MN Healthcare News September 2016

September 2016 • Vol 14 Number 9

Prediabetes

By Houa Vue-Her, PhD, RD, and Katelyn Engel, MPH, RD, LD

Complications of type 2 diabetes

By Elizabeth R. Seaquist, MD

Treating styes

By Tina McCarty, OD, FAAO

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CONTENTS

SEPTEMBER 2016 • Volume 14 • No. 9

MINNESOTA HEALTH CARE ROUNDTABLE

7

FORTY-SIXTH SESSION

4

NEWS

8

PERSPECTIVE The sexual health of Minnesota’s youth Pregnancies down, diseases up

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PEOPLE

Value - Based Reimbursement:

10 QUESTIONS Autoimmune diseases An interview with Paul H. Waytz, MD

A new way to pay for health care

Jill Farris, MPH

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SPECIAL FOCUS: CHRONIC DISEASE Prediabetes Act now to protect your health

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Complications of type 2 diabetes Reducing your risk

By Elizabeth R. Seaquist, MD

By Houa Vue-Her, PhD, RD, and Katelyn Engel, MPH, RD, LD

CALENDAR

SPECIAL FOCUS: CHRONIC DISEASE

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS Recognizing excellence

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EYE CARE Styes Treat quickly to avoid complications

MMXVI

By Tina M. McCarty, OD, FAAO

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Thursday, 2016 • • 1:00-4:00 1:00-4:00 PM PM Thursday, November November 3, 3, 2016

The Minneapolis Hilton Hilton and and Towers Towers The Gallery Gallery (lobby (lobby level), level), Downtown Downtown Minneapolis Background driven by by federal federal health health care care reform reform Background and and Focus: Focus: As As initiatives initiatives driven move forward, the term “Value-Based Reimbursement” (VBR) is being move forward, the term “Value-Based Reimbursement” (VBR) is being applied But what what does does this this mean? mean? CMS CMS is is applied to to aa wide wide spectrum spectrum of of issues. issues. But developing to date, date, to to define define what what “value” “value” developing measurements, measurements, well well over over 150 150 to means these metrics metrics will will be be used used to to means in in health health care. care. ItIt is is proposed proposed that that these create care in in every every element element of of health health create incentives incentives that that pay pay more more for for better better care care home care, care, and and long-term long-term care delivery. delivery. Hospitals, Hospitals, physician physician practices, practices, home care new math. math. care will will all all be be reimbursed reimbursed by by an an emerging emerging new

Objectives: We will explore the motivations behind this changing Objectives: We will explore the motivations behind this changing approach to purchasing health care. We will examine what is being approach to purchasing health care. We will examine what is being measured and what value really means. We will discuss the arguments measured and what value really means. We will discuss the arguments that claim VBR is a bad idea and those that believe it is the best solution. that claim VBR is a bad idea and those that believe it is the best solution.

We will discuss how a collaborative, transparent system, that integrates We will discuss how a collaborative, transparent system, that integrates care teams, health information technology and improved reimbursement care teams, health information technology and improved reimbursement methods will help achieve increased access to high-quality, cost-effective methods will help achieve increased access to high-quality, cost-effective care for patients. care for patients.

Panelists include: • Don Flott, Director of Utilization and Integration Panelists include: • Don Flott, Director of Utilization and Integration Services, Mayo Medical Laboratories • Allison LaValley, MBA, Executive Services,athenahealth Mayo Medical Allison LaValley, Executive Director, • Laboratories David Melloh,• JD, Chair, Health MBA, Law Practice Director, • DavidLLP Melloh, Chair, Health Practice • RossJD, D’Emanuele, JD,Law Co-Chair, Group at athenahealth Lindquist & Vennum • Ross JD,Lisa Co-Chair, Group Care at Lindquist & Group VennumatLLP Health Industry Dorsey & D’Emanuele, Whitney LLP • Simm, MBA, Health Care Industry Group at Dorsey & Whitney LLP • Lisa Simm, MBA, Manager of Risk Management, Coverys Manager of Risk Management, Coverys Sponsors include: • athenahealth • Lindquist & Vennum LLP include:Laboratories • athenahealth • Lindquist & Vennum LLP & Whitney LLP • Coverys •Sponsors Mayo Medical • Dorsey • Mayo Medical Laboratories • Dorsey & Whitney LLP • Coverys

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SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

3

NEWS

Work Begins on Affordable Housing for Veterans Construction has begun on a $14.3 million affordable housing community for veterans on a site near the Minneapolis VA Health Care System.

Interagency Council on Homeless“Our shared goal and guiding ness. “We are honored to join with principles with our new partnerso many partners to help end veteran ship are to offer a local, ‘destination cancer and infusion center’ to meet and chronic homelessness.” the needs of the patients and comThe project is funded by public munities we jointly serve,” said Miand private partners, including $7.7 chael Phelps, chief operating officer million in deferred loan funds from of Ridgeview Medical Center. “The Minnesota Housing and $5.2 million new Minnesota Oncology & Ridfrom UnitedHealth Group through a geview Cancer & Infusion Center partnership with Minnesota Equiwill help our patients have the best ty Fund (MEF), a subsidiary of the quality of life possible through the Greater Minnesota Housing Fund, common clinical pathways, comusing low-income housing credits. bined medical records, access to Veterans East is expected to be additional clinic research, enhanced completed next summer. patient navigation and support services, as well as expanded cancer rehabilitation via Ridgeview’s STAR program (Survivorship Training and Rehabilitation).”

The project, called Veterans East, is a five-story, 100-unit efficiency apartment community that will provide permanent supportive housing for veterans struggling with homelessness. It will also provide onsite services to assist residents with health care, case management, life skills, financial management, benefits assistance, education, and employment resources through partnerships with the Veterans Administration, the Community Housing Development Ridgeview Medical Center and Corporation, BDC Management Minnesota Oncology have entered Company, and Hennepin County. into a partnership to form a consol“This new community will be idated oncology services program. a model for providing permanent The Minnesota Oncology & Ridhousing and services for military geview Cancer & Infusion Center veterans,” said Mary Tingerthal, will be located in two current MinMinnesota housing commission- nesota Oncology locations in Chaska er and co-chair of the Minnesota and Waconia.

Ridgeview, Minnesota Oncology Partner on Cancer Center

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

Minnesota Eye Consultants to Expand in Woodbury

Minnesota Eye Consultants has finalized plans to open a new Woodbury office location in summer 2017.

The new location will combine and expand Minnesota Eye Consultants’ two smaller locations in Maplewood Ridgeview will close its hemaand Falcon Heights. tology/oncology outpatient clinics in The 41,000 square foot medical Chaska and Waconia on Sept. 1 when office building will include a clinic the partnership goes into effect, but and surgery center. will continue to provide infusion therapy services in its Waconia hos“With the growing demand for pital for inpatients within the hospi- high quality medical care on the tal and patients needing after hours east side, and our own space limitaor emergency infusion services. tions, the move to Woodbury made “We are fully committed to sense for us and we feel fortunate providing our patients with the to become part of the Woodbury

TBD

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best possible care and access to the services they need,” said Phelps.

“Though the clinic location at which our hematology/oncology and specialty infusion patients receive care will change, we are working closely with our Minnesota Oncology partner to ensure a smooth transition.”

community,” said William Lipham, MD, oculoplastic subspecialist and current managing partner at Minnesota Eye Consultants.

Smoke-Free Policies in Public Housing Reduce Secondhand Exposure

MDH to Lead Region in National Plan to Combat Antibiotic Resistance The Centers for Disease Control and Prevention (CDC) has named the Minnesota Department of Health’s (MDH) Public Health Laboratory as one of seven new regional laboratories that will form the new national Antibiotic Resistance Laboratory Network. The network is being created in response to President Obama’s call for a national action plan to combat antibiotic resistant bacteria.

The Minnesota Department of Health’s Office of Statewide Health Improvement Initiatives (SHIP) has conducted a study showing that smoke-free policies at public housing properties reduce secondhand smoke exposure for nonsmokers and “It is an honor for our state’s motivate residents who do smoke to public health laboratory to be chosmoke less or even quit. sen as a regional lab for this effort,” For the study, eight public hous- said Ed Ehlinger, MD, Minnesota ing properties implemented smoke- commissioner of health. “It speaks free policy changes through SHIP. to the great skill of our laboratory The locations, a mix of urban and staff and the work they have done rural properties, prohibited smoking over the years.” in all indoor areas and three propThe regional laboratory locaerties prohibited smoking on all tions were selected in part based outdoor grounds. Once the policies on past performance and quality of were implemented, there was a 46 work. They will track changes in percent decrease in frequent indoor antibiotic resistance and help idensecondhand smoke exposure among tify outbreaks by providing techninonsmokers as the percentage of rescal support to other local and state idents reporting exposure to secondhealth departments within their rehand smoke a few times per month gions. Minnesota will coordinate the fell from 44 percent to 24 percent Central Region, which also includes after the policy was implemented.

North Dakota, South Dakota, NeIn addition, 77 percent of smokers braska, Kansas, Oklahoma, Iowa, reported that they had reduced the Missouri, and Arkansas. The other amount they smoked and 5 percent six regional labs will be located in reported that they had quit.

Maryland, New York, Tennessee, “These results show that imple- Texas, Washington, and Wisconsin. menting smoke-free policies at pubThe MDH lab and other regional lic housing properties can produce labs will provide support to analyze positive results and healthier enviorganisms and support response efronments,” said Ed Ehlinger, MD, forts when highly antibiotic resistant Minnesota commissioner of health. organisms or outbreaks associated “These policies protect residents, with them are detected in health who are more likely to experience care facilities or in state and local tobacco-related health inequities and labs. They will also work to prevent be exposed to dangerous secondand combat future threats by creathand smoke in their homes.” ing and sharing data, support innoThe U.S. Department of Housing vations in antibiotic and diagnostic and Urban Development has pro- development, and conduct special posed changes that would prohibit threat assessments upon request for the use of cigarettes, cigars, or pipes antibiotic resistant threats identified in all public housing living units, in- by the CDC. door common areas, administrative “Not only will this effort enoffices, and possibly outdoor areas hance our ability to help in the within 25 feet of housing and administrative office buildings. The final rule is expected this fall.

News to page 6

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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News from page 5

nation’s fight against antibiotic resistance, but it will aid our efforts to advance our One Health antibiotic stewardship initiative in Minnesota,” said Ruth Lynfield, MD, state epidemiologist at MDH. “Being able to detect antibiotic pathogens is essential to track trends and inform public health interventions.”

MDH will receive about $2.7 million to support the work as part of a $67 million total that will be given to help health departments combat antibiotic resistance and other patient safety threats, including health care associated infections.

Nearly 1 in 5 Mental Health Bed Days Potentially Avoidable The Minnesota Hospital Association (MHA) has conducted a pilot study showing that nearly 1 in 5 days mental and behavioral health patients spend admitted to inpatient community hospital psychiatric units

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been more appropriately served in a different care setting. Bottlenecks exist throughout the mental health care delivery system, resulting in paThe study is the first of its kind. tients remaining in community hosIt tracked mental health patients ad- pitals for extended periods of time— mitted to inpatient psychiatric units which in turn means that hospital at 20 hospitals and health systems beds are unavailable to others in across the state between March 15 the community experiencing mental and April 30, 2016 and found that of health crises.” the 32,520 total mental health bed MHA’s study identified 26 readays at all 20 hospitals, 6,052 (19 sons why these days occurred, which percent) were potentially avoidable. can all be grouped into two cateUsing those numbers, MHA esti- gories—64 percent of potentially mates that there are about 48,000 avoidable days were due to lack of potentially avoidable days each year space in a state-run mental health at the 20 hospital locations. There hospital, residential treatment center, are 147 hospitals in Minnesota. nursing home, group home, chemical is potentially avoidable, meaning they would have been more appropriately treated in a different care setting.

“On any given day, approximately 134 patients across these 20 hospitals could have been treated in a more appropriate care setting,” the study’s authors wrote.

dependency treatment services, or other setting; and 30 percent were due to social service or government agency delays, including identifying an appropriate treatment location for a patient, completing agency approvals, other administrative processes, or resolving legal proceedings involving the patient.

“Mental illnesses affect us all.

Behind these numbers are patients and families who are not getting the care they need in the right place at the right time,” said Rahul Koranne, The most frequently cited reasons MD, chief medical officer at MHA. were lack of beds at state-run Com“On any given day, 134 patients munity Behavioral Health Hospitals across these 20 hospitals could have (14 percent of potentially avoidable

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

days); chemical dependency treatment facilities (11 percent); Intensive Residential Treatment Services (10 percent); and Anoka Metro Regional Treatment Center (7 percent). In addition, 8 percent of potentially avoidable days were due to a delay in a patient’s legal proceedings, including civil commitment.

North Memorial Opens First Pediatric Clinic North Memorial Health Care has opened its first pediatric clinic in its North Memorial Health Care Medical Office Building at Maple Grove Hospital. It has five pediatricians on staff and offers urgent care services and easy access to acute pediatric hospital care at the hospital.

“Through our partnership with the University of Minnesota Masonic Children’s Hospital, children receive expert care from hospital-based pediatricians and bridge communications with primary care physicians when they’re admitted,” said Andy Cochrane, CEO of Maple Grove Hospital.

PEOPLE Douglas Hughes has been named deputy commissioner of veterans health care at the Minnesota Department of Veterans Affairs. He replaces the interim deputy commissioner, Andrew Burnside, who has been in the position since February and has now returned to direct the veterans home in Hastings. Hughes stepped into the position July 5 Douglas Hughes after being with the U.S. Department of Veterans Affairs in Minneapolis for five years and serving as acting director of health care for the past two years. In his new position, Hughes oversees operations for the five State Veterans Homes in Fergus Falls, Hastings, Luverne, Minneapolis, and Silver Bay. He is a retired military veteran who served in the Army’s Special Forces for most of his career. Before that, he worked at 3M as an advanced regulatory associate (Latin America) where he moved into the position of regional business manager (Latin America). He earned a master’s degree in business administration from Fayetteville State University in North Carolina.

Lora Princ, MD, has joined the obstetrics and gynecology team at North Memorial. Princ practices the full range of obstetrics care. She earned her medical degree at the University of North Dakota School of Medicine and Health Sciences and completed her residency in obstetrics and gynecology at the University of Minnesota, where she also Lora Princ, MD served as the chief administrative resident. Princ’s professional memberships include the American College of Obstetrics and Gynecology, and the American Institute of Ultrasound Medicine. In addition, Ross Sage, MD, has joined the gastroenterology team at North Memorial Health Care. Sage has a special interest in interventional endoscopy/ERCP, gastrointestinal oncology, diseases of the pancreas and biliary system, and inflammatory bowel disease management. He earned his medical degree from the Ross University School of Medicine in Portsmouth, Dominica. He completed a fellowship in gastroenterology/hepatology/nutrition at Beaumont Health in Michigan and a fellowship in hepatology at the Loyola University Medical Center in Illinois. He completed his Ross Sage, MD internal medicine residency at New York Methodist Hospital in Brooklyn, New York. His professional memberships include the American Gastroenterological Association and the American College of Gastroenterology.

Rene Cronquist, JD, RN, director of practice and policy at the Minnesota Board of Nursing, has received the Exceptional Contribution Award from the National Council of State Boards of Nursing, Inc. (NCSBN). The award is given for significant contribution and demonstrated support of NCSBN’s mission, which is to provide educaRene Cronquist, tion, service, and research through collaborative JD, RN leadership to promote evidence-based regulatory excellence for patient safety and public protection.

Cronquist has been with the Minnesota Board of Nursing for 23 years.

She earned her juris doctor degree from Mitchell Hamline School of Law and her nursing degree from Gustavus Adolphus College.

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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PERSPECTIVE

The sexual health of Minnesota’s youth Pregnancies down, diseases up

D

id you know that teen pregnancy and birth rates are at all-time lows? That young people are waiting longer to have sex than teens of a generation ago?

That teens are using long-term, extremely effective birth control methods? Contrary to messages in mainstream media, our young people are making wise and healthy decisions about their sexual health. However, many challenges remain.

Numbers and impacts

Jill Farris, MPH Healthy Youth Development–Prevention Research Center Ms. Farris is director of adolescent sexual health training and education at the University of Minnesota’s Healthy Youth Development– Prevention Research Center, where she assists youthserving organizations and practitioners seeking to implement adolescent sexual health programs. She also leads the creation and dissemination of the annual Adolescent Sexual Health Report, as well as various county health reports and fact sheets that are widely utilized by youth-serving agencies and professionals.

Teen pregnancy rates have declined 66 percent since their peak in the early 1990s. In that same time period, the birth rate among teens declined 58 percent. While every racial and ethnic group has experienced steep declines in pregnancy and birth rates, the birth rates for American Indian, black, and Hispanic/Latina youth are more than three times higher than the rates for white youth. To eliminate these persistent disparities, we must address social determinants of health—poverty, racism, unequal access to health care, and education—that disproportionately affect the health of young people in communities of color.

Teen pregnancy and birth rates are at all-time lows [but] many challenges remain.

Young people are disproportionately affected by sexually transmitted infections (STIs). This is likely related to a lack of access to STI prevention services, poverty, discomfort with facilities designed for adults, and concerns about confidentiality. Teens aged 15–19 represent just 7 percent of the state’s population, but they account for 24 percent of chlamydia and 16 percent of gonorrhea cases diagnosed in 2015. Young people from communities of color experience an even more disproportionate STI burden. The gonorrhea rate is 33 times higher for black youth and 11 times higher for American Indian youth when compared to white youth; the chlamydia rate is more than eight times higher for black youth and more than four times higher for American Indian youth when compared to white youth.

STI rates have continued to climb while teen pregnancy and birth rates have declined.

Geographic disparities also persist. The 10 counties with the highest teen birth rates are all in Greater Minnesota. In northern Minnesota, these counties include Mahnomen, Cass, Red Lake, and Pennington; in west central Minnesota, these counties include Kandiyohi and Swift; in southern Minnesota, these counties include Watonwan, Martin, Nobles, and Mower. Chlamydia and gonorrhea also impact young people throughout the state—STIs are

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

not just a “metro problem.” Thirty-three percent of gonorrhea cases were diagnosed in rural counties, while 16 percent of cases were diagnosed in urban counties.

Responses

We can address these issues on several fronts.

Communities. To fully support young people’s sexual health, we need to address their physical, social, emotional, and cognitive development, and give them skills and supports to navigate healthy relationships. There are several community-based agencies in Minnesota receiving federal funding through the U.S. Department of Health and Human Services to provide sexual health education to youth from underserved populations, including those who are LGBTQ, gender non-conforming, from rural areas, homeless, in foster care, in juvenile justice settings, and/or from populations of color.

Parents. Parents need to be supported in their role as sexuality educators. Honest, accurate, and developmentally appropriate information from parents, grandparents, and other adult caregivers is the first step toward raising healthy children who make responsible decisions about sex, sexuality, and relationships. Several funding streams are focused on the role of parents, and include education and outreach to parents to support them in their role as primary sexuality educators for their children.

Sexual health services. Young people deserve access to confidential, affordable, and accessible health care services, including sexual health care services. Access to these types of services is sparse in rural areas of Minnesota, and health care providers everywhere can improve the delivery of youth-friendly sexual health care services. The Minnesota Family Planning Program provides free contraception services to those that qualify, and young people are able to access family planning services without parental consent through the Minnesota Minor’s Consent law.

However, more must be done to educate young people about this program and their eligibility for these services.

Schools. The systems that educate young people are not providing the supports needed to ensure overall health, including sexual health. The Minnesota Department of Education receives funding from the Centers for Disease Control and Prevention’s Division of Adolescent and School Health; the funding is focused on helping schools to implement exemplary sexual health education, ensuring linkages to sexual health services for youth, and creating a safe and supportive environment where all young people can thrive.

Summing up

While Minnesota’s youth have made great strides in reducing teen pregnancies and teen births, rates of STIs have risen, and disparities continue in Greater Minnesota and among communities of color. A concerted effort by parents, schools, and community services could help to support our young people in making wise decisions to promote sexual health.

OCTOBER 15, 2016

FR

9am – 3pm

EE

EV

Minneapolis Convention Center 1301 2 Avenue South, Hall E Minneapolis, MN 55403 nd

EN

T

Learn how to be healthy, active and live well with diabetes Make Healthy Food Choices

• Cooking demonstrations • Healthy food sampling • Tasty and healthful recipes

Get Active

• Learn how to work fitness into your everyday life • Fitness demonstrations • Exercise tips

Free Health Screenings • • • • • • • • •

A1C Stroke Risk Assessments Blood Pressure Foot Screenings Diabetes Risk Assessments Eye Screenings BMI (body mass index) Oral Cancer Screenings Kidney Screenings

Ask the Expert

Come prepared with questions for health care professionals who can answer your diabetes questions one-on-one.

Learn more about how to manage diabetes and prevent devastating complications.

Family Fun

Interactive entertainment for the whole family.

Faces of Diabetes

Look for areas within the exhibit hall featuring information tailored to meet the specific needs of you and your family.

Visit diabetes.org/expominneapolis to print a FREE Metro Transit pass to the event!

Follow us for updates at: Facebook.com/ADA.Minnesota • Twitter: @DiabetesMN

For more info or to preregister: diabetes.org/expominneapolis or call 1-888-DIABETES ext 6592

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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10 QUESTIONS

Autoimmune diseases Paul H. Waytz, MD Dr. Waytz is a semi-retired rheumatologist with Arthritis and Rheumatology Consultants in Edina, where he currently serves as principal investigator for drug studies. He is board-certified in internal medicine and rheumatology.

What is an autoimmune disease?

Our immune system defends our body against disease by recognizing external intruders and then destroying or neutralizing them.

A series of complex reactions provide protective inflammation, designed to rid us of invading agents. With an autoimmune disease, areas of our “self” become considered foreign and our immune system responds by attacking healthy cells. In many situations, this means that the inflammatory reactions—normally defensive and beneficial—cannot be turned off. Ordinarily hidden components of damaged cells may then become exposed and recognized as “nonself,” perpetuating or initiating further abnormal immune responses.

Depending on the disease, one or many different types of body tissue may be affected and various degrees of organ dysfunction or damage result.

Do autoimmune diseases affect any particular age group?

Unfortunately, no age group is spared the possibility of getting an autoimmune disease, from babies born with neonatal lupus syndrome to people older than 55 with diseases such as polymyalgia rheumatica and giant cell arteritis. Most autoimmune illnesses are seen between the ages of 20–50, although juvenile inflammatory arthritis and type 1 diabetes occur before the age of 16.

Please share some information about the different kinds of autoimmune diseases.

We currently recognize close to 100 autoimmune diseases, although that number appears to be increasing as science uncovers further knowledge about the causes and origins of disease, especially through detailed discoveries of the human genome. When the concept of autoimmunity was first postulated, the most common illnesses in this category were rheumatic diseases, especially rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). This was partly based on blood tests suggesting that the immune systems of certain patients had gone awry, based on the reactions of antibodies (an essential part of the immune response) with various components of the body, as well as other laboratory tests. A number of conditions unassociated with “aches and pains” are now considered autoimmune, including type 1 diabetes, multiple sclerosis, celiac disease, certain thyroid diseases, and various conditions of the skin, hair, and blood.

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

How do genetics, gender, race, and ethnicity predispose an individual to autoimmune diseases?

Autoimmune diseases can affect any person, regardless of gender, cultural, or racial background. However, interesting features are noted for various groups or conditions. For example, more women than men have RA, SLE, and multiple sclerosis, yet the opposite holds for ankylosing spondylitis and type 1 diabetes. African-American women tend to have more severe cases of systemic lupus and sarcoidosis, and certain Native American tribes tend to have more serious issues with RA. Multiple sclerosis is much more common in Caucasians, and the incidence increases the farther one lives from the equator. Gender differences suggest that hormonal influences may also be involved.

Though we do not know how people acquire autoimmune diseases, there is likely a strong genetic component. Current thinking holds that a combination of some trigger(s), superimposed on a background of genetic predisposition, is essential. One person exposed to a virus develops a self-limited cold. Another person encounters that same virus, has no initial symptomatology, and subsequently develops an autoimmune disease. Our complicated immune response reactions are most definitely under genetic control. Interestingly, however, identical twins raised in similar environments develop the same autoimmune diseases far less often than one might expect. As we uncover more knowledge about the relationship between genetics, the immune system, and disease processes, we are learning that a number of diseases of unclear causation may indeed be autoimmune.

How can environmental factors contribute to acquiring an autoimmune disease?

This is a huge question in medicine today. More than likely, there are many environmental triggers, especially viruses and bacteria. However, the role of other environmental agents such as pollutants, radiation, or toxins is within the realm of possibility.

Anytime the body encounters something “foreign” to its system, there is a potential for the body to attempt to protect itself and react to the offending agent. It remains to be seen if some type of cross-reactivity will develop and result in an autoimmune “attack.” In most cases of autoimmune disease, the offending agent has long ago disappeared—leaving no trace of its existence.

What are the symptoms of autoimmune disease?

Symptoms are secondary to the organs involved. In the realm of rheumatic diseases, patients will usually experience joint and muscle discomfort; rash and fever may also be part of the picture. Numbness and tingling are features of multiple sclerosis. Lack of blood sugar control (because of the attack on the

pancreas) is the cardinal feature of diabetes. Manifestations are various and can range from the obvious to the subtle, depending on the disease.

How are autoimmune diseases diagnosed?

As with any medical illness, diagnosis starts with a good history—asking all of the correct questions—and detailed physical examination. However, in many cases, the diagnosis can be confusing, or a problem may take months or years to fully unfold. There may be an overlap of symptomatology, so pinpointing a specific autoimmune disease can be extremely difficult. Laboratory testing can be helpful but confusing as well, because no one blood test necessarily indicates a specific illness. And some people with autoimmune illnesses may have normal blood tests. Common rheumatologic testing may include markers of inflammation or rheumatoid factor, but false positive blood tests can lead physicians and health care providers astray.

What kind of care teams are required to treat autoimmune diseases?

The basic care team is led by the physician, and often, a specialized physician, depending on how confident a primary care provider feels about managing these disorders. A secondary care team of physical and occupational therapists is often essential for people with mobility or strength issues.

Nutritionists play a prominent role in the management of diabetes and celiac disease.

Psychologists are important when coping skills arise. Perhaps the most essential members of the team are the family and friends who provide day-to-day understanding and support.

We do not know how people acquire autoimmune diseases.

Please tell us about some of the treatments for autoimmune disease.

Once again, treatment depends on the individual disease and the individual patient. With diabetes, supplemental insulin is primary. In celiac disease, dietary management is the key. For rheumatic diseases, the spectrum of treatment ranges from simple anti-inflammatory agents to antimalarial medications to corticosteroids to disease-modifying drugs to complex biologic agent

What advice do you have for patients who have just been diagnosed with an autoimmune disease?

Certain realities need to be understood, especially that most autoimmune conditions cannot be cured and that not every medicine will necessarily work the same way in every patient. Of note, the responses to medication might be mediated by the immune system as well. On the other hand, modern medicine has provided us with outstanding tools for treatment of many underlying pathological processes that allow not only excellent control, but also the potential to prevent serious or damaging complications.

Autoimmune diseases are rarely fatal per se, but their persistent and chronic nature is a significant burden to bear.

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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SPECIAL FOCUS: CHRONIC DISEASE

Prediabetes Act now to protect your health

By Houa Vue-Her, PhD, RD, and Katelyn Engel, MPH, RD, LD

W

hen Sandy was first diagnosed with prediabetes, she was nervous. She knew it could lead to type 2 diabetes, and, like many others, she felt scared, nervous, and unsure what to do next. People with prediabetes or with risk factors for type 2 diabetes often wonder whether they can give up their favorite foods and take up a more active lifestyle, or they may dread facing a regimen of testing and medication if they do develop the disease.

Fortunately, losing 5 to 7 percent of your body weight through small lifestyle changes, such as walking 30 minutes daily, watching and recording what you eat, and enjoying smaller portions of some foods, can help reduce the risk of type 2 diabetes. You don’t have to do it on your own; there are supportive community programs to help you make and stick with these kinds of changes, reducing or even eliminating your risk while contributing to overall health.

Definitions and risk factors Prediabetes means that your blood glucose (blood sugar) levels are higher than normal, but not high enough to be diagnosed as diabetes.

Prediabetes can lead to heart disease, stroke, and type 2 diabetes —the most common form of the disease, and one that can lead to cardiovascular disease, nerve and organ damage, blindness, and other serious complications.

About 1 in 3 American adults have prediabetes… but most don’t even know it.

About 1 in 3 American adults have prediabetes. That means that as many as 1.5 million Minnesota adults may have prediabetes, but most don’t even know it.

You may be at risk if: • You are overweight, defined as having a body mass index (BMI) higher than 25 for most people and higher than 22 for those of Asian descent.

• You had diabetes while pregnant or had a baby who weighed more than nine pounds at birth.

• You are over 45 years old.

• Your parent or sibling has type 2 diabetes.

• You are physically active fewer than three times per week.

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

Race and ethnicity can also affect your risk. According to data from the Centers for Disease Control and Prevention (CDC), African Americans, Hispanic/Latino Americans, American Indians, Pacific Islanders, and some Asian Americans are at particularly high risk for type 2 diabetes.

Take control If you are at high risk, act now. The CDC estimates that, without some form of intervention, 15 to 30 percent of those with prediabetes will develop type 2 diabetes within five years.

Weight loss and physical activity are key. Even small amounts of weight loss pay huge dividends: shedding 5 to 7 percent of your body weight (for someone weighing 200 pounds, about 10–14 pounds) cuts your risk of type 2 diabetes in half. A dietician could help outline the best personal strategy.

lab results. In addition to changes in weight and energy levels, some people report improvements in their blood sugar, blood pressure, and levels of triglycerides or cholesterol after just a few months. All of these factors reduce the risk for prediabetes and type 2 diabetes.

Learn more Speak with your doctor about your diabetes risk, or complete the online risk test at https://doihaveprediabetes.org/. Learn all you can about prediabetes and type 2 diabetes. If you already have either condition, or if you are at risk, control your weight, make healthy lifestyle choices, and continue to follow up with your doctor to prevent or delay prediabetes or type 2 diabetes.

Shedding 5 to 7 percent of your body weight… cuts your risk of type 2 diabetes in half.

If you have trouble getting started, consider a structured program such as the Diabetes Prevention Program (DPP), a CDC-led lifestyle change program that can help people with prediabetes cut their risk in half.

Participants join eight to 16 others in the classes. Lessons focus on specific skills, such as eating healthier and tracking their food intake, reading food labels, setting physical activity goals, and dealing with stress. They hear from other classmates about what has worked well and what is not working, and discuss changes they will make during the upcoming week. Some groups organize walking groups or trips to the grocery store together.

To find a DPP class in your area, visit the Minnesota Department of Health’s Diabetes Prevention website at www.health.state.mn.us/diabetes/ programs/, or call (888) 643-2584.

For more information about the CDC’s National Diabetes Prevention Program, visit www.cdc.gov/diabetes/prevention/.

Houa Vue-Her, PhD, RD, is a diabetes prevention planner at the Minnesota Department of Health (MDH). Katelyn Engel, MPH, RD, LD, is a diabetes health educator at the MDH.

Trained lifestyle coaches provide additional tips to improve and encourage them throughout the program, while the group support underscores both the benefits and the difficulties of making lifestyle changes.

DPP classes are offered all over Minnesota, both in person and online. During the yearlong program, participants attend a minimum of 16 weekly meetings during the first six months, then meet monthly for the rest of the year.

Whether you go it alone or join a group of other patients, remember to: • Stay active to lower blood glucose levels and decrease body fat.

• Learn which foods can cause blood glucose to spike, and avoid or limit portions.

• Sleep well. This will help your weight-loss program, and will help your body use insulin effectively to lower blood glucose levels.

• See your doctor regularly, both for personal support and for feedback on how your plan is progressing.

For some, the payoff can be measured in the form of improved

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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SPECIAL FOCUS: CHRONIC DISEASE

Complications of type 2 diabetes Reducing your risk

By Elizabeth R. Seaquist, MD

T

ype 2 diabetes is increasing across the globe in an epidemic fashion. In 2014, more than 29 million Americans were estimated to have diagnosed or undiagnosed diabetes; if this

rising trend continues, 1 out of every 3 adults could have the dis-

ease by 2050. The personal and economic costs of this epidemic are enormous. Patients with diabetes spent $176 billion on direct medical costs and $69 billion in indirect costs from lost workdays, restricted activity, disability, and early death in 2012. Patients with diabetes must be proactive in their care to reduce the impact of diabetes on their lives.

Cardiovascular disease People with diabetes develop cardiovascular disease at a rate two to four times that of nondiabetics of the same age and gender, a risk that follows them throughout their lives and represents a large proportion of the deaths seen in patients with diabetes. Research offers clear evidence, though, that maintaining a systolic blood pressure (the “high� number of a standard blood pressure reading) of less than 140 mm Hg will improve cardiovascular outcomes.

The best drug to achieve this blood pressure target is not clear, but most experts would consider an angiotensin-converting enzyme inhibitor (ACE) as the best first choice. These drugs have been shown to have a positive effect on the development of diabetic eye disease and the progression of diabetic kidney disease. Many patients with type 2 diabetes require more than two drugs to achieve this targeted systolic blood pressure.

Statin drugs, commonly used to control cholesterol, have also been shown to reduce risk of cardiovascular disease. This is particularly true in patients who have already had a cardiovascular event, but also applies to all patients over the age of 40 who have diabetes, regardless of their cholesterol level.

More controversial is whether daily aspirin use can reduce the risk of cardiovascular disease. The American Diabetes Association recommends that patients over the age of 50 who are at increased risk of cardiovascular disease because of smoking or a family history of atherosclerotic cardiovascular disease (in which plaque builds up inside the arteries), hypertension, dyslipidemia (irregular levels of plasma cholesterol, triglycerides, and high-density lipoproteins), or the presence of albumin in the urine consider taking 75–162 mg of aspirin each day. Patients at lower risk may not benefit from the use of aspirin. Aspirin is also recommended for diabetics of all ages who have already had a heart attack or stroke.

Controlling levels of glucose (blood sugar) has not been shown to have a substantial impact on reducing the cardiovascular complications of diabetes. Three large clinical trials over the last decade all showed that lowering glucose to near normal levels was not effective in reducing cardiovascular disease in older patients at high risk for this complication.

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

For patients with type 1 diabetes or short duration type 2 diabetes, however, separate studies have shown that good glycemic control at one point in time can pay off years later. In these studies, one random group of patients followed strict levels of glucose control for a few years and then were left to achieve the level of control suggested by their doctors, while a separate random group followed less stringent levels of glucose control throughout the study. The group that followed the more stringent standard developed cardiovascular disease at a lower rate more than a decade later.

exam is the best way to screen for diabetic retinopathy, and patients with type 2 diabetes should have this done annually following initial diagnosis. Kidney functions are assessed by levels of creatinine in the blood and albumin in the urine, again with annual exams. Screening for neuropathy includes asking patients if they have numbness or tingling in their feet, along with an exam to determine if they have normal sensation. Patients with reduced sensation are at great risk for foot injury and ulceration and require education on how to keep their feet healthy.

Managing blood sugar levels Achieving good glucose control requires a careful balance of food, activity, and medication. All patients with type 2 diabetes should attempt to maintain and achieve a lean body weight, but the loss of just 10 pounds can help improve glucose control.

Regular physical activity is key to achieving these weight goals, and current recommendations suggest at least 30 minutes of daily movement. The diet used to achieve weight goals should be well balanced, provide all the nutrients a person needs each day, and be sustainable for the long term. Many patients find it beneficial to work with a dietician to develop the best personal meal plan.

Patients with diabetes spent $176 billion on direct medical costs‌ in 2012.

Microvascular complications While good glucose control does not substantially reduce cardiovascular complications of diabetes, it can substantially reduce complications affecting the eyes, kidneys, and nerves. The American Diabetes Association now recommends that most patients with diabetes try to achieve a hemoglobin A1c (an average value of blood glucose over three months) of less than 7.0 to reduce the risks of these microvascular complications. This A1c target may be relaxed for patients with multiple co-morbidities or advanced age, and made more stringent for younger patients with new onset diabetes. Blood pressure control is also essential, and lipid-lowering drugs such as statins may be of benefit.

Early treatment can slow the rate of these complications, so patients with diabetes should have regular screenings. A dilated eye

Complications of type 2 diabetes to page 17

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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WORLD ALZHEIMER’S DAY– SEPT. 21 Alzheimer’s disease affects about 5.4 million people in the U.S., and of those, an estimated 5.2 million are age 65 and older, according to the Alzheimer’s Association.

Officials estimate that with the upcoming aging population, the number of people age 65 and older with Alzheimer’s disease may nearly triple by the year 2050.

While no current treatment can stop Alzheimer’s disease from progressing, they can temporarily slow the progression of dementia symptoms and improve quality of life for people with Alzheimer’s and their caregivers. It’s important to schedule an appointment with a doctor if you notice any of the 10 warning signs of Alzheimer’s disease in yourself or in a loved one: memory loss that disrupts daily life; challenges in planning or solving problems; difficulty completing familiar tasks; confusion with time or place; trouble understanding visual images and spatial relationships; new problems with words in speaking or writing; misplacing things and losing the ability to retrace steps; decreased or poor judgment; withdrawal from work or social activities; and changes in mood and personality.

Early detection can help you get the maximum benefit from available treatments to gain symptom relief and help you maintain independence longer.

In addition, catching Alzheimer’s disease early may increase your chances of participating in clinical drug trials that help advance research.

SEPT. 24

Memory Screenings Alzheimer’s Foundation of America is offering free 10-minute memory screenings for those concerned about memory loss, experiencing warning signs of dementia, at risk due to family history, or those who want to check their memory for future comparisons. Call Anoka County Family Caregiver Connection at (763) 422-6960 to set up an appointment.

Saturday, Sept. 24, 9:30 a.m.–12 p.m., First Congregational Church UCC of Anoka, 1923 3rd Ave. S., Anoka

CALENDAR SEPT. 14

Diabetes Support Group

Fairview Health Services hosts this free monthly support group for people with type 1 and type 2 diabetes. Learn helpful tips about living well with diabetes and share strategies with others living with the disease. Friends and family members are welcome. For more information, call Anna at (763) 502-4877.

Wednesday, Sept. 14, 1–2 p.m., Fairview Health Services, 2nd Flr., Roberts Rm., 6401 University Ave. NE, Fridley

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Joint Protection for Lupus

The Lupus Foundation of Minnesota offers this free seminar to discuss joint anatomy, body mechanics, and joint protection tips to decrease pain, fatigue, and inflammation for people living with lupus and/or other autoimmune diseases. Registration required by Sept.

16; call (952) 746-5151.

SEPTEMBER-OCTOBER 2016

OCT. 4

Bone Marrow Transplant Support

The University of Minnesota Fairview facilitates this free monthly support group for patients following bone marrow transplantation. Connect with others going through similar treatments, ask questions, and learn tips for post-transplant care.

Other dates and times available. Call (612) 3796352 for more information.

Tuesday, Oct. 4, 9:30–11:30 a.m., ACS Hope Lodge, 2500 University Ave. SE, Minneapolis

6

Dementia–Caregivers Support Group

Park Nicollet hosts this free monthly support group for people who care for others with dementia. Join this supportive environment where questions are answered, ideas for coping are discussed, and friendships are shared. No registration required. Call (952) 993-8739 for more information.

Monday, Sept. 19, 6–7:30 p.m., Highland Park Library, 1974 Ford Pkwy., St. Paul

Thursday, Oct. 6, 10–11 a.m., Burnsville Park Nicollet Clinic, 3rd Flr., Conference Rm. B, 14000 Fairview Dr., Burnsville

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10

Pancreas Cancer Support Group

Allina Health hosts this free support group for those living with pancreas cancer and their families. Come share information and gain support from others on a similar path. Meetings are facilitated by a nurse coordinator and oncology social worker. No registration required; call (612) 863-7553 with questions or to learn about other meeting dates.

Growth Through Grieving

HealthEast offers this group to anyone who is grieving the loss of a loved one. While grieving can be painful and lonely, sharing experiences and support with others going through similar losses can help. Contact Ted at (651) 232-7397 or thein@healtheast.org for more information.

Tuesday, Sept. 20, 4–6 p.m., Abbott Northwestern Hospital, Piper Building, 913 E 26th St., Ste. 602, Minneapolis

Monday, Oct. 10, 4–5:30 p.m., Maplewood Professional Building— St. John’s Hospital, Watson Education Center, Ste. 202, 1575 Beam Ave., Maplewood

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18

Bullying Prevention Class

Heart Safe

PACER presents this free workshop for parents. Come for a comprehensive overview for parents to learn what they can do to address and prevent bullying. Off-site video streaming is an option for those who can’t attend in person. Call (952) 838-9000 for more information or to sign up.

Hennepin County Library and the Rotary Club of Plymouth offer this free class for anyone who would like to learn the symptoms of cardiac arrest and receive training for CPR and the use of an automated external defibrillator (AED). Call (612) 543-5669 to sign up or for more information.

Tuesday, Sept. 27, 6:30–8:30 p.m., PACER Center, 8161 Normandale Blvd., Minneapolis

Tuesday, Oct. 18, 7–8 p.m., Plymouth Library, 15700 36th Ave. N., Plymouth

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Email submissions to amarlow@mppub.com or fax them to (612) 728-8601. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

America’s leading source of health information online 16

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

Complications of type 2 diabetes from page 15

If these lifestyle measures are not enough to achieve glycemic goals, medications will become necessary. Most experts agree that metformin is the first drug a person with type 2 diabetes should take because it is safe, inexpensive, has known side effects, and has been used effectively by millions of people.

Most patients will eventually find that metformin alone will not keep their blood sugars in target, and will need to have a second drug added. There now are more than six classes of medications that physicians can prescribe, in addition to metformin, to achieve good glucose control, including oral agents and insulin. Unfortunately, we do not know which of these drugs will work best with metformin over the long term to maintain glucose control. Currently, doctors and their patients make choices based on cost, insurance coverage, and willingness to experience the side effects associated with each drug.

a study called Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). In this study, patients with less than 10 years of type 2 diabetes who have sub-optimal control on metformin alone will be randomized to receive a drug from one of the four major drug classes used to treat the disease.

The study hopes to determine which drug gets patients to target first and which drug keeps the patients at target the longest. Study participants are provided free medications, free diabetes visits, and free diabetes-related lab tests for the duration of the study, which is expected to go to 2020. Minnesota has two sites participating in the GRADE study, one on the Minneapolis campus of the University of Minnesota (grade@umn.edu or 612-626-0143) and one at the International Diabetes Center site in St. Louis Park (952-993-9605). Contact either site to learn more.

People with diabetes develop cardiovascular disease at a rate two to four times that of nondiabetics.

The GRADE study To determine which medication works best with metformin to achieve long-term glycemic control in patients with type 2 diabetes, the National Institutes of Health is currently sponsoring

Elizabeth R. Seaquist, MD, is director of the Division of Diabetes and Endocrinology, Pennock Family Chair in Diabetes Research, and professor of Medicine at the University of Minnesota. She served as 2014 president of Medicine and Science for the American Diabetes Association.

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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Tom Arneson MD, MPH

Research Manager Office of Medical Cannabis Minnesota Department of Health Changes: The 2014 law that established the Minnesota Medical Cannabis Program tasked the MDH with running it and set a tight timeframe to make it operational.

Having key aspects of the program differ from most other states’ medical cannabis programs added to the challenge—and opportunity (laboratory-tested extraction products with specified cannabinoid content; participant experience).

Challenges: Cost has emerged as a major issue, because the medical cannabis products available through the program are quite expensive and not covered by insurance. A rapid, feasible solution to this issue is not in sight. There is widespread lack of awareness among clinicians on what is known about the endocannabinoid system and research into therapeutic potential of plant-based cannabinoids and synthetic modulators of the ECS.

Hanna E. Bloomfield MD, MPH

Ruby Azurdia-Lee

Susan A. Berry

Joseph Bianco

Immediate Past President Minnesota Chapter of the American Academy of Pediatrics

Chief of Primary Care Essentia Health

Changes: We worked to increase the number of active member advocates and enhance engagement with other primary providers who care for children. In collaboration with others, we were successful in changing newborn screening in Minnesota. This restored the ability of the Minnesota Department of Health to maintain records of the life-saving early screening assessment, which is an essential public health measure.

Changes: Our movement from volume-based to value-based reimbursement has led us to completely transform our practice. By continuing to strive to meet the goals of the Triple Aim, the changes to all aspects of our care delivery are profound.

President CLUES

MD

Changes: We promote integrative approaches to access health care and stimulate community well-being. Latinos in Minnesota continue to experience increased barriers and a lack of culturally and linguistically appropriate treatment. We focus on a model of service that advances two generations forward and out of poverty. Our services work with families in a holistic way, and we emphasize prevention and behavioral change.

Challenges: The explosive growth of Latinos in Minnesota will necessitate our innovation and cultural and bilingual responsiveness in the provision of health and wellness services. Most Latino families today have mixed immigration status, and some face barriers to accessing health care. The stresses of acculturation can impact health outcomes and the healthy functioning of the family, which we want to strengthen.

Bob Bonar MA, MS, DrHA

Associate Chief of Staff for Research Minneapolis VA Medical Center

CEO Children’s Minnesota

Changes: The biggest changes we have made are to prioritize the growth of clinical and health services research, strengthen research infrastructure (e.g., personnel, equipment, data management systems), and remodel space to better meet the needs of clinical and basic science researchers.

Changes: We’ve developed laser focus on producing top outcomes for the children and families that we serve, across our hospitals, specialty clinics, primary and virtual care settings.

There’s an art and science to pediatrics and I’m very proud of what our team has accomplished.

Challenges: The biggest challenge for the Minneapolis VA Research enterprise is to recruit a new generation of well-trained investigators who are passionate about conducting well-designed research projects that address the major health care problems affecting veterans, including post-traumatic stress disorder, obesity, cardiovascular and metabolic disorders, and diseases of the aging brain.

Challenges: What Children’s offers this community is unique. We know that kids do best in a health environment that’s dedicated solely to kids. As the industry continues to transform, we must be courageous, innovative, and selfless in partnering with others to protect this asset and to ensure better health for our kids.

Challenges: As advocates for children, our group needs to remain vigilant, focused, and committed. Positive change happens with attention and preparation.

MD, FAAFP

Challenges: Working to promote the health and well-being of not only our patients, but our workforce will be a great challenge in the midst of rising prevalence of chronic disease. We will need to partner with our communities to address health behaviors and the social determinants that lead to disease. The challenge will be to create the partnerships that will lead to positive outcomes.

Mary Brainerd

Matt Brandt

President and CEO HealthPartners

CEO PrimaCare Direct

Changes: We’ve expanded care options, in person and virtually, where we’ve provided over 200,000 treatments, and over 20 worksite clinics, including virtuwell. com, our online medical clinic. We’ve created more affordable options using measurement tools like Total Cost of Care. We’re serving more people: twice as many patients and 38 percent more members than five years ago.

Changes: PrimaCare Direct has expanded to include 13 practices with 20 clinic sites. By expanding the network of clinics, we are now able to offer employers primary care services for a low monthly membership fee to all their employees across the Twin Cities.

Challenges: Care will come to patients— at work, at home, or on their phones— and fundamentally change how we relate to them. Our efforts to tackle mental health stigma, health care disparities, early childhood development, opioid addiction, obesity, and chronic disease will create healthier communities. We’ll remain focused on affordability, measuring cost, and quality to improve results!

Challenges: The current economics of health care make it tough to change.

Premiums continue to rise placing a burden on employers, governments, and patients, however the flip side is that more money is flowing into the health care system. Innovative models that try to disrupt these burdens meet a lot of resistance from the current health care players. I see this battle daily.

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Shirley A. Brekken

Sally T. Buck

Christopher Cassirer

Steven Connelly

Executive Director Minnesota Board of Nursing

CEO National Rural Health Resource Center

President and CEO Northwestern Health Sciences University

President Park Nicollet Health Services and HealthPartners Institute

Changes: We’ve focused more on changes in the environment rather than on internal organization. Technology, economics, the ACA, millennials entering the field, and greater utilization of nurses in primary care are causing a historic transformation of health care. Increased scrutiny of the effectiveness and efficiency of regulatory models demands increased transparency and accountability.

Changes: The Center has been collaborating and innovating to improve rural health for over 20 years. Our services have expanded beyond rural clinics and hospitals to health networks and communities. We continue to develop and disseminate knowledge of the new models for rural providers and identify strategies to bridge the gap between the current structure and the emerging environment.

Changes: We are committed to optimizing patient, family, and community health through nutrition, early diagnosis, and treatment. We work in partnership with conventional health and medical providers to start with conservative, natural approaches to care before considering more aggressive treatments like drugs and surgery.

Changes: The combination of Health Partners and Park Nicollet in 2013 is certainly the biggest change. The cultures of the two organizations were extremely similar before the combination, as they both centered on the Triple Aim. This allowed us to concentrate on and accelerate our efforts around health outcomes and affordability.

Challenges: We must implement regulatory solutions with increased relevance and responsiveness to the changes in health care, the transformation of education, and emergent trends in workforce and population health. Greater mobility, response to emergencies, and communication with patients across state borders call for a new licensure model that supports interstate practice. Regulation must be innovative and pragmatic.

Challenges: The Center has witnessed a growing number of challenges facing rural providers. They are striving to maintain local health care resources including workforce, technology, and capital, while preventing the out-migration of patients and adapting to value-based purchasing from being reliant on quality, population health, and patient satisfaction.

Kathryn Correia

Kent Crossley

J. Kevin Croston

President and CEO HealthEast

Chief of Staff Minneapolis VA Healthcare System

CEO North Memorial Health Care

Changes: Implementing lean and aligning leadership to reach our strategic objectives were some of the biggest changes we’ve undergone over the past four years. We made those changes while rolling out our new electronic health record—so, these were courageous decisions to be sure. With a clear focus on best serving our patients, physicians, employees, and community, these were the right decisions.

Changes: The Minneapolis VA has expanded available specialty services, increased its number of community clinics, grown its education and research activities, and worked to be more patient-centric. We offer same-day access in primary care and mental health, have developed a comprehensive integrative health program, and offer online services and provider access. Our tele-health and tele-ICU programs are state of the art.

Changes: We transitioned from being a hospital that owns clinics to that of a value-based health care delivery system.

We improved health care access and services in the ambulatory setting and introduced online care and retail clinics.

We also placed our customers squarely in the center of our decision-making so our work is entirely mission-driven.

Challenges: Our biggest challenge will be to continue to reduce the burden of medical care as we work in partnership with our patients and our communities to improve health and well-being.

Challenges: The VA is the largest provider of health care in the U.S. and part of a complex system. Decision-making may be a challenging process.

Our leadership may change with the presidential election and this could lead to modification of our current priorities.

MS, RN

MHA

20

MS

MD, MHA

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

ScD, MPH

Challenges: Our challenge is to prepare our graduates for a rapidly evolving health care system and educate communities that the best approach to health is to prevent disease. The best primary care option isn’t to take a pill, but to first try natural care solutions like chiropractic, acupuncture, therapeutic massage, getting more rest, or improving nutrition. We want to be culturally aware that the communities we serve are diverse and may have different health traditions.

MD

Challenges: Value-based reimbursement requires collaboration between customers, providers, and payers, but the insurance industry is reluctant to compensate smaller systems equitably.

While our small size lets us make necessary changes faster, we aren’t currently rewarded for these efforts by payers.

Larger systems are paid more because of market share dynamics that reward patient access over outcomes. To offset this inequity, we need to empower our customers to achieve their best health.

MD

Challenges: Addressing patients’ needs in an ever-changing environment is a growing challenge. We must offer options—from traditional office visits to telemedicine, to virtual and online care. Also, we need to continually improve the current EMR functionality to contribute to a more efficient and fulfilling clinical practice. We must address this to succeed in providing access.

John Dahm

President and CEO Accra

Changes: Our biggest changes were driven by rapid growth while experiencing unprecedented change in our industry. We created efficiencies within our systems and added staff to ensure that we meet and exceed the needs of our participants and our mission. Our focus also included participating in stakeholder groups, and working with other organizations and thought leaders to influence change.

Challenges: The greatest challenge will be the changing demographics that will result in the demand for more people needing services and a reduced workforce to meet their needs. Our focus will be to manage this continued growth and the rapidly changing regulatory environment, while continuing to help families and older adults find what services are available to meet their needs.

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Bobbi Daniels

Rhonda Degelau

Edward Ehlinger

Executive Director Minnesota Association of Community Health Centers

Commissioner Minnesota Department of Health

Changes: We’ve focused heavily on preparing member clinics to participate in accountable care models, such as the Medicaid Integrated Health Partnerships, and to prepare for a value-based payment world. We’ve also stepped up our advocacy work on emerging payment reforms at the national and state levels, to ensure that new payment models work for safety net clinics.

Changes: To address health equity, we created the Triple Aim of Health Equity, which provides the framework for the transformation of public health practice. These aims include using a health in all policies approach, with health equity as the goal; expanding our understanding of what creates health; and strengthening communities to create their own healthy futures.

Challenges: Big challenges remain, such as an aging population, persistent health inequities among Minnesotans, and better access to mental health and dental care, especially in Greater Minnesota. It will take all of us working together to meet these challenges, while keeping health care affordable for Minnesotans who need it.

Challenges: Current marketplace and legal barriers to Health Information Exchange will limit successful participation in accountable care models.

Our member clinics also face financial resource barriers to securing the data analytics capacity needed to succeed under new models. We must ensure that payment reform works for the safety net by recognizing the impact of social determinants of health on health outcomes.

Challenges: The dominant public narrative is that health is created by access to high quality health care and good personal choices. The biggest challenge is for people to understand that health is mostly due to the physical, social, and economic environments in which they live, and that to improve health in a socially responsible way, we need to invest in community-wide public health efforts.

James W. Eppel

Al Franken

Kevin Garrett

U.S. Senate

MD, FCCP, FAASM, CPE

Julie Gerndt

President and CEO UCare

Senior VP, Chief Medical Officer HealthEast

Chief Medical Officer Mankato Clinic, Ltd.

Changes: This has been a period of great change in health care and at UCare. We have entered the individual commercial market on MNsure, introduced value-based relationships and “private-labeled” products with our delivery system partners, and experienced significant growth, followed by significant contraction.

Changes: Because of the ACA, we’ve seen the rate of uninsured Americans fall below 10 percent nationally, and under 5 percent in Minnesota.

Because of the provision I wrote in the ACA, known as the Medical Loss Ratio, insurance companies are now required to spend more on health care and less on administrative costs, saving consumers billions of dollars.

Changes: A redesign of our care delivery system included the creation of dynamic, dyadic relationships between operations leaders and our physician leaders. This has allowed us to keep everyone moving in the same direction, led by the same strategy. We have also continued our efforts to deepen our culture of continuous improvement.

Changes: We have focused on relationships with our community and with one another. Full engagement of providers in leading change and cascading goals and incentives down to front line staff has been key in producing the best health care outcomes for our patients. We are fully transparent about outcomes and the use of care-related data to improve our work.

MD

CEO University of Minnesota Physicians Changes: We established an enhanced collaboration with Fairview called University of Minnesota Health, which paved the way for our Clinics and Surgery Center, enhanced financial support for the medical school, and greater integration of UMP and UMMC. We developed a new ambulatory care model coupled with a different architectural design and expanded hours to enhance the patient experience and our ability to do clinical research and education.

Challenges: We will need to continue to innovate in all parts of our commitment to academic medicine and work with partners who share that goal. Patient care needs to become even more patient focused, evidence based, and efficient and that goal takes on additional importance as we educate the next generation of health care professionals.

Challenges: The exchange market remains immature and volatile; we all have to work together to find solutions. Despite the high level of collaboration today, we have significant work to do to reduce health care costs. The entire health care system will need to focus on viewing our world through the patient’s eyes, recreating the system accordingly.

Mark Dayton Governor of Minnesota

JD

Changes: Minnesota has been a national leader in health care reform. Our uninsured rate has been cut in half, and is now the second lowest in the nation.

We have implemented reforms to improve health and lower costs in our public health care programs, including a competitive bidding process for managed care contracts. Integrated Health Partnerships in Minnesota’s Medicaid program have saved $150 million, while providing better care to low-income Minnesotans.

Challenges: We need to focus on delivery system reform. I think Minnesota is a great model for the rest of the country. For example, in the ACA, I helped establish the National Diabetes Prevention Program, based in part on work done in Minnesota. So far, the results have been clear: not only does this program make people healthier, it also saves taxpayers a significant amount of money.

Challenges: Staying aligned with the right work to better respond to evolving community needs; providing capacity for physicians to find a pathway to personal and professional success; and continuing to move in a strategic, unified direction.

MD, MSPH

MD

Challenges: Our ongoing success will hinge on keeping pace with changes in payment and providing access for patients in the face of a physician shortage. We will address provider burnout by further developing our care teams, expanding our use of technology, and developing purposeful leadership.

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Dean Gesme

H. Theodore (Ted) Grindal

Julia U. Halberg

Peter J. Henry

President Minnesota Oncology

Partner Lockridge Grindal Nauen, PLLP

Chief Wellness Officer, VP Global Health General Mills

Chief Medical Officer Essentia Health–Brainerd

Changes: We continue to grow with many new physicians and expanded utilization of advanced practice providers to integrate a broader range of patient services including palliative care, genetic assessment, survivorship care, and end-of-life counseling in addition to our core services. Outcomes measurement and reporting have driven improved internal efficiency, enhanced value delivery, and high patient satisfaction.

Changes: The biggest changes for my clients have been complying with the ACA and reacting to the continued consolidation in the health care delivery system in Minnesota. Also, there seems to be no reason to believe that continued integration in the health care provider market will not continue to leave us with even fewer large delivery systems.

Challenges: The cost of breakthrough therapies for our cancer patients has reached unsustainable levels. Preauthorization and payment approvals have frequently resulted in delays of potentially life-saving treatment. The complexities of precision medicine, expanded diagnostic testing, and complicated new therapies requires greater time and attention by providers in an environment in which many of these cognitive services are unreimbursed or under-reimbursed.

Challenges: Managing costs and quality will only continue to be more challenging. Purchasers are demanding both and all the large health care delivery systems are embracing these priorities.

The pressure on providing lower costs and higher quality will be supported by more and more data analytics. The ability to access and manage this data will continue to impact every level of the delivery systems.

Changes: Transitioning from a company-owned, prevention-based, onsite clinic with specialties (dental screens, cardiology, optometry, PT) to a Wellness Center. While our onsite clinic was outsourced, we’ve added integrative services (acupuncture, nutrition, aromatherapy) and also designed Zenergy rooms where employees can re-energize in zero-gravity chairs, use brain-fitness technologies such as MUSE, or nap.

Changes: To ensure access for patients in rural communities, we’ve expanded our clinical team to include advanced practice clinicians. As our teams have grown, standardizing our workflow in primary and specialty care has improved the quality of care all patients receive. We are becoming a truly integrated health system, where the community and patients are seen as “ours” to care for.

Challenges: Evolving an ongoing innovative, holistic (mind, body, community) approach to the well-being of our employees; identifying technologies and programing that engage our employees to be active, make healthy nutrition choices that incorporate our Brands (Cheerios, Annie’s, Yoplait, Nature Valley); and connect with the community by volunteering—making their time at work the healthiest and safest time of their day.

Challenges: Although the quality of life and teamwork are strong differentiators, it’s a challenge to attract candidates who want to care for patients in rural communities. Continuing to evolve and improve patient care makes all health systems better and benefits our communities. As health care moves to a value payment model, aligning compensation to this change will pose new challenges.

John R. Hering

David C. Herman

Patrick Herson

Ken Holmen

Chief Medical Officer CentraCare Health–Monticello

CEO Essentia Health

President Fairview Medical Group

President and CEO CentraCare Health

Changes: In 2013, our Critical Access Hospital transitioned from an independent organization run by a hospital district to a regional affiliate of CentraCare Health. Our patients and community have benefited tremendously from the additional resources and support that come from being a member of a large health system.

Changes: We have made the commitment and built new systems to support the move from volume to value.

The design of our Primary Care team model, along with the great support our care teams provide our patients, have dramatically improved our ambulatory care quality measures. We are working to sustain the resilience of our staff as well.

Changes: As a multispecialty group that is only seven years old, we have embraced being integrated and interdependent. This has meant having challenging conversations about where to invest in new programs and areas of growth, and how to have one set of clinical and financial standards across an almost 600 provider group. We have also begun to do the necessary work to succeed in a value-based model.

Changes: We recognize that our employees and physicians ultimately make the difference in how well we serve our patients and the community. Based on a culture change transformation, we migrated our organizational structure so executives and physicians share responsibility for leading all clinical service areas. Then we realigned our governance structure to ensure optimal oversight of our strategic initiatives.

MD, FACP, FASCO, FACPE

MD

Challenges: The biggest challenge we face is our intensely competitive market; multiple health systems converge in our area. It is vital for us to work collaboratively with our local physician partners, most of who are in independent practices, to ensure that we deliver the quality and value of care our community deserves.

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JD

MD

Challenges: Health care in a community accounts for just 10 percent of residents’ health status, while socioeconomic factors, behaviors, and the environment contribute to 80 percent of overall health. Our challenge is building strong partnerships within the communities we serve to address those factors to keep our communities healthy, while continuing to build the systems of care needed when people become ill.

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

MD, MS, MPH

MD

Challenges: We want to perform well across a balanced scorecard of measures including clinical quality, patient experience, provider and staff engagement, and financial excellence.

It is relatively easy to perform well on one or two—it is much more challenging to perform across all of them in a balanced fashion.

MD

MD

Challenges: Whenever organizations attempt deep and systemic change, they risk having insufficient employee engagement to sustain the work. Understanding this, we have processes that regularly re-energize and support our team. We plan to develop change management tools that employees will need to ensure success under the new structure. This is essential to recruit and retain excellent people in a competitive labor market.

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Dan Holub

Mary Hondl

Maria Huntley

Brooks Jackson

Executive Director Minnesota Association of Professional Employees

CEO Regional Diagnostic Radiology

Executive Vice President Minnesota Academy of Family Physicians

VP for Health Sciences and Dean of the Medical School University of Minnesota

Changes: Our newer members are looking for a greater sense of connection to their workplace and union. As a result, we are more relational in the way we approach our work. We led efforts to establish better parental leave for state employees, because a newer group of members took up the issue, organized around it, and created positive change.

Changes: HealthCare Reform has affected every aspect of operations for providers and health care facilities, and we have focused on understanding those regulations. We developed additional practices and policies to meet and exceed compliance standards, while providing the best possible care to our patients and serving our referring clinicians.

Changes: In 2015, our Legacy Staff Leader of 30 years retired. I arrived with a whole new set of experiences and expectations to help drive change.

We are evolving as an organization to ensure that we meet the needs of all of our members and keep up with industry trends.

Changes: I have increased scholarship and developed new interprofessional practice models across all our health sciences schools, increased diversity in our student body, promoted groundbreaking research, and brought the best possible clinical care to people across the state. We also launched an initiative in partnership with the state to create Medical Discovery Teams focused on pressing health issues facing Minnesota.

JD

MBA

Challenges: Our biggest challenge is organizing professional employees in a way that results in positive change and builds relationships. Like everyone else, we are trying to control rising health insurance costs without sacrificing quality. We will also continue to prioritize healthy work climates that are free from bullying and other conditions that impact mental and physical health.

Challenges: Continuous regulatory changes are a big challenge. Advanced technology is essential for producing metrics and meeting the reporting requirements, but comes at a high price. Educating physicians and staff on new ways to practice and on new reporting processes is necessary, yet takes time. We are working with our hospitals and referring clinicians to meet these challenges and with this team approach, we are confident that our community will be well served.

William Katsiyiannis

Nissim Khabie

MD

MD

President and Chairman of Cardiology Minneapolis Heart Institute; Abbott Northwestern Hospital/Allina Health

President ENT Specialtycare

Changes: While there is a rich history of innovation in cardiovascular medicine, from surgery to stents to pacemakers, we are now innovating in the delivery of cardiovascular care.

This means evolving from practicing in silos to practicing in coordinated teams. We’re also recognizing and reducing unnecessary variation in care. These innovations have improved quality and reduced costs.

Changes: Although the EMR is ubiquitous in physician’s offices and hospitals, we are just beginning to scratch the surface in terms of optimal utilization of technology to improve effective and efficient patient care. Although we have already aligned our practices with care systems and independent groups, with the advent of ACOs and changes in payer models, we are seeing an acceleration in developing these relationships.

Challenges: The next four years will challenge us to balance the tension between novel and innovative care delivery and the antiquated reward systems that currently exist. Many of the needed changes in care delivery currently carry negative financial incentives for providers and health systems.

Challenges: Our increased utilization of technology will improve data collection and best practice elements, and will expand our reach to patients via improved portal access and telemedicine. We need to leverage our experience in delivering top-notch otolaryngology care with the advantages inherent in having a patient-centered medical home and integrating best practices into these systems.

CAE, MAM

Challenges: I am excited about the opportunities these changes are going to bring to family physicians.

We are actively working to cultivate diverse future leaders in family medicine. We will do this by offering our members not only top notch CME, but enhanced networking and advocacy support.

Amy Klobuchar

MD, MBA

Challenges: Health care is changing rapidly with an increasing focus on bundled payments and team care, while higher education is struggling with declining state support. High quality facilities and faculty is critical to providing leading edge education, research, and care. Building partnerships to ensure necessary resources will continue to be a priority.

Rahul Koranne

U.S. Senate

MD, MBA, FACP

Changes: I have focused on bringing down the high prices of prescription drugs.

That’s why I’ve introduced the Medicare Prescription Drug Price Negotiation Act to empower Medicare to negotiate for the best possible price of prescription medication for seniors; the Safe and Affordable Drugs from Canada Act to help Americans access safe, affordable prescription drugs from Canada; and the Preserve Access to Affordable Generics Act to expand consumers’ access to cost-saving generic drugs.

Changes: In order to continue to deliver the best health care in the nation, Minnesota’s health systems are re-engineering the value chain of outpatient offerings, hospital care, and home and community-based services.

Financing innovations in Medicare and Medicaid are increasingly supporting these new delivery models.

Chief Medical Officer Minnesota Hospital Association

Challenges: The increasing prices of prescription drugs are a huge burden on families across the country. One in five Americans skip medication doses or decline to fill a prescription because of cost concerns. I’ll continue working with my colleagues from both sides of the aisle to pass these bills into law.

Challenges: Ensuring true patient, family, and community engagement with health care stakeholders; reducing burnout while increasing clinician satisfaction; and transforming the overall financing of health care in order to reduce the burden being placed on society remain mission critical work in progress. Information technology vendors and pharmaceutical companies will be key in supporting the goal of improving population health.

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Kelby K. Krabbenhoft

Gayle M. Kvenvold

Richard F. Kyle

President and CEO Sanford Health

President and CEO LeadingAge Minnesota

Chairman Emeritus, Department of Orthopaedics Hennepin County Medical Center

Changes: After significant growth from 2007 through 2013, we fully aligned our 1,500 physician clinics, care institutions, and health plan. All necessary competencies are established to support alternative payment models and maximize value for patients. Sanford also refocused its research efforts in areas with the greatest potential for patient care (genetics, genomics, immunotherapy, and cellular therapies).

Changes: Expanding our membership for a growing array of senior care services, particularly new configurations of housing, including services for both post- and pre-acute care and home and community based services—for example, we just merged with Minnesota Adult Day Services Association. Finding solutions to our growing workforce challenges is a priority, alongside performance and quality improvement.

Changes: We moved to computer documentation of all records for patient care from physicians, physician assistants, and nurses. Overall, the records are certainly more accessible and organized with computer navigation. Patients who are computer savvy have access to their information, which is good.

Challenges: Driving the shift from volume to value requires aligning interests external to Sanford, including consumers, employers, independent providers, government, and private insurers. Application of medical discovery is constrained by bureaucracy.

An efficient process to assess new treatments is as critical as ensuring their safety and efficacy.

Challenges: We’ll strive to find the common causes that ignite passion and fuel action among diverse constituents, while meeting the specialized needs of an individual member segment. Keeping pace with the unprecedented amount of experimentation in new service delivery and payment models, gathering and analyzing relevant data, and creating tools providers and consumers will need to work across siloes of care.

Challenges: We must make time for adequate patient contact including examination, counseling, and personal interaction during clinic and hospital visits despite time spent documenting on the computer. Communicating with patients on a personal level is incredibly important. I am concerned about the accuracy of entering data when providers want to save time and get back to patient care. Data that is not accurate when initially entered may lead to errors in patient care.

Jeff Lindoo

Richard L. Lindstrom

Jennifer P. Lundblad

Susan M. Markstrom

VP of Governmental and Regulatory Affairs Thrifty White Pharmacies

Founder and Attending Surgeon Minnesota Eye Consultants

President and CEO Stratis Health

Chief of Staff St. Cloud VA Health Care System

Changes: We expanded the use of technology for product fulfillment and product offerings to include specialty medications. We also engaged our pharmacists in clinical services to transition the community pharmacist from a provider of product to a provider of patient care services to help control the total health care spend.

Changes: We are growing 8–10 percent per year and will be opening a new facility in Woodbury next year. We continue to add new providers to help us meet expanding needs of an aging population and growing community. Our advances include: presbyopia correction surgery, minimally invasive glaucoma, advanced corneal transplantation, aesthetic and functional ophthalmic plastic surgery, and new therapies in dry eye and ocular surface disease.

Changes: Improving quality and safety continue to be our focus and we translate research into practice to improve care. The widespread recognition that the majority of health happens outside formal care settings has led us to test new models of care. Some of our most groundbreaking work has the community as the unit of improvement, reflecting the need to address population health and social determinants.

Changes: We have a strong commitment to providing highly accessible care. To meet that need, we developed and expanded our telemedicine program. Through multiple modalities, we are connecting veterans with physicians not only within our system, but throughout the nation. Additionally, the Choice Act was signed to further enhance access. Considerable effort and resources have been focused to stand up this program and develop strong networks with community hospitals and medical services.

MBA

RPh

Challenges: We want continued access to our patients through pharmacy network contracts and maintaining sustainable reimbursement for product and clinical services. We are working with state and federal legislators and regulators to ensure an environment that allows patients to receive the full benefit of a pharmacist’s clinical training and expertise from the pharmacy of their choice.

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MSW

MD

Challenges: The biggest challenge is managing decreased reimbursement while, continuing to provide high quality care, new technology, and an extraordinary patient experience. It is critical, and we are deeply committed, to enhance the value we bring to each individual patient; the third party payers; and the Minnesota and Midwestern community we serve.

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

MD

PhD, MBA

Challenges: It is an exciting time in health care, and we are thriving in the midst of change. Our new work requires creative and strategic thinking; disciplined approaches in engaging patients; focusing on the health of populations; developing meaningful collaborations; integrating care delivery across settings and into the community; and using robust data analytics.

Leota Lind CEO South Country Health Alliance

Changes: Building on our existing partnerships and care model, we met the increased demand for data to support value-based care and local health care reform initiatives. We are working toward implementing an HIE that will provide interoperability between disparate electronic medical records, and that allows us to work collaboratively with our providers and counties, coordinate services, and reduce costs.

Challenges: As we face an aging population and workforce shortages in our rural communities, technology that provides data and analytics becomes crucial to improving health outcomes, operational efficiency, and reducing costs as regulation increases and reimbursement continues to trend downward. We must continue to look for opportunities to collaborate with our communities to ensure access to quality and cost-effective local health care.

MD

Challenges: Recruitment of health care professionals is an ongoing challenge in today’s market. Connecting with our community non-VA partners requires strong care coordination and communication to assure seamless care. This can be challenged by an EMR that is separate and distinct from the private system’s records. Sharing medical information with our Choice Act community partners is often challenging.

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Ruth M. Martinez

Lawrence J. Massa

David McKee

Robert K. Meiches

Executive Director Minnesota Board of Medical Practice

President and CEO Minnesota Hospital Association

CMO, Integrity Health Network Northland Neurology and Myology, P.A.

CEO Minnesota Medical Association

Changes: Minnesota enacted the Interstate Medical Licensure Compact (IMLC) and we are working to issue expedited licenses in 2017. We are implementing legislative changes to statutes, including the addition of two new license types (genetic counselors and medical faculty); making modifications to the medical, physician assistant, and traditional midwifery practice acts, chapter 214 relating to temporary suspension of health provider licenses, and chapter 152 relating to mandatory prescriber registration; and expanding access to the prescription monitoring program.

Changes: We, along with our hospital and health system members have led significant work to improve health care quality and safety for patients and families across Minnesota. We are among a select group chosen to participate in the Centers for Medicare and Medicaid Services’ Partnership for Patients, to reduce preventable hospital-acquired conditions by 40 percent and readmissions by 20 percent.

Changes: The most significant changes at IHN relate to moving from a successful utilization of the shared savings model to the more demanding requirements of TCOC especially as it relates to our MSSP ACO. We established one of the first ACOs in the state and have continued collaboration between primary and specialty care physicians to establish optimal care protocols.

Challenges: We need to establish and orient a new advisory council for genetic counselors, develop applications and database requirements to manage and track new application and license information, train staff on new procedures, and engage in rule-writing and other implementation processes for the IMLC.

Challenges: Minnesota’s hospitals and health systems will strive to deliver the highest-quality health care; ensuring meaningful access and holding down the rate of health care cost growth. They will adopt and leverage new technologies and transform the way caregivers work together as a cohesive and coordinated team to improve the health of individuals over their lifetime and entire communities over generations.

Challenges: Penalties exist for groups that were high quality/low cost before establishing the ACO. Since success is defined by reductions in cost and improved quality metrics, IHN, is punished for its past success. We also face a CMS-invoked disadvantage in reimbursement relative to hospital-owned clinics.

We will continue to do more with less, while integrating data from numerous clinics over different EHR platforms.

Changes: We have worked to be more responsive to our members and the rapid changes in health care. We are helping Minnesota physicians to improve patient health, make Minnesota the best place to practice medicine, and strengthen the profession.

We have improved member needs through research, listening sessions, and policy conversations. We have also sought guidance from a wider range of physicians with diverse backgrounds.

Aaron J. Milbank

Steven Mulder

Jon S. Nielsen

Allison O’Toole

President Metro Urology

President and CEO Hutchinson Health

President and CEO Oakdale ObGyn, a division of Premier ObGyn of Minnesota

CEO MNsure

Changes: We are continuously adapting to the rapidly evolving medical landscape, including the changing payment model that is beginning to favor quality over quantity. It has been an exciting challenge to adapt, while continuing to provide the same high level of care to our patients. This has required a focus on value (quality divided by cost) while continuing to enhance our patients’ experience.

Changes: First, we completed our integration with Hutchinson Medical Center, our local 30-provider multispecialty physician group and adopted a common electronic health record. Our primary care clinics have become certified health care homes and we invested financial and staff resources to develop a truly teambased care model (including our formal collaboration with McLeod County Public Health).

Changes: We advanced our affiliation with Premier ObGyn of Minnesota, an independent divisional merger and have improved quality, access, and satisfaction for our patients. We have advanced gynecological surgical expertise and services for an ever-aging population of women, with a focus on minimally invasive surgical procedures and urogynecology. We’re offering more appointment times and an online patient portal.

Changes: Four years ago MNsure didn’t even exist. We’ve come quite a long way in our short history and are now considered the place for Minnesotans to shop and compare health insurance options, whether that’s for a private plan or one of Minnesota’s public program options.

Challenges: The downward pressure on fee-for-service reimbursement and upward pressure on expenses will continue to require us to find ingenious efficiencies to provide a high level of care. As a large, independent subspecialized practice, we are well positioned to thrive in this changing environment.

Challenges: Solving the financial riddle of moving from volume to value compensation models will be essential. As an independent community health system, we must determine the best corporate model to ensure that we can achieve our mission of “Advancing Health with our Community” into the future.

MA

MD

MS, FACHE

MD

MD

MD, FACOG

Challenges: One of our greatest challenges is maintaining our independent obgyn practice model, while continuing to work with most of the large health care systems.

Expanding our data analytics capabilities will require a forward-thinking approach that anticipates our patients’ changing needs and use of health care services. It will be a challenge to continue to provide patient-centered and individualized health care in our increasingly “commoditized” environment.

MD, MBA

Challenges: It is important to be inclusive and listen to all voices. We will continue to be challenged by physician dissatisfaction and burnout and shrinking resources. Staying true to our vision and mission, and having a laser-like focus on the most important initiatives where physicians can make a difference will be crucial for success.

JD

Challenges: We have done a lot in our short time, including helping to lower Minnesota’s uninsured rate to the lowest level in state history. Over the next four years, we will continue to increase health insurance awareness and work to make sure that all Minnesotans have access to quality, affordable coverage.

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Joel V. Oberstar

Vicki Oster

Mark S. Paller

CEO PrairieCare

Pediatrician and President Southdale Pediatric Associates, Ltd.

Senior Associate Dean and Professor of Medicine University of Minnesota Medical School

Changes: PrairieCare and PrairieCare Medical Group together have grown exponentially and now comprise one of the largest psychiatric group practices in Minnesota. Our efforts to provide each individual patient the psychiatric care they truly need have positively impacted patients from all parts of Minnesota and beyond.

Changes: The biggest change our organization made was moving to an electronic medical record system just over two years ago. This was a major change for us, and even though we were well prepared it has taken a long time for us to get back to a comfortable level of functioning.

Changes: The Medical School adopted a strategic plan that re-emphasizes research, education, and clinical excellence. We partnered with the state to develop Medical Discovery Teams focused on solving key health issues.

We opened the Clinics and Surgery Center focused on new models of care.

Challenges: We will continue to be challenged moving forward with our EMR, especially as we try to communicate electronically with other EMR systems. The Health Information Exchange is something that needs to be addressed by payers, hospitals, and the government so that a solution can be found!

Challenges: Our faculty must work to balance scholarly work and clinical service when research and academic funding is tight. Only by finding that proper balance can we effectively bring the benefits of an academic health system to all Minnesotans. We also need to develop an integrated academic health system to better serve the state and must continue to work with Fairview and others to accomplish this.

MD

Challenges: Deployment of innovative strategies to reduce morbidity and mortality, while achieving reductions in total cost of care will result in expanded access to mental health care across Minnesota. Partnering with primary care and specialty clinics, schools, and the use of televideo technologies are critical pathways to achieving these goals and more.

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MD

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

MD, MS

Erik Paulsen U.S. House of Representatives

Changes: I became the newest member of the Ways and Means Health Subcommittee last December. This position gave me the opportunity to successfully turn off the harmful medical device tax for two years, which means more Minnesota jobs and more investment in life-saving innovation.

I will continue to push for reforms to Medicare, so that it works better for both doctors and our seniors.

Challenges: Partisanship from both sides of the aisle continues to be a hindrance to enacting better policy.

Thankfully, I am second in the House for the number of members supporting my legislation and first in the Minnesota House delegation for writing bipartisan bills. By working together, we can overcome this partisanship and get things done.

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Emily Piper JD

Commissioner Minnesota Department of Human Services Changes: We serve more than 1 million Minnesotans a year, through programs such as child care assistance to services that help people stay in their homes as they age. Medical Assistance enrollment has more than doubled in the past decade, while we controlled costs through statewide competitive bidding and payment reform. We have begun to improve the child protection system and continue to do so.

Challenges: Improving the mental health system remains a top challenge as we expand community services and address issues in state-run facilities. Long term, our goal is to provide a full continuum of mental health services.

Rita M. Plourde

Jon L. Pryor

Brian Rank

CEO Hennepin County Medical Center

Co-Executive Medical Director Park Nicollet HealthPartners Care Group

Changes: We continue to grow our services in family medicine, with the integration of behavioral health and care coordination services. This growth provides us with the opportunity to focus on developing patient-centered services, involving patients and their communities in their health care experience, and growing access to care for all, regardless of their ability to pay.

Changes: The two changes that have improved our ability to advance care are the integration of the Hennepin Faculty Associates physician practice into HCMC and the continued expansion and adoption of Lean methodologies.

These efforts promote engagement of staff and allow us to align strategies across the organization improving patient care and business operations.

Challenges: Our challenges today and tomorrow are to be present, and expect and provide the highest standards of care with adequate insurance and financial reimbursement for all services.

We also want to welcome all patients, listen to their questions, and assist them in their healing journey while supporting and promoting a healthy community to live in. The challenge remains the goal: Continue to provide access to quality health care to all!

Challenges: With our high percentage of uninsured or under-insured patients, finances will always be a challenge.

Moving to a value-based care model, will pose challenges within the reimbursement methodology. We are investing in the infrastructure to align with a population health model, but payment models and financial incentives will need to be developed to support this transition and reward organizations that advance the health of our community.

Changes: Combining HealthPartners and Park Nicollet in 2013 enhanced our ability to support patients, families, and our community by finding new ways to offer high-quality care, reduce costs, and improve health.

Together, we’ve focused on improving all we do, particularly around mental health outcomes, health care disparities, children’s health, and chronic illness.

CEO Sawtooth Mountain Clinic, Inc.

MD, MBA

MD

Challenges: Aligning all we do to support our clinicians to provide high-quality, effective care that meets our patients’ needs, whether in person, online, or on the phone. In addition, continuing to build stronger connections across our care group to seamlessly provide the best care and best experience for those we serve.

SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Megan Remark MHA, MBA

Scott Riddle MBA

Rose Roach

MD

Changes: Our organization has made significant changes related to the ACA. We are working on a demonstration project with the state of Minnesota to form the only safety-net network Accountable Care Organization in the state. We are the only participating Indian Health Service funded in the United States to form an ACO. We remodeled our clinic facilities to reflect the ACO model and improve workflows and care coordination.

President and CEO Regions Hospital

CEO and President Walker Methodist

Changes: Neurological illnesses such as stroke and Alzheimer’s are among the leading causes of death in the U.S. and we’ve made significant investments in this area. In 2014, Regions Hospital became the first Joint Commission-certified comprehensive stroke center in Minnesota.

Next year, HealthPartners will open a neuroscience center dedicated to care, rehabilitation, and research. It will be the largest free-standing neuroscience center in the upper Midwest.

Changes: We developed the mission, vision, and values for our organization, which puts the customer first, followed closely by our employees.

We want to provide the best place to live for our customers and the best place to work for our employees.

Everything we do centers on this objective. We now not only focus on delivering excellent care but also providing superior service.

Changes: For decades, we have promoted effective RN staffing and safe working conditions for both patients and registered nurses in direct patient care, policy, and political arenas. In 2015, we partnered with police officers to create a law that established violence committees, preparedness plans, and de-escalation training. We also worked on system reforms to recognize health care as a human right.

Challenges: It is a challenge to find quality employees to meet the increasing number of older adults who are seeking senior housing and care.

The increase in demand is outpacing growth of the labor pool. We are going to have to be creative when recruiting and utilize technology to improve how we care for people.

Challenges: We want a Safe Patient Standard based on a nurse’s professional judgment of acuity, census, and daily needs. We need procedures to keep health care workers and patients safe from violent assaults in hospitals. We want to focus legislative, educational, and organizing efforts by advocating for the creation of a universal publicly financed, privately delivered health care system.

Challenges: By 2025, one in five Americans will be over the age of 65 and we must be prepared to meet the needs of our aging population. Our focus on providing state-of-the-art, patient-centered specialty care in areas of oncology, orthopaedics, and neurosciences will provide a needed community resource to address this challenge.

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

Patrick M. Rock

Executive Director Minnesota Nurses Association

CEO Indian Health Board of Minneapolis, Inc.

Challenges: The biggest challenge we face is related to funding from the Indian Health Service for the work that we do under the ACA. We also have to comply with ACA technology requirements that will require us to change IT platforms or modify them.

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Catherine M. Rydell CAE

Executive Director and CEO American Academy of Neurology Changes: We’ve expanded our leadership training programs and developed a clinical data registry currently in pilot phase. We’re working to identify the causes of physician burnout and find well-being tools to combat it. We continue to advocate for resources and assistance to our members for MOC and changes due to Medicare and Medicaid reimbursement.

Challenges: We want to expand and monetize our data registry to assure goals are met and patient care is improved. We want to continue to evolve our annual meeting to best meet the needs of all member segments and to build capacity to segment services to our members. We will strive to communicate MACRA implementation to our members in impactful ways.

Sue Schettle

Jeff Schiff

William F. Schnell

Medical Director Minnesota Department of Human Services

Vice President Orthopaedic Associates of Duluth

Changes: We have moved to address quality and efficacy more significantly in our health care strategies.

Our foci, on both specific issues (e.g., the ongoing opioid crisis) and more overarching efforts (e.g., accountable care models), align to create real mechanisms to provide greater value to those we serve and the Minnesota community.

Changes: We recently incorporated occupational and physical therapy services into our practice and expanded the range of surgical procedures to include outpatient hip and knee replacement. Additional changes involved technology, such as installing onsite digital X-ray and magnetic imaging equipment. We also implemented a new electronic medical record system.

CEO Twin Cities Medical Society

MD, MBA

Changes: We have deliberately moved away from the traditional role of a county medical society. It became apparent that we had to serve as convener, coordinator, and catalyst to advance public health initiatives such as tobacco policy, environmental health issues, and end-of-life care planning. That switch in focus has successfully increased revenue and more importantly, made a significant impact on the health and well-being of the patients that our members serve.

Challenges: I would say that competition is probably one of our biggest challenges. Once you create a successful model there are others that work to replicate it. There are also significant challenges that physicians are facing and joining their medical association is sometimes not top priority.

MD

Challenges: We need to make progress on real sustainable integration of services in health care and between health care and social services. We need to rethink quality measurement and improvement so that the efforts are meaningful to our communities and to our providers. This work must align to decrease disparities in health outcomes.

Challenges: Keeping up with the latest EMR technology is an ongoing challenge, and often the benefits are questionable. In our practice, the time and effort it takes to implement the EMR or the computerized physician order entry (CPOE) systems takes away from patient care. It’s very important to us to spend as much time with patients as possible.

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Jim Schowalter

David M. Schultz

Kathleen Sheran

Janice M. Sinclair

President Minnesota Council of Health Plans

Medical Director MAPS Medical Pain Clinics

Minnesota Senate

Former President Minnesota Academy of Ophthalmology

Changes: Council members made a huge commitment to make reform work in Minnesota. We are working more closely than ever before with hospitals, doctors, and the broader community to make sure people get the care they need in new and hopefully more convenient ways.

Changes: In 2014, we merged with a larger pain clinic to become part of a bigger, regional medical practice. This integration allowed us to reduce costs and gain financial stability in a rapidly changing and sometimes unpredictable health care marketplace. The merge created significant changes in our workflows, electronic infrastructure, and corporate culture.

Changes: Over the past four years, we have advanced numerous reforms in the area of health care. The largest change has been the implementation of the Affordable Care Act at the state level. We also passed a bill removing barriers for advanced practice registered nurses, giving more Minnesotans access to advanced health care.

Changes: The Minnesota Academy of Ophthalmology has had to become a stronger voice to advocate for and protect our patients’ access to high quality eye care.

Challenges: Declining reimbursement and restrictions in patient access to interventional pain procedures have reduced revenue at the same time that costs have increased. Computerized automation of systems increases efficiency, but maintaining a compassionate connection to our patients while using computers is challenging. Our challenge is to reduce the abuse and diversion of prescription opioids, while safely providing opioid medications to chronic pain patients who truly need them.

Challenges: As with all changes, the challenges ahead will be to keep them in place and continue to improve upon them. While we are pleased with the implementation of the ACA, there are certainly changes we can make to improve delivery and cost of care.

MPP

Challenges: We need to figure out a better way to deal with increasing medical expenses. Health insurance is so expensive because care is so expensive. Unless we come together and do something to slow down galloping prescription drugs and other medical expenses, none of us will be able to afford the care that we need.

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MD

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

RN, MS, APRN

MD

Challenges: It will continue to be a challenge to ensure the delivery of the best eye care as we strive to improve outcomes, reduce cost, and pursue technological innovation all at the same time.

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Cindy Firkins Smith

Deborah L. Smith-Wright

John Solheim

Tony Spector

President and CEO ACMC Health

Director of Pediatrics Shriners Hospitals for Children –Twin Cities

CEO Cuyuna Regional Medical Center

Executive Director Emergency Medical Services Regulatory Board

Changes: The most visible change is the transformation of our leadership team. Leaders who had served our organization for 10 to 15 years either retired or transitioned to new positions. In the last year we’ve welcomed a new chief administrative officer, CMO, medical director of quality and innovation, and I stepped into my role in January 2016.

Changes: Until five years ago, all care was provided free of charge. When we began to bill insurance, our mission changed to assisting families with out-of-pocket expenses that caused them financial hardship. The billing change necessitated multiple changes in resources, manpower, and clinical services. We continue to provide specialty pediatric orthopaedic care regardless of ability to pay.

Changes: The biggest change has been the explosive growth since we integrated with our medical staff. We have recruited more physicians and built a $16 million renovation that includes a new OR suite, PACU, and outpatient area.

Our new EMR and financial reporting systems gave us one platform between the hospital and clinic, which has been beneficial to our patients.

Changes: This agency has become more transparent, collaborative, and mission-focused. The Board has been more engaged in establishing policies that address emerging issues that impact the public’s health and safety generally and the EMS system specifically. Staff have operationalized and executed these policies with integrity, with responsibility, and with professionalism that includes timely responses to our clients, our stakeholders, and our partners.

MD

Challenges: We have ambitious goals to transform health care delivery in rural Minnesota, while keeping patients first. We must transition to a system where we are reimbursed for the value we deliver. We will be challenged by geographic, age, economic, social, and racial diversity when we design systems for our communities. Our biggest challenge will be to recruit talented and committed providers and support staff.

MD

Challenges: As an independent hospital system, we anticipate facing an increasingly competitive environment where hospitals and clinics are merging and forever changing the medical landscape.

We anticipate in order to compete as a standalone specialty center, we will need to embrace the use of technology such as telemedicine and other programs to provide our care in an affordable, efficient, and accessible manner.

MA, FACHE

Challenges: The biggest challenge in the future is to remain an independent medical center as health care consolidation continues. We are converting to a 501-(c)3, which will give us more flexibility in a competitive environment. We need to recruit a quality workforce to meet the growing demand of medical services and manage the infrastructure needed to ensure quality outcomes while moving toward population health management.

MA, JD

Challenges: As new and emergent diseases and hazards pose greater threats to the public, this agency must be proactive in establishing standards that serve the public and protect the EMS professional. In addition, we must be at the forefront of creating guidelines and benchmarks for those EMS provider categories created to address gaps in the health care system.

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Keith Stewart

L. Read Sulik

Allison Suttle

Lori Swanson

Carlson and Nelson Endowed Director Mayo Clinic Center for Individualized Medicine

Chief Integration Officer, PrairieCare Executive Director, PrairieCare Institute

Senior VP and Chief Medical Officer Sanford Health

Minnesota Attorney General

Changes: For every patient to benefit from precision medicine the Mayo Clinic Center for Individualized Medicine continues to make significant advances to employ genomic sequencing to reach the correct diagnosis faster, provider safer drug prescribing, and identify novel treatments for cancer. Transforming how we deliver care to our patients, results in better-informed care and outcomes, reduced side effects, earlier interventions, and increased prevention and prediction of disease.

Changes: The PrairieCare Institute has developed innovative approaches to integrating behavioral health services into primary care, specialty care, and employer clinics. The Institute houses the headquarters for our Integrated Health and Wellness Clinics that are now in six different primary care sites serving a total of 15 clinics here in the Twin Cities.

Changes: We have worked to prepare our organization for value-based health care. The delivery model for primary care needed redesigning to better meet the needs of patients. For example, we’ve implemented options for virtual care and created a teambased medical home. Additionally, our integrated structure has allowed Sanford to standardize care delivery to remove unnecessary variation and improve quality.

Changes: This is a period of significant change in our health care system. As insurance costs rise, more patients are shifted to high deductible health plans. The problem is that many families can’t afford these high deductibles. We have also seen patients impacted by increases in prescription drug costs.

MB, ChB, MBA

Challenges: To revolutionize how we improve and treat disease through precision medicine, we need to rapidly modernize the treatments and diagnostics.

We also need to improve and maintain efficiency, productivity, and quality to provide high quality, affordable outcomes at a low cost. This requires intentional efforts to innovate to determine if new methods produce better results.

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MD, FAAP, DFAACAP

Challenges: We are keeping up with growing demands for the innovative, Integrated Health and Wellness Clinics. We are building teams of talented behavioral health specialists committed to flexibility, adaptability, innovation, and patient-centered and partner-centered care. We are now partners with companies that are self-insured and recognize that their commitment to their employees’ health and wellness is their secret to success!

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

MD, MBA

Challenges: The new model of health care demands adaptability. Sanford will need to maintain a workforce and have mechanisms in place to incentivize value-based health care.

Technology is an extraordinary tool, but it’s important to keep medicine a personal and connected experience. It’s critical that we leverage the valuable data collected to impact outcomes.

JD

Challenges: Our state faces many challenges: Competition is the best regulator of rates and services, and I’m concerned about consolidation.

Rising health insurance costs continue to squeeze employers and individuals.

The system must ensure that financial incentives in ACOs don’t result in undisclosed rationing. The system also lacks capacity and resources to properly serve the mentally ill.

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Paula M. Termuhlen

Paul Thissen

Jon Thomas

Regional Campus Dean University of Minnesota Medical School–Duluth Campus

Minnesota House of Representatives

Minnesota Commissioner Interstate Medical Licensure Compact Commission

Changes: The biggest change for our campus has been the recruitment of new leadership with fresh ideas to reinvigorate our campus mission to serve rural and Native American communities through research and medical education. Education and health care are becoming increasingly interprofessional. We have embraced this goal with enthusiasm.

Changes: The biggest change we’ve seen is the proliferation of new models of care delivery and risk assignment.

Minnesota is a creative, exciting place to be as someone who thinks hard about how to fit new ideas into outdated regulatory boxes.

Changes: As chair of the Federation of State Medical Boards in 2013–2014, I shepherded development of the Interstate Medical Licensure Compact Commission legislation. This set forth the idea of a compact, which is an agreement between states that would facilitate and expedite medical licensure. The goal is that once a qualified physician has a license in one of the compact states, he or she would be able to become licensed in any or all of the other compact states within days to weeks. This will facilitate licensure, mobility of a qualified physician workforce, and telemedicine.

MD

Challenges: While Minnesota is one of the healthiest states, it also has some of the largest health disparities, particularly in its Native American and rural communities. We hope to promote health equity through research and practice. Funding for research of all types is challenging and yet essential to ensure better understanding of disease.

JD

Challenges: The biggest challenges we face as a state government and in the private/non-profit sector of health care is moving away from a discussion of health insurance reform (which is where the conversation has been) and into true health care reform. How do we deliver high-quality health care services to everyone as inexpensively as possible and how do we make the tremendous amount of health care data work for us while balancing privacy concerns?

David Tilford

MD, MBA

Challenges: The biggest challenges are political barriers and the erroneous belief that this is somehow related to MOC.

President and CEO Medica

Changes: The ACA has impacted nearly every segment of our business.

Changes to the individual market have resulted in new opportunities, but great challenges. Our Medicaid business has grown significantly due to how the state awards that business.

We have begun to make changes in our Medicare business as we prepare for the sunset of the Medicare Advantage program.

Challenges: Affordable health care is our biggest challenge. Advancements in medical technology and treatment are exciting. At the same time, we need to use health care dollars wisely and efficiently. The individual market continues to be a challenge. Insurer losses on ACA plans nationwide are expected to run into the billions. It will take time for pricing and medical expenses to get in line.

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100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Christopher Tillotson

Ensor E. Transfeldt

Misty Tu

Jeffrey L. Tucker

President and Musculoskeletal Radiologist Consulting Radiologists, Ltd.

Spine Surgeon, Twin Cities Spine Center Medical Director, Allina Spine Program

Senior Medical Director for Psychiatry and Behavioral Health Blue Cross and Blue Shield of Minnesota

President and CEO Integrity Health Network

Changes: Our biggest change has been converting to a completely physician-led practice. In the past, we had utilized a non-physician CEO. Our reasoning is that only through physician leadership could the group fully realize its potential and be in a position to respond to the rapidly changing health care environment in the upper Midwest. Also, the high degree of physician involvement promotes cohesion and more fully leverages our intrinsic talents.

Changes: We have moved from a boutique spine surgery practice toward an integrated, comprehensive spine practice with other providers and health systems. The partnership with Allina has allowed us to focus on patient-centric care. Measurement of outcomes and costs makes it possible to eliminate waste and encourage continuous quality improvement, while reducing costs.

Changes: We are deeply committed to advancing health equity. We are proud to have made a healthy difference over the past few years by increasing access to healthy food and improving conditions where Minnesotans live, work, and play. Finally, behavioral health is a growing area where we need to continue asking the right questions in order to make progress.

Changes: We launched a Medicare Shared Savings Program ACO and a state of Minnesota Medicaid ACO through the Integrated Partnership Program. We received grant dollars from the State of Minnesota State Improvement Model to help us develop and implement a health information exchange. Additional funding allowed us to develop a regional accountable community for health (ACH).

Challenges: The biggest challenge is to pay for services, without sacrificing quality. We don’t have enough mental health care inpatient beds or a robust enough outpatient and safety network. Funding is available, but that won’t help if we aren’t offering the right services at the right time.

These are some of our most vulnerable members, and they need us to do the best job we can.

Challenges: A rapidly evolving health care market taxes our clinics’ ability to respond and apply limited resources.

We need to find ways to make each initiative sustainable and keep partners at the table (counties, hospitals and clinics). Increasing government regulation and decreasing reimbursement and resources has accelerated consolidation in the Minnesota marketplace and caused the loss of independent clinics in large numbers.

MD

Challenges: We are a large independent physician group and wish to remain so. There is a fair amount of uncertainty as to how to maintain a successful practice as we move further into the ACO era. For example, what is the best approach, configuration and size to navigate in this rapidly changing environment?

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MD

Challenges: The biggest challenges these changes face are: Providers across the continuum must embrace the changes needed. An integrated network must be created and maintained throughout a vast population and geographic area. Consensus needs to be achieved among providers regarding care pathways.

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

MD

EFPM

100 INFLUENTIAL MINNESOTA HEALTH CARE LEADERS

Paul E. Van Gorp

Tim Weir

Penny Wheeler

Cody Wiberg

Family Physician CentraCare Health–Long Prairie

CEO Olmsted Medical Center

President and CEO Allina Health

Executive Director Minnesota Board of Pharmacy

Changes: From my perspective as a small-town rural family physician, there have been two major changes for us in the past few years: our teambased care pilot project to improve the care of those with chronic disease, and our drive to build a new medical campus to serve our community.

Changes: Many of our recent changes relate to our continued patient engagement initiatives, care redesign efforts, and market share growth strategies.

Employee and provider recruitment and retention continue to be critical for our ongoing success.

Changes: We increased our focus on supporting health in addition to responding to illness. We also invested in community collaborations (even with competitors!), which improved the community’s health, while improving affordability and decreasing unnecessary duplication of services in our community. We worked with HealthPartners on the ACO-like NW Alliance; Mother-Baby partnered with Children’s; we merged with Courage to create Courage-Kenny; and worked with the state on Integrated Health Partnerships.

Changes: The Board has worked on legislation to tighten the regulation of compounding pharmacies, allow pharmacists to administer vaccines to children 13 years of age or older, improve our Prescription Monitoring Program (PMP), and allow pharmacies to collect unwanted drugs for disposal.

MD

Challenges: We need to put a succession plan in place to ensure continuity of quality care. We currently cover the bases with a relatively young group of advanced practice providers, but our physician leaders are nearing retirement and must be replaced and expanded to allow comprehensive care to continue. Furthermore, growth will be necessary to cover the cost of the new facility.

MA, MBA

Challenges: Ongoing declining reimbursement, coupled with required capital and IT obligations, will continue to challenge our organization. Additionally, change management skill sets that are required to be successful in a rapidly changing health care delivery system, will be critical. We will see challenges related to employee satisfaction and retention as our patients expect their care to be available in a variety of delivery models.

MD

Challenges: Declining revenue will have us reduce costs, while we invest in new models of care (not yet paid for) that support the health of our community (such as mental health resources, care management, data/information systems to improve care, etc.) We’ll also shift our thinking to value-based services for volume-based successes.

PharmD, MS, RPh

Challenges: We continue to have problems with compounding pharmacies that are not fully complying with the laws. It has been difficult to get PMP legislation passed, due to concerns about data privacy. Prescription drug abuse has become an epidemic, making it a challenging issue to respond to, but the Board is working with many other state agencies to address it.

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EYE CARE

Styes Treat quickly to avoid complications

By Tina M. McCarty, OD, FAAO

A

stye is a painful, red bump at the edge or the inner surface of the eyelid, caused by a bacterial infection of oil-secreting glands. While most styes clear up quickly with home remedies, there can be long-term consequences.

Inside and out The clinical term for stye is “hordeolum.� There are two types: An external hordeolum appears at the edge of the upper or lower eyelid margin, where the eyelid meets the eyeball itself. If one

36

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

of two oil glands (Zeis or Moll) becomes infected, it can produce a pimple-like stye, often topped with a white head.

An internal hordeolum forms in the inner eyelid, typically a few millimeters away from the eyelid margin, as a result of infection in a third oil-secreting gland (meibomian). Internal styes resemble external styes, displaying a bump or lump.

While treatment and long-term impacts vary slightly, both external and internal styes are typically caused by bacteria in the Staphylococcal family. Staph bacteria live on the surface of our skin

and are usually harmless, but when they infect the glands in the eye, they may produce pain, redness, and tenderness starting a day or two before the visible lid lump or bump of a hordeolum appears.

If a chalazion becomes recurrent, especially if it is recurrent in the same gland, a biopsy should be performed at removal to test for any potentially cancerous skin cells.

Treatment The quicker a stye is treated, the less likely it is to develop more significant problems. Initially, a warm compress held over the infected eyelid gland, followed by eyelid massage with an eyelid soap, is often enough to work out the blocked material in the gland.

Prevention Several behavioral and health factors may increase your risk of developing a hordeolum.

This warm compress could be as simple as a hot washcloth held against the affected area for 3–5 minutes (being careful not to burn the delicate eyelid skin). Some patients also have success using a clean, long sock filled with rice and heated in a microwave, then applied to the infected area. There are also several commercial eye masks that can be heated and used to loosen the trapped contents of the infected gland. In each of these approaches, the warmer the gland and the contents inside, the easier the infection will be to work out.

Most styes clear up quickly with home remedies.

Poor eyelid hygiene. Patients may be very good at washing their hair and face routinely, but they can easily forget to pay close attention to the eyelid margin. Over time, oil and dry or dead skin can build up and eventually block one of the glands on the eyelid margin, creating a perfect scenario to develop a bacterial-induced eyelid infection.

Blepharitis. This inflammation of the eyelids causes red, irritated eyelids and possibly the formation of dandruff-like scales on the eyelashes. It is a common eye disorder caused by either bacteria or a skin condition such as rosacea that affects people of all ages.

Although uncomfortable, blepharitis is not contagious.

Meibomianitis. This specific type of blepharitis is an inflammation of the meibomian glands, a group of oil-secreting (sebaceous) glands in the eyelids with tiny openings that spread oils onto the outer layer of our tears. When these glands are inflamed, production of this oil layer increases. Tears then evaporate quickly, causing

Styes to page 38

It is critical to apply manual, digital pressure to the eyelid bump to help work the infected material out. Lid massage should be performed with warm, soapy water, working in a fashion to expel and push the contents of the infected eyelid gland toward the surface of the eyelid. For infections in the upper lid, massage downwards. For infections of the lower lid, massage upwards. There are a number of commercial eyelid soaps—formulated to target the oil that can collect at the eyelid margin—that are gentle enough to be used near the eyes. Baby shampoo is also an alternative.

If the hordeolum is persistent or the symptoms are troubling, an antibiotic or an antibiotic/steroid combination can aid in a quick recovery. If the hordeolum is external, it is relatively easy to apply a topical antibiotic or antibiotic/steroid combination in the form of a drop, suspension, or ointment. If the hordeolum is internal, a topically applied pharmaceutical will have a difficult time reaching the infection and often is not useful. In these instances, an orally administered antibiotic can be effective.

Typically, a hordeolum isn’t contagious. The antibiotic is applied to improve comfort more quickly and to lessen the risk of forming a chalazion, an internal “eyelid bump” that often evolves from an internal hordeolum. A chalazion is non-infectious and is not painful, but it does leave an annoying bump or cyst below the eyelid surface. If a chalazion is relatively new, it can be worked out with aggressive warm compresses, followed by eyelid hygiene and eyelid massage. If the chalazion has been present for more than a few weeks, it can require steroid injection or surgical excision.

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37

Styes from page 37

bumps. These are usually not painful and are seen on a baby’s face, but not on the eyelid margin itself.

a burning, dry sensation and possibly red, irritated eyes. This type of inflammation is a leading cause of dry eyes. Rosacea and meibomianitis often co-exist and some call meibomianitis “ocular rosacea.”

I believe that blepharitis and meibomianitis are very common and are two of the most under-diagnosed eye diseases seen by eye care providers. Chronic and undertreated cases of each disease are leading causes of hordeolum and ultimately chalazion.

Xanthelasma—raised, yellow patches of varying size seen around the eyelid margin—are filled with cholesterol. These chronic patches are relatively flat and are not painful. Patients with xanthelasma should have their blood cholesterol evaluated.

Conjunctivitis (“pink-eye”) can result from infection (bacterial or viral), an allergic response, or inflammation associated with the lining that covers the sclera (the white part of the eye) or the inside lining of the lids. There is typically not a cystic bump, and the eyelids are usually not involved.

Proper eyelid hygiene… is critical to preventing styes.

Proper eyelid hygiene, especially if you have blepharitis, meibomianitis, rosacea, or a natural tendency to develop extra oil along the eyelid line, is critical to preventing styes. Cleansing this area nightly can go a long way to protect eyelid glands from becoming clogged and later infected. In addition to eyelid hygiene, it is always a good idea to remove all makeup before going to bed.

Stye or not?

Patients often confuse these other conditions with styes:

Milia, typically seen in very young people, are skin flakes trapped in glands just below the skin surface that produce white

Conclusion Whenever infection or inflammation develops in or near the eye, the quicker it is diagnosed and treated, the better the outcome in terms of speedy resolution and limited longterm complications. Seeking care from an eye care professional is advised and can make all the difference.

Tina M. McCarty, OD, FAAO, is a Diplomate of the American Board of Optometry and a partner at the Eye Care Center in Maple Grove, Fridley, and Maplewood.

August 2016 Survey

M I N N E S OTA H E A LT H C A R E

C O N S U M E R A S S O C I AT I O N

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited.

2. I am aware of the range of conditions that are described as autoimmune diseases.

60 50

50

50 40

40 30 20 10 0

Strongly Agree

Agree

No Opinion

Disagree

4. I understand the therapeutic options available to treat autoimmune diseases.

Strongly Agree

Agree

No Opinion

Disagree Disagree

Strongly Strongly Disagree Disagree

60 50

70 50 60 40 50

Percentage of respondents

Percentage of respondents

38

10 10

5. I am aware that family medical history and/or ethnicity may predispose an individual to autoimmune disease.

60 80

30 40 30 20 20 10 10 0

60 40

40 30 30 20 20

0

Strongly Disagree

Strongly Strongly Agree Agree

Agree

No Opinion

Disagree

Strongly Disagree

50 40 40 30 30 20 20 10 10 0

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2016

3. I understand the symptoms of autoimmune diseases.

Percentage of respondents

60 Percentage of respondents

Percentage of respondents

1. I understand what is meant by the term “autoimmune disease.”

Strongly Agree

Agree

No Opinion

Disagree Disagree

Strongly Strongly Disagree Disagree

35 50 30 40 25 30 20 15 20 10 10 5 0

Strongly Agree

Agree

No Opinion

For more information, please visit www.mnhcca.org.

We are pleased to present results of the most recent survey.

Disagree Disagree

Strongly Strongly Disagree Disagree

JOIN US.

Be heard in debates and discussions that shape the future of health care policy. There is no cost to join this informed and informative online community.

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org SEPTEMBER 2016 MINNESOTA HEALTH CARE NEWS

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rehabilitate T oowith rehabilitate aa body, body, we we start start with the the mind mind and and soul. soul.

If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. That’s our approach. treats your body, mind and soul. That’s our approach.

Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area. outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.

To make a referral or for more information, call us at To make a referral or for more information, call us at (888) GSS-CARE or visit www.good-sam.com/minnesota.

(888) GSS-CARE or visit www.good-sam.com/minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, stateGood or local laws. Some services may housing be provided a thirdtoparty.

All faiths or beliefs are welcome.

2015color, The Evangelical Lutheran Goodfamilial Samaritan Society.

All rights 15-G1553statuses according The Evangelical Lutheran Samaritan Society provides and by services qualified individuals without regard to©race, religion, gender, disability, status, national origin reserved. or other protected to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. © 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553