Vo l u m e X X I X , N o . 5 A u g u s t 2 015
Reducing hospitalization for seniors The role of a life care manager By Joel Theisen, RN, and Dave Moen, MD
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s the impetus for value-based care continues to grow, reducing hospital admissions for seniors remains a top priority for payers and providers alike. According to the 2014 Healthcare Cost and Utilization Project Statistical Brief on hospital stays, spending on hospitalizations accounted for 29 percent of all health care expenses, making them one of the most expensive types of health care treatments. In 2014, nearly 18 percent of Medicare patients who were hospitalized were readmitted within a month, costing an estimated $26 billion, with $17 billion coming from potentially avoidable readmissions. For Minnesota, the impact has hit 27 percent of the hospitals with 36 being penalized for high readmission rates. There remain large-scale opportunities for further reductions and cost savings.
Dealing with high utilizers No easy solution By Robert L. Kane, MD
H
ealth care’s movement toward a value-based model increases the pressure to reduce costs. Two cost reduction targets immediately come to mind: 1) eliminating unnecessary or ineffective care, and 2) addressing high utilizers. It has long been recognized that a small group of patients (of every age) account for a disproportionate amount of care. For health care organizations, patients who use a lot of services pose a problem. High utilizers have become
While physicians have readily available solutions for acute problems, there have been inadequate and often unmeasured solutions for chronic and complex health and social problems, especially in the community. The easy way out was all too frequently to send them to the Emergency Department (ED). In fact, new Reducing hospitalization for seniors to page 12
pariahs because they make disproportionate demands for care that make poor economic sense in a fixed-price environment. Even if payers cover their costs, high utilizers challenge clinicians to find ways to address their multiple complex interactive needs. Care providers seek effective ways of managing these complex cases. Continued effort is feasible (and desirable) if value-based payment Dealing with high utilizers to page 10
L ife. We help people get back to it! 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.
To make a referral or for more information, call us at (866) 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, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. Š 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G0933
August 2015
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Volume XXix, No. 5
Features Dealing with high utilizers
1
No easy solution By Robert L. Kane, MD
Reducing hospitalization for seniors The role of a life care manager By Joel Theisen, RN, and Dave Moen, MD
MINNESOTA HEALTH CARE ROUNDTABLE
1
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
8
Jim Schowalter, MPP
Radiation oncology By Elizabeth H. Cameron, MD, MPH
Policy
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Pediatrics
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The future of health care By Timothy A. Johnson, JD, and Julia C. Marotte, JD
Electronic health care By Jeffrey Weness, MBA, and Laura M. Gandrud, MD
Health equity for the LGBTQ community By Mary Beth Dahl, RN
RADIOLOGY
The Minnesota Council of Health Plans
FORTy-FOURTH SESSION
HEALTH DISPARITIES 18
Behavioral Health Integration Thursday, November 12, 2015 • 1:00-4:00 PM Downtown Minneapolis Hilton and Towers
Pharmacology
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ADMINISTRATION
28
Physician/pharmacist collaboration By Cory Nelson, PharmD; Kyle Turner, PharmD; and Jaskiran Sandhu, MD
New pathways to care
24
A new era in coding By David K. Haugen, MA, and Terence Cahill, MD
Special Focus: Oncology The skyways of cancer By Emil Lou, MD, PhD
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Cancers of the neck and head By Deepak Kademani, DMD, MD, FACS
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Background and Focus: Increasing evidence supports the link between access to mental health care and reducing health care costs. Primary care physicians often lack the expertise to diagnose behavioral health correctly and are not always able to easily refer a patient to a mental health care provider. Many initiatives nationwide are addressing this issue. It is so important that the ACA stipulated the development of the Behavioral Health Home in 2015. Some states, including Minnesota, are also creating Behavioral Health Home programs. Objectives: We will review numerous initiatives that support the development of new pathways to behavioral health care. We will introduce new ideas and discuss how to incorporate them into our health-care delivery system. We will examine the value they can bring and the challenges they will face. Our panel of industry experts will outline the steps that must be taken to increase the overall access to mental health care and the broad improvement in population health that this increased access will bring. Panelists include: • Sarah Anderson, MSW, LICSW, CEO, Psych Recovery, Inc. • Lee Beecher, MD, President, Minnesota Physician-Patient Association • Judge Kerry W. Meyer, Hennepin County Criminal Mental Health Court • Jane Pederson, MD, Medical Affairs Director, Stratis Health • Jeff Schiff, MD, MBA, Medical Director, MN Dept. of Human Services • L. Read Sulik, MD, Chief Integration Officer, PrairieCare Sponsors include: • MN Dept. of Human Services • PrairieCare • Psych Recovery, Inc. • Stratis Health
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HealthPartners Offering Online Treatment for Anxiety and Depression HealthPartners has implemented an online self-help program to treat patients with mild and moderate depression and anxiety. The program, called Beating the Blues, is based on cognitive behavioral therapy. Patients go through eight weekly sessions that take about 50 minutes each. They identify their specific problems, determine what causes them, and learn techniques and skills to cope and break the cycle of negative thinking and behaviors. The patients’ physician will receive progress reports after each session, but otherwise all the information they enter into the program is anonymous. According to Beating the Blues, the research shows that the program is just as effective
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as drugs in treating mild and moderate anxiety and depression, and is more effective at preventing the problems from reoccurring. HealthPartners is the first in the region to offer it.
Abortions Increase After Several Years of Decline The number of abortions performed in the state rose by 2.2 percent last year, according to an annual report from the Minnesota Department of Health. There were 9,903 abortions in 2013 and 10,123 in 2014. This was the first time Minnesota’s abortion rates increased since 2006, when 14,000 abortions were performed. The highest increase in abortions was among American Indians, at 5 percent. Rates also rose slightly among Asian Americans and decreased
Minnesota Physician August 2015
slightly among whites and African Americans. However, the majority of abortions performed were among white women, at 5,336. About 90 percent of all abortions took place in the first trimester of pregnancy; the rest took place in the second trimester. Obstetrics and gynecologists performed about 69 percent of the procedures; the rest were performed by general or family practice practitioners with the exception of three cases that were performed by emergency medical workers. According to the report, 85 percent of women who had abortions in 2014 were unmarried; 91 percent were from Minnesota; 76 percent were between 20 and 35 years old; 60 percent had never had an abortion before; 58 percent had previously given birth to at least one child; and 66 percent didn’t use contraceptives at the time of conception. The most common reason women gave for having an abortion was that
they did not want children at this time, while 74 women said the reason was that their pregnancy was a result of rape and 13 said it was a result of incest.
Preventable Health Care Visits Added $2 Billion in Costs More than 1.2 million emergency department visits and 72,000 hospital admissions that were potentially preventable cost Minnesota employers, health plans, and individuals almost $2 billion in 2012, according to a study from the Minnesota Department of Health (MDH). “Minnesota has one of the most efficient and cost-effective health care systems in the nation, but this study shows we still have room for improvement,” said Ed Ehlinger, MD, Minnesota commissioner of health. “Equipped with these findings, we will work with
providers and community leaders to ensure patients more consistently receive the right care, in the right place at the right time.” Researchers analyzed data from the Minnesota All Payer Claims Database to estimate how many patients made potentially preventable hospital and emergency department visits. Potentially preventable health care events were defined as those that “possibly could have been avoided under the right circumstances such as timely access to primary care, improved medication management, greater health and health system literacy, and better coordination of care among clinicians, social service providers, patients, and families,” according to the report. These visits accounted for about 4.8 percent of total health care spending in Minnesota in 2012. However, the authors note the potential savings could be misleading because not all events were actually preventable, and that prevention measures that could have been taken would have meant added costs in other areas. Results of the study show that as many as 50,000 Minnesotans each had at least four potentially preventable emergency department visits each in 2012, and that Medicaid patients accounted for 40 percent of emergency department visits though they only make up 14 percent of the population. The most common diagnoses for potentially preventable emergency department visits were infections of the upper respiratory tract (9 percent), abdominal pain (7 percent), and musculoskeletal system and connective tissue diagnoses (7 percent). Within preventable hospital visits, about 50,000 were regular admissions and about 22,000 were readmissions. The most common conditions for potentially preventable hospital admissions were pneumonia, excluding when it is related to bronchitis and respiratory syncytial virus (13 percent), heart failure (12.1 percent), and COPD (8.1 percent). The most common conditions for potentially preventable readmissions were heart failure (6.6 percent),
blood infection and disseminated infection (5.1 percent), and major depressive disorder and other unspecified psychosis (3.5 percent).
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an option for you: took part in an industry stan651-232-3111 | |healtheast.org/cyberknife 651-232-3111 healtheast.org/cyberknife dard benchmark study designed To learn more or to find out if more is out if CyberKnife is 651-232-3111 |CyberKnife healtheast.org/cyberknife To learn or to find to measure the level of IT anhospitals option for you: adoption in U.S. and an option for you: health systems. The survey was 651-232-3111 | healtheast.org/cyberknife conducted by Health Forum, 651-232-3111 | healtheast.org/cyberknife an American Hospital Association information company, who distributed, collected, and analyzed the data and developed benchmarks for measuring IT adoption. Organizations were identified as foundational, core, advanced, expert, or leader in 6514-122457 CyberKnife Star Tribune ad.indd 1 3/10/14 11:06 AM each of four focus areas for use of IT—infrastructure; busi6514-122457 CyberKnife Star Tribune ad.indd 1 ness and administrative management; clinical quality and safety; and clinical integration. 6514-122457 CyberKnife Star Tribune ad.indd 1 3/10/14 11:06 AM More than 740 respondents 6514-122457 CyberKnife Star Tribune ad.indd 1 3/10/14 11:06 AM representing 2,200 hospitals participated in 2015, and a total of 338 were recognized on the Most Wired list, which is in its 17th year.
The Minnesota organizations recognized on the 2015 Most Wired list include HealthCapsules to page 6
August 2015 Minnesota Physician
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Partners, based in Bloomington; Kittson Memorial Healthcare Center in Hallock; Mahnomen Health Center; Mayo Clinic Hospital in Rochester; Perham Health; and Windom Area Hospital. In addition, RiverView Health in Crookston was recognized as on The Most Wired–Small and Rural list, and Winona Health was recognized on The Most Improved list. “After more than a decade of building the foundational elements of a digitized health care environment, and billions of dollars in federal and private sector spending, hospital and health systems are tapping into the power of the bits and bytes they’ve been collecting,” Hospitals & Health Networks magazine said in a statement. “This coincides not only with the requirement to meet federal standards for meaningful use of health information technology, but also the push toward value-based payments, popula-
tion health management, and cost-efficiency.” According to the survey results, 96 percent of the Most Wired hospitals use intrusion detection systems, compared to 85 percent of all participants; almost 80 percent of Most Wired hospitals conduct incident response exercises each year, compared to about 40 percent of all participants; and more than 75 percent of Most Wired hospitals use portals and electronic health records to exchange results with other organizations, while only 56 percent of all participants do so. Overall, the most significant improvement in 2015 was in patient engagement.
New Risk Factors for Long-Term Opioid Use Identified One in four patients who are prescribed opioid painkillers
Gregory L. Barth, M.D. Merrill A. Biel, M.D., Ph.D. Carl A. Brown, M. D. Thomas E. Christenson, M.D. Karin E. Evan, M.D. William J. Garvis, M.D. Matthew S. Griebie, M.D. Michael B. Johnson, M.D. Nissim Khabie, M.D. Jeffrey C. Manlove, M.D. Darren R. McDonald, M.D. Michael P. Murphy, M.D. Michelle C. Naylor, M.D. llya Perepelitsyn, M.D. Julie C. Reddan, M.D. Benhoor Soumekh, M.D. Jon V. Thomas, M. D. Rolf F. Ulvestad, M.D. Larry A. Zieske, M.D.
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Minnesota Physician August 2015
for the first time progress to long-term prescriptions, according to results from a study at Mayo Clinic. The increase in opioid addiction and accidental overdoses prompted researchers to identify which patients are at the highest risk. “Many people will suggest it’s actually a national epidemic,” said W. Michael Hooten, MD, anesthesiologist at Mayo Clinic. “More people now are experiencing fatal overdoses related to opioid use than compared to heroin and cocaine combined.” Researchers used a random sample of 293 patients from the Rochester Epidemiology Project, funded by the National Institutes of Health. Each patient had received a new opioid painkiller prescription in 2009. After analyzing the data, researchers found that 21 percent of the sample group had progressed from short-term use to prescriptions lasting three to four months. And 6 percent
progressed even further to a prescription lasting more than four months. Patients who had a history of tobacco use or substance use were at the highest risk for long-term use of opioids. Hooten says this is because the neurobiology related to chronic pain, chronic opioid use, and addiction is similar. He says it’s important for physicians to be careful about prescribing opioids to patients with a history of tobacco or substance use and to use a minimal dose and limit the duration of opioid use in order to lessen the risks of patients progressing to longterm use. “The next step in this research is to drill down and find more detailed information about the potential role of dose and quantity of medication prescribed,” said Hooten. “It is possible that higher dose or greater quantities of the drug with each prescription are important predictors of longer-term use.”
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Medicus Charlie Lakin, PhD, has received the Minnesota Department of Health (MDH) and the Minnesota Board on Aging’s Policy Award at the 2015 Minnesota Age & Disabilities Odyssey Conference in Duluth. The award is in recognition of Lakin’s 40 plus years of work improving policies for people with intellectual and developmental disabilities, Charlie Lakin, which also effected change at national and PhD international levels. Lakin served as director of the Rehabilitation Research and Training Center on Community Living at the University of Minnesota’s Institute on Community Integration for more than 30 years and as director of the National Institute on Disability and Rehabilitation Research for three years before retirement. He earned his doctor of philosophy degree in educational psychology at the University of Minnesota and master of arts and master of education degrees in special education from Teachers College, Columbia University in New York. Cindy Firkins Smith, MD, has been elected as the new president and CEO of Affiliated Community Medical Centers. Smith has been with ACMC for 25 years, practicing dermatology and dermatologic surgery. She also serves as a clinical professor at the University of Minnesota in the department of dermatology and was Cindy Firkins appointed to the Blue Ribbon Commission on Smith, MD the University of Minnesota Medical School by Gov. Mark Dayton in 2014. Smith previously served as president of the Minnesota Medical Association and is currently an alternate delegate for the American Medical Association. She earned her medical degree from the University of Minnesota, where she also completed her dermatology residency, and completed a transitional internship with Hennepin County Medical Center. Smith will step into the role on Jan. 1, 2016, succeeding Ronald Holmgren, MD, who has served in the position for 15 years and recently announced plans to retire in late December. William Roberts, MD, MS, FACSM, professor of family medicine at the University of Minnesota and director of the St. John’s Hospital Family Medicine Residency Program, has received the American College of Sports Medicine (ACSM) 2015 Honor Award in recognition of his outstanding contributions to the field. Roberts William Roberts, earned his medical degree at the University of MD, MS, FACSM Minnesota, where he also completed a residency, and received a subspecialty certification in sports medicine through the American Board of Family Medicine. Roberts has been the medical director for the Twin Cities Marathon since its inception and has spoken internationally on marathon medicine. He has been a member of ACSM since 1982, where he has served as president of ACSM and the ACSM Foundation Board, and is currently the editor of ACSM’s clinical journal.
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August 2015 Minnesota Physician
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Interview
Coordinating agendas, promoting ideas What is the mission of the Minnesota Council of Health Plans?
What is the Council of Health Plans working on that would be of special interest to physicians?
The Council is a collaborative effort to enable Minnesota’s health plans to work together and connect with the broader community to improve our health care system. We are grounded in a vision of high standards of care; broad access to health care coverage; affordable health care services; and information and attitudes to constantly improve our system.
Jim Schowalter, MPP The Minnesota Council of Health Plans Mr. Schowalter joined the Minnesota Council of Health Plans as its president/CEO in January 2015. In this role, he works with all of the state’s nonprofit health plans to pursue high quality and affordable health services for all Minnesotans. Prior to assuming this role, Mr. Schowalter served in leadership roles for the state of Minnesota. Most notably, he was appointed by Gov. Dayton as his commissioner at Minnesota Management & Budget as a key advisor on critical fiscal, budget, and policy issues. Mr. Schowalter received his master’s degree in public policy from the Kennedy School of Government at Harvard University and his bachelor’s degree with a major in economics from Macalester College.
The first area of collaboration is in building the next phase of MinnesotaCare. We have enjoyed the benefits of roughly 20 years of sound public policy that has led to broader coverage and more opportunities for Minnesotans. However, with the planned phase-out of the provider tax looming, we need to assess the future. The provider tax was the most broad based, and therefore the most fair funding source. MinnesotaCare didn’t have to compete with other state priorities and revenue increased as health care Tens of thousands costs increased. If the repeal of the tax of Minnesotans have remains, how is the benefit going to be health coverage who paid for? We need to come together to didn’t have it before. ensure that current successes are sustainable in the future.
What’s unusual about the Council is that we have perspectives that span the entire health care system, from the clinic or hospital where service is delivered, to the treatments, devices, and drugs that heal and manage disease all the way up to population health. Our connections with people who manage all of these services make the discussions at the Council unique. We want to use our understanding and connections to keep making our community healthier.
Fortunately, I came into this role with our team already doing well. The Minnesota Business Partnership recently released a McKinsey study that showed Minnesota at or near the top in quality and access. My job is to lead the Council so that we continue that success and build support for policies and ideas where we need to do better. What unique perspectives does your experience at Minnesota Management & Budget bring to your current position at the Council? I am acutely aware that the spending growth is not sustainable and have seen firsthand how the growth in health care spending substantially closes off options for other priorities like education or community supports. I believe that change is coming and that connectors like the Council will help us better prepare and manage that change. My work of coordinating agendas and promoting ideas also transfers to the Council. As a key adviser to the governor on critical fiscal, budget, and policy issues, I identified and managed the concerns of 23 cabinet agencies and dozens of smaller organizations. The process of listening, prioritizing, and communicating is at the heart of the Council’s work and a big part of my new job. Finally, I bring a growing appreciation of cross-sector solutions to tough policy issues. In health care, progress will have to come from everyone so the public and private sectors build upon each other’s strengths, not just shift the costs or blame.
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Minnesota Physician August 2015
Council members are also actively looking at the drug prior authorization (PA) process and how it can work better. We initiated a discussion among the health plans that has led to an ICSI (Institute for Clinical Systems Improvement) project to assess what prior authorization does, what it misses, and how it works end to end. Though the Council is not part of the group, its efforts will help clarify problems and potential solutions. I do not want anyone to think we will completely eliminate PA. It is a tool used by many purchasers, including the federal government and self-insured companies. It simply cannot be swept out of the marketplace, as there are cost and patient safety concerns that it can address. What can you share with us about the work that the Council does with the Minnesota Legislature? The Council’s work at the Legislature is to explain the policies and challenges that the health plans see in the marketplace. For the last several years, the discussion has revolved around implementation of the Affordable Care Act (ACA) and its many operational and policy impacts. The facts are confusing and with so much changing it is even harder for legislators to make an informed decision. Thankfully, they keep trying to learn and we keep trying to help connect the dots. What goals do you have for your tenure as the president and CEO of the Council? My goal is for the Council to be a connection point. We have tremendous, local organizations delivering coverage and care. The Council’s unique viewpoint, understanding of market information, and history of collaboration can help our state improve.
The trick is understanding the health care “system.” When we work together with other experts, we can better diagnose the system’s problems. If we just do that one thing well, our public policies will provide improvement that people will see in their day-to-day lives. Tell us about the Center for Community Health (CCH). The CCH brings together 21 local public health agencies, hospitals, and health plans in the seven-county metro area to improve the health of our community. CCH serves as a catalyst to align the community health assessment process and create action plans to address top public health concerns. The Council is proud to be a part of this important work.
difficult to implement and carry with them some level of uncertainty. You need look no further than MNsure and the individual market to see that forecasting the future isn’t easy. That doesn’t mean that we are necessarily on the wrong track, but it does underscore the work before us to stabilize insurance markets. What are some of the successes and problems the health plans have faced when working with MNsure?
Our success is simple—tens of thousands of Minnesotans have health coverage who didn’t have it before. The challenge is holding together the enrollment process so that people get the insurance services they deserve. There are a lot of technical problems on the state side that are slowly being worked out and we all hope for a better end-to-end product this year. But no matter what, physicians From a health plan perspective, what are the biggest pros and cons of the Af- should understand the level of effort and personal fordable Care Act as it moves forward? sacrifice that has been made at the county, state, and partner health plans. It’s thanks to the hard The ACA makes a profound change by ensuring work of many individuals that more Minnesotans that everyone can access health insurance. We in than ever before have health insurance coverage. Minnesota have been somewhat shielded from this concern because we had a successful high-risk ofWhat changes are occurring in how fering, but as a nation this is a huge improvement. Minnesotans get health care coverage? The biggest con is the oversized expectations For some Minnesotans the change is huge. of the reforms. The changes in the market are
Three patients. Who is at risk for diabetes?
For others, not much has changed. The increase in income guidelines ($16,105 for an individual) and the elimination of the asset test provides more access to Medical Assistance through ACA’s Medicaid expansion. Funding from MNsure to community organizations that offer in-person enrollment help has also increased coverage. On the commercial side, the change continues for individuals and families who buy coverage on their own in the individual market—about 6 percent of Minnesotans. The ACA defines their coverage and lets them choose a health plan without fear of being denied because of a pre-existing condition. With that peace of mind for individuals comes unpredictability as health plans learn more about the health care needs and associated costs of new enrollees and price premiums to reflect the cost of care. While more than 70 percent of Minnesotans aren’t seeing much change because the ACA didn’t significantly alter self-funded employer or Medicare coverage, these groups aren’t immune from the effects of the unsustainable growth of health care costs. With the ACA’s substantial reforms, we all must turn our attention to the more thorny issues around the cost of care.
When there are no signs or symptoms, you may not know until it’s too late. Act now. Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk. • Refer your at-risk patients to a proven lifestyle change program and help cut their risk of developing type 2 diabetes in half.
1 in 3 adults are at risk!
• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications. Find groups in Minnesota at www.health.mn.gov/diabetes/programs
Minnesota Department of Health DIABETES PROGRAM
August 2015 Minnesota Physician
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Dealing with high utilizers from cover
adequately recognizes the costs involved. Within a closed system of capitation payments, an internal business case holds that it makes sense to improve primary care for high utilizers if it will reduce hospital and post-hospital care. In more traditional fee-for-service systems, payers (especially government payers) are offering rewards and inducements to take on the tough cases. The health care home is an example of such a program, although the price may not yet be correctly set. High utilizers use a lot of medical services, whether measured by volume or cost. They are often referred to as “frequent flyers.” Any good spreadsheet can flag them. Superficially they share some basic characteristics. They tend to have multiple diagnoses and chronic conditions. For example, the 14 percent of Medicare beneficiaries with six or more conditions accounted for 46
percent of Medicare spending. When it comes to younger patients, who are on average typically healthier, the disproportionate utilization is even more obvious. Here, other fac-
Describing the high utilizer problem is much easier than fixing it.
tors like addiction and mental illness play a larger role. These comorbidities make it less likely that these patients will play a productive role in addressing their care. High utilizers typically see a lot of doctors because they have a lot of problems. Presumably,
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no one has taken charge so they visit a lot of doctors because their problems are not being adequately managed. This is the rationale for aggressive coordinated management
Minnesota Physician August 2015
strategies. Emerging models of proactive primary care closely monitor patients (at home) and track their status by computer. As long as the patient stays on the expected clinical trajectory, nothing is done. But if the patient’s status deviates outside the confidence limits, the patient is seen immediately and evaluated to understand the developing problem before it becomes a crisis. In patients with multimorbidity, each condition can be monitored. This approach eschews the scheduled return appointment in favor of seeing patients when their change in condition dictates. It is obviously feasible only with patients who can cooperate but it reinforces the concept of patient-centered care. Treating a high utilizer Describing the high utilizer problem is much easier than fixing it. High utilizer patients across the age spectrum share a common bond. They are hard to treat effectively. Managing an individual chronic disease can be challenging, but dealing with the interaction of several is a much greater task. The challenge is more multiplicative than additive; some would even suggest it is exponential. Older patients with multimorbidity are virtually walking chemistry sets, and are at risk for poor medication compliance and drug interaction problems. The obvious answer is that someone needs to take charge and
coordinate the care, but that is no easy task. Alas, treating all of their problems well (i.e., following the guidelines for each problem) threatens to do more harm than good. While every guru of chronic disease management exhorts us to actively involve the patient in his or her care, younger patients with mixed portfolios of medical and mental disease and older patients with cognitive impairment are hard to involve in self-management plans. The downside for providers At the very least, health care programs should not be penalized for taking on (or being assigned) high utilizers. The traditional payment remedy for high utilization has been case mix adjustment, but providers complain with good cause that this is an inexact science. Predicting utilization works pretty well for groups, but poorly for individuals. This problem may be less of an issue for health care corporations that enroll large numbers across a population because averages may indeed average out; but it is a big problem for individual practices with limited clientele where a big variation around a modest-sized set of cases can make a big difference in payment error. To entice clinicians into aggressive innovative care management, estimates of the extra demand used to create risk adjustments should err on the generous side, at least until they can be honed. Addressing high utilizers Programs to address high utilizers have existed for a long time. Coming up with a solution typically involves teams with representatives from many different professions. Such “big team” care is not efficient, especially if the team needs to meet often to coordinate its efforts. Nor is it necessarily effective. The jury is still out on the various approaches to addressing complex care, and the early returns do not offer much optimism. At the moment, enthusiasm has replaced evidence because we rely on what feels right without necessarily
testing it. As reflected in the projects funded by the Center for Medicare & Medicaid Innovation, the key phrase is scalability. Can a program be operationalized and replicated?
resources: coaching, caregiver workshops, and support group meetings. It showed no effect on frequency of use of emergency departments, hospitals, or skilled nursing facilities.
While there is some room for many different opinions, I believe that we still have a long way to go. The overall picture is not encouraging, although a few programs have been carefully tested. (A more complete list of project summaries is available from the author.) The GRACE program The GRACE Team Care program, developed at the University of Indiana, is built around home-based care management of frail older patients by a nurse practitioner and a social worker collaborating with a primary care provider and a geriatrics interdisciplinary team. The underlying rationale holds that more effective primary care will prevent expensive catastrophes. To aid the primary care team, the program developed 12 care protocols: • Difficulty walking/falls • Memory loss • Urinary incontinence • Depression • Malnutrition/weight loss • Chronic pain • Visual impairment • Health maintenance • Hearing loss • Advance planning • Medication management • Caregiver burden The initial demonstration project showed better results in four of the eight SF-36 scales, which are commonly used to assess function and quality of life. There were no differences in activities of daily life or death; there were fewer emergency department visits; and hospitalizations were not different overall but were lower in the high-risk group. Guided Care Guided Care, a model developed at Johns Hopkins, relies on non-physician clinicians and encompasses patient education and referral to community
An underlying question in this process to create effective care is what constitutes evidence. Medicine likes to describe itself as evidence-based but how strong is that base
Fourteen percent of Medicare beneficiaries … accounted for 46 percent of Medicare spending.
IMPACT Variations of the IMPACT approach to coordinating primary care and depression treatment have reported some success (especially in treating the depression), but the Minnesota version, the DIAMOND project, could not be sustained because of problems coordinating payment. In addition, a number of larger organizations, like Kaiser Permanente and Geisinger, have implemented models that address the high utilizer problem, but they have not been formally evaluated. The Center for Medicare & Medicaid Innovation is investing millions of dollars in projects that will be hard to evaluate in a rush toward scalability. It is not clear if 1,000 flowers or 1,000 weeds will bloom. Conclusion Chronic disease and multimorbidity remain the clinical challenges of our decade. Some clinical groups will take up the challenge because they recognize its social significance. The rest will find themselves struggling with the problem whether they want to or not. We need to find more effective ways to address the issue. We need good evidence of what constitutes good care in this arena. Unfortunately the research results have not been encouraging. But neither can we afford to wait for someone else to find the solution.
and how strong does it need to be? Randomized trials work in many areas but are harder to pull off around complex interventions. In contrast to medicine, the business world relies on a very different empirical basis for strategic decision-making. Their rate of innovation is incompatible
with strict trials. They rely on rapid cycling. So is comprehensive care in response to high utilizers more like drug therapy (which needs a strong causal effectiveness foundation of proof) or more like a new product ready to market? The projects currently funded by the Center for Medicare & Medicaid Innovation seem to reflect this style of thinking. No one disputes that the key to success is learning how to manage high utilizers, not just because they use resources but also because they have the most problems. Ultimately the question is how to do it on a budget, but maybe we have to do it first and then worry about efficiency later. Robert L. Kane, MD, is a professor who holds the Minnesota Chair in Long-term Care and Aging at the University of Minnesota School of Public Health, where he also directs the Center on Aging and the Minnesota Evidence-based Practice Center.
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August 2015 Minnesota Physician
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Reducing hospitalization for seniors from cover
research published in the Annals of Internal Medicine (June 2015) shows that ED re-visits after an initial ED encounter actually more than double (8 percent above the previously reported rate of 3 percent) and are often more costly. This drive toward fewer hospitalizations and ED visits has created a shift toward providing more care in the community where people live their day-today lives. Community-based care has been, in many ways, a black hole for physicians with few practitioners working in the community and getting brief, if any, glimpses into effective models. While outcomes from programs such as Medicare home health agencies have become standard, few programs outside the Medicare realm are producing outcomes, and yet this private-pay arena for non-medical care is not only one of the fastest growing in the
country, it is pivotal for affecting readmissions. Measurable communitybased outcomes Value-based contracts reward providers for paying attention to all factors that influence a person’s health and well-being. Social isolation and a person’s purpose (reason for being) play roles that are as important as physiological risk factors such
hip, providers may first have to identify grief as an issue and heal her broken heart. According to the National Institutes of Health, with the shift toward providing more care in the community there is a need “for proven treatments and approaches that not only provide measurable outcomes but also take into account patients’ wishes and preferences.”
Seniors experience other life challenges beyond physical challenges. as high blood pressure, obesity, or physical inactivity. Under new payment structures, providers will need to go beyond physical ailments to identify such issues as grief, social isolation, and lack of purpose as contributing factors for poor outcomes and increased rehospitalizations. For example, to fix Betty Ann’s broken
Physicians—as health care leaders—need to be able to evaluate different options based on measurable outcomes. How can they know what works unless providers measure their results and track them over time? The best way to avoid overusing the ED and hospital is to create accessible and capable community-based teams that build relationships with patients and families over time. Care plans informed by a clear understanding of patient and family goals help physicians address inevitable changes that people will experience once they’re home. In the new home care frontier, smart teams supported by engaged and accountable physicians are emerging as a key driver of value, especially for the highest-cost patients. Tracking hospitalization and ED visits Within this environment, Life sprk has been providing population health management for seniors through a combination of care management and home care services in the Twin Cities metro for 10 years. In response to marketplace dynamics, we have developed a whole-person senior care model designed to respond to these problems. In 2014, we undertook a comprehensive effort to fine-tune this model and develop ongoing outcomes management protocols through surveys and other work.
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We work with partners and industry leaders to define which Minnesota Physician August 2015
key indicators to track. From a long list of options important to different stakeholders, we settled on tracking hospitalizations and ED visits along with quality-of-life indicators including connectedness, happiness, control, and engagement. As we set up the capabilities and technology to track these outcomes on a more sophisticated ongoing basis, we undertook a baseline study. For the baseline, our company gathered the data through client/family interviews using an external evaluator and reviewed our medical records. The study looked at client experience one year prior to working with our organization and then during a year while working together. The baseline study included clients who had initiated services within the last two years. Longer-term clients were eliminated due to the challenge of gathering accurate, self-reported data regarding their experience prior to using our services. The study involved 221 people and examined their actual experiences. Clients lived in a variety of settings spanning from single-family homes to senior campuses where we served as the in-home care provider. The study found a 73 percent reduction in hospitalizations and a 52 percent reduction in ED visits for community clients (n=58) and a 42 percent reduction in hospitalizations for all clients regardless of setting with a 37 percent drop in ED visits. Starting in December 2014, we instituted an ongoing outcomes tracking effort to measure rehospitalizations and ED visits for all new clients as well as quality-of-life indicators using the National Institutes of Health’s PROMIS (Patient Reported Outcomes Measurement Information System) tool. PROMIS is a responsive assessment tool that is used globally. Efforts are also underway to enhance the risk stratification of client data. Our overall goal is to prove the efficacy of our whole-person senior care approach, while simultaneously providing continuous data to refine the model.
Reducing rehospitalization Seniors experience other life challenges beyond physical challenges. When left unchecked, these life issues can lead to frequent ED visits and hospitalizations. This isn’t just a “health care” issue, it is a life issue. A study by researchers at Boston’s Beth Israel Deaconess Medical Center (Annals of Internal Medicine, June 2015) found that many of the risk factors for readmissions, especially those occurring eight days or longer post-discharge, are beyond the typical scope of hospital efforts, and include such issues as socioeconomic status or access to support systems. Yet once the patient is home, these changing risk factors play a very real role in the potential for rehospitalization, especially when chronic conditions are present. These risk factors create the need for a comprehensive approach that goes beyond the scope of transactional home care services. Our whole-person senior care model builds patient engagement right from the very start with a goal to “spark lives,” which means to actively engage people in identifying and achieving their priorities for living a richer, more fulfilling life with as much independence as possible. The model, which includes private-pay home care services as needed, is also designed to plug in to many different types of partner organizations—from health systems and physician clinics to senior living campuses, and even employers and associations—to expand their reach into the communities where patients live. We achieved these outcomes through several key program components: Assigning a life care manager All clients are assigned a dedicated Life Care Manager (LCM). A registered nurse, the LCM becomes an ongoing guide and coach for all aspects of well-being, not just health issues. LCMs collaborate closely with physicians, clinics, hospitals, home health, and hospice providers, as well as any other service involved in supporting the client and family.
An often missing, or shortterm, component in other approaches, the LCM becomes a hub for the team of providers involved in the client’s care. LCMs cross all settings and work with every type of provider. They become the eyes and ears in the client’s home, providing hands-on support to implement the physician’s care plan at home and address such critical needs as support for physician appointments and medication management. LCMs
services. Through our experience, we have seen how these discussions effectively engage clients’ enthusiasm and active participation in their life plans, which helps to achieve positive outcomes. One 105-year-old client was so enthusiastic about her well-being she decided she wanted to regain the strength to be able to walk into her 106th birthday party, and she did, producing health ramifications that tied directly to her outcomes.
A growing body of research points to the need for a long-term coordinated team approach to reduce hospitalizations. also examine the broader realm of psycho-social and non-medical needs along with client wishes. A growing body of research points to the need for a long-term coordinated team approach to reduce hospitalizations and foster patient success at home. LCMs also partner with clients and families to provide a wide range of practical, proactive support and services to safeguard seniors against life challenges and improve their quality of life. The end result is that issues and crises are caught early. Having a purpose A whole-person discovery process is designed to engage clients. Our whole-person approach uses a structured, collaborative discovery process that engages clients to identify and prioritize their preferences as the main focus of their individual life plan. The discovery tools use specific questions to review seven elements of well-being, including 1) identity, 2) social support, 3) purpose and passion, 4) finances, 5) health and wellness, 6) home and safety, and 7) thinking and memory. The issues of social support and client engagement explored through discussions of people’s purpose in life are often missing in traditional provider
Avoiding gaps in care A flexible, long-term approach eliminates gaps in support. Most reimbursed services are episodic with limits to their duration and scope. These limits create gaps
with little support, ongoing guidance, or continuity for the client beyond a 30- or 90-day post-acute period. Our model provides ongoing, long-term support that adjusts based on a client’s need to ensure there are no gaps in support. Addressing social isolation A combination of evidence-based algorithms and creative approaches is used. Clinical pathways are well established for conditions such as heart failure and pneumonia, but lacking for emerging issues such as social isolation. Several studies in JAMA Internal Medicine (formerly the Archives of Internal Medicine, July 2012) detail how factors such as social isolation undermine health and well-being, and need to be addressed to stop rehospitalizations and improve outcomes. Yet few physicians address it, or even ask patients about it. Our model not only Reducing hospitalization for seniors to page 38
American Diabetes Association EXPO Healthcare Professional Breakfast Saturday, October 11, 2014 at 7:00am Minneapolis Convention Center Meeting Room 103 DEF What are the Most Effective Weight Loss Interventions for Diabetes and Prediabetes Presentation by Dr. Charles Billington, MD Losing a few pounds can dramatically improve health and quality of life especially for people with diabetes and prediabetes. Effective weight loss can involve multiple techniques and strategies including lifestyle changes, medication and surgical options. Please join us for an informative discussion on the most effective weight loss interventions for those with diabetes and prediabetes as well as how to guide your patient through the weight loss process. Objectives: Compare the range of approaches for weight loss Describe the body’s physiologic mechanisms to protect against weight loss Identify ways to support a patient working to lose weight 7:00 am - 8:15am Breakfast, Networking, Presentation and Discussion RSVP on-line at http://diabetesmn.wufoo.com/forms/hcp-breakfast-rsvp/ Space is limited. Please RSVP by Friday, October 3, 2014 Event is free of charge and open to all healthcare professionals to attend August 2015 Minnesota Physician
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Policy
D
Telephone Equipment Distribution (TED) Program
espite the challenge of the fast-changing pace of the health care industry, it is imperative that physicians keep current with the changes to be properly prepared. Increased consumer demands, the evolution of technology, and ever-increasing pressure from lawmakers and regulators to reduce health care costs are pushing the industry into new realms. While physicians may wish to fight some of the changes, it appears that such a strategy is generally not successful in the long term—it is inevitable that the industry today will look very different from the industry in five, 10, or 20 years. This article touches on five general categories where the industry is expected to experience continued change. These categories include: 1) reimbursement, 2) care delivery models, 3) practitioner licensure, 4) technological advances, and 5) fraud and abuse enforcement.
The future of health care What lies ahead for physicians By Timothy A. Johnson, JD, and Julia C. Marotte, JD
Reimbursement It is well-recognized that the growth in health care spending is not sustainable. Historically, federal and state governments have tried various approaches to control this growth. Unfortunately, most of these approaches have shown limited success. The most recent government initiative to try to reduce health care spending was the enactment of the Affordable Care Act (ACA) in 2010. The ACA represented a major shift by the federal government in
Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.
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Minnesota Physician August 2015
controlling health care spending by focusing on ways to shift health care reimbursement from a fee-for-service approach, which encouraged providers to offer more services, to an approach that paid providers based on the quality or outcomes of their services. The ACA was the impetus for the development of Accountable Care Organizations (ACO) as well as Centers for Medicare & Medicaid Services’ (CMS) new and ambitious goals for shifting provider reimbursement from volume based, such as fee-for-service, to value-based reimbursement (see Minnesota Physician article, June 2015). Given the amount of attention and government funding to this value-based reimbursement approach, it is only a matter of time before these approaches are adopted by commercial plans. In addition to the transition to value-based reimbursement, employers and health plans will continue to shift health care costs on to the patient. As a result, consumers will become more frugal and make more thoughtful decisions regarding their medical care. In light of the expected health care reimbursement changes, physicians should spend time thinking about their practice and how they can best be prepared. Physicians should become familiar with these upcoming reimbursement changes and plan a course of action that best suits their practice. New care delivery models While the growth in health care costs are causing employers, plans, and the government to reassess their reimbursement
strategies, it has also resulted in the outgrowth of new delivery models. In response to consumer demands for easy access to low-cost health care services, innovative providers are introducing new care delivery models. A classic example is the introduction of retail clinics such as MinuteClinic at CVS and Target Clinic. These clinics have grown exponentially in recent years. They appeal to consumers because they offer efficient and low-cost services, provide flexibility by way of walk-in appointments, and have undeniably convenient locations. While, historically, the services provided by retail clinics have been limited, it is likely that with technological advancements and consumer acceptance of such arrangements, the retail clinic model will move beyond providing just a few limited services to providing more complex diagnostic and treatment services. For example, orthopedic providers have discovered that certain emergent and urgent orthopedic services are well suited to being marketed and delivered to consumers using the retail clinic model. In addition to retail clinics, the Internet is fertile ground for innovative parties to develop creative ways to provide health care services. Today, the Internet is probably a consumer’s greatest resource for information about health care conditions and illness. As a result, Internet-based providers of diagnosis and treatment services have become readily accepted. For example, the use of HealthPartners’ virtuwell product by consumers has grown significantly since its introduction. The virtuwell product bills itself as a 24/7 online clinic, combines retail clinic principles with online accessibility, and is in perfect harmony with today’s technology-driven consumer. Physicians should think about how their current practice can meet the needs of this evolving consumer, which may mean exploring innovative care delivery models that provide flexible and convenient health care services.
and physicians should expect in technology have also been to see new and innovative uses cited as a primary reason for of technology to investigate and the increased cost of care. recoup improper payments. For While there will continue to be example, CMS’ Fraud Prevenadvances in expensive diagnostion System uses predictive tic and treatment technology algorithms and other sophissuch as the use of robotics in ticated analytics to evaluate surgeries and more advanced billing patterns imaging capaagainst every bilities, for most Medicare physicians it is fee-for-sermore importThe growth vice claim. ant to monitor The Fraud advancements in health care Prevention that impact spending is not System has the their specapability to cific medical sustainable. stop payment specialties. of improper For primary claims eleccare physicians, tronically by their time sending a denial message to should be spent monitoring the provider’s claims payment the significant technology system. In only its second year advancements that not only of operation, this program help patients monitor and recovered or prevented more improve their health, but also than $210 million in improper diagnose medical conditions. The focus on wellness programs payments. As a result, CMS plans to extend the application has prompted a significant of the Fraud Prevention System growth in products and and has other pilot projects services. For example, there
Timothy A. Johnson, JD, is a principal at Gray Plant Mooty and a member of its Health & Nonprofit Organization Practice Group. Julia C. Marotte, JD, is an associate at Gray Plant Mooty and a member of its Health & Nonprofit Organization Practice Group.
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Fraud and abuse enforcement Along with the vast growth in health care spending, there has been an increased focus on enforcement actions to reduce fraud, waste, and abuse by providers. This focus will continue
Planning for the future The transformation of the health care landscape is unavoidable. The good news is that, armed with the right tools, the future is exceptionally bright. With good education and appropriate planning, physicians have the ability to ride the wave and take their practice into new domains.
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Technology There is no question that technology plays a critical role in the health care industry. While advancements in medical technology are credited with improving the care provided to patients, advances
underway to combat health care fraud and abuse. With this increased focus on cutting-edge enforcement technology, physicians should continue to monitor their billing procedures to ensure standard practice is in line with federal and state laws and regulations.
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This trend can be attributed to many factors, including both the shortage of primary care physicians as well as the reduction in reimbursement for such services. Regardless of the reason, the use of APRNs and provider assistants is expected to increase as more state agencies become comfortable with granting them greater authority to provide care. As a result, physicians should explore how they may use these professionals for the benefit of their practice, such as to improve efficiency or shift their focus to more complex services that receive higher reimbursement.
has been a surge of wearable accessories for individuals such as fitness tracking devices made by Fitbit, Jawbone, Nike, Apple, and others to help patients monitor their fitness activities. Similarly, there has been a large growth in downloadable medical-related applications used by individuals. The innovation and development of personalized, technology-driven health solutions will be a significant focus of the industry in years to come. Because of their popularity, it is important that physicians stay current on these innovations. Some of these new services and products may be useful aids for physicians in treating patients, especially as ways to encourage patients to increase their exercise regimen, participate in weight loss programs, and better monitor health goals.
CON T
Practitioner licensure As the health care industry evolves, so does the regulation of health care professionals. One common trend that is expected to continue is the expansion of regulatory authority of non-physician providers. As regulatory agencies begin recognizing that certain health care services may be provided by qualified non-physicians, these agencies are more willing to expand the services these non-physicians may provide. For example, most states now have laws regulating the scope of services that may be provided without physician supervision by one or more types of Advanced Practice Registered Nurses (APRNs), which include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives. For example, starting in 2015, Minnesota permits qualified licensed APRNs to practice independently, without physician supervision. In addition to the expansion of authority of APRNs, there has been significant growth in the types, programs, and use of provider “assistants” such as physician assistants, physical therapist assistants, and medical assistants.
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Pediatrics
I
f you walk down the health technology aisle of a major retailer you’ll observe a tremendous variety of activity tracking devices—Fitbit, Jawbone, Garmin, Misfit, and others. But look closer and you’ll see the emergence of the next generation of devices that address more specialized areas: Kinsa, a smart thermometer; Mimo, a smart onesie; Sproutling, a “Fitbit” for babies; and the iHealth suite of products including blood pressure cuffs, scales, and glucometers. Online you’ll find products like AliveCor, a smartphone connected ECG or CellScope, and a smartphone connected otoscope. All of these products can be alluring for the tech-savvy parent. But all of the data from these devices can be overwhelming to a health care provider. Until recently the data from these sensors had little use in a clinical setting. The data lived in a proprietary app and cloud with little connectivity to any clinical setting. Advances in secure integration are turning that disconnected data into
Electronic health care Logging on to your children By Jeffrey Weness, MBA, and Laura M. Gandrud, MD
actionable information when coupled with proper clinical oversight. Pediatrics and health technology As these emerging health management tools gain greater traction, they will impact clinical interactions across the patient spectrum—none more so than for pediatrics. As parents adopt these technologies with their children, particularly those with chronic conditions such as diabetes and asthma, clinicians will need to become adept at using these new sources of information. Through this persistent connectivity, we can
improve health outcomes and lower costs for many patients. Three years ago, fitness trackers were primarily for “early adopters.” Now fitness trackers are everywhere, from wrist-worn bands to those embedded in phones, watches, clothing, and even car seats. Consumer-grade pediatric health devices will likely follow a similar path. As we think of innovation in health devices, who better than kids and young parents to lead the charge? Kids love technology, as do many young parents. Neither group has a fear of technology; in fact, they embrace technology more than any other generation.
Plus, they give honest feedback. Mobile technology is firmly entrenched in their everyday lives. It’s entirely possible that a baby born today could have every heartbeat in their lifetime monitored and digitized. From a baby’s smart onesie to wearable heart rate monitors to integrated sensors in mattresses, automobiles, and other everyday items, every aspect of their life might be quantified, and available to their health care team at the touch of a button. The challenges Creating meaningful action from this onslaught of data is a tremendous challenge. Text alerts for sports scores, online posts, and weather are ubiquitous, but you are a passive recipient of that type of information. Parents, kids, and providers will need to become engaged and responsive users of health care data. Systems to alert the parent of a chronically ill child of a meaningful health event are not readily available. Until recently, the parents of a diabetic child had to “hack”
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Minnesota Physician August 2015
into their children’s glucose monitor to access the information in real time. Providing this relevant health information (glucose levels, pollen count, etc.) at the right time and in a format that achieves the greatest engagement for parents and health care providers is a top priority for many digital health companies today, however this is not without challenges. Four primary challenges exist in the pediatric health monitoring space: regulation, market size, data security, and connectivity to the care team. Regulation Most connected health devices are making only general wellness claims, thus avoiding FDA regulation. This results in marketing the devices that track a baby’s respiration, heart rate, O2 saturations, and sleep position as “smart baby monitors.” Just as a medication can be used off label, devices are also used off label. There are stories of parents removing the motion sensors from the smart onesie
and sewing them into larger pajamas as a means of notification that their nine or 10 year old was having a seizure during the night. Parents have learned how to “hack” a product or system and create something that better fits their needs. Nightscout is a widely used data sharing cloud-based system that
monitoring device; security in the transmission of data to the cloud; and rights and controls in accessing the data in the clinic and by parents/guardians. Parents and caregivers can’t act on data if it isn’t available or communicated.
of a health device for infants and children is crucial for accuracy and ease of use. Given that the market is small (and the regulations more complex), major manufacturers have made the pediatric market a lower priority, but we are now starting to see products come to market.
Connectivity to a care team Diseases that require daily management such as diabetes, asthma, heart disease, and eating disorders all lend themselves to daily remote monitoring and care team connectivity. In most existing care models, intervention happens between clinic visits only. With emerging connected technology, health care providers can access data between scheduled clinic visits. In the case of a type 1 diabetic child, connected glucose monitors (intermittent and continuous) allow real-time transmission of blood glucose data to both parents and the clinic. When paired with a connected insulin pump or “smart insulin pen,” caregivers can
Real-time management of our patients will become a viable reality. came out of parents “hacking” an FDA-approved continuous glucose monitor (CGM). Parents are clamoring for ways to better manage their kids with chronic conditions. Market size The pediatric market for health management tools is small in comparison to the adult market. Since kids are not simply small adults, tightening the strap on an adult Fitbit doesn’t make it work for kids. Dedicated design
Data security Physicians must address and prioritize the privacy of patient data from remote sources. Having secure transfer and integration methods are important factors when choosing health management partners such as Validic, and companies like it. They make secure integration of data in the patient record possible. As we consider remote monitoring in pediatrics, many complex issues must be addressed: security on the
Electronic health care to page 34
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HEALTH DISPARITIES
Health equity for the LGBTQ community Advancing the quality of care By Mary Beth Dahl, RN and culturally competent providers. • LGBTQ populations have the highest rates of tobacco, alcohol, and other drug use. According to the 2014 Rainbow Health Initiative report, Voices of health: A survey of LGBTQ health in Minnesota, of the 1,859 people surveyed who identified as LGBTQ: • Twenty-five percent smoked every day or some days per week. • Thirty-three percent reported binge drinking in the past two weeks. • Sixty percent of LGBTQ respondents report being diagnosed with depression and 50 percent report being
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Minnesota Physician August 2015
diagnosed with anxiety. “When you are a member of a minority that experiences stress, that has a negative net effect on all kinds of longterm health issues,” said John Azbill-Salisbury, MPH, director of programs for the Rainbow Health Initiative (RHI). Another factor is accessing health care. “We were able to collect our Voices of health survey data in 2013 and 2014, both before and after the implementation of the Affordable Care Act in Minnesota,” said Azbill-Salisbury. “And what we saw was that the overall uninsured rate in Minnesota went down to about 4 to 5 percent, and for LGBTQ folks it went
down too, but from a much higher 16 to 12 percent, so the overall decrease in the number of uninsured had less effect on LGBTQ folks.” Economics plays a role as well, and Azbill-Salisbury pointed out that more LGBTQ people live in poverty, experience job insecurity, or are underemployed based on their education level than their nonLGBTQ counterparts. Confidence and open communication are vital Research also suggests that these negative outcomes and lack of access may be due to low cultural competence in the health care system, which can sometimes be articulated in an unwelcoming and negative attitude expressed by staff toward people in this community. The 2014 Voices of health survey reported that after mental health, a full third of LGBTQ respondents identified health care provider’s knowledge of LGBTQ issues as a top health issue. Carrie Link, MD, assistant professor at the
La traviata, 2011 © Michal Daniel
E
ven though Minnesota consistently ranks as one of the healthiest states in the U.S., opportunities for high-quality health care are not equally available to all Minnesotans. For our lesbian, gay, bisexual, transgender, and queer (LGBTQ) community in particular, unique health inequities exist that can lead to negative health outcomes and lifelong health problems. The U.S. Department of Health and Human Services national Healthy People 2020 initiative notes that LGBTQ health requires attention from health care and public health professionals to address a number of specific disparities: • Transgender individuals have a high prevalence of mental health issues and suicide, and are less likely to have health insurance than heterosexual or LGB individuals. • Elderly LGBTQ individuals face additional barriers to health because of isolation and a lack of social services
University of Minnesota and family medicine physician at Smiley’s Family Medicine Clinic, describes the problem more directly. “Smoking and depression rates are twice as high in the LGBTQ community as in the general population. For the trans and gender non-conforming community, the suicide attempt rate is 41 percent compared to less than 2 percent for the general population,” said Link. “But the biggest problem is that people aren’t seeking care because they don’t feel safe or comfortable. That’s based on both real and perceived discrimination. Once they’ve experienced discrimination they’ll start to anticipate it. You could be the most open and awesome doctor in the world, but they have to interact with four or five people before they interact with you.” Because of this avoidance of care, health issues can often go undetected in the LGBTQ community. For example, data show that lesbian and bisexual women receive less routine care
than other women, including breast and cervical cancer screening. It is important for LGBTQ people to feel welcome and comfortable enough to seek care and routine health screenings, and for health care providers to be positive and accepting of sexual and gender diversity. This is vital to improving care.
community, despite evidence that these patients often face a unique set of health risks.
clinic so when someone who is LGBTQ comes in the door they feel comfortable and supported.”
“We know that most providers are going out into the field and unless they’ve made an effort to access some sort of training, they don’t have very much education on LGBTQ,”
Becoming more inclusive Link and staff have been working to make University of Minnesota Physicians Smiley’s Family Medicine Clinic an inclusive and welcoming place for all patients, including LGBTQ. “I think physicians have the power to influence change to access to care. Patients come in and fill out forms with an “M” and an “F” to identify their gender and have no other options,” Link said. “Research shows that things like gender-neutral bathrooms, and forms that have more options for partner and gender, make a big difference. It doesn’t feel like the traditional job of the physician to redesign the forms, but it is our job to treat everyone respectfully, and when you think about it from that framework it becomes a lot easier. We changed our forms so you fill in your gender,
“People aren’t seeking care because they don’t feel safe or comfortable.” Carrie Link, MD Knowing how to create and maintain that kind of open environment is not something many providers are taught. Azbill-Salisbury cites a 2011 study from the Stanford University School of Medicine published in the Journal of the American Medical Association, which said, on average, medical students spend just five hours learning about the health care needs of the LGBTQ
said Azbill-Salisbury. “That being said, there are quite a few organizations, RHI included, that do offer training and resources to providers. We have a program that works to help providers understand what they need to create inclusive spaces for LGBTQ folks. It’s a little bit less about ‘here is the specific medical training you need’ but more about asking how do you create an environment in a
Health equity for the LGBTQ community to page 32
Many Faces oF coMMunity HealtH tenth AnnuAl ConferenCe
Thursday – Friday, October 22 – 23, 2015 • Marriott Minneapolis Southwest – Minnetonka, MN Join us for a two-day conference that explores ways to improve care and health equity in under-served populations and among those living in poverty. It brings information and resources on chronic disease prevention and care, public policy and health innovations to Minnesota’s health care community, with a focus on safety net providers. The conference offers two tracks: Management / Policy and Clinical. Continuing Medical Education credits applied for.
sPeaKeRs incluDe:
Keynote: Pedro Jose Greer, Jr., MD
Assoc. Dean of Academic Affairs and Chair of Dept. of Humanities, Health and Society, Florida Int’l University School of Medicine
Keynote: John R. Finnegan Jr., Ph.D Dean of the School of Public Health, Epidemiology & Community Health, University of Minnesota
For a complete list of speakers and times, visit the conference web site:
manyfacesconference.org
For more information contact Sean Schuette at 952-564-3077 or sschuette@intrinxec.com August 2015 Minnesota Physician
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SPECIAL FOCUS: Oncology
I
have spent many winters in upstate New York, but when I was being recruited to work at the University of Minnesota, I didn’t know what to expect. In fact, I had never been to Minnesota before my first interview. As is the case with people from the East Coast, our vision of Minnesota includes the Mall of America (and its famous indoor roller coaster), the films “Fargo” and “Grumpy Old Men,” ice fishing, and all those lakes. What fascinated me the most, however, were the skyways. The reason is simple. Studying skyways at the cellular level has become my life’s work. In upstate New York, we did not have skyways; at best, there were a few basementlevel tunnels to protect us from the vicious winter cold. I have many ruined sets of dress pants splattered with black snow to attest to the messiness of it all. Skyways are a unique and simple concept: an aboveground pedestrian tunnel that connects buildings and allows car traffic
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The skyways of cancer How cancer cells communicate By Emil Lou, MD, PhD to flow underneath at the street level. Most important, skyways are a highly efficient way for people to walk from building to building without having to venture out into the cold or inclement Minnesota weather. It is notable that while you can on occasion find skyways in other parts of the country, they are most often found in coldweather states like Minnesota. Tunneling nanotubes The reason that skyways fascinate me is that they represent a macrocosm of what happens in cancer cells. Skyways exist in cancer; they are called tunneling nanotubes.
Minnesota Physician August 2015
I first stumbled upon this field while doing my postdoctoral research and clinical fellowship at Memorial Sloan Kettering Cancer Center in New York. My initial task was to isolate and characterize malignant cells from patient-derived tumors, and to study their ability to perpetuate despite drug treatment. While looking at these cells under the microscope, I saw long, drawbridge-like extensions that cancer cells formed between themselves, especially between cells that were located long distances from each other. Uniquely, these extensions seemed to be hovering, much like a tightrope. I had access to world-class experts in cell and cancer biology, and nobody could explain or verify what these structures were. We delved into the research literature, and found that a research team in Heidelberg, Germany had published on this phenomenon a few years prior, and called these structures tunneling nanotubes. The word “tunnel” is self-explanatory; “nano” refers to the fact that these extensions were unusually narrow. The descriptions in the journal Science in 2004 matched what we were seeing under the microscope. Because our focus was on invasive cancers, our team pursued work on characterizing nanotubes (or TNTs) in the aggressive cancers we were working on at the time, such as malignant pleural mesothelioma and lung cancers. We found that nanotubes formed spontaneously and served as direct pipelines connecting distant cells, not just in cell lines but also in cells we derived directly from pleural effusions and ascites from patients with advanced cancers. By that time, a few groups worldwide had published
further work demonstrating the unique functions of nanotubes in the propagation of infection or in facilitating communication between immune cells. For example, a group in Paris showed that neurons could form nanotubes and facilitate intercellular transfer of prions, the causative agent for Creutzfeldt-Jakob (mad cow) disease. Other groups showed direct cell-to-cell transmission of HIV and other forms of viruses, and that immune cells (e.g., B lymphocytes) could communicate directly with macrophages. The field was opening, but the question remained of in vivo relevance. The biggest criticism of the field was that this was an in vitro phenomenon that was not present in disease in actual living beings. We then addressed that question by imaging intact tumors resected from human patients with mesothelioma and lung cancer. Taking advantage
[Nanotubes] would create a new approach to targeting cancers for therapy.
of new technology and software allowing for three-dimensional reconstructions of individual microscopic images, we visualized nanotubes in all six of our initial tumor samples. This represented a big breakthrough for this new field of cancer biology, and launched my interest in pursuing this further. I took inspiration from seeing skyways for the first time, as this gave me a real-life full-scale model to consider as I imagined the next steps to study the function of nanotubes. microRNAs Over the past decade, there has been a true revolution in understanding and targeting the genomics of cancer, and in identifying targets for more effective therapy. In addition, there have been advances in
understanding the cell biology of cancer that have facilitated studies that, while not yet ready for human clinical trials, have provided building blocks for understanding formation and advancement of human cancers. The field of microRNA biology is one prime example. microRNAs are short, non-coding forms of RNA that can alter (upregulate or downregulate) target genes. There are more than a thousand forms of microRNAs, each of which has the potential to affect different sets of genes, including those that instigate increased growth of cancer, metastasis to distant sites, and development of resistance to drug therapies. The widely-held assumption has been that microRNAs are inherited from parent cells following cell division. In recent years, an advancement in cell biology has been the identification of exosomes or microvesicles—small pockets of cells that can be extruded by the larger cell, and serve as small “shuttles” for intercellular cargo transfer. This cargo can include messenger signals (such as microRNAs) that can be transmitted to other cells to alter their behavior. No group had yet shown that microRNAs—or any genetic material—could be exchanged in this manner from cell to cell via nanotubes. Thus, I initiated a collaboration with experts in the field of micro RNAs at the University of Minnesota, in order to determine whether this was the case. A communication network for cells Our team had to first overcome some technical challenges in working with such small genetic codes, but we were able to first identify forms of microRNA that were overexpressed or altered in cancer cells resistant to chemotherapy. We then marked these forms of microRNA with a fluorescent tag that allowed us to visualize them under the microscope. Using this approach, we were able to successfully witness direct intercellular transfer of these microRNAs through nanotubes not only connecting cancer cells, but also
connecting cancer cells directly to benign (e.g., epithelial) cells. This latter observation had been hypothesized, but was nonetheless surprising, and opened up an entirely new avenue of research and potential consequences. As we have learned how malignant cells interact among themselves in the vast and complex tumor micro environment, we have also learned how they interact with nonmalignant cells in their “neighborhood,” which in biologic terms is called the tumor microenvironment. There is more evidence than ever before to suggest that nonmalignant stromal cells (e.g., fibroblasts, vascular endothelial cells, etc.) play a critical role in cancer growth and invasion. Our finding that microRNA genetic materials can be shared in an efficient manner via nanotube conduits provides evidence to support that a communication network between cells can help facilitate this.
treatment include chemotherapies, many of which target genetic material (e.g., DNA) but are not selective for cancer cells alone; newer biologic agents target other mechanisms of tumor growth, including blood vessels induced by cancer cells to facilitate their own nutrition and growth through a process called angiogenesis. Cellular communication is important to all aspects of cancer growth and advancement. There are no current standard therapies targeting this mechanism,
but elucidating mechanisms of nanotube communication in cancer may lead to ways to prevent this unique form of tumor cell communication. In the Land of 10,000 Lakes, skyways provided the inspiration for studying something much smaller, but perhaps critical to our understanding of how cancer cells communicate. Emil Lou, MD, PhD, is a physician-
scientist and medical oncologist at the University of Minnesota.
We have learned how malignant cells interact among themselves. In this era of social media and instantaneous (specific) communication, it does make sense that cancer cells can adopt similar methods quite effectively. In the way our society communicates, we have graduated from the pony express to switchboard phone calls to mobile phones instantly capable of connecting us selectively with anyone in the world, whether it be by voice, text, email, or Facebook. If cells use nanotubes as a network to convey signals and with great skyway-like efficiency, we propose that they represent a promising topic of study. Of even more relevance, if disrupting the lines of communication prevents cells from organizing and synchronizing within a tumor, then this would create a new approach to targeting cancers for therapy. Current standard forms of cancer August 2015 Minnesota Physician
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special focus: ONCOLOGY
T
umors of the head and neck are the fifth most commonly occurring malignancy with 50 percent of all head and neck tumors appearing in the oral cavity. This accounts for approximately 615,000 new cases worldwide with 300,000 being primary oral cavity squamous cell carcinoma (OCSCC) each year. OCSCC accounts for 2 to 3 percent of all malignancies. In the U.S., recent SEER data suggests that 43,500 new cases and approximately 9,000 deaths will be attributable to oral, head, and neck cancer this year. This makes oral cancer the sixth leading cause of cancer-related mortality, accounting for one death every hour in this country. Unfortunately, despite advances in screening tools, imaging technology, and access to primary care physicians there continues to be a significant burden of patients presenting with advanced stage disease. Symptoms and detection Clinical signs and symptoms of head and neck tumors are often discreet and may be mistaken for other common ailments. Patients often seek care from
Cancers of the neck and head Early detection and treatment methods By Deepak Kademani, DMD, MD, FACS primary care physicians and dentists regarding complaints within the oral cavity. It is imperative that providers are aware of the increasing incidence of oral malignant disease, particularly in young patients without traditional risk factors of alcohol and tobacco abuse, and are vigilant in screening all patients for oral mucosal lesions. Although the presence of an oral lesion is quite common, the ability to predict which lesions will progress to invasive carcinoma and which will remain stable and follow an indolent clinical course is a continuing challenge. Patients with occult oral lesions may be asymptomatic and require detection with routine screening. However, when patients are symptomatic they
typically present with nonspecific symptoms including pain, loose teeth, bleeding, dysarthria (difficulty in speech articulation), dysphagia (difficulty swallowing), odynophagia (pain on swallowing), otalgia (ear pain), sensory and motor nerve compromise, mass lesions at the primary site, or cervical lymphadenopathy. Given that the oral cavity is amenable to physical examination requiring limited sophisticated equipment, the persistence of patients presenting with advanced stage disease is troubling. Premalignant lesions typically present with a leukoplakia (white), erythroplakia (red), and/ or an erythroleukoplakia (red and white) discoloration on the oral mucosa. Early OCSCC often
originates from one of these premalignant conditions. As the lesion matures, it can become centrally ulcerated with indistinct, indurated borders. Lesions may have concerning exophytic or endophytic growth with time. The early presentation of OCSCC is typically painless and asymptomatic. However, with cancer maturation, symptoms will develop prompting self-directed referral. The most common sites of OCSCC are the dorsal and lateral borders of the tongue (40 percent), followed by the floor of the mouth (30 percent), followed by the retromolar trigone, buccal mucosa, and the maxillary and mandibular gingiva. Risk factors Historically, OCSCC has been associated with males older than 60 who regularly consume tobacco and alcohol products. This patient demographic is changing with a steady increase in the incidence of OCSCC occurring in patients under 40, and in particular females without identifiable risk factors. There has been a tremendous interest in recent years focusing on the role of viruses in the development of
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Minnesota Physician August 2015
OCSCC. In particular, human papilloma virus (HPV, 16, 18, and 31 subtypes) is now considered an independent risk factor for development of oral cancer. HPV 16 and 18 have been found in 22 percent and 14 percent of oropharyngeal tumors and have shown to increase the risk of OCSCC by approximately threeto five-fold. Fortunately, the prognostic implications of HPV presence are favorable, with HPV positive oropharyngeal tumors having improved responsiveness and survival as compared to HPV negative tumors. Tobacco use has a long, well-established causative relationship to the development of OCSCC with the development of field cancerization. Approximately 80 percent of OCSCC patients smoke or have used tobacco products, and they are at a five to seven times greater risk of developing malignant head and neck tumors. Diagnosis Diagnostic approaches to OCSCC include dental, head, and neck evaluation and directed biopsy of concerning areas. Diagnostic imaging including an
orthopantogram, CT, and MRI scanning is useful for staging. Positron electron tomography (PET) has an increasing role in tumor surveillance. PET scanning uses a radiolabeled glucose isotope (18-FDG) to label areas of hypermetabolism. This is a valuable tool in oncologic staging and surveillance.
respectively, whereas T3–T4 lesions have significantly higher risk of regional neck disease. The overall five-year survival rate for OCSCC for all stages is between 45 to 72 percent in most large series studies. Early stage tumors (T1–T2) are associated with a 60 to 80 percent five-year survival rate. The status of the
The importance of smoking and alcohol cessation cannot be overemphasized. The TNM classification system has proven to be a reliable indicator of patient prognosis, with primary tumor size and cervical lymph node status being the two most significant factors affecting patient survival. However, biologic aggressiveness resulting in early regional metastases and death has been found in a number of clinically small or undetectable primary tumors. Conversely, some large tumors may be slow to metastasize both regionally and distantly. Typically, T1–T2 lesions are associated with a risk of regional metastasis of 10 percent to 30 percent
cervical lymph nodes is the single most important prognostic factor in OCSCC, with the development of neck metastases reducing five-year survival by a further 50 percent. Treatment Surgical resection The mainstay of treatment for OCSCC continues to be primary site surgical resection. Posterior oropharyngeal, laryngeal and hypopharyngeal tumors are typically treated with “organ-preservation” utilizing chemoradiotherapy as the initial mode of treatment. In
these cases, surgery is reserved for the management of small primary tumors, and persistent or recurrent disease. The goal of all curative primary resection is complete eradication of local disease with adequate treatment of the cervical lymph nodes. Patients with clinically and radiographically staged N0 neck disease are treated with prophylactic staging lymph node neck dissections when the risk of occult neck disease is greater than 15 percent. In essence, this means all patients with >4 mm tumor depth of invasion, T2 (2–4 cm), T3 (>4 cm), and T4 (invasion into adjacent critical structures such as bone) are treated with a staging neck dissection. Typically, if neck dissection specimens are histologically negative no further adjuvant therapy is initiated. In situations of occult neck disease, with one or more metastatic lymph nodes, multilevel disease, or the presence of extracapsular spread, regional radiotherapy with either conventional 2- or 3-Dimensional or intensity-modulated radiation Cancers of the neck and head to page 37
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RADIOLOGY
W
hat exactly is radiation therapy and how does it work? To most, it is a black box in a weird department hidden somewhere in the basement. To find out we need to step back and take a closer look. Radiation is defined as energy that comes from a source and travels through material or space. Obvious examples of radiation include light, heat, and sound. As we all dutifully memorized in our premed physics classes, these examples of radiation differ in their energy and wavelength. Many of us think of radiation as a scary, weird, and therapeutic modality, but we must remember that radiation existed long before humans did. Humans adapted and lived unknowingly with this constant flow of radiation that emanated from space or from the ground. The discovery of X-rays The story of radiation begins with the famous 1895 image of
Radiation oncology A closer look By Elizabeth H. Cameron, MD, MPH Wilhelm Roentgen’s wife’s hand with her wedding band. This skeletal image was the result of a stream of electrons in a vacuum tube that produced a ray that had not yet been defined. These mysterious rays were eventually called X-rays where “X” signified the unknown. This discovery earned Roentgen a Nobel Prize in 1901. In the wave of excitement following Roentgen’s discovery, Henri Becquerel noticed that a particular rock seemed to have similar rays emanating from it. This rock was a uranium-rich mining castoff called pitchblende ore and it developed a photographic plate exactly like the mysterious X-rays did. But, how could a stream of electrons in a vacuum tube and a rock
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Minnesota Physician August 2015
produce the exact same result? The thought that energy could be “locked up in a rock” captured the interest of Marie Curie, a PhD student in Paris. During the process of characterizing and measuring this energy she and her husband, Pierre, discovered and isolated radium after an arduous extraction from pitchblende ore. Marie and Pierre Curie, along with Henri Becquerel, shared the 1903 Nobel Prize in physics for the discovery and characterization of radiation. Roentgen’s rays from a cathode tube and Becquerel’s rays from pitchblende highlight the difference between X-rays and gamma radiation. Simply put, the two are defined by the source. If the energy comes from a stream of electrons they are X-rays; if the energy comes from a decaying nucleus in a rock they are gamma rays. Other than the source, the energy is similar. If the energy is similar, then the radiation is similar because radiation is defined as energy traveling in space. Therapeutic applications How did the discovery of X-rays and gamma rays lead to therapeutic applications? Fact and fiction are difficult to tease out. Focusing on gamma radiation, Pierre Curie was found to have erythema on his chest where the tube of radium he carried in his shirt pocket rested. If this energy could produce a reaction on normal skin, then the next logical target was cancerous skin. It worked; tumors shrank when exposed to gamma radiation. Radium as a source of radiation for therapeutic application was expensive in the early 1900s. A cheaper and more plentiful supply of radiation was found in cobalt (known as cobalt-60). A simplistic model of gamma radiation is to think of it as a radioactive rock in a box. The constant is the half-life
of the source as measured by the decay constant, while the variables are created by the distance from the source and the exposure time. Expanding therapeutic use and delivery As therapeutic applications of radiation expanded, the need to add more variables arose. The gamma energy from cobalt-60 was relatively low, about 2.8 MV. The lower the energy the less it is able to penetrate the skin and reach deeper tissue. Attempts to dose deeper tissue led to significant skin reactions or burns because longer exposure time was necessary for the dose to reach a deeper depth. Therapeutic applications of radiation do not involve thermal energy and do not involve heat transfer. The common term “burn” used in relation to radiation is a bit of a misnomer. Both thermal injury and radiation injury produce similar reactions on the skin, but the sources are completely different. If a temperature probe is placed in the tissue and then subjected to radiation it will only register a temperature change from the vasodilation. The tissue is not “cooked.” When it came to using X-rays, radiation from streaming electrons produced in a cathode ray tube didn’t have much therapeutic application because of its inability to dose deeper tissues. Eventually this problem was solved by accelerating the stream of electrons to make them more energetic, which led to the creation of the modern radiation therapy machine known as a linear accelerator. By accelerating electrons along a linear path and smacking them against tungsten—which acts as a dense target in the head of the machine—the kinetic energy of the electrons transforms into energy traveling out of the head of the linear accelerator. This higher energy radiation is now referred to as photon radiation rather than X-rays. The advantage of using an accelerator is that higher energies can be produced so instead of the 2.8 MV radiation from cobalt-60, linear accelerators can produce 6, 10, and 15 MV
of radiation. With higher energy, therapy can be delivered to deeper tissues without as much of a skin reaction. The energy needed for more superficial breast cancer may use only 6 MV, whereas a deep-seated prostate cancer may need 10 MV. Another way to improve radiation delivery is to tweak other variables, like the number of beams. If 100 percent of the dose is delivered by one beam then 100 percent of the dose has to transverse all the intervening normal tissues to get to the deeper target tumor. If four equal beams are used to intersect at the target, where each beam is only 25 percent of the total dose needed, then there will be less damage to normal tissue. The number of beams that a radiation oncologist can choose is infinite. Increasing the beam number also shapes the dose volume. Four equal beams result in a box shape. If you add beams to the corners of the box to soften them you get a more circular dose volume until the beam finally becomes an arc. Linear accelerators can also use other variables such as dose intensity modulated radiation therapy (IMRT) and motion volume modulated arc therapy (VMAT) to create a more customized dose distribution. IMRT uses more beams and varies the dose intensity of each beam, which further shapes the dose. VMAT varies the dose intensity and increases the beam number delivering so many beams that an arc is produced. All of these variables improve the ability to target and shape a dose. In radiation oncology, we deliver doses in a three-dimensional volume and sometimes add the variable of time to create a four-dimensional volume. This becomes important in tumors that move, like lung cancer. Targeting radiation In medicine in general, there is an emphasis on targeting and radiation oncology is no exception. All of the above-mentioned variables, energy, number of beams, intensity, and motion can be manipulated in combination with target visualization
imagined using all the availcancer, despite many attempts to improve the aim of the radiable and emerging radiation to show the advantage of proation to hit the tumor but just tons there is no convincing data technologies. as importantly to avoid normal that proton thertissue. Conclusion apy translates Radiosurgery Radiation oncology is evolving into improved (literally radiaand the variables are endless. outcomes. This tion as sharp as The variables We are learning how to make has resulted in a knife) is a term the best use of our targeting are endless. the closure of that is often capabilities. The energy we one proton ramisunderstood deposit simply drives chemical diation facilioutside of radireactions in normal and tumor ty and concern ation oncology. cells alike. Normal cells recover as other facilities are slated to The targeting capabilities can if we fractionate and target open. At least two-thirds of the be taken a step further so the correctly. Tumor cells cannot volume of these centers is from field edges become as sharp as recover so they die. If you think patients with prostate cancer. a scalpel enabling it to remove about it, radiation is one of The good news is that with the cancerous tissue without actuthe most “natural” therapies exception of a very few cancers, ally cutting the skin. Radiosuravailable, as it merely involves gery is an outpatient procedure. nonparticle (i.e., photon not the transfer of energy. Put your proton) radiation is able to deWith sharp field edges, higher doses can be used for each frac- liver very targeted radiation that previous assumptions about is clinically equivalent to proton radiation therapy aside and tion of radiation delivered. Just talk to your radiation oncology or other particle radiation. as with standard radiation, the colleagues—we are listening. With the ability to target source defines the name. For radiation therapy more effecexample Gamma knife involves tively, radiation oncology has the use of cobalt radiation, Elizabeth H. Cameron, MD, MPH, completely evolved and the old while Cyberknife uses a linear is medical director of radiation on adage that once radiation is givaccelerator. Gamma knife uses co logy at HealthEast and is boarden it can never be given again cobalt-60 strategically placed in radiation oncology, and certified is no longer true. We are now in a space that delivers a prehospice and palliative care. re-treating sites never before cise dose to a static target. Cyberknife is a linear accelerator on a robotic arm that can aim very precisely when delivering radiosurgery to static and moving targets. The mix of variables is potentially endless and the pace of radiation technology is moving faster than our ability to evaluate it. An example of this is with particle radiation therapy. Gamma and photon radiation have neither mass nor charge so are not particles. Particles include neutrons, which have mass but no charge and protons, which have both mass and charge. Each variable has a unique effect on the dose distribution. We are not sure, however, if the effects of particle radiation on dose matters clinically. It has taken considerable financial investment in these new technologies because the mass of the particles requires very expensive facilities to accelerate them ($100+ million compared to $10+ million). This is a very controversial topic in the field of radiation oncology because of the high cost of protons and the Psychiatric Care evolved. 888-9-prairie prairie-care.com seeming lack of clinical superiority except in the case of some very specific types of cancer. To date, for example in prostate August 2015 Minnesota Physician 25
Pharmacology
H
ealth care is seeing changes in payment from fee-for-service to pay-for-performance (shared risk models) here in Minnesota and across the country. This shift opens the door for innovative team-based patient care. One very natural relationship as a result of this change is collaboration between physicians and pharmacists. Both professions work together to identify and treat acute and chronic conditions by using optimal, cost-conscious therapies that effectively improve the health of patients. Physicians and pharmacists already work together in almost all patient care settings. For years pharmacists have communicated with physicians to ensure there is clarity in medication orders. This interaction continues today between the community pharmacist and the ordering physician and has expanded in some settings to include therapeutic interchanges,
Physician/ pharmacist collaboration An opportunity to improve patient care By Cory Nelson, PharmD; Kyle Turner, PharmD; and Jaskiran Sandhu, MD
answering questions about medication, and monitoring for diversion. In the latter half of the 20th century, hospitals began placing pharmacists throughout hospitals to perform clinical services such as anticoagulation monitoring, antimicrobial stewardship, and drug therapy monitoring. According to a 2014 National Pharmacist Workforce Study prepared by the Midwest Pharmacy Workforce Research
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Minnesota Physician August 2015
Consortium, 33 percent of a hospital pharmacist’s time is spent in non-dispensing related clinical services (roles outside of preparing and verifying medications). These services place pharmacists side by side with physicians to help initiate, adjust, and monitor drug therapies. This service is now being mirrored in the outpatient setting with pharmacists providing comprehensive medication management. Pharmacists around the country often look to Minnesota because it is progressive when it comes to the practice of pharmaceutical care in a primary care setting. A recent case study by the University of Minnesota called Integrating Medication Management (https://z.umn. edu/mncasestudies) showed the commitment and investment that six integrated health care systems in Minnesota made in pharmacist-run medication management programs. No longer in our silos As the health care landscape continues to evolve, health systems will need to find ways of delivering highquality, evidence-based care at a lower cost to patients and payers. Effective use of care team members to provide the highest level of care can save money and improve the patient experience. The benefits of working with other care team members, however, is only effective if team members communicate. It is no different when it comes to communication between physicians and pharmacists.
Historically, physicians have conferred with pharmacists when they needed answers to difficult questions about medications or drug therapy. In these instances, pharmacists were asked for a “curbside” consultation where they only briefly became involved in a patient’s care. Once the pharmacist answered a specific question, he or she returned to their traditional and separate role. This system has been utilized for many years and has the potential to improve patient care, however this is often not the most efficient use of anyone’s time—the pharmacist’s, the physician’s, or the patient’s. It is also not an effective model for care as the expertise of the pharmacist is employed in a limited way and often without the full details and history of the patient. Pharmacists and physicians could continue to maintain these separate roles, but health care in the future is going to demand more of each team member. Physicians and pharmacists are ready to answer the call to work together to improve patient care. Physician feedback At our team-based clinical practice sites, we have collected information about collaborating with physicians. Here is a cross-section of experiences that physicians have shared with us. “ Having a pharmacist available in clinic means having an extra set of eyes to review our care, ensuring that medication management is upto-date, avoiding medication interactions, and reinforcing patient education.” “ As a physician, I feel that the physician/pharmacist collaboration is a practice that can optimize patient outcomes, by identifying and managing a patient’s drug-related problems.” “ The increasing complexity of medication therapies and newer drug regimens requires the need for a strong working relationship
between pharmacists and physicians to optimize patient care.” “ I hope to have a pharmacist working in my future practice.” A win-win situation Interaction between the doctor and pharmacist must be seamlessly integrated to improve patient care and avoid duplication of work and inaccurate or incomplete utilization of information. Physicians will be able to work more efficiently knowing that they can count on this partnership to serve as a safety net in their work and to help them provide the best patient care. This includes the ever-increasing number of new therapies that come to market each year.
management (MTM) services to patients through these types of arrangements. The framework of these arrangements often rests in a collaborative practice agreement (CPA), which is a legally binding document that describes which responsibilities pharmacists have under the
clinical service that aligns with the principle and practices of team-based care. This is in contrast to the pharmacist’s previous role where they only dispensed drugs in community-based and hospital pharmacies. Pharmacy residents at the College’s Ambulatory Care
The relationship between physicians and pharmacists continues to grow.
physician’s medical license. These agreements are not without challenges however: • Trusting that each partner will fulfill his or her responsibility.
Many hospitals in this state and around the country already • Determining the scope have protocols in place to that the pharmacist has in include pharmacists in certain initiating, changing, and aspects of a patient’s care. This monitoring drug therapy includes anticoagulation in and keeping the physician and out of the hospital, antibiinformed of these actions. otic stewardship, psychiatric • Engaging the patient in services, oncology, and more. this type of collaborative In addition, many health care can be a challenge care systems in Minnesota since it’s out of the norm have invested in medication of what they are accusmanagement programs that tomed to. make it easy for providers to refer patients to these services. Each perceived barrier can Certain patients—those just be overcome as physicians and discharged from the hospital, pharmacists work together for those not reaching chronic disthe benefit of the patient. ease goals, or those whose poor Another issue that must health affects quality metrics be addressed is whether a important to the clinic—get pharmacy workforce is trained system-driven referrals to medand ready to practice in this ication management programs new health care environment. to ensure that their medications Minnesota is again at the are optimized.Email – Clinic@whla.net forefront of this effort through A well-integrated pharmaPharmD curriculum and cist/physicianTelephone-651-426-6995 collaboration residency training. Students doesn’t only take place in large and residents who train at the health organizations. Many University of Minnesota College examples of well-designed of Pharmacy, Minnesota’s only relationships exist between pharmacy school, are all taught physician groups and a commu- from Cipolle, Strand, and nity pharmacist, where broad Morley’s “Pharmaceutical Care or protocol-driven agreements Practice,” in which each drug is are in place. Some pharmacists evaluated for indication, efficaworking in community-based cy, safety, and convenience. The retail pharmacies provide dispractice of pharmaceutical care ease-focused or protocol-driven is pushing the pharmaceutical interventions as well as comprofession to deliver a well deprehensive medication therapy fined, reproducible, and quality
Residency Program use this method each day in collaborative practice sites across the state and learn from expert preceptors who have spent their careers providing this type of care. After completing their residency training, they are fully prepared to work with physicians to optimize medication use, control costs, and achieve patient care goals.
Starting the conversation First, find out what opportunities already exist in your clinic, hospital, or health system for partnering with pharmacists to improve patient care. There might already be a program or protocol in place for how pharmacists can improve your workflow and enhance patient care. Ask a pharmacist in your work environment how they can help you manage your patients’ many medications and multiple conditions. If there is no program in place for physicians to partner with pharmacists where you work, ask administrators why this service is not available. If a partnership program already exists, don’t be afraid to approach administrators with suggestions for how these programs can be improved to make collaborating easier. In addition, let the pharmacist know how the collaboration can be more effective when it comes to patient care. Physician/pharmacist collaboration to page 36
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For more information: Email: Clinic@whla.net
Telephone: 651-426-6995 August 2015 Minnesota Physician
27
ADMINISTRATION
A
fter four delays, the federally mandated transition from the current medical diagnoses and inpatient hospital procedure coding system, ICD-9, to its successor, ICD-10, is now only weeks away from an Oct. 1, 2015 implementation deadline. According to the federal Centers for Medicare & Medicaid Services (CMS), because “ICD-9 codes are used in almost every clinical and administrative process” in health care, the change to ICD-10 will require corresponding significant “system and procedural changes … to implement and correctly use the new codes.” Not surprisingly then, the transition to ICD-10 requires planning and follow-through, with only a little time now remaining to meet the October implementation deadline. The relatively short time remaining before implementation will be cheered by some who feel prepared and are anxious to move forward, but may be daunting to others who
A new era in coding ICD-10 becomes effective October 1, 2015 By David K. Haugen, MA, and Terence Cahill, MD
are behind or uncertain of what to do to meet the deadline. It’s time to update ICD-9 While ICD-9 has served as a valuable tool and resource, much has changed in the three decades since it was adopted. Procedures that are now common, such as laser and laparoscopic surgeries, and many others, were virtually unknown in practice when ICD-9 was adopted. As new waves of medical advances and complexity roll across the health care system, ICD-9’s coding structure is already at capacity in many categories and cannot accommodate new diagnoses and procedures. New forms of care delivery and financing, including value-based purchasing,
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Minnesota Physician August 2015
accountable care, and greater emphasis on population health, require much more sophisticated, nuanced information regarding patient conditions and care. As a result, health care’s reliance upon increasingly more detailed, specific data for complex decision-making is rapidly outpacing what CMS has described as ICD-9’s “outdated and obsolete terminology” and “outdated codes” that can result in “inaccurate and limited data.” ICD-10 offers better specificity Overall, ICD-10 features much more coding detail and specificity, and is structured to allow for a significantly expanded number of descriptive diagnosis and procedure codes that can grow over time. According to CMS, the new coding system offers: 1) improved reporting of laterality; 2) inclusion of clinical concepts that do not exist in ICD-9 such as underdosing; 3) blood type and blood alcohol level; and 4) expansion of codes for such important topics as injuries, diabetes, substance abuse, and postoperative complications. For example, as reported by CMS, ICD-9 has only two major codes for diabetes, “diabetes” and “secondary diabetes” respectively. ICD-10 separates type 1 diabetes from type 2, and eliminates the broad category of “secondary diabetes” in favor of more relevant and descriptive secondary options for underlying conditions or causes, along with additional subcategories to convey information regarding complications and affected body systems. Similarly, ICD-9 has only a single code for angioplasty; ICD10 has 854 codes for detailed reporting of the procedure approach, body part, and device. ICD-9 has nine pressure ulcer codes that can distinguish broad
location, but not the depth of the ulcer. ICD-10 has 150 codes that can show more specific location, as well as depth. While much of the focus on ICD-10 has centered on its expanded code set, in some cases, as with hypertension, end-stage renal disease, and chronic respiratory failure for example, the number of ICD-10 codes has been reduced to bring about simpler reporting of meaningful data. These improvements in coding detail and structure are foundational to longer-term, far-reaching health care research, organizational and system-wide transformations. However, ICD-10 is an important part of the medical armamentarium that will be available Oct. 1, 2015 to communicate key patient data for immediate uses and benefits. Even in the absence of other medical chart information, knowing the ICD-10 codes assigned to the patient, with their greater detail regarding severity, location, and other specifics of the patient’s condition, will serve as an initial guide to help physicians more rapidly and accurately assess and meet patient care needs. Significantly for physicians, ICD-10’s improvements provide greater coding specificity and clinical information, for a much more complete picture of the patient and their needs at this time. CMS has described ICD-10’s more granular, robust medical data as a gateway to: • Improving patient care • Measuring the quality, safety, and efficacy of care • Reducing the need for attachments to explain the patient’s condition • Designing payment systems and processing claims for reimbursement • Conducting research, epidemiological studies, and clinical trials • Setting health policy • Devising operational and strategic plans • Designing health care delivery systems • Monitoring resource use
• Improving clinical, financial, and administrative performance • Preventing and detecting health care fraud and abuse • Tracking public health and risks Not ICD-10 ready? CMS and many other payers, including the Minnesota Department of Human Services’ (DHS) Minnesota Health Care Programs (MHCP), have published guidance that claims that have ICD-9 codes for dates of service on or after the October deadline will be denied. Those who are not ICD-10 ready will not realize the coding system’s benefits already described, and will risk immediate delays or losses in revenue that could significantly affect their bottom line and their relationships with patients, business partners, and others. The results of several recent national surveys by organizations such as the national Workgroup for Electronic Data Interchange (WEDI)—a broad-based coalition of providers, payers, and other industry stakeholders serving as a federally authorized advisor to the secretary of the federal Department of Health and Human Services (HHS)—show that these financial risks are very real for some providers, especially in smaller and solo practices. For example, the WEDI survey, conducted in the early spring of 2015, found that all industry segments must make a “dedicated and aggressive effort to move forward with their [ICD-10] implementation efforts” … to prevent “significant disruption to industry claims processing on Oct 1, 2015.” Other national polls from approximately the same time period also reported indications that many in the industry, particularly smaller provider groups, were behind in their ICD-10 readiness. A national survey by one industry vendor reported for example that only 21 percent of physician practices felt that they were “on track” for moving to ICD-10. Steps you can take now While the clock to ICD-10 readiness is rapidly ticking
down, there is much that can and should be done to prepare for the conversion to the new coding system and to mitigate any risks associated with its implementation. Clinical documentation Physicians, coding professionals, and billing managers all have important functions in implementing ICD-10. A primary role of physicians in the transition to ICD-10 will be to assure the consistent, high
• ICD-10 does not change CPT codes and their use. The mainstay for the majority of physician billing and payment is the Current Procedural Terminology (CPT) code system and the related Healthcare Common Procedure Coding System (HCPCS). CMS has stated that when “ICD-10-CM/PCS is implemented on Oct. 1, it will not affect physicians’, outpatient facilities’, and hospital outpatient departments’ use of CPT codes
ICD-10 does not change CPT codes and their use. levels of clinical documentation needed for quality patient care that are also prerequisites for equally high quality ICD-10 coding. According to CMS, an important role of the coder is to assure that “coding is consistent with the documentation,” and the business manager will help assure that “billing is accurately coded and supported by the documented facts.” The three functions together are essential for successful outcomes, but are so dependent on appropriate documentation that ICD-10 readiness has often been described not as a medical coding issue, but as a clinical documentation issue.
on Medicare Fee-For-Service claims. Providers should continue to use CPT codes to report these services.” CMS further clarified that when ICD-10-CM codes replace ICD-9-CM codes, it will not impact how CPT and HCPCS codes, including CPT/ HCPCS modifiers for physician services, are reported. While
ICD-10-CM codes have expanded detail, including specification of laterality for some conditions, CPT and CMS guidance should continue to be followed when reporting CPT/HCPCS modifiers for laterality. • The logic and process of finding and using the appropriate ICD-10 codes will be familiar, and tools are available to help. As with ICD-9, ICD-10 code sources will include both a tabular listing and an alphabetic listing of codes. The disease/condition of interest will correspond to an alpha-numeric code that can be confirmed in the tabular list, which displays relevant ICD-10 codes by chapter, category, and subcategory. There are a variety of online tools to learn more about and find appropriate ICD10 codes. • There are still opportunities to test your ICD-10 codes before the go-live date. CMS has issued guidance clarifying that ICD-10 acknowledgement testing is open to all Medicare A new era in coding to page 30
Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.
Keeping ICD-10 in perspective In moving rapidly to become ICD-10 compliant, it will be important to keep ICD-10 in perspective, and to remember what is changing and what is not in order to focus efforts where they will have the most impact. For example: • ICD-10 has many more codes, but providers will continue to use only a subset of them. The greater specificity and extensiveness of ICD-10 has been likened to a large, comprehensive dictionary. ICD-10-CM is a similar large reference tool, with 68,000 codes, compared with ICD-9’s 13,000. Some of ICD-10’s numerous codes have attracted considerable negative attention as subjects of lampoons and satire, but will have little actual use or relevance in practice.
For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
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MN Physician 4" x 5.25"
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A new era in coding from page 29
fee-for-service (FFS) electronic submitters, and acknowledgment testing can be undertaken at any time. This type of testing will not confirm payment or return an electronic remittance advice (ERA) to the provider, but it will return a 277CA or 999 acknowledgement, as appropriate, to confirm that the claim was accepted or rejected by Medicare. For more information see “MLN Matters Number: SE1501” (http://go.cms. gov/1hfLml2). Additional resources and help CMS maintains a wide range of ICD-10 tools and resources on its ICD-10 website (www. cms.gov/Medicare/Coding/ icd10/). Its “Road to 10” collection in particular is geared to smaller providers and can be accessed from the main ICD-10 webpage. Providers who feel especially late in their preparations or are unfamiliar with ICD-10 at this time may want to start with CMS’ “ICD-10 Quick
Start Guide” (http://go.cms. gov/1FxeQir). In addition, CMS and the American Medical Association (AMA) released a joint press release on July 6 announcing new efforts to help physicians transition to ICD-10 by the Oct. 1 deadline. The parallel assistance will include webinars, on-site training, educational
CMS reiterated that Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after Sep. 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes. However, CMS also issued additional ICD-10 guidance intended to ease providers’ transition to the new coding system by:
ICD-10’s improvements provide greater coding specificity. articles, and national provider calls to help providers learn about the updated codes and prepare for the transition. CMS also announced that it is taking a number of steps to promote ICD-10 readiness, including establishing an ICD-10 communications and coordination center, and creating the position of an ICD-10 ombudsman to triage and answer questions about the submission of claims.
• Creating a one-year grace period during which claims with incorrect ICD-10 diagnoses codes will not be denied, so long as the claim includes a valid ICD-10 code from the right family. • Suspending penalties associated with several quality reporting programs for program year 2015 if the penalty was related to the use of
ICD-10 coding, and so long as a valid ICD-10 code from the right family is used. • A nnouncing the availability of “advance payments” to providers if Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems such as contractor system malfunction or implementation problems. For further information, see the CMS ICD-10 website and the AMA’s website (http://bit. ly/1DVGyq3). David K. Haugen, MA, is the director
of the Center for Health Care Purchasing Improvement at the Minnesota Department of Health. Terence Cahill, MD, is a family physician in Blue Earth, Minn. and is medical director at United Hospital District Clinics. He is working with CMS as physician champion for ICD-10 implementation.
OBJECTIVE, INNOVATIVE OBJECTIVE, INNOVATIVE HEALTHCARE HEALTHCARE REAL REAL ESTATE SOLUTIONS ESTATE SOLUTIONS For more than 25 years, the CWN Healthcare Real Estate Advisory For more than 25 years, the CWN Healthcare Real Estate Advisory team has exclusively represented healthcare clinics and systems, team has exclusively represented healthcare clinics and systems, delivering unbiased and uncommon real estate solutions tailored delivering unbiased and uncommon real estate solutions tailored specifically to your unique priorities, not ours. Call or visit us online, specifically to your unique priorities, not ours. Call or visit us online, and take the first step toward a healther practice through real estate. and take the first step toward a healther practice through real estate. 952.837.8517 952.837.8517 healthcare.cushwakenm.com 952.837.8517 healthcare.cushwakenm.com healthcare.cushwakenm.com 30 Minnesota Physician August 2015
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S HEaLTH SER R E v i R viC iC BIGFORK, MN • COOK, MN
Northern Minnesota Physician Opportunities
Ski, hike, run, fish, canoe, kayak, camp, or hunt in your own backyard or in the Boundary Water Canoe Area, Voyageur’s National Park, Superior National Forest and countless State Parks
ES
Located throughout beautiful Northern Minnesota, Scenic Rivers Health Services is a provider-driven not-for-profit organization. Currently, we are seeking a Family Practice Physician at our location in Cook, MN. This position focuses on local family healthcare, in a wellestablished modern facility helping to support our growing patient needs. You will quickly develop a gratifying panel of patients. Participation in on-call schedule, inpatient and afterhours care is shared (no OB), BC/BE and current or eligible for MN license required.
Work – Life Balance: • 4 day work weeks • Significant starting and residency bonuses • Competitive salaries • Full benefit package • 20 vacation days • 12 sick days • 10 CME days • 6 holidays • 3 personal days
Eric Scrivner, MD
For more information or Cook Area Health Services, Inc. to send a resume: Travis Luedke
20 5th St. SE, Cook, MN 55723 | tluedke@scenicrivershealth.org | 218-361-3190 April 2015 Minnesota Physician
37
Health equity for the LGBTQ community from page 19
and you fill in what you would prefer to be called, and that enhances the relationship and their physician and physician team knows that.” Link stressed that even if providers don’t feel empowered enough to change forms or whole processes, or change to gender-neutral bathrooms, the main thing that physicians can do is to make no assumptions. “When someone comes into your office, don’t assume that the person they’re with is their partner, or that the person is not their partner,” Link said. “Let the patient fill in the blanks—‘Who’s here with you today?’ ‘What do you go by?’ I often ask which pronouns to use (He/him, She/her).” It’s important to train staff to ask questions in ways that invite the patient in. “It’s an ongoing thing,” said Azbill-Salisbury. “We talk about inclusion and diversity training as this ongoing process that people
should constantly be thinking about because it’s tough. We’re set up in a lot of ways to think about sexual orientation and gender as binary: you’re either gay or straight or you’re male or female. But for LGBTQ folks, that binary construction is not descriptive of their experience, so it’s important to be aware of how often you use gendered language when you’re not certain of someone’s gender or their partner’s or family member’s gender.” Smiley’s started with regular education for all staff—providers, lab personnel, medical assistants, front desk personnel, administrators, everyone—about LGBTQ health issues. Then they added gender-neutral bathrooms, enhanced forms, and worked on changing their approach in how they talk to patients to try and remove some of the assumptions. They also asked the vendor for their electronic medical record program to add a preferred name that will
appear at the top of a patient’s electronic record. “I want all my patients—all genders, all backgrounds—to feel that their doctor’s office is a safe space, and I can individualize the care from there, but if I start from that super-open spot, then patients will be able to talk about what their real concerns are,” said Link. Conclusion There are many skills needed to provide LGBTQ culturally competent and supportive care.
The most essential one centers on maintaining an awareness of our own preconceptions of the nature of gender and sexual identity, and sustaining and displaying an openness towards how LGBTQ patients see and identify themselves.
Mary Beth Dahl, RN, leads health equity initiatives at Stratis Health. She also provides oversight to the culturecareconnection.org website.
Resources for providers Family Tree Clinic: familytreeclinic.org LGBTQ sexual and reproductive health care access
Minnesota Transgender Health Coalition:
Smiley’s Family Medicine Clinic: umphysicians.org/Clinics/ smileys-family-medicine-clinic LGBTQ-friendly primary care clinic
Training to Serve:
mntranshealth.org Transgender-focused LGBTQ training and resources
trainingtoserve.org/about-us Elder-focused LGBTQ training and resources
Rainbow Health Initiative:
Voices of Health: bit.ly/1IL4LGS A survey of LGBTQ health in Minnesota, 2014 Data
rainbowhealth.org LGBTQ training and resources
Sioux Falls VA Health Care System Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.
The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine
• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery • Pediatrics
• Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Sleep Medicine • Urgent Care
F O R M O R E I N F O R M AT I O N :
Kari Lenz, Physician Recruitment | karib@acmc.com | (320) 231-6366 www.acmc.com |
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Minnesota Physician August 2015
The VAHCS is currently recruiting for the following healthcare positions in the following location.
Sioux Falls VA HCS, SD Cardiologist
Oncologist/Hematologist
Endocrinologist
Orthopedic Surgeon
ENT (part-time)
Primary Care (Family Practice or Internal Medicine)
Emergency Medicine Geriatrician (part-time) Hospitalist Neurologist
Psychiatrist Pulmonologist Urologist (part-time)
(605) 333-6852 www.siouxfalls.va.gov Applicants can apply online at www.USAJOBS.gov
Join the top ranked clinic in the Twin Cities
MAYO CLINIC HEALTH SYSTEM is a family of clinics, hospitals, and other health care facilities serving more than 60 MAYO CLINIC HEALTH SYSTEM is a family of clinics,
A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:
• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.
Please contact or fax CV to:
Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429
763-504-6600 Fax 763-504-6622
www.NWFPC.com
Family or Internal Medicine Physician
communities Minnesota, Iowa,facilities and Wisconsin. Mayothan Clinic hospitals, andinother healthSYSTEM care serving more 60 MAYO CLINIC HEALTH is a family of clinics, Health System links the expertise of Mayo Clinic in practice, communities in Minnesota, Iowa, and Wisconsin. Mayo Clinic hospitals, and other health care facilities serving more than 60 education and research with the health-delivery of our Health System the expertise of Mayo Clinicsystems in practice, communities in links Minnesota, Iowa, and Wisconsin. Mayo Clinic local communities. education and research with the health-delivery of our Health System links the expertise of Mayo Clinicsystems in practice, local communities. The Northwest Wisconsin Region opportunities include: education and research with the health-delivery systems of our local communities. The Northwest Wisconsin Region opportunities Dermatology Occupational Medicine include: Emergency Medicine Ophthalmology (General & Glaucoma) The Northwest Wisconsin Region opportunities include: Dermatology Occupational Medicine Family Medicine Orthopedics Emergency Medicine Ophthalmology (General & Glaucoma) Dermatology Occupational Medicine General Surgery Pediatrics Family Medicine Orthopedics Emergency Medicine Ophthalmology (General & Glaucoma) Hospitalist Psychiatry GeneralMedicine Surgery Pediatrics (Adult & Child) Family Orthopedics Internal Medicine Pulmonary/Critical Care Hospitalist Psychiatry General Surgery Pediatrics (Adult & Child) Nephrology Urgent Care Internal Medicine Pulmonary/Critical Hospitalist Psychiatry (Adult &Care Child) Neurology UrologyCare Nephrology Urgent Internal Medicine Pulmonary/Critical Care Neurology Urology Nephrology Urgent Care Mayo Foundation is an affirmative action and equal opportunity Neurology Urology employer and educator. Mayo Foundation is an affirmative action and equal opportunity employer educator. Mayo ismore an affirmative action and equal opportunity If you Foundation wishand to learn or to express interest in these positions, employer and educator. please contact us at 800-573-2580; email If you wish to learn more or to express interest in these positions, euphysicianrecruitment@mayo.edu; or apply at please 800-573-2580; If you wish to learncontact more orus toat express interest inemail these positions, http://www.mayoclinic.org/jobs/physicians-scientists euphysicianrecruitment@mayo.edu; apply at please contact us at 800-573-2580;oremail http://www.mayoclinic.org/jobs/physicians-scientists euphysicianrecruitment@mayo.edu; or apply at http://www.mayoclinic.org/jobs/physicians-scientists U:\MN Physician AUGUST 2015.docx U:\MN Physician AUGUST 2015.docx U:\MN Physician AUGUST 2015.docx
Family Medicine St. Cloud/Sartell, MN
An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required.
We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.
GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites.
Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.
For more information Call Kirk Stensrud, CEO 320.634.4521
HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefit package, paid malpractice and a commitment to providing exceptional patient-centered care.
Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334
Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE
Email CV to: kirk.stensrud@glacialridge.org
www.glacialridge.org
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August 2015 Minnesota Physician
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Electronic health care from page 17
start to see a more complete picture. Through smartphones and secure cloud-based portals, real-time management of our patients will become a viable reality in the coming years. When connected devices can securely transmit data to a connected care team, the model of care starts to shift dramatically. Interesting emerging models include Glooko and Marucci. Glooko is a connected diabetes management system allowing for near real-time remote management of patients with diabetes. When a patient performs a glucose test using their standard glucose meter, they connect and sync through the Glooko device and transmit their results to a secure patient-management platform. In addition to glucose data fitness, activity data also syncs to the management tool. A clinician (or parent) can log in and review the glucose and activity data. Parents can now ask their child about a math test or afterschool practice instead
of opening every conversation with “What were your numbers?” And clinicians can manage patients between scheduled quarterly visits. Glooko is adding continuous glucose monitoring (CGM) and insulin pump data in future versions of their software, which will enhance the functionality and usefulness of the service. Research is underway to start creating data sets that may eventually enable more advanced machine-based, real-time disease management. Marucci is a sporting goods manufacturer. Their BodiTrak
player is pulled from the field of play. Once a hit of significant force is detected, and the player is removed from the game, a diagnostic assessment via a tablet can take place in the locker room. An immediate, virtual connection, with impact and baseline data, will be made to a concussion specialist through the MDLive care platform. By the time the child leaves the locker room, they’ve been evaluated by a concussion specialist, have a care plan in place, and an appropriate follow-up scheduled.
A baby born today could have every heartbeat in their lifetime monitored and digitized. system integrates in-helmet concussion sensing, locker room baseline testing, and virtual clinical care. Many helmets are now incorporating impact detection, but the true innovation at Marucci comes after the
Conclusion Technology is moving forward at an increasingly rapid rate. Dramatic changes to care models will emerge as these advances in health monitoring become more ingrained in
A Diverse and Vital Health Service
pediatrics. As hardware and software merge with smart systems, physicians will have access to information not previously available. For children with chronic conditions, these tools could be game changers. Smart connected systems could alert the patient, the parent, and the provider to potentially harmful health events such as an abnormally low glucose reading. For otherwise healthy kids, connected technology could quantify an impact to the head that needs ongoing treatment and allow that child to recover and return to school more quickly. The technology, in all cases, is simply another tool to keep children healthy and safe.
Jeffrey Weness, MBA, is senior
director of Innovation and Partner ships at Children’s Hospitals and Clinics of Minnesota. Laura M. Gandrud, MD, is a pediatric endo Health Service crinologist Boynton at the McNeely Pediatric Diabetes Center at Children’s Hospitals and Clinics of Minnesota.
Boynton Health Service
Welcome to Boynton Health Service Located in the heart of the Twin Cities East Bank campus, Boynton Health Service is a vital part of the University of Minnesota community, providing ambulatory care, health education, and public health services to the University for nearly 100 years. It’s our mission to create a healthy community by working with students, staff, and faculty to achieve physical, emotional, and social well-being. Boynton’s outstanding staff of 400 includes board certified physicians, nurse practitioners, registered nurses, CMAs/LPNs, physician assistants, dentists, dental hygienists, optometrists, physical and massage therapists, registered dietitians, pharmacists, psychiatrists, psychologists, and social workers. Our multidisciplinary health service has been continuously accredited by AAAHC since 1979, and was the first college health service to have earned this distinction. Attending to over 100,000 patient visits each year, Boynton Health Service takes pride in meeting the health care needs of U of M students, staff, and faculty with compassion and professionalism.
Gynecologist/Clinical Supervisor Boynton Health Service is seeking a gynecologist or primary care physician with extensive experience in women’s health to serve as Assistant Director of Primary Care in charge of the Women’s Clinic. The Assistant Director will provide clinical services, ensure staff adherence to relevant regulations, assure the highest professional and ethical standards, and work with the Director of Primary Care and Chief Medical Officer to formulate long range planning and policies. This position offers a competitive salary and a generous academic status retirement plan. Professional liability coverage is provided. Apply online at www1.umn.edu/ohr/employment, select “External Applicants” and then search for keyword: Gynecologist. Job ID#: 300363 To learn more, please contact Hosea Ojwang, Human Resources Director 612-626-1184, hojwang@bhs.umn.edu. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer
410 Church Street SE • Minneapolis, MN 55455 • 612-625-8400 • www.bhs.umn.edu
34
Minnesota Physician August 2015
At Allina Health, we’re here to care for the millions of patients we see each year throughout Minnesota and western Wisconsin. From rural to urban settings, you’ll find a practice and community that is right for you, with ideal staff support and the widest range of clinical practice options, physician leadership opportunities and competitive benefits. EO M/F/Disability/Vet Employer
Make a difference. Join our award-winning team.
MB 0415 ©2015 ALLINA HEALTH SYSTEM. TM- A TRADEMARK OF ALLINA HEALTH SYSTEM.
Join our team
St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria
Opportunities for full-time and part-time staff are available in the following positions: • Associate Chief of Staff • Ophthalmologist • Dermatologist • Hematology/Oncology • Internal Medicine/ Family Practice
• Psychiatrist
• Occupational Health/ Compensation & Pension Physician
1-800-248-4921 (toll-free) Katie.Schrum@allina.com
• Physician (Pain Clinic)/ Outpatient Primary Care
• Urgent Care Applicants must be BE/BC.
physicianjobs.allinahealth.org
WORK-LIFE BALANCE
SURROUNDED BY LAKES POSITIONS AVAILABLE: INTERNAL MEDICINE– No call EMERGENCY MEDICINE FAMILY MEDICINE – Full-scope practice avail. (ER, OB, C-Section, Hospitalist, Clinic)
Erik Dovre, OB/GYN
Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with five primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and benefits. Relocation and sign-on bonus available.
Visit www.lakewoodhealthsystem.com, or contact Brad Anderson at 218-894-8587 or bradanderson@lakewoodhealthsystem.com.
US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.
For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303
www.lakewoodhealthsystem.com
(320) 255-6301 August 2015 Minnesota Physician
35
Physician/pharmacist collaboration from page 27
If no formal process is set up at your place of work, you’ll need to take a different approach. If you’re considering how to better integrate a pharmacist you probably already have a good working relationship with a pharmacist. Figure out which area of your practice that you feel a pharmacist could help the most. No one else knows more about your patient population. Do you struggle with getting your patients’ diabetes numbers under control? Do you have many patients with polypharmacy? Go to a pharmacist with a vision for how they could systematically solve the problems you are facing. Then ask them if they can help you achieve your vision. Be ready to help formalize the process. Multiple options exist for this enhanced collaboration including having pharmacists
provide direct patient care within established protocols in an organization, as well as formalized CPAs between physicians and pharmacists where they don’t necessarily have to be coworkers. CPAs allow pharmacists to manage drug therapy
CPAs to potentially reduce cost and improve care for chronic disease. Minnesota law currently allows for broad physician/ pharmacist CPAs. The NGA article also highlighted efforts within Minnesota to care for Medicaid patients and state
Pharmacists around the country often look to Minnesota. for acute and chronic conditions more efficiently. They also allow pharmacists to provide certain aspects of a patient’s care—generally drug selection, modification, and monitoring after diagnosis.
employees through the use of CPAs. Analyses of that program showed an improvement in diabetes measures and modest cost savings for patients who were cared for with a model of care that utilizes CPAs.
The CDC, the U.S. surgeon general, and a recent article by the National Governors Association (NGA) recommended that all states adopt
The future As health care continues to focus on improved patient care, better outcomes, and lower
cost, teams of health care professionals practicing at the top of their licenses will be essential. It is key that the relationship between physicians and pharmacists continues to grow. Working in either formal or informal collaborative models to take advantage of both profession’s unique expertise can only serve to improve the lives of patients here in Minnesota and across the country.
Cory Nelson, PharmD, is a pharmaceutical care leadership resident at the University of Minnesota and practices at North Memorial’s Camden Clinic. Kyle Turner, PharmD, is a pharmaceutical care leadership resident at the University of Minnesota College of Pharmacy and practices in an interprofessional care team at the HealthEast Maplewood Clinic. Jaskiran Sandhu, MD, is a resident at the University of Minnesota and is board-eligible in family medicine.
Olmsted Medical Center, a 220-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
Opportunities available in the following specialties: Family Medicine
Pain Medicine
Sleep Medicine
Spring Valley Clinic
Rochester Northwest Clinic
Rochester Northwest Clinic
OB/GYN
Psychiatrist – Child & Adolescence
Urology
Hospital – New Women’s Health Pavilion
Hospital
Rochester Southeast Clinic
Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904
email: dcardille@olmmed.org • Phone: 507.529.6748 • Fax: 507.529.6622
www.olmstedmedicalcenter.org 36
Minnesota Physician August 2015
Cancers of the neck and head from page 23
therapy (IMRT) may be initiated. Furthermore, the violation of the lymph node capsule (extracapsular spread) has been associated with a worse prognosis contributing to an increased rate of regional failure, distant metastasis, and death. Several recent quality-of-life studies have determined that the most important functional outcomes for patients after ablative head and neck surgery are the preservation of speech and swallow. The now common use of microvascular free tissue transfer has significantly improved the functional outcomes of ablative oral cavity tumor surgery. One of the major advances in the treatment of patients with oral and maxillofacial cancers has been the use of vascularized bone and/or tissue transplantation for reconstruction. Ultimately, the goal is to reestablish normal function and appearance as quickly as possible. Radiation therapy Primary radiotherapy is generally reserved for those patients
with significant comorbidities or in situations where the primary tumor or patient is not amenable to surgery. Additionally, the presence of high-grade histology, close or positive margins, multiple metastatic lymph nodes, extracapsular extension, perineural or angiolymphatic invasion, and stage III or IV disease are indications for postoperative radiotherapy. Using 2-Dimensional, 3-Dimensional conformal or Intensity Modulated Radiotherapy (IMRT), therapeutic doses of 60–66 Gy are delivered to the primary tumor site and involved cervical lymph nodes for optimizing local and regional disease control. Chemotherapy Chemotherapeutic regimes are also used more frequently as a radiosensitizer and for patients with locoregional recurrence, distant metastases, or as a neoadjuvant preoperative treatment with chemoradiotherapy in patients with gross T4 disease to improve resectability. The role of postoperative chemotherapy in the treatment of oral cavity squamous cell carcinoma is
Family Medicine & Emergency Medicine Physicians
Great Opportunities
• Immediate Openings • Casual weekend or evening shift coverage • Set your own hours • Competitive rates • Paid Malpractice
continuing to evolve. Recently, trials have shown a clear survival benefit of 11 percent improvement with the use of concurrent single agent chemoradiotherapy (Cisplatin) in the postoperative high-risk advanced stage oropharyngeal tumor patient. Currently, it is common for patients with advanced stage oral cancer to receive multimodality treatment with surgery and chemoradiotherapy. Although this has improved locoregional control rates, when recurrence occurs in a previously treated field this can be a significant surgical challenge. Increased rates of complications due to fibrosis, hypovascular tissue, and lack of donor vessels for microvascular free flap reconstruction result in complex patient management. Conclusion The best opportunity for a cure is at the time of initial diagnosis. For continued improvement in survival rates from OCSCC the complex interrelationships between patient, tumor, previous treatment rendered, type of recurrence, salvage options, functional outcome, quality of
life, and overall prognosis need to be considered and individualized in order to optimize patient outcomes. The greatest improvement in survival from oral cancer in the future will likely be due to increased public and practitioner awareness resulting in diagnosis at an earlier stage. The importance of smoking and alcohol cessation cannot be overemphasized as it plays an important role in reducing the risk of second primary tumors. As the treatment needs for patients diagnosed with OCSCC continue to become increasingly complex, the needs of these patients are best suited to tertiary care institutions with multidisciplinary teams established to support the surgical, medical, and psychosocial needs of the patient and families. Deepak Kademani, DMD, MD, FACS,
is a board-certified oral and maxillofacial surgeon. He is the fellowship director of the Oral/Head and Neck Oncologic Surgery and Reconstructive Surgery Program at North Memorial Medical Center and The Humphrey Cancer Center.
Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team. We currently have opportunities in the following areas: • Dermatology • Dermatology
•• Hospitalist Hospitalist
•• Pain Medicine Pediatrics
• Emergency • Emergency
•• Hospice Hospice
•• Psychiatry Psychiatry
Medicine Medicine
• Endocrinology • Family Medicine • Family Medicine • General Surgery • General Surgery
• Geriatric
• Medicine Geriatric
Medicine
•• Internal Medicine Internal Medicine •• Rheumatology Rheumatology •• Med/Peds Med/Peds
•• Urgent Care Sports Medicine
•• Ob/Gyn Ob/Gyn
• Urgent Care
•• Orthopedic Orthopedic
• Vascular Surgery
Surgery
Surgery
Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org
Sorry, no J1 opportunities.
763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer
August 2015 Minnesota Physician
37
Reducing hospitalization for seniors from page 13
addresses and measures social isolation through the PROMIS tool but has also developed other creative approaches. Creating a life plan A customized whole life plan is important. Broader in scope than a typical patient medical record, the Lifesprk Life Plan is created to build a pathway toward achieving the client’s individual goals, incorporating best practices and best fit resources. The plan is then continually measured and adapted to assess outcomes and address new goals and issues. Preventing hospitalization While we currently serve many people who are over the age of 65 and who have already experienced one hospitalization, the model is designed for earlier involvement to prevent even initial hospitalizations. Based on experience with our model, the
• Provide ongoing guidance and support over the long-term, which closes gaps in patient support where problems or issues can germinate into major health events.
team has learned that there are key opportunities for improvement in home and community-based care to further reduce hospitalizations and ED visits. Practitioners need options that go beyond traditional reactive home care services to:
• Provide long-term continuity of coordination between discrete programs of care, crossing all settings.
• Address psychosocial issues that are beyond the scope of other models or covered services.
Eighteen percent of Medicare patients who were hospitalized were readmitted within a month.
• Provide proactive guidance to catch issues early, preventing avoidable hospitalizations and ED visits rather than providing services after an initial health event or crisis.
The next step for physicians Going forward, physicians can help patients and families make effective decisions on how to invest limited resources, even a patient’s own private-pay funds, by seeking outcomes data from home and community-based
providers. Our model with its measurable outcomes provides a baseline benchmark they can use to evaluate other home and community-based options. Physicians can use our services for their patients who may be at risk for higher rates of hospitalization as well as for any senior even before a health crisis to establish an ongoing proactive plan to keep patients as healthy and independent as possible in the community. Physicians also have an opportunity to become more actively involved in home and community-based care and help shape those measurable outcomes in the community by participating in task forces and collaborative efforts to more fully develop community-based population health programs.
Joel Theisen, RN, is founder and CEO of Edina-based Lifesprk. Dave Moen, MD, is principal consultant for MoenMDConsulting.
You’ll love what you hear!
DID YOU KNOW? X 21% of diabetics have hearing loss – compared to 9% of non-diabetics X Hearing loss is tied to three-fold higher incidence of injury-causing falls, as well as more frequent and longer hospitalizations X Untreated hearing loss can affect cognitive brain function – and is associated with the early onset of dementia
After discovering I needed hearing aids, I wanted the best-trained, most competent and experienced audiologist I could find. I also wanted the widest selection of quality products and finest follow-up services. After information-seeking visits with several recommended audiologists, Dr. Paula Schwartz easily rose to the top of my list. Paula and her excellent group of audiologists, all with doctorates, have given me outstanding care over the past eight years.
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www.audiologyconcepts.com 38
Minnesota Physician August 2015
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