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MINNESOTA

DECEMBER 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 09

A practice built on principle Taking a stand BY JEANNE MROZEK, MD

A

fter 35 years of service, 12,775 overnight shifts, and countless life-changing encounters with families and patients at our Children’s Hospital Minneapolis location, Minnesota Neonatal Physicians is moving into the North and West Metro. It would be lying to say this change isn’t difficult and emotional. The relationships we’ve built with medical staff and families of medically fragile newborns are deep and, we hope, lasting.

Physician unionization A path worth considering

A practice built on principle to page 164

BY MANDY RAE HARTZ, MA “Hospital administrators easily manipulated physicians, treating them as if they were hired hands. Insurance companies were dealing with them as if they were employees. Government programs … controlled key aspects of doctors’ work, told them how much they would be paid, and what procedures they would be paid for.” —Sanford A. Marcus, MD, founding physician of the Union of American Physicians and Dentists (AFL-CIO)

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My first job out of fellowship training was in another state, as a hospital-employed neonatologist in a community hospital. Our family of five, including a six-month-old, picked up our roots to begin life in a new state, away from friends and family. I started the job with optimism and energy, ready to share my knowledge and skills, gleaned over 14 years of post-high school education, with the patients, families, and staff in my new home. I knew how to work hard, how to share childrearing responsibilities with my spouse, and most

r. Marcus’ reflection on why he spearheaded his physician’s union with the AFL-CIO in 1973 resonates today. As the health care industry has grown and consolidated into fewer large players, physicians face ever-increasing challenges to Physician unionization to page 104


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New Location. Efficient Space. Medical Neighborhood. Optimal Care. We focus exclusively on healthcare real estate and have a number of space options that may be right for you. We help your practice design space that works for you and your patients. Our healthcare team has proven results and will guide you through the process of getting the right space for your practice. Leased By:

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DECEMBER 2018 MINNESOTA PHYSICIAN

Owned By:


ST 51 SESSION DECEMBER 2018

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Volume XXXII, Number 9

COVER FEATURES Physician unionization

A practice built on principle

By Mandy Rae Hartz, MA

By Jeanne Mrozek, MD

A path worth considering

Taking a stand

DEPARTMENTS CAPSULES

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MEDICUS

7

INTERVIEW

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Challenges and rewards of independent practice Keith A. Oelschlager, MD Entira Family Clinics

ADMINISTRATION Regaining the voice of our profession

ELECTRONIC HEALTH RECORDS Leveraging your information resources

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Correcting the curve

Put your data to work By Sara Richter, MS, and Samantha Carlson, MPH

Thursday, April 25, 2019, 1-4 p.m. The Gallery, Hilton Minneapolis | 1101 Marquette Avenue South BACKGROUND AND FOCUS:

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A clinic’s journey to unionize By Emily Onello, MD, and Louise Curnow, PA-C

SPECIAL FOCUS: RURAL HEALTH Supporting unpaid caregivers in rural Minnesota

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What physicians should know By Carrie Henning-Smith, PhD, MPH, MSW; and Megan Lahr, MPH

Rural Health Innovations

OBJECTIVES:

By Kami Norland, MA, ATR

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Improving access and outcomes By Muhammad Fareed K. Suri, MBBS

www.MPPUB.COM PUBLISHER

______________________________________________________________

Astonishing advances in medical science are coming more quickly than they can be incorporated into best practice. Unfortunately, another area of rapid advance involves social disparities. Social and economic factors can account for the greatest single element of being healthy. Whether we call it health equity, health inequity, social disparity, health disparity, or any related term, matters of race, age, disability, sexual orientation, geography, and economics create barriers to care with measurable negative downstream consequences. The number of people who are suffering and dying needlessly is growing and in five years projects as a major epidemic.

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An integrative behavioral health program

Stroke and telehealth

SOCIAL DISPARITIES IN HEALTH CARE

Mike Starnes, mstarnes@mppub.com

EDITOR___________________________________________________ Richard Ericson, rericson@mppub.com ASSOCIATE EDITOR_________________________ Amanda Marlow, amarlow@mppub.com ART DIRECTOR_______________________________________________Scotty Town, stown@mppub.com ACCOUNT EXECUTIVE_______________________________ Shawn Boyd, sboyd@mppub.com

To solve any problem we must first understand the question, and we will start by defining the terms. We will examine the reasons certain populations are alienated and discouraged by our health care delivery system. We will share some of the extensive work that has been done to address these issues and discuss why it is not being implemented. We will discuss the role that every health care industry sector plays in creating these disparities and ways they can work together to correct them. Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub.com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX

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

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Please mail, call in, or fax your registration! • mppub.com MINNESOTA PHYSICIAN DECEMBER 2018

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CAPSULES

University of Minnesota Teams Up to Commercialize Technology for Early Detection of Alzheimer’s A collaboration and licensing agreement between the University of Minnesota and medical imaging company RetiSpec will allow the company to further develop and bring to market a University-developed technology for early detection of Alzheimer’s disease. Through the collaboration, Toronto, Canada-based startup RetiSpec will gain exclusive access to the imaging system developed by researchers in the Center for Drug Design (CDD) in the University’s College of Pharmacy and licensed through U of M Technology Commercialization. The organizations say this will allow RetiSpec to expand its technical knowledge base and accelerate time-to-market for a commercially viable screening tool for Alzheimer’s disease.

The system, which has been confirmed in preclinical studies and a human pilot study, scans a patient’s eye to detect small quantities of a protein called beta amyloid long before they collect in large enough clusters to form plaques in the brain, which is a biological sign of Alzheimer’s disease progression. “This is the first diagnostic method developed to detect signs of Alzheimer’s well before plaques form in the brain and patients begin to exhibit the outwardly observable symptoms of this devastating disease, such as disorientation and memory loss,” said Robert Vince, PhD, one of three CDD researchers who developed the system. “We are excited by the potential early detection holds in giving existing treatments the best chance of success and opening the doors to the development of new drug therapies.” In preclinical studies at the University, the system detected Alzheimer’s disease in mice 25 percent

sooner than methods based on visible plaque formation. In addition, a recent successful pilot clinical study demonstrated the capabilities of the technology, with 31 human participants both with and without Alzheimer’s. Next, RetiSpec will integrate the early detection technology into its own machine learning platform, allowing it to perform data analysis as it tests the combined technologies in diagnosing Alzheimer’s during an upcoming three-site clinical trial.

Tool Will Provide Real-Time Information to Improve Opioid Overdose Prevention Efforts A new initiative has launched in Hennepin County that will link first responders on scene to a mapping tool in which they can enter real-time information about suspected overdoses. The tool, called OD MAP, will make this information

available to analysts and other response personnel so they can track suspected overdoses more accurately, detect spikes in geographical areas, and create strategic response plans. The tool allows first responders to quickly enter important data into the system by identifying whether or not an incident was fatal or non-fatal, and whether or not naloxone was administered. No personal identifying information is entered, and the data is not meant to be used for investigations. The goal is to use it as a prevention and education tool that will allow first responders to focus drug prevention outreach in areas that are being most affected by the opioid epidemic. According to the Hennepin County Sheriff Rich Stanek, the tool will allow them to access this information much faster than they are able to currently, which can take weeks or months. “I believe that OD MAP will be our biggest step forward in the fight against the opioid epidemic, providing

COLON CARE THEY’LL WANT TO TELL THEIR FRIENDS ABOUT. M N G A S T R O S M A R T FA C T:

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DECEMBER 2018 MINNESOTA PHYSICIAN

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CAPSULES

first responders with information we have never had access to before,” said Stanek. “Our current data can take weeks or months to gather, but this will provide missing information regarding the trends happening this week, or even during the last 24 hours. With this real-time information, I believe our agencies can begin to curb opioid overdoses before the 911 call is ever made.”

MPH, executive director of PCORI. “The ultimate goal for PCORI and AHRQ is to bring rigorous science to produce generalizable evidence that improves the quality of care and the health of individuals, both within and beyond these centers of excellence.”

Funding Awards Will Support Learning Health Systems Researchers

Shriners Hospitals for Children– Twin Cities and Gillette Children’s Specialty Healthcare are expanding their collaboration for treatment of children with orthopedic and neuromuscular conditions. The two organizations, which will remain independent, have worked together since the 1920s and are now expanding the collaboration into surgery and inpatient care. In November, Shriners Hospitals for Children–Twin Cities began performing the majority of their surgeries and inpatient stays at Gillette. Patients of Shriners Hospitals for Children– Twin Cities continue to receive outpatient services including physician visits, child life, radiology exams, rehabilitation, orthotics, and prosthetics at the Shriners location in Minneapolis. The move follows nationwide trends away from inpatient care. Shriners will eliminate 35 full time positions and will no longer be a full-service hospital after the change goes into effect.

A Minnesota-based program is one of 11 institutions selected to receive a total of $40 million in awards over five years from the Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI) to support the training of researchers to conduct patient-centered outcomes research within learning health systems (LHS). The Minnesota Learning Health System Mentored Career Development Program (MN-LHS), a collaboration between the University of Minnesota, Mayo Clinic, and Hennepin Health, is one of the new LHS Centers of Excellence. MN-LHS is designed to train health care practice-embedded researchers who will systematically generate, adopt, and apply evidence quickly to improve personalization, quality, equity, and outcomes of care. The purpose of the program is to create a dynamic training environment for scholars to learn in, and meaningfully improve, health care systems serving children, the elderly, underrepresented minorities, rural populations, veterans, and those with multimorbidity. “The researchers supported by this initiative will support efforts to bring health care systems, clinicians, and patients fully into the process of developing the data needed to better support personalized medical decision-making,” said Joe Selby, MD,

Shriners, Gillette Expand Collaboration

Partnership Brings Expanded Cardiac Services to Brainerd Lakes Area Essentia Health is partnering with the Minneapolis Heart Institute to expand cardiac care in the Brainerd lakes area. Specialists from the Minneapolis Heart Institute have begun working at the Marilyn Covey Heart & Vascular Center at Essentia Health-St. Joseph’s Medical Center in Brainerd. In addition, the Minneapolis Heart Institute will be adding

COMMUNITY C AREGIVERS REQUEST FOR NOMINATION Publication Date: March 2019

Recognizing Minnesota physician volunteers Minnesota Physician Publishing announces our annual Community Caregivers feature. We are seeking nominations of Minnesota physicians who have volunteered medical services in communities in Minnesota, in the U.S., or abroad. The nominees selected for recognition will be featured in the March 2019 edition of Minnesota Physician, the region’s most widely read medical publication. To qualify, nominees should be physicians practicing in Minnesota who have performed medical services, either locally or abroad, during 2018. Both teams and individual physicians may be nominated; if the nomination is for a team, please designate one or two physicians who could fill out a questionnaire if selected for the feature. To nominate a physician or team of physicians, please fill out the nomination form at mppub.com/community-caregivers.html or mail the form below by January 9, 2019.

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

Brief description of the physician’s medical volunteer service:

Nomination submitted by: Phone #: Email: Send to: Minnesota Physician Publishing: Community Caregivers 2812 East 26th Street, Minneapolis, MN 55406 Online form: www.mppub.com/community-caregivers.html Fax: 612.728.8601 Email: rericson@mppub.com For more information, call 612.728.8600

www.mppub.com

MINNESOTA PHYSICIAN DECEMBER 2018

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CAPSULES

to existing Essentia Health services through in-person and telecare consultations at Essentia Health St. Joseph’s–Brainerd Clinic. Patients will be able to consult with subspecialties in areas such as electrophysiology, advanced heart failure, cardiothoracic surgery, vascular disease, and valve and structural heart disease. They can begin making appointments at the Brainerd clinic in late October.

Mayo Clinic Locations in Waseca And Fairmont Expanding Services Two Mayo Clinic locations are expanding services to better meet the needs of their respective communities. Mayo Clinic Health System in Fairmont opened its new urgent care department on Nov. 2, when it also discontinued operations at The Clinic at Walmart as part of Mayo Clinic Health System’s transition plan announced in May.

“Urgent care allows our patients access to additional same-day care right here in Fairmont,” said Marie Morris, MD, medical director of Mayo Clinic Health System in Fairmont. “We’re able to treat patients of all ages and those with slightly more complex needs in the urgent care setting. The Clinic at Walmart didn’t provide as many treatment options for patients and had certain age restrictions.” In addition, Mayo Clinic Health System in Waseca is expanding its family medicine practice, planning to add a significant number of sameday family medicine appointments as well as new providers to its primary care team as of Dec. 23. In effect, Mayo Clinic says its Waseca location will transition away from urgent care to accommodate the new family medicine model. As part of the transition, weekend urgent care services were discontinued in mid-October, but weekday services will remain available through Dec. 21.

Construction Begins on Ridgeview’s New Emergency Center in Waconia Ridgeview Medical Center broke ground in late October on its new Norman and Ann Hoffman Emergency Center on its Waconia campus. The $18.8 million, 23,000-squarefoot remodel and emergency department expansion is slated for completion in 2020. “This is one of the most exciting and important improvements we will make to Ridgeview’s Waconia campus,” said Mike Phelps, president and CEO of Ridgeview Medical Center. “Ridgeview and the community are deeply grateful to Norman and Ann Hoffman for their lead gift to make this significant project possible.” The expansion will include improved patient experience and privacy, increased treatment and support space, eight observation rooms, four

behavioral health emergency department rooms, and space for cardiac/ pulmonary rehabilitation services.

Allina to Open Third Clinic Location in Uptown Allina Health is planning to open a third clinic in the Uptown neighborhood of Minneapolis. The 11,000-square-foot clinic will offer primary care, mental health care, and women’s health services. Allina extensively renovated another location in the neighborhood, the Isles Clinic, last summer. It also operates a clinic in the Uptown Row building on Lake Street. The new clinic will be located on the second floor of Calhoun Village at 3200 W. Lake St. and open in spring of 2019.

V Autism and Obstructive sleep apnea are now approved conditions V

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

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

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

• Intractable Pain

• Obstructive sleep apnea

• Autism

• Post-Traumatic Stress Disorder

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

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

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

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

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DECEMBER 2018 MINNESOTA PHYSICIAN


MEDICUS

Minnesota Chorale A New Year Celebration

Charles Lazarus

Kejal Kantarci, MD, MS, and David T. Jones, MD, of Mayo Clinic have received de Leon Prizes in Neuroimaging from the Alzheimer’s Association. The awards are presented to those who are judged to have published the best paper in their peer group in any peer-reviewed journal on the topic of advanced medical imaging to show diseases that affect or destroy nerve cells in the brains of people with diseases such as Alzheimer’s, Parkinson’s, and ALS. Kantarci, director of the neuroimaging core of the Mayo Clinic Alzheimer’s Disease Research Center and professor of radiology, received the Senior Scientist de Leon Prize for her paper “White Matter Integrity on DTI and the Pathologic Staging of Alzheimer’s Disease,” published in Neurology of Aging in August 2017. Her research focuses on using advanced brain imaging technology for early diagnosis of dementia in patients. She earned her medical degree at Marmara University School of Medicine. Jones, senior associate consultant in the department of neurology and assistant professor of neurology and radiology at the Mayo Clinic College of Medicine and Science, received the New Investigator de Leon Prize for his paper “Tau, Amyloid, and Cascading Network Failure Across the Alzheimer’s Disease Spectrum,” published in Cortex in December 2017. His research focuses on developing methods to derive measurements of brain connectivity and to evaluate their potential as biomarkers in healthy aging and diseases such as Alzheimer’s and other dementias. Jones earned his medical degree at Georgetown University School of Medicine.

See full concert schedule online.

Gregory Porter

Kelly Han, MD, director of advanced congenital cardiac imaging at the Minneapolis Heart Institute and Children’s Heart Clinic at Minnesota Children’s Hospital, has been selected as the first recipient of The Jon DeHaan Foundation Award for Innovation in Cardiology. She is being recognized for making significant contributions to improving the safety and quality of imaging congenital heart disease and treating and caring for adult women with congenital heart disease who either want to become pregnant or have become pregnant. Han received $200,000 as part of the award to expand services, research, and care. She earned her medical degree at the University of Wisconsin Medical School.

HOME H O L I DAYS e for th

Home for the Holidays

Judith Eckerle, MD, director of the Adoption Medicine Clinic at the University of Minnesota Medical School, has been nominated as a 2018 Congressional Coalition on Adoption Institute Angels in Adoption Honoree for her work with international and domestically adopted and foster care children in Minnesota. Eckerle has been on the forefront of change with her research and clinical care as well as her advocacy for change in adoption policy. Currently, she says the clinic is embarking on a partnership grant with the Minnesota Department of Human Survives for the next four years that could double their capacity. She was nominated by U.S. Sen. Amy Klobuchar and joined other nominees in Washington, D.C., to meet with governmental leaders. Eckerle earned her medical degree at the Medical College of Wisconsin.

Nat “King” Cole and Me, starring Gregory Porter with the Minnesota Orchestra

Sat Dec 1 8pm

A Christmas Oratorio

Sat Dec 8 8pm / Sun Dec 9 2pm

Home for the Holidays

Fri Dec 14 8pm / Sun Dec 16 2pm / Thu Dec 20 11am

A Big, Brassy Christmas with Charles Lazarus* Sat Dec 15 8pm

A New Year Celebration: Vänskä Conducts Bernstein, Copland and Gershwin Mon Dec 31 8:30pm

Includes a midnight countdown and champagne toast! *Please note: the Minnesota Orchestra does not perform on this program.

612-371-5656 / minnesotaorchestra.org Orchestra Hall / #mnorch PHOTOS Lazarus & Hicks: Travis Anderson Photo. Other photo credits available online.

MINNESOTA PHYSICIAN DECEMBER 2018

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INTERVIEW

Challenges and rewards of independent practice Keith A. Oelschlager, MD Entira Family Clinics Please tell us a little about the history of Entira Family Clinics.

management. Third, since we are not a nonprofit, new residents cannot participate in the government loan forgiveness program. Fourth, we do not have the size to negotiate more favorable contracts with insurance companies.

Minnhealth Family Physicians was formed in 1986 with the merger of Bellaire and Maplewood family clinics. Afton Family Clinic joined in 1987, and Larpenteur Family Clinic joined in 1991. East Metro Family Practice was formed in 1995 with the merger of the Gorman Clinic, Inver Grove Family Clinic, Woodland Family Clinic, Arcade Family Clinic, and Maryland Family Clinic. Highland Family Clinic joined in 1999. Minnhealth and East Metro Family clinics merged in 2008 to form Family Health Services Minnesota. The name of Entira Family Clinics was adopted in 2012. We serve the St. Paul and east metro communities with 12 primary care clinics and two express/retail clinics located in Hy-Vee stores.

Independence allows us to choose what is best for patient care. We can choose the best hospital and specialty care based on the Triple Aim: quality, patient satisfaction, and cost. We are not limited to referring inside a large, vertically integrated system. Our constraints are those of the insurance plan the patient has chosen. What are some of the challenges posed by maintaining your independent status? The largest challenge is financial. T here a re not deep pockets backing us up. The physician shareholders’ salary makes up the not-so-deep pockets that balance the books at the end of the year. Second, we do not have the luxury of a large analytics department to help with population

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DECEMBER 2018 MINNESOTA PHYSICIAN

“...” Independence allows us to choose what is best for patient care. “...”

In an era of frustrating health care policies and pressure to join big systems, why is it important to maintain the independent private practice of primary care medicine?

What are some of the rewards? Knowing that we have some of the best quality metrics, the best patient satisfaction, and can provide care at one of the lowest price points in the state. Our physician management team all practices at least three-quarter time. This allows those who make decisions to be on the front line of patient care and make better care and provider decisions. Our staff take tremendous pride in caring for our patients, and are extremely loyal to the organization. Our providers are on clinical practice committees that develop our patient care strategies, rather than having a distant organization dictating these.

Entira recently joined Fairview Physician Associates Network. What are your plans to remain an independent family practice as part of the network? Joining Fairview Physician Associates (FPA) Network is part of our strategy to remain independent. It provides us access to a group of patients that are within their narrow network. Our contracts that will go through FPA will account for about 9 percent of our business. These contracts through FPA give us better reimbursement, which puts us in a better financial position. This is not the only collaborative arrangement we are part of. We have recently entered into an arrangement with North Memorial’s ACO (accountable care organization) that serves the Medicare population. We participate in an IHP (Integrated Health Partnership) with HealthEast to provide care for the Medicaid population. We also have strong working relationships with HealthPartners and Blue Cross and Blue Shield of Minnesota. We are playing the field to find the best way to provide care for our patients and the resources to remain independent. How does your clinic design facilitate optimal care? I work out of the Vadnais Heights clinic. We have the clinic divided into teams that work in hallways, with workstations in line of sight of the exam rooms. With the electronic medical record, much of the communication within care teams uses that medium. Entira emphasizes team-based patient communication, with individual medical professionals setting standards for personal interactions. Please describe how this works. Our care teams consist of a physician, physician assistant (PA), or nurse practitioner (NP) working with a certified medical assistant (CMA). The PAs and NPs are supervised by the physicians in that office. These teams are


Family practice differs from other specialties. Please describe Entira’s philosophy in treating family members who might span several generations. Family practice is unique in that we provide a relationship with patients longitudinally. It is not uncommon to care for three and occasionally four generations in one family. This puts us in the unique position to understand the dynamics of the family support or lack thereof. These strong relationships allow trust to develop and help during difficult times and when making hard decisions. How does Entira address the needs of patients with behavioral health issues? Family practice providers are trained to provide short-term counseling and medication

management for many mental health problems. Many of our sites have a therapist or counselor present to assist in mental health concerns. Our

“...” some of the best We have quality metrics, the best patient satisfaction, and can provide care at one of the lowest price points. “...”

supported by a care manager and medical home registered nurse. Communication between these team members is conducted via email and direct conversations. The team determines which team member communicates with the patients depending on the issue.

care managers assist patients in finding mental health resources, when needed, outside of Entira. The Entira mission is centered around community-based care. As issues of health care equity become more extreme, how do you deal with them? We do not have resources to act as a social service agency. Our care coordinators assist patients in getting plugged into the local, county, or state agencies that can help them. We have remained committed to staying in underserved areas of St.

Paul. Our newest clinic under development will be in one of these areas. In a profession with a growing litany of problems, what advice can you offer your fellow physicians that may provide some hope? The enjoyment is the relationships. These include patients, clinic staff, and other providers. The solution to health care will not come from Washington; it will come from building relationships within the Entira family and then extending those relationships to health care systems and health plans. Through these collaborative relationships, we can reduce duplication of services and waste. Keith A. Oelschlager, MD, is CEO of Entira Family Clinics, where he has practiced for 30 years. Board-certified in family practice by the American Board of Family Medicine, he is a member of the American Academy of Family Physicians and the Minnesota Medical Association. A 1979 graduate of the University of Minnesota Medical School, he completed a family practice residency in 1982 at Methodist Hospital in St Louis Park.

MINNESOTA PHYSICIAN DECEMBER 2018

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3Physician unionization from cover

computerization of practice (24 percent); insufficient compensation (24 percent); lack of control/autonomy (21 percent); and feeling like just a cog in a wheel (20 percent).

retain decision-making power over their schedules, their personal economics, and even their patient care practices. In the current environment of corporate Physicians won’t be surprised to see that 56 percent of their colleagues mega-mergers, physicians are hired as employees, and pay is dictated by report having too many bureaucratic tasks like charting and paperwork, 39 unstable and unfair reimbursement practices. It’s percent think they spend too many hours at work, no wonder that as private practicing physicians or 26 percent feel disrespected by employers and and those employed by larger systems alike are administrators. However, they may be surprised struggling to meet their moral and professional that solutions to these issues can be found in obligation to deliver the best care to their patients, union contracts covering the wages, benefits, and Physicians face ever-increasing some are turning to organized labor to regain working conditions of union physicians and other challenges to retain control over their professional environments. health care workers. “Large corporations are stripping physicians of professionalism and belittling our management role,” said Niran Al-Agba, MD, a pediatrician in Washington State who sees collaboration between unions and physicians as a path forward.

decision-making power.

This diminished role in decision-making is taking a toll on our country’s physicians. According to this year’s edition of Medscape’s National Physician Burnout and Depression Report, an alarming 42 percent of respondents reported burnout, affecting physicians across a wide variety of specialties. The reasons for this turmoil run deep. The top seven factors cited by survey respondents: too many bureaucratic tasks such as charting and paperwork (56 percent); spending too many hours at work (39 percent); lack of respect from administrators/employees, colleagues, or staff (26 percent); increasing

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DECEMBER 2018 MINNESOTA PHYSICIAN

Dr. Al-Agba ventured, “Physicians certainly qualify as an industry sector whose bargaining power has fallen below the value of their effort. That’s where a physicians’ union could come in.” A labor union is a group of workers who come together to use their collective strength to achieve common objectives such as safer working conditions, higher pay and benefits, and decision-making power over the practices that govern their work. Generally speaking, individual employees—even those with exceptional educational and personal backgrounds, like physicians—have less bargaining power and fewer opportunities to negotiate and enforce fair working conditions than their union-represented counterparts.

Enforceable collective bargaining agreements A collective bargaining agreement (CBA) is an agreement between a single employer and the union on behalf of a group of employees, or “bargaining unit.” The National Labor Relations Board (NLRB), which decided in 1974 that non-supervisory physicians were eligible to organize labor unions, determines and defines individual bargaining units by considering whether that group of employees has a “community of interest,” or common characteristics such as: skills and education; supervisors or human resources; and wages, benefits, and other terms of employment. Once a majority of employees elects to form their union, leaders chosen by their physician peers bargain alongside professional union negotiators with hospital administrators in order to reach the terms and conditions of the CBA. In this way, frontline physicians identify the issues impacting their workplace and utilize their expertise to negotiate an agreement that is uniquely tailored to meet the needs of a particular group of health care professionals. The unionized health professionals at Lake Superior Community Health Center (LSCHC), including physicians, went through this process when they joined the United Steelworkers Union in Minnesota. Emily Onello, MD, and Louise Curnow, PA-C, were strong advocates during the organizing campaign and served as frontline representatives on the bargaining committee, and entered union contract negotiations in 2013. “We were already highly motivated to make improvements for our colleagues and patients,” said Curnow, “but knowing that it was illegal for the employer to retaliate against us for union activity gave us an extra boost.” They worked with their fellow health care professionals (MDs, NPs, PAs, RNs, LICSWs) to bargain an agreement that addressed, among other things, a more fair pay system that better reflected the needs and insurance status


of the clinic’s patient population and a scheduling system that recognized the negative effects on providers when the patient schedule overflows and provider admin time is minimal. According to Curnow, “We were also able to have some small but meaningful impact on scheduling meetings during regular work hours and not during charting time, which provided us with better work-life balance.” The ability of union physicians and practitioners at LSCHC to influence policies contrasts sharply with an experience earlier this year of Anh Le, MD, an internal medicine and pediatric-trained physician practicing in California.

Unions as the future Public support for unions is growing. According to a January 2017 survey conducted by the Pew Research Center, 60 percent of Americans view unionization favorably, the highest indicator in more than a decade. The confluence of public support, physician burnout, and the fractured state of our country’s health care system could signal an approaching surge in organizing for physicians. Union organizers, negotiators, and policy experts stand at the ready. The next step is one physicians must take.

Individual physicians may be reluctant to consider unionization.

Without consulting physicians, Dr. Le’s employer implemented a new scheduling policy which, among other things, replaced already limited administrative time with additional patient visits. This is the time that “we often use to answer patient messages, review lab results, or even just to catch up on seeing patients,” Dr. Le said. Frustrated with the changes, she and her colleagues met with administration. Despite the well-reasoned data for why the new policy did not make sense for physicians or for patients, Dr. Le and her colleagues simply did not have the bargaining power to force administrators to adjust the policy. If Dr. Le and her colleagues had been protected by a union contract, such a policy would have been a “mandatory subject of bargaining” under the National Labor Relations Act (NLRA) and the administration would have had to bargain with doctors before implementing a policy that so clearly changed their working conditions.

“We are already strong. We have resiliency, “ says Dr. Le. “However, we are not used to standing up for ourselves. I would like to believe that if we could stand together, we would be better able to reclaim our positions as the drivers of healthcare delivery in this country.”

Individual physicians may be reluctant to consider unionization, perhaps out of fear of retaliation or a sense that such a move would be inconsistent with their professional status. At the same time, the law is clear on their rights to seek union status. For health care professionals concerned about preserving their ability to deliver optimal patient care, devote adequate time to exercise professional judgment, and Physician unionization to page 124

Dr. Le expands, “Physicians are highly driven and when we do not have enough time to achieve at the level we want to achieve for our patients, we burn out. If this trend continues, physicians are going to leave medicine.”

Beyond the bargaining table The sphere of potential influence of physician unions extends far beyond the bargaining table and into state and federal governments, where lawmakers make many decisions impacting physicians. Long-established labor unions have proven programs with policy specialists, relationships with lawmakers, and grassroots mobilization capacity. Health care employers and industry associations already utilize their power to influence government. A formal relationship between physicians and unions could help reinstate physicians’ voices into debates about health care and advance pro-physician and propatient policies.

Private practice physicians Since private practitioners, unlike physicians working for health care systems, are not employees, they are currently ineligible to organize unions under the NLRA. However, physicians in private practice could collaborate with unions on strategic initiatives. One example of such collaboration might be for private practice physicians in a particular market to band together to negotiate with insurance companies for better reimbursement rates, as well as a procedure to challenge denied payments. In this scope, a partnership between a physician collective and unions could provide a necessary check to the unilateral power of insurance companies to deny reimbursement payments. MINNESOTA PHYSICIAN DECEMBERR 2018

11


3Physician unionization from page 11

States and Canada. For more than a decade, Ms. Hartz has empowered union health care workers in a wide variety of professional settings to win

practice to the top of their license in the face of consolidation or evolving reimbursement structures, unionization may be a path worth considering.

and enforce market leading collective bargaining agreements. She believes

For a step-by-step guide on how to organize a union within your organization, see Figure 1.

health care delivery and that building strong, patient care-focused unions is

health care workers know best the challenges—and solutions—to improving the most effective way for health care professionals to make meaningful advancements in their work

Summary As physicians face increasing challenges to retain decision-making power over their schedules, There is a clear path personal economics, and even patient care forward for physicians practices, forming unions is an effective way to who want to form unions. regain professional and personal control. Standard collective bargaining agreements address the staffing, scheduling, financial, and quality-oflife issues that physicians commonly name as contributing factors to burnout. Long-established lobbying and policy programs within unions can also provide physicians with political access and power they need to reclaim their places as the primary decision makers in patient care policies. There is a clear path forward for physicians who want to form unions.

political science from American University and is a graduate of the Trade Union Program at Harvard Law School.

A step-by-step guide to organize your union 1.

Build interest. Once physicians talk to their colleagues and conclude there is an interest among the group to form their union, they call the organizing department of a trusted labor union to assist in building the organizing campaign.

2.

Membership organizing campaign. Member leaders and union organizers speak with employees about their concerns regarding their working conditions and indicate their interest by signing “union authorization cards.”

3.

Petition for election. Once a majority of employees have completed authorization cards, union staff will contact the NLRB and file for an election. (The NLRB requires a minimum of 30 percent of employees to indicate interest before scheduling an election, but many unions require a stronger showing before moving forward).

4.

NLRB sets a date for the election. After verifying the 30 percent minimum interest, the NLRB will schedule an election.

5.

NLRB election. During the election, all employees in the bargaining unit have the opportunity to vote “Yes” to form their union or “No.” When a simple majority (50 percent + one) vote “Yes,” physicians have won their union.

6.

Frontline physicians and union negotiators prepare for negotiations. Members of the unit choose their bargaining committee, set priorities, and write proposals to meet them.

7.

Negotiations for the first contract. Negotiations begin when the union and employer trade proposals until they agree on a comprehensive “Tentative Agreement.”

8.

Bargaining unit members review and vote. Members vote on the proposed contract. When a majority of the members vote to ratify the agreement, the contract setting wages, benefits, and working conditions is implemented.

9.

Ratification. After physicians ratify the contract, they become union members and begin paying dues.

Mandy Rae Hartz, MA, leads the United Steelworkers Health Care Workers Council, which coordinates collective bargaining, education, policy, and communications for more than 50,000 union health care workers in the United

and personal lives. She holds a master’s degree in

Figure 1. Source: supplied by the author.

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DECEMBER 2018 MINNESOTA PHYSICIAN


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ADMINISTRATION

Regaining the voice of our profession A clinic’s journey to unionize BY EMILY ONELLO, MD, AND LOUISE CURNOW, PA-C

U

nion organizing was not at the forefront of our thoughts when we were having workplace difficulties with management. Like most professionals, we tried to address issues of concern with management—issues such as patient visit time and productivity. These weren’t necessarily new issues—our previous CEO of many years had brought up proposed changes to address the ever-increasing drive to increase productivity. But our new CEO of one year’s duration began to push through changes with little to no input from providers. These changes not only affected patient care (shorter visits, increased numbers of visits, less time for charting/documentation, phone calls, prescription refills, etc.) but also changes to our workday that directly impacted provider work hours, access to insurance coverage, and wages and benefits. We tried to address these issues at provider/management meetings, only to have changes implemented despite overwhelming objection. It was extremely stressful. The level of disregard and disrespect is something that caught many of us off guard. We belong to highly respected professions of medicine and

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nursing, recognized as such in public opinion polls, including one cited recently in Forbes (see www.tinyurl.com/mp-forbes). How could we be treated this way? The stress was so high that two of our seven medical providers left due to health concerns. Another left because he was losing family insurance coverage due to forced redefinition of work hours, despite not working any fewer hours. Management was enforcing changes, including a new employee handbook that included significant changes that had never been discussed with medical staff. These changes not only affected the provider-patient interaction, but also our livelihoods. As health professionals, we tried to respectfully communicate with management, to no avail. In fact, these efforts to communicate were quickly labeled as insubordination. Management’s version of retribution quickly followed, resulting in suspensions, censure with verbal and written warnings. A climate of fear and intimidation prevailed without any avenue of recourse. We were “at will” employees and could be fired at any time without cause.

Anonymous phone call It was then that an anonymous phone call was made to a union organizer. Could unionizing reopen channels of respectful communication? What would unionizing look like in our health care setting? Nationwide, many physicians are no longer practice owners (see www.tinyurl.com/mp-amawire). Despite a strong regional union presence, we were unaware of any other unionized medical doctors in our area. Some of our colleagues questioned whether professionals have the right to unionize. Yes, employed physicians do have this right (see Table 1). For example, physicians and other health professionals across the U.S. are represented by the Union of American Physicians and Dentists. In fact, many educated professions have successful unions: pharmacists, teachers, nurses, professors, and airline pilots. The next few months remained challenging. The union organizer informed us that for a realistic chance at success we would need to get 40–50 percent of employees to sign a card expressing interest in unionizing (the card campaign).

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DECEMBER 2018 MINNESOTA PHYSICIAN

Fear among us Employees were initially scared to talk, scared to express interest. It wasn’t long before management found out that an organizing effort was underway. Meetings were imbued with tension and insecurity because we did not yet understand our rights and protections under the law. Despite this uncertainty, many staff spoke openly. The meetings proved to be amazingly informative and empowering. We had attendance from all employee departments. We heard stories of intimidation and bullying. As people shared their stories, frustrations, and concerns, the inevitable outcome of shared experience occurred—we realized we weren’t alone. We started to feel the strength of unity. Management fought back, hiring a “union buster” and deploying ageold tactics of divide and conquer, bullying, and intimidation. Some of their tactics and behavior would later be revealed as labor law violations.


Several new providers were hired to replace those who had left. These new providers joined the organization eager to perform and unaware of the ongoing struggles. While fresh perspectives have the potential to offer new vision and creative solutions, without historical context those perspectives may not recognize serious structural or organizational problems. Other factors can contribute to physician reluctance to advocate for healthy work environments. Health professional ethics demand that we put the patients’ needs before our own. For those who work for small nonprofit organizations that exist on narrow financial margins and provide health care services where needed most, guilt is a powerful force that can “shame” physicians and other health professionals into silence about unsustainable work practices.

The vote was held under strict guidelines with designated election observers from both management and staff. A federal mediator was present during the vote count. The medical professionals and medical support staff had voted in favor of unionizing. The dental and social worker groups voted against unionizing.

The challenges and the charges It took another four months before we started negotiating our first union contract in October 2013. It would be another two and a half years before the professional unit would finally have a signed contract. Even though we had negotiated our own individual employee contracts in the past, negotiations for our professional unit were something for which we, as providers, were not prepared. Thankfully we had the strength and knowledge of the USW representatives and attorneys to guide us in what was to be the monumental task of achieving a first union contract. Negotiations were difficult from the first session. Not only was it difficult to sit across the table from management during negotiations, but they continued to harass employees during the work day.

Efforts to communicate were quickly labeled as insubordination.

The union vote date was set: June 28, 2013.

The vote Our clinic included a wide variety of job classifications, including social workers, laboratory technicians, physician assistants, dentists, and others. It was determined by consensus of management, local United Steelworkers (USW) representatives, and a National Labor Relations Board (NLRB) representative that employees would be categorized into five separate bargaining units: medical professionals, medical support staff, dental professionals, dental support staff, and non-licensed social workers. Each separate unit had its own opportunity to unionize. We continued to encourage our coworkers to vote for protection from

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“at will” employment status, for due process, and for a voice in the workplace. The day of the vote was tense—the outcome was uncertain.

Regaining the voice of our profession to page 384

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15


3A practice built on principle from cover importantly, how to take care of medically fragile babies. What I didn’t know or understand was the concept of expendable physicians in a health care system. I realized two things very quickly:

• They sought out participation in the initial clinical trials which resulted in FDA approval for surfactant treatment in premature babies. In fact, their site provided the largest number of patients in the trial. • They brought ECMO (extracorporeal membrane oxygenation) to the hospital, a life-saving technology that could better support critically ill babies.

• The skills I had trained so hard and long to learn were not valued by my new employer. • Doctors in that system were considered interchangeable; if one left, he or she could easily be replaced. • Most alarming to me was that if patient care got short-changed in the course of changing doctors, so be it.

Physicians are commonly perceived as intellectually incapable of making business decisions … . That perception is wrong.

Unable to practice neonatal medicine according to my principles, I left that position and headed home to Minnesota. A private practice neonatology group in Minneapolis had reached out to me. I didn’t know much about the group at that time, other than that they took care of sick babies. That sounded pretty good to me. It was in June 2000 that I had the good fortune to join Minnesota Neonatal Physicians. When I arrived, I knew I had found my “tribe” in the world of neonatal medical practice. My partners were doctors with a never-before-seen dedication to their patients: • They were the first neonatologists in Minnesota to work 24/7 in the hospital, not because of administrative mandates, but because it was best for their patients.

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DECEMBER 2018 MINNESOTA PHYSICIAN

• They were surrounded by nurses, nurse practitioners, respiratory therapists, and physician colleagues who were equally devoted to the primacy of clinical care. In such a perfect environment, the results were astounding: • Survival rates of infants born near the edge of viability unequaled throughout the world.

• Survival of infants with congenital diaphragmatic hernias, again, in the top of national registries. • More importantly, because they survived and thrived, babies were able to go home, grow up, graduate from high school and college, have families, and enter the work force. These are children, born in the early 1990s, that would not be routinely resuscitated in many hospitals in the U.S. even in 2018.

And then things began to change Work hour rules were ushered in to increase the safety of patients and balance education and service demands. In 1999, the Institute of Medicine released a report entitled “To err is human: building a safer health system.” This report initiated a cascade of events culminating in common duty hour requirements for residents. The results are far from impressive. A 2015 Journal of Graduate Medical Education article concludes that focusing on duty hours alone has not resulted in improvements in patient care or resident well-being. But the genie was out of the bottle, and the concept of work-life balance took on a life of its own … except in our private practice group. As a group, we agreed to not abandon our primacy of care ethos, despite the trends we saw around us. We continued to work three out of four weekends a month, treated holidays like any other day, and grew prematurely gray from chronic sleep deprivation. We missed ball games, school conferences, you name it. We told our children and family members that we are lucky to be healthy, that holidays are about spending time with family, not a day on a calendar, and that the babies in the hospital needed care. Most importantly, we believed it. We kept our group small by design, waiting to hire physicians who shared our passion for providing direct patient care to babies. We had no attrition, despite some urging from our spouses that we “work too much.” Our kids survived, even thrived, and so did we. We had a purpose, and purpose gives people energy.

Impact to NICU families By keeping a “baby-centric” approach at the core, our business decisions and care model grew organically. We worked 7-day stretches in the NICU to provide continuity of care that seemed paramount to achieving optimal outcomes. As a result, parents knew us all by name and were part of the team treating their child. By alternating rounding weeks, it was not uncommon for a family to have only two or three physicians rounding on their child over the course of a four–six week hospitalization; unheard of today when physicians in some systems change daily. We balanced this intense work with stretches of time off to spend with our


families or pursue outside interests. The benefit of our ability to control our own work schedule, work load, and number of partners was no burnout in our group. If your personal or family needs required that you cut back, you did just that. Sometimes we had to hire more people to cover the loss, but it was our group that worked out the needs to support our practice.

systems. We saw hospitals merge, align, re-align, split, and then reconnect with former partners. And that was just in the Twin Cities. Nationally, Dignity Health and Catholic Health Initiatives plan to have a national chain of hospitals in 28 states. Hospital Corporation of America is a for-profit operator of health care facilities that went public in 1969, private in 2006, then public again in 2011. It Impact to the business currently trades at $132/share. Its CEO reportedly Meanwhile, the hospital thrived. From a 12-bed unit earned $21,331,574 in 2016. A recent article reflects the in 1979, the NICU grew to have over 100 neonatal consequences of these changes. It reports a 93 percent beds and three affiliated hospital systems. We saw As physicians, we put increase in medical center CEO compensation from our program grow and we were excited to see other patient care first. 2005–2015, a 10 percent increase in physician salaries, programs in our hospital prosper. We developed a and a 7 percent increase for non-clinical workers. transport program that brings mobile intensive care to Notable was the growth of non-clinical workers over the five-state region. We grew neonatal research from this same time frame, accounting for 27 percent of the 160partner First Street a single study site to a much sought-after in SE, Suite 5, New Brighton, MN 651-383-1083-Main growth of overall health care workers. Nowhere is it Providers of Business Communication Solutions – www.laserwave.net multi-center national trials. With our cardiology and mentioned that the patients received better care, were cardiovascular surgery colleagues, we saw the creation safer, or were more satisfied with their care. of a cardiac intensive care unit. We saw the creation of 160 a fetal treatment center. 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main FirstFirst Suite 5,MN New Brighton, MN 651-383-1083-Main 160First FirstStreet Street SE,Suite Suite 5,New New Brighton, MN 651-383-1083-Main 160 160 First Street SE, 160 SE, Suite 5,Street Street 5, SE, Brighton, New SE, Brighton, Suite 5, 651-383-1083-Main New MN 651-383-1083-Main Brighton, 651-383-1083-Main Providers of Businessin Communication Solutions – www.laserwave.net People MN about changes health care, for example the move for Providers of Business Communication Solutions –talk www.laserwave.net We are seeing the birth of a cardio-pregnancy center. All innovation Providers Business Communication Solutions www.laserwave.net Providers Providers ofofBusiness of Business Communication Providers Communication ofconceived Business Solutions Communication Solutions ––www.laserwave.net – www.laserwave.net Solutions – www.laserwave.net hospitals to employ physicians, as “business decisions.” As if to say that HelloMakers Technology Decision Makers of and nurtured to completion by private practice physicians championing Hello Technology Decision Hello Technology Decision Makers Hello Hello Technology Technology Hello Technology Decision Decision Makers Decision Makers Makers We market Digital Copier/Network Printer/Scanner every business decisionSystems is a good one. Physicians are commonly perceived the needs of their patients. We thought we could continue to serve our as intellectually incapable of making business decisions, because all we ever patients along with our colleagues until our individual Printers careers had reached & Wide-Format to savvy business owners studied was medicine. That perception is wrong. The move for hospitals to their natural conclusion. Then our contract was terminated, we were offered We market Digital Copier/Network Printer/Scanner Systems We market Digital Copier/Network Printer/Scanner Systems We market Digital Copier/Network Printer/Scanner Systems We We market market Digital We Digital market Copier/Network Copier/Network Digital Copier/Network Printer/Scanner Printer/Scanner Printer/Scanner Systems Systems physicians isSystems multifactorial: issues with private practice physicians Throughout the Midwest, and employ across North America. employment by the people who terminated us, andUpper everything changed.

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17


SPECIAL FOCUS: RURAL HEALTH

Supporting unpaid caregivers in rural Minnesota What physicians should know BY CARRIE HENNING-SMITH, PHD, MPH, MSW; AND MEGAN LAHR, MPH

A

ccording to the AARP, the vast majority of all long-term care is provided by unpaid friends and family members, who provide an estimated nearly $500 billion worth of care annually. At the last count, more than 40 million Americans are providing unpaid care to a loved one.

While this is a labor of love for many, it can come with health consequences for caregivers who experience stress and burden as a result of their caregiving role. For caregivers who are also working outside of the home, either full- or part-time, the demands of juggling employment and caregiving—often on top of other responsibilities—can be overwhelming. For caregivers living in rural areas, where employment opportunities and access to health care are both more limited, accessing the support they need to successfully balance their multiple roles can be especially challenging.

Juggling employment with unpaid caregiving For unpaid caregivers who hold outside jobs—in retail, offices, farming, or other settings—employers could play an important role in helping to

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navigate the balance of employment and caregiving roles; however, not all workplaces are created equally. In a University of Minnesota Rural Health Research Center study entitled “Rural-Urban Difference in Workplace Supports and Impacts for Employed Caregivers,” published in the Journal of Rural Health (2018), we presented findings from the 2015 Caregiving in the U.S. survey. This survey collected data from unpaid caregivers across the country, conducted by the AARP and the National Alliance for Family Caregiving. We used these data to examine differences in workplace supports for unpaid caregivers by rural and urban location. The nationally representative sample included 635 employed caregivers from across the country, 12.5 percent of whom lived in rural areas. Across rural and urban locations, volunteer caregivers holding outside jobs were, on average, more likely to be female, in their 40s, with a household income between $30,000 and $74,999. Employed caregivers in rural areas were significantly less likely to have a college degree (26 percent vs. 42 percent) and were also more likely to be non-Hispanic White (76 percent vs. 59 percent), compared with employed caregivers in urban areas. Employed caregivers in urban areas were providing 20.5 hours per week of unpaid care and employed caregivers in rural areas were providing 15.6 hours per week of unpaid care, on average. At the same time, employed caregivers in both urban and rural locations were working approximately 35 hours per week outside of the home for an employer. We found that employed caregivers in urban locations had significantly more supportive services available to them through their workplace than employed caregivers in rural locations. Specifically, volunteer rural caregivers holding separate jobs were less likely than employed urban caregivers to be able to telecommute or work remotely (9.7 percent vs. 24.9 percent); less likely to have supportive programs, such as employee assistance programs (EAP), information, and referrals available to them through their workplace (15.2 percent vs. 25.8 percent); and less likely to have paid leave available to them (17.7 percent vs. 34.1 percent). Fewer than half of all employed rural caregivers had paid sick leave (45.6 percent vs. 52.7 percent of employed urban caregivers) and flexible work hours (49.3 percent vs. 54.7 percent of employed urban caregivers), although the rural-urban differences in those two measures were not statistically different. These differences are shown in Figure 1. We also examined the number of negative workplace impacts among rural and urban employed caregivers and found that nearly half of all volunteer caregivers with outside jobs, regardless of location, had taken time off, gone into work late, and/or left early from work, despite the relatively low rate of paid leave and paid sick time available to caregivers. For caregivers without access to paid leave or flexible hours, taking this time off or missing hours of work may mean foregoing wages. The only significant rural-urban difference that we identified in negative workplace impacts was in the rate of turning down promotions: 6.5 percent of employed caregivers in urban

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DECEMBER 2018 MINNESOTA PHYSICIAN


locations reported that they had turned down a promotion, compared with 1.5 percent of employed caregivers in rural locations. However, the lower rate of turning down promotions among volunteer rural caregivers holding outside jobs may be indicative of the fact that fewer promotion opportunities were available to them in the first place. In multivariate regression models, we found that having more negative workplace impacts from one’s caregiving role was associated with increased caregiver burden, even after adjusting for the hours one works, demographic and socioeconomic characteristics, and the amount of care one provides. Prior research has found a strong link between increased caregiver burden and strain and poorer health outcomes for unpaid caregivers, making it urgently important to find ways to reduce strain and burden for caregivers. For employed caregivers who are juggling multiple demanding roles with their responsibilities for loved ones and their employers, focusing on supports within the workplace is one logical starting place to alleviate strain.

areas have recovered more slowly from the Great Recession, rural caregivers have fewer job options available to them than do urban caregivers, and may be less likely to choose a job based on the benefits it provides. This leaves rural caregivers in a precarious position, coupled with more limited access to health care and increased barriers related to transportation and accessing supportive services in general. There are a variety of policy and programmatic interventions that could be used to address poor access to workplace supports for rural caregivers employed in outside jobs. At the employer level, this might include expanding access to employee assistance programs and ensuring that employees are aware of existing benefits Supporting unpaid caregivers in rural Minnesota to page 344

What employers could do Overall, our findings indicate significant room for improvement in workplace supports for employed caregivers generally, with much greater need in rural areas. Because of the difference in economic and occupational landscapes between rural and urban settings, including the fact that rural

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SPECIAL FOCUS: RURAL HEALTH

Rural Health Innovations An integrative behavioral health program BY KAMI NORLAND, MA, ATR

L

iving with a mental illness in rural Minnesota is more challenging than one might anticipate. Lack of local behavioral health providers, limited access to tele-psychiatry and inpatient psychiatric beds, and new or unknown community awareness of support services, all contribute toward a health system that fails for many patients with mental illness. However, there are some critical access hospitals across Minnesota that are engaging their communities to address these challenges and provide wholeperson care through the integration of behavioral health.

A common scenario Consider this series of developments, all too common in rural areas. When Matt, a 39-year-old male, is seen crawling around on the ground with a knife below his neighbor’s windows and screaming in agitation and fear, the sheriff gets called. The sheriff knows Matt. She has brought him to the local critical access hospital emergency department (ED) many times, as Matt suffers with severe psychosis. When Matt experiences a mental health crisis, he is often a danger to himself and a perceived danger to others.

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The community has limited behavioral health providers, so Matt is brought once again to the ED. In this hospital, tele-psychiatry options are no longer available to ED staff, as the remote provider got burned out and opted into early retirement. Naturally, it is also late Friday night, so any possibility of connecting with the psychiatrist two counties over must wait until Monday morning. Meanwhile, Matt becomes increasingly agitated due to the lack of care and support he needs at that moment. The ED is unequipped to provide for these unique needs, and Matt’s family members grow increasingly concerned, because they have seen a cycle of lengthy ED visits that have not resulted in a sustainable improvement in the quality of life of their loved one. The local ED puts Matt on a 72-hour commitment hold and identifies that he could benefit from psychiatric stabilization in an acute inpatient facility. However, bed space is exceptionally limited across the state—and even into the Dakotas—due to state budget cuts and closings of inpatient psychiatric facilities. In fact, nine out of ten rural ED physicians report that individuals experiencing a mental health crisis are being held in the ED, sometimes up to weeks at a time, until an inpatient bed becomes available. Nurses struggle for hours going through the highly coveted list of inpatient facilities that may have space available and are willing to accept Matt, who has a criminal record and multiple comorbidities. While Matt waits to be transferred out of town, his symptoms escalate because he’s afraid. When an inpatient psychiatric bed is eventually secured, the ED, as it often does, coordinates with local law enforcement to transport him. This is humiliating for Matt, as it reinforces the stigma of mental illness. It’s also costly for law enforcement, and takes an officer off of local patrol for hours, affecting the community. Matt is dropped off for inpatient psychiatric care, alone and scared, because his family doesn’t have reliable transportation, the funds to get to the inpatient facility, or the time off from work to offer emotional support. Matt, who is in crisis, feels increasingly isolated and disconnected. After his psychiatric medications are stabilized, Matt is released and tries to return to life as normal…until another trigger occurs that becomes too unbearable to deal with and a new crisis ensues, perpetuating the pattern of cyclical care through the ED.

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Finding answers Unfortunately, this scenario plays out daily across rural Minnesota. One remedy is for hospitals and their communities to rally together to minimize the unintended gaps in care and begin providing whole-person care that integrates behavioral health. That’s the vision for 13 Critical Access Hospitals (CAHs) and their communities across Minnesota who are participating in Rural Health Innovations (RHI)’s Integrative Behavioral Health Program. RHI is a subsidiary of the National Rural Health Resource Center, a nonprofit organization designed to build and sustain health care in rural communities across the country. CAHs cited access to mental health care as their top health concern, according to a statewide analysis of Community


RHI guides a community strategic planning process that helps prepare all parties to respond to or prevent behavioral health crises. Participants learn about the various strengths, services, and resources available throughout the community that they could coordinate, transition, or refer patients to. Community members are often surprised to learn about all of the local resources or services that haven’t been tapped into yet, despite each of these communities being rural. “Many people tend to problem-solve independently,” said Meller, To continue to ignore the impact “but when we get together in these Community that mental health plays on one’s Collaborative events, people begin to recognize physical health is faulty. that working together saves time and effort.”

Health Assessment Findings conducted by the Minnesota Department of Health (MDH). In response to inquiries from that department’s Office of Rural Health and Primary Care, RHI designed a program using a Performance Excellence Framework—one that has yielded substantial success to date, according to Alyssa Meller, chief operating officer at RHI. This Performance Excellence Framework—a systemic approach for managing the integration of behavioral health—includes essential organizational and operational components. One essential organizational component is engaging buy-in of the program from leadership at all levels throughout the organization. It is imperative for CAHs to address the mental and behavioral health needs of individuals in the transition towards population health and value.

“To continue to ignore the impact that mental health plays on one’s physical health is faulty, dangerous, and leads to poor quality health outcomes,” said Meller. Operationally, it is essential to unite key community stakeholders, including schools, law enforcement, clergy, public health, city and county leaders, business owners, and others under a Community Collaborative to establish a strategic plan and action steps for coordinating care and improving the quality of life for individuals experiencing a mental or behavioral health crisis. “When rural communities come together around a common cause, we see change happen,” said Meller.

Outcomes Community members quickly identify the value of integrating behavioral health and working together. One specific example: LifeCare Medical Center’s outpatient Behavioral Health Department hired a clinical social worker to serve as a roving therapist, providing behavioral health and care coordination for individuals who are incarcerated. Some of these patients had been transferred from the correctional facility to the ED for mental or behavioral health crises, creating a costly concern and burden for all involved. By treating incarcerated patients onsite, the local hospital has seen these transfers drop to almost zero. Rural Health Innovations to page 254

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ADVERTORIAL

Meals for Healing Second Harvest Heartland’s FOODRx program tackles food insecurity and chronic illness, paving the way for better outcomes and lower costs BY MO PERRY AND QUINTON SKINNER Ralph and Lisa, a married couple in St. Cloud, Minnesota, have a range of challenging health diagnoses between them, including type 1 diabetes, type 2 diabetes, and congestive heart failure. They also struggle with food insecurity, with Lisa’s health conditions making it difficult for her to work. At a recent trip to their doctor’s office, they were offered a unique opportunity to enroll in a new program, FOODRx, that would provide them with a monthly box of shelf-stable, wholesome food at no cost—food specifically chosen to support their health conditions. “They gave us healthier foods, like beans and milk, that we incorporated into our diet,” says Ralph. Lisa’s blood sugar levels showed improvement after they started receiving the boxes, and Ralph lost weight. When the program ended after 12 months, the family continued to enjoy their new favorite healthy foods. “I buy a lot more healthy food now than before the FOODRx boxes,” says Ralph. “I know how to enjoy it more.”

“FOODRx pilots showed improved health outcomes, lower costs, and fewer hospital visits.”

It’s no secret that nutrition plays a vital role in wellbeing. Health care professionals and hunger-relief organizations alike have looked across the divide at one another and seen the value of one another’s work. But what about that divide? A physician may give a chronically ill patient detailed nutrition advice, but if that person doesn’t have consistent access to healthy food due to financial or logistical barriers, there’s not much either the patient or physician can do. Even if that patient makes her way to a local food shelf, she may be wary of choosing unfamiliar items or produce that she doesn’t know how to prepare or is worried she won’t like. The question is how both guidance and affordable access can be woven together, with nutritional support undergirding medical interventions in a way that promotes better health outcomes and reduces medical costs. The Minnesota pilot program FOODRx, spearheaded by regional hunger-relief organization, Second Harvest Heartland, aims to bridge the historical divide between health care and nutrition support for food-insecure people with chronic illnesses. It aims to reach diverse populations with an intervention that can both manage and improve disease states—as well as improve outcomes and cost effectiveness for health care leaders and providers.

The High Cost of Hunger and Disease Research has firmly e stablished s trong l inks b etween hunger a nd c hronic disease. A 2017 report from the U.S. Department of Agriculture concluded that food insecurity is tied to 10 out of 10 major chronic illnesses (only 3 of 10 could be strongly associated with low income), with even relatively mild hunger raising rates of hypertension and diabetes by 20 and 59 percent, respectively. These chronic diseases have the greatest impact on quality of life, life expectancy, and societal costs in the form of medical expense and emergency room visits.

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Another study at the University of Minnesota estimated that food insecurity in the state leads to $800 million to $1 billion in annual health care costs. A 2013 study conducted by the Boston Consulting Group also found strong connections between hunger and chronic conditions such as diabetes and heart disease and, even more provocatively, estimated that providing food through health care channels could lead to providing 30 to 45 million needed meals per year in the state. FOODRx sprang from this insight—that the doctor’s office could be a means of reaching hungry individuals who might otherwise not access food shelves or state supplemental nutrition benefits. “If we can effectively integrate our work into the health care system, we can reach people we don’t usually reach,” says Jason Reed, Second Harvest’s Director of Strategy and New Ventures. “And our data showed that hungry people were accessing the health care system more often than the general population.”

FOODRx has strategically addressed the hunger-chronic disease linkage with a focus on creating a workable model that could be employed throughout the state. Its foundational idea is creating better outcomes and return on investment for health care systems, along with a financial model based on scale and sustainability. This business model is crucial—rather than create a philanthropy-based model FOODRx has focused on funding from health care systems, insurance providers, and other partners that stand to gain positive financial benefits for value-based cost lowering and positive health outcomes. “FOODRx enabled us to test this value-based care model and see whether patients improved their health,” Reed adds. “Pilots showed improved health outcomes, lower costs, and fewer hospital visits.” FOODRx pilots have focused on acute and chronic hunger among low-income patients in the Minnesota health care system. Qualifying individuals receive roughly 25 meals in a 30-pound box of food every month for six to 12 months. A staff dietitian at Second Harvest develops and designs the food boxes, which are tailored for chronic conditions such as diabetes and heart disease. The contents of the boxes, which contain recipes and nutrition information, can also be tailored for specific cultural populations such as Somalis, Latinos, and traditional American (these are options, not proscriptions—in one case, for instance, a younger Somali individual preferred the traditional American food option). Giving patients agency in choosing the boxes they prefer increases the likelihood that they will consume the contents. “We were able to meet with patients at least quarterly, to talk about what was in their box, and which foods were good for their chronic disease states,” says dietician Paula Redemske, who worked with a pilot at the CentraCare Family Health Center in St. Cloud. “I saw people we’d had trouble getting into the clinic come and sit through education sessions and be successful because we were providing the food for them.”


ADVERTORIAL

Targeting Conditions and Supplementing Nutrition The FOODRx pilot program at CentraCare focused on patients with diabetes and cardiovascular disease, and also featured a partnership with a local grocery store for ten-dollar monthly vouchers good for fresh fruits and vegetables. Redemske adds that she saw visible relief for patients in their financial lives; while FOODRx isn’t intended to meet an individual’s entire food needs for the month, it has a tangible benefit both in supplying solid nutrition and creating some potential breathing room in tight household budgets. In urban communities such as that served by North Memorial Health, food insecurity is exacerbated by limited access to healthy food options for individuals lacking independent transportation. Many patients with chronic conditions in these “food deserts” rely on small independent stores that they can reach on foot, which are often lacking in fresh, healthy food options. “Food insecurities impact our patients across all cultural lines,” says Orenthal Avery, a clinic manager at University of Minnesota Physicians Broadway Family Medicine Clinic. “It’s still early in our pilot, but at a minimum this is a good educational tool for establishing healthy eating habits for our patients in regard to their chronic conditions. It also takes some stress and pressure off families. They look forward to food distribution dates, because it makes their food supply stretch.”

donate their own time. These professionals see an opportunity to provide nutritional support for those with chronic conditions, as well as a way to help them stabilize their lives: it’s this kind of integrated approach to hunger and medicine that makes as much sense on the clinical level as it does in higher-level research. “Ideally, we’d like to see individuals graduate from the FOODRx program and find stability in other, different aspects of their lives,” adds Koch. “If we can start building up stable legs for them, it’ll help them with their overall health and their overall lives.” This is the higher goal: relieving food insecurity with balanced nutrition, supporting healthy function to improve chronic conditions, and empowering individuals to lead more proactive lives. The potential is to benefit the individual, families, and the health of the greater community while reducing considerable stresses and costs in the health care system.

“Addressing hunger as a health problem within the health care system makes a lot of sense.”

On the clinic level, FOODRx programs also yielded surprises. Manny Ravelo, a Second Harvest Project Coordinator who set up systems for screening needs in a St. Cloud pilot, soon learned that the status of an individual’s food insecurity was often unrelated to their dress or appearance. One well-dressed elderly couple only revealed their food insecurity while filling out a questionnaire; like many clinic patients, they were unaware of options for supplementing their food through assistance programs. “I learned the importance of not assuming based on appearance,” says Ravelo, whose program screened patients for additional resources needs such as food, housing, and employment. “You never know what somebody might be going through.” One recurring concern at the clinic level for FOODRx trials has been helping participating patients to physically transport their monthly 30-pound food boxes. Individuals with chronic health conditions and no vehicle face obvious obstacles getting their food from the health care setting into their home. One solution has been matching volunteers with FOODRx participants. “Some of our individuals on Medicaid also have issues with their transportation,” says Michael Koch, a project manager at Minneapolis’s North Memorial Health who has been overseeing enrollment into the FOODRx program “Just recently we’ve been able to arrange delivery for some of these patients, mostly through partnering with medical teams and paramedics.” It speaks volumes that these food deliveries are being done on a volunteer basis—front-line medical and transportation staff see such an obvious value for their patients’ health in FOODRx deliveries that they’re willing to

“Probably the biggest thing is that those not participating wish it was more widespread,” adds Avery. “It’s also raising awareness of other resources for food insecurity, and now we’re always conscious of that with our patients. And with the chronic disease focus, we’re not just providing food—we’re letting people know that what’s in the box has a purpose.”

In terms of education, FOODRx enables crucial nutritional information to be delivered in a clinical setting to people with chronic conditions. Both dieticians and patients report that pairing education with actual food enables a breakthrough in viewing nutrition. “One person with diabetes using the food shelf here ended up with improved lab tests after he worked with a dietician to pick out food,” says Hennepin Healthcare pediatrician Diana Cutts, MD. “He said, If you care enough to actually give me the food instead of just talking about the food, I should pay attention and use it.’”

The Long-Range Picture Cutts’ office window looks out on a busy downtown Minneapolis street. She’s worked at the front lines of the intersection between public policy and children’s health care for decades, recently celebrating the 20th year of Children’s HealthWatch, which was launched to track the effects of 1998 cuts in national welfare spending. She’s been involved in extensive research-focused work on questions related to food insecurity and childhood development. “It isn’t just about food, it’s about health and clearly drawing that intersection,” Cutts says. “Those of us who work in healthcare have to ask what is our opportunity and obligation to use the infrastructure of health organizations to do our part. It benefits our patients to address food insecurity.” Hennepin Healthcare’s facility features an onsite food center for patients and those being discharged from care, as well as a summer meals program for kids and referrals to food outreach counselors. Cutts is involved in a FOODRx research program among the facility’s diabetic patients, and is focused on delivering more and more data to health care decision makers and practitioners to make the case for the improved health outcomes and Meals for healing to page 244 MINNESOTA PHYSICIAN DECEMBER 2018

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ADVERTORIAL

3Meals for healing from page 23 economic benefits of systematically bringing nutritional solutions to the health care setting. “There’s a financial payoff, aside from the philosophy that people should simply have access to healthy food,” Cutts adds. “Addressing hunger as a health problem within the health care system makes a lot of sense. The economic rationale is an important piece of the puzzle.”

A Model That Works To date, Second Harvest Heartland has six FOODRx contracts, each based on different services. As with the studies with CentraCare and Hennepin Healthcare, the focus has been on the chronic illnesses such as diabetes and heart disease that drive up the cost of health care, putting a strain on the resources of hospitals and clinics, health care groups, and government. “We’re drilling into where the cost is for providers,” says Second Harvest’s Reed. “Medicaid has encouraged states to pursue the value-based care model, with certain outcomes for care and lowering costs.” The 10 diseases studied in the Department of Agriculture’s 2017 report—hypertension, coronary heart disease, hepatitis, stroke, cancer, asthma, diabetes, arthritis, chronic obstructive pulmonary disease, and chronic kidney disease—are a who’s who of those conditions that most seriously impact health, mortality, and quality of life. They’re also the source of billions of dollars in spending for the health care system on office appointments, ER visits, expensive procedures, and costly treatments.

No one argues that food is the cure for chronic disease. But when research links hunger to all 10 of the most common chronic diseases, professionals across the health care spectrum take note. “In my work, we often pose the question: How would things be different today if we’d done a certain thing 20 years ago?” says Cutts. “If we had allocated certain funds to address this problem 20, or even 30, years ago, how would the system be better off? How would our workforce look different?” How could our society and workforce look 20 or 30 years from now, if we put the full force of our human ingenuity into braiding hunger relief and health care? “There’s a recognition today that health is based on social determinants rather than just genetics or access to health care,” Cutts adds. “They’re so powerful. And of all these determinants, food insecurity is the lowest-hanging fruit. We have the infrastructure, and we have the resources. It’s a new landscape.”

If you have patients who would benefit from the FOODRx program, please contact Alexandra De Kesel Lofthus at alofthus@2harvest.org or 651.282.0887 to learn more about bringing the program to your clinic. Mo Perry and Quinton Skinner, are co-principals of Logosphere Storysmiths, a boutique content agency that creates vivid narratives for impactful companies, organizations, and leaders.

Experts at integrating food prescriptions into care for patients with type 2 diabetes and other illnesses Research shows that food prescriptions, like those filled by FOODRx, can lower HbA1c scores and the total costs of caring for patients with type 2 diabetes. FOODRx brings healthy food directly into health care settings, removing common barriers to nutrition and creating a cost effective, simplified prescription for wellness. “We need to take off our blinders and start learning new ways to address the real-life circumstances that make our patients sick. FOODRx creates the partnerships we need to do this work. We’ve got some real ‘Ah-ha’ moments ahead of us.“ —Dr. Diana Cutts, Hennepin Healthcare To learn more, contact us at 651.282.0887 or at foodrx@2harvest.org

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3Rural Health Innovations from page 21

artists to help change the conversation and perspective on mental illness and to support mentally healthy communities.

The cost savings generated by the roving therapist’s involvement grabbed Extending the model the attention of county corrections officials, county commissioners, and For organizations or communities that are looking to integrate behavioral the county justice department. The staff at health into their programming, a systemic Roseau’s LifeCare Medical Center’s ED has approach is needed that engages leadership at all also recognized that their partnership with law levels and gains the support and actions of the enforcement, clergy, and other key community community. No monetary funds were provided stakeholders, such as the Crisis Response Team, to the CAHs and the Community Collaboratives Begin providing helps to provide higher quality care and to reduce participating in RHI’s Integrative Behavioral whole-person care that the overall number of transfers to inpatient Health Program, as the value proposition for integrates behavioral health. psychiatric facilities. This focus on coordination each participant needed to be self-identified and preventive support reduces crisis situations, to promote sustainability. When a community improves the quality of life for the patient, offers works together under a common goal, the cost savings from more expensive and duplicative outcomes will be much greater. For more treatment, and starts to break the cyclical pattern information on the Performance Excellence of ED use and uncoordinated care. “There is a Framework or RHI’s Integrative Behavioral Health Program, contact paradigm shift in thinking when community members start to see the Alyssa Meller at ameller@ruralcenter.org value proposition of working together, both from a fiscal perspective as well as a quality of life perspective,” says Meller. Kami Norland, MA, ATR, community program manager at the National One of the common themes throughout RHI’s participating Community Rural Health Resource Center, provides education and facilitation to rural Collaboratives’ strategic plans is to educate the community on eliminating communities on community engagement for improved health and wellness. the stigma associated with mental illness and offering community education on where to go for support when a crisis arises. Therefore, RHI’s next venture is aimed toward partnering Community Collaboratives with local

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ELECTRONIC HEALTH RECORDS

Leveraging your information resources Put your data to work BY SARA RICHTER, MS, AND SAMANTHA CARLSON, MPH

O

ver the past decade, the transition to electronic health records (EHRs) has increased the amount of health data at our fingertips. At the same time, the pressure to improve access to care and patient outcomes is steadily increasing. Fortunately, advances in technology now allow providers to more easily leverage the data in the EHR to make improvements in care, recognize trends in their patient population, improve clinical processes, and publish and disseminate research.

Leveraging existing EHR data EHRs contain a wide range of information about patients and their visits: demographic characteristics, diagnoses, vital signs, lab values, medications, patient-reported outcomes, dates and departments of appointments, billing codes, and more. The more complete and accurate the data being entered into the EHR, the more this wealth of information can be used to enhance the following: Reimbursement. As Medicare and private insurers move to value-based reimbursement, providers will need to submit not just the appropriate billing codes, but documentation of improvement in patient outcomes.

Individual patient outcomes. During each visit, the patient’s EHR is pulled up for documentation of the visit. Having the chart up provides access to the patient’s complete medical history, making it easier to see trends in vital signs and symptoms over time and helping to diagnose diseases. EHRs can also alert providers when a new medication might be contraindicated—preventing a possible adverse event—and when the patient is due for preventive screenings. Clinic-wide patient outcomes. With consistent and complete information being captured in the EHR for individual patients, providers can look at outcomes and trends among all patients who meet certain criteria. For example, providers can find out which chronic conditions are most prevalent in their clinic; what percentage of their patients with diabetes are meeting blood sugar goals; and what percentage of patients with hypertension are prescribed anti-hypertensive medications. With this information, providers can update clinic processes, refine standards of care, and target their continuing education to better treat their patients. Research studies and quality improvement projects. Data from the EHR can also be used to support scholarships for research studies, quality improvement projects, and other initiatives. For example, if you are conducting a study on a rare condition, it may be helpful to use EHR data to estimate how many patients with that condition attend your clinic. This could inform your project’s recruitment plan and feasibility. As described below, the EHR can also be the source of data for research projects.

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If you’re interested in using EHR data, seek out assistance to obtain and analyze the data. In-house IT teams are a good place to start, but they may not have the statistical background needed to fully analyze and interpret the data. Contact your in-house research department, if you have one, to see what statistical resources are available. If in-house resources are not available, consider retaining an outside data analyst. When interviewing external analysts, make sure they are familiar with the unique strengths and challenges of health care and EHR data, as well as HIPAA requirements. Data analysts and statisticians can advise you regarding the best study design to answer your research question, calculate sample sizes, decide which pieces of EHR data to collect and how to collect them, analyze statistics, interpret results, and prepare manuscripts for journal submission. In the cases of clinical trials, statisticians can help with randomizing patients to study arms and submissions for FDA approval. Statisticians and analysts can also help initiate quality improvement efforts, streamline clinic processes, consult on how to use EHR data for clinic improvements, identify best practices, analyze and interpret quality improvement data, and prepare presentations and posters for medical conferences and key stakeholders.

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DECEMBER 2018 MINNESOTA PHYSICIAN

While your EHR already contains valuable data, you may wish to extract and collect more information to support all of the goals we have identified. There are many data collection methods, including EHR chart abstraction (“chart


reviews”), surveys (via phone, paper, or web), key informant interviews, and will record the data (paper forms that are entered into a database or data focus groups. Select the best method based on your research questions and entered directly into a database), and where the data will be stored. the data required to answer them. For example, chart reviews are well suited Standardize data collection procedures. Thoroughly document the process, for understanding patient demographics, co-morbid conditions, health care procedures, and decisions made by staff during data collection. If the data utilization, health outcomes, and tracking trends collection is complex, consider creating a training in these metrics over time. However, chart reviews guide for staff. This will help ensure that all staff follow may not be able to explain why trends are occurring, the same procedures, provide a resource for new team provide patient satisfaction or patient-reported members, and serve as a starting point for the write-up outcomes, or describe the patient or staff experience. of your methods in a presentation or publication. Patient data … can lead to To obtain these types of qualitative data, a survey or Protect patient data. Train your study team meaningful improvements in interviews would be more appropriate. on your organization’s policies for storing and patients’ experiences and health. General data collection tips transferring sensitive data. Be conscious of Regardless of the data collection method you choose, potential HIPAA violations when collecting data. it is important to gather accurate and appropriate You may need to get approval (or a waiver) from data. Haphazard data collection methods could your organization’s Institutional Review Board lead to inaccurate or indefensible findings, wasted (IRB) before you start collecting data. This will resources, and potential harm to patients. Some general tips: help determine if your patients need to provide informed consent before you can use their data. Have a plan for your data. Collect the data you need to answer your questions and describe the characteristics of the patients. Brainstorm the data points you expect to use and then plan how you will use them in your analysis or final report/presentation. If a piece of data does not serve a clear purpose, consider not collecting it. You may wish to involve a statistician or data analyst. Devote time to project planning. Dedicate time to plan the logistics of the project with the study team before you begin data collection. For chart reviews, decide who and how many people will collect the data, how they

Chart review considerations Before conducting an EHR chart review, develop clear data collection guidelines and project goals. When deciding which pieces of data to collect, include those that relate directly to your project aims as well as participant characteristics that will allow you to describe your sample—these may Leveraging your information resources to page 324

MINNESOTA PHYSICIAN DECEMBER 2018

27


SPECIAL FOCUS: RURAL HEALTH

Stroke and telehealth Improving access and outcomes BY MUHAMMAD FAREED K. SURI, MBBS

A

ccess to specialty care in rural areas is often limited by distance and accessibility. Rural Minnesotans and specialty providers are well aware of this challenge. Residing in or visiting the remote areas of Minnesota can mean long drives to medical facilities and, in certain cases, additional time needed for emergency medical transportation, evaluation, and initial treatment, resulting in vastly varying outcomes.

One patient’s experience In rural Long Prairie, Minnesota, an 80-year-old resident experienced this firsthand. Waking up with tingling in her left arm, numbness in her left leg, and the inability to eat her breakfast, she knew something wasn’t right. Looking in the mirror, the facial droop that was reflected back wasn’t good. What she had feared was confirmed quickly at CentraCare Health– Long Prairie, where a CentraCare Health telestroke provider located in St. Cloud solidified the stroke diagnosis via telehealth. In this case, the online technology was utilized to provide care remotely, offering instant access to critical care and an off-site stroke specialist. A telestroke specialist was

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able to review scans and suggest further care at the moment of the stroke presentation. For many patients that otherwise would not have the means to access early specialty care, telehealth technology speeds treatment decisions, thereby improving patient outcomes. Weeks later, after treatment and extensive inpatient rehabilitation at the CentraCare Health– St. Cloud Hospital, the patient was able to return home. This wasn’t something she was expecting based on her initial reflection in the mirror, but thanks to early evaluation, treatment, and transportation, what could have been worsened by delay was avoided. Further post-stroke recovery and rehabilitation continued at her rural Long Prairie home health care facility via the Telestroke/Vascular Neurology Clinic.

Online access to care The Telestroke/Vascular Neurology Clinic was established to improve access to care and health outcomes among rural Minnesota patients recovering from stroke or transient ischemic attack (TIA). It provides nurse care coordination services by a trained registered nurse patient navigator, who works directly with patients to eliminate barriers to care and to guide rural patients through the systems of care. The program also coordinates follow-up appointments with a stroke specialist from the St. Cloud Hospital Stroke Center via telemedicine at consortium hospitals and clinics. This enables patients to stay in their home areas and visit their primary care providers in local offices as they always have, but visits with specialists, such as stroke neurologists, are conducted via the telehealth equipment. Recovery plans are also developed for each patient, with the patient navigator ensuring that discharge instructions, medications, and follow-up appointment schedules are followed, while also assisting with resources to obtain medications, equipment, transportation, and anything else they may need. If gaps in care are identified, the nurse navigator works with the stroke provider and the patient’s primary care provider. Providers that are in the CentraCare telestroke network can refer patients to the telestroke/vascular clinic for follow-up.

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More than 11,000 square miles and almost 500,000 people now have access to CentraCare telestroke services.

DECEMBER 2018 MINNESOTA PHYSICIAN

• Long Prairie–CentraCare Health • Madison Hospital*


• Melrose–CentraCare Health • Monticello–CentraCare Health * • Olivia–Renville County Hospital * • Paynesville–CentraCare Health • Redwood Falls–Redwood Area Hospital* • Sauk Centre–CentraCare Health • Staples–Lakewood Health System • St. Cloud Hospital–CentraCare Health • Wadena–Tri-County Health Care • Willmar–Carris Health (Asterisks indicate sites that are not operational for post-stroke care yet, but will be in the next three years due to further grant funding.)

30-day readmission at CentraCare (Stroke & TIA) 30-day readmission rate with telestroke program (Stroke & TIA)

Readmissions

Population

%

28

312

8.97%

9

132

6.82%

Table 1. Thirty-day readmission rates for inpatient care and telestroke participants.

Stroke and telehealth to page 304

Background In 2015, a needs assessment identified that targeted counties in the central Minnesota area had almost 6 percent more senior citizens residing in them than the state average. These senior citizens are at greater risk for stroke or TIA. Several gaps in care were identified: difficulties with transportation for follow-up care at the stroke clinic in St. Cloud; lack of education on post-stroke care; and the need for navigation to therapies and medicine post-stroke. These gaps in care increased the risk of repeat strokes and hospital readmissions. In response to this need, CentraCare Health–Long Prairie was awarded a Health Resources and Services Administration (HRSA) Rural Health Care Services Outreach grant in 2016.

Outcomes This instant access to stroke care and coordinated after-care services— which often surpasses resources available in rural areas—has improved readmission rates, patient experiences, post-stroke quality of life, and degrees of post-stroke disability:

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Readmission rates. From program initiation on June 1, 2015, to program close on April 30, 2018, a total of 132 patients were enrolled in the program. Among the 132 enrolled, 26 percent (n=34) had a TIA and 74 percent (n=98) had a stroke. Overall among the enrollees, there were 24 readmissions, nine within 30 days of discharge. This rate is lower than CentraCare’s all-cause 30-day readmission rate as of March 31, 2018. See Table 1. Patient experience survey. Twenty-five patients, all of whom had a telehealth visit, completed the patient experience survey. Questions and responses: • I feel the quality of care I received today through the video conference is as good as a face-to-face visit: 87 percent. • I would rather drive farther for a face-to-face appointment than have a visit again through a teleconference: 8 percent. • I felt comfortable talking freely with the stroke doctor or nurse via the video conference equipment: 100 percent. • I was comfortable meeting with the stroke doctor or nurse via teleconference: 96 percent. • I could clearly see and hear the stroke doctor or nurse on the video conference: 83 percent.

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29


3Stroke and telehealth from page 29 Patient quality of life and degree of disability. The patient navigator administered the Ferrans and Powers Quality of Life Index Stroke Version–III to patients via mail at enrollment. The index was re-administered at six months post-program enrollment via mail. The index is scored on a scale of 0–30, with 30 being good quality of life. Since program initiation, 35 patients completed the QOL at baseline and at six months. The mean change across these patients was 5.40. A paired sample t-test comparing the means at baseline and at 6 months was significant (p≤.01). See Table 2. The patient navigator also administered the modified Rankin Scale (mRS) to patients during the first visit. The scale was re-administered at three and six months via phone. The index is scored on a scale of 0–6, with 0 being no symptoms and 6 being clinically dead. Since program initiation, 81 patients have completed the mRS at baseline and at six months. The mean change from baseline to six months was -.59, which is statistically significant (p≤.01). See Table 3. Evaluation findings suggest that patients view the Telestroke/Vascular Neurology Clinic positively, and program data demonstrates that patients enrolled and assessed in the clinic experienced statistically significant improvements in both quality of life and degree of disability. Out of 25 patients surveyed, most (87 percent) felt that the quality of care they received was as good as a face-to-face visit.

Baseline

Follow-up

Change

P-value for change baseline to 6 months

20.96

26.37

5.40

p≤.01

35

35

Average score

N

Table 2. Ferrans and Powers Quality of Life Index Stroke Version–III.

Average score

N

Baseline

3mo

6mo

Change baseline to 6 months

1.00

0.50

0.41

-.59

81

74

81

P-value for change baseline to 6 months

p≤.01

Table 3. Modified Rankin Scale.

Change Lives Boynton Health is a national leader in college student health. We serve the University of Minnesota, delivering comprehensive health care services with a public health approach to campus well-being. Our patients are motivated and diverse undergraduate, graduate and international students, faculty and staff. On campus, you will have access to cultural and athletic events and a rich academic environment. Boynton is readily accessible by transit, biking and walking. With no evening, weekend or on-call hours, our physicians find exceptional work/life balance.

PHYSICIAN Boynton Health is seeking a Full-Time Physician with a Sports Medicine background to work in our Primary Care and Urgent Care Clinics. We have in-house mental health, pharmacy, physical therapy, lab, x-ray and other services to provide holistic care of your patients. This position offers a competitive salary, comprehensive benefits, CME opportunities and a generous retiremetnt plan. Professional liability coverage is provided.

To learn more, contact Michele Senenfelder, Human Resources at 612-301-2166, msenenfe@umn.edu Apply online at http://www1.umn.edu/ohr/employment and search Keyword 324537. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer.

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

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DECEMBER 2018 MINNESOTA PHYSICIAN


The SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis confirmed that key program strengths include continued optimism among program partners that the Telestroke/Vascular Neurology Clinic can improve access to care and patient health outcomes. The SWOT analysis also identified several opportunities for future expansion of teleneurology and telemedicine. The Telestroke/Vascular Neurology Clinic can serve as both a model for telemedicine in other rural areas and for other disease conditions. Evaluation findings demonstrate the importance of assisting patients in barriers common to rural areas that would otherwise impede them from receiving proper care.

• There are numerous opportunities to expand and sustain program components, many of which have been identified and incorporated into new models and funding streams at CentraCare Health. These include expansion of the Telestroke/Vascular Neurology Clinic to additional sites throughout rural Minnesota. Muhammad Fareed K. Suri, MBBS, is the stroke medical director at St. Cloud Hospital.

More than 11,000 square miles and almost 500,000 people now have access to telehealth services.

He is board-certified in vascular neurology and neurocriticial care and is a fellowship-trained interventional neurologist. He received his medical education through Army Medical College/Quaide-Azam University and completed an internship and residency at the University Hospitals of

Summary The Telestroke/Vascular Neurology program evaluation demonstrated that:

Clinic

• Patients report a high degree of satisfaction and positivity with their telehealth experience. • Patients enrolled and assessed in the Telestroke/Vascular Neurology Clinic experienced statistically significant improvements in both quality of life and degree of disability.

Cleveland, an interventional neurology fellowship at the University of Minnesota–Department of Vascular Neurology, and a vascular neurology fellowhip at the UMDNJUniversity Hospital. His services include: interventional neurology, stroke care, neurocritical care, and vascular neurology.

• Patients enrolled in the program demonstrated a lower 30-day allcause readmission rate compared to the CentraCare Health rate.

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3Leveraging your information resources from page 27 vary by field of study or project topic. Even if you are not going to look for subgroup differences in your project, these characteristics can help you understand if you could apply your findings to other clinics and patient populations. In addition, identify the time period you’ll be collecting from and which patients are eligible to be included. To ensure consistency in data collection, create working definitions for each piece of data you want to collect, how to record it, and where in the record you will find that information. That way, if two people are doing the reviews, they are searching the EHR in the same way for the same information (e.g., searching only flowsheets, searching flowsheets first and then looking at specialty visit notes, etc.). They are also recording it consistently. Be sure to involve at least one provider with content-area expertise to help plan and to answer questions that arise during the chart review process. This expert will know the feasibility (and credibility) of the data in the EHR. While abstracting the data from the EHR, you’ll likely encounter situations you didn’t think of beforehand. Keep detailed notes regarding the decisions you make and update the working definitions with these decisions. If multiple people will collect data from the charts, have them work together for the first three patients following the working definitions; then independently review three additional cases and compare the data they found to verify that they used the same process to collect the data. If they did not find the same data for the second set of cases, they should discuss where they found the information, agree on where to look for that data

Urgent Care Physicians HEAL. TEACH. LEAD.

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE

going forward, and revise the definitions. Project planning should also include setting up a database that will be used for data entry and analysis. Regardless of which system you use, the database should correspond to the data collection forms and working definitions and should be set up to protect patient data (e.g., password protected or de-identified). To the extent possible, data validation rules should be set up in the database to help prevent data entry errors (e.g., if all included patients were over the age of 65, the database should not allow an age of 40 to be entered). A statistician or analyst can help you develop the database, create the electronic data entry forms, and set up the validation logic. If the data are being collected on paper forms and manually entered into the database, you may want to consider an additional step to verify the accuracy of the data entry. One way to do this is through a double data entry process, where each form is entered twice and then compared for discrepancies. Another, less resource-intensive way is to randomly check 10–20 percent of the forms for data entry errors and keep track of the number of errors found. If the number of errors is concerning, consider retraining of staff and double data entry.

Survey administration considerations With survey administration, simple is often better. Try to choose survey collection methods that seem feasible and fit within the clinic workflow. Patients could fill out a survey in the waiting room or while they are waiting in the exam room, or they could be mailed/emailed/ called. Depending on your institution and project, you may not be able to connect with patients via email and web. Make sure you review your organization’s specific policies. If you use an online survey, check with your IT department to make sure the survey site is HIPAA compliant. To decrease survey respondent burden, ask only the “need to know” questions. It is difficult to write good questions, so first search for questions from reputable sources or validated questionnaires rather than creating your own. There are many free, validated questionnaires available, saving you the time and hassle of creating your own questions. If you create your own questions, become familiar with survey development best practices. Many organizations and universities have such guidelines, including the Harvard University Program on Survey Research and the American Association for Public Opinion Research’s “Best Practices for Survey Research.”

Summary Planning, consistency, documentation, and data privacy are critical in all data collection. Whether you’re using the wealth of data in your EHR or asking patients to fill out a short survey before they leave the clinic, patient data collected purposefully doesn’t have to be difficult and can lead to meaningful improvements in patients’ experiences and health. Sara Richter, MS, is a senior statistician at Professional Data Analysts, Inc. She has over 10 years of experience in health care research, including health services research, clinical trials, and quality improvement.

Samantha Carlson, MPH, is an associate analyst at Professional Data Analysts, Inc. She received her master’s degree in epidemiology with a minor in biostatistics, and has experience working in clinical trials and public health research, as well as quality improvement in primary care.

32

DECEMBER 2018 MINNESOTA PHYSICIAN


PRACTICE WHERE BEAUTY SURROUNDS YOU

YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.

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

WORK-LIFE BALANCE: • Competitive salary •  Significant starting & residency bonuses • 4-day work weeks •  51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest.

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Carris Health is the perfect match “I found the perfect match with Carris Health.” Dr. Cindy Smith, Co-CEO & President of Carris Health

Carris Health is a multi-specialty health network located in west central and southwest Minnesota. Carris Health is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/ BC physicians in the following specialties: • Dermatology • ENT • Family Medicine • Gastroenterology • Geriatrician • Hospitalist

• Internal Medicine • Nephrology • Neurology • OB/GYN • Oncology • Orthopedic Surgery

• Pediatrics • Psychiatry • Pulmonary/ Critical Care • Rheumatology • Urology

Loan repayment assistance available.

FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | Shana.Zahrbock@carrishealth.com | (320) 231-6353 | acmc.com Carris Health is an innovative health care system committed to reinventing rural health care in West Central and Southwest Minnesota. Carris Health was formed in January 2018 and is part of CentraCare Health. Visit www.carrishealth.com for more information.

MINNESOTA PHYSICIAN DECEMBER 2018

33


3Supporting unpaid caregivers in rural Minnesota from page 19 physicians in a unique position to be able to speak to the importance of and programs; providing a quiet space for employees to make phone calls (i.e., scheduling medical appointments for their loved ones); allowing time and space supporting caregivers for the sake of population health. for volunteer caregivers across the organization to At a minimum, physicians should make it a meet with one another to commiserate and offer standard practice to ask patients about the many, ideas and support; and offering flexible break times, and various, roles that they juggle and whether, and working hours, and work locations, to the extent how, those are impacting their well-being. They that doing so is possible. Being at the front lines of should then be prepared to connect patients with

treating both caregivers and At the local, state, and federal policy level, resources, ideally by partnering with a social worker their care recipients puts solutions might include expanding access to or other expert in available resources. Physicians are physicians in a unique position. broadband internet to make it possible to work also in a unique role to advocate for the importance remotely; providing caregiver stipends and/or tax of addressing the well-being of caregivers, especially credits so that caregivers can work less if they choose those in rural areas who provide an irreplaceable to; expanding requirements around paid leave and service that too often goes unnoticed. paid sick time to include caregiver responsibilities; increasing the minimum wage; and expanding community supportive services Carrie Henning-Smith, PhD, MPH, MSW, is an assistant professor of for caregivers, as well as increasing public awareness around those programs health policy and management at the University of Minnesota School of that already exist, such as the Senior LinkAge Line in Minnesota. Public Health, and the deputy director of the University of Minnesota Rural

What physicians could do Physicians should be aware of this issue and have an important role to play in addressing it. They may find themselves treating the health consequences of stress and strain related to juggling work and unpaid caregiving. Being at the front lines of treating both caregivers and their care recipients puts

Health Research Center.

Megan Lahr, MPH, is a research fellow and project manager at the University of Minnesota Rural Health Research Center.

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.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist

Ely VA Clinic

Hibbing VA Clinic

• Tele-ICU (Las Vegas, NV)

Current opportunities include:

Current opportunities include:

• Nephrologist

Internal Medicine/Family Practice

Internal Medicine/Family Practice

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

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

34

DECEMBER 2018 MINNESOTA PHYSICIAN

www.minneapolis.va.gov


Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

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

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

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

• Physician (Care In the Community/ Integrative Whole Health) • Physician (Hospice & Palliative Care)

• Physician Psychiatrist (Mental Health)

• Physician (Hematology/Oncology) Part-Time • Physician (Pulmonologist) Part-Time

• Physician (Orthopedic Surgeon) Part-Time 763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

• Physician (IM/FP) St. Cloud MN • Physician (IM/FP) Brainerd MN

• Physician (IM/FP) Montevideo MN

• Associate Chief of Staff/ Education (Office of the Director)

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POSITIONS AVAILABLE:

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

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

For more information:

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

(320) 255-6301

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

MINNESOTA PHYSICIAN DECEMBER 2018

35


3A practice built on principle from page 17

• We believe we share a goal with the hospital of mutually improving patient care, and that should be the only reason to make any changes to our current structure.

recruiting new partners, cuts in Medicare payment for office-based imaging, the burden of “meaningful use” in the EMR and value-based payment schemes, and the effort to gain more favorable rates from insurers, to name a few. Yet a recent Harvard Business Review article demonstrates that many large health care systems’ physician operations are operating at a loss. It’s not to say it can’t be done. Hospitals and systems that work together can be successful, as exemplified by the Mayo system. “The needs of the patient come first” is written on Mayo Clinic stationery. Similar quotations from the Mayo brothers continue to be perpetuated and realized in how the organization is run. While not perfect, the Mayo Clinic continues to achieve worldwide recognition and is financially sound. Because physicians are at the core of any health care enterprise, they must be in alignment with management. Physicians and administration in opposition is a recipe for failure.

What makes us different Change is hard. We get that. The world is changing. We get that, too. But the answer is not always to do what everyone else is doing. The answer is not always to consolidate, to grow, to become employed. The answer for our practice—what helps us sleep at night—is to stick to our core value to put babies first. Every decision we make, when put through a baby-centric filter, becomes simple, obvious: • Minnesota Neonatal Physicians believe that physicians, not administrators, determine the best care model for their patients based on evidence, patient outcomes, and parent satisfaction.

• We believe we should be partners with and not competitors to our own hospital system. • We believe we should have the autonomy to pick the consultants we feel are best for our patients. • We believe we should control the hiring of our partners. • We believe we share the responsibility with the hospital to make our Neonatal Intensive Care Unit an amazing place to be a patient, a parent, and a provider. One thing we don’t believe is that the route to the future is through physician employment. So, we stand on principle and we made a choice. We are leaving the unit we developed. We are leaving the nurses, colleagues, and patients who mean the world to us. As physicians, we put patient care first. We will be starting over with our group and our integrity intact. Jeanne Mrozek, MD, is a native Minnesotan and a graduate of the University of Minnesota, with degrees in chemistry and medicine. She completed her pediatric and neonatal training at the University of Minnesota. In addition to her work as a neonatologist, she is the founder and president of Minnesota Neonatal Foundation.

Join the Best. Join Entira Family Clinics. Entira Family Clinics is an award-winning, physician owned and operated group of primary care, after hours care, and express care clinics serving the East Metro for over 50 years. If you want the opportunity to influence how your practice is run, then look no further. Where Generations Thrive®: Our community-based clinics offer high-quality care specializing in family medicine and serve families at all stages of life.

Join our team today!

For more information, contact: Len Kaiser: 651-772-1572 or lkaiser@entirafamilyclinics.com

| entirafamilyclinics.com | 36

DECEMBER 2018 MINNESOTA PHYSICIAN

|


Family Medicine Northfield Hospital & Clinics is seeking a Family Medicine Physician (no OB) to join our growing practice in our Lakeville Clinic, conveniently located just off Hwy 35.

with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices.

Joining our independent healthcare organization allows you to advocate for patient choice while providing the best care for the individual. We use a team approach to provide seamless, integrated care with easy access to a variety of services and specialties.

Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan.

Learn more at www.northfieldhospital.org/careers or submit your resume to recruiting@northfieldhospital.org. For more information contact our Recruiter, Erin, at 507-646-8170.

We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Apply online at www.mankatoclinic.com

Sioux Falls VA

HEALTH CARE SYSTEM

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

The VAHCS is currently recruiting for the following positions: ★ Cardiologist

★ Pulmonologist

★ Endocrinologist

★ Women Health Director

★ Neurologist

★ Emergency Medicine (part-time)

★ PACT

★ ENT (part-time)

★ Physiatrist

★ Gastroenterologist (part-time)

★ Psychiatrist

★ Urologist (part-time)

★ Psychologist

★ Vascular Surgery (Invasive) (part-time or full time)

apply online at www.USAJOBS.gov

(605) 333-6852 ·

www.siouxfalls.va.gov

MINNESOTA PHYSICIAN DECEMBER 2018

37


SI

3Regaining the voice of our profession from page 15

served the various members’ needs. We recognized that a unionized group in a larger health care organization would have advantages at the bargaining table.

Employees were reprimanded and suspended under false pretense. It was at this point that some union members took the emotionally difficult step to file charges of unfair labor practices (ULP) with the NLRB.

After 42 bargaining sessions, we finally had a contract that we could bring to our professional unit for a vote. As a first contract, we knew that this contract was a start. We had attained our goal of no longer being at-will employees; our contract offered a strong disciplinary article that included due process. We had attained our goal of having a voice at the table.

Following an NLRB investigation, the clinic management, including the medical director, were found guilty of 42 NLRB ULPs. (To view these, visit www.nlrb.gov and search for Case Numbers 18-CA-123942, 18-CA126399, 18-CA-129828, and 18-CA-133033). The clinic was forced to pay restitution to one of the providers and remove all reprimands and suspensions from the records of the aggrieved. Management backed off after that, but they continued intractable negotiations. After several sessions, a federal mediator had to be called in to help us move forward with negotiations.

Hard bargaining Negotiations focused on two distinct areas: economic and non-economic bargaining. Despite most employees’ initial focus on the economic aspect, we soon learned that it is the non-economic language portion of the contract that has the most significant impact on the everyday working conditions. As medical professionals, salary was not at the top of our list of concerns. Matters affecting our workday and hours, especially policies that we felt adversely affected patient care, largely fell under the category of non-economic bargaining. Some of the most complicated issues were productivity and just cause for discipline. Given our small USW unit size, as well as the diversity of health care professionals within it, it was challenging to ensure that the negotiated contract

Going forward, if management tried to change or add any policies that would affect our work conditions, wages, benefits, or work rules, they would have to negotiate it at the bargaining table. We also established a labor management committee within the contract. This committee provided an opportunity for labor and management to meet on equal footing to discuss current and foreseeable issues in order to create solutions and prevent problems.

Summing up Establishing a union at our workplace was a difficult endeavor, more difficult than we had imagined, but it was a worthwhile journey. Not only did it provide us safeguards at our workplace, but it provided us perspective as well. Earning workers’ rights is a challenge and, for some industries, it has been a deadly challenge. As medical professionals, we generally have the “comfort” of good wages and benefits. Ours is the challenge of regaining the voice of our professions, the challenge of regaining what it means to be a medical professional, of regaining the art of medicine, regaining the human side of medicine. Medicine, at its best, is a collaboration of many. If we are to take back our professions, then that too will have to be a collaboration, a union, of many. Emily Onello, MD, is board-certified in family medicine. She received her medical degree in 1995.

Louise Curnow, PA-C, completed physician assistant training in 1992 and practices primary care.

Your rights as an employed physician under the National Labor Relations Act

Helping physicians communicate with physicians for over 30 years. MINNESOTA

AUGUST 2018

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

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

Exploring new potential BY MICK HANNAFIN

W

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

Share new diagnostic and therapeutic advances Develop and enhance referral networks Recruit a new physician associate

Advertise! IN MINNESOTA PHYSICIAN www.mppub.com

38

DECEMBER 2018 MINNESOTA PHYSICIAN

(612) 728-8600

Federal law gives you the following rights: To form, join, or assist a union. To choose representatives to bargain on your behalf. To act together with other employees for your benefit and protection. To choose not to engage in any of these protected activities. To know that health care professionals represented by a labor organization may engage in picketing, a concerted refusal to work, or a strike, but you must comply with requirements and timelines outlined in the National Labor Relations Act.

Table 1. Source: National Labor Relations Board webpage at www.tinyurl.com/mp-nlrb-rights (accessed Oct. 5, 2018).


STAY FOCUSED AMONG THE DISTRACTIONS.

Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E  A N A LY T I C S  R I S K M A N A G E M E N T  E D U C A T I O N

Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company® MINNESOTA PHYSICIAN DECEMBER 2018

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Heart Center YOUR LEADER IN CHILDREN’S HEART CARE The Heart Center at University of Minnesota Masonic Children’s Hospital helps your youngest patients get back to living happier and healthier once again. Minnesota’s largest pediatric cardiovascular practice World-renowned surgeon Dr. Massimo Griselli, MD Some of the nation’s lowest operative mortality scores Comprehensive team of CV intensivists, care coordinators, cardiologists and surgeons

Refer your patients or learn more: MHealth.org/HeartCenter | 888-543-7866

University of Minnesota Health is a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ©2018 University of Minnesota Physicians and University of Minnesota Medical Center

Minnesota Physician December 2018  

Physician unionization A path worth considering By Mandy Rae Hartz, MA A practice built on principle Taking a stand By Jeanne Mrozek, MD int...

Minnesota Physician December 2018  

Physician unionization A path worth considering By Mandy Rae Hartz, MA A practice built on principle Taking a stand By Jeanne Mrozek, MD int...

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