at Mayo Clinic’s national

network of hospitals, clinics, physicians and other providers. The parties have also established a new relationship that will give members enrolled in UHC Medicare Advantage plans in-network access to Mayo Clinic Rochester and Mayo Clinic Health System sites in the Midwest for the first time, effective January 1, 2023. “We look forward to building on the continued strong relationship between Mayo Clinic and UnitedHealthcare,” said Lyell Jones, MD, a Mayo Clinic neurologist and medical director for Contracting and Payer Relations. “Agreements between Mayo Clinic and leading insurers such as UnitedHealthcare help ensure access for patients who need serious and complex care.” UHC is the nation’s largest Medicare Advantage provider and for some time had been unable to agree with Mayo Clinic on terms allowing its members’ access to Mayo Clinic

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JULY 2022 MINNESOTA PHYSICIAN


CAPSULES

services. UHC (or mayo?) offers a full spectrum of health benefit programs for individuals, employers and Medicare and Medicaid beneficiaries; it contracts directly with more than 1.5 million physicians and care professionals, as well as 7,000 hospitals and other care facilities nationwide. “We’re grateful for the opportunity to begin providing our Medicare Advantage members network access to Mayo Clinic’s facilities and physicians,” said Craig Stillman, CEO, UHC Medicare & Retirement of the Upper Midwest. “We’re expanding and strengthening our longstanding relationship with Mayo Clinic, one of the most highly regarded medical institutions in the world.” In 2021, Mayo Clinic cared for more than 1.4 million patients from every U.S. state and 139 countries.

GS Labs Counter Sues BC/BS Minnesota GS Labs, a nationwide provider of COVID-19 rapid tests, has filed new counterclaims in the company’s ongoing legal battle against Blue Cross Blue Shield (BC/BS) of Minnesota. The June 29th filing in U.S. District Court for the District of Minnesota flatly denies all prior allegations made by BC/BS of Minnesota against GS Labs. GS Labs has also alleged 21 counterclaims against BC/BS of Minnesota, detailing a scheme to harm competition in violation of the federal antitrust laws. Its conspiracy with other Blue insurance companies, in a cartel to fix prices and illegally boycott quality testing labs, resulted in COVID testing shortages in Minnesota. The counter complaint also sets forth factual allegations showing BC/BS of Minnesota committed consumer fraud by misleading Minnesotans in need of COVID testing, tortiously interfering with GS Labs’ business relationships, and violating the CARES Act by refusing to reimburse GS Labs for thousands of COVID tests for its insureds.

“Throughout the pandemic, GS Labs has been there to provide fast and accurate testing for more than 300,000 Minnesotans,” said Jen Rae Wang, a representative for the company. “While insurance companies across the U.S. have paid GS Labs for these services, BC/BS of Minnesota has colluded with other Blues to suppress testing, boycott GS Labs, and price-fix across the state and the nation. That anti-competitive act of greed has made it harder for residents to get critical medical information and has dangerously impacted public health.” David Leibowitz, a GS Labs spokesperson, also highlighted an irony regarding the original BC/BS lawsuit against GS Labs: on the very day that BC/BS of Minnesota sued GS Labs for fraud and abuse, it also extended an invitation to GS Labs to become an in-network participating provider. GS Labs is seeking full payment for unpaid bills that currently total tens of millions of dollars, plus legal fees, investigative fees and compensation for lost goodwill. The company also seeks three times the actual damages for each of Blue Cross’ antitrust violations, together with costs and disbursements, including reasonable attorneys’ fees, compensatory damages, interest and legal fees.

Direct Access Replaces Rule 25 Funding Effective July 1, 2022, the Minnesota Department of Human Services (DHS) has replaced Rule 25 funding for substance use disorder (SUD) treatment services with Direct Access, supposed to be in blue? now the only process for publicly paid SUD treatments. Direct Access expands patient treatment access and options and also creates new provider certification criteria. Under the new process, any provider who certifies an individual for treatment coverage must enroll and participate in the Drug and Alcohol Abuse Normative Evaluation System (DAANES). This will create a much

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CAPSULES

wider and quicker path to covered treatment, allowing an individual to go directly to any DANNES certified provider they choose to receive a comprehensive assessment and access care immediately. Direct Access removes barriers of timing associated with going through a placing authority, allows for individual choice and removes duplication of comprehensive assessments. Beginning in the late 1980s, the Rule 25 process has been the method for eligible people to access publicly paid SUD treatment services in Minnesota. In October of 2020, Minnesota began running a parallel process during which a person could either follow the traditional Rule 25 process or, via Direct Access, go directly to a provider for an assessment and treatment.

in an inpatient treatment program. Direct Access allows for an individual to choose where they would like to access treatment by removing Rule 25 placing authority and the MMIS Service Agreement which dictated the provider and units authorized by the placing authority. In the Direct Access process, there is no service agreement with a specified level of care and treatment location that the individual must follow. The new process will allow the individual to have a complete comprehensive assessment, followed by the choice of provider and level of care, up to the highest level of care determined necessary. It is a major improvement for an individual assessed for a residential level of care to now have other options.

Beyond expanding and improving assessment options, Direct Access addresses other Rule 25 shortcomings, such as covered treatment options for individuals who are unable or unwilling to participate

New Mental Health Crisis Line, 988, Now Operational

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JULY 2022 MINNESOTA PHYSICIAN

People facing a mental health crisis can now dial 988 to connect to

support. The new service is part of a nationwide effort to strengthen and expand the National Suicide Prevention Lifeline to a phone number people can more easily remember and access that will serve and support anyone experiencing mental health-related distress or crisis. The nationwide service also includes an online chat feature and new texting option. It follows NAMI’s does everyone know what this is? standard of care and is billed as “a direct connection to compassionate accessible care.” Funding for the program comes through the Substance Abuse and Mental Health Administration (SAMHSA). Is that last “S” supposed to be there? They envision a robust crisis care response system that will link callers across the country to community-based providers and resources that can deliver a full range of crisis care service. The new 988 dialing code will serve as a universal entry point, so people can

reach a trained crisis counselor who can help regardless of where they live. Anyone can dial or text 988 for 24 hours a day, seven days a week, to reach crisis support or to use an online chat feature to connect with crisis support. People can also dial 988 if they are worried about a loved one who may need crisis support. The network features over 200 call centers. Minnesota has four Lifeline centers that connect callers to nearby or state-specific resources and services quickly and efficiently. Interpretation services are available in Minnesota through calling the number. Currently, chat and text are only available in English. To reach the Veterans Crisis Line, dial 988 and press 1. Calls will route to the same trained Veterans Crisis Line. The Veterans Crisis Line will still be available by chat (VeteransCrisisLine.net/Chat) and text (838255) There are expected growing pains, as there were rolling out 911, but the


CAPSULES

hope is to help address the growing mental health crisis responders. People should still call 911 if they suspect drug overdose or need immediate medical help.

U of M Awarded $3.7 Million Pediatric Cardiology Research Grant

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Allina Announces Site for New Cambridge Medical Center

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After months of research and planning, the site selected for Cambridge Medical Center’s new facilities will be located between Highway 65 and Xylite Street Northeast, just north of Highway 95. “From the start of our planning process, we knew the importance of keeping the new hospital within the city of Cambridge and the role location plays in providing convenient, accessible care for the community’” said Cambridge Medical Center president Josh Shepherd. “The new location, about two miles from our current site and just off Highway 65, meets this important goal.” Krause Anderson will be the builder and BWBR Architects will be the design firm. Location selection is an important step forward for the project and Allina will continue to engage with the community as it works through the local and state regulatory processes. All services will remain operational at the existing campus until the new medical center opens, which is expected in 2025.

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A University of Minnesota Twin Cities-led team of researchers recently received a $3.7 million grant from the U.S. Department of Defense to prepare for a human clinical trial of artificial, bioengineered blood vessels that grow with the patient. If successful, these new vessel grafts would prevent the need for repeated surgeries in children with congenital heart defects. The funding is part of the Department of Defense’s Congressionally Directed Medical Research Programs that finance programs which are “transforming healthcare through innovative and impactful research.” Where does quote come from? Recipients who have heart defects at birth often outgrow current vessel grafts and need to have larger vessels implanted several times as they grow. “This grant is a major step forward and will allow us to do everything that’s necessary to get to day one of a first clinical trial where we would implant one of our lab-created blood vessels into an infant with a heart defect,” said Robert Tranquillo, a Distinguished McKnight University Professor this is a particular title awarded for outstanding performance so ok to capitalize in the Department of Biomedical Engineering and the Department of Chemical Engineering and Materials Science. To prepare for the clinical trials, the vessel-like tubes will be manufactured by the U of M start-up company, Vascudyne, Inc. The tubes are grown in the lab from a donor’s skin cells and then removed to minimize the chance of rejection. When implanted, the tube is repopulated by the recipient’s own

cells, allowing it to grow. In addition to developing the tubes, the grant will cover any remaining pre-clinical studies needed before the human clinical trials. Tranquillo and Zeeshan Syedain, a senior research associate in Tranquillo’s lab who now also serves as Vascudyne’s chief scientific officer, will partner with Experimental Surgical Services in the U of M Medical School to test the tubes in lambs. “This research could have a major impact for children with heart defects. Instead of three, four or even five surgeries or interventions during their childhood, children would only need one surgery,” Tranquillo said. “This would substantially reduce trauma and risk for children and the overwhelming health care costs for families.”

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MINNESOTA PHYSICIAN JULY 2022

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INTERVIEW

Changing the Future of Health Care Kevin J. Mullaney, MD

This month you graduate your 50th class

of employment or responsibilities requiring the use of their hands. We realize our reputation is a key part of our identity, and this, thankfully, has allowed us to maintain a strong pipeline of outstanding applicants from all areas of our country and beyond our borders.

from your fellowship program. Please tell us something about the first class.

Over the years, how has the program both changed and remained the same?

The program has grown in a number of ways. As our practice grew, we were able to expand the number of yearly fellows we desired to accept and train. We typically have four fellows a year now, who rotate among the 10 Board Certified and Fellowship Trained surgeons that make up Twin Cities Spine Center. The emphasis of the training has also grown— from primarily scoliosis and spinal deformity care to all conditions of the spine, including degenerative, traumatic and tumors. Perhaps the most dramatic change to our program was the addition of cervical pathologies, which now make up roughly 30-40% of our patients. What has remained constant in our program and our practice is our commitment to excellence, leadership, education, research and outstanding patient care. What can you tell us about the kind of person that is drawn to your program?

Our fellowship program attracts orthopaedic and neurosurgical trained surgeons interested in

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JULY 2022 MINNESOTA PHYSICIAN

Looking at the last 50 years, what have been some of biggest advances in your specialty?

“...”has remained What constant… is our commitment to excellence, leadership, education, research and outstanding patient care. “...”

The John H. Moe Spine Fellowship program is named for our founder and a true pioneer of spine care, Dr. John Moe. Over the past 50 years, the program has trained 189 spine surgeons from 16 countries. Our first John Moe Fellowship class started in 1971, and it focused primarily on the care and treatment of scoliosis. There were two fellows in that initial group that graduated in 1972: Dr. Claudio Pedras, from Brazil, and Dr. Edgar Dawson, who later became chief of staff at both UCLA and Shriner’s Hospital in Los Angeles. Dr. Dawson also served in 1995 as the President of the Scoliosis Research Society (SRS), which Dr. Moe had helped to establish and served as its first president in 1966.

subspecializing in spine and seeking a training program that will provide a large and diverse number of spine patients. Twin Cities Spine is known for seeing some of the most complicated spine cases, as well as doing what would be considered more routine spine care and surgery of the lumbar, thoracic and cervical spine. Our teaching surgeons use a wide variety of surgical approaches, from traditional open surgery to minimally invasive techniques and robotic assisted procedures. Applicants choose our program because it is comprehensive in the sense that we emphasize conservative care, taught by a balance of clinical assessments, research and surgical exposure. Because our fellowship includes a research component, we also attract applicants with an interest in research and academics. We seek applicants who are ethical, moral and come with a strong training foundation. We look for self-motivated individuals with early positions

Over the past 50 years, we have seen a significant number of advances in regard to techniques applicable to spinal pathology. This ranges from minimally invasive techniques to roboticassisted procedures and high-tech CT-guided instrumentation, placement and confirmation. We have been able to care for patients with more spinal pathologies with less morbidity. There have also been significant advances in perioperative pain management, which often allows us to perform surgeries with a shortened length of hospital stay or same-day discharges. Patients are able to return back home sooner to familiar surroundings and comfort. Imaging of spinal pathology has also been greatly enhanced with the onset of 3D images, robotic reconstruction, high-grade MRI and CT. What kinds of research/clinical trials is your practice working on?

We study surgical and non-surgical treatments for adult neck and low back disorders and adolescent idiopathic scoliosis. We also investigate related topics like the effectiveness of osteobiological agents for bone healing and the prevention of postoperative surgical site infections. And we seek to evaluate new and developing technologies such as minimally invasive techniques and robotassisted spine surgery. The fellows in our program are required to take on at least one research project during their year with us. They have the support (and extensive data) of the Twin Cities Spine Research Department as they set out to


answer a spine specific research question. The ultimate goal and expectation of this project is a completed and published article in a peerreviewed medical journal. Please tell us about how Fellows interact with other health care professionals as part of the care team that serves your patients.

Our fellows play an integral role amidst the teams that care for and support our patients. These teams include the partner surgeon, physician assistants, nurse practitioner, social worker, RNs and ancillary support staff. In their role as fellows, they are under the supervision of a TC Spine surgeon. Fellows rotate quarterly with the various spine teams and take part in clinical exams, non-operative management, surgical decision making and planning, observing and assisting in the OR, consulting on cases in the ED, rounding on patients in the hospital and conducting follow up with patients. Fellows also work closely with our research department as they pursue their spine research projects. We have a Thursday Lecture component to our program which brings guest lecturers in to

present and dialogue with our fellows. These guests are leading providers in a variety of subspecialties including radiology, neurology, pain medicine, orthotics, chiropractic and others. We emphasize collaborative and coordinated care. On Monday mornings, the fellows present cases and research to our staff surgeons and others at a 60-90 minute spine conference. These conferences (excepting the first Monday of the month) are open to all providers interested in learning and dialoguing about optimal spine care.

That decision process is more important than the type of incision (the technique of surgery) that might be performed. We train spine surgeons. But we first want to train them to be excellent spine clinicians. Getting an accurate patient history, conducting a thorough exam and knowing when to seek additional diagnostics is key. Arriving at an accurate diagnosis is paramount for treatment planning. We emphasize conservative management. How does having the role of teacher/

Is there a key emphasis or learning that

trainer impact the spine surgeons at

your program seeks to teach fellows?

Twin Cities Spine Center?

Perhaps the thing we work hardest to impart to our fellows is best summed up in a phrase used by my mentor and our past fellowship director, Dr. Ensor Transfeldt, who always taught that “the decision is more important than the incision.” The decision occurs between the surgeon and patient—listening to the patient’s concerns, priorities, goals and expectations and truly understanding the unique factors and needs of the individual patient in order to determine if surgery should even be an option.

We see the fellowship as an integral part of our fabric at the Twin Cities Spine Center. We view our fellows as colleagues that have come to us from all parts of the country and the world. They bring new ideas and techniques, and they are inherently inquisitive. Frankly, this keeps us, as the trainers, current. When your practice is training the next generation of spine surgeons, you need to be at the Changing the Future of Health Care to page 304

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3Optimum Medical Care from cover dominance of government- and corporate-run medicine, are physicians still in a position to honor their ethical duty when it comes to the appropriate use of telemedicine? Or have their employers now taken over control of what the patient is offered when it comes to options for care? Is telemedicine yet another great promise by some to “save” heath care in the United States? Another panacea? Or is it yet another quagmire? While studies still seem to suggest that patients rank interpersonal interactions with their caregivers at the top of their medical care list, the rest of that list has changed dramatically in recent years, most notably in relation to the notion of “convenience.” Consumers of medical care, henceforth referred to as “patients,” still desire competent, empathetic, affordable medical care. Just as important, they now want the provision of that care to fit their lifestyles. In other words, they want it fast and easy, as well as inexpensive. Like everything else in America, though, “fast and easy” is never supposed to imply “risky and unpredictable.” Kind of like that hamburger from McDonald’s. Why? Because there is always someone in America looking out for the welfare of the consumer of everything commercially branded, right?

Buyer beware Anyone with half a functioning brain understands the potential risk in buying five pounds of shrimp on a 90-degree day from some guy selling it off the back of his rusty pickup truck. The sign for “Jim and Bob’s Bungee Jumping/ Go-Cart Track/Hog Roast” establishment should likewise get one to think

critically about whether exiting I-95 to check it out. For most anything else in America, we have a vast array of consumer protection agencies, oversight bureaus and government commissions to ensure that anything we touch, consume or breathe should always be free from harm. Exactly why “fast and easy” is never supposed to imply “risky and unpredictable” here in America. There is, of course, a pecking order of trust that further aids Americans in making choices when it comes to their actions. A January 2020 article published in “MarketWatch” (“Americans trust Amazon and Google more than the police or the government”) takes note of a study regarding the most trusted brands, public figures and institutions in the U.S. In that study, subjects were asked to consider entities such as teachers, law enforcement officers, doctors, public figures and celebrities. The study included the question of whether the subjects trusted information from health and weather advisories or scientific studies. Score one for the family doc. Based on the study’s results, 50% of subjects–the greatest share–trusted their family doctor to do the right thing. The military was listed next at 44%. Hollywood scored only a 4% share, with Wall Street at 5%, the U.S. government at 7%, capitalism at 14% and religious leaders at 15%. In between 50% and 14%, Amazon took 39% and Google 38%, followed by extreme weather warnings, teachers, the police, scientific studies and health warnings or advisories. Tom Hanks and Oprah also beat out the president and Warren Buffett. So, what does this have to do with optimum medical care? On the surface, perhaps it means that people trust their family doctor more than Tom Hanks or Wall Street to provide their medical care. That’s a good thing, as trust is an extremely important part of the doctor-patient relationship. Given that good medical care can mean the difference between life and death, it’s indispensable to have formed relationships with trusted clinicians in the event those situations should ever present.

What is optimum care?

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What about medical care for less emergent, but still urgent situations? Everyone knows that it’s time to go straight to the emergency room if the bungee cord at Jim and Bob’s broke and someone dropped thirty feet directly onto cement. What about a cough? What if the patient’s eye is red with lashes stuck shut upon waking up in the morning? What if there is abdominal pain–off and on? Not severe, yet not going away? In an ideal world, everyone would own their own hospital and have instant access to an ophthalmologist for an eye problem, a pulmonologist for a cough and a surgeon to evaluate abdominal pain. There is a sweet spot somewhere between having no access to care and owning one’s own hospital. For economists, we’ll call it the “affordability spot” on the Laffer Curve of medicine–the place where people get care—care we all would like to believe is optimum. At its heart, optimum care means care in which the diagnosis is correct, the treatment is correct and both are done in a timely manner–with the care being accessible and affordable. Care provided in a timely, accessible and affordable manner is useless, and potentially dangerous, if the diagnosis and/or treatment are incorrect. This, of course, begs the following question: How does a patient know that the diagnosis and/or the treatment is correct once the medical system has been engaged? Answer: the patients don’t, at least not until they get better, or until the medicine they are taking makes their eyelashes fall out. Why, then, would anyone engage the medical system at all, given that lack of certainty? There are two reasons, and they both relate to a risk/benefit ratio.


First, no one would engage the medical system if they felt there was more risk than potential benefit in doing so. On a more subconscious basis, the same type of reasoning is behind the choice to get up each morning and take the risk of driving to work. Indeed, many individuals take their chances and choose to not engage Western medicine at all. They are not convinced that the risk is worth the potential benefit. Second, the patient had developed enough trust in Western medicine or in their “provider” of choice. Physicians, in general, take exception to the word “provider.” Provider is a term that has the effect of devaluing clinicians and making them all appear interchangeable. In any case, the level of trust allows engagement with a system having more risks than eating the roadside shrimp and risks as serious as the bungee cord rupturing.

providing care by telemedicine, more so than just the nuts and bolts of getting connected with their patients and figuring out how to have them stick their iPhones down their throats to try to get a peek at their tonsils, right? Certainly, in a rush to capitalize on the new age of telemedicine, a large medical conglomerate would not attempt to direct as many patients as possible toward video visits, even if they already had presented at a clinic for a face-to-face visit right? Certainly…Certainly. Likewise, who wouldn’t trust a slick online medical “provider” (here the term is more appropriate) with a picture of a handsome young clinician on the first page? This “provider” notes how easy it is to book an online appointment and that “we can treat almost anything” simply through a visit on your phone. The subsequent list is almost endless: “prescriptions, antibiotics, diabetes, refills, birth control, gout, hypertension, PrEP, pneumonia, hypothyroidism, lipid regulators, IBS, asthma, depression, ear infection, acne, anxiety, STDs, sinus infection, erectile dysfunction, cough, flu, UTI… and almost anything else!” Why stop there? Surely, the home appendix removal kit is right around the corner. Just because telemedicine is now being offered to evaluate and treat almost anything doesn’t mean that telemedicine is safe to evaluate and treat almost anything.

Optimum care means care in which the diagnosis is correct, the treatment is correct and both are done in a timely manner.

Who wouldn’t trust a large medical conglomerate which owns hospitals and all sorts of shiny new multiple-story buildings when it advertises its telemedicine services with the following: “Get the same great care as an office visit”? Certainly, those large medical conglomerate physicians buy in completely to the provision of urgent care by telemedicine for just about any condition imaginable, right? Certainly, those physicians were consulted as to how the telemedicine process would be set up, how it would work, and–most important—what conditions as presented by patients would be routed through for a telemedicine visit, right? Certainly, those physicians were trained in the intricacies of

Optimum Medical Care to page 124

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3Optimum Medical Care from page 11 How about this bit of telemedicine advertising: “The last thing you want to do is trek across town to see a doctor”? Perhaps, then, we should add a line to Jim and Bob’s sign that would read: “The last thing you want to do is drive another two miles up the road to where the bungee jumping is safety monitored.” The implication seems to be that no one ever really needed to be examined in person by a doctor. It just took until now, when technology would allow, for us to admit that an interaction on a screen is, in fact, superior to an interaction in person.

The future of telemedicine Undeniably, telemedicine now has a definite place in the delivery of medical care. In fact, in some instances and some circumstances, it is the best available modality through which to access certain kinds of care. There is no doubt that, in remote areas or in small hospitals without immediate access to specialty care, telemedicine can be a godsend as a conduit to that specialty care. There are also certain services (such as diabetic consults or mental health visits) that, while still best delivered by face-to-face visits, can be reasonably delivered through telemedicine consults when circumstances demand. In early 2020, as we all know, circumstances regarding medical care changed drastically. In an effort to continue to support the provision of medical care during the COVID-19 pandemic, CMS substantially amended the rules previously governing the delivery of and remuneration for telemedicine services.

win for health care conglomerates. In some sectors, there appeared to be promotion of urgent care by telemedicine for just about any condition imaginable. Unfortunately, the level of practicing physician involvement in this rush to telemedicine was nominal. How much were doctors consulted about how the telemedicine process would be set up, how it would work, and what conditions as presented by patients would be routed through for a telemedicine visit? How much physician training was given regarding the intricacies of providing care by telemedicine? In order to provide optimum medical care, physician engagement is critical. The control of the delivery of medical care in the U.S. must never be taken out of the hands of clinicians. To sum up, the expanded use of telemedicine is here to stay and does offer some benefits in its use. Optimum care, however, means care that is always safe and appropriate. Patients need to be fully aware of their care options and of the limitations inherent in the use of telemedicine so they may be guided in using that knowledge to obtain optimum medical care. For telemedicine to be used safely and appropriately, practicing physicians— along with their patients—need to decide if, how, and when it is used. Wayne Liebhard, MD, is a family practice physician now practicing in an emergency medicine clinic. He is also the author of the recently published book, “Walking The Tightrope—Trusting Your Life To Telemedicine.”.

Large health care systems took notice–immediately. Access to the same reimbursement for telemedicine consults as for live visits was a financial

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability? Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

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3Outstate Behavioral Health Care from cover Prior to the pandemic, the demand for mental health care far exceeded the supply, and now that equation has been made worse with one in every four job openings in the field unfilled. This situation is even worse in outstate areas where patients face unique barriers to seeking care. In small towns, not only is it more likely for everyone to know everyone else’s business, and such things to travel quickly, but the stigma—internal or external—of dealing with mental health concerns can be higher. Farmers, for example, have an ingrained can-do attitude of pulling themselves up by their boot straps, an admirable attitude but one that does not translate well, for example, to dealing with depression or anxiety disorder. As of mid 2022, nearly 30 farmers in America are dying by suicide every day, meaning they have one of the highest suicide rates of any occupational group. Though it may not help with climate change related drought or poor government policies, better access to mental health services would certainly help address this. The Zero Suicide Initiative, a national program with the goal of reducing suicides to zero through use of a set of tools—one of those being screening and assessment in clinics and emergency departments—is a program we have been using since 2016. The majority of suicides—75%—take place within 60 to 90 days after a medical encounter. This doesn’t assess any blame; it’s just a reality check for all of us, and it points to an opportunity for prevention. We won’t always catch it—in fact, research tells us that the decision to take one’s own life is usually made only a couple of hours earlier. But if we can spot a downward trend and encourage that person to take action, we might save a life.

Another element for concern relates to substance use disorder (SUD). Many people assume that large cities are havens for mind-altering drug use and alcohol abuse, however smaller communities have seen dramatic increases in opioid misuse and overdoses, and meth may be even more available there than in urban and suburban areas. What is not available are inpatient treatment beds, after care programs and certified counselors to help people understand and deal with these problems. While there are tools available to help start these kinds of programs, the infrastructure and staffing to accomplish this is rarely present. Some estimates suggest that as many as 50% of patients have SUD issues, no matter whatever other primary medical problem there might be. A basic mental heath patient in-take screening tool could help identify these concerns.

Increasing access to care One recent positive development is the new 988 Lifeline. Going live on July, 16, 2022, this nationwide service follows NAMI’s standard of care and is billed as “a direct connection to compassionate accessible care.” Designed to strengthen and expand the National Suicide Prevention Hotline, this 24/7 service will serve and support anyone experiencing mental healthrelated distress. Funding for the program comes through the Substance Abuse and Mental Health Services Administration (SAMHSA). They envision a robust crisis care response system that will link callers across the country to community-based providers and resources that can deliver a full range of crisis care service. There are expected growing pains, as there were rolling out 911, but the hope is to help address the growing mental health crisis; this action is an example of the scope and serious nature of the challenges this presents. Another area of emerging awareness, and crisis, involves pediatric mental health. It is now estimated that one in seven children aged 10-19 has some kind of mental illness with depression, anxiety or behavioral disorders leading the way. Almost 20% of U.S. high school students have given serious thought to suicide and almost 10% have actually tried to kill themselves. Evidence clearly shows a sharp increase in pediatric behavioral issues over the past 15 years, despite some calling it a hoax. Many factors for the increase can be cited, but there have also been many outstanding responses. Children require a different approach to treating behavioral health issues, and many medications for adults are not appropriate for developing brains. One recent response that is proving beneficial is the development of the school-based health center and incorporating behavioral health services into these centers. It is an expansion on school nurses who may have to visit several schools each week and can work with a variety of community resources. As an example of this, our organization has been working for the past five years with school teachers in Brookings to help them understand ways they can assist students who may be facing behavioral health issues. We have recently expanded this outreach to include a middle school in Sioux Falls. The growing creation of dedicated adolescent behavioral health inpatient treatment facilities, and dedicating sections of hospitals to this use, further illustrates the scope and importance of the issue. Children whose issues can be identified and treated early in life can minimize the development of chronic conditions later in life that can have serious adverse effects on their overall health.

Dedicated facilities Additionally, and importantly, the creation of new modern facilities addresses several issues. On a very basic level, these facilities build awareness around the

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serious nature of behavioral health treatment and foster acceptance replacing health concerns and must be treated with equity and awareness of the stigma. Depression is no different than high blood pressure or diabetes and unique challenges they may face. should not be viewed as a weakness. Psychiatry was often confined to a As we move forward, solving the many challenges facing the delivery broom closet at the back of the top floor of a hospital, a mistake leading to of behavioral health care will require building new partnerships. As an many downstream complications that are slowly industry, this will mean new ways of involving being corrected. Our hospital, Avera Behavioral and working with employers, communities, payers Health Hospital, was originally constructed in and state government. Each of these entities has a 2006 to serve all behavioral health care needs in vested interest in everyone’s individual health and, our area; recently we added 60,000 square feet, as we have discussed, behavioral health is a big part Simple mental health baseline which includes 24/7 behavioral health urgent care of overall health. Each of these entities must be data should be a part of every and youth addiction care services. We now have encouraged to continue their work in removing the patient’s medical record. almost 150 inpatient beds and the facility is truly a stigma a person may feel around seeking help for world-class destination for mental health services. behavioral health care concerns. Public and private People come from all over the country to study our partnerships are an incredibly effective way to help model, and we hope it will lead to similar advances meet this challenge. We must all work together to in other markets. raise awareness of what these concerns are and how Perhaps we have proven the Field of Dreams maxim of “if you build it, they will come,” but that does not address the lack of behavioral health providers, especially in the outstate areas. There it becomes the de facto proxy of primary care providers to prescribe medications around whose benefits and uses they may have received minimal training. PAs, nurse practitioners, masters level social workers, psychologists and others are also called into service and must all work together with as much coordination as possible to address the workforce shortage crisis. There are phone counseling services available that can be accessed during a patient visit that can be very helpful. Telemedicine applications to behavioral health have existed at Avera for 25 years, but that use was significantly increased during the pandemic. From the difficulties of the pandemic, it is important we use this as an opportunity to revolutionize the care of behavioral health patients. Developing the trust to make therapeutic progress can take time, but it is a pathway to care that is now more widely available. It should be explored and offered as an option, as it offers the flexibility to be incorporated into any clinical setting in a variety of ways. Most insurance continues to cover it, and while some patients simply do not have access to the internet or have limited literacy around computers and related technology, almost everyone can use a smart phone. The convenience of seeing a professional from their own home, or in the case of a farmer from their tractor, can have a significant appeal. In fact, research over the years has shown that some patients feel it is easier to build rapport with a therapist and to talk about difficult subjects via televideo instead of in person.

they may be treated. Thomas Otten, MA, is the behavioral health service line administrator for Avera Health, where for the past 22 years he has held positions relating to managing, improving and expanding behavioral health care within the hospital, university health center and the region.

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Addressing the future Another challenge facing the delivery of behavioral health care is an increasingly diversified patient base. Different cultures perceive and respond to common diagnoses in different ways. In our practice, we see this most clearly in serving the Native American population. We provide specialized training to providers and support staff around how to best communicate around sensitive and complex issues. Oftentimes, when dealing with behavioral health concerns, listening is as important, or even more important, than offering a care plan. Part of diversity training is learning what to listen for. It is also important to understand that diversity goes beyond race and must also include age, economic status, people with disabilities and more. People from all of these groups may have behavioral

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15


RESEARCH

The Efficacy of Medical Cannabis Removing the stigma, doing no harm BY STEPHEN DAHMER, MD

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hat if suddenly you could not prescribe NSAIDs, corticosteroids or beta blockers because “there is not enough research.” Think of the impact this would have on your patients. Unfortunately, many of your patients are missing the benefits of medical cannabis for this exact reason. As a profession we need to move beyond this. Cannabis is the most widely used psychoactive substance in the western world and has been used medicinally for at least 5,000 years. Phytotherapies (plant medicines), from common birch to willow bark, while materia medica for many of our modern pharmaceuticals, are also incredibly complex and difficult to research in their natural form. Nonetheless, current evidence supports exploring medical cannabis for patients that might benefit. Regardless of our personal opinions, our patients and peers are already making decisions about cannabis, potentially from questionable resources like doctor Google. Support for allowing medical cannabis is strong: 76% of doctors, 93% of Americans, and 83% of veterans support its legal medical use. At the time of writing this, 36 states have effective medical cannabis

laws, 13 states have laws pertaining to low-THC, high-CBD cannabis and no states have repealed effective medical cannabis laws. In some form, 49 states acknowledge the medical benefits of cannabis. Statutes establishing the medical cannabis program in Minnesota were enacted in 2014. Minnesota licensed physicians, advanced practice registered nurses and physician assistants can certify a patient’s qualifying medical condition. They must be enrolled in the Medical Cannabis Registry before certifying a patient’s qualifying condition. Of the 24,643 physicians with active Minnesota licenses, there are 3,739 practitioners that have registered for the medical cannabis program. Estimates as low as 1.4% of all those Minnesotans dealing with chronic pain had linkage to care or saw a provider that certified patients for medical cannabis.

Deceptive statistics Unfortunately, most research to date has been funded by NIDA (National Institute on Drug Abuse) and has focused on the harms associated with the plant, further supporting a long history of stigma. Nearly half of the 30 journals that have published the largest number of cannabis studies contain harm-associated words in their titles, such as “abuse,” “addictive/ addiction,” “dependence” and “forensic.” How might our opinion of any other medication might change if such resources were mobilized to study its potential for harm? In addition, research funds for products our patients are using are limited, and there is a daunting thicket of regulations to be negotiated at the federal level—those of the Food and Drug Administration (FDA) and the Drug Enforcement Administration (DEA)—and at the state level. Designation as a Schedule I substance in the Controlled Substance Act only adds even more complexity and expense to any clinical evaluation. Frustration with these barriers to research, enough to make even the head of NIDA reluctant to conduct studies on Schedule I drugs like marijuana because of the “cumbersome” rules that scientists face when investigating them, has even led me to accept a policy position with the U.S. Cannabis Council (USCC). In the United States prescribing medications is regulated the FDA, which most of us accept as an important system overdue for an overhaul. Of critical concern to the FDA and all of us is that the products we prescribe are safe. Naturally, we also assume they will present therapeutic value; however, here the bar can be surprisingly low. When Prozac went through its initial clinical trials, the patients reporting the best results were from the control group taking the placebo. We all know that not all patients respond the same to all medications. This is where the art of medicine comes in. When a patient first presents with hypertension, it usually takes some experimentation to find what will work best, and it oftentimes will require three different medications to achieve the best outcomes. Based on thousands of years of use, anecdotal reports and extensive research, we know that cannabis is a remarkably safe medication when used in the medical context. There is no known case of a lethal overdose, and we have been monitoring patients closely in Minnesota since the inception of the program.

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Sometimes there are no results. For the many patients who report positive outcomes, medications with far greater risk and downstream complications oftentimes are replaced. It is important to be aware of and open to this option.

Additional research Additional research holds the promise of better informing us of both benefits and risks of cannabis, but it isn’t so simple. The issue with cannabis is not a lack of research, but rather the complexity of plant medicines which offer a challenge to the well-designed, randomized controlled trials of single-constituent pharmaceuticals to which we are accustomed.

Supporting the patient

Much of what we do in clinical practice is not crystal clear. To approach health and disease in the absence of absolute clinical evidence is no new challenge. Unfortunately, many of us may feel, when dealing with cannabis, that we prefer to turn our backs to the matter—despite solid evidence that this plant might offer a unique and versatile tool for some of our most difficult to treat patients. As clinicians, including with cannabis, we need to weigh the needs of individual patients against broader social issues and make best decisions based on States acknowledge the nuanced individual data points specific to the patient. medical benefits of cannabis.

The cannabis plant can produce many therapeutic benefits and creates multiple research challenges when analyzed by the “One-Molecule, One-Target Paradigm” reductionist approach which has served us well in acute care medicine. Further research is paramount to optimizing the complex pharmacognosy of the plant as a form of personalized medicine while minimizing harm. Emerging research around the endocannabinoid system, a biological system in which endogenous lipid-based retrograde neurotransmitters bind to the proteins in the cannabis plant and are expressed throughout the vertebrate central nervous system and peripheral nervous system, supports a wide range of therapeutic benefits and are well worth further study.

Patients who are currently suffering from complicated and intractable conditions, who are unrelieved by currently available drugs and might find relief with cannabis, are those we see often at Cannabis Patient Centers (CPCs). These patients find little comfort in a promise of a better drug 10 years from now, and many have already tried FDA-approved synthetics without the same subjective, yet positive, clinical response. As with other therapies we offer, our assessment of the scientific data on the medical value is but one component of complex clinical decision-making. Don’t be fooled by the mainstream mantra that the evidence is not there. In 2017, over 10,000 studies were reviewed by the National Academies of The Efficacy of Medical Cannabis to page 264

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DIVERSITY, EQUITY AND INCLUSION

Advancing health care equity How Minnesota’s health plans are leading the way BY LUCAS NESSE, JD

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ealth equity–it’s giving all people and their communities the opportunity to achieve their highest level of health by eliminating gaps in care. It’s at the core of how we make health care work better for everyone.

Achieving equitable health outcomes is multilayered. It requires those of us in the health care industry to not only be culturally competent and antiracist in our policies and approaches, but that we are looking at all the factors that lead to successful outcomes in life–also known as the social drivers of health. This includes ensuring that people have ample access to good jobs, quality education, safe and stable housing, reliable transportation and many other life assets. The disproportionate impact of the COVID-19 pandemic on people of color is just one example of how health disparities have weighed heavily on our diverse communities. It reveals that there is much more work to do to improve access and deliver equitable care to everyone, but also that we must listen more to communities of color to better understand what their needs are. With this, Minnesota’s nonprofit health plans have a renewed focus on equity, creating a number of initiatives that will support

Minnesotans–particularly those from vulnerable communities – in their health care journey. I am grateful to highlight a few of those equity programs, along with the people who helped bring those initiatives to life.

HealthPartners Health Equity Champions teach ways to reduce bias, promote cultural humility HealthPartners has mobilized a grassroots movement to help close gaps in outcomes and educate colleagues on ways to reduce bias and promote cultural humility and anti-racism. Some 350 employees have stepped up to become Health Equity Champions, serving as a resource to advance equitable care throughout the enterprise. “Being welcome, included and valued is a basic human need and essential to health and well-being,” said HealthPartners Chief People Officer DeLinda Washington. “Our Health Equity Champions are a great resource as we work to educate our colleagues.” In addition to being ambassadors, the Health Equity Champions also help research, write and share the HealthPartners Culture Roots newsletter. Recent issues have focused on addressing disparities in depression screening and treatment, microaggressions and advancing LGBTQ health.

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DeLinda Washington, Chief People Officer, HealthPartners

In an issue on maternal and infant health disparities, the newsletter shared how HealthPartners is addressing bias to provide the best care and service to patients and members. HealthPartners team members collect data on births and prenatal and postpartum care and partner with community organizations to ensure patient needs are met.

The United States has some of the highest maternal and infant mortality rates among developed countries, especially among people of color. Black infants, for instance, are nearly four times as likely to die from complications related to low birthweight compared with white infants. In an effort to eliminate these disparities, HealthPartners has implemented structured, consistent practices for how clinician teams address the complications that can occur during pregnancy and childbirth. This includes things like managing hypertension during pregnancy, addressing abnormal fetal heart beats during labor and preventing and managing hemorrhaging that can happen after pregnancy. These structured approaches are called “safety bundles,” and include steps to: • Be ready. • Recognize and prevent. • Respond. • Report and learn.


Medica recommends new guideline to support more equitable renal care for Black Americans

people are also less likely to receive a transplant evaluation, have less access to the waitlist, spend longer time on the waitlist are less likely to survive on the waitlist and have lower rates of transplant success.

Medica is calling on its network of providers to adopt a new clinical guideline to diagnose and assess kidney disease that will lead to more equitable renal care and improved outcomes among Black Americans. The change is expected to reduce delays in referrals for specialist care and kidney transplants.

Charlotte G. Hovet, M.D., Sr. Medical Director for Quality, Care and Utilization Management at Medica

Medica’s Medical Policy Committee, comprised of credentialed Medicanetwork physicians in a variety of disciplines, voted to adopt a new guideline that recommends providers use either a direct measure of GFR or another method of estimating GFR using serum cystatin C which does not involve consideration of the patient’s race. The new guideline aligns with leading advocates for the advancement of equity in kidney care.

Medica is asking doctors to stop using the most common method to diagnose and assess the severity of kidney disease, which is estimated glomerular filtration rate (eGFR). Most providers calculate eGFR by assuming Black people generally have higher baseline levels of serum creatinine and therefore adjust their scores upward. This method can overestimate kidney function in people with African ancestry and lead to worse outcomes.

Blue Cross looks at how police interactions impact community health Blue Cross and Blue Shield of Minnesota is partnering with three local entrepreneurs to look at police interactions as a social driver of health. After Daunte Wright was fatally shot during a traffic stop by Brooklyn Center police in 2021, Twin Cities entrepreneurs Jazz Hampton, Esq., Andre Creighton and Mychal Frelix developed TurnSignl, an app connecting users to an attorney in real time if they are stopped by law enforcement or have a car accident. The attorney provides legal advice to the user.

“Using race as a factor when estimating kidney health is imprecise and disproportionately puts Black Americans at risk for severe health complications that could otherwise be treated,” said Senior Medical Director Charlotte G. Hovet, MD, who has been in charge of this effort for Medica.

“The three of us sat down and decided that with our professional and community backgrounds, we were uniquely placed to create a solution to help keep people’s rights protected, reduce stress, trauma and anxiety – and get everyone home safely,” said Hampton, co-founder and CEO of TurnSignl.

Black people are about three times more likely to develop kidney failure than white people, according to the National Kidney Foundation. Black

Equitable outcomes for all: to page 204

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3Equitable outcomes for all: from page 19 Blue Cross and Blue Shield of Minnesota, under the leadership of Bukata Hayes, its vice president of Racial and Health Equity, is funding TurnSignl as part of a five-year strategy with the city of Brooklyn Center that aims to improve racial and health equity. The pilot program will provide up to 3,000 residents free access to the TurnSignl app. Bukata Hayes, Vice President of Racial and Health Equity, Blue Cross and Blue Shield of Minnesota

UCare Community Response Team focuses on COVID, medical screenings in diverse areas Among UCare’s 630,000+ members are new Americans, BIPOC and LGBTQIA+ individuals and people with disabilities. The organization is proactively working to provide more inclusivity to them and anyone else facing greater social and economic burdens due to structural oppression. The organization formed a Community Response Team in early 2021, allowing team members to flex as necessary to members’ needs.

The technology is designed to protect driver’s rights, de-escalate roadside police interactions and help ensure both drivers and police officers return home safely.

Experts say police-involved shootings of Black people are having a negative effect on the wellbeing of communities, regardless of whether the residents had a personal connection to those incidents. “We know that 80% of health is determined by environment, neighborhoods, income and other stressors that exist outside of interactions with doctors and the health care system,” Hayes from Blue Cross said. “The impact of historical and contemporary trauma and systemic racism felt within BIPOC communities have long added increased mental health burdens to the already large overarching health inequities that exist throughout Minnesota. Our partnership with TurnSignl is an innovative, relevant and responsive way to address those priorities and create a healthier future for all.

The 15-plus member team is focusing on COVID-19 response, but it also screens for medical issues, mental health and substance use disorders or other social needs that may be adversely affected by the COVID-19 pandemic. Jennifer Garber, Vice President of Mental Health and Substance Use Disorder Services for UCare

The Community Response Team includes a manager, a team lead, case managers, community health workers and engagement specialists. Team members speak multiple languages, come from diverse cultural backgrounds and bring diverse skill sets to their role. “The pandemic accelerated our concerns about health equity for the members we serve,” said Jennifer Garber, UCare’s vice president of Mental

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Health and Substance Use Disorder Services, who’s been leading the response team. “We wanted to remove barriers to vaccinations such as transportation and language, and also to de-complicate all the conflicting information about COVID-19 for our members.”

• Identifying barriers and creating solutions to address them.

UCare Foundation team members and community relations staff also connect with trusted community leaders and organizations to reduce health inequities. For example, UCare recently operated 80 COVID-19 vaccine clinics in partnership with Hennepin Healthcare, The Stairstep Foundation and the MN Department of Health, providing 8,300 vaccines and 95,000 KN95 masks to individuals in underserved communities across the state.

• Attending appointments and advocating on members’ behalf.

Sanford Health Plan Navigators and Guides join members in their health care journey Sanford Health Plan is helping its members overcome barriers with an assist from dedicated staffers who join members in their health care journey. The organization uses health guides and health navigators to identify member challenges and develop solutions to connect them to the resources they need. Health guides are available to all members, while health navigators are a resource for members of Medicare Advantage from Align, powered by Sanford Health Plan. Sanford Health Guides, a no-cost benefit to plan members, help connect members to their providers, follow care plans and build relationships with them to better understand their barriers to care. Other services include: • Helping members with financial and prescription assistance.

• Building relationships with members’ care teams.

• Connecting members to resources in their communities. Leading these programs is Julie Smith, the plan’s executive director of Value Strategy and Clinical Operations, who added: “The guides and navigators form personal relationships with members to get to know their priorities and challenges and ensure they’re able to access appropriate care.” Sanford Health Plan serves patients and plan members across 250,000 square miles, which include Minnesota communities such as Thief River Falls, Bemidji, East Grand Forks, Canby and Worthington.

Julie Smith, Sanford Health Plan’s Executive Director of Value Strategy and Clinical Operations

These are just a few examples of how Minnesota’s nonprofit health plans are reaching BIPOC communities and vulnerable members. We know our work around health equity will never be done, but greatly reducing disparities must always be at the forefront of everything we do. Lucas Nesse, JD, is President and CEO of the Minnesota Council of Health Plans.

Health care equity – leading the way to better outcomes Health care equity is increasingly recognized as an important element in improving patient outcomes and lowering medical costs. Recognizing the wide range of issues that go into improving health care equity is the first step in removing barriers to care that should not exist. This article looks at some current initiatives to address these issues is brought to you by the Minnesota Council of Health Plans.

MINNESOTA PHYSICIAN JULY 2022

21


EMERGENCY MEDICINE

Fluorescence Microangiography A new tool in the management of frostbite BY THOMAS MASTERS, MD

A

Frostbite is caused when skin is exposed to cold temperatures. Parts of the body such as hands, feet, nose, and ears that are most exposed to the cold environment are the most commonly afflicted areas. After a period of cold-induced vasoconstriction, ice crystals form in the tissues. This freezing process causes direct cellular damage and disrupts perfusion.

Naturally, depending on the temperatures seen in the winter, hospitals may see greater or fewer victims of cold. In an average winter though, I suspect that every hospital in the state/region will see patients with hypothermia and frostbite, of varying degrees of severity. While there are no “hypothermia centers,” the standard of care is that severe frostbite will be managed at a burn center. This means that each winter, the state’s two burn centers (Regions Hospital in St Paul and Hennepin County Medical Center) will see dozens (if not hundreds) of patients with frostbite. These volumes have allowed these hospitals to develop expertise in the management of frostbite victims and to refine the care provided.

Unreliable diagnoses

nyone who has spent a winter in Minnesota can speak to the severity of this season. The upper Midwest has a reputation throughout the rest of the country for an artic-like climate with extreme cold and protracted periods of winter weather. While this weather undoubtedly wears on the emotions of the “denizens of the north,” winters also present physical threats. Every season, hypothermia and frostbite cause mortality and morbidity to people who have been caught out in the cold too long.

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Traditional descriptions of frostbite have been comparable to burn descriptions in that both describe depth of tissue involved. Patients presenting with first degree frostbite are described as having loss of sensation with reddened skin. Second degree frostbite victims have clear blistering. In third degree frostbite, victims have hemorrhagic blisters and skin darkeningto-necrosis. Finally, in forth degree frostbite, patients will have discolored skin and digits will be hard and frozen.

First and second degrees of frostbite are considered superficial whereas third and fourth degrees are considered deep. It is felt that the deeper the tissue involvement, the greater the threat of tissue and digit loss. Unfortunately, studies have shown that bedside evaluation of frostbite has proven unreliable. Making the appropriate diagnosis of severity is important as it impacts the therapies given. Rewarming is the mainstay of all frostbite therapy, regardless of the depth of tissue involved. When a patient presents with suspected frostbite, affected extremities are placed in warm water baths until rewarmed. After rewarming, the challenge is then deciding if thrombolytic medication is needed. Studies done in the early 2000s demonstrated that individuals with deep frostbite showed increased perfusion to digits using technetium (Tc)-99m agent through scintigraphy nuclear medicine bone scanning after receiving rTPA. Several additional subsequent studies have shown benefit of rTPA in improving patient outcomes and preventing amputations. At our facility, IV rTPA is the accepted therapy for individuals with deep frostbite when they present within 12 hours after rewarming.

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JULY 2022 MINNESOTA PHYSICIAN

The challenge though is making the diagnosis of deep frostbite. As noted earlier, determining deep frostbite is challenging when using clinical exam alone. As such, numerous other modalities have been used to confirm the involvement of deep tissues such as bones. These include angiography and bone scans. Unfortunately, studies like this that have shown the strongest correlation with eventual amputation are resource intensive. For example, nuclear medicine studies require specially trained technicians and nuclear material. Other more conventionally available studies such as x-rays have not shown to correlate well with clinical outcome. Since the pioneering work on rTPA, our facility has used the bone scans to evaluate patients with suspected deep frostbite. Our burn service has long considered this the gold standard to make the diagnosis. However, even in a tertiary referral center such as ours with an exceptional radiology department, staffing and budgetary challenges have made continuous availability of bone


scan challenging. Invariably, we have our coldest days with the most victims of frostbite on weekend nights when staffing is tightest. As such for the past two winters, we have been working to refine our approach to frostbite to optimize and expedite diagnosis of deep frostbite.

have found the device useful in monitoring a patient’s healing progress and helpful in assessing the efficacy of wound healing techniques.

Taking less than 5 minutes, the study is very well tolerated by the patients. The dye is metabolized by the liver and is therefore safe in patients with renal issues. There is no radiation involved. The only contra-indication is an iodine allergy. There have been multiple previous studies about the efficacy of fluorescence microangiography in plastic surgery patients and the device has been used intraoperatively evaluating bowel anastomoses. We

patients with frostbite, we did find that fluorescence microangiography correlated at least as well as bone scan with anticipating eventual amputation sites. As the physicians who work in the hyperbaric department also work in the emergency department, we felt that there may be an opportunity

After gaining multiple years of experience with fluorescence microangiography in wound patients, the hyperbaric and burn services began to collaborate to explore the role that Combing technologies hyperbaric medicine may play in patients who have In 2015, the department of hyperbaric medicine been diagnosed with deep frostbite. The rationale (as a part of HCMC’s limb preservation program) behind this therapy was that arterial occlusion is a began using fluorescence microangiography (Luna; part of the pathophysiology of frostbite that leads to Invariably, we have our coldest Stryker Corporation; Kalamazoo, Michigan) digit loss. Acute arterial occlusion is an approved days with the most victims to monitor the status of nonhealing wounds, of frostbite on weekend nights indication for therapy with hyperbaric oxygen and compromised flaps and grafts, crush injuries and when staffing is tightest. it stood to reason that patients with severe deep other injuries effecting perfusion. This study frostbite might benefit from therapy with hyperbaric involves injecting patients with an iodine-based dye oxygen. However, knowing that patients do not (ICG) that binds to blood proteins. This dye will always respond to therapies as expected, we utilized fluoresce under infra-red light and a camera on the periodic microangiography as they were receiving device will allow a clinician to visualize perfusion therapies with hyperbaric oxygen to monitor patient’s response to therapy. 3 – 5 mm below the skin. Images range from a bright white (denoting robust perfusion or inflammation) to a gray (suggesting compromised Improving decision-making. perfusion) to black (fully ischemic). While we are still evaluating whether hyperbaric oxygen has a role in treating

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Fluorescence Microangiography to page 244

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3Fluorescence Microangiography from page 23 to employ microangiography in the acute setting prior to receiving rTPA to evaluate patients for deep frostbite. The goal was to pair fluorescence microangiography (using a slightly different version of the Stryker device than we used in the subacute setting) with bone scans to help guide clinical decision making.

(about 3 minutes) there were occasions where the ICG could be re-dosed to track reperfusion.

We continue to learn about the role of microangiography in the management of frostbite, but the initial results seem encouraging. Certainly, the ease of access has been a benefit in obtaining relevant clinical data faster than the historical methods. Also, keeping the machine in the ED allows for roundMany patients with frostbite also -the-clock availability. We are optimistic that struggle with psychosocial and microangiography may allow for more prompt substance abuse issues. appropriate administration of rTPA with benefit to patient morbidity.

Given previous experience with microangiography and the importance of rewarming in the management of frostbite, the direction was to perform the study once the patient had been rewarmed. All emergency department physicians were oriented to the use of microangiography and the mechanics of the device itself. Hyperbaric physicians were available to provide real-time feedback, interpretations, and provided over-reads on each study.

In addition to the relative-safety of the study, microangiography has the additional benefit of being a performed at the bedside by the provider. This allows the clinician to evaluate the patient promptly and determine the appropriate course of action as it pertains to therapies. We found many instances where there was frank ischemia (with complete absence of fluorescence despite rewarming) in which the clinician felt compelled to give rTPA without delay. Additionally, given the short half-life of ICG

Many patients with frostbite also struggle with psychosocial and substance abuse issues, which makes long term evaluation and management challenging. However, the difficulties inherent with life in the upper Midwest will present an opportunity to provide excellent cutting edge care to a disease with significant consequences. Thomas Masters, MD, FACEP, FAAEM, specializes in Emergency Medicine and has a sub-specialty in Hyperbaric Medicine. His primary research interests include the use of hyperbaric oxygen for wound healing and limb preservation.

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3The Efficacy of Medical Cannabis from page 17 Sciences, Engineering and Medicine, which led them to opine: conclusive or substantial evidence that cannabis or cannabinoids are effective in the treatment of chronic pain, chemotherapy-induced nausea and vomiting and multiple sclerosis spasticity symptoms. There is no link between smoking cannabis and lung cancer, and there is no gateway effect.

on average per year, per state. Chronic pain has consistently been the most common patient-reported qualifying condition, making up over 60% of the patients we see.

Current studies

As Vireo-Health is a physician-founded and led company, we are adding to the evidence base for you to have more confidence in this tool Research has shown a 64% and offer it as a form of personalized medicine Cannabis is already a mainstream medicine. It decrease in opioid use among for your patients. Current projects include a chronic pain patients in Michigan is estimated there are currently over 5.4 million partnership with Dr. Julia Arnsten and her who used medical cannabis. state-legal medical cannabis patients in the team of opioid research experts at the Albert U.S. Illicit market users (a solid harm-reduction Einstein College of Medicine and Montefiore argument for clear cannabis policy) further eclipse Health System. This work involves playing an these numbers. Cannabis is readily available. active role in study development for a unique Being readily available, like other medications, National Institute of Health R01 $3.8 million researchers should determine the “five rights” as soon as possible and be grant for medical cannabis research. Listed on www.clinicaltrials.gov, proactive in minimizing harm. the MEMO-Medical Marijuana and Opioids Study is ongoing, but has One specific area of focus has been the impact of medical cannabis on already produced a number of peer-reviewed publications. In the January opioid use. Research has shown a 64% decrease in opioid use among chronic 2022 issue of “NEJM Catalyst,” an overview of the Montefiore Medical pain patients in Michigan who used medical cannabis. 48% of patients in Cannabis Program (MMCP), describes the future of medical cannabis another study reduced opioid use after three months of medical cannabis based on its five years’ experience of certifying more than 1,600 patients at treatment. In a 2016 survey, 78% of patients either reduced or stopped opioid an academic medical center. use altogether. For patients participating in Medicare Part D, when medical We are currently recruiting for a randomized double-blind placebocannabis was an option, 1,826 fewer doses of painkillers were prescribed controlled trial of vouchers for discounted medical cannabis soft-gel capsules. In this 4-arm study, “Do Discounted Vouchers for Medical Cannabis Reduce Opioid Use in Adults with Pain (ReLeaf-V) ReLeaf Trial,” participants must suffer from chronic pain, be over 18 years old and have utilized prescription opioids in the last 90 days. The trial lasts 14 weeks, and patients are randomized to a discounted voucher for one of the three soft-gel capsule medical cannabis products (THC-dominant, balanced THC and CBD, and CBD-dominant) or the placebo soft-gel capsule product.

Helping physicians communicate with physicians for over 30 years. MINNESOTA

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PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

U

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

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In Minnesota, Vireo Health is working with Monica Luciana, Angela Birnbaum and others at the University of Minnesota actively recruiting for a pre-post assessment of 90 adults, ages 35 to 55, who are prescribed medical cannabis to treat intractable pain. In the “Neurobehavioral Impacts of Medical Cannabis in Adults with Chronic Pain” study, outcome variables will include: • Neural structure measured using T1-weighted and T2-weighted MRI scans as well as function measured using functional resting state and task-based MRI. • Cognition (with an emphasis on learning, memory and executive functions). • Mental health, including symptoms of anxiety and depression. Pain relief, use of concomitant medications including prescribed opioids and quality of life indices will also be examined as secondary outcomes. Participants are actively recruited from CPCs in Minnesota and will be asked to complete four hours of measures prior to ingesting the first The Efficacy of Medical Cannabis to page 284


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3The Efficacy of Medical Cannabis from page 26

I encourage you to peruse the existing evidence base as well as the numerous ongoing studies related to the cannabis plant and its constituents. Don’t prescribed medical cannabis dose. This exciting and unique trial will further hesitate to reach out to us, if only to be better informed. We are at an examine the neurobehavioral impacts of medical cannabis on adults using exciting and pivotal moment which promises marked potential for both cannabis for chronic pain. help and harm to our patients. The plant is not going away, and the sooner we acknowledge Despite widespread and increasing use of this, the more positive impact we can make. both medical and recreational cannabis, many Through understanding cannabis better and physicians are unwilling to learn about and improving personalized medical research of therefore unprepared to discuss or recommend complex interventions in the future, it is still my these numerous benefits of medical cannabis to Neuropathic pain is a very difficult hope we can support our patients in exploring the problem with no easy solution. their patients. In efforts to address this, a two-day beneficial aspects of the plant while minimizing symposium for medical professionals interested potential for harm. in learning more about medical cannabis was hosted in Minnesota. The Spring into Cannabis Symposium was one of the first medical cannabisfocused events to also offer a Continuing Medical Education track to health care practitioners. At the symposium, physicians and researchers from around the country presented on key topics, including cannabis as an alternative to opioids, medical cannabis in neurology and mental health, pediatric uses of medical cannabis and more. Access to the same education from this event, along with other resources, is now available online at “https://visitgreengoods.com/cannabinology/” Yes, we need more research: well-designed condition, product and patient specific research. What is also needed is more physician involvement. To date, there have been no negative legal outcomes for providers supporting medical patients.

Stephen M. Dahmer, MD, is a family physician and since 2015 has served as chief medical officer of Vireo Health. He is also assistant clinical professor of family medicine and community health at the Icahn School of Medicine at Mount Sinai and director of holistic primary care in Scarsdale, New York.

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

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With more than 35 specialties, Olmsted Medical Center is known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: • Active Aging Services - Geriatric Medicine/Palliative Care • Dermatology • ENT - Otology

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29


3Changing the Future of Health Care

weakness, problems with balance or scoliosis. We treat all aspects of spinal disease for all ages.

from page 9

forefront of the specialty. You need to know about what’s new, up and coming, as well as what works and what doesn’t and why. You need to have solid expertise and be able to clearly explain foundational decision-making as it relates to spine care. The fellowship program adds a level of enthusiasm to what we do and a stimulation to be better. It’s a great pleasure to share one’s own sense of specialty and expertise with others. And it is satisfying to have a hand in changing health care for the future.

What about your program makes you the most proud?

It has been my honor to be the fellowship director at the Twin Cities Spine Center over the

“The decision is more important than the incision.”

as well. We invest heavily in education, as our 50 years have proven, as well as research and continued innovative techniques. We are very encouraged we have earned a reputation as a top program, as indicated by the sheer volume of applicants, the numerous calls we receive from applicants’ residency program directors and the feedback we receive from the applicants with whom we have met. This year, we “matched” with all of our top four candidates for the 2023-2024 fellowship year. The future is bright. Kevin J. Mullaney, MD, has been fellowship

What are some examples of reasons a

director of the John H. Moe Spine Fellowship

primary care physician would refer a

Program at the Twin Cities Spine Center since

patient to your practice?

2012. Dr. Mullaney completed his John Moe Spine

We are a surgically conservative spine specialty practice. We are experts in the care and decision making for patients with spinal pathology and deformity. At times, patients do benefit from surgical procedures. Oftentimes primary care providers refer patients to us that have radiating arm or leg pain with or without

last decade. While this is only a small fraction of the time since this program was created by Dr. Moe, I can state with certainty our program has always held the patient first and we never apply shortcuts to their care. We have always sought to be the leader in spine care not only in the region, but in the national and international forums

Fellowship in 2004.

Opening January 2023

Clinic space and practice opportunities available Matt Brandt | 715-531-6862 mbrandt@hudsonphysicians.com

HudsonMedicalCenter MINNESOTA PHYSICIAN JULY 2022

Hudson MedicalCenter

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Pictured left to right: R. Scott Stayner, MD, PhD, David Schultz, MD, Peter Schultz, MD, MPH

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