Volume XXVl, No. 5
The Independent Medical Business Newspaper
Reducing health inequities What physicians can do By Melanie Ferris, MPH, and Paul W. Mattessich, PhD
care delivery to payment models, organizational structure, government regulation, and health improvement programs. Many of the responses from health care leaders reflected both the promise and challenges of those changes. The responses also underscore the importance of another significant health care trend: teamwork and collaboration in achieving goals, whether in quality of care, efficiency in delivering care, or improving accessibility to care. A number of leaders lauded the efforts of their staff and colleagues, as well as the crucial role of patients in the health care equation. We wish this group of health care professionals the best in leading the state through these exciting and challenging times.
Detriot Lakes, MN Permit No. 2655
100 LEADERS to page 14
PRSRT STD U.S. POSTAGE
innesota Physician Publishing is pleased to present this special feature honoring Minnesota’s health care leaders. Once every four years, we invite our readers to submit the names of colleagues whose outstanding work in health care might be acknowledged in this feature. We thank all those who participated in the nomination process and in submitting responses. Minnesota has long had a national reputation for excellence in health care. In an industry with so much talent and dedication, it is difficult to limit the number of leaders to only 100. The leaders selected for this feature represent a cross section of the breadth and depth of Minnesota’s health-care delivery system, from clinical care to health care policy, research, and management. Though the health care industry is always evolving, the past four years have seen sweeping changes at all levels, from
ven when physicians offer the best care possible, patients have unequal opportunities to experience good health outcomes. Factors largely outside of a physician’s control, at least in the short term, put large numbers of patients at a disadvantage, not because of their genes or their health behaviors, but because of where they live, the money they have, and the intended and unintended discrimination they experience. The World Health Organization labels such disadvantages “health inequities,” which result from unfair, unjust, and modifiable social conditions. A growing body of literature demonstrates that factors shaping the conditions were we live, work, and play—called social determinants— strongly influence our overall health and largely contribute to health inequities.
Minnesota: A healthy state for many, but not all
Minnesota shines nationally with an image of good health among its residents. The Kaiser Family Foundation INEQUITIES to page 12
SMOKER SUPPORT PERSON STUDY Do you see smokers in your clinical practice who would like to quit but are not quite ready? Do you see nonsmokers in your practice who are concerned about a smoker?
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AUGUST 2012 Volume XXVI, No. 5
FEATURES 100 influential health care leaders Recognizing excellence
Reducing health inequities What physicians can do
By Melanie Ferris, MPH, and Paul W. Mattessich, PhD
T H I R T Y- E I G H T H
Alan Page, JD Minnesota Supreme Court
Background and Focus
MINNESOTAHEALTH HEALTH CARE ABLE MINNESOTA CAREROUNDT ROUNDTABLE
PROFESSIONAL UPDATE: NEUROLOGY Carotid artery disease 12 By Andrew Grande, MD, Ramachandra Tummula, MD, and Bharathidasan Jagadeesan, MD
HEALTH CARE AND THE LAW The Minnesota False Claims Act
The recent Supreme Court ruling on the Affordable Care Act clears the way for implementation of Health Insurance Exchanges. States have the option of creating their own exchange or joining one created by the federal government by January 2014. A Health Insurance Exchange would provide consumers a place to compare and shop for health insurance coverage. In Minnesota this idea was first proposed as part of the Assuring they are meaningful Pawlenty administration’s health care reform task force, Thursday, November 1, 2012 and Gov. Dayton is a strong 1:00 – 4:00 PM • Duluth Room supporter of creating a stateDowntown Mpls. Hilton and Towers run program. Though simple and compelling at first brush, creating a consumer-accessible, “apples to apples” website for comparing health insurance costs is challenging and very complex.
Health Insurance Exchanges:
By Brian Dillon, JD
The Independent Medical Business Newspaper
We will define what a health care insurance exchange is and, considering the detailed and proprietary design of health insurance coverage, how it can be meaningful. Health insurance policies contain terms like “medically necessary,” “investigative,” “cosmetic,” “not medically necessary” and “contract/benefit exclusion”—all terms that are defined differently by different insurers. This alone makes it virtually impossible for anyone to compare plans effectively. Further, networks of providers vary, depending on whether you choose the “bronze,” “silver,” “gold,” or “platinum” option within a given insurer, as will access to hospital-based facilities, DME providers, and ancillary services. Throw in features like “deductibles,” “co-insurance,” “maximum out-of-pocket expenses,” “formulary design” and “covered preventive services,” and you have a bewildering mathematical matrix. We will offer suggestions as to how an insurance exchange can address these issues and provide a meaningful, consumer-friendly comparison service.
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AUGUST 2012 MINNESOTA PHYSICIAN
Joint Effort Continues to Reduce Hospital Readmissions A pilot program to reduce hospital readmissions continues to exceed expectations, according to officials involved in the project. Two years after Fairview Health Services and UCare began the program, readmissions to two Fairview hospitals of enrollees from the UCare For Seniors Medicare Advantage health plan has dropped to at least half the national average. The program, a joint effort between UCare and Fairview Physician Associates (FPA), involves seniors who are admitted to Fairview Southdale Hospital and Fairview Ridges Hospital. So far, about 2,000 patients have taken part in the program. UCare estimates it saves $10,000 with every prevented readmission. The pilot project is designed to keep patients enrolled in UCare for Seniors Medicare Advantage from returning unnecessarily to the hospital within 30 days of discharge.
Seventeen FPA-member independent and Fairview-owned primary care clinics are participating in the pilot. Initially, FPA hoped to see a 20 percent reduction in readmissions. In fact, nine months into the project, efforts show between a 30 percent and 44 percent reduction, depending on measurement and definition of readmission, says William Nersesian, MD, FPA chief medical officer. â€œNo one really knew how far we could reduce readmissions,â€? Nersesian says. â€œI was hoping for twenty percent, but weâ€™re in the high 30s and low 40s.â€? Nersesian says the key to Fairview and UCareâ€™s success is a 3-pronged approach that includes relatively quick followup visits to a patientâ€™s primary care physicians in the week following discharge; an approach to pharmacy coaching that includes pharmacists going over all medications with the patient; and care managers that discuss issues with patients such as nutrition and transportation to
physician appointments. In addition, hospitalists with FPA now dictate their discharge summaries the day of discharge. This, Nersesian notes, seems like a simple thing but was not always done in the past. â€œGetting the discharge summary with complete information emailed out to the personal physician is an important part of the process,â€? he says.
State Ranked High In AHRQ Report Minnesota received the top overall score and was rated â€œstrongâ€? in health care quality by the federal Agency for Healthcare Research and Quality (AHRQ) national report. The agencyâ€™s annual stateby-state report finds that Minnesota does very well in the areas of cancer, diabetes, heart disease, and respiratory disease. For maternal and child health, along with home care, Minnesota rated below average. The state ranked first in the nation for flu vaccination among adults with diabetes and
second for both preventing pressure sores among nursing home residents and pneumonia vaccinations for adults older than 65. Its lowest rank was 44th in the nation, for vaccinations of young children.
Asthma Report Finds Higher Rates In Twin Cities A new report on asthma in Minnesota finds that some trends are encouraging but that the Twin Cities area still has a much higher rate of asthma cases than the rest of the state. â€œThe good news is that hospitalizations have been trending down and that Minnesota has a lower prevalence of asthma than the nation,â€? says Minnesota Commissioner of Health Ed Ehlinger, MD. â€œBut we need to do more to address this troubling difference between the Twin Cities and greater Minnesota and to make sure that children and adults are getting the most effective asthma care available.â€?
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MINNESOTA PHYSICIAN AUGUST 2012
The report from the Minnesota Department of Health (MDH) found that Minnesota’s adult asthma rate of 7.6 percent, or 302,000 Minnesotans, is lower than the national average of 9.1 percent. The state’s childhood asthma rate of 7.0 percent, or 90,000, is lower than the U.S. rate of 8.4 percent. The report finds that rates for adults and children re-mained relatively stable between 2000 and 2010. Hospitalizations due to asthma have steadily declined from 9.4 per 10,000 residents or 4,626 in 2000 to 6.7 per 10,000 residents or 3,553 in 2010. However, MDH officials raise concerns about higher rates of asthma hospitalizations in the seven-county Twin Cities metropolitan area, where rates are 50 percent higher among children and 30 percent higher among adults compared with rates for children and adults living in greater Minnesota. Similarly, rates of emergency department visits for asthma are 70 percent higher among children living in the seven-county Twin Cities metropolitan area than among children living in greater Minnesota, the report finds. “We are not sure what is causing this difference,” says Wendy Brunner, MS, PhD, MDH’s Asthma Program epidemiologist. “But we know a lot about what can trigger asthma episodes, such as secondhand smoke, mold, pet dander, and air pollution, and that theoretically, hospitalizations can be prevented when a person’s asthma is managed through medication and minimizing exposure to triggers.”
PhRMA Report Finds Minnesota Well Suited for Drug Trials Minnesota is well suited to host clinical trials of pharmaceutical drugs, a new report from PhRMA says. The report says Minnesota has an excellent infrastructure for testing pharmaceuticals, with major research facilities and health-care
delivery capabilities. Jeff Trewhitt, senior director of communications and public affairs for PhRMA, says the report shows that although pharmaceutical companies are not as highly visible in Minnesota as device manufacturers such as Medtronic or St. Jude’s, drug trials are still important to the state’s health care industry. “Although the biopharmaceutical research industry may not have a very prominent brick-and-mortar presence in Minnesota, it does, nevertheless, have a very positive impact on the state through its sponsorship and conduct of clinical trials,” Trewhitt says. “Not only are these trials that have been sponsored and conducted by [pharmaceutical] companies good for patients, they’re also good for the state’s economy as well as the advance of science.” According to the report, pharmaceutical companies have conducted more than 2,400 clinical trials of new medicines since 1999 in Minnesota. The report notes that the University of Minnesota and Mayo Clinic are sites of major research and the health care systems in the state are also excellent partners for research. Trewhitt points out there are a number of companies helping to conduct clinical trials in partnership with universities and health systems in Minnesota. The PhRMA report emphasizes the work of the Minnesota Clinical Research Alliance (MCRA), a coalition of research groups that formed one year ago to promote clinical trials in Minnesota. According to Trewhitt, PhRMA and MCRA are trying to get the word out about the importance of clinical trials. “At a time when so many trials don’t have enough patients, MCRA is doing a very good job of raising awareness and understanding of clinical trials of new medicines and medical devices.” CAPSULES to page 6
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First Community Paramedic Class Graduates Hennepin Technical College (HTC) has graduated 13 students from its first-in-the-U.S. Community Paramedic training program. Community paramedics are a new model of health care providers recently approved by the state legislature. Community paramedics deliver primary care services such as case management, wound care, immunizations, and patient education in rural areas where access to physicians is limited. Health delivery experts say the model will save money by preventing emergency room visits and 911 calls for health issues that could be more appropriately addressed with preventive care. “The new certification is another demonstration of the leadership shown in Minnesota as we move forward to reform health care,” says O.J. Doyle, EMS consultant and lobbyist for
the Minnesota Ambulance Association, a group that supported the bill. “In addition, it provides a creative way to fill gaps in the health-care delivery system and will significantly reduce costs for health care providers and taxpayers. Also, it will provide a solution for preventing unnecessary hospitalization and ambulance transportation, which can average $4,000 a visit, and doesn’t compete with existing health care services.” To gain the necessary skills, traditional paramedics need extra training, and the program at HTC provides that. Minnesota is the first state to establish an official certification for community paramedics, with the passage of the Community Paramedics Bill in April 2011. The first training program, developed in partnership with the Minnesota Ambulance Association, began that May at HTC’s Eden Prairie campus. “This new career path for paramedics is really exploding,” says Kai Hjermstad, Customized Training Services Coordinator for emergency medical
2012-13 CME Activities (All courses in the Twin Cities unless noted)
FALL 2012 Pediatric Clinical Hypnosis (NPHTI) September 20-22, 2012 Psychiatry Review & Update October 1-2, 2012 North Central College Health Association Conference - Duluth, MN October 2-4, 2012 Twin Cities Sports Medicine October 5-6, 2012 Maintenance of Certiﬁcation in Anesthesiology (MOCA) Training October 20, 2012 Internal Medicine Review & Update October 24-26, 2012 Practical Dermatology for Primary Care - Duluth, MN October 26-27, 2012
services at HTC, who recently received his certification. “Community paramedics will take on various roles including outreach, wellness, health screening assessments, health instruction, dispensing of immunizations, disease management, recognition of mental health issues, wound care, safety programs, and functioning as an extension of physicians in rural clinics and hospitals.”
Mayo, U of M Sign Letter Supporting NIH Funding Mayo Clinic and the University of Minnesota have joined a national coalition of medical research institutions in urging Congress to maintain current funding levels for the National Institutes of Health (NIH). The letter asks Congress to maintain the FY 2013 funding of $32 billion for NIH. Officials note that recent years have seen cuts in NIH awards and the number of grants. In addition, a new salary cap for NIH workers
has raised concerns that some scientists will be driven away by the resulting 10 percent salary cut for NIH researchers. The letter asks that salaries be restored to previous levels. “We respect the difficult decisions you must make, and we urge you during those deliberations to view medical research as an investment in our nation’s health, security, and economy,” the letter says. “NIHfunded research happens in all 50 states, and occurs in large and small communities across the nation—strengthening the economy and creating jobs. The investment in NIH not only improves the health of the nation, but also benefits our economy in the short term and long term.” The letter is signed by Mayo Clinic and 18 other medical research institutions, including the University of Wisconsin, the University of California Health System, the University of Texas System, the New York University School of Medicine, the Duke University School of Medicine, and the Cleveland Clinic Lerner Research Institute.
www.cmecourses.umn.edu Emerging Infections in Clinical Practice & Public Health November 16, 2012 Geriatric Orthopaedic Fracture November 29-30, 2012 Maintenance of Certiﬁcation in Anesthesiology (MOCA) Training December 8, 2012
SPRING 2013 Maintenance of Certiﬁcation in Anesthesiology (MOCA) Training January 19, 2013 WORLD Symposium - Orlando, FL February 12-15, 2013 Maintenance of Certiﬁcation in Anesthesiology (MOCA) Training February 23, 2013 Lillehei Symposium April 4-5, 2013 Integrated Care Conference April 12, 2013
Chronic Pain April 19, 2013 Cardiac Arrhythmias April 26, 2013 Maintenance of Certiﬁcation in Anesthesiology (MOCA) Training April 27, 2013 Controversies in Cardiovascular Disease May 4-5, 2013 Global Health Training (weekly modules) May 6-31, 2013
ONLINE COURSES (CME credit available) www.cme.umn.edu/online Fetal Alcohol Spectrum Disorders (FASD) Global Health (7 Modules)
Ofﬁce of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: email@example.com
Promoting a lifetime of outstanding professional practice
Sarah Schram, MD, has joined the University of Minnesota Department of Dermatology, and will split her time between the University and Maple Grove clinics. Her interests include Mohs surgery, cosmetic and laser procedures, and general dermatology. She completed medical school, residency, and fellowship at the University of Minnesota. Schram has been active in research projects relating to skin Sarah Schram, MD cancer, Mohs micrographic surgery techniques, dermal fillers, laser treatment for photo rejuvenation, and allergic contact dermatitis. Russell Luepker, MD, MS, has received the 2012 Carole J. Bland Outstanding Faculty Mentor Award for the University of Minnesota Medical School. The award is given to faculty who have served as outstanding mentors to other faculty members. Since 1978, Luepker has mentored more than 100 individuals. He is a Mayo Professor of Public Health in the School of Public Health’s Division of Epidemiology and Community Health. Laura Andreson, DO, has joined the obstetrics and gynecology department at Altru Health System in Grand Forks, N.D. Andreson earned Laura Andreson, DO a doctor of osteopathy degree from Des Moines (Ia.) University Osteopathic Medical Center and completed a residency in obstetrics and gynecology at the University of Minnesota. She is board-certified by the American Board of Obstetrics and Gynecology and is a fellow of the American College of Obstetrics and Gynecology. Blue Cross and Blue Shield of Minnesota has announced the appointments of Paul Karazija, MD, as executive medical director for commercial and government programs, and Lawrence (Larry) Lee, MD, as executive medical director for provider relations and quality. In these roles, Karazija and Lee will provide direction and oversight of medical policies, credentialing, provider relations, and quality improvement programs. Karazija joined Blue Cross in May 2011 as senior medical director of key accounts. A board-certified internist, he has been in medical director leadership roles since 1996. Prior to joining Blue Cross, Karazija was chief medical officer at Wellmark Blue Cross Blue Shield of Iowa and South Dakota. Lee joined Blue Cross in February 2012 as medical director of provider analytics and clinical performance. He is a board-certified internist and has been in medical director leadership positions since 2006. The health management business unit of Minnetonka-based Medica has promoted Jim Jim Guyn, MD Guyn, MD, to vice president and senior medical officer. Guyn, who joined Medica in 2006 as medical director, provider relations, will focus on provider relations and continue to lead efforts to improve health care quality, efficiency, and patient satisfaction. All Medica medical directors will report to him. He is a graduate of the UCLA School of Medicine, and did his residency in family practice at Ventura County General Hospital in Ventura, Calif. The American Academy of Orthopaedic Surgeons has presented its 2012 Diversity Award to Franklin H. Sim, MD, of the Mayo Clinic, Rochester. The Diversity Award recognizes members of the academy who have distinguished themselves through their outstanding commitment to making orthopedics more representative of, and accessible to, diverse patient populations. The award citation noted that since the 1970s, Sim has mentored nearly 500 young physicians, including many women who have achieved prominent positions within orthopedics. In addition, he has hosted visiting international orthopedic surgeons, residents, and fellows over the past four decades, through Mayo Clinic’s Visiting Clinicians Program, from countries where orthopedic surgery continues to evolve.
Telephone Equipment Distribution (TED) Program
Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.
1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services
On the field of leadership ■ How would you define leadership?
You know, I’ve asked that question a number of times, and quite frankly I don’t know that I have a good answer. I think leadership involves really intangible qualities in people that inspire others to act, however that may be and in whatever context that may be. ■ In your career you’ve seen people in leadership
■ Tell us a little about the Page Education
capacities in different areas. Could you share some examples of individual leadership that you’ve found inspiring? Alan Page, JD Minnesota Supreme Court Alan Page, JD, has been an associate justice of the Minnesota Supreme Court since 1993 and has found success in a wide range of endeavors, including playing for the Minnesota Vikings from 1967 to 1978. After his football career, which led to his induction into the NFL Hall of Fame in 1988, Page began a legal career that included being named Minnesota Assistant Attorney General in 1987. In addition, Page has worked as a broadcaster for National Public Radio and the Turner Broadcasting System, and was National Football League Player’s Association representative during the 1970s. Page is the founder of the Page Education Foundation, which has awarded grants to thousands of students of color in return for a commitment to serving the community.
I think much beyond that, (a) I don’t know, and (b) I probably shouldn’t say. But you know, we live in a political society, and thank goodness I’m in the branch of government that doesn’t have to be involved in that part of the political process. We get to make decisions, exercising our judgment in terms of sorting out what the law is, not what we would like it to be. Foundation and the role education should play in developing leadership.
I think education is obviously critical to any sucThe one that comes immediately to mind is cess that anybody’s going to have. It’s the school Nelson Mandela. If he is not a leader, nobody is. that prepares people for doing whatever it is they His actions were geared toward bringing equality to all the people of South Africa. He has been com- may choose to do. The Page Education Foundation is a tool, particularly for the disadvantaged and mitted to his principles and acts on that commitpeople of color, that puts them in the position of ment in ways that certainly have inspired me over overcoming whatever the disadvantage may be, the years, and in a way that is, at least from my and I think that’s critical to achieving whatever vantage point, for the benefit of others, not necesone’s hopes and dreams are. sarily for his own personal And because I believe that benefit, and that is certainly Ultimately we’re everybody has the right to the inspirational. to achieve their influenced by those we opportunity hopes and dreams, I think the ■ There are some parallels with our own civil rights can literally reach out more we can do to ensure that everybody has the opportunity movement. and touch far more than to learn, the better. It’s critical. Yes, clearly. Martin Luther King Jr. was another visible we are by example of someone who is a set up on leader, but I think back on my football playing days and I think of Jim Marshall and Joe Kapp, who both by their words and by their actions, inspired others to perform probably at a level higher than what they might otherwise have done.
the people we the pedestals.
■ Is there a common thread through those differ-
ent kinds of leadership? Oh, I think so. I think leadership is unselfish. I think it’s inspirational, and I think the qualities generally apply no matter what you’re doing, whether you’re a doctor or a lawyer or a football player or a CEO in a corporation or the owner of a small mom and pop grocery store. ■ The road taken for the Affordable Care Act to
reach the Supreme Court exemplifies the animosity of partisan politics. Especially considering how the ruling will be used in the presidential election process, how would you have approached this case? Well, hard for me to say because I know nothing more than what I’ve read in the newspapers, and I suspect in the grand scheme of things, that’s not very much. The reality is that it’s been a political issue from the beginning and it will remain a political issue, and sadly, oftentimes, the politics don’t necessarily look to what is best for the community, for the people.
MINNESOTA PHYSICIAN AUGUST 2012
■ How does the foundation
We do two things. One, we provide financial assistance to young men and women of color to encourage and assist and motivate them to pursue their education beyond high school. We provide financial grants ranging in amount from $1,000 to $2,500, renewable on an annual basis, to Minnesota students of color going to Minnesota schools, and they are outright grants. The second thing we do, and I think it’s the most important thing, is that we require our grant recipients—we call them Page Scholars—to go back into the community where they come from, back into the community where they went to school, to work with young children, kindergarten through eighth grade, specifically in the area of education. This is so those young children can see somebody who looks like them, somebody who comes from where they come from, somebody who may have some shared experience, using education as a tool and, by both word and deed, helping those younger children understand the importance of education.
■ It sounds like a great example of leadership, as
we were talking about earlier. Well, it certainly puts our Page Scholars in positions of leadership. Interesting, I haven’t necessarily thought about it in the context of leadership, but as a society, we spend a lot of time talking about who our heroes are and who our role models
are. Ultimately we’re influenced by those we can literally reach out and touch far more than we are by the people we set up on the pedestals, whether it be athletes or entertainers, or whoever it might be. Our Page Scholars are true heroes and true role models. In fact, a few years ago we adopted the motto, “Creating heroes through education and service,” but as I sit here and think about it—those scholars are really acting as leaders and are working in a leadership capacity, inspiring, motivating, and assisting the young children they work with. The work that they do certainly inspires me. ■ Childhood obesity and many related fit-
ness issues are becoming significant concerns for the health care profession. How does your work with children relate to these topics? I haven’t done anything directly related to those kinds of topics other than I do spend a lot of time in schools, talking with young children about the importance of education. But as part of that, I discuss my history and my background, and invariably the subject of my running comes up, and having a conversation about why that’s important, physically, mentally, and emotionally. [Page was the first active NFL player to complete a marathon.] So I suppose in an indirect way I do talk with young people about being phys-
ically active, which ultimately I think works to reduce the likelihood of obesity. Being physically active, first of all, just makes you feel better, makes you feel good, and it’s something that we can all benefit from, unless we have been afflicted with some disability that prevents us from being active. As I say, for me it’s been important physically, emotionally, and mentally. You get a chance to get out and clear your mind. No matter what it is, whether you’re out walking, whether you’re running or biking or playing soccer or football, you learn a lot about yourself, you learn a lot about how you can deal with challenges, you learn how you relate to other people. I’ve found it invaluable over the years ■ I’m sure that some kids look at exercise as
a chore, or something you do to get to a certain point, but it’s great that they hear the message that this is rewarding. Well, my experience is that when I started playing football, the conditioning, the running was a chore, was something that I didn’t like, didn’t want to do, and wouldn’t do unless I had to, but I’ve been fortunate to be able to talk with young people about, “How did that change and why did that change?” Why would somebody who at one point in life thought running laps on a football field was something that was to be
avoided as much as possible, why would somebody like that end up running 100 kilometers? And the answer is because you learn about yourself. In having that conversation with these young people, I think they get it. Now maybe they don’t go out and run a 100K the next day, but I think they actually begin to understand that there’s something to it beyond just hard work. ■ What thoughts can you share about
the cases of former players suing the NFL over failing to adequately protect them from brain injury? Probably nothing, because … first of all, they are pending cases, and it wouldn’t be out of the realm of possibility that some of that could show up in our courts; and so, again, I probably should not go there. I can tell you I think whatever the problems with brain injuries as a result of playing football are, we have to be aware that we have 8-, 9-, 10-, 11-year-old children playing football, and it seems to me that in the grand scheme of things, we ought to be concerned about those young children. These children are at a stage where they are not fully developed, and to have brain injuries at that age, I just think it’s a big concern.
When changes in the local health care landscape promised a major inﬂux of new UCare members coming through metro-area clinics and hospitals, we made sure those providers were prepared. In a span of just two weeks, May Ly was among the UCare staff that personally visited 449 unique health care locations to offer a heads-up and explain the impacts. Because being responsive to our partners’ needs isn’t just talk—it’s what we mean by health care that starts with you.
| provider assistance: 1-888-531-1493 | ucare.org/providers |
Inequities from cover has ranked Minnesota best among all states in terms of cardiovascular-related deaths. Health rankings in national publications typically place Minnesota at or near the top. Nevertheless, inside the state, residents of different races experience large differences in mortality due to heart disease, diabetes, and cancer, for example. Economic conditions that influence health vary widely. For example, while 9 percent of Minnesota residents overall live in poverty, fewer white residents live in poverty compared to residents of color (6 percent, compared to 24 percent, respectively). In a recent study commissioned by the Blue Cross and Blue Shield of Minnesota Foundation, we delved into health inequities in the sevencounty Twin Cities metro area and found startling differences in health outcomes, based on place, race, and income. Although Twin Citians tend to live about three years longer than the typical American,
average life expectancy in different neighborhoods varies widely, from 68 to 92 years. Those differences in life expectancy consistently relate to the neighborhoods’ social characteristics. So, residents of areas with the lowest household incomes (median less than $35,000) live on average seven years fewer than residents of neighborhoods with the highest incomes (median $75,000 or higher). We learned that both the racial and income characteristics of neighborhoods influence mortality rates—and that racial differences diminish, but do not disappear, in higher income areas. For example, mortality rates for American Indian and African American residents improve in higher income neighborhoods; nonetheless, they exceed those of other groups (Fig. 1). Our study demonstrates that, in our region, strong relationships exist among place, race, income, and health; it confirms the existence of regional health inequities. It also prompts deeper thinking about
MINNESOTA PHYSICIAN AUGUST 2012
the influence of underlying economic and social conditions on health inequities in the future. Economic/demographic changes
How will recent economic/demographic changes influence future health outcomes? Since 2000, Minnesota has experienced dramatic economic changes: • Residents earn less. Median household income stood at $56,000 in 2010, a decrease of $5,000 since 2000. • More residents live in poverty—up from 8 percent in 2000 to 12 percent in 2010. • More residents are housing cost–burdened. Today, onethird of households spend 30 percent or more of their income on housing—up from 22 percent in 2000. These economic changes can influence state residents’ health in multiple ways. Residents who lose jobs may find themselves uninsured or with poorer health insurance coverage; they may reduce expenses by purchasing cheaper, less nutritious foods, by delaying health care, or by rationing medications (taking them less frequently, or in smaller doses than recommended). With residents earning less, a smaller tax base can decrease government funding for preventive efforts to improve neighborhood conditions that facilitate healthy behaviors and that influence life expectancy. The Affordable Care Act will mitigate some of these negative effects by improving access to insurance, especially for young adults, the group most likely uninsured, and by covering individuals with existing conditions. Demographic shifts in the state also have implications for health. • Cultural diversity is increasing. Between 2000 and 2010, the state’s population of color grew by 55 percent. Racial diversification will continue, particularly in the Twin Cities region. The Metropolitan Council projects that, by 2040, over 40 percent of Twin Cities residents will be persons of color.
• Our senior citizen population is growing. By 2030, the number of Minnesotans over age 65 will double; older adults will account for about onefifth of our population. Simultaneously, fewer available workers will support the health care and other needs of our aging population. Demographic shifts present both challenges and opportunities for reducing health in-equities. For example, many new immigrant and refugee families reach the U.S. with healthy diet and lifestyle behaviors that eventually tend to erode. Our region should identify opportunities to help new immigrants maintain healthy lifestyle choices. While we cannot predict exactly how regional economic and demographic changes will influence health outcomes, data clearly demonstrate that many residents in our region have less financial resources than before. Our growing senior citizen population places increased stress on our economy, as we develop ways to provide necessary services for a larger and larger number of residents. In addition, persons of color in our state tend to have poorer outcomes across a variety of measures, including health, education, and employment. Anticipated cultural diversity in our state only heightens the sense of urgency we have to eliminate racial inequities. The role of physicians in reducing health inequities
Physicians treat illness, prevent disease, and advise healthy behaviors for the patients they serve. However, many factors that influence health cannot be solved in the doctor’s office. Instead, we need to look “upstream” to address other factors. In addition to promoting social justice, eliminating health inequities is a cost-saving measure. The Joint Center for Political and Economic Studies estimated in 2009 that eliminating health disparities in the U.S. could produce $56 billion per year of savings in direct medical costs alone. In our view, physicians can work towards reducing health INEQUITIES to page 38
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Heading to the OR to reduce the risk of stroke By Andrew Grande, MD, Ramachandra Tummala, MD, and Bharathidasan Jagadeesan, MD
which patients with stenotic vessels should undergo medical management and which will benefit from revascularization. Major contemporary studies
have evaluated surgical endarterectomy and endovascular stenting to determine how best to reduce the risk of a
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stroke from carotid stenosis. Some patients with carotid disease can tolerate a progressively stenotic carotid artery without having any symptoms.
Endovascular approaches became a widely available option in 2004, when the Food and Drug Administration approved stents for carotid artery disease.
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Carotid artery disease
ver the last few decades, public awareness has steadily increased about the health risks of obesity, hypertension, and hyperlipidemia. Many people are now well informed about how atherosclerotic plaque in coronary arteries can heighten the likelihood of heart attacks. Less attention, however, has focused on how the same risk factors can also contribute to progressive occlusion of the carotid artery and blood vessels in the brain. But the numbers speak volumes: Of the 700,000 strokes a year in the U.S., an estimated 50,000 are caused by carotid artery disease. The effects of stroke are devastating to individuals and their families, and weigh heavily on society in costs for rehabilitation and long-term care and lost productivity. Fortunately, awareness is growing about carotid artery disease and about the steps that can be taken in prevention, management, and treatment. Studies spanning the last two decades have helped determine
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MINNESOTA PHYSICIAN AUGUST 2012
In fact, some learn they have a partially occluded vessel during diagnostic tests for other conditions, like evaluation of headache or an injury following a car accident. Studies have shown that for patients who have no symptoms, medical management with statin inhibitors, daily aspirin, and blood pressure reduction can be sufficient to address a narrowing vessel. When patients become symptomatic, they may experience a transient ischemic attack (TIA), involving periods of blindness or paralysis that resolve within 24 hours, or a completed stroke in which the same symptoms persist beyond 24 hours. When TIA symptoms appear, the risk of the patient having a large stroke can be as high as 6 percent within the next two days, up to 19 percent within the next 90 days, and up to 30 percent within the next five years. The North American Symptomatic Carotid Endarterectomy Trial (1991) and European Carotid Surgery Trial (2003) showed that patients symptomatic from carotid artery narrowing greater than 50 percent of the diameter of the artery can benefit significantly from undergoing carotid endarterectomy
(CEA). Other trials, such as the Asymptomatic Carotid Artery Study (1995) and the Asymptomatic Carotid Surgery Trial (2004), have shown that CEA can be beneficial in asymptomatic patients when their internal carotid arteries are narrowed by more than 60 percent. Surgical and endovascular treatments reduce the plaqueinduced stenosis and widen the vessel. Over the years, however, controversy has arisen over which treatment, CEA or carotid artery stenting (CAS), is superior. Recent studies have helped clarify the risks-to-benefit ratio of each procedure and provide an opportunity to evaluate the options for each patient. Carotid endarterectomy (CEA)
Three studies over the last decade, conducted in North America, Europe, and within the U.S. Veterans Affairs system, have investigated the effectiveness of CEA and found that it is highly effective in symptomatic patients who have more than 70 percent stenosis and incomplete occlusion. During CEA, neurosurgeons approach the artery from an anterior approach of the neck, exposing the internal carotid artery, and clamp the vessel both proximally and distally. The procedure can be done in patients who are awake or are under general anesthesia, usually depending on the preference of the surgeon and the anatomy of the patient. Awake patients can provide immediate feedback of potential neurological problems. For patients who cannot tolerate being awake for the procedure, general anesthesia can be used, but electrophysiological monitoring is required to provide assurance that collateral blood supply is adequate to the brain (If the patient has evidence of poor collaterals manifested in diminished amplitude of EEG waves, a temporary shunt can be put in to reroute blood past the stenosis during the procedure.) After opening the vessel, neurosurgeons then dissect out the plaque and suture the open edges of the artery. CEA has been found to be
most beneficial when performed within two weeks of TIA (in patients with only 50 percent to 69 percent stenosis, the studies showed modest benefit for surgery in women, and no benefit in men when the procedure was done beyond two weeks of TIA). For optimal results, patients need to be fit for surgery, and surgeons performing CEA must have low complication rates (less than 7 percent in symptomatic patients and less than 3 percent in asymptomatic patients). In addition, the benefits have been found to be most significant in male patients, particularly those over the age of 75. When the degree of stenosis is between 50 percent and 69 percent, the surgery is of only modest benefit. Contraindications to surgery include recent myocardial infarction; coexistent active cardiac and carotid disease; contralateral carotid occlusion; and multiple, tandem stenoses. In addition, patients with neck irradiation and previous carotid endarterectomy are not good candidates for CEA. Carotid artery stenting (CAS)
Endovascular approaches became a widely available option in 2004 when the Food and Drug Administration approved stents for carotid artery disease. During CAS, interventionalists begin with a diagnostic angiogram to view the stenosis, and then install a distal embolic protection device (a tiny umbrella-like filter) in the vessel to catch plaque particles. They navigate the stent through the stenosis, which can be difficult in patients with tortuous vascular anatomy. Contemporary stents are selfexpanding and exert an outward radial force to widen the diameter of the vessel; occasionally a balloon is positioned into the stent, or into the vessel before the stent is placed, to widen the stenosis. Early studies were promising: In patients with 80 percent stenosis, the stents opened narrow arteries 92 percent of the time, and complication rates were low, with only about 10 percent of patients who received the carotid stent experiencing a
Carotid endarterectomy has been found to be most beneficial when performed within two weeks of transient ischemic attack. stroke, heart attack, or death within 30 days of the procedure. However, much controversy ensued about whether stenting is safer or more effective than surgery. The relative contraindications for CAS include renal disease, because the contrast can be nephrotoxic, and highly tortuous carotid vessels, which make placing a stent difficult. A circumferentially, heavily calcified stenosis can also prohibit safe placement of a stent. Patients are maintained on dual antiplatelet therapy with aspirin and clopidogrel for one month after stent placement and then on daily aspirin thereafter. CEA/CAS comparison
An article in the New England Journal of Medicine in 2010 reported the results of the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) and answered many long-debated questions. The multicenter randomized investigation included 2,500 symptomatic and asymptomatic patients. The study found that CAS and CEA were equally effective and that complications with either procedure were low, with periprocedural stroke or death less than 6 percent for symptomatic patients and less than 3 percent for asymptomatic patients. It also showed that patients who underwent surgery were at a higher risk for myocardial infarction after the procedure (2.3 percent with CEA and 1.1 percent with CAS) but at significantly lower risk for perioperative stroke (2.3 percent for CEA and 4.1 percent for CAS). Because rehabilitation from a heart attack is typically faster than from stroke, the results can be interpreted to mean that surgery may be preferable. The study also showed that contrary to prior assumptions, patients older than 70 years
derived more benefit from CEA than from CAS, perhaps due to the tortuous nature of their carotid arteries and aortic arch, which can make CAS difficult. Regarding long-term benefits conferred by CEA or CAS, large studies have shown that the risk of having a stroke in the first year following these procedures is 1 percent to 2 percent for symptomatic patients and 0.5 percent to 0.8 percent for asymptomatic patients. The long-term durability of these benefits (beyond five years) is not yet clearly known. Sometimes the arteries can also narrow again after CEA (about 5 percent in the first year) and CAS (about 10 percent in the first year). However, such narrowing does not always need
to be re-treated with another procedure. Currently, both CEA and CAS are endorsed by the American Heart Association and the American Stroke Association for treatment of symptomatic patients with â‰Ľ50 percent narrowing of their carotid arteries and for asymptomatic patients with â‰Ľ70 percent narrowing of their carotid arteries. When the procedure is feasible, CEA has emerged as the procedure of choice, its standing having been further reinforced by the findings from the CREST trial. CAS still has a prominent role, particularly in patients determined to be highrisk candidates for CEA. Andrew Grande, MD, Ramachandra Tummala, MD, and Bharathidasan Jagadeesan, MD, are assistant professors in the Departments of Neurosurgery, Neurology, and Radiology at the University of Minnesota, Minneapolis. Grande and Jagadeesan are co-directors of the Earl Grande Stroke and Stem Cell Laboratory in the Stem Cell Institute at the University of Minnesota, Minneapolis.
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Sue Abderholden, MPH NAMI Minnesota Title: Executive Director Interesting projects: NAMI has been working to transform how the various systems view and interact with children and adults with mental illnesses. We have been building a greater understanding of mental illnesses, confronting common myths, reducing stigma, and creating a more empathetic response in order to eliminate barriers to treatment. Mental Health First Aid has been part of this strategy. Additionally, we have been trying to help professionals understand the importance of natural supports—family and friends—in recovery. If we want to have positive outcomes and reduce health care costs, we must eliminate all barriers to accessing treatment early and must assist and engage families and friends to provide the ongoing support that is needed. Biggest challenges: Trying to integrate mental health and health care and to develop intensive supports for children with a serious mental illness who are at risk of residential treatment and who are failing in school.
Jim Abeler, DC Minnesota House of Representatives Title: State Representative Interesting projects: The 2010– 11 health and human services budget was quite a project. Working with stakeholders, providers, the governor, and the departments, we crafted a consensus budget and created many positive reform initiatives, including an attempt to redesign our Medicaid program for greater budget certainty and service delivery flexibility. In 2011 we worked with colleagues and the White Earth tribe to transfer health and human service responsibilities from Mahnomen County to the White Earth Band of Ojibwe. This redirects funds from the county to the tribe and allows for more culturally appropriate care to members of the White Earth Nation.
n preparing this feature, we asked each of the nominated health care leaders to answer two questions: • What are the most interesting projects you have worked on in the past four years? • What are the biggest changes facing your organization? We invite you to read their responses.
Biggest challenges: The rising cost of health care continues to be a daunting challenge, as do chronic health conditions and poor health across our state and nation. Reducing costs, improving access, and bettering the health of the population are all part of the challenge in creating a sustainable, effective health care system.
David Abelson, MD Park Nicollet Health Services Title: CEO Interesting projects: Being very intentional about changing and improving our internal culture of Head + Heart, Together (treating the emotional needs of our patients as well as their clinical needs). We have worked hard to hire the right people and instill a strong sense of purpose and pride in working at Park Nicollet. It’s the right thing to do for our team members, and without it we can’t accomplish one of our most important goals: Improve the patient experience. Biggest challenges: In a time of historic and transformational change in health care, our biggest challenge is to navigate the transition from volume to value. The fee-for-service business model is breaking apart and will soon be gone. All entities in health care must have the same incentives to meet the goals of the Triple Aim: healthy communities with great experiences and outcomes for individuals provided at a sustainable cost.
Macaran Baird, MD, MS University of Minnesota Medical School Title: Professor and Head, Department of Family Medicine and Community Health Interesting projects: Over the past four years our U of M family medicine medical practices have used tools from the
MINNESOTA PHYSICIAN AUGUST 2012
Lean model for improving our practice effectiveness and efficiency, followed by leadership training and skill-building to change our four residency and teaching practices into certified health care homes. In the process, we have become a more cohesive group of clinicians, educators, and staff. Our patients and future patients of our graduates will benefit from these improvements. Biggest challenges: How to simultaneously serve our mostly underresourced patients while also training the next generation of bright, dedicated, skilled physicians, therapists, pharmacists, nurses, and others to work and learn collaboratively. Our goal is the same as that for our whole health care system: improving outcomes, improving the patient experience, and lowering overall costs. This challenge is complicated by the enormous cost pressures on all of higher education.
Eric T. Becken, MD Midwest Ear, Nose, & Throat Specialists, St. Paul Title: Staff Physician Interesting projects: My current focus is to ensure patient and payer access to patientcentered care from independent, high-value physicians through the development of the Collaborative Care Cooperative. Our organizational structure enables us to drive quality measures across practices. We also improve patient care though a communications vehicle that allows real-time collaboration between independent specialty and primary care physicians. Biggest challenges: My principal challenge is to provide exemplary, cost-effective care to every patient. Secondarily, the consolidation of large health care organizations limits patient access to independent, high-value physicians. Extraordinary effort is required to maintain patient access to and awareness of our practice.
Lee Beecher, MD Minnesota PhysicianPatient Alliance Title: President; Psychiatrist, private practice Interesting projects: Of greatest interest to me is the privilege of participating in patient care at my independent psychiatric office practice. Patients are the essential collaborators in their medical care, and we physicians need our patients’ alliance in order to practice our profession. I monitor the Minnesota PhysicianPatient Alliance email listserv featuring discussions and interchanges. I enjoy writing professional articles about the challenges and rewards to patients and physicians in their pursuit of quality, patient-centered care. Biggest challenges: Regarding MPPA, bringing the voices of patients and their families to policymakers, organized medicine, and the public. My medical practice is an ongoing “project” to collaboratively deliver patientcentered, psychiatric, and addictions care. I believe that doctors recommend and patients decide, except in emergencies. Regarding U.S. medical care policy, patients and their families should, to the extent possible, be the medical care decision-makers, rather than deferring to insurance companies or the government.
Mary Sue Beran, MD, MPH Park Nicollet Clinic, St. Louis Park Title: Staff Physician; Researcher Interesting projects: A research evaluation of a primary care redesign involving the patient-centered medical home. We compared the medical home implemented in one clinic to another with respect to disease specific outcomes, staff satisfaction, patient experience, and utilization patterns to see if this model of care offers improvements. What we learn may help identify innovative ways to care for patients with complex chronic medical problems. Biggest challenges: There are simply not enough primary care
10 0 I N F L U E N T I A L H E A LT H C A R E L E A D E R S physicians to meet the needs of the aging and growing Medicare population. We must develop team-based care models that allow us to provide high-quality care for more patients.
Richard M. Bergenstal, MD International Diabetes Center at Park Nicollet Title: Executive Director; Past President, American Diabetes Association Interesting projects: IDC participated in an NIH study of intensive glucose control in type 2 diabetes. Working with the American Diabetes Associat-ion, we helped translate this research into practice through development of an international, patient-centered management guideline. The IDC WHO Collaborating Center, partnering with China’s Ministry of Health, is delivering a five-year diabetes training program. Biggest challenges: Effectively managing diabetes in the wake of health care reform is a perfect challenge for IDC working with Park Nicollet’s integrated health care system. IDC research shows it takes teams (including the patient) armed with effective technology to optimize quality and the patient experience at a reduced cost.
Mary K. Brainerd, MBA HealthPartners Title: President and CEO Interesting projects: The projects I care about very deeply have focused on building new approaches and models of care to improve quality. We have done that work in primary care, hospital care, and specialty care. The results speak for themselves—topnotch quality, health, and safety. That matters. Biggest challenges: The biggest challenge we face is making health care affordable, because whether employers pay for it or we pay through our taxes or out of our wallets, it is costing too much. And we need payment reform.
Matt Brandt, MD
Julie Brunner, JD
Raymond G. Christensen, MD
Multicare Associates of the Twin Cities
Minnesota Council of Health Plans
University of Minnesota Medical School–Duluth Campus
Title: CEO Interesting projects: Patients need and want care delivered to them by physicians who are looking out for them and working for them. They want physicians who are more than just gatekeepers to an insurance company and/or feeders to a hospital system. So I am seeking out, exploring, and implementing new business models that hopefully will unlock the value of primary care delivered in an independent physician group setting. Biggest challenges: There are lots of economic and political pressures that everyone in health care is dealing with, so our biggest challenge is staying focused on doing what we do best—taking care of patients—and avoiding gettting sidetracked or getting lost in the fear of the unknown.
Title: Executive Director Interesting projects: Most of our work in the past four years falls into two categories: state and federal health reform. The constant balance is providing the best coverage possible while trying to make coverage more affordable for employers and individuals. Biggest challenges: Ensuring every Minnesotan has access to health care coverage while working to slow the rising cost of care. In addition, nation-leading work has been underway to change how care is paid for in Minnesota, moving away from paying per procedure toward paying for health while slowing the rising cost of care.
Charles Bransford, MD
Affiliated Community Medical Centers–Granite Falls
Title: Assistant Dean for Rural Health, Associate Professor of Family Medicine; Family Physician, Gateway Family Health Clinic, Moose Lake Interesting projects: Development of the Rural Medical Scholars Program on the U of M Duluth campus. The program is a mandated, longitudinal rural Family Medicine experiential rotation that recurs for one-week periods during the basic science years one and two. Continuing to pursue my personal mission of assuring access for rural citizens and our visitors, to high-quality rural health care 24/7 that maximizes the “golden hour” with high-functioning, interprofessional, local community health care systems. Biggest challenges: Conceptualizing the rural medical practice of the future for appropriate selection and training of tomorrow’s physicians and health care workforce. Identifying and supporting energetic and enthusiastic rural family physician educators and practice sites in supportive rural communities and health systems. This component is essential to complete the university’s extended rural medical school campus.
Lakeview Hospital and Lakeview Hospice/Palliative Care Program Title: Medical Director Interesting projects: Bringing hospice/palliative care into the public consciousness by developing a community-based palliative care program in Stillwater. I have also been an active participant in the Tibetan Healing Initiative, with the goal of sharing the knowledge of our two healing systems for our mutual benefit. Biggest challenges: The danger of “corporatization” of medicine. How do you provide loving, humanistic, individual care to patients in a large corporate system? Our challenge becomes creating the new healers that come out of our Western system, who can use the EMR to its max to still come up with that loving suggestion that can lead a client to health. We must find a way to instill the old joy of primary care in our new physician population, and reward them for the most difficult task in medicine—greeting the terrified person at the front door and walking with them on their particular journey.
Darrell L. Carter MD, DABFP, FAAFP, FACEP Title: Family Physician; Co-founder and Program Director of CALS Program Interesting projects: I have helped develop, write, and teach Comprehensive Advanced Life Support Program (CALS) training designed to improve rural/remote emergency and critical care. The training teaches rural providers the skills, knowledge, teamwork, proper use of needed equipment, and a universal approach focused on the essential medical needs of patients who present to their facilities, especially those patients with time-sensitive life- and organ-threatening conditions. Biggest challenges: Financing and providing the training needed by rural and remote health care providers so as to deliver the same high-quality emergency care in the rural communities that the American health care system delivers to urban populations.
Y. Ralph Chu, MD Chu Vision Institute Title: Founder and Medical Director, Chu Vision Institute; Adjunct Associate Professor of Ophthalmology, University of Minnesota Interesting projects: Chu Vision Institute has participated in over 25 FDA clinical trials, including an ongoing study in which we are evaluating a corneal inlay that corrects presbyopia. In this trial, an implantable contact lens is placed beneath a LASIK flap to help refocus light to improve reading vision without sacrificing distance vision. With over 90 million baby boomers in need of reading glasses, this type of technology will have a significant impact. Biggest challenges: In the current MINNESOTA PHYSICIAN
10 0 I N F L U E N T I A L H E A LT H C A R E L E A D E R S health care environment, practices face increased administrative, regulatory, and economic challenges. It is difficult not only to understand these changes for ourselves as providers but also to communicate these changes to our patients. Creating an organization that can provide high-quality patient care as well as the education needed to make patients feel comfortable in this new environment is our biggest challenge.
Kathryn Correia HealthEast Care System Title: President and CEO Interesting projects: I was privileged to support the complete redesign of inpatient care that was initiated, developed, and implemented by nurses in collaboration with an interdisciplinary team. The model resulted in significant improvement in quality, cost, and patient satisfaction. Prior to that, I was able to build a medical group from the ground up. Now I am intent on supporting everyone at HealthEast to reach our full potential in providing the best value for our patients and in helping to create healthy, vibrant communities. Biggest challenges: Time. Time is always our scarcest commodity. Every day we improve care is a day someone in our community is able to smile brighter, go to work, sing a song, experience less pain, or spend time on something else they would rather do. In health care we have so much to improve, and so little time … it’s personal.
Sara Criger Allina Health Title: Senior Vice President, Allina Health; President, Mercy Hospital, Coon Rapids Interesting projects: At St. Joseph’s Hospital, where I served as CEO until June 2012, we made a strategic decision to not try to be everything to everyone, but to focus on the things we could be excellent at. It was very rewarding to partner with physician leaders and others to evolve programs like the National Brain
Aneurysm Center and HealthEast Stroke Care, HealthEast’s Kidney Stone Institute, Addiction Medicine, and HealthEast Heart Care. Biggest challenges: To engage physicians, nurses, and other health-care team members in needed health-care delivery transformation. They know what to do to improve care and health and how to help avoid unnecessary services. It is the job of leadership to inspire them in this work and unleash the knowledge and creativity they possess so we end up with a better health care system.
Kent Crossley, MD
and shadow-hosting dozens of premedical students of color. It has been rewarding to see many of the students now enrolled in medical school. Biggest challenges: Maintaining the privilege, value, and quality of the patient-physician relationship. I frequently hear patients express frustration at being unable to see the doctor of their choosing due to insurance changes. They are losing longstanding physician relationships, which detracts from quality care. I strongly support patients’ ability to access a physician of their choice.
Minneapolis VA Medical Center
Peter J. Daly, MD
Title: Chief of Staff Interesting projects: Expanding access for our veterans. Our VA now has a network of 11 community clinics in Minnesota and Wisconsin. We increasingly use telecare to provide services to our patients in their homes and for consultations to our clinics and other midwestern VA hospitals. Our TeleICU service works with other VAs as far away as Spokane, Wash. Biggest challenges: Working to optimize services so that we can successfully compete for patients in the future. Recruiting and hiring great physicians to provide outstanding care to our veterans. Spreading the message that VA has evolved to become a worldclass provider of care and a leader in quality.
Charles E. Crutchfield III, MD Crutchfield Dermatology Title: Medical Director; Clinical Professor of Dermatology, University of Minnesota Medical School Interesting projects: I co-authored a children’s book centered on sun protection and Little League Baseball to appeal to children of all backgrounds. We are proud of the result and hope it will have a lasting impact on children and their families. I also participate in the Future Doctors program at the University of Minnesota Medical School, mentoring
MINNESOTA PHYSICIAN AUGUST 2012
Title: Orthopedic surgeon Interesting projects: Leading a group of independent medical specialists in discerning how we can maintain patients’ interests (choice, access, high quality, cost control) at the center of health care reform. Establishing the Collaborative Care Cooperative, which allows care collaboration on a platform from which we can communicate and integrate with primary care without assuming a single tax ID number. The cooperative facilitates more direct provider discourse and larger scale outcome data, and it can plug into an ACO model and wrap around a health care home. Biggest challenges: Coordinating care requires enhanced communication tools and improved technological solutions, all of which demands IT capital and engaged, innovative physicians.
Bobbi Daniels, MD University of Minnesota Medical School; University of Minnesota Physicians Title: Vice Dean for Clinical Affairs, U of M Medical School; CEO, U of M Physicians Interesting projects: Certainly our upcoming Ambulatory Care Center, in partnership with Fairview, has been an interesting and promising project. This facility will give us a unique opportunity to offer new
care and research models while promoting interdisciplinary collaboration and health care education. Biggest challenges: At a time of decreasing state support for medical education and decreasing reimbursement rates, it’s important we still find ways to support not only clinical care, but research and education as well.
Gary L. Davis, PhD University of Minnesota Medical School–Duluth Campus Title: Regional Campus Dean Interesting projects: Strategic planning to better position the medical school campus in Duluth to address the changing economic environment and prepare students for the changes coming to health care delivery and organization. This included departmental reorganization, new faculty recruitment, and extensive curricular revisions. Biggest challenges: Finding new sources of revenue to compensate for continual decreases in state funding to medical education. We are also challenged by the need to recruit new faculty to replace the retirement of a substantial portion of our faculty in a short time frame. The challenge is not only to hire new faculty but also to find the resources to support the new hires.
Rhonda Degelau, JD Minnesota Association of Community Health Centers Title: Executive Director Interesting projects: Navigating the public and private sector industry reforms on behalf of the state’s urban and rural Community Health Centers (CHCs) and working to line up the resources and partnerships they need to succeed in a rapidly transforming health-care delivery system. CHCs in Minnesota have made great strides in implementing electronic health records, moving toward health-care home certification, utilizing best practices in quality improvement, and creating innovative Medicaid and Medicare payment-reform pilots.
10 0 I N F L U E N T I A L H E A LT H C A R E L E A D E R S Biggest challenges: Defining the role of Community Health Centers in an “ACO world”— which will differ by market (metro, small city, rural, sparsely populated rural). The Medicaid coverage expansion under the Affordable Care Act will create greater demand for CHC services. CHCs will need additional federal and state funding resources to expand capacity for providing culturally competent services to low-income populations.
Peter Dehnel, MD Blue Cross and Blue Shield of Minnesota Title: Medical Director Interesting projects: I work to bring a physician’s perspective to my role, helping adjudicate complex medical coverage cases. My focus has been in working to forge closer collaboration between the physician/clinician community and our health plan on behalf of members. Biggest challenges: I think there’s opportunity to better inform the physician community about the role of health plans, the complexities around coverage, and how insurance plans operate. Ultimately, our goal is to optimize the interface between the insurance world and provider community, and help our members get the right benefits and services within the context of their plan, in order to deliver the best possible outcomes.
Edward P. Ehlinger, MD, MSPH Minnesota Department of Health Title: Commissioner of Health Interesting projects: Providing a long-range public health framework for health reform during a time when budget deficits narrow perspectives to the next biennium and when the role of government in health care is being questioned. Working to integrate clinical care with public health and social services as a way to improve population health and decrease costs. Biggest challenges: Having people
understand that strengthening Minnesota’s public health enterprise is essential if we are to improve health and control costs. Rebalancing our investment between individual treatment and population-focused prevention efforts. The need to increase our investment in primary care and engage citizens in creating healthy communities.
Thomas E. Elliott, MD Essentia Institute of Rural Health, Duluth Title: Executive Director Interesting projects: We are building Essentia Institute of Rural Health, which is Essentia Health’s center for research and education, launched January 2010. We support health services research, translational research, clinical trials, education programs for students and practicing physicians, and credential practitioners. We have recruited great scientific talent, developed a research informatics department with a virtual data warehouse, and joined the HMO Research Network and Midwest Research Network. An excellent strategy guides our growth, and Essentia Health, our parent organization, provides great support. Biggest challenges: The greatest threat to health care research is declining federal funding for research grants, which will slow down the discovery and dissemination of knowledge, decrease jobs in health care research, and limit the growth of our institute and other research centers across the nation.
James W. Eppel Blue Cross and Blue Shield of Minnesota Title: Chief Operating Officer Interesting projects: Our ongoing work in establishing “aligned incentive” relationships with delivery system partners is resulting in highly collaborative and mutually beneficial approaches that will improve quality and decrease the cost of health care.
We’re only beginning to realize the tremendous benefits that these partnerships will generate for our members. Biggest challenges: While I’ve never witnessed such positive energy and collaboration in 30 years of working in this industry, we are facing a level of unprecedented change that will require the requisite changes in structure, process, systems, and talent. Continually evolving to meet these needs and the opportunities before us presents the most significant, and exciting, challenge.
Nancy Feldman UCare Title: President and CEO Interesting projects: Since our membership has doubled over the past four years, we’ve been working to manage our growth and help members connect to the health services they need. We’ve increased our Medicare membership every year, and we were a very successful bidder when the state introduced competitive bidding for state health program members. We’ve been exploring innovative new payment models and relationships with our healthcare system partners for both our Medicare and Medicaid products. Biggest challenges: We need to figure out our place in a world of health reform, focusing on how we can be a link for our diverse members between the health insurance exchange and state programs. We will continue to be challenged by the fiscal pressures on government-supported health programs and how we can continue to provide value to our members and purchasers.
John R. Finnegan Jr., PhD University of Minnesota School of Public Health Title: Professor and Dean; Assistant Vice President for Public Health Interesting projects: Most important? So many in public health! Definitely, health reform that finally acknowledges and is beginning to incorporate the indisAUGUST 2012
pensable role of public health in population and community health. Also. the Taconite Workers Lung Health Partnership that unites U of M scientists, union, industry, government, and community leaders in a scientific initiative to understand the occupational health of this group of workers and their spouses. Biggest challenges: Our biggest challenge is the accelerating disinvestment in higher education. It threatens the school’s capacity to produce the world-class research for which we are famous, and to keep training public health professionals, scientists, and the current public health workforce.
Thomas P. Flynn, MD Minnesota Oncology Title: President Interesting projects: In 2009 we brought nine physicians employed by a hospital into our independent practice. The synergies were clear, as were differences in culture and employment models. The common purpose of high-quality patient care brought us together. Next came the development of a partnership with a health system to enhance the delivery of community cancer care. Finally, we have been engaged in a long-term organizational culture change process to become a more patientcentered practice. Biggest challenges: Changes in reimbursement for care will require us to be better, faster, and cheaper while continuing to deliver the best care to our patients.
Al Franken U.S. Senate Title: Senator Interesting projects: It was incredibly rewarding to pass legislation that’s helping lower health care costs and increase access to coverage for people in Minnesota and across the country. I authored a provision in the health reform law requiring insurance companies to spend at least 80–85 percent of their premium dollars on actual health care. Because of that provision, 9 million Americans— MINNESOTA PHYSICIAN
10 0 I N F L U E N T I A L H E A LT H C A R E L E A D E R S including 123,000 Minnesotansâ€” will get $1.1 billion in refunds from their insurance companies this year. More recently, legislation I wrote to get lifesaving medical devices to patients more quickly and safely was sent to President Obama to be signed into law. Biggest challenges: Providing high-quality, low-cost care is the biggest challenge we face when it comes to health care. While Minnesota does an exceptional job of accomplishing this balance, achieving the same success nationwide will continue to be one of my top priorities.
Aaron Friedman, MD University of Minnesota Title: Vice President for Health Sciences; Dean, U of M Medical School Interesting projects: We at the University of Minnesota have made significant strides in finding interdisciplinary solutions to impact health access and care across the state of Minnesota through education, models of clinical care, and outreach programs within our health schools.
Biggest challenges: A dedication to funding for quality health-care education will help ensure a solid foundation for the future of health care not just in Minnesota, but nationwide. Improving patient care and the health of our communities, along with delivering more effective and efficient care, need to be priorities as physicians, health care providers, and educators look ahead.
Alan L. Goldbloom, MD Childrenâ€™s Hospitals and Clinics of Minnesota Title: President and CEO Interesting projects: The $300 million expansion and complete renovation of our two campuses in Minneapolis and St. Paul. The result is a state-of-theart facility that features all private patient rooms and reflects our philosophy of family-centered care. Another unique aspect was integration of the arts into the healing environment. Finally, in an age of universal connectivity, we are the only hospital in the country to have a Geek Squad precinct onsite,
thanks to a gift from Best Buy. Biggest challenges: We must find ways to continually improve quality, safety, and patient experience while reducing the total cost of care. We are determined to live up to our commitment of turning no child away and providing every child with the highest quality of care. If we can successfully change the model of care delivery, develop stronger partnerships across the system, and change the payment model, I believe we can meet that commitment.
H. Theodore Grindal, JD Lockridge Grindal Nauen PLLP Title: Partner Interesting projects: Working with physicians, hospitals, and other health care providers as they evolve to compete and collaborate in the everchanging state and federal healthcare reform environment. Counseling providers on the business and public policy aspects of these changes has been exciting and fascinating. Biggest challenges: Representing clients in this era of con-
solidation remains a challenge. New business ventures are possible, however, because of the need for collaboration without ownership. Networks are going to be stronger and demand creative arrangements to compete in this evolving health care market.
Jon Hallberg, MD University of Minnesota Physicians Title: Medical Director, Mill City Clinic; Assistant Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School; Health and Medical Analyst, Minnesota Public Radio Interesting projects: Helping design the innovative and awardwinning Mill City Clinic, an interprofessional primary care, fullservice, neighborhood-based clinic in the Mill District, near the Guthrie Theater in Minneapolis. With this effort weâ€™re trying to rethink what a clinic can and should be, especially focusing on ways to engage the community. One very successful project has
Courage Center is proud of our CEO, Jan Malcolm, who has been recognized as one of the 100 most inďŹ‚uential health care leaders in Minnesota. Jan Malcolm, CEO
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