Presents… 3
C o n t e n t s David Naster COLORADO EDITION | MAY 2012
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WELCOME LETTER
From the Medical Voyce President
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H U M O R I N H E A LT H C A R E
YOU J6UST HAVE TO
You Just Have to Laugh ® With David Naster
C OV E R F E AT U R E
Childhood Regained
WHEN LIFE GETS TOUGH
WWW.NASTER.COM
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MEDICAL NEWS
SpringsComedian ’ Community Health International &Partnership Award-
to
Participate in TBD Colorado
Nominated Documentary Film
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producer David
L E A D E R S H I P I N H E A LT H C A R E
Managing Conflict With Peers Naster Ideas Into Action Series brings
his
22world-famous program
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MEDICAL PRACTICE MARKETING
Lord...Give Me More Patients
CLINICAL GUIDELINES: DIABETES
to DHealthy Coloradan! Revised iabetes Guideline
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B E H AV I O R A L M E D I C A L NEWS
CORHIO Issues New Report on Behavioral No One Escapes Tough Times - How We Respond To It Makes A Difference! Is There Laugh After Death? ~ Living with Serious Illness ~ Humor in Crisis ~ Humor After injury Health Integration Humor in Grief ~ Tough & Thankless Jobs ~ Dangerous Jobs
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MEDICAL VOYCE NEWS
PENRAD Imaging Expanding its Line of Service
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H E A LT H C A R E P O L I C Y
The Constitutionality of the Individual Mandate
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Dear
Physician
Publisher’s Note: Colorado residents and referring providers are fortunate to have the clinical, programmatic, and physician resources of National Jewish Health in such proximity. Few are unaware that NJH ranks as the #1 Respiratory Hospital in the United States, and arguably around the world – a distinction that is well-earned and maintained each and every one of the past 14 years.
D i r k R. H o b b s , P r e s i d e n t Medical Voyce, Inc.
Now, we are privileged to share some insights into the Pediatric Day Program at National Jewish Health. Erwin Gelfand, MD, Chairman of the Department of Pediatrics and Dan Atkins, MD, Head of the Division of Ambulatory Medicine unpack the multidisciplinary model of the program for those children and their families whose management of the disease is no longer working. Going digital only! Medical Voyce has received numerous requests preferring receipt of our publication online and via email. You, our readers, continue to request information on the pertinent healthcare issues facing our state be included in the magazine, but you have asked for online delivery instead of paper. We have heard you. Given that providers have so much to read and so little time, we’re going to make this very easy. Medical Voyce will now appear on our site www.medicalvoyce.com/medical-voyce-magazine, but also in digital format via most of the county medical societies throughout the state and soon via a new Medical Voyce APP! Physicians and other health care personnel will soon be able to quickly scan those stories from every major agency in the state via their mobile phone and skip those in which they have less interest. Submit your content for free! Got news that will edify the physician community? Medical Voyce is now accepting content from all relevant clinical, policy and administrative thought leaders in the state at no charge for the first page and subsequent pages for only $50.00. Advertising can be placed for as little at $50.00/month in the digital publication with direct links back to your Web site! It’s a new age in publishing and physicians want their information on the go! Look for your MV APP coming to the Medical Voyce tab on your county medical society Web site or download it as soon as it becomes available from www.medicalvoyce.com! Until next month,
Dirk R. Hobbs President, Medical Voyce Sciences & Multimedia, Inc.
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Medical Voyce Magazine Colorado Edition Executive Publisher: Dirk R. Hobbs Medical Direction: Bhaktasharan C. Patel, MD Senior Medical Editor: Marty Banks Creative Director: Marta Podkul Printing Consultant: Marcum Group Media Contributing Writers: Dan Atkins, MD; Erwin Gelfand, MD; Thomas Warda; Jan Friedlander; David Naster; Mike Ware; and Robert Semro Medical Voyce Sciences & Multimedia, Inc. President: Dirk R. Hobbs EVP Operations: Scott W. Casey Chief Medical Officer: Buck C. Patel, MD Associate Medical Director: Sheldon Ravin, MD EVP Communications: Kim Ronkin EVP SEO Services: Greg Walthour Director of Web Services: Winn Jewitt DocVoyce VP Development: Abhay Natu DocVoyce Project Manager: Arun Raval Territory Managing Directors, NM: Michele Sequiera and Michael Westphal Medical Voyce Magazine is published by Medical Voyce Sciences & Multimedia, Inc. 212 Washington Street, Suite E Monument, Colorado 80132 PO Box 2942, Monument, CO 80132 Phone: 719.884.1184 | Fax: 719.884.1189 Email: info@medicalvoyce.com Web: http://www.medicalvoyce.com To advertise, reprint or submit sponsored content in Medical Voyce, contact us at info@medicalvoyce.com, 719.884.1184, ext 1 Copyright 2012 Š Medical Voyce Multimedia, Inc. POSTMASTER: Use form 3579 to 212 Washington Street, Suite E Monument, Colorado 80132 PO Box 2942, Monument, CO 80132.
Every attempt is made to ensure accuracy of published materials. Medical Voyce cannot be held responsible for the opinions, facts, or ideas expressed by its authors or contributors. Medical Voyce Magazine – Colorado Edition is availabe in a digital edition at: www.medicalvoyce.com/medical-voyce-magazine
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Cover f e a t u r e
C hildhood Regained BY MARTY BANKS
S ummar y When children with chronic diseases such as asthma and eczema repeatedly fail to respond to treatment, physicians around the country often refer them to the Pediatric Day Program at National Jewish Health, where comprehensive evaluation, extensive education and novel treatments give them a truly new lease on life.
S
ound like asthma, multiple food allergies and eczema to you? If it doesn’t, perhaps it should. Says Dr. Erwin Gelfand, chairman of the department of pediatrics at National Jewish Health in Denver, “The big concern for us is, many people see asthma and eczema as trivial diseases, versus cancer or heart disease. The fact is people die every year of these diseases. And many, many children and their families are suffering with these chronic diseases and illnesses.” At the Pediatric Day Program at National Jewish Health, children and their families receive more than a balm for the chronic issues of their disease. The program literally gives many kids their first chance of living a real childhood.
Team Effort
The program, which treats about 16 pediatric patients at a time, cares for kids with major, chronic allergic and immune-system diseases: asthma, food allergy, eczema and immunodeficiency. It uses a unique team approach to first undertake a comprehensive, thorough evaluation, followed by team-led therapeutic treatments and extensive education. The program serves those children and their families whose management of the disease is no longer working: whether that be a lack of effective outcomes; the number of medicines taken; the safety of the medicines prescribed; too much school absenteeism due to the disease; or a basic sense that the family is suffering under the stress of managing the child’s illness. The children and their families come from across Colorado and the country and frequently stay one to two weeks. They spend their days in the hospital but stay in an outpatient setting such as a hotel, or with relatives at the Ronald McDonald House.
Dr. Erwin Gelfand, M.D., chairman of the department of pediatrics at National Jewish Health in Denver DR. ERWIN GELFAND, MD
Each child has a primary team of an attending physician, an allergy fellow-in-training or physician assistant, and a nurse. Because chronic illness affects the emotional and social well being of everyone in the family, a psychosocial clinician also is part of the team. Gelfand says, “Any disease that’s chronic leaves a scar on the emotional behavior of the entire family.” Other providers who may be consulted include speech therapists, rehabilitation therapists, dieticians, pulmonologists, gastroenterologists and immunologists. “It’s really an integrated team,” says Gelfand. “Unlike most places, all the specialties involved are right here, so we talk to each other on a regular basis. We make rounds together, have our planning sessions together.”
Caring for a child with chronic illness inherently brings significant family stress. Dr. Dan Atkins, head of the division of ambulatory medicine in pediatrics at National Jewish Health and a clinician in the Pediatric Day Program, says that the multidisciplinary nature of the program is one reason for its success. “The child might be seeing an allergist and a gastroenterologist at home, but they’re usually not talking to each other,” he says.
What Is It, Really?
The first order of business for any patient is a thorough, comprehensive evaluation. Gelfand says that some diseases are so complex they masquerade as another disease. For example, the team will often pose the question, which foods is a child truly allergic to, and which foods can be added to his diet? “We have kids who have been taken off foods because of their alleged sensitivities,” says Gelfand. “They actually come in wasting away.” The program administers food challenges
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Dr. Dan Atkins, head of the division of ambulatory medicine in pediatrics at National Jewish Health and a clinician in the Pediatric Day Program DR. DAN ATKINS, MD
Throughout each procedure, a nurse stays with each child, oneon-one. “The nursing staff is superb,” says Gelfand. “They’re with the families eight hours a day, and they’re sort of our conduit with the physical and behavioral needs of the family.”
Family Matters
Caring for a child with chronic illness inherently brings significant family stress. Thus, the day program has psychosocial clinicians who work with each family to identify the sources of stress and explore ways of improvement. The goal is to reduce the overall level of family stress and improve the quality of life as much as possible.
under careful diagnosis and supervision. They often find up to 80 percent of foods can be reintroduced into a child’s diet. This can be the difference between a child who doesn’t eat and one who enjoys pizza and cake at a birthday party.
For the patient, there are a number of interventions such as art and play therapy that help the child cope with feelings and fears. Art therapists, psychologists and social workers are an integral part of the program.
Atkins says other common issues are: not understanding what exacerbates the underlying problem; not taking prescribed
For the whole family, there are group sessions with parents and kids. Says Gelfand, “There’s an ambiance that is very conducive to a cathartic experience.”
Each patient and family learns about treatment, early warning signs, triggers to avoid, medications to take and practical solutions and techniques to use at home. medication or poor technique in administering medications; treatments that are so stressful to the child that the family finds it almost impossible to administer them; or families who hear so many opinions they become “paralyzed by the differences of opinion.”
One-On-One Education
One of the biggest concerns is often financial and how the child’s care affects the family’s resources. Most insurance covers the day program, often at a negotiated rate. However, because of the very time-intensive nature of the program, many things are not reimbursable. Gelfand says the program provides a lot of subsidized care and “we turn nobody away based on their ability to pay.”
Model Day Program
In fact, the Pediatric Day Program was born out of an insurance challenge. About 15 years ago, insurance carriers pushed back on allowing kids to come for what was then extended hospital
Once the disease has been accurately diagnosed, patients and their families receive one-on-one instruction on how to manage the disease and provide optimal treatments, including answers to all the parents’ questions and concerns. Says Atkins, “It’s hard to teach them as much as they need to know in the time allotted to an office visit.” In the day program, for example, a nurse can help an eczema patient who fears getting in the tub due to burning of her skin. Through reassurance and careful, trained supervision of the appropriate bathing process - including hydration of the skin with moisturizers and topical steroid ointments - the child’s skin has usually improved within 24 hours to the point where she can bathe without pain. Gone are the days of the child’s screams and the family’s tension at bath time. Each patient and family learns about treatment, early warning signs, triggers to avoid, medications to take and practical solutions and techniques to use at home.
ART THERAPY HELPS COPE WITH FEELINGS OF FEAR
8 outcomes that we desired,” says Gelfand. The result had an enormous positive-impact on the cost. The team also is involved in research, and new methods are applied within the program. Says Gelfand, “We’ve understood severe asthma based on research that was done here. We’ve looked at eczema and the risk and importance of topical infections.” He says that, for example, about 40 percent of children with eczema have Methicillinresistant Staphylococcus aureus (MRSA), which poses a major challenge because the kids have to be isolated. “So a lot of our interventions have actually come from both the bench and clinical research,” he says.
The Ultimate Outcome stays for what they termed “diseases that are so common.” Says Gelfand, “It was clear that we needed to change the way we approach the treatment of these diseases.” At that time, the staff saw both the frequency and severity of these chronic allergic diseases increasing significantly. Gelfand says that National Jewish was “called on more and more by doctors and parents, but insurance became an issue with an overnight unit.” National Jewish moved to a day program to avoid overnight costs. They created a program where “kids come in the morning and were exposed to the most intensive diagnostic and therapeutic interventions,” says Gelfand. As the program became adept at the day model, length of stays decreased to the current five- to 10-day average. A key component in this was the coordination “with all the team in order to achieve the
Once a stay is over, the team creates a triangle of care between the referring local physician, the family and National Jewish. “It’s a partnership,” says Gelfand. The children emerge into a brave new world. Atkins relates the example of a nine-year-old patient who, upon arrival, was asked what would happen if a school bully rubbed peanut butter on him. The boy’s response was, “I would die.” After evaluation, the team found that not to be the case. They talked him through his fears and true issues, and then rubbed peanut butter on his skin in the safety of the hospital environment. With the burden of fear lifted the boy went home with more than a manageable allergy. “Our expectation,” says Gelfand “is that any child who comes through the door will see such significant improvements in health that he will leave as a different child.”
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Medical Practice m a r k e t i n g
Lord...Give Me More Patients BY TOM WARDA AND DR. ROBERT KOTLER, M.D., FACS
Tom Warda, founder and principle at Colorado Business Partners, LLC. Teams of MBAs, CEOs, COOs, Attorneys and CPAs, provide cost-effective, fixed-priced consulting services to start-up and emerging
S ummar y Tired of throwing your arms up in the air and frustrated with keeping up with the latest most effective practice marketing technologies? So am I! As a small business consultant specializing in medical practices, I have seen it all. I have been involved with every sort of accounting system, scheduling software and “best practices” protocol. Unfortunately most clients suffer from the same issue - not enough revenue because of not enough patients.
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veryone talks about KPI’s (Key Performance Indicators) for measuring the business part of a practice however; very few know the difference between leading and trailing KPI’s. I want to talk about leading KPI’s and in a medical practice that means more patients. Simply put, the more patients I see in a day: the more my overhead is reduced,
companies.
Tom Warda
patients is through a professionally created and managed Social Interactive Marketing Campaign (SIMC) that includes a comprehensive and interactive web presence. A SIMC keeps your office open even when no one is there.
Interactive web presence? What does that even mean? Our research indicates that a professionally created medical practice website should attract on average about 750 visitors per month. Where are all those visitors going? How many of those new visitors actually turn into patients? Statistically around 1.1 percent of all website visitors turn into business. This may seem low but it is still much higher than direct mailing, local advertising or sponsoring your favorite charity or event.
”I have been pleasantly surprised at the volume of website traffic that has been directed into my practice. Most importantly, our patients report satisfaction with their engagement experience. I find butterflyMD.com to be very professional and reliable, it has performed very well, and thus I highly recommend this service.” –Dr. Robert Kotler, M.D., FACS Beverly Hills, CA
the more my staff is utilized, the more equipment is amortized and the more cash flow I create. But best of all I get to help more people.
How do you measure an effective social interactive marketing campaign? And what does that even mean? And what is the best leading metric to use?
The best way to get more patients is to create a positive memorable experience for your current patients. Patient referral to their friends and family members is your easiest way to fill your practice.
That is where conversion rates come into play (the number of website visitors that join your practice). Although a well thought out and professionally executed SIMC can drive them to your website and introduce thousands of people to you and your practice, they don’t turn visitors into patients. So what does?
But what if you already do this and you are still at only a 65 percent capacity? There are new technologies. Our analysis suggest one of the most cost effective ways to acquire new
The fastest way to convert virtual visitors into patronizing patients
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(average for websites) from your 750 visits, your return-oninvestment (ROI) from your website is:
Dr. Robert Kotler, M.D., FACS Beverly Hills, CA Expert on www.WebMD.com and happy client of www.butterflyMD.com Dr. Robert Kotler, MD
is to professionally engage your soon-to-be patients on-line. You can increase the conversion rate from one percent to over seven percent each month by creating a live interaction with an interested visitor and answering their immediate questions leading to a set appointment.
7.5 patients/month x $150/patient/month = $1125 extra per month. Well, that’s not bad but since you have already paid for your website, what if you could increase your conversion rate by utilizing an interactive engagement service (IES)? So, a typical IES service can boost your conversion rate anywhere between five to seven times. Doing the math again with the same number of website visitors: 45 patients/month x $150/patient/month = $5625 extra per month. ($67,500 extra each year)
According to industry experts at Google, GoDaddy and HP, within the next five years virtually every business website will have some form of IES.
An effective IES also solves this industry’s largest problem in maintaining practice quality, which is office staff turnover.
Now you could do this yourself by hiring three receptionist type people (one for each eight hour shift); at about
In selecting the right interactive engagement service for you, make sure that you have references and understand their payment schedules. You can pay a fixed monthly rate, a variable rate based on volume or pay a percentage of whatever revenue the service creates. Also, be certain that they understand your specialties, qualifications and exactly what makes you the perfect fit for your new patients.
$10/ hr or $4800/month, train them, provide internet access, computers and telephones (another $200/month) and supervise them on a 24 hr basis and let them monitor your website - that’s about $5,000 per month. Or you can hire a professional interactive engagement service to inform, guide and create an appointment for your prospective clients and initiate their positive meaningful experience for about 20 percent of that. This is the new way people do business –at home and after business hours.
So, why isn’t everyone doing this? According to industry experts at Google, GoDaddy and HP, within the next five years virtually every business website will have some form of IES.
Invest in yourself and grow your business by utilizing an online interactive engagement service. It is the fastest way to increase your practice revenue.
There are several services to consider, but let’s do the math first. Let’s just assume that you get 750 visits on your website each month, which is an average number for a professional practice. Then let’s also assume that on average you get $150 per visit for twelve months each year. So potentially each new patient can make your practice about $1800 per year. I also want to assume that you are a really good doctor and that every prospective patient you see turns into your patient for many years to come. So currently, if you are getting a one percent response
www.butterflyMD.com We recommend www.butterflyMD.com to all of our clients.
NEUROSCIENCE
ABOUT COLORADO NEUROLOGICAL INSTITUTE
We have been providing research, education and patient services for those dealing with neurological conditions since 1985. As the only nonprofit organization in the Rocky Mountain Region of its kind, we offer programs that benefit physicians, affiliate health care providers, patients, caregivers, and the general public. CNI was originally founded by neurosurgeons at Swedish Medical Center, but now CNI’s unique model serves physicians and patients across the region. Member physicians come from private practices and HealthONE hospitals throughout the area and patients come from all over the nation – and even the world.
www.theCNI.org
MOVEMENT DISORDERS // STROKE // GENERAL NEUROLOGY // NEURO-ONCOLOGY // BRAIN & SPINAL TUMORS // PARKINSON’S DISEAS & BALANCE) // EPILEPSY & SEIZURE DISORDERS // NEURO-VISION // NEUROPSYCHOLOGY // NEUROIMAGING // RADIATION ONCOLOGY NEURO-ONCOLOGY // BRAIN & SPINAL TUMORS // PARKINSON’S DISEASE // HUNTINGTON’S DISEASE // ESSENTIAL TREMOR // HEAD P
For Health Care Professionals
As a member of CNI, you will benefit from:
RESEARCH
EDUCATION
PATIENT SERVICES
Conduct research without the bureaucracy of an academic institution. CNI offers:
Your CNI membership offers you many opportunities to:
Your patients have access to numerous programs, such as:
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Network and learn with the neuroscience community of the Rockies.
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Integrated care across all specialties and a robust referral network.
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Attend conferences & lectures including grand neuro rounds, brain & spinal tumor conferences, web conferences, stroke summits, epilepsy lectures, and more.
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Monthly support groups for nearly all neuro disease lines.
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Earn continuing education credit while networking with professionals across the region.
Quality outpatient neurobased rehab including services for uninsured and underserved patients.
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Patient navigation: access to community resources, help with forms, counseling services, etc.
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Patient assistance funds.
•
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Support for core research functions: study coordination, fi nancial oversight, risk management, federal grant administration (pre- and post-award), contract negotiation, feasibility and ethics review, clinical trial tracking, outcome data collection, regulatory compliance, investigator development, and training.
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Writing support: Support with writing proposals, seeking publication and preparation of conference presentations.
START ENJOYING MEMBER BENEFITS. Call 303-788-4010 to join. Memberships now open to all neuroscientists, physicians and affiliate health care staff within the HealthONE system, and/or those involved with current CNI programs & services
For Persons with Neurological Conditions We offer comprehensive, integrated, cutting-edge treatment programs. If you or someone you love is suffering from a neurological condition, call CNI today at 303-788-4010. CNI’S PATIENT SERVICES
• •
Access to internationally recognized physicians and health care providers Programs, activities and integrated care for every neurological condition
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Clinical trials
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•
Support groups
• •
Chronic disease management courses
Outpatient neuro-rehab (speech, occupational and physical therapy) Counseling
Patient assistance funds
PATIENTS: For more information, call 303-788-4010.
SEASE // HUNTINGTON’S DISEASE // ESSENTIAL TREMOR // HEAD PAIN // SLEEP DISORDERS // MULTIPLE SCLEROSIS // NEURO-OTOL OGY // STEREOTACTIC RADIOSURGERY (GAMMA KNIFE) // VASCULAR MALFORMATION // MOVEMENT DISORDERS // STROKE // GENERA AD PAIN // SLEEP DISORDERS // MULTIPLE SCLEROSIS // NEURO-OTOLOGY (HEARING & BALANCE) // EPILEPSY & SEIZURE DISORDERS //
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B e h av i o r a l H e a lt h news
CORHIO Issues New Report on Behavioral Health Integration S ummar y Nearly 90-percent of stakeholders surveyed believe behavioral health should be considered a part of a person’s overall health care. Reason: “Not enough patients.”
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s a measure to improve integration of behavioral and physical health, the Colorado Regional Health Information Organization (CORHIO) partnered with a multistakeholder behavioral health Steering Committee and solicited feedback from communities across Colorado to create a report with recommendations and future strategies for effective inclusion of behavioral health in health information exchange (HIE). The report was written as part of the CORHIO Behavioral Health Information Exchange Project with support from Rose Community Foundation. The report is now available on the CORHIO website at www.corhio.org. “Unfortunately, there is still a stigma associated with mental health conditions and some people fear that their diagnosis may fall into the wrong hands and will be used against them,” says Amanda Kearney-Smith, director of the Colorado Mental Wellness Network and member of the project’s Steering Committee. “We have to be sure to strike a careful balance between protecting individual privacy with the need to have comprehensive information available for high-quality health care treatment and services.” To solicit information for the report, CORHIO helped facilitate six meetings in communities across Colorado, which were chosen to represent a broad cross-section of perspectives and attitudes regarding HIE. A total of 124 consumers, physicians, and other behavioral health stakeholders were in attendance to discuss the concerns, opportunities and priorities of exchanging behavioral health information. The meetings took place in collaboration with community mental health centers and other behavioral health community organizations, so participants could feel comfortable and have open and honest dialogue. A few key points that came out of the community discussions include:
• Consumers expressed significant interest in having access to their health information within the HIE. • Both physicians and patients expressed significant concerns, such as privacy issues and inappropriate use of information. • Behavioral health stakeholders agree that better information sharing can lead to better outcomes for individuals and populations receiving behavioral health care. • Participants expressed they would have more comfort with information sharing if there were more choice about which information would be shared with whom. Current models of all-in or all-out information sharing do not seem to meet the needs of this community. • Across all six events, only one participant felt that better information sharing was not needed.
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B e h av i o r a l H e a lt h news Studies have shown that the average life expectancy for those with serious mental illness ranges from 13 to 30 years less than the rest of the population.1 Much of this can be attributed to fragmented, inconsistent, and episodic care. Individuals requiring behavioral health services have a unique need for integrated care due to frequent use of the healthcare system and a greater need to coordinate care among diverse providers. However, today, behavioral health care services are not well integrated with physical or medical care. According to the CORHIO report, nearly 90 percent of participants surveyed agree that behavioral health should be considered a part of a person’s overall health care. “HIE is an invaluable tool for the behavioral health community because it enables information to truly follow consumers through the entire treatment path, across a variety of care settings. It provides immediate access to vital patient information, which reduces the chance that a consumer will experience a drug interaction or other medical complication and improves the overall consumer experience as they navigate the health care system,” said CORHIO Policy Director, Liza Fox-Wylie. “CORHIO remains committed to working with the behavioral health and physical health communities to
“Unfortunately, there is still a stigma associated with mental health conditions” improve care coordination and population health outcomes through HIE, while protecting patients’ rights to privacy.” CORHIO is developing an action plan based on the results and recommendations in this report, including working with project Steering Committee members and other stakeholder organizations on consumer, provider and policymaker education and working with CORHIO’s technology partner, Medicity, to improve the robustness of HIE technology to support more granular options for patient choice regarding which information is shared with whom. In September 2010, the Rose Community Foundation awarded CORHIO a two-year grant
to support the Behavioral Health and Health Information Exchange Project, which funded the creation of CORHIO’s behavioral health report. “Individuals’ physical health, mental health and substance use are closely intertwined,” said Whitney Connor, Rose Community Foundation’s health program officer. “Provider access to timely information about their patients’ medical and behavioral health is critical to delivering effective care.” Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis [serial online] 2006 Apr. URL: http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm .
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M e d i c a l V oyc e news
PENRAD Imaging Expanding its Line of Service
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RI exams have become one of the fastest growing types of medical diagnostic tests in the United States. This is due in large part to its ability to provide noninvasive diagnostic images of soft tissues, bone, fat and muscles and to help in the detection and diagnosis of a variety of health conditions, including orthopedic injuries, breast cancer, neurological disorders and cardiac diseases.
PENRAD Imaging is expanding its line of service by introducing two 3T open bore Magnetic Resonance Imaging systems. PENRAD’s new MAGNETOM Skyras from Siemens Healthcare has the most powerful magnet commercially available—3 Tesla—and a 70 cm Open Bore design. In the past, MRI exams have not always been comfortable for or well-tolerated by certain patient groups, including
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Dr. Derek Bergeson, MD, received his fellowship in MR and Body Imaging at Northwestern University Medical School and has been instrumental in advising and securing the MAGNETOM 3T Skyras. Dr. Derek Bergeson MD
the elderly, obese individuals or those who experience claustrophobia, excessive pain or limited mobility. This is due to the relatively small doughnut-like opening where the patient lies, called the bore, and the long tube-like structure of the machine, which can feel confining. However, the MAGNETOM Skyra’s large 70cm open bore, along with its short length (173 cm), can help reduce patients’ anxiety and help put them at ease. The Skyra can accommodate patients weighing up to 550 pounds and has the ability to allow patients to enter feet first. This allows the option of leaving the head outside the magnet, enhancing patient comfort and minimizing claustrophobia and anxiety.
“This new equipment gives PENRAD Imaging one of the most cutting-edge pieces of MRI equipment on the market today” –Dr. Derek Bergeson, MD Derek Bergeson, MD, has been with PENRAD Imaging since 2007. Dr. Bergeson received his fellowship in MR and Body Imaging at Northwestern University Medical School and has been instrumental in advising and securing the MAGNETOM 3T Skyras. “We are excited to introduce the 3T. We feel this system will allow our referring providers to have one of the widest ranges of imaging capabilities while being able to cater those services to patients in almost any situation.” The 3T MRI boasts the strongest magnet field strength used clinically today and gives access to many applications, including neurology and functional neurology evaluation, orthopedic and cartilage assessment, as well as other general MR applications. The three-tesla field strength allows acquisition of higher quality images, as well as shorter exam times in most patients.
The 3T MRI has up to 102 integrated coil elements and up to 48 independent radiofrequency channels, which allow flexible coil combinations that make patient and coil repositioning virtually unnecessary. “This new equipment gives PENRAD Imaging one of the most cutting-edge pieces of MRI equipment on the market today,” says Dr. Bergeson. “This system has a magnet that functions at the highest clinically-used field strengths and allows us to deliver one of the most comfortable imaging experiences to our patients. Your patients will be comfortable in our Skyra—you’ll be delighted with the image quality.”
PENRAD Imaging is Southern Colorado’s leader in freestanding radiology accredited by the American College of Radiology with four locations in Colorado Springs and Monument. PENRAD is comprised of seventeen board-certified radiologists expert in a full range of specialties and modalities. PENRAD anticipated go-live date to begin receiving patients for the 3T MR Sykra will be late summer / early fall of 2012.
PENRAD Locations Audubon Medical Campus 3050 N. Circle Drive Colorado Springs, CO 80909 719.785.9000 Monument Radiology 550 Hwy. 105 Suite 101 Monument, CO 80132 Walk-in X-Rays Only 719.488.9872 MRI Nevada 2202 N. Nevada Colorado Springs, CO 80907 719.785.9000 Sisters Grove Pavilion 6011 E. Woodmen Rd #10 Colorado Springs, CO 80923 719.785.9000
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Humor
in
health care
You Just Have to Laugh ® BY DAVID NASTER
S ummar y The following are from David’s international awardwinning book, You Just Have to Laugh, When Work Gets Tough. David’s specialty is finding humor in the tough stuff of life. Regarded by medical and behavioral experts as a thought leader on the subject of the therapeutic benefits of humor and laughter, David has coached tens of thousands of folks to learn to spot the opportunity to insert levity in otherwise tough situations.
“Hello, My Name Is”
An airline canceled a flight. The ticket counter agent had to handle a long line of irritated people by herself. A middleaged man pushed up to the front of the line, slapped his ticket on the counter and yelled, “I demand to be on the next flight and it better be in first class!” The agent said politely, “I’m sorry sir, I’ll be happy to help, but these folks were in line first. As soon as I take care of them, I’ll be glad to help you.” The man yelled back loud enough for everyone to hear,
David Naster, International Comedian and Award-nominated Documentary Film Producer, You Just Have to Laugh® DAVID NASTER
“Do you know who I am?” The ticket agent took the microphone and calmly announced: “Attention please. We have a lost man. He doesn’t know who he is. If anyone can identify him, please come to the counter.” The people in line laughed. The man gritted his teeth. “Screw you lady!” he said. “I’m sorry sir, but you’ll have to wait in line for that too,” she replied.
“Head Start”
Phyllis: I’m a breast cancer survivor. After my mastectomy, I wore [a breast] prosthesis and was determined to live with it. One night, my husband and I were getting ready for bed. I whipped out my fake boob and said, “Here honey, get a head start.” To see excerpts from the award-nominated documentary film, You Just Have to Laugh, go to www.naster.com. Got stories you want to share? Send to info@medicalvoyce.com - Your story could find its way into David’s next series!
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M e d i c a l V oyc e news
Springs’ Community Health Partnership to Participate in TBD
C
arol Bruce-Fritz, Executive Director of Community Health Partnership (CHP), has been selected to participate in two TBD Colorado regional meeting groups. Carol will participate in discussions and activities that identify priorities, drive consensus, and consider outcomes. We are excited that CHP will have a voice in this important conversation. TBD Colorado is a nonpartisan, collaborative effort designed to create informed and constructive conversations among Coloradans about some of the biggest issues facing Colorado. TBD is an acronym for “To Be Determined”, which truly captures the intended outcome of this effort – it’s to be determined.
Carol Bruce-Fritz is the Executive Director of Community Health Partnership CAROL BRUCE-FRITZ
consideration of public policy issues; determine policy outcomes, based on broadly-shared perspectives on the future and not by short-term political agendas or ideological conflicts; and promote widespread public participation that includes an array of interests (geographically, culturally, professionally, and age) in determining what Colorado will look like in the future.
A final written report will be shared with the Governor, the General Assembly and other state leaders that will offer both quantifiable and qualitative public policy recommendations for improving Coloradan’s quality of life. Recommendations may include specific actions, opinions, and innovative ideas on topics such as: • Managing limited resources with increasing demands for service • Advice on local and state-wide regulatory policies • How to approach potential revenue increases, including strategies that do not contemplate increasing taxes (e.g., savings from CNG vehicles, increasing support for K-12 education to ensure every school district operates five days a week, increasing use of regional transportation planning, etc.). • Policy considerations, such as improving the health of Coloradans, reduction in State services with minimal impact, etc. • Cost savings through privatization, consolidation of facilities or services, and/or public, private, and non-profit partnerships Specific goals of the multi-region summits are to develop pragmatic, realistic solutions and consensus on big issues facing Colorado; develop a credible, enduring mechanism for non-partisan deliberation and
Robert Nathan, MD
Diplomat of the American Board of Allergy and Immunology Clinical Professor of Medicine Board of Directors, American Academy of Allergy, Asthma and Immunology President, Joint Council of Allergy, Asthma and Immunology
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Daniel Soteres, MD, MPH
Board Certified Asthma, Allergy & Immunology Award-‐Winner, American Federation of Medical Research
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Staff Debra Walters, ANP-‐C Jamie A. Allen, PA-‐C
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Leadership
in
h e a lt h c a r e
Managing Conflict With Peers
BY TALULA CARTWRIGHT, PH.D. | SENIOR PROGRAM ASSOCIATE
S ummar y The following material is used with permission in association with Medical Voyce’s strategic partnership with the Center for Creative Leadership, headquartered in Greensboro, North Carolina. This feature is one of dozens of “Ideas Into Action Guidebooks,” which you can find on their Website at www.ccl.org.
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great many peer conflicts arise from incompatible goals or from different views of how a task should be accomplished. With honest dialog, these kinds of conflicts can usually be resolved. But other peer conflicts are more troublesome because they involve personal values, office politics and power, and emotional reactions. Navigating these issues won’t rid an organization of conflict, among
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Positively express emotions: Watch out for your hot buttons. Be sure that your expression of emotions is helpful to the process. Explain how you feel and why. Choose your words carefully. Keep them courteous and professional. Don’t cast blame. Express your desire to understand. Ask if the other person understands your feelings. Admit responsibility for your part of the conflict. Ask what you can do to make amends. If you have caused emotional distress, sincerely apologize and mean it.
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Reach out and touch someone: Think about how you want to be viewed after the conflict is over. Follow up with the person with whom you were in conflict. Take (or make) the opportunity to talk informally with your peers outside of work projects – meet them for lunch, acknowledge birthdays and ask about their interests.
“Admit responsibility for your part of the conflict. Ask what you can do to make amends. If you have caused emotional distress, sincerely apologize and mean it. peers. But by paying attention to them, managers can build effective relationships that will survive these inevitable conflicts and bolster their ability to achieve organizational goals.
Six Paths to Managing Conflicts with Peers
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Take a walk in your peers’ shoes: Try to understand their point of view, motivation and reaction to the conflict. As for examples to clarify their issues, rephrase, restate or summarize what you think has been said. Focus on the other person’s words and behavior rather than your own assumptions. Examine the flaws in your position.
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Create a solution together: Identify each other’s motives, goals, and agendas. Look for points of mutual agreement and interdependence. Begin with less complicated issues and work toward resolving more difficult ones. Together, suggest possible solutions without evaluating them and then narrow the choices to the best two or three. Select a solution or combination of solutions that best meets each person’s needs.
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Reflect and understand: Note your initial reaction to a conflict and analyze why you had that reaction. Consider the impact of differences in style and opinions between you and your peers. Review alternative reactions and the pros and cons of each. Solicit input from other parties (if appropriate) and allow them to raise issues. Organize your thoughts and strategies. Give your peer time to reflect. Remind yourself that a delay in responding isn’t the same as avoiding or ignoring the conflict.
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Go with the flow: Look forward, not back. Find the best in people and in the situation. Always look toward adapting and accepting. Communicate optimism. Seek out sympathetic co-workers or friends with your need to “unload” or need a pep talk. If opportunities to reconcile or resolve the conflict fail, keep trying. Stay professional in your attitude, words, and behavior. Avoid sarcasm and cynicism, and keep a sense of humor!
To order the entire 31-page Guidebook and other Guidebooks, go to www.ccl.org/guidebooks and order your copy today!
El Paso County Medical Society By Mike Ware, EPCMS Executive Vice President Taking over for a championship-caliber quarterback is never easy, though that’s the experience I am fortunate to find myself in. For thirty-four years, Carol Walker led the El Paso County Medical Society in contributing to its over 100 years of success, and now I’ve taken the ball and will keep moving our organization down the field.
Our physicians are community focused
Health care is changing: electronic health records are more prevalent; Medicare and insurer payments haven’t kept pace with the cost of practicing medicine, putting more and more pressure on practices; the pace of new state and federal regulations is forcing physicians to spend more time on paperwork and less time doing what they do best, treating patients. And one thing has stayed the same - trial lawyers want to weaken our tort reforms.
You are served by a dedicated and innovative Board and staff
Since my family and I moved here three months ago, I’ve spent a lot of time talking with our members and staff, reading reports, meeting with community leaders, and generally trying to learn all that is the El Paso County Medical Society. What have I learned?
Physicians worldwide care about their community, but it’s very evident here. There is a willingness to move beyond the needs of each physician’s practice, and focus on how to improve the health care system in our community. Most communities talk about it, but we’ve made it happen.
They are passionate, focused, forward thinking, and, most of all, committed to building an amazing health care community in the Pikes Peak region. El Paso County Medical Society is strong and vibrant, and the only way to remain so is to stay ahead of the changing health care environment. We must anticipate our members’ future needs, while still meeting their current ones. This takes courage. It takes leadership. And it takes a commitment to sustained effectiveness that few organizations have.
For example, General Motors watched as the American auto industry changed around it. In spite of overwhelming I’ve worked with over one hundred county medical socie- evidence that more and more Americans no longer ties during my eleven years advocating for physicians. wanted GM cars, it kept making the same cars, using the There is a collaborative ethos here that I’ve seen in few same commercials, and ignoring the same evidence. It other places. Of all the communities I’ve worked with, this was a textbook case of Freudian insanity. Without a fedis the only one where I’ve seen all the major health care eral bailout, who knows what would have happened to the players in the same company. room and not fight. In most communities, Like the US auto industry, our industry is changing. EnEPCMS is the voice of these groups would suring El Paso County Medical Society never faces a simiprofessional medicine in be maneuvering lar situation takes leadership. And that leadership will El Paso & Teller Counties. against each other. show over the coming months as we launch additional Here, they are fomember benefits and find better ways to serve you. If your practice would cused on building a benefit from greater visistronger health care I’ve learned a lot in three months, more than I can outbility in our area, call community. Instead line here, and I’ll keep learning. What I’ve found so far, of fighting over their however, shows an organization – both physicians and 719.591.8723 corner of the sandand ask about staff – that is committed to our community, focused on box, they’re building serving our members, and driven to make the Pikes Peak Associate Membership. a better one. region a great place to practice medicine.
We have a unique, collaborative culture
Medical Voyce is a print media sponsor of EPCMSnews and publishes this excerpt free of charge so that the Colorado medical community may receive relevant information and resources in one convenient publication. The El Paso County Medical Society is solely responsible for the subject matter included in its newsletter, and is not responsible for the content of articles found in other sections of Medical Voyce. Neither the EPCMSnews nor Medical Voyce is responsible for the opinions expressed or facts presented by the authors of articles.
El Paso County Medical Society 730 Citadel Drive East, #206 Colorado Springs, CO 80909 www.epcms.org 719.591.2424
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Clinical Guidelines: d i a b e t e s
Revised Diabetes Guideline Focuses on Type 2 S ummar y HealthTeamWorks has revised its clinical diabetes guideline to give providers a new screening algorithm, updated medication information and new tools for patients. Users familiar with the previous version, released in 2006, will first notice the new title: Guideline for Type 2 Diabetes. We make the distinction between Type 1 diabetes, which usually requires care by an endocrinologist, and the acquired form, which usually falls under the purview of primary care.
The revised guideline features: • • • • • • •
A message noting that type 2 diabetes can be prevented or delayed by a healthy diet, an active lifestyle and a healthy body weight; A new algorithm to screen for type 2 diabetes; A recommendation to assess medication adherence, glucose control/hypoglycemia, and alcohol and drug use; A new glucose management algorithm; A flow sheet indicating what needs to be done for the patient at every visit, quarterly and annually; A patient handout and action plan; and A medication chart.
“The new guideline allows the clinician to determine, ‘How much do I need to get the HgA1c* down, and what’s going to be the
HealthTeamWorks is mailing the revised guideline to more than 7,500 healthcare providers across Colorado. All HealthTeamWorks’ clinical guidelines and supplements are available for free download. If you have questions about the guidelines or would like laminated copies, contact HealthTeamWorks at 303-446-7200 or e-mail egingerich@healthteamworks.org
Diabetes affects 8.3 percent of Americans — nearly 26 million people.1 Almost 19 million new cases are diagnosed each year, but another 7 million go undiagnosed.2 Diabetes is the leading reason for kidney failure, nontraumatic lower-limb amputations and new cases of blindness among adults, as well as a major cause of heart disease and stroke. It’s the seventh leading cause of death in this country. In adults, type 2 diabetes accounts for about 90 percent to 95 percent of all diagnosed cases. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce it. Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity and ethnicity. African Americans, Hispanics, American Indians, and some Asian Americans and
“If you can decrease HgA1c by 1 percent, you reduce the risk of [diabetic] complications by 40 percent.” best [therapeutic] agent?’” says Stephanie Bacon, MS, RD, PA-C. She and Rocio Pereira, MD, chaired the guideline revision committee. Other members included two public health officials, seven physicians, two midlevel providers, a doctor of pharmacy, an optometrist and HealthTeamWorks Guidelines staff. The committee revised the guideline using evidence from the American Diabetes Association, the U.S. Preventive Services Taskforce and the American College of Endocrinology. Funding came from The Colorado Health Foundation.
Pacific Islanders are at particularly high risk for type 2 diabetes and its complications.3 The incidence of type 2 diabetes mirrors the incidence of obesity among Americans. From 1980-2009, the number of Americans with diabetes has more than tripled, from 5.6 million to 19.7 million. 4 If the trend is not reversed, one in three Americans will have diabetes by 2050. 5
23 “Preventing a patient from becoming diabetic is much better than treating it after the fact,” Bacon says. “If you can decrease HgA1c by 1 percent, you reduce the risk of [diabetic] complications by 40 percent.” HealthTeamWorks is mailing laminated copies of the revised diabetes guideline to 5,210 clinicians across Colorado. It’s also available for free download at http://healthteamworks-media.precis5.com/7b 1ce3d73b70f1a7246e7b76a35fb552; http://healthteamworksmedia.precis5.com/c6335734dbc0b1ded766421cfc611750 on our website. If you have questions about the guideline, please contact Emily Gingerich. *Hemoglobin A1c: test that shows the average amount of sugar in the blood over three months — an indicator of diabetes control.
sources
1. National Diabetes Information Clearinghouse, a service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. 2011. www.diabetes.niddk. nih.gov/dm/pubs/statistics/#fast 2. Ibid. 3. Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet. www.cdc. gov/diabetes/pubs/general11.htm 4. Centers for Disease Control and Prevention. Diabetes Data and Trends. www.cdc.gov/ diabetes/statistics/prev/national/figpersons.htm 5. American Diabetes Association. Diabetes basics. www.diabetes.org/diabetes-basics/
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H e a lt h C a r e p o l i c y
The Constitutionality of the Individual Mandate ROBERT SEMRO
F
rom the beginning, there was little doubt that one of the Affordable Care Act’s most important provisions would end up in the Supreme Court. That section of the law, known as the “minimum coverage provision,” or “individual mandate,” would require most American citizens and legal residents to purchase a minimum level of health insurance coverage from a private insurer or pay a tax penalty. After previous and conflicting appellate court rulings, the court agreed to review the law, and on March 26-28, the justices heard oral arguments on the mandate and other provisions of the ACA. While not a solid predictor of the court’s final ruling in June, the conservative justices did appear to be skeptical about the mandate’s constitutionality. If the mandate alone is ruled unconstitutional, it may not be possible for some of the most popular provisions of the ACA to be successfully implemented. Those provisions would most likely include guaranteed issue of coverage (which would prevent insurers from using health status as a condition for not offering coverage) and community rating (where insurers would have to offer coverage at the same price to everyone without medical underwriting and without regard to health status). Even though alternatives to the mandate exist, it is unlikely that the current Congress would agree to implement them in order to rescue the law. If the entire law is ruled to be unconstitutional because the court considers the mandate to be unseverable from the rest of the law, then health care reform would return to square one. The argument over the constitutionality of the individual mandate centered on whether the decision not to purchase health insurance is a form of commercial activity that can be regulated by Congress under the Constitution’s Commerce Clause and whether the minimum-coverage provision is constitutional in its own right. Opponents of the mandate argued that the provision is an inappropriate use of Congress’ commerce power, because for the first time, Congress would attempt to compel American citizens to purchase a private product that they may not wish to purchase, may never have purchased in the past and may never use. The decision not to purchase health
Robert Semro is a health policy analyst at the Bell Policy Center. The Bell Policy Center believes Colorado should be a state of opportunity. ROBERT SEMRO
insurance, they maintained, would constitute economic or commercial “inactivity,” which is not related to interstate commerce and therefore, is not subject to regulation under the Commerce Clause.
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Opponents also argued that, should the individual mandate be allowed to stand, there would be no limiting legal principle to prevent the unchecked expansion of Commerce Clause powers in the future. If the mandate were ruled constitutional and Americans were required to purchase health insurance from a private company there would be no legal barrier to preventing lawmakers from compelling the purchase of other products from private industry in other markets. Finally, as a regulatory solution, the provision is constitutionally suspect because it would require people to purchase private insurance and maintain that coverage for the remainder of their lives. All of this would be done without considering whether these individuals are able to pay for the cost of their health care or have sought those services either now or in the future.
Supporters of the mandate argued that the minimumcoverage provision is a proper use of congressional authority granted under the Commerce Clause. They questioned the argument that individuals will never purchase or need health insurance or engage in economic activity regarding the health care market. They maintained that unlike every other commercial market it is virtually certain that at some point, an individual will become actively engaged in the health care market. Individuals cannot guarantee that they will not become sick. Without insurance, individuals cannot guarantee that they will be able to completely pay for their treatment. And unlike commerce in other markets, hospitals cannot refuse service based upon an individual’s ability to pay. The real issue is how and when individuals will consume and pay for those services and not whether they will consume them.
“Supporters of the mandate argued that the minimum-coverage provision is a proper use of congressional authority granted under the Commerce Clause.�
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H e a lt h C a r e policy Furthermore, people are not just “sitting alone in their homes and doing nothing” when they make the decision to self-insure. In aggregate, the decision to self-insure is a decision about how to manage future financial risk and is in itself an active economic decision. The decision to self-insure or purchase insurance represents two alternatives for addressing the same financial risk. One decision is no less “active” than the other one, and each directly involves commerce. In 2008, the uninsured were unable to pay for about 63 percent of the cost
and constitutional solution that redesigns the market and the individual’s interaction with it in a way that is compatible with existing case law and precedent. Finally, supporters argued that the mandate does not represent a slippery slope to unchecked federal authority because existing Commerce Clause case law directly limits how those powers can be used. In addition, the health care market is so uniquely one of a kind – in that everyone
“Even though alternatives to the mandate exist, it is unlikely that the current Congress would agree to implement them in order to rescue the law.” of their treatment, leaving some $43 billion in uncompensated costs that were passed on to insurers, which in turn were passed on to their customers. The mandate represents a constitutional solution because it focuses on stabilizing the entire health care market and not merely regulating individual conduct. It resolves an otherwise intractable problem in the current health care market in which the uninsured inflict disproportionate harm on the rest of the market because of their inevitable consumption of health care services. Congress merely applied an inventive
will use health care; hospital emergency rooms must treat patients regardless of their ability to pay; uncompensated care costs are shifted on to others; and health insurance is by far the most common way to pay for health services – that the mandate could be restricted to that market alone. Regardless of which argument holds sway, the results of the Supreme Court’s decision will forever affect health care in America and define the scope of federal authority in the future.