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Volume XXVl, No. 9

December 2012

The Independent Medical Business Newspaper

Preserving the safety net

Brain research Keys to healthy aging

Why it’s important

By Apostolos P. Georgopoulos, MD, PhD, and Margaret Y. Mahan

By John Tschida

B

T

BRAIN to page 10

PAID

A number of conditions can inflict brain damage. First, there are conditions that alter the local milieu in which brain cells bathe and which can adversely modify their function or cause their death. Such conditions include high blood pressure, high lipids, environmental exposure to toxic chemicals, drug abuse, and congenital disorders of metabolism (e.g., phenylketonuria, or PKU). Other direct insults include brain injury inflicted, for example,

PRSRT STD U.S. POSTAGE

Brain insults and brain health

as the result of an accident, playing rough sports, or gunshot wounds. Psychological trauma also can have serious adverse consequences resulting in brain malfunction, as in post-traumatic stress disorder. A more subtle cause of potential cell damage involves lack of neuroprotection. Neuroprotection is a relatively recent concept that has drawn considerable interest because of its potential to increase the resilience of the brain and promote brain health. The single most important neuroprotective factor is exercise. Regular physical exercise can reduce the risk for dementia by as much as 40

Detriot Lakes, MN Permit No. 2655

he brain is a huge network consisting of more than 100 billion massively interconnected and communicating cells (neurons) and support cells (glia). As a network, the brain never declines. It evolves, adapts, learns, acts; in fact, it gets better and better with time, culminating in what we collectively call “wisdom.” The problem is that the brain is made of perishable material, subject to all kinds of insults. Although repair and renewal mechanisms are present and unceasingly active, cell damage occurs and takes its toll, leading to decline in brain function because of material loss. Therefore, healthy aging translates into preserving cell biology, e.g., by avoiding disease and lifestyle behaviors that can damage cells.

y many measures, Minnesota has long been a standard bearer for promoting the health and independence of individuals (of all ages) with disabilities. The community-based safety net that has been developed over the last four decades recognizes that many of our most vulnerable citizens require many areas of public policy to be working in concert for successful community living to be fully realized. It’s not uncommon for government to play a role in supporting the health, housing, transportation, and employment needs of tens of thousands of disabled Minnesotans. But that safety net is fraying at the edges. Burgeoning budget deficits at the state and federal level have led to significant cuts in payments to providers over the past several years. Demographic pressures will only increase the need for resources to support this growing population. Multiple stakeholders are demanding changes in how the current fragmented

Senior and long-term care Page 20

SAFETY NET to page 12


26 January 2013 - 8 a.m. to 5 p.m. To Register:

www.mayo.edu/cme/psychiatry-and-psychology-2013r271 Registration fee includes morning lectures, lunch, ticket to play and post-play discussion.

Windows

into HOPE:

Stories of Addiction and Recovery Held at the Guthrie Theater, this innovative education program is designed to enhance the understanding of addiction. It combines morning lectures from Mayo Clinic addiction experts with an afternoon Guthrie Theater theatrical performance.

Actress Melissa Gilbert, morning keynote speaker • Mark A. Frye, M.D. and Timothy W. Lineberry, M.D., Mayo Clinic Department of Psychiatry and Psychology, course directors • Visiting faculty, Susan Tapert, Ph.D., University of California, San Diego and Kathleen Brady, M.D., Ph.D., University of South Carolina.

Photo by Mark Vancleave

Join us for the day in exploring addiction and recovery in an innovative medical educational event designed for members of the general public and medical professionals. In fast-paced and interactive conversations, morning keynote speaker Melissa Gilbert, Mayo Clinic experts and visiting faculty will explore the scientific basis of addiction and its impact on individuals and families.   Following the lunch included in the program, at 1 p.m. participants will see the Pulitzer Prize- and Tony Awardwinning play Long Day’s Journey into Night presented on the Guthrie’s Wurtele Thrust Stage. After the play, Euan Kerr from Minnesota Public Radio will moderate a discussion of the play’s themes to help participants reach deeper insights into the complex pathology of addiction—and the liberating hopefulness of recovery.   College of Medicine, Mayo Clinic, designates this live activity for a maximum of 7 AMA PRA Category 1 Credits™.


CONTENTS

DECEMBER 2012 Volume XXVI, No. 9

FEATURES Brain research Keys to healthy aging

1

MINNESOTA HEALTH CARE ROUNDTABLE

By Apostolos P. Georgopoulos, MD, PhD, and Margaret Y. Mahan

Preserving the safety net Why it’s important

1

By John Tschida

T H I R T Y- N I N T H

DEPARTMENTS CAPSULES

4

MEDICUS

7

INTERVIEW

8

POINT OF VIEW Policies, politics, and physicians

16

By Robert W. Geist, MD

NEONATOLOGY Development of a young specialty

Timothy Henry, MD, FACC

28

By Mark Bergeron, MD, MPH

Minneapolis Heart Institute Foundation

DIABETES “Cheetos are not vegetables”

PATIENT SAFETY Creating a culture of patient safety

14

32

By Lori Wilcox, MD, and Mary Martinie, MD

By Janelle Shearer, RN, BSN, MA

SPECIAL FOCUS: SENIOR AND LONG-TERM CARE HELP for hospitalized elders

Design innovation 20

By Paula Duncan, RN, and Kasey Paulus, RN, CPHQ

Seniors and addiction Elder abuse

22

24

By Alanna Carter, Assoc. AIA, LEED-AP

26

By Steve Tschida, BES, LADC

By Julie Switzer, MD, and Avery Michienzi

The Independent Medical Business Newspaper

SESSION

Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle Creating measures that work choices into health care delivery is Thursday, April 25, 2013 necessary, but how 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).

Patient engagement

Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential.

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

ASSOCIATE EDITOR Janet Cass jcass@mppub.com Name ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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Please mail, call in or fax your registration by 04/18/2013

DECEMBER 2012 MINNESOTA PHYSICIAN

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CAPSULES

Mayo Clinic Creates Diabetes Health Atlas Mayo Clinic has created a resource that shows county-bycounty data on diabetes in Minnesota. The Minnesota Health Atlas is an online source of information about diabetes, provided in maps, charts, tables, and data downloads. The site was created and is maintained by the Decade of Discovery in Diabetes, a major initiative of the Minnesota Partnership for Biotechnology and Medical Genomics. The goal of the Decade of Discovery is to prevent, treat, and ultimately cure type 1 and type 2 diabetes, officials say. The partnership includes Mayo Clinic, the University of Minnesota, and the state of Minnesota. “As programs and projects for preventing diabetes roll out across the state, the Minnesota Health Atlas will be increasingly valuable and help inform strategies for diabetes care over large populations,” says David Etzwiler, executive director of the Decade of Discovery.

Mayo Clinic officials say the most common searches in the atlas are 30-day hospital readmission rates; total health care reimbursements; monthly rates of poor mental health days for persons with diabetes; and metrics on physical inactivity.

November Elections Mean ACA Will Move Ahead The road is clear for implementation of the Affordable Care Act (ACA) in Minnesota, with new DFL majorities in the state House and Senate. The Nov. 6 election that saw Barack Obama re-elected as president also brought the House and Senate under DFL control. With DFL Gov. Mark Dayton in charge of the executive branch, the 2012 election resulted in DFL control of both houses and the governorship for the first time since 1990. The election seems to settle the question of whether the ACA would be fully put into place, although opposition to the

sweeping health reform law remains. According to Rep. Tom Huntley, who for the past two years has been the ranking DFL member of the House Human Services Finance committee and also serves on the Health and Human Services Reform committee, the new DFL majorities in the Legislature will join with Dayton to move forward quickly on issues such as health insurance exchanges, Medicaid expansion, and state health-care payment reforms. “We’re not going to agree with the governor on every comma and semicolon, but overall, we have a similar view on where we need to go,” Huntley says. “All three groups want to move ahead with the ACA, so I think that will be done.” The state is facing federal deadlines for designing the health insurance exchanges, a central part of the ACA. Exchanges will provide coverage for individuals currently without insurance and small businesses who have not been able to offer health plans to employees. The

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Republican-led Legislature last spring declined to work on preparing for the exchanges, despite being urged to do so by health care and business leaders. Huntley says the looming federal deadlines are a concern but expressed confidence that the new Legislature and the Dayton administration would find a way to complete work on the exchanges. “We have very difficult timelines that we’re going to have to try to meet,” Huntley says. “I think that we will get some flexibility from the federal government, but … there’s going to be a lot of work done between now and Jan. 1.” Huntley says the Legislature will work on a range of other health issues in 2013, including Medicaid expansion, medical homes, and establishing accountable care organizations. “I think the two biggest things are the medical homes and the ACOs,” Huntley says. “Both of those will reward primary care physicians and systems for keeping people with chronic illnesses out of the hospital.”


Groups Promote 39 Weeks for Healthy Childbirth

Hazelden Unveils New Program for Opioid Abuse

State health groups are working together on a public campaign to discourage births from being scheduled before 39 weeks of pregnancy. Early births can’t be avoided in many cases, but the March Of Dimes, one of the sponsors of the Healthy Babies Are Worth the Wait campaign, is urging expectant parents and their physicians to not induce labor before 39 weeks. Thirty-seven weeks of pregnancy is considered full term, but health officials say health outcomes are better for babies delivered at or after 39 weeks, with exceptions for medical need. March of Dimes officials say new research has shown that a baby’s brain nearly doubles in weight during the last few weeks of pregnancy and that important lung and other organ development occur at this time. They add that although the overall risk of death is small, it is double for infants born at 37 weeks of pregnancy when compared with babies born at 40 weeks, for all races and ethnicities. “With one in 10 babies being born premature in Minnesota, we need to do more to make sure that more babies are being born healthy, excess health care costs are being reduced, and families are being spared the heartache of having a baby born too soon,” says Glenn Andis, March of Dimes chapter board chair. March of Dimes has been working with the Minnesota Department of Human Services and the Minnesota Hospital Association (MHA) on reducing early births. The three groups have worked together to create hospital policies barring medically unnecessary deliveries before 39 weeks. MHA has also begun public education efforts with a pregnancy and birth safety program, which includes a focus on preventing elective deliveries prior to 39 weeks, patient education, and provider/nurse training in key areas.

Hazelden, the Center City-based addiction treatment and education organization, has launched a major new effort to address a growing rate of addiction to prescription painkillers and to stem the number of fatalities related to overdose from such opioid drugs. “Deaths from drug overdose, driven by the increase in prescription painkiller abuse, now outnumber those caused by car accidents,” says Marvin Seppala, MD, Hazelden’s chief medical officer. “This is an unspeakably tragic public health crisis—one that demands up-to-date, evidence-based treatment protocols that offer the brightest promise of recovery.” Hazelden officials say the death toll from prescription painkiller overdose across the U.S. has increased more than fivefold in the past decade (from 3,000 deaths in 1999 to 15,500 in 2009), prompting the Centers for Disease Control and Prevention to define the problem as an epidemic. In Minnesota, the Minnesota Department of Human Services (DHS) identified opiate addiction as a growing problem in its semiannual report monitoring drug abuse trends. In the June report, DHS officials said use of heroin and opiates (a term often used interchangeably with opioids) was on the rise. “That opiate treatment admissions are second only to alcohol admissions is unprecedented and should be of great concern,” Human Services Commissioner Lucinda Jesson said at the time. Hazelden officials report that their facilities have seen a corresponding increase in the number of patients seeking treatment for opioid addiction, including a dramatic jump in admissions for young people. As part of a comprehensive response to this crisis, Hazelden will offer medication-assisted treatment for opioid dependence along with a focused Twelve

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NECC Injectables Still a Concern for Health Officials Minnesota health officials said in November that injectable drugs made by the New England Compounding Center (NECC) continue to cause health problems in Minnesota. NECC drugs have been linked nationwide to serious cases of meningitis, with 461 cases of illness—including meningitis, stroke, and peripheral joint infections—reported since September. Nationally, there have been 10 deaths linked to the outbreak. In Minnesota, 13 people had been sickened as this issue went to press, but no deaths had been reported. On Nov. 15, the Minnesota health officials reported a new case of osteomyelitis, a bone

infection that is linked to the NECC drugs. Officials say patients who received NECC steroids and have persistent symptoms should see their providers, and they add that providers should watch for infections in the bone and for abscesses.

Researchers Develop New Therapy For Bulimia Researchers in Fargo, N.D., and Minneapolis have developed a new therapy for bulimia. The therapy was developed over a period of more than 10 years by researchers at the Neuropsychiatric Research Institute (NRI) in Fargo and at the University of Minnesota in Minneapolis. The eating disorders research team was led by Stephen Wonderlich, an NRI director and a researcher at the Sanford Eating Disorders and Weight Management Center in Fargo, and by Carol Peterson, an investigator with the University of Minnesota’s Department of

Psychiatry. University of Wisconsin-Madison researchers also participated in the effort. The results are described in a report comparing a new psychotherapy treatment for bulimia nervosa, integrative cognitive-affective therapy, with an established treatment from England. “In a scientifically controlled comparison with the treatment developed by Chris Fairburn at Oxford University, which is the most scientifically supported treatment available for adult individuals with bulimia nervosa, this new treatment performed comparatively well,” says Wonderlich. The study found the new approach had one of the lowest dropout rates ever seen with a bulimic population. “Just about everyone who started the trial completed the treatment, which with these patients is important—just getting people to complete the treatment.” “When we did the scientific comparison, there was no difference between our treatment and the established treatment in

terms of outcomes; they were comparable, or equal, in their efficacy,” Wonderlich says. “This is good news for the field because now there is another promising alternative treatment available which is a little different in nature than the Oxford treatment.” The new treatment focuses more on changing eating habits, researchers say, as well as looking at emotional triggers to bulimic behaviors. “Our treatment is basically saying that we think that emotional processes—feeling badly— are very important in triggering bulimic behaviors,” Wonderlich says. “People actually engage in the bulimic behaviors because they feel better momentarily.” The new approach allows patients to report on negative feelings via smart phone applications, and to receive support to make healthy choices.

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MEDICUS

Michaela Tsai, MD, has joined Minnesota Oncology. In addition to practicing at the group’s Minneapolis clinic, Tsai will hold the endowed Martha Bacon Stimpson Chair in Medical Oncology at the Virginia Piper Cancer Institute. Tsai’s areas of special interest include clinical research, leukemia and lymphoma, and genetic counseling for breast and ovarian cancer syndromes. Tsai holds a medical degree Michaela Tsai, MD from Harvard Medical School and completed her fellowship in medical oncology, hematology, and transplantation at the University of Minnesota. Byron Marquez, DO, has been named senior medical director and chief of community primary care at Hennepin County Medical Center (HCMC), and is now seeing patients at Whittier Clinic in Minneapolis. In addition to direct patient care, Marquez will work with clinicians in six community primary care clinics, two convenience clinics, and one worksite-based clinic to improve continually the care Byron Marquez, DO they provide their patients. Marquez graduated from the College of Osteopathic Medicine of the Pacific in Pomona, Calif., and completed a family medicine residency in Detroit. He worked as a family physician for 12 years in Madison, Wis., before joining HCMC. Martin Freeman, MD, FASGE, was honored by the American Society for Gastrointestinal Endoscopy (ASGE), receiving the 2012 Master Endoscopist Award. The award recognizes a physician who spends the majority of his or her time in patient care and is recognized regionally or nationally for his or her expertise and longitudinal contributions to the practice of gastrointestinal endoscopy. Freeman is a professor of medicine at the University of Minnesota Medical School in the Division of Gastroenterology, Hepatology, and Nutrition, with specialties in gastroenterology, islet transplant medicine, pancreatectomy, and islet autotransplant medicine. The American Academy of Otolaryngology—Head and Neck Surgery presented the organization’s Honors Award to Tina Huang, MD, at its 2012 Annual Meeting in Washington, D.C. in September. The award recognizes medical professionals for meritorious service through the presentation of instructional courses and scientific papers, and participation in the organization’s committees or leadership. Huang is an otolaryngologist and neurotologist practicing at the Ear, Nose and Throat Clinic, and Lions Children’s Hearing and ENT Clinic at UMPhysicians. Okeanis Vaou, MD, has joined the Noran Neurological Clinic in Minneapolis. She graduated from Semmelweis University in Budapest, Hungary; continued her training in neurology at New York Medical College; and completed fellowships in movement and sleep disorders at Boston University Medical Center. Vaou is boardcertified in neurology and board-eligible in sleep medicine. Her clinical interests include Parkinson’s disease, dystonias, autonomic nervous system disorders, essential tremor, and sleep-related disorders. The West Metro Medical Foundation of the Twin Cities Medical Society has honored two physicians with the Charles Bolles BollesRogers Award: Joseph J. Westermeyer, MD, and Anthony A. Spagnolo, MD. The award recognizes a physician’s professional contribuOkeanis Vaou, MD tion to medicine on the basis of medical research, achievement, or leadership. Westermeyer, a psychiatrist at the Minneapolis VA Health Care System, is a clinician, teacher, researcher, author, and international expert in cross-cultural psychiatry. Spagnolo, a primary care physician, cofounded the Shakopee Medical Clinic, which merged with Park Nicollet Clinic in 1985. He retired earlier this year.

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INTERVIEW

From the bench to the bedside ■ Please tell us about the Minneapolis Heart

Institute Foundation.

Timothy Henry, MD, FACC Minneapolis Heart Institute Foundation Timothy Henry, MD, FACC, directs research at the Minneapolis Heart Institute Foundation. He is an interventional cardiologist at the Minneapolis Heart Institute/Abbott Northwestern Hospital, a professor of medicine at the University of Minnesota Medical School, and is known nationally for his leadership in cardiovascular research. Henry has served as national principal investigator of multiple large, multicenter trials in acute coronary syndromes, myocardial infarction, and angiogenesis, including ongoing cardiovascular stem cell trials. He is also principal investigator for one of seven NIH Clinical Cardiovascular Stem Cell Centers nationwide.

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The Minneapolis Heart Institute Foundation is the research and education arm for the Minneapolis Heart Institute at Abbott Northwestern Hospital. It has been here for 30 years. It was started by a group of cardiologists and cardiovascular surgeons that felt that providing cutting-edge research and education would enhance patient care. All the physicians in the Minneapolis Heart Institute work here, so the foundation is the way we do our research. For me, it’s indistinguishable from the Minneapolis Heart Institute; it’s the research and education arm of the practice. We have 120 to 130 cardiovascular research trials ongoing at any one time, and we publish more than 100 peer-reviewed papers per year. Our goal is to be the preeminent clinical cardiovascular research institute in the country. A lot of research is done through the University of Minnesota and the Mayo Clinic, which is much more focused on basic research. What’s unique about us is our focus on clinical research [which involves] patients versus animal research or basic Petri dish research.

were 200 miles away you didn’t. We now have outcomes that are unsurpassed, with a really low rate of mortality. ■ Stem cell research has been associated at

times with embryonic stem cells. Is there still controversy around that? It’s not an issue now. Embryonic stem cells are not being used in people. They’re probably never going to be used in people. Everything we use are adult stem cells. There are no trials going on in the world with embryonic stem cells. It’s not because of political reasons; it’s because when you put an embryonic cell in the body, it becomes a tumor called a teratoma. Not too many patients want to have teratomas. I think embryonic research is basic research that helps teach us about the function of stem cells, but it’s not currently being used in people.

Research is critical to making clinical care better.

■ What are some of the projects the foundation

has been working on? We have the largest clinic for patients with refractory angina. These are people who have ongoing chest pain but are not candidates for further surgery. We call it the OPTIMIST program. Our goal is to provide a comprehensive approach to the problem, so we want to learn about the natural history, we want to learn about what the risk factors are, then we want to have the best available therapies. We’ve treated more than 300 people with stem cell therapy at Minneapolis Heart Institute, more than anyplace else in the U.S. We’re using this therapy for people with heart attacks, heart failure, refractory angina with severe blockages, and in people with peripheral arterial disease. We’re also creating the largest network in the U.S. for patients with heart attacks. We call it the Level 1 program. If you have a heart attack and arrive in, say, [a hospital in] Hutchinson, you get treated with the standardized protocol and then you get transferred here. If you have a heart attack in any of about 30 places in Minnesota, we fly you to Abbott Northwestern and you get angioplasty and stenting to open up your artery. It’s an approach to bringing patients in quickly for the best care. We’ve treated nearly 4,000 patients over the past nine years with this program. This network allows us to treat people quickly, and it’s really incredible because there used to be significant rural-urban disparities. If you were in Minneapolis you would get good care, but if you

MINNESOTA PHYSICIAN DECEMBER 2012

■ We often hear about the translation of research

from the lab to accepted standards of medical practice; what can you tell us about that concept? What we believe is that, to have the best patient care, you need to involve the most cutting-edge research. As you progress in treatments for heart attacks or treatments for atrial fibrillation or treatments for preventive cardiology, you need to make advances. We’re involved in taking those advances from the bench to the bedside, applying them in people. Our job is to do that safely and effectively. ■ What can you tell us about your recent trip the

American Heart Association conference? We had a very good meeting. We had over 40 presentations, with a couple of very important things. We had a late-breaking trial that looked at stem cell therapy for acute MI, for acute heart attacks. We also presented a study that looked at heart failure admissions through the Allina system, primarily at Abbott. We showed that when patients were taken care of by a heart failure team, you had fewer readmissions, which leads to decreased costs. So more specialized care with a heart failure team led by a cardiologist resulted in decreased readmissions. ■ Does the Affordable Care Act affect research?

Do you see an effect from health care reform law in your work? We don’t see an effect yet, and it’s difficult to know what the effect will be. What you can say is that, in general, research is critical to making clinical care better. And one of the problems and challenges we face in the U.S. is that clinical research is being done increasingly outside the U.S., particularly in India and China. That’s a major challenge to our


health care system. We need to find a way to continue to do outstanding clinical research in the U.S. because this is our patient base and we need to know, does it work here? It’s been disappointing to me that, in all of the health care discussions, there has been very little discussion of how we fund and how we continue to do cutting edge clinical research in this country. Personally, I think that’s a challenge that we face. ■ Have you seen any improvement in the

timeline for FDA approvals? It’s safe to say we’re more challenged than other countries, in particular for devices. With the percutaneous valve, for instance, the U.S. was one of the last countries to have it approved. The majority of the world had percutaneous valves approved prior to us. So that led to medical tourism; many Americans were actually going overseas to get their valves, which I don’t think is what we want. ■ What steps has the foundation taken to

help other physician groups establish research efforts? One of our values is not only to do good clinical research but to do good education. We’ve spent a lot of time training other systems. We just published several articles about our research structure to help other people learn how to do strong clinical

research. From a clinical standpoint, more and more community-based practices are interested in being involved in clinical-based research. I think people understand that to do outstanding patient care, you need to be familiar with the cutting edge of clinical research. ■ What advances do you see overall for car-

diology in the next 10 to 15 years? A number of areas are game changers where we’ll see dramatic changes. No. 1, I think we’ll see continuous advances in percutaneous valve replacement and repair. For both aortic and mitral valves, a lot of what we now do surgically we’ll be able to do clinically. No. 2, from the standpoint of cardiovascular cell therapy, we’ll see an increasing number of cell therapies addressing cardiovascular diseases. No. 3, we’ll continue to see innovation in preventive cardiology. This will include changing population health to improve cardiovascular care from a preventive standpoint, like the Heart of New Ulm project. That’s critically important. The U.S. faces an epidemic of obesity and diabetes. From our viewpoint, it’s critical that we develop community-based preventive care.

CHART TALK

■ How do you feel about those kinds of

preventive care efforts so far? Right now, there are a lot of companies, individuals, institutions doing it on a caseby-case basis. It will be even more effective when we can do it cooperatively. But even doing it individually is helpful because at least that teaches you what works and what doesn’t. Heart of New Ulm, for example, focuses on one community but hopefully what you learn from that project is what’s effective and what’s not effective, so you can apply it in cities throughout Minnesota. ■ What advice do you have for primary care

providers who might have patients with cardiology issues? At the Minneapolis Heart Institute, we have close relationships with 35 clinics throughout Minnesota, and we work hard to partner with them to provide up-to-date cardiovascular information. Partnership is important because it’s such a rapidly changing field. It’s important for internal medicine groups to have close relationships with their cardiologists. When we go to Hutchinson, or Mora, or Cambridge, or Akin, or New Ulm, most of the care is given by primary care physicians. And that’s what we want. But our goal should be to help them put protocols in place that work effectively. It should be a partnership.

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MINNESOTA PHYSICIAN

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Brain from cover percent, though the mechanism by which exercise promotes brain health is not understood. Finally, cell damage is also caused by a host of explicit brain diseases (e.g., Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, stroke), including diseases of genetic origin (e.g., Huntington’s disease), which may or may not be amenable to treatment to various degrees. A key aspect of brain health is that the effects of insults to the brain are cumulative and interacting. For example, the symptomatology of Alzheimer’s disease can be much more devastating on a brain subjected to long-standing, untreated hypertension or atherosclerosis. This cumulative aspect of brain damage compounded by multiple injuries is very important, as illustrated recently by the devastating effects of successive traumatic brain injuries inflicted by sports injuries (called chronic traumatic encephalopathy). This type of damage is the

The interplay between genetics and environment is key.

direct result of the brain injury–compounding effect. The reason is that brain tissue does not really regenerate, so that residual brain damage remains after each injury and is compounded after multiple injuries. Therefore, the recipe for healthy brain aging is simple: • Avoid/reduce brain insults as early as possible and by the best possible means. • Prevent diseases such as hypertension, atherosclerosis or treat them early. • Avoid negative conditions or habits (e.g., smoking). • Support positive lifestyle behaviors such as exercise. The brain and genetics

A different factor that affects brain health is our genetic

makeup. In the worst case, brain diseases due to certain genetic abnormalities can be fatal, as with Huntington’s disease. Other genetic abnormalities involve inborn errors of metabolism that, if diagnosed early, can be taken into account and brain health achieved despite them. For example, eliminating the amino acid phenylalanine in the diet will prevent brain damage in individuals who have the genetic disorder PKU. However, apart from such clear-cut cases, genetic makeup can influence in subtle ways the way the brain works, its sensitivity to specific insults, its resistance to injury, and the efficacy of its repair mechanisms. This is what is meant collectively by the concepts of “vulnerability” and “resilience,” meaning susceptibility and resistance to insults, respectively, in speaking of brain health. Identification of such genetic influences will have a major effect in considering brain health and in guiding and steering individuals toward graceful brain aging. The interplay between genetics and environment is key: If we knew which part of our individual genetic makeup makes a difference, we could better protect ourselves from insults to which we might be most vulnerable. In fact, the Minnesota Women’s Healthy Brain Project (HBP) aims at exactly those broad goals, by identifying factors that are associated with and promote healthy brain aging. The Minnesota Women Healthy Brain Aging Project

The Healthy Brain Project started in 2010 as a joint initiative of a group of women in the Twin Cities (led by Sally Kling, Anita Kunin, and Barbara Forster) and a group of investigators at

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MINNESOTA PHYSICIAN DECEMBER 2012

the Minneapolis Veterans Affairs Health Care System (Minneapolis VAHCS) and the University of Minnesota. Study subjects are recruited through the Women’s Health Center of the Minneapolis VAHCS, where women veterans receive routine health care. Testing is done at the Brain Sciences Center at the Minneapolis VAHCS. The first subject was studied on Oct. 16, 2010. Since then, we have studied 145 women (age 31–97 years), of whom 62 (54–97 years) have been studied again after a year. We conduct comprehensive assessment of brain, cognition, language, and genetics. We acquire comprehensive, multimodal data from each subject to derive composite descriptors of brain status and associate them with cognitive, language, and genetic information. Testing and assessment

Assessing brain function. The brain’s job of information processing is accomplished by the continual communication among neuronal populations. We evaluate this neural communication with the highest fidelity using magnetoencephalography (MEG), a high-tech method that measures tiny magnetic fields (one-billionth of the magnetic field of the earth) generated when ensembles of neurons communicate. We complement this functional evaluation with structural information from structural MRI, white matter integrity information from diffusion MRI, brain chemistry information from magnetic resonance spectroscopy, and brain neurovascular coupling from functional MRI. A major challenge is to integrate all this information in order to derive a “brain health index”—essentially, a forecasting tool that can be used in a clinical assessment. Assessing cognition and language. The brain measurements above are coupled with an assessment of cognition and language. For the former, we use the Montreal Cognitive Assessment (MoCA) to score performance on visuospatial,


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executive, naming, memory, attention, abstraction, delayed recall, and orientation functions. For language, we assess phonemic and semantic fluencies (“Tell us as many words as you can that start with the letter A” for phonemic fluency and “Tell us as many animals as you can” for semantic fluency). Assessing lifestyle factors. Lifestyle plays a most important role for overall health and for brain health. Regular exercise, healthy diet, and preventing and treating medical conditions (such as hypertension and atherosclerosis) are all crucial components conducive to healthy brain aging. We are fortunate in our study to have access to such records of our participants from several years back. We are currently in the process of retrieving, coding, and quantifying the various components of lifestyle for further use in our analyses. Analyzing genetic factors. We draw blood for DNA analysis. We plan to start by looking at effects specific polymorphisms (i.e., gene variations)

might have on the various measures above and, ultimately, on the brain health index. Preliminary analyses are promising in that direction. Study design

The design of our project comprises both cross-sectional and longitudinal components. In the former, we collect data from as many subjects as we can (aiming for 100 subjects per year), whereas in the latter we reexamine the same subjects every year. The cross-sectional data will enable us to develop hypotheses regarding healthy brain aging, and the longitudinal data will help validate (or modify) the hypotheses. To date, we have collected data from 145 subjects cross-sectionally and from 62 subjects longitudinally. We have just entered the third year of longitudinal acquisitions. We expect this project to continue in perpetuity: the

more data that are available, the better and more solid the hypotheses, and the better the predictions for longitudinal validation. Finally, it is possible that some of our participants may develop a brain disease, and it would be interesting to investigate whether such a disease onset could have been forecast by our prior measurements on that subject. The future is the lifespan

Our plan is to open this project to include men and women of all ages, from 8 years (the earliest age group we can study with the MEG) to 100+ years of age. A problem we have encountered is that research funding for healthy aging does not seem to be a priority of federal agencies (e.g., National Institutes of Health, Veterans Administration), which typically are focused on diseases. It is puzzling that with all the emphasis on health mainte-

nance, healthy aging is practically ignored as a field of legitimate research. Therefore, we still rely on private philanthropy to fund our project, and this precious support is paying off for the benefit of everyone. More information about the Healthy Brain Aging Project can be found at www.healthy brainproject.org. Apostolos P. Georgopoulos, MD, PhD, is McKnight Presidential Chair in Cognitive Neuroscience; American Legion Brain Sciences Chair; and professor of neuroscience, neurology, and psychiatry at the University of Minnesota Medical School; and is director of the Brain Sciences Center at the Minneapolis Veterans Affairs Health Care System. Margaret Y. Mahan is a graduate student in the Biomedical Informatics and Computational Biology Graduate program at the University of Minnesota. She is working on the Minnesota Women Healthy Brain Aging Project for her dissertation, for which she has received a National Science Foundation Graduate Research Fellowship.

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.

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MINNESOTA PHYSICIAN

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Safety net from cover system of supports is operated and reimbursed, and multiple efforts are underway to make it more responsive and accountable to those it is designed to serve. The demand for savings

An open question now being asked by some state Capitol policymakers is: How much independence can we afford? Many of the support needs for people with disabilities are Medicaid-funded services. This state-federal program is consuming an increasingly larger portion of governmental budgets. The expense trajectory for this program is unsustainable. At the state level, 30 cents of every taxpayer dollar is funding health services for those who are impoverished and/or disabled. (This is second only to K–12 education funding in terms of dollars spent.) A disproportionate share of this budget is devoted to the needs of the elderly and disabled. Whenever the state faces a budget deficit—as the Minnesota Management &

Budget Office predicts it will again in 2013—it is nearly impossible to balance the overall budget without additional cuts in this area. It is important to note that these are not just medical services being purchased. In fact, the fastest growing portion of the Medicaid budget supporting people with disabilities is community-based social supports that are critical to achieving overall health. These include services like in-home supports and training, and service coordination. The demand for value

Since the state Health Reform Act of 2008, Minnesota has been laying the groundwork for a significant shift in how we pay for medical services in both the public and commercial market. The goal is to stop paying for a service just because it is delivered and instead reward the better health outcomes those services may (or may not) achieve. While much of the state’s employer-based coverage is now moving rapidly toward

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MINNESOTA PHYSICIAN DECEMBER 2012

total cost of care (TCOC) financing—meaning health plans and large provider systems have a shared financial incentive to manage health and costs—neither the health plans nor the state has figured out a way to pay for the most expensive population using the health system: people with disabilities. The 2011 Legislature mandated that people with disabilities within the Medicaid program join a managed care plan. This was done purely as a costsaving move. But every health plan serving this population is losing money serving the disabled. Many of the state’s health plans are refusing to enter the market to serve this population. The state has also delayed bringing children into this managed-care financing arrangement because (1) the health plans have no experience in this area and (2) the state is unsure how to build successful (and sustainable) financial models to fund it. But the changes in paying for medical services and the move to managed care still don’t touch the growing long-term care or social support services needed by the elderly and disabled. These managed care plans are responsible only for the medical services needed by people with disabilities. Remember, this is the fastest growing part of the state health budget. In this area, how do we know who the good providers are and what outcomes they are achieving with taxpayer dollars? Which programs and services are reducing the need for expenditures in other areas of the state budget? The short answer is: We don’t know. This must change. The demand for new service delivery models

The safety net for people with disabilities largely has grown out of the deinstitutionalization of people with developmental disabilities in the early 1970s. It has been successful in promoting community integration, largely through a four-bed group home model and through day-service programs that provide meaningful activities and

employment in nonresidential settings. But new and innovative service models are needed—for both medical and long-term care supports. In the future, services for individuals with disabilities will be more flexible and based on individual needs. Consumers will also have more control over how their service dollars are spent and a better understanding of what their support budget looks like, in order to decide what mix of services works best in the short and the long term. How will these changes occur and when? The state Department of Human Services (DHS) has requested permission from the federal government to redesign how long-term social supports are accessed and delivered. This was done with the extensive input of multiple stakeholders and is part of a broader reform effort underway at the state level to deliver the right services at the right time, and (ideally) for lower cost. (More details on the Medicaid reform efforts can be found at www.dhs.state.mn.us.) New service models are also expanding in the medical services area, with many centered on the health-care home model. This primary care-based approach involves comprehensive care planning and coordination of services for people with disabilities. Courage Center has created just such a model that incorporates comprehensive care planning, strong primary care, and coordination of medical and social services from an interdisciplinary team of providers. A rigorous, multifaceted evaluation also examines how willing and ready patients are to take control of their own health, whether their mental health is stable or improving, and how many fewer hospital days and emergency room visits they are experiencing. This highly complex target population has an average of nine chronic conditions and has spent nearly two weeks of the year hospitalized (on average) prior to choosing Courage Center as their primary care clinic. The data show that since this model was imple-


mented, hospitalizations have fallen for Medicaid recipients by nearly 75 percent. (More details on outcomes can be found at www.couragecenter.org.) Additional provider-based networks, similar to the accountable care organization models (ACOs) created by the federal Affordable Care Act, are also being tested by DHS. These groups of providers are hoping to share in the savings generated by delivering positive health outcomes for Medicaid recipients at a lower overall cost. The current system is fragmented and unaccountable. No one medical provider suffers financial consequences if the health status of an individual with a disability declines— or dies. The demand for new payment models

Nearly a decade of budget cuts at the state level have left most players in the disability services system reeling—including the people with disabilities who rely on it in order to achieve their goals in life.

Today’s era of fiscal austerity means an increased level of accountability is needed to ensure the state preserves the safety net.

equacies of the fee-for-service payment system that provide no incentive for physicians to do anything but avoid people with disabilities in their clinics and practices. A fragile commitment

Providers have seen reimbursement levels for services delivered decrease dramatically. Government agencies at the state and county level have seen similar budget challenges, meaning they are administering and regulating programs with an increasing population, but with far fewer employees and other resources. To combat the falling reimbursements that are happening under the current fee-for-service system, innovative providers are asking a series of questions of both health plans and the state: How can we package service together for a fixed price? How can we change the menu of services to achieve optimal success for the people we serve? The only way to get providers to behave differently is to

pay them differently. Rewarding individual providers for their contributions in maximizing the health and independence of those they serve must happen if the safety net for the state’s most vulnerable citizens is to remain intact. This is especially true for the most complex and costly individuals in our taxpayer-funded Medicaid program. Private sector strategies like TCOC have not yet arrived for this population. Predictive modeling programs used by health plans and large provider systems can’t accurately gauge the future expenditures of these Medicaid enrollees, nor do they address their complex social support needs. New measurement tools and financing strategies are needed if we are to leave behind the systemic inad-

What protections exist to ensure that the state maintains its historic commitment to those who rely on the fragile and fraying safety net? In 1999, the U.S. Supreme Court, in what is now commonly referred to as the Olmstead decision, determined that individuals with disabilities had a right to live in the “least restrictive setting” possible. Since this ruling, most states have aggressively moved toward a standard that Minnesota has long since adopted: People in need of governmental assistance should be served in integrated, community-based settings rather than in institutions. This was easy to do in the flush years following the turn of the millennium, when Gov. Jesse Ventura was mailing SAFETY NET to page 38

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MINNESOTA PHYSICIAN

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PAT I E N T

C

reating a patient safety culture has become a priority for hospitals since the 2000 publication of “To Err is Human: Building a Safer Health System,� an Institute of Medicine (IOM) report. The report estimated that 44,000 to 98,000 people die in hospitals each year from preventable medical errors. Subsequent IOM reports have cited inadequate health care systems and processes as the root of most medical errors and have recommended improving the culture of safety within health care organizations as essential to preventing or reducing errors. Joint Commission leadership standards today require hospitals to create a culture of safety and to measure safety with indicators that focus on communication, identifying patients at risk, medication safety, and preventing infections and surgical errors. In addition, the nonprofit National Quality Forum (NQF) has developed 34 safe-practice recommendations for hospitals to measure their safety culture

Creating a culture of patient safety Hospitals focus on teamwork, leadership, communication By Janelle Shearer, RN, BSN, MA and conduct interventions to reduce the risk of medical errors. Indicators measure a variety of factors, including

number of registered nurses, licensed practical nurses, and unlicensed caregivers on staff, in addition to the number of

Critical access hospitals in Minnesota are stepping up to the challenge of changing their attitudes, behaviors, and practices to ensure their patients are receiving care in a safe place. mortality rates, medication errors, falls, infections, and pressure ulcers, as well as behavioral health. NQF workforce indicators measure the

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SAFETY

MINNESOTA PHYSICIAN DECEMBER 2012

nursing care hours per patient. In Minnesota, Stratis Health, a local nonprofit health-care quality improvement organization, is facilitating a collaborative patient safety project with 10 rural critical access hospitals (CAHs), listed in the sidebar on page 15. Funded by the Minnesota Department of Health Office of Rural Health and Primary Care, the project is based on the Institute of Healthcare Improvement Breakthrough Series model. The project goal is to achieve organizational changes that reduce errors by changing integrated patterns of behaviors, norms, attitudes, and practices that characterize the hospital’s culture. CAHs receive assistance and resources to improve performance in targeted areas. The project is the fourth in a series of patient safety projects conducted by Stratis Health for Minnesota hospitals, including critical access hospitals. Fostering a safety culture

The IOM defines patient safety culture as an atmosphere of mutual trust in which all staff members can talk freely about safety problems and how to solve them—without fear of blame or punishment. A safety culture recognizes the inevitability of human error and encour-

ages supervisors to avoid inappropriate disciplinary actions. Solutions are based on prevention, not punishment. Managers are encouraged to give constructive feedback based on fact and critical analysis. Staff must feel comfortable speaking up about problems, errors, and conflicts. The collaborative project includes educational sessions focused on evidence-based models that foster a safety culture by improving teamwork, leadership, and communication. Participating hospitals learn about the philosophy and practice of a Just Culture of shared responsibility developed by David Marx, JD, and the AHRQ’s (Agency for Healthcare Research and Quality) TeamSTEPPS approach to improving teamwork and performance through information-sharing, resolving conflicts, and engaging leadership. Hospitals also participated in the Minnesota Alliance for Patient Safety (MAPS) Patient Safety Roadmap Workshop in May 2012. The collaborative provides CAHs with a forum for exchanging ideas and strategies for implementing safer practices and processes. Together, teams with shared goals learn about patient safety theory and have the opportunity to try out tools and processes to make and test improvements. They can solve problems and address common challenges and barriers together, and they can capitalize on lessons learned and best practices from other CAHs that have successfully applied strategies in their own organizations. AHRQ patient safety survey

Participating hospitals begin the project by assessing their safety culture using the Hospital Survey on Patient Safety Culture (HSOPS) developed by the AHRQ. The goals of the survey are to raise awareness of hospital patient safety among participants and to assess the current status of safety in their own organizations. Studies show that higher scores on patient safety surveys are correlated with improved clinical outcomes and higher staff retention. Stratis Health staff helps hospitals interpret their survey results and


build organizational capacity to improve their culture. Each hospital develops and implements an action plan for improvement based on analysis of the survey results, and completes a remeasurement survey to evaluate improvement at the end of the cycle. In September 2011, all staff at the 10 participating hospitals completed surveys for the project. Among the findings: • The average response rate to the baseline survey was 66 percent. Of those responding, 74 percent had direct patient contact. The survey assessed areas such as communication openness, frequency of events reported, and nonpunitive response to errors, as well as management expectations and support for patient safety. The survey also measured factors related to teamwork, staffing, handoffs and transitions, and staff and management perceptions of safety. • Overall, hospitals scored highest in the following domains: teamwork within department (80 percent); manager actions

Names and locations of the 10 Minnesota hospitals participating in the rural patient safety project • Appleton Municipal Hospital, Appleton • Cook County North Shore Hospital, Grand Marais • Essentia Health–Deer River, Deer River • LakeWood Health Center, Baudette • New River Medical Center, Monticello

promoting safety (69 percent); organizational learning (69 percent); and management support for safety (69 percent). The lowest scores were shown in nonpunitive response to errors (44 percent); handoffs and transitions (48 percent); and communication openness (54 percent). • For number of patient safety events reported, 58 percent of respondents reported no events; 24 percent reported 1–2 events; 11 percent reported 3–5 events, and 4 percent reported 6–10 events. The project goal is to increase the number of events reported. • For an overall patient safety grade, 20 percent of respon-

• Perham Health, Perham • Rainy Lake Medical Center, International Falls • Redwood Area Hospital, Redwood Falls • River’s Edge Hospital & Clinic, St. Peter • Sanford Bagley Medical Center, Bagley

dents were rated excellent; 53 percent good, 23 percent adequate, 3 percent poor, and 1 percent failing. As illustrated in Figure 1 (p. 19), benchmark results for Minnesota collaborative hospitals that completed the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) compared favorably in all areas listed to hospitals recorded in the 2009 national AHRQ database. With an increase in national standards and requirements for measuring indicators of safety in hospitals, critical access hospitals in Minnesota are stepping up to the challenge of changing their attitudes, behaviors, and practices to ensure their patients are receiving care in a safe

place. Remeasurement results for the project are expected in December of this year. Two hospitals’ experiences with the patient safety project

Participating in the project has been particularly helpful for staff at LakeWood Health Center, a 15-bed CAH in Baudette, Minn. LakeWood has a 10-year history of focusing on patient safety and staff training that includes recent participation in the national Catholic Health Initiatives’ SafetyFirst program. Quality coordinator Danielle Abel says, “Although we have taken the AHRQ survey before, this time the entire staff took it—providing more accurate results.” Survey results showed LakeWood excelled in teamwork, hospital management support for safety, and staff’s perception of the importance of safety. In addition, the hospital’s safety software has shown an increase in incident reporting. The team is now focusing its efforts on handoffs and transiSAFETY to page 19

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POINT

A journey through 40 years of medical cost-control panaceas By Robert W. Geist, MD

Beginnings: managed care

ance to cover even expected and affordable first-dollar care. Because care appeared to be free (“the boss paid for it”), demand inflation followed. The HMO cost-control concept was touted to employer and government agency “buyers” of care, who were panicked by sudden 1970 cost-price inflation, linked to the increasing use of health care services. The sales pitch for the HMO model was that a gatekeeper of such services would be mutually profitable to corporations, to clinicians, and to the “necessity of preserving society’s scarce resources.” To my mind, neither of the proposed HMO bills passed the sniff test. The bills would make it legal for managed care corpo-

I started navigating the many and divergent paths of managed care cost-control panaceas in 1973. An article in the St. Paul Pioneer Press had reported that the state legislature was going to pass a health maintenance organization (HMO) bill that would mimic an HMO bill proposed to the U.S. Congress. Policymakers were responding to the abrupt onset of the first medical-cost price inflation in nearly 100 years (see Fig. 1). By the late 1960s, tax-subsidized insurance had grown to cover about 85 percent of Americans (workers and the official old, poor, and disabled). Tax-free insurance dollars encouraged the buying of ever more insur-

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16

VIEW

Policy, politics, and physicians

T

he question sometimes arises—after giving testimony at the state legislature, at health-care policy seminars, during annual meetings of medical professionals: Why am I “doing” medical politics? It may be a colleague asking the question; it may be myself. Here’s my story.

driven by your

OF

MINNESOTA PHYSICIAN DECEMBER 2012

rations to control the benefits they insured—a perverse power allowed to no other casualty insurance company. Concerned about the bills’ implications for physicians, I met with the Minnesota Medical Association (MMA) board of trustees and asked, “Do you know what this Minnesota HMO bill says?” The trustees told me that the MMA supported the bill. They believed that if doctors formed an HMO insurance corporation, they, not the hospitals, would control the money in medicine. Doctors would be able to spend money more wisely than hospitals, or even patients. And clinics would be able to meet burgeoning patient demand by setting adequate prices for expanding services— without violating antitrust law. The Health Maintenance Organization Act of 1973 became law—but the MMA’s paternalistic hubris turned into unintended consequences— the irony of physicians, once employed by patients, gradually becoming employees of the once-feared hospitals and other third parties. Delving into medical policy

My experience with the 1973 HMO laws was the first step on a long (and continuing) journey. What I had not considered, in this first foray into health care policy, were the political and economic externalities that were far more powerful than my old typewriter or young voice. Policymakers were not going to consider repealing the popular, but inflation-driving, tax subsidy for health insurance—which is still considered the third rail of politics. Being a naif, I began publishing papers on the perils of commercial corporations controlling medicine, in hopes of

stopping futile public policy and of preventing the destruction of patient control of the medical marketplace. In 1974, I published a piece in the New England Journal of Medicine (N Engl J Med. 1974; 291:1306-1308) pointing out that “incentive payments” contingent on behavior intended to reduce the volume of orders for care was double-speak for third-party bribes (“money or favor given or promised to a person in a position of trust to influence his judgment or conduct,” MerriamWebster, 10th ed.). A few years later, I wrote that commercial and professional enterprises have different primary goals (N Engl J Med. 1978; 299: 483–486). Commercial enterprise deals with buying and selling goods and services; its primary goal is to serve the economic interests of the entrepreneur or the enterprise—indeed, the principle of caveat emptor works best in ordinary microeconomic market sectors where refrigerators, shoes, thumb drives, autos, and most services, are sold. In contrast, professional enterprise in medical practice has the primary goal of serving the interests of patients. Physicians are professionals not because of some salable expertise, but rather by professing to always serve their patients’ interests first. In practical implementation of this distinction between commercial and professional enterprise, 1970s state laws and American Medical Association (AMA) ethics policy limited a practicing physician’s economic gain to reimbursement for the services that he or she rendered a patient. Elementary stuff, but not the stuff recognized by policymakers. Thus, by 1981 the Federal Trade Commission (FTC) had succeeded in forcing the AMA to change its code of ethics, by removing restraints on the corporate practice of medicine, i.e., a clinic and HMO insurance corporation could collude to profit from restricting orders for patient care. Managed Care (MC) 1.0

The upshot was that actions defined as legal under HMO law


acquired the patina of being “professionally� ethical. The way was cleared for HMOs and its doctors to profiteer by decreasing the volume of care ordered, while it remained illegal under state medical practice law for doctors to profiteer by increasing the volume of care ordered, such as when they collude with others to split patient service fees. The FTC “victory� created a legal and ethical double standard for physician behavior, depending on the patient’s insurance policy. As time passed, medical organizations changed from wondering “what happened?� to making futile attempts to recoup their marketplace power by bragging about being “patient advocates�—even though their membership is powerless when they are no longer employees of patients. Managed Care 2.0

Though the HMO panacea (MC 1.0) has lost its luster for policymakers, clinicians are now offered alternative power as system gatekeepers in accountable care organizations (ACOs)—the

FIGURE 1. Medica prices relative to Consumer Price Index, 1948-2000

Modified from Phelps CE. Health Economics. 2003:18 Fig 2.2

Managed Care 2.0 “fixâ€? for failure of MC 1.0 to control costs. ACOs are mini-insurance companies created by the 2010 Patient Protection and Accountable Care Act. Though the Centers for Medicare & Medicaid Services describes ACOs as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve,â€? they are envisioned by others as hospital-medical staffs profit-driven to restrain the volume of patient care ‌ or go broke.

ACOs can merge and collude with HMO corporations in profitable rationing of care—the ultimate volume-driven big box “medical home.� MC 2.0 creates a public cartel system, a combination of independent commercial or industrial enterprises to limit competition and fix prices in collusion with government sovereignty that shields the cartel from legal actions (Journal of Law and Economics 39(1996): 241–283). Thus “customers�— businesses and people—are mandated by one cartel partner’s legislation to buy the other part-

ner’s insurance, and ACOs can merge and collude with HMO corporations in profitable rationing of care—the ultimate volume-driven big box “medical home.� Some policymakers predict that in the next decade, local ACO-HMO mergers will be followed by massive national mergers and acquisitions. An oligopoly of four or five national corporate health services would then control all “health care� in a politically created cartel system similar in power to the monopoly national health-service systems abroad. Medical politics: lessons learned

Nearly four decades after beginning my health policy journey, I’ve realized that I have been an Econ 101 and Professionalism 101 missionary preaching against several theological-like beliefs in managed care’s specious and futile illusions. The first belief is that medical inflation is due to poor quality, profligate care provided by POLICY to page 18

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Policy from page 17 “culprit� clinicians driven to avarice by an evil fee-for-service system, with no distinction between pay for services and pay contingent on volume of referrals. The second belief is that costs will be contained by transfer of the mega “payer� (corporate and/or government agency) gatekeeping role by means of capitation payments to small, independent physician practices or small hospital ACOs for servicing the “payer� populations. This creates a patently corrupt financial conflict of interest between gatekeeping doctor and patient, hidden by the sophistry of different forms of behavioral “pay-for-performance� (quality, value, efficiency, prevention, outcomes, and so forth). Yet my journey has also taught me that almost none of the actors in health policy matters are corrupt. They may lack system or philosophic insight, but they are trying to do the best job they can. This includes politicians, medical colleagues, and even most of the maligned HMO administrators. The latter were

Engaging in politics is demanded when a profession (and a dedicated, highly trained professional medical workforce at all levels) is speciously demonized. politically given incredible power, but were also handed the impossible job of controlling costs by rationing supply, when the fundamental problem was politically created demand. It is interesting that once the HMO industry gained control of a significant portion of the money in medicine, they were able to parlay job failure into unparalleled profits and then into enormous MC 2.0 political power as cartel partners with government regulators. Now, which partner will control the other? An important lesson for anyone involved in the world of health care policymaking is this: Win or lose, the manners of politics are important. Never question the motives of opponents in political debate; believe it or not, they are most often pure. Motives of some may

indeed be nefarious, but one must always argue from Econ 101 facts or from Professionalism 101’s covenant of more than 2000 years, in which physicians profess to be loyal to a patient’s interests first. A journey of hope

Engaging in politics is demanded when a profession (and a dedicated, highly trained professional medical workforce at all levels) is speciously demonized. For this reason alone, I would do politics again—justice demands it. There will be no change in control of medicine by the profit-driven, commercial interests of a few managed-care barons (corporate, governmental, or cartel) until millions of American families again reign as kings in the medical marketplace. That means informed

policymakers and politicians looking at sane alternatives to a microeconomic sector too complex to manage without real prices. It requires doing politics. For me, being a medical Econ101/Professionalism 101 missionary in a land of failed cost-control panaceas is, nonetheless, a journey of hope. There is already a successful, pricedefined, private-sector path (health savings accounts/highdeductible health plans) to a professional medical marketplace—one ruled by American families—and, thus, a path to affordable universal health insurance and delivery of patient-centered services. It’s been a worthwhile journey. Robert W. Geist, MD, is a retired urologist. He has served as president of the Ramsey County Medical Society, chair of the Minnesota Medical Association Committee on Ethics and Medical Legal Affairs, and chair of the Ramsey Medical Society Council on Professionalism and Ethics (later, the Twin City Medical Society Forum).

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FIGURE 1. HSOPS composite results Benchmarking hospital results to the 2009 comparative database

Safety from page 15 tions. Abel attributes the success of LakeWood’s program to the commitment of leadership and staff. Its multidisciplinary safety team, which includes the administrator, vice president of health services, directors of nursing, risk manager, and quality coordinator, meets weekly. Abel adds that “we now begin each nursing staff meeting with a safety story, which has proved to be a positive, healing approach to reinforcing our culture of safety.” Safety, quality, and risk manager Janell Thomson and her project team at Appleton Municipal Hospital (Appleton Area Health Services) are also participants in the collaborative and have recently implemented a new communication strategy along with staff education to improve communication among clinicians and patients. Nurses now wear laminated tags that list SBAR and AIDET communication techniques. SBAR (Situation, Background, Assessment, Recommendation) is a process for communicating important information quickly and accu-

rately in a health care setting. AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) is a technique for communicating appropriately with patients and families. Reminders to use the techniques have been placed by the phones and in the nurses’ report room. Thomson says, “Through report audits and observation of

nurse-to-nurse reports, our hospital director of nursing has identified continued education on conveying important information as a key communication priority. Our goal is to continue to improve this crucial communication. We also are working to improve our use of Just Culture principles related to event and near-miss reporting—both

strategies will contribute to the safety of our patients.” Thomson’s voicemail message, “Have a safe day,” is a friendly reminder of and testament to Appleton’s commitment to creating a culture of safety. Janelle Shearer, RN, BSN, MA, is a project manager at Stratis Health, Bloomington.

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DECEMBER 2012

MINNESOTA PHYSICIAN

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SPECIAL

This month’s special focus articles represent a range of issues physicians and other health care professionals, as well as seniors them-

FOCUS:

SENIOR

AND

LONG-TERM

HELP for hospitalized elders Preventing delirium in the acute-care setting By Paula Duncan, RN, and Kasey Paulus, RN, CPHQ

selves, face as the “senior tsunami� of baby boomers approaches. They include improved processes to reduce delirium in hospitalized patients; design of built spaces for a take-charge, technology-savvy aging population; age-specific addiction programs; and increased awareness of how to identify and report elder abuse.

D

elirium is underdiagnosed in most hospitals. As awareness of hospitalacquired delirium rises, so does the frequency of its diagnosis. At Park Nicollet Methodist Hospital (PNMH), increased recognition of delirium unmasked the true incidence of delirium in our patients and led the hospital to implement a volunteer-staffed delirium prevention program called HELP (Hospital Elder Life Program). Launched in April 2010, HELP has resulted in a reduction in the rate of hospitalacquired delirium. PNMH is the first and, to date, the only HELP site in Minnesota.

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Background

Delirium is defined as a disturbance of consciousness with reduced ability to focus, sustain, or shift attention. It is an acute change in cognition that develops over a short period of time and tends to fluctuate over the course of the day. Many aspects of hospital care can contribute to the development of delirium, including adverse effects of medications, complications of invasive procedures, immobilization, malnutrition, dehydration, the use of bladder catheters, and sleep deprivation. Symptoms of delirium typically resolve in 10 to 12 days. Most patients have a full recovery; however, elderly patients are more likely to experience persistent cognitive deficits if the diagnosis and treatment are delayed. In addition, delirium is associated with increased morbidity and mortality. According to Sharon Inouye, MD, who conceived of and developed the HELP intervention strategy, delirious elderly patients have an increased risk of suffering from hospital-acquired problems such as pneumonia and bedsores. Delirium in hospitalized patients results in lengths of stay (LOS) that are up to three times longer than LOS of patients who do not develop delirium. Patients with delirium are also three times more likely to be discharged to a nursing home and three times more likely to have a decline in health status compared to patients who do not suffer from delirium. Further, these patients have a higher risk of institutionalization and death.

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20

MINNESOTA PHYSICIAN DECEMBER 2012

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her colleagues at Harvard Medical School. HELP is an innovative strategy that provides an enhanced, team-based, patient-centered approach to the care of our hospitalized geriatric patients. The program partners community volunteers with professional staff in an effort to prevent delirium in the hospital. HELP goals include maintaining physical and cognitive function of elderly patients throughout their hospital stay; maximizing their independence at discharge; assisting them with the transition from hospital to home; and preventing unplanned readmissions. The team consists of an elder life specialist (ELS), who is responsible for program operations, training, patient screening, and volunteer coordination; an elder life nurse specialist (ELNS), with responsibilities including direct patient care, staff education, and clinical support to the ELS; and a team of trained volunteers. HELP also benefits from the support of senior leadership, physicians, therapists, pharmacists, and others, all of whom have a focus on preventing delirium. At PNMH, all patients 70 years of age and older are assessed upon admission by the nursing staff using the CAM (Confusion Assessment Method) tool, which identifies predisposing and precipitating factors for delirium. A nurse completes the initial CAM within four hours of admission. When a patient is deemed CAM-negative—that is, free from delirium—upon admission, an order for a HELP volunteer visit is entered in the electronic medical record to ensure the patient remains CAM-negative. All patients with a CAMpositive score are considered to have had delirium prior to their hospital admission. Although we are concerned about CAM-positive patients, we can’t prevent delirium when a patient presents with delirium upon admission. There are protocols in place for managing delirious patients, and treatment is started within 15 minutes of a CAM-positive score being recorded for a patient. PNMH provides HELP volunteer visits to high-risk patients


FIGURE 1. Park Nicollet Methodist Hospital outcome data on the cardiac, general medicine, orthopedic, and neurosurgical/neurology patient care units. During 2013, the program will be offered to all at-risk patients on all patient-care units within the hospital. Patients are visited by trained volunteers three times each day for the duration of their hospital stay, with each visit lasting approximately five to 20 minutes. Two of the visits are aimed at understanding whether the patient is aware of his or her surroundings. During these visits, volunteers will engage patients to determine whether they know, for example, where they are, what day it is, and names of family members, and to help patients remain oriented throughout their stay. In addition, a once-daily therapeutic visit by a HELP volunteer concentrates on providing stimulation to keep the patient exercising their brains, for example, by providing crossword puzzles, books, magazines, and coloring activities. The activities are targeted and standardized to the patient’s needs, based on five delirium risk factors: • Cognitive impairment • Sensory impairment • Dehydration • Immobility • Sleep disturbances A sixth factor, polypharmacy, does not require volunteer activities, but rather is analyzed by the elder life specialist. If medications prone to causing delirium (e.g., analgesics such as meperidine and propoxyphene; psychotropics, including barbiturates, and benzodiazepines; skeletal muscle relaxants such as cyclobenzaprine; and some antihistamines) appear on the patient’s electronic medication administration record, a consultation between a pharmacist, the attending physician, and/or the elder life nurse specialist may be initiated. Data collection and results

The number of patients with a HELP order and the number of visits performed by the HELP volunteers are tracked monthly through the HELP office to understand the program out-

comes (see Fig. 1). This data is also used to calculate the average number of volunteer visits per hospital stay for patients seen by HELP volunteers. For the year to date, the average of 3.0 visits per patient stay/hospitalization has been sustained. It takes a minimum of 21 volunteers to provide three visits per day, seven days per week. Currently, 100 trained

FIGURE 2. CAM-negative maintenance rate patients enrolled in HELP program

volunteers provide HELP services. The ultimate measure of the success of HELP is preventing hospital-acquired delirium as measured by the CAM-negative maintenance rate. In implementing the HELP strategy, our goal was that 97 percent of patients would remain deliriumfree (defined as CAM-negative at discharge). As Fig. 2 shows, that goal has been attained for 17 months of the program since its initiation and for every month in 2012 to date. Implementing the HELP strategy has contributed to our patients remaining delirium-free during their hospitalization (as defined by maintaining a CAMnegative status). In addition to financial benefits associated with reduced incidence of delirium and complications of delirium (including hospital readmissions), the benefits of the implementation of HELP have included improved patient and family experience during the hospital stay, improved institutional focus on geriatric care, community volunteers serving in the communities in which they live, and, ultimately, families staying together longer.

Paula Duncan, RN, is coordinator of the Hospital Elder Life Program at Park Nicollet Methodist Hospital in St. Louis Park.

Kasey Paulus, RN, CPHQ, is the clinical project director for hospital quality at Park Nicollet Methodist Hospital.

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SPECIAL

E

lder abuse is an important issue in our society; it affects as many people as child abuse and intimate partner violence and should be treated with equal sensitivity. However, a lack of education and awareness on this subject means that many victims suffer silently. According to prevalence studies published by Karl Pillemer and David Finklehor in 1988, and more recently by Ron Acierno in 2010, 3.2 percent to 11.7 percent of elders—approximately 1 million people—are affected by abuse every year. Physicians in all specialties can help improve the quality of treatment in the geriatric population by being able to identify the signs of elder abuse and understanding how to report it.

What constitutes elder abuse?

The National Center on Elder Abuse (NCEA) defines elder abuse as any intentional or neglectful acts by a caretaker or trusted individual that cause harm to a vulnerable elder. A vulnerable elder is one who is

FOCUS:

SENIOR

AND

LONG-TERM

Elder abuse A need to improve identification, reporting by physicians By Julie Switzer, MD and Avery Michienzi

older than age 60 and is dependent on a family member or a health care professional for shelter, nourishment, and safety. A caretaker’s failure to provide these necessities for the dependent elder is recognized as abuse. Elder abuse can occur in both

categories, identified by the NCEA as: • Physical abuse, defined as any unwanted physical contact that causes harm to an elder, including hitting, pushing, pinching, burning, and force-

Those who practice emergency medicine and orthopedic surgery should be particularly sensitive to the signs of physical abuse. institutionalized and non-institutionalized settings. Elder abuse can be divided into as many as seven different

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feeding • Sexual abuse, which is any unwanted sexual contact • Emotional abuse, which is any distress caused by verbal or nonverbal acts such as insults, threats, humiliation, or forced isolation • Neglect, which occurs when a caretaker fails to provide an elder with food, water, medication, shelter, or hygiene • Abandonment, in which the caretaker completely deserts an elder • Financial abuse, or the illegal use of an elder’s assets • Self-neglect, which includes behavior by an elder that jeopardizes his or her own health. Self-neglect is not always included as a category of elder abuse by investigators. The National Elder Abuse Incidence Study done in 1996 by the NCEA reported that neglect, emotional abuse, financial abuse, and physical abuse were the most common forms of elder mistreatment. Risk factors

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MINNESOTA PHYSICIAN DECEMBER 2012

Many risk factors for elder abuse have been identified. According to research published by Mark Lachs and Karl Pillemer in a 1994 edition of the Journal of

CARE

the American Geriatrics Society, elders are at a higher risk for abuse than the general population if they have shared living arrangements, are socially isolated, have a history of domestic abuse, or are cognitively impaired. A literature review article by Andrew Chen and Kenneth Koval in a 2002 edition of the Journal of the American Academy of Orthopaedic Surgeons also cited poor health and financial strain as risk factors. Chen and Koval mentioned dependence of the abuser on the elder and substance abuse or mental illness of the abuser as risk factors as well. Abusers tend to be adult children or spouses of the elders. It is important to note that cognitive impairment is almost always stated to be a risk factor for elder abuse, yet most data on abuse excludes cognitively impaired and institutionalized elders. As a result, the prevalence of elder abuse in the country is underestimated and we have a poor understanding of abuse stemming from institutionalized settings. Signs and symptoms

Physicians in all specialties are in a position to identify uncharacteristic behavior in geriatric patients and recognize signs of abuse. Those who practice emergency medicine and orthopedic surgery should be particularly sensitive to the signs of physical abuse. Victims of physical abuse may present with multiple fractures, past fractures that have not healed, and fractures that do not match the stated mechanism of injury. Physical abuse victims may also make frequent visits to the emergency department and provide unclear or inconsistent histories. These abnormal signs should alert a physician to the possibility of abuse and the need for further investigation. For example, a patient may come to the hospital, accompanied by her caretaker, with a fractured tibia that the caretaker insists is a spontaneous fracture due to osteoporosis. The patient, however, informs you that she fell. This discrepancy in history warrants a closer examination of the injury to determine whether


it was accidental or intentional. Primary care physicians who have more regular contact with elder patients than do surgeons may appreciate more subtle signs of abuse in their patients. Abnormal bruising, malnourishment, dehydration, and changes in behavior such as withdrawal can all be caused by physical, sexual, or emotional abuse, neglect, or abandonment. Noncompliance with medical regimens could also be the result of neglect. Differential diagnosis

Once abuse is suspected, more should be done to determine whether the suspected injury is the result of abuse or a factor other than abuse. In all cases of suspected abuse, it is important to interview the patient. If possible, the patient should be interviewed alone, as the presence of a spouse or any other suspected abuser may prohibit the patient from answering questions honestly. If you cannot talk privately to the patient, make note of who else was in the room at the time of the interview. Many investigators and care providers who specialize in this area suggest that it is best to phrase your questions in a gentle manner and to show support for the patient, as some patients are embarrassed by the fact that they have been abused. Asking simple questions such as, “Do you feel safe at home?” and “I’ve seen other patients with similar injuries and someone they know injured them. Did someone you know do this to you?” are appropriate ways to begin a conversation about abuse with patients. For patients who are cognitively impaired or unable to speak for themselves, you must rely on clinical signs to identify abuse. Lachs and Pillemer published an article in 1995 in the New England Journal of Medicine that summarized the clinical procedures for detecting abuse. They recommended examination of the body to look for traumatic alopecia, lacerations, or bruising, and to evaluate cleanliness. Bruising in elder patients may be difficult to attribute directly to abuse, as it may occur because of fragile skin or the use of anticoagula-

As more Americans live longer and the senior population grows, the impact of elder abuse as a public health issue will increase. tion medicine. A study by Aileen Wigglesworth in the 2009 edition of the Journal of the American Geriatrics Society reported that bruises resulting from abuse were likely to be over 5 cm in size and found on the face, neck, lateral right arm, and posterior torso. Bone scans and MRIs can be ordered to find occult soft tissue injuries or bone contusions as further evidence of abuse. Radiographs of patients who present with fractures may reveal past unhealed fractures that may indicate abuse. Laboratory tests may also be appropriate to determine whether a patient is complying with his or her drug regimen. Reporting elder abuse

Elder abuse is severely underreported in the U.S. In December 2011, the New York City Department for the Aging and the Weill Cornell Medical Center published a report titled “Under the radar: New York state elder abuse prevalence study.” The study compared self-reported abuse cases to officially documented cases, and found that only one in every 23.5 cases of elder abuse is actually reported to the appropriate social service agency. Most states mandate that physicians report abuse; if their suspicions of abuse have not diminished after closely examining and interviewing a patient, it is necessary to report the case to Adult Protective Services. Unfortunately, surveys have shown that most physicians are ill equipped to identify and report abuse. Investigators have noted that barriers to physicians reporting include a lack of education on how to report cases, discomfort with their evaluation skills, and not wanting to offend the patients by reporting abuse. What should you do if you suspect elder abuse? In the

state of Minnesota, physicians are mandated to report cases of suspected elder abuse. Check with your hospital or clinic to see if there is a social worker available to whom suspected abuse cases should be reported. If there is no social worker at your workplace, the Senior LinkAge Line (800-333-2433) for the state of Minnesota is open to callers 24/7 and will connect reporters of abuse to the appropriate local reporting agencies. When dealing with suspected abuse of a patient in a nursing home, it may be appropriate to call the Minnesota Office of Ombudsman for Long Term Care (800-657-3591). As more Americans live longer and the senior population grows, the impact of elder abuse as a public health issue will

increase. Physicians play a major role in the detection of, prevention of, and intervention in elder abuse. It is imperative that they be educated on the matter. The National Center on Elder Abuse, of the U.S. Administration on Aging, is a national resource center dedicated to the prevention of elder mistreatment. Information for medical professionals, as well as others who work with older victims of elder mistreatment, may be found on its website, at www.ncea.aoa.gov. Increased research efforts to identify injuries indicative of elder abuse and to understand the extent of abuse in institutionalized and cognitively impaired elders will also help to improve geriatric care. Julie Switzer, MD, is an orthopedic surgeon and director of Geriatric Orthopaedic Trauma at Regions Hospital in St. Paul. Avery Michienzi is a research assistant in the orthopedics department at Regions Hospital.

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DECEMBER 2012

MINNESOTA PHYSICIAN

23


SPECIAL

T

he “senior tsunami,” as trend analysts, economists, and political pundits are calling the baby boomer generation will soon be upon us. As this demographic bulge reaches its apex, an unprecedented wave of retirement-age men and women will flood health care, workplace, and living environments with nontraditional demands and needs. This is the generation, after all, raised on rock and roll. And no one expects them to go quietly into their golden years. According to the U.S. Department of Labor’s Bureau of Labor Statistics, 19 percent of the U.S. workforce will be 55 years old or older by the year 2050. Other studies put that population as high as 25 percent. A significant percentage of those baby boomers will be working. A recent AARP study found that almost seven out of 10 workers over the age of 45 responded that they would work, in some capacity, during the years traditionally considered retirement.

FOCUS:

SENIOR

LONG-TERM

Design innovation Accommodating baby boomers By Alanna Carter, Assoc. AIA, LEED-AP

Clearly, businesses need to consider how to support and enhance the productivity of a multigenerational workforce. Developers of residences with a variety of aging-in-place options—from apartments and condos to assisted living to skilled-nursing facilities—need to plan for residents who have active work/play lifestyles. And health care facilities need to prepare to accommodate the needs of a nontraditional senior demographic that scoffs at terms like “geriatric.” Many architecture and design firms are actively researching design solutions that will cater to aging baby boomers and are educating clients about those progressive solutions. Following are several key examples of design innovations for the senior tsunami.

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24

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MINNESOTA PHYSICIAN DECEMBER 2012

Universal design: environments accessible to all

Many aspects of our built environment pose challenges to users, regardless of their age or ability. Universal design results in living, working, health care, and public places that anyone can use and enjoy, without stigma-inducing features that connote adaptation or specialization. Universal design is invisible and often intuitive. Automatic doors? Raised curb cuts? Lever door handles? All are examples of universal design. Universal design concepts were first articulated by architect Ron Mace, founder of the Center for Universal Design at North Carolina State University. He came up with seven design principles for creating spaces that are accessible to all: • Equitable use: design that enables people with diverse abilities • Flexibility in use: design that accommodates a wide range of individual abilities • Simple and intuitive use: design that’s easy to use, regardless of experience, knowledge, and language skills • Perceptible information: design that communicates on various sensory levels • Tolerance for error: design that maximizes safety • Low physical effort: design that is easy and efficient to use • Appropriate size and space: things are easy to use, reach, and move regardless of an individual’s ability, size, posture, or mobility In other words, universal design focuses on access and inclusion, as well as ease and safety. In our architectural practice, we’ve been designing enabled environments that include shelving that all can reach. In health care facilities and aging-in-place facilities, we put faucets to the side of a sink (rather than toward the back) for easy access. We design towel

CARE bars that are built into countertops (using the same material as the countertop, for a seamless effect) and that also function as grab bars. Multigenerational workplaces

Economic realities, modern medicine, healthier lifestyles, and an ongoing desire to remain contributing members of society are all reasons baby boomers will keep working past the traditional age range for retirement (age 55 to 65). Designers are now innovating to accommodate the needs of a workforce that is diverse in terms of both age and culture, by incorporating aspects of universal design. Driving these innovations are factors shared by a multigenerational workforce, such as flexible hours, telecommuting, technological mobility and access, and the need for flexible and multipurpose workspaces. For older workers, factors such as adequate lighting, accessible workstations, and privacy are taken into account as well. In our designs, for example, we incorporate movable walls, doors, and partitions that can easily be reconfigured to create a variety of environments, from the very private (for the worker who requires a quiet space with minimal disruptions) to more open and collaborative spaces. We also specify desks, tables, and countertops that easily adjust in height, to accommodate a variety of tasks and users of various abilities, heights, and wheelchairs. We also focus on workplace lighting. A combination of natural daylight and adjustable task lighting helps all employees accomplish their work with greater comfort and efficiency. Nonskid flooring benefits employees in high heels, as well as resident using wheelchairs and walkers. Clear wayfinding, with colors and easy-to-read visual cues, enhance the workplace for workers of all ages. Using technology to assist in predictive medicine

Baby boomers are a take-charge and high-tech generation. They Google their symptoms and research their medical options and health care online. This gen-


eration’s comfort level with technology is inspiring designers to create systems that can assist with predictive medicine: a field that predicts disease and institutes preventive measures in order to significantly decrease the impact of illness on an individual. Aging-in-place living environments, whether a singlefamily home or a unit in a multiresident facility, are beginning to include technologies for telehealth and teleclinics that allow seniors to live-chat with specialized medical professionals about symptoms or concerns. Designers are also creating sensors for home environments that can predict when medical attention might be needed. Using technology similar to that of the popular Wii entertainment and exercise system, designers have created gait sensors. Gait sensors embedded in the floor measure an individual’s walking patterns, and signal a health care professional if a person’s gait has changed or the person has fallen. To reduce the additional energy load such a

system puts on a multiresident facility, some institutions use solar panels to power the sensors. Research is developing ways to capture kinetic energy from an individual’s footsteps and use it to power the system. Bed sensors can notify caregivers of such changes in health as upper respiratory infections, since restless sleep is a predictive symptom of this illness. Sensors that track urination can notify health care practitioners if an individual is on the verge of an infection, as an increasing need to urinate is a symptom of urinary tract infection, a major illness in older women. These seamless monitoring systems call attention to health issues without waiting for the individual, who may be unwilling or incapacitated, to notify the caregiver. As the number of seniors in need of health care increases, designers are working on technologies that keep seniors healthy, in their homes, and out of urgent care facilities. This will be key to keeping our health care system from becoming overburdened.

Specialized senior care

Another trend in preventive and predictive medicine is a transition from general practitioner care for seniors to geriatric care in the form of urgent care centers, therapy suites, emergency rooms, and clinics geared toward the unique needs of this demographic. Staff needed for such facilities includes specialists who understand how an individual prescribed 20 or more medications should balance those medications for optimal health. In 2010, Johns Hopkins Medical Center opened one of the first geriatric urgent care centers in the nation. Our health care clients have asked us to research the feasibility of a similar facility in the Twin Cities. One of the challenges we’ve already encountered is what to name such a facility, as baby boomers are averse to thinking of themselves or being referred to as geriatric. In Arizona, we solved this challenge by embedding a preventive clinic for seniors in a community center. Area seniors

visit the community center for activities, to have coffee and chat with their friends—and can stop into the clinic for their medical needs without making a special trip. This nonthreatening, nonstigmatizing, dual-purpose environment also increases the possibility that individuals will return for preventive care and checkups before a lifealtering adverse event occurs. As the senior tsunami heads our way, so does a new wave of design, technology, and living and working options for baby boomers that will nurture and support body, mind, and spirit. Now is the right time to begin preparing for aging boomers’ nontraditional lifestyles, demands, and needs. By thinking about senior living and working in innovative ways, and by implementing design that supports and enhances innovation, we can initiate a positive ripple effect ahead of the impending tsunami. Alanna Carter, Assoc. AIA, LEED-AP, is a senior associate and director of environments for aging at RSP Architects, Minneapolis.

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P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com DECEMBER 2012

MINNESOTA PHYSICIAN

25


SPECIAL

A

ddressing problems of addiction with seniors has always been complicated. And the need to focus on seniors and addiction is taking on ever greater importance: Baby boomers started to reach age 65 in 2010, and over the next 18 years the population of people 65 or older will increase from 13 percent to 19 percent of the U.S. population, according to the federal Administration on Aging. What this means for physicians and other medical providers is that they will be seeing more aging patients with addiction to drugs or alcohol. Alcohol has been the drug of choice and will remain the drug of choice for seniors, but due to the social unrest of the ’60s and ’70s, seniors will have been exposed to many illicit drugs. In addition, misuse and abuse of prescription drugs will be a concern; even now, when seniors comprise 13 percent of the population, they consume 25 percent to 30 percent of all prescription drugs. Physicians can play a significant role in identifying symp-

FOCUS:

SENIOR

LONG-TERM

Seniors and addiction Age-related issues in diagnosis and treatment By Steve Tschida, BES, LADC

toms of drug and/or alcohol abuse in older patients and in helping them find an appropriate treatment program for their addiction(s). An often hidden problem

Part of the complexity in dealing with addiction in older patients is that problems associated with addiction in this population often go unnoticed in our society. There are numerous reasons for this: • Because most seniors are retired, their addiction problems do not show up in a workplace setting, where an employer might encourage or mandate an employee to seek treatment. • Seniors receive fewer DWIs than younger citizens and thus

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MINNESOTA PHYSICIAN DECEMBER 2012

avoid the legal system, which could mandate treatment. • As people age, it is common to become isolated, as spouses and siblings die and friends and children move away. This allows alcohol or drug abuse to go unnoticed by relatives or close friends. • People who have been using alcohol or drugs “successfully” —i.e., without experiencing negative legal, social, or employment-related penalties—tend not to see the negative consequences of their use. (This typically shows up as denial of treatment: “It’s never caused any problems for me.”) • In society at large, denial may take the form of statements such as “His drinking isn’t hurting anyone” or “She’s had a long life and deserves to do what she likes.” Diagnosing addictions in seniors

A number of factors complicate the diagnosis of addiction in elderly patients. Addiction researcher Belinda Basca, MEd, has noted that many symptoms of addiction will look like common signs of aging: Memory loss, disorientation, lack of balance, shaky hands, mood swings, depression, and chronic boredom are all symptoms of addictions but are also associated with many other medical conditions. The differential diagnosis must also take drug interactions into consideration. Many seniors take multiple medications, and it is not uncommon for an elderly patient to have more than one doctor prescribing medications. If you suspect a patient is abusing alcohol or drugs, there are screening tools available, including the CAGE, MAST (Michigan Alcohol Screen Test), and AUDIT (Alcohol Use Disorder Identification Test).

CARE The popular CAGE screening test was developed by John Ewing, MD, founder of the University of North Carolina Center for Alcohol Studies. The CAGE can identify alcohol problems over a lifetime though it consists of only four questions (each question’s focus provides a letter in the acronym): 1. Cutting down: Have you ever felt you should cut down on your drinking? 2. Annoyance by criticism: Have people annoyed you by criticizing your drinking? 3. Guilty feeling: Have you ever felt bad or guilty about your drinking? 4. Eye-openers: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? Two positive responses are considered positive and indicate that further assessment is warranted. For busy primary care physicians, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has a onequestion screening tool: “On any single occasion during the past three months, have you had more than X drinks containing alcohol?” (X is five for men and four for women.) If the answer is yes, further assessment is warranted. For seniors with alcohol use disorders, the most common comorbid disorder is major depression, followed by anxiety and cognitive spectrum disorders (Stephen Ross, MD, Psychiatry Weekly, 2005). Depression and anxiety can be caused by or exacerbated by using alcohol or drugs. Therefore, a thorough psychiatric exam is recommended when dealing with seniors with addiction. In addition, clinicians need to evaluate social factors in considering treatment. Identifying supports and hazards (e.g., related to the patient’s social network, housing and food, access to medical care, transportation) will play an important role in determining the best treatment. Treatment considerations

However, providers should be mindful that many seniors with alcohol or drug problems face


Key points both physical and psychosocial barriers to recovery, as years of addiction often have taken a severe toll on both body and mind. The elderly in general are more likely to suffer from chronic illness, further increasing their risk of cardiopulmonary complications. In prescribing medications for aging patients with addiction, it is important to consider the effects of physical changes such as reduction in body mass, total body water, and renal and liver function. Addiction also may cause deficits in memory, visual-spatial skills, abstract thinking, and problem-solving, as well as alcohol-associated amnestic disorders and dementia. It is important that the treatment program be comprehensive so that comorbid conditions of medical and mental health can be addressed, with interventions ranging from psychosocial to psychopharmacologic. Pharmacologic interventions include naltrexone, acamprosate, and antidepressants. In addition to physical and mental health complications, many seniors face financial barriers to treatment. Although Medicare does cover the cost of treatment, it will not cover the cost of room and board in a residential program or an extended care facility (halfway house). Clients will need to selfpay or qualify for chemical dependency consolidated funding through the state of Minnesota. Some treatment programs offer financial assistance through their agency or parent organization.

• Substance abuse and dependency mimic many medical problems. • Be aware that there may be more than one provider writing prescriptions. • Be informed about how older patients may react to medication(s). • Use electronic medical records to help follow the patient and medications prescribed. • Using quick screening questions in your practice.

The least intensive approach—for “abusive” users— is supportive, occurs in the medical clinic or an outpatient setting, is time-limited, and requires minimal training to administer. Physicians can follow up with patients during clinic visits and continue to advise patients about their drug/alcohol behavior. Patients with moderate to severe alcohol/drug use may benefit from outpatient treatment by specialized addiction providers/programs. Treatment in these settings may range from weekly one-on-one sessions with an addiction psychiatrist to once-a-week group meetings to structured daily programs. Treatment may also include pharmacotherapeutic interventions to reduce cravings and/or to reduce anxiety or depression, for example. Community support groups such as AA can be beneficial at this time. For the most severely impaired patients, inpatient treatment programs include inpatient detox programs, inpatient rehabilitation programs, intensive inpatient diagnosis and therapy, and long-term residential programs. The number of hospital-based inpatient programs has decreased greatly as many treatment facilities in Minnesota have adopted an outpatient residential model.

Treatment options

Seniors with addiction problems must be assessed to determine the appropriate level of care. Family members or support people should be involved in the assessment whenever possible. The choice of treatment or referral for these patients will depend on the severity of the alcohol or drug use. A detailed description of treatment modalities is beyond the scope of this article; however, there are several basic approaches to treatment.

Specialty programs for seniors

In both outpatient and inpatient treatment, many seniors are more comfortable in programs with same-age peers. A number of treatment programs in Minnesota have designed tracks specifically for seniors. In many of these programs, the term senior no longer means “65 and older”; rather, clients are now screened for the senior program at age 50. This is due in part to age-related medical problems, as well as patients’ preference to be with same-age peers.

Outpatient residential programs generally are not staffed to handle medical needs of seniors. For example, medications are tracked by the residential facility, but the senior is responsible for taking medications as prescribed. And, referrals from hospitals following surgery present problems, as residential facilities typically do change dressings for the client. A senior’s ability to perform activities of daily living, or ADLs (e.g., bathing, dressing, eating, using the toilet) must be assessed before he or she is admitted to an outpatient treatment program. Seniors who are not able to perform ADLs may need a referral to convalesce at a nursing home or with a family mem-

ber before entering a treatment program. Counselors working with seniors need to take things slowly and avoid confrontation, taking time to learn what is important to clients and what motivates them to change. Because many seniors have a limited support network of family and friends, it is important that counseling staff be knowledgeable about services that are available in the client’s community for the aging population. Be ready for the challenges

As the population ages, we can expect the incidence of substance abuse and dependency to increase. Providers can learn more about treating patients with alcohol and drug problems at the NIAAA website, www.niaaa.nih.gov. Steve Tschida, BES, LADC, is a senior counselor at Recovery Plus addiction and mental health services at St. Cloud Hospital, part of CentraCare Health System.

Medical Director Duties and responsibilities: • Provides 24-hour call coverage • On site two times per week for 1 to 2 hours • Evaluate and provide written documentation (supporting statement) for clients involved in the civil commitment process • Annual review of policies as mandated by MN Rule 32 licensure • The medical director reports directly to the program director Mission Detox Center Making Change Possible By Never Giving Up On Anyone Opened in 1978, Mission Detox Center provides medically supervised detoxification services for suburban Hennepin County and Anoka County. Admission to Mission Detox Center is frequently the first professional intervention in a destructive pattern of chemical use, and a difficult point in any chemically dependent person's journey. Each client is welcomed with respect and provided professional and compassionate care by the staff of nurses, counselors and trained technicians.

Qualifications: • Licensed to practice medicine in the state of MN • Knowledge of chemical dependency

If interested, contact the Program Director at (763) 559-1402 or to apply, send a cover letter and resume to: Mission Detox Center, 3409 East Medicine Lake Blvd., Plymouth, MN 55441 or fax to (763)559-1195 Or check out our website at: www.missionsinc.org

DECEMBER 2012

MINNESOTA PHYSICIAN

27


N E O N AT O L O G Y

A

s medical specialties go, the practice of neonatalperinatal medicine, commonly known as neonatology, is relatively young. Spawned by technological advances of the Industrial Revolution and a desire to reduce urban infant mortality rates of nearly 20 percent, American facilities for the care of preterm and underweight infants appeared in the early 1900s—usually in conjunction with fairs, amusement parks, and expositions. The infant incubator invented by Parisian physicians Stéphane Tarnier and Pièrre-Constant Budin, for example, first gained notoriety in the U.S. at the Trans-Mississippi Exposition in Omaha, Neb., in 1901. These “Incubator Baby Side-Shows” presented by Dr. Martin Couney, a former student of Tarnier and Budin, continued until 1943 with the longest exhibit in Coney Island, N.Y., featuring rows of incubators with round-the-clock nursing and physician care. Over time, the primitive incubators were superseded by more sophisticated devices capa-

Development of a young specialty High-risk infant care: yesterday, today, and tomorrow By Mark Bergeron, MD, MPH

ble of oxygen delivery, which saw widespread use in the U.S. beginning in the 1950s. Concurrently, the development of infant formulas in the 1920s and polyethylene feeding tubes in the 1950s led to improved survival of preterm infants. In the years that followed, Dr. Virginia Apgar would develop her scoring system to assess infant response to resuscitation at delivery, and Drs. Mary Ellen Avery and Jere Mead would elucidate the cause of preterm infants’ respiratory distress syndrome (then dubbed hyaline membrane disease) as a deficiency in lung surfactant. Avery and Mead’s research led to the emergence of positive pressure ventilators for infants.

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MINNESOTA PHYSICIAN DECEMBER 2012

These ventilators were developed in large part as a response to the highly publicized 1963 death of the third child of President John F. Kennedy and Jacqueline Bouvier Kennedy at 34 weeks’ gestation, due to respiratory distress syndrome, an event that led to widespread acceptance of the need for facilities specializing in intensive care for newborns. While the first neonatal intensive care unit (NICU) opened just two years later in 1965 at Yale University, it wasn’t until 1975 that the American Board of Pediatrics established the subspecialty of neonatology. Today’s neonatologists complete a three-year neonatal-perinatal medicine fellowship following completion of a three-year pediatrics residency. Neonatology today: Comprehensive newborn intensive care

Most regard the 1960s as the birth of modern neonatology. Driven largely by technological advances, our profession has seen treatment options dramatically improve neonatal morbidity and mortality as a result. Unlike the experience of President and Mrs. Kennedy in 1963, parents of a 34-week preterm infant born today would expect survival near 100 percent. Today, treatments such as with antenatal steroids and artificial surfactant replacement, along with gentle ventilation techniques such as volume-targeted computerized ventilators and nasal continuous positive airway pressure (CPAP), have changed the face of neonatal morbidity from respiratory causes, particularly in the larger preterm infants born after 30 weeks’ gestation. Better nutrition, both enteral and parenteral, has also improved postnatal growth and subsequently has

enhanced pulmonary and neurologic development. Improved antenatal care and antibiotics administration during labor have reduced the incidence of neonatal sepsis, and surgical advances have dramatically improved outcomes for infants born with gastrointestinal, neurological, cardiovascular, or orthopedic birth defects. Today, the most vulnerable of the preemies are the so-called “micropreemies,” infants born at 22–25 weeks’ gestation and weighing as little as 400–500 grams. These infants face the highest mortality and morbidity and can have NICU stays lasting several months. The sophisticated techniques of ventilation, nutrition, and fluid management pioneered in the 1990s have translated into improved outcomes, with survival at around 10 percent for the most premature infants above 22 weeks, and as high as 70 percent for infants born at 24–25 weeks. These outcomes have remained variable and, particularly, center-specific, with better outcomes reported at larger, tertiary centers that have NICUs experienced in managing a relatively high volume of such infants. However, both NICU providers and parents will argue that survival is but one of the issues at hand. Many surviving micropreemies suffer a disproportionate burden of morbidity, including intraventricular hemorrhage, posthemorrhagic hydrocephalus, cognitive and motor impairment, retinopathy of prematurity, and chronic lung disease, all of which can last years, if not into adulthood, and affect the child and family in ways impossible to imagine at the time of birth. Thus, the moral and ethical dilemmas of resuscitation at the threshold of viability continue to challenge us in the NICU community. Thankfully, this group of patients represents a small fraction of the infants cared for in the NICU, with approximately 15 percent of preemies born at or less than 30 weeks’ gestation. The vast majority of preterm infants are the “moderately preterm” infants at 30–33 weeks, SPECIALTY to page 30


2012 physician opinion survey 4of 4

4. I feel that my patients trust my advice. 1. I understand what is meant by the term patient activation measure.

27.4%

0

8.1%

Strongly agree

Agree

Disagree

Strongly disagree

2. My place of employment requires me to track patient activation measures.

Percentage of total responses

35

14.5%

15 10 5.6% Strongly agree

7.3%

Agree

Does not apply

Disagree

22.6%

20 13.7%

10 4.8%

Percentage of total responses

25

Strongly agree

Disagree

Strongly disagree

23.4% 20

17.7% 13.7%

10

Agree

No opinion

Disagree

No opinion

Disagree

Strongly disagree

Strongly disagree

16.9% 12.1%

10

5.6% Strongly agree

No opinion

Disagree

Strongly disagree

62.1%

50 40 30 16.9%

20

Strongly disagree

0

15 6.5%

4.0% Agree

Agree

60

10

20

Strongly agree

Disagree

22.6% 20

1.6%

26.6% 25.8%

25

0

No opinion

30

No opinion

To participate in future surveys or offer suggestions, please contact us at comments@mppub.com.

Disagree

Strongly disagree

9.7%

9.7%

1.6% Strongly agree

Agree

No opinion

Disagree

Strongly disagree

10. I think some metric of patient engagement should be included as part of a patient's medical record. 58.1%

60

5 Agree

Agree

9. Developing empirical, well-defined tools to measure the individual patient's level of engagement in their health care improvement is possible and worthwhile.

37.1%

30

10

Strongly agree

80

30

Strongly agree

11.3%

10.5% 4.0%

40

0

35

28.2%

10

16.9%

70

40

30.6%

15

No opinion

0.0%

6. If I had more electronic communication with my patients, their health status would improve.

35 30

Agree

0.8%

40

0

Strongly disagree

3. I am in favor of physician compensation being tied to aggregated patient outcomes instead of treating individual patients.

Percentage of total responses

4.0%

43.5%

25

0

10

33.1%

20

5

20

50

30

0

30

5. When an employer and/or health plan communicates directly with my patients about their medical treatment plans, it undermines the trust my patients have in my advice.

39.5%

40

5

40

Strongly agree

20

42.7%

43.5%

0

30

50

Percentage of total responses

10

16.1%

40

8. My ability to provide the best medical care possible is compromised when patients' attitude and lifestyle becomes tied to my compensation.

51.6%

50

50

0

Percentage of total responses

20

57.3%

Percentage of total responses

30

Percentage of total responses

Percentage of total responses

40

Percentage of total responses

48.4%

50

60

7. There is an inherent conflict of interest between improving overall population health and improving the health of one individual.

Percentage of total responses

We are pleased to present the results from the fourth of four physician opinion surveys we have published in 2012.Through a number of sampling methods, we received 124 responses to Phase 4. If you would like to be included in future surveys, please contact us via e-mail at comments@mppub.com or call 612-728-8600.The surveys are online, are quick to complete, and are completely anonymous and confidential. We welcome your suggestions for this and future surveys. Our thanks to those who participated.

50 40 30 20

16.1%

12.9%

10

11.3% 1.6%

0

DECEMBER 2012

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

MINNESOTA PHYSICIAN

29


As new technologies are integrated into the daily care we provide in our NICUs, we continue to strive to remain close to the bedside.

Specialty from page 28 who require intensive care to manage, most commonly, respiratory distress syndrome, apnea of prematurity, hyperbilirubinemia, and feeding problems and fluid management issues; and the “late preterm� infants born at 34–36 weeks’ gestation, who have excellent prognoses but tend to require NICU care for issues related to temperature instability, respiratory distress, jaundice, and immature feeding patterns. The final group of patients in the NICU is the term infants who require intensive care for illnesses including hyperbilirubinemia, congenital heart disease, genetic syndromes, meconium aspiration syndrome, encephalopathy, bowel obstruction, neurological malformations, and sepsis, among others. Neonatology tomorrow: An emphasis on family-centered care

Historically, neonatology has been a technologically driven specialty, its development spurred by the invention of the

incubator and, eventually, the infant ventilator. Today, new ventilators with “gentle� modes of ventilation minimize barotrauma and volutrauma associated with mechanical ventilation, while nasal CPAP has largely replaced the need for intubation and surfactant replacement in many preterm infants, and administration of maternal antenatal corticosteroids has greatly reduced the severity of respiratory distress syndrome. The recent adoption of therapeutic hypothermia for the treatment of neonatal hypoxic-ischemic encephalopathy has improved neurodevelopmental outcomes of term infants. Many of us anxiously await the next breakthrough that will revolutionize the way a condition or syndrome is treated. Some look to our colleagues in

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MINNESOTA PHYSICIAN DECEMBER 2012

obstetric research for new methods to effectively slow or even “cure� preterm labor altogether. However, we need not wait for these breakthroughs to radically improve our patients’ lives. Indeed, in recent years we have seen a radical change in the way the infants and their families receive care. Today’s NICUs are designed with the patient and family in mind, instead of considering just the needs of the health care team. My NICU was among the first in the country to completely overhaul the unit design in the last few years, providing each patient and family with a private room, ensuring privacy, developmentally appropriate care, and low ambient sound and lighting. Families once excluded from bedside rounds can now sleep at their infant’s bedside and are encouraged to participate in bedside care and rounds as a vital part of the care team. As we continue to better understand the emotional toll that a NICU course takes on a family, we have expanded the social supports available to them during their child’s hospitalization. Staff social workers and chaplaincy offer services, and parents of former preemies have developed an independent support group that sponsors gatherings such as scrapbooking nights or pizza parties as a means for current NICU parents to learn from previous NICU parents and gain much needed encouragement. We recognize that the stress of the NICU can leave a lasting impression on some parents, and researchers have begun to study these posttraumatic stress responses to better understand how to better recognize and support these family members affected. Despite the great technological and developmental advances that have certainly improved neonatal outcomes from a century ago, neonatal morbidity

and mortality levels have remained somewhat stagnant for the past decade. In response, NICUs worldwide have formed collaboratives to share outcomes data and, potentially, develop better practices in an environment of transparency and cooperation. The best known of these collaboratives is the Vermont Oxford Neonatal Network, which has a database of tens of thousands of infants from its member NICUs, from which benchmarks for quality care have been established. Locally, the Minnesota Perinatal Quality Collaborative, formed last year, includes all the NICUs from the state and seeks to improve neonatal care through quality improvement projects and sharing of best practices and outcomes. Minnesota has also taken a cue from other states’ success and formed a coalition of medical, nursing, community health, advocacy, and education stakeholders to address health and developmental issues related to prematurity statewide. This coalition called on the Minnesota Legislature to form a Task Force on Prematurity, which was authorized in 2011 and will issue an official report next year that will provide specific recommendations to improve neonatal health in Minnesota. Neonatology is a field of pediatrics that, like the patients we serve, continues to grow and develop. As new technologies are integrated into the daily care we provide in our NICUs, we continue to strive to remain close to the bedside, enriching the lives of each infant and family we touch while also working together outside of our NICU setting to improve the health of all newborns. Mark Bergeron, MD, MPH, practices neonatology with Associates in Newborn Medicine, PA at Children’s Hospitals and Clinics of Minnesota–St. Paul and at HealthEast St. John’s, St. Joseph’s, and Woodwinds hospitals. He is medical director of the Special Care Nursery at Regions Hospital in St. Paul. He is immediate past president of the Minnesota Perinatal Organization and a member of the Minnesota Prematurity Coalition, Minnesota Task Force on Prematurity, and Minnesota Perinatal Quality Collaborative.


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DECEMBER 2012

MINNESOTA PHYSICIAN

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DIABETES

“Cheetos are not vegetables”

D

ana is your first patient of the day, scheduled for a postpartum visit. [All patients’ names are fictitious.] She is age 30, of German and Swedish descent, and six weeks ago underwent her fourth cesarean delivery, scheduled at 39 weeks. Her medical history is notable for polycystic ovarian syndrome, and each of her four pregnancies was conceived with the aid of clomiphene citrate. Her prenatal care was complicated by gestational diabetes, diagnosed at her one-hour glucose challenge test with a result of 244. She gained 40 pounds over the course of her pregnancy. Her BMI today is 39. During pregnancy, she had poor control of her blood sugars. She had a hard time following her dietary restrictions, and frequently forgot to check her blood glucose at the appropriate times. She did not have transportation to Diabetes Education. She runs a day care from her home, and cares for six children ages 2 through 5 years. Her own infants all weighed over 10

A protocol for screening women for the resolution of gestational diabetes By Lori Wilcox, MD, and Mary Martinie, MD

pounds. Her newborn was hospitalized for seven days with jaundice, hypoglycemia, and transient respiratory difficulties. Samantha is your next patient. She presents to your

significant medical history, and her family history is notable for type 2 diabetes in her mother and grandmother, and a myocardial infarction in her father at age 77.

As obstetricians, we have the opportunity to actively screen our patients who have had gestational diabetes. office for her postpartum visit as well, after vaginal delivery of her first child. She is of Pacific Islander descent, she has no

She is pleased that her weight has returned to her prepregnancy value of 135 pounds. Her prenatal care was compli-

cated by advanced maternal age (37 years), with a normal level 2 ultrasound, and gestational diabetes. She had a three-hour glucose tolerance test, with two values just above the upper limits of normal. She followed her usual vegetarian diet in pregnancy, and had a 17-pound total weight gain. She checked her blood glucose fasting each morning and after each meal, and counted carbohydrates carefully. She modified her diet by reducing her intake of rice- and cornmeal-based products. More than 90 percent of her glucose readings were within the goal parameters. She continued to take Pilates and dance classes until 37 weeks gestation. Despite her rigorous fitness regimen, Samantha had a highdensity lipoprotein level of 30 mg/dL prior to pregnancy, and plans to resume a niacin supplement to improve her value. At term, she experienced spontaneous labor, and underwent DIABETES to page 34

VA Health Care System In South Dakota & North Dakota Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following locations. Sioux Falls VA HCS, SD

Black Hills VA HCS, SD

Fargo VA HCS, ND

Urologist Psychiatrist Hospitalist Family Practice

Psychiatrist General Surgeon Physician (Primary Care) Hospitalist (Internal Medicine) Urologist Podiatrist

Psychiatrist Hospitalist Family Practice Internal Medicine

Orthopedic Surgeon Cardiologist Internal Medicine

Sioux Falls VA HCS (605) 333-6858 www.siouxfalls.va.gov

Black Hills VA HCS (605) 720-7487 www.blackhills.va.gov

Fargo VA HCS (701) 239-3700 x2353 www.fargo.va.gov

Applicants can apply online at www.USAJOBS.gov

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MINNESOTA PHYSICIAN DECEMBER 2012


Spine Surgeons, join our team and set the standards for patient care. Orthopaedic Associates of Duluth is seeking a highly motivated passionate and experienced SPINE SURGEON to provide outstanding orthopaedic care to its patients. The successful candidate will be part of our expanding and growing, well-respected team that serves patients from Duluth to northern Minnesota. Orthopaedic Associates of Duluth is a group of nine orthopaedic surgeons that provide comprehensive orthopaedic services ranging from specialty specific exams and diagnosis to state-of-the-art inoffice MRI and imaging and surgery at their physician-owned surgery center.

Email CV to jwaller@slhduluth.com or call 800-461-8843 (Sue) or 218-625-2731 (June) © Paid for by the U.S. Air Force. All rights reserved.

Opportunities available in the following specialties: Adult Psychiatry Child Psychiatry

Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Family Medicine St. Cloud/Sartell, MN

Southeast Clinic

Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

AIRFORCE.COM/HEALTHCARE

Dermatology Southeast Clinic

Family Medicine Chatfield Clinic, Pine Island Clinic, Plainview Clinic

Hospitalist Rochester Hospital

Internal Medicine

We are actively recruiting exceptional part-time or full-time BC/ BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/ GYN and pediatrics. Previous electronic medical record experience is preferred, but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals.

Southeast Clinic

Sleep Medicine

Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent benefit package, a rewarding practice and a commitment to providing exceptional patientcentered care. St. Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal.

Rochester Hospital

Sports Medicine Orthopedic Surgeon Southeast Clinic

Orthopedic SurgeonJoint Replacement Southeast Clinic

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622

www.olmstedmedicalcenter.org

Apply on-line at healthpartners.jobs or contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

EOE

healthpartners.com DECEMBER 2012

MINNESOTA PHYSICIAN

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Diabetes from page 32 uncomplicated delivery at 39 weeks and four days. Her infant weighed 6 pounds 12 ounces, and had no episodes of hypoglycemia. Which of these patients is at risk for type 2 diabetes? The answer is both. Despite very different prenatal and delivery courses, both patients will benefit from screening outside of pregnancy. An estimated 2 percent to 5 percent of patients develop diabetes during pregnancy, thereby increasing their risk of type 2 diabetes. The list of risk factors for diabetes is lengthy, and it includes family history, being a member of a high-risk ethnic or racial group, delivery of a 9-pound or larger baby, and a history of gestational diabetes. Additionally, health issues such as hypertension, dyslipidemia, vascular disease, and polycystic ovarian syndrome are risk factors. The American Diabetes Association recommends testing for diabetes outside of pregnancy either with fasting plasma

glucose levels or with a two-hour glucose tolerance test. Implementing a screening protocol

As obstetricians, we have the opportunity to actively screen our patients who have had gestational diabetes, likely at a point in their lives where dietary education, weight loss recommendations, and exercise programs can

began May 1, 2011. Over the next 12 months, 1,438 pregnant patients, without a preexisting diagnosis of diabetes, were tested for gestational diabetes with the standard one-hour glucose challenge, followed by the threehour glucose tolerance test as needed. Following delivery, those patients with gestational diabetes received postpartum instructions, prior to leaving the

An estimated 2 percent to 5 percent of patients develop diabetes during pregnancy, thereby increasing their risk of type 2 diabetes. be of maximum benefit. The clinical services committee at Oakdale Obstetrics and Gynecology implemented a structured protocol to increase the number of our patients with a history of gestational diabetes screened for type 2 diabetes, beginning at the postpartum visit. Our pilot collection of data

hospital, regarding diabetes testing at the time of their postpartum visits. Additionally, a registered nurse phoned each patient at four weeks postpartum, to remind the patient to arrive at her postpartum visit in the fasting state. A fasting glucose was obtained for each patient, with results of 100 mg/dL or less con-

sidered normal, results of 101 mg/dL to 125 mg/dL categorized as likely impaired glucose tolerance, and results of 126 mg/dL or higher classified as suspected diabetes mellitus. During our data collection time frame, 134 patients were diagnosed with gestational diabetes. Ninety-six of those patients (72 percent) delivered with our group and followed through with their recommended postpartum testing. Seven of the 96 patients (7 percent) had abnormal fasting glucose test results of 101 mg/dL or higher. Patients with normal test results received a letter in the mail reminding them of their increased lifetime risk of diabetes, with recommendations for periodic glucose testing every one to three years. Weight loss and regular exercise were encouraged for those patients with a body mass index placing them in the overweight or obese category. DIABETES to page 36

Heart of Minnesota Lakes Country Practice Opportunities Sanford Clinic North – Excellent practice opportunities in communities located in the ‘Heart of Minnesota Lakes Country’. Good call arrangements and modern well-managed community-owned hospitals. Alexandria • Dermatology • Family Medicine • Hospitalist/IM • Internal Medicine • Obstetrics/ Gynecology Detroit Lakes • Dermatology • Family Medicine • General Surgery • Internal Medicine • Pediatrics

East Grand Forks • Dermatology • ENT • Family Medicine • IM/Peds • Orthopedics Moorhead • Family Medicine New York Mills/ Perham • Family Medicine • Orthopedic Surgery

Thief River Falls • Family Medicine • General Surgery • Hospitalist/IM • Internal Medicine • Optometry • Urology Wheaton • Family Medicine

THE STRENGTH TO HEAL

and stand by those who stand up for me.

Sanford Health, serving western Minnesota, eastern North Dakota and South, is redefining health care. Sanford offers innovative technology, support of a multi-specialty organization and dependable colleagues. Our employment model includes: market competitive salary, comprehensive benefits, paid malpractice insurance and a generous relocation allowance. To learn more contact: Shannon Ellering, Physician Recruiter Email: Shannon.Ellering@sanfordhealth.org

Phone: (701) 280-4817 EOE/AA

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MINNESOTA PHYSICIAN DECEMBER 2012

Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference. 7ROHDUQPRUHFDOORUYLVLW ZZZKHDOWKFDUHJRDUP\FRPT Š 2010. Paid for by the United States Army. All rights reserved.


Emergency Medicine Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:

Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:

recruiting@epamidwest.com

St. Cloud VA Health Care System is accepting applications for the following full or part-time positions: • Associate Chief, Primary & Specialty Medicine (Internist-St. Cloud)

• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo)

• Dermatologist (St. Cloud) • Director, Primary and Specialty Medicine (Internal Medicine) (St. Cloud)

or visit our website at

www.epamidwest.com

• ENT (St. Cloud)

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We will be opening a new Urgent Care clinic in Hugo, MN in the spring of 2013! Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

• Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud) • Psychiatrist (Brainerd, St. Cloud)

• Geriatrician (Nursing Home-St. Cloud)

Your Emergency Practice Partner

• Hospice/Palliative Care (St. Cloud)

• Hematology/Oncology (Part Time-St. Cloud)

• Radiologist (St. Cloud) • Urgent Care Provider (MD: IM/FP/ER) (St. Cloud)

US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including: Favorable lifestyle

Competitive salary

26 days vacation

13 days sick leave

CME days

Liability insurance

Interested applicants can mail or email your CV to VAHCS

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

Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

healthpartners.com DECEMBER 2012

MINNESOTA PHYSICIAN

35


Diabetes from page 34 Of our seven patients with abnormal fasting glucose test results, two had additional testing through our office that confirmed a diagnosis of diabetes. One had a two-hour glucose challenge test result of 183 mg/dL, and the second had a hemoglobin A1C result of 7.1 percent. This second patient declined to participate in the glucose challenge test. The remaining five patients with abnormal fasting glucose testing elected to see an internist or family medicine physician for further testing and treatment recommendations. All were provided with nutrition information in the form of a poster detailing the major food groups, as well as representative foods and serving sizes, with accompanying calorie counts. Thirty minutes of physical activity daily was encouraged as well. An opportunity to educate patients

The formal establishment of this screening protocol in our

office has proven to be an effective means to increase compliance with the American Diabetes Association’s recommendations for postpartum glucose testing in patients with a history of gestational diabetes. It has increased awareness of the lifetime risks of developing diabetes for women with prior gestational diabetes, and has pro-

betes. Samantha’s risk factors lie deeper in her medical and family history, but nonetheless increase her chances of developing type 2 diabetes. In fact, Samantha failed her two-hour glucose tolerance test at her postpartum visit. She has now increased her protein intake, reduced her carbohydrate intake, and continued with

Following delivery, those patients with gestational diabetes received postpartum instructions, prior to leaving the hospital, regarding diabetes testing at the time of their postpartum visits. vided an opportunity to educate patients and encourage positive lifestyle modifications to reduce that same risk. Let’s return to our patients Dana and Samantha. As physicians, we recognize the risk factors present in Dana’s case for the development of type 2 dia-

her overall active and healthy lifestyle. With careful monitoring of her blood glucose levels, she is managing her type 2 diabetes very well. Dana was found to have a hemoglobin A1C of 7.1 percent at her postpartum visit. She is now seeing a nutritionist and

an endocrinologist. She is learning that “despite being orange, Cheetos are not vegetables!” She is experimenting with healthy cooking for her family and the children in her charge during the day. Dana is incorporating more physical activity into her daily schedule. She has set a weight loss goal of 10 percent of her body weight and is losing about one pound per week. We are privileged to partner with patients in education regarding their health issues and implementation of healthy lifestyle choices. Oakdale Obstetrics and Gynecology plans to continue this program of diabetes screening in postpartum women. Lori Wilcox, MD, and Mary Martinie, MD, practice at Oakdale Obstetrics & Gynecology, a division of Premier ObGyn of Minnesota, in Maple Grove, Plymouth, and Robbinsdale.

Minneapolis VA Health Care System The Minneapolis VA Health Care System is a 341-bed tertiary-care facility affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel. The Twin Cities offers excellent living and cultural opportunities. License in any state required. Malpractice provided. Applicants must be BE/BC. Opportunities for full-time and part-time staff are available in the following positions: • Chief, Radiation Oncology • Chief, Surgery/Specialty Care Director • Chief, Emergency Medicine • Cardiac Anesthesiology • Compensation & Pension Examiner • Emergency Medicine • Gastroenterology • Internal Medicine or Family Practice o General Medicine Clinic o Post Deployment Clinic

• Hematology/Oncology • Hospitalist • Outpatient Clinics: Internal Medicine or Family Practice o Maplewood, MN o Ramsey, MN o Rochester, MN o Chippewa Falls, WI o Rice Lake, WI

• Outpatient Clinics: Psychiatry o Superior, WI o Ramsey, MN o Rice/Hayward, WI–V-tel and on-site o Maplewood, MN –V-tel and on-site • Medical Director, Rochester Outpatient Clinic • Pathology • Radiation Oncology • Rheumatology • Spinal Cord Injury and Disorder

Competitive salary and benefits with recruitment/relocation incentive and performance pay possible.

For more information: Visit www.usajobs.gov or email Brittany.Sierakowski@va.gov EEO employer

36

MINNESOTA PHYSICIAN DECEMBER 2012


The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Internal Medicine • Psychology • Family Medicine • Med/Peds Hospitalist • Pediatrics • General Surgery • OB/GYN • Pulmonary/ Critical Care • Geriatrician/Outpatient • Oncology Internal Medicine • Radiation Oncology • Orthopedic Surgery • Hospitalist • Rheumatology • Psychiatry • Infectious Disease For additional information, please contact:

Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366

Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

With Essentia Essentia He H Health, alth, yyou’ll ou’ll find

www.acmc.com

group more a supportive supportive gr o of mor oup e than 750 medical 7 50 physicians physicians across across 55 55 me dical

Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000.

specialties. large spe cialties. Located Located in lar ge and

Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact:

patient-centered care. p atient-centered c are. EEOE/AA OE//A AA

small communities communities across across Minnesota, Minnesota, Wisconsin, North Dakota Idaho, Wis consin, Nort th D akota and Idah o, Essentia Health emerging E ssentia He alth h is emer ging as a leader cost-effective, le ader in high-quality, high-q quality, c ost-effectivve,

LEARN MORE

EssentiaHealth.org/Careers E ssentiaHealth.org/Careers 800.882.7310 8 00.882.7310

Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org AA/EOE - Not subject to H1B Caps

DECEMBER 2012

MINNESOTA PHYSICIAN

37


Safety net from page 13 rebate checks to Minnesota taxpayers. State services expanded. People with disabilities were given increased access to nonmedical supports. Times were good. Today’s era of fiscal austerity means an increased level of accountability is needed to ensure the state preserves the safety net. An Olmstead Planning Committee, named for the court decision, was created by DHS in December 2011. This 15-member body, which includes individuals with disabilities, family members, providers, advocates, and senior decision-makers from DHS, is charged with developing a plan to “fulfill the promise of the Americans with Disabilities Act,” according to the committee’s website (also found at www.dhs.state.mn.us). DHS hopes to begin implementing the plan in early 2013. The case for physician action

Given the tenuous recovery of the current economy and the certainty of a budget deficit to

begin the 2013 legislative session, individuals with disabilities and the physicians they turn to for medical care need to understand the implications of these environmental factors. This is particularly true for those who serve the most complicated patients, who rely on Medicaid for their health insurance. Without increased state revenue, it is nearly impossible to balance the state’s budget without cuts to human services programs. People with disabilities are the major cost driver in this budget area. Government has three levers to control these expenditures: limiting access to services (tightening eligibility), cutting payments made to providers, or eliminating services or programs. Each option will adversely affect Minnesotans with disabilities. Physicians who serve those who rely on state-funded programs for their health and independence should be active and engaged in understanding how their practices will be affected by these evolving policy and environmental factors. Interest

groups like Minnesota Medical Association and Minnesota Hospital Association have been very active in the multiple community dialogues now occurring that will determine the future of state health policy. Perhaps the most forwardthinking of these conversations has been at the Governor’s Health Reform Task Force (www.mn.gov/health-reform/). Here, state leaders are asking how we can better measure the success of and better align financial incentives for those serving Minnesotans with disabilities. These questions, and the panel’s recommendations, are sure to be discussed in the upcoming legislative session. Similarly, Medicaid redesign efforts—especially for long-term care services—will be front and center for state politicians as they formulate a new two-year budget. Interested physicians should contact their local elected officials or trade association to understand the implications for their patients— and for their financial bottom line.

A sustainable future?

Health and other policy reforms must continue at the state and federal level for the safety net to continue to support those it was designed to serve: people with disabilities and complex medical conditions at every point in the life cycle. Multiple stakeholder groups must look beyond their parochial needs to design an innovative system that addresses the demands for savings, value, new delivery models, and new payment models outlined above. If they can’t do so, then legislative bodies at the state and federal level will do it instead, with those who need and rely on the safety net—and the providers who serve them—suffering the direst consequences. John Tschida, vice president of public affairs and research at Courage Center, has worked for decades to improve financing and delivery of health services for people with disabilities.

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MINNESOTA PHYSICIAN DECEMBER 2012


A landscape of opportunities

Physicians Gundersen Lutheran Health System, based in LaCrosse, Wis., offers you the opportunity to practice cuttingedge medicine. But we also believe that medicine is about people and that’s why our medical outcomes are among the nation’s best (gundluth.org/accomplishments). Currently seeking physicians for the following: • Family Medicine • Neurology • General Surgery • Emergency Physician • Dermatology • Endocrinology • Psychiatry • Otolaryngology We are a physician-led health system, where teaching and research are possible with competitive salary, benefits, CME and loan forgiveness.

Cathy Mooney (608)775-3637 camooney@gundluth.org gundluth.org/MedCareers

EOE/AA/LEP


NEW ICD-10 DEADLINE:

OCT 1, 2014

2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems. CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10


Minnesota Physician December 2012