Minnesota Physician July 2018 by Minnesota Physician Publishing

MINNESOTA

JULY 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 04

The BME complaint review process A physician’s guide BY RUTH MARTINEZ, MA, AND DAVID BUNDE, JD

ince 1883, physicians in Minnesota have been licensed by the state Medical Board. Originally known as the Board of Medical Examiners, the Minnesota Board of Medical Practice has steadily grown and expanded its functions during its 135 years of existence. The Board’s mission is to protect the public’s health and safety by ensuring that physicians and other allied health professionals are competent, ethical practitioners with the necessary knowledge and skills.

Minnesota’s price transparency law A good first step BY NEIL A. SHAH, MD, FAAD

n March 20, 2018, Gov. Mark Dayton signed into law SF 3480, a bill that calls for price transparency and disclosures from health care providers, including doctors and hospitals. The purpose of this article is to review those changes in the law, provide background on price transparency in health care, and discuss why increasing price transparency is critical to reducing health care costs. SF 3480 takes a few simple but important steps towards price transparency: 1. When asked by a patient, a provider must provide a good faith estimate, within Minnesota’s price transparency law to page 124

Since the 1980s, the Board’s jurisdiction has expanded well beyond physicians to include physician assistants, respiratory therapists, acupuncturists, athletic trainers, genetic counselors, traditional midwives, and naturopathic doctors. In all, the Board licenses over 31,000 practitioners, despite having fewer full-time staff than it did 15 years ago. The BME complaint review process to page 144

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TH 50 SESSION JULY 2018

CONSOLIDATION IN HEALTH CARE

Volume XXXII, Number 4

COVER FEATURES Minnesota’s price transparency law A good first step

The BME complaint review process A physician’s guide

By Neil A. Shah, MD, FAAD

By Ruth Martinez, MA, and David Bunde, JD

Examining cost and quality issues

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Serving half a million rural Minnesotans

Ken Holmen, MD CentraCare Health

REGENERATIVE MEDICINE 16 Documenting outcomes A new national patient-reported registry By Roger Hogue, MD, RVT

MINNESOTA’S MEDICAL CANNABIS PROGRAM Documenting outcomes

HEALTH CARE POLICY The 2018 legislative wrap-up

Thursday, November 1, 2018, 1-4 pm The Gallery, Downtown Minneapolis Hilton and Towers 1101 Marquette Avenue South

Much ado about nothing By Tom Hanson, JD, and John Reich

PEDIATRICS Transitioning to adult health care

Meeting the needs of children with medical complexities By Roy Maynard, MD, FAAP

BACKGROUND AND FOCUS: Consolidation in health care threatens the viability of the system and is escalating at an alarming pace. Patients are left with fewer choices, both in terms of which doctor to see and in terms of treatment options, including medications, from the doctor they do see. Costs are often increased and quality often decreases when systems become too large. Demands to comply with increasing regulations leave many medical practices in a bind. How can they maintain independence without the infrastructure of a large system?

OBJECTIVES:

A new report on outcomes By Tom Arneson, MD, MPH, and Michelle Larson, PhD, MPA

MINNESOTA HEALTH CARE ROUNDTABLE The Opioid Epidemic: 22 Complex Problems, Complex Solutions

We will examine the root causes of health care consolidation. We will illustrate what has worked and what has not. We will explore cases where FTC regulations are pushed to the limits and the threat to patients this poses. We will look at the larger continuum of care and how public health issues are impacted by consolidation. We will discuss state legislative initiatives that need to be in place and what must be done to keep patient well-being at the center of health care delivery.

Panelists include:

Sponsors include:

Scott M. Jensen, MD Senator, District 47, MN Legislature

Center for Diagnostic Imaging

Scott R. Ketover, MD, AGAF President and CEO, Minnesota Gastroenterology, PA

Minnesota Gastroenterology, PA

LIz Quam Executive Director, CDI Quality Institute

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; email mpp@mppub.com; phone 612.728.8600; fax 612.728.8601. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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CAPSULES

New Clinic Will Meet High Demand for Affordable Dental Care NorthPoint Health and Wellness Center plans to open a new dental clinic to serve residents in north Minneapolis, with a $600,000 grant from Delta Dental of Minnesota Foundation. The Hennepin County board approved the grant in mid-June. The new clinic, called the Dr. John Williams dental clinic, will be a community satellite dental clinic and an integrated model with medical, behavioral health, and human services. It will be located at the center’s 800 West Broadway location in Minneapolis. The clinic will meet the high demand of residents seeking affordable dental care by providing an additional 2,300 annual dental visits per year. In 2016, NorthPoint’s call center reported 1,212 new patients called to schedule dental appointments that could not get an appointment.

NorthPoint hopes the increased access to primary oral health care will reduce health disparities among residents in the area. NorthPoint Health and Wellness Center has been serving north Minneapolis for 50 years with health and social services to populations that experience the highest rates of health and socioeconomic disparities in the country. According to Capital Link, a nonprofit that provides technical expertise on capital projects for community health centers, NorthPoint’s operations save the health care system more than $30 million and generate a total economic impact of over $53 million annually.

Essentia Health–Grand Rapids Clinic Opens Essentia Health has opened its new Grand Rapids Clinic and Pharmacy after completing a $14 million expansion and renovation project that began last July. The project included a partnership

between Essentia Health and Lakewood Surgery Center. The expansion brought the total number of exam rooms to 25, from the original six. The clinic also added specialty services including audiology, cardiology, podiatry, and orthopedics, as well as an on-site retail pharmacy.

Hennepin Healthcare Installs Nation’s First Pass-Through Endoscope Reprocessor Hennepin Healthcare Clinic & Specialty Center is the first in the U.S. to install a pass-through automated endoscope reprocessor. Currently, health care facilities face challenges to standardize processes that safely disinfect flexible endoscopes. This is due to the highly complex device designs and conflicting industry reprocessing standards. The new device, called the Advantage Plus Pass-Thru Automated Endoscope Reprocessor, establishes a physical separation between

dirty and clean reprocessing areas to support a one-way workflow that streamlines processes while minimizing the risk of cross contamination and human error. In addition, Hennepin Healthcare transformed its endoscope reprocessing room during the construction of its new clinic and specialty center. Other renovations include ergonomic power lift sinks to reduce technician fatigue and promote proper posture; a system to check for device damage between each patient procedure; endoscope cassettes that only require technicians to handle endoscopes once from high-level disinfection to pre-procedure transportation, which saves time and reduces the potential for cross contamination; cabinets that digitally track drying and storage times and include secure storage that requires staff credentials for access; and covered transport for all scopes that indicate whether a scope is clean or dirty based on the color of the cover.

COLON CARE THEY’LL WANT TO TELL THEIR FRIENDS ABOUT. M N G A S T R O S M A R T FA C T:

WE TREAT YOUR PATIENTS LIKE YOU TREAT YOUR PATIENTS. According to recent CAHPS survey data, 99% of MN Gastroenterology patients say they were treated with courtesy and respect, were made to feel comfortable during their procedure, and would recommend us to their family and friends. Don’t your patients deserve the best quality and experience when it comes to colon care? Refer your patients today by using our secure online Referral Site at https://referrals.mngastro.com or by calling 612-870-5400.

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Visit uhc.com/mnbusiness. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. 6/18 ©2018 United HealthCare Services, Inc. 18-8426-C

MINNESOTA PHYSICIAN JULY 2018

CAPSULES

“The current industry standards are not enough to ensure patient safety and positive outcomes,” said Uggen Jigmey, sterile processing department manager at Hennepin Healthcare. The health care system is continuing renovations, and plans to upgrade all of its flexible endoscope reprocessing facilities to the new system in the next 18 months.

HPV Vaccine Safe For Pregnant Women, Study Shows A new study led by HealthPartners Institute has shown that the quadrivalent vaccine against human papilloma virus (HPV) does not increase the chances of miscarriage. Currently, the vaccine is recommended for girls and women ages 9 to 26 but is not recommended for women who are known to be pregnant. Despite that, some women mistakenly receive the vaccine around the time of pregnancy. This study evaluated data on pregnancies

“The Hub helped me get back on Social Security so that I could pay my bills while I continue to work on my health.”

JULY 2018 MINNESOTA PHYSICIAN

and HPV vaccine exposure for 2,800 women at seven health systems that participate in Vaccine Safety Datalink, which is funded by the Centers for Disease Control and Prevention to monitor vaccine safety. “Fears about the HPV vaccine are far-ranging,” said Elyse Kharbanda, MD, MPH, senior investigator at HealthPartners Institute who led the study. “Some people believe the vaccine affects current or future fertility.” Researchers looked at rates of miscarriage among women who received the quadrivalent HPV vaccine during or just before pregnancy and compared this to rates of miscarriage among women who received the vaccine 16 to 22 weeks prior to pregnancy. They found that rates of miscarriage did not differ significantly by group. “We found no evidence that HPV vaccination during or around the time of pregnancy increased a woman’s risk of miscarriage,” said Kharbanda. “The HPV vaccine is safe and effective. If the vaccine is given around the

time of pregnancy, patients should not worry. Instead clinicians should provide reassurance to them.”

Practices Recognized for Pregnancy and Newborn Care Five Minnesota facilities have received the Triple Aim Best Practice designation from the American College of Nurse-Midwives (ACNM) for achieving exceptional results in pregnancy and newborn care. Fairview Center for Women– Edina; Fairview Clinics–Riverside in Minneapolis; Health Foundations Birth Center in St. Paul; Minnesota Birth Center in Minneapolis; and Thrive Midwives, LLC, in New Brighton received the designation, which recognizes practices that meet the Institute for Healthcare Improvement’s triple aim of improving patient experience, reducing cost of care, and improving the health of populations. To receive the designation, clinics must demonstrate

pre-term birth rates less than 11.4 percent, cesarean rates less than 23.9 percent, and exclusive breastfeeding for the first 48 hours greater than 81 percent. Of the 257 practices participating in the 2017 ACNM Benchmarking Project, 97 were designated Triple Aim Best Practices.

Collaborative Refining Benchmarks For Post-Operative Opioid Prescribing The MN Health Collaborative, a group of 14 health care systems, is currently developing an innovative approach to prescribing opioids for post-operative pain. The new approach addresses the unique needs of patients based on their health histories, current diagnoses, and required surgical and post-operative treatment needs. To combat potential problems of overprescribing, such as side effects and dependence for some individuals, surgeons within the collaborative have

Resources, tools, solutions. With Disability Hub MN, you can put an essential resource directly in your patients’ hands. From explaining health coverage options to submitting medical benefit applications, Hub experts are uniquely positioned to support people with disabilities.

Patients with regenerative medicine questions?

Regenerative medicine focuses on the body’s natural ability to repair, replace, and regenerate damaged or aging tissues. At MINNESOTA REGENERATIVE MEDICINE (MRM), a specialty clinic of HOGUE CLINICS, autologous bio-cellular agents such as platelet-rich plasma (PRP), fat aspirate concentrate (FAC), and bone marrow aspirate concentrate (BMAC) are used to treat degenerative conditions. To ensure proper placement, ultrasound or fluoroscopy guidance is used when clinically indicated during regenerative medicine treatments.

Regenerative medicine treatment categories at MRM include: • Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine) • Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING • Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT

8 Hogue Clinics locations in Minnesota www.mregm.com • (763) 447-2500 or Toll Free (866) 219-4699 MINNESOTA PHYSICIAN JULY 2018

CAPSULES

begun an effort that uses a specific, nuanced approach to post-surgical opioid prescription. It was developed in part as an answer to the lack of evidence-based guidelines for post-operative opioid use and is based on available literature, expert consensus, and community data relevant to the effort. The best practices and takeaways will be shared with the health care community as the efforts progress. Some of the collaborative’s goals are to help reduce, and eventually eliminate, opioid overdose deaths, as well as provide better prevention and treatment practices for opioid addiction. These require a multi-pronged approach including stricter prescription guidelines, improved drug disposal, true care coordination, and stronger education and support for both patients and providers. The new approach to post-operative opioid prescription expands upon the State of Minnesota’s Department of Human Services newly released guidelines. “We applaud DHS on its new guidelines, and want to build on

that foundation by testing the approach recommended by surgeons within the MN Health Collaborative,” said Claire Neely, MD, chief medical officer for ICSI. “We believe this work will provide a clearer determination of the varying pain management needs required by different surgical procedures. This effort will help support a significant need to develop more patient-centered prescription practices where opioids are concerned.”

Kidney Transplant Team Earns National Honor The University of Minnesota Medical Center has received the 2018 Excellence in Teamwork Award from the National Kidney Registry for demonstrating excellence in teamwork for a complex kidney swap. The hospital is one of ten member centers to receive this award. Together, the centers conducted a complex kidney transplant chain that involved 18 patients—nine donors

and nine recipients—and resulted in nine life-saving transplants. “Most paired-exchanged chains we participate in are three or four pairs long,” said transplant coordinator Margaret Voges, RN, BAN. “It was amazing that so many transplant centers teamed together to help so many people that needed a kidney. Transplant chains like this one bring down barriers, because we are all part of one team, working towards one goal.” Paired exchange programs allow a transplant candidate with a willing but incompatible donor to match up with other donor-recipient pairs in the same situation. Once a match is found, the surgeries can be scheduled so that participants can be transplanted, usually on the same day. When swaps are arranged between more than two pairs, they are often referred to as transplant chains. These chains can be long, with dozens of people and numerous transplant centers involved across the country. Kidney chains can also be

started by altruistic donors—people giving a kidney without an intended recipient, as was the case in this 18-person chain. “We routinely educate and offer paired exchange to help inform our patients and families of all their options,” Voges said. “Some choose paired donation even when they are compatible—because they can leverage paired donation for a younger donor or a better match, or even just to help other patients. We share the ultimate goal—to get them transplanted prior to needing dialysis, and with the best long-term outcome.” More than 100,000 people in the U.S. are in need of a kidney transplant but are currently waiting for a matching donor to become available. Recipients generally have two options—a transplant from a living donor, or a transplant from a deceased donor. Because of a donor shortage, an average of 13 people die each day waiting for a new kidney.

V Autism and Obstructive sleep apnea are now approved conditions V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

• Severe and persistent muscle spasms, including those characteristic of MS

• Intractable Pain

• Obstructive sleep apnea

• Autism

• Post-Traumatic Stress Disorder

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS (651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

JULY 2018 MINNESOTA PHYSICIAN

MEDICUS

Kumar Belani, MD, of the University of Minnesota, has received the 2018 University of Minnesota President’s Award for Outstanding Service. He is one of 12 recipients of the award, which recognizes faculty and staff, current or retired, who have provided exceptional service to the University, its schools, colleges, departments, and service units. Belani holds the rank of professor in the departments of anesthesiology, medicine, and pediatrics, as well as adjunct professor in the School of Public Health. He cares for children at the University of Minnesota Masonic Children’s Hospital and participates on the Equity, Diversity, and Inclusion Council in the department of pediatrics. Belani earned his medical degree at Bangalore University in Bangalore, India. Sundeep Khosla, MD, a researcher and physician at Mayo Clinic, has received the 2018 American Association of Clinical Endocrinologists (AACE) Frontiers in Science Award, which is considered the association’s highest honor. Regarded internationally as an expert in osteoporosis, Khosla researches the mechanisms of age-related bone loss, sex steroid regulation of bone metabolism, and the detrimental effects of diabetes on bone. His work has the potential to significantly affect how patients with osteoporosis are diagnosed and treated. Khosla also serves as a council member on the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the director of the Mayo Clinic Center for Clinical and Translational Science. He earned his medical degree at Harvard Medical School. Michael Holte, MD, has joined Glacial Ridge Health System in Glenwood as its first full-time, on-staff orthopedist. Holte brings 27 years of experience to his new role. Most recently, he was head of surgery and chief medical officer at local medical centers in Morris and Benson. Prior to that, he was surgeon/owner/partner in private orthopedic practices in Aberdeen, South Dakota. He specializes in knee and hip replacements, as well as minimally invasive procedures, sports medicine, rotator cuff repairs, carpal tunnel, ACL reconstruction, fractures, and other orthopedic procedures. Holte earned his medical degree at the University of North Dakota in Grand Forks. Craig Samitt, MD, MBA, was named the new president and chief executive officer of Blue Cross and Blue Shield of Minnesota and its parent company, Stella, effective July 30. Samitt has nearly 25 years experience in health care leadership. Most recently, he served as executive vice president and chief clinical officer at Anthem, Inc. Prior to that, he held a number of senior executive positions including partner and global provider practice leader at Oliver Wyman; president and CEO of HealthCare Partners, a subsidiary of DaVita HealthCare; and president and CEO of Dean Health Systems, Inc. Samitt currently serves as a board member of the National Committee for Quality Assurance and is a former commissioner on the Medicare Payment Advisory Commission, an independent agency that advises Congress on Medicare payment policy. He earned his MBA from the Wharton School of Business and his medical degree from Columbia University.

Osmo Vänskä

Paul Jacobs

Emanuel Ax

Women of the Minnesota Chorale

Santtu-Matias Rouvali

Gil Shaham

Season Opening: Osmo Vänskä and Emanuel Ax Sep 21-22

Vänskä Conducts The Planets Sep 27-29

Celebrating Northrop's Restored Pipe Organ Oct 12-13 | Northrop Memorial Auditorium

Shaham Plays Prokofiev Oct 18-19

612-371-5656 / minnesotaorchestra.org Orchestra Hall / #mnorch PHOTOS Vänskä: Travis Anderson Photo. Other photo credits available online.

MINNESOTA PHYSICIAN JULY 2018

INTERVIEW

Serving half a million rural Minnesotans Ken Holmen, MD CentraCare Health What were the driving forces that led to the creation of Carris Health?

In this rapidly changing health care environment, our organizations—ACMC Health, Rice Memorial Hospital, and CentraCare Health—share a common purpose: to serve more than half a million rural Minnesotans in Central and Southwest Minnesota.

The Carris Health co-CEOs have joined the CentraCare Health senior executive group, reporting directly to me.

By coming together, we can provide local access, maintain a qualified workforce, invest in capital improvements, and remain financially viable while delivering high-quality care to the people we serve. Together, we can better prepare for new payment arrangements with the government and private health insurers.

Carris Health is being structured to ensure physicians have critical leadership responsibilities employing the dyad leadership model, similar to that of CentraCare and other leading health care organizations. Physicians will be at the core of shaping Carris Health’s new delivery model.

The Rice Memorial Hospital Board will remain intact with oversight responsibility, including a voice in proposed capital improvements. This board will also have enforcement authority of the lease and operating agreement. Carris Health, as a subsidiary of CentraCare Health, has its board chair on the CentraCare Health Board and CentraCare Health Executive Committee. Additionally, other Carris Health Board members and leaders have joined other CentraCare Health Board committees and operational groups.

JULY 2018 MINNESOTA PHYSICIAN

“...” will be at the Physicians core of shaping Carris Health’s new delivery model. “...”

Carris Health, a not-for-profit 501(c)(3), was formed by CentraCare, a not-for-profit 501(c) (3), as it acquired ACMC Health (a private practice multispecialty group) and entered into a long-term lease and management agreement with the City of Willmar for the operations of Rice Memorial Hospital. Other joint ventures/ assets/locations of ACMC and/or Rice were also brought into Carris Health.

The new partnership puts us in a better position to attract and retain physicians and provide more access to specialty services. We are also looking at ways to share subspecialties where appropriate. Physicians will also transition from using several separate electronic health records systems to the Epic EHR platform. The implementation of Epic will improve standardization and enable a higher quality of patient care and improved clinical efficiency.

What can you tell us about your governance structure?

Carris Health is currently governed by a 10-member board: four from Rice Memorial Hospital, four from ACMC, and two from CentraCare. The co-CEOs of Carris Health— Mike Schramm, CEO of Rice Memorial Hospital, and Cindy Firkins Smith, MD, president and CEO of ACMC Health—serve as non-voting members.

How will the physicians in this new alliance benefit?

Should other regional stakeholders wish to join Carris Health, there is a welcoming hand and capability to expand the Carris Health Board. How will your patients benefit from this new alliance?

The benefit to patients will be substantial. This partnership allows us to reach beyond our individual capabilities to combine the talent and skills of every organization. This means physicians and other providers will be more connected and have greater resources to better serve patients. The goals are to keep patients close to home for care whenever possible, reduce costs, and increase access to specialists.

What are some of the challenges you are facing from a systems integration perspective?

Change is always a challenge, but there is excitement in creating something new and promising for the future of health care delivery. Our integration work is overseen by an operations integration committee, made up of leaders from Carris Health and CentraCare. The committee provides input on opportunities and priorities, provides communication insight, measures staff acceptance and engagement, and acts as champions and leaders of change. Focused teams from materials management, supply chain, IT, finance, human resources, clinical support, and other areas are eager to share ideas, learn from one another, and work together to provide solutions. What are some of the challenges you face from a branding perspective?

As with any new organization, creating awareness and an understanding of what Carris Health is presents a challenge, but also a great opportunity. Carris Health will need to establish itself as a health

system that brings together CentraCare’s strength and access to services with Carris Health’s excellence in rural medicine. What goals do you have for this new partnership?

Our goals are to keep patients close to home for care whenever possible, reduce costs, and increase access to specialists. With closer integration, we want to make sure patients have exactly the right care, at the right place, at the right time. In the majority of cases, this will mean receiving care in local communities. Can other organizations become a part of Carris Health?

Yes. Our vision for care in Central Minnesota is inclusive. We are open to discussions with any regional health care provider that shares our values and commitment to providing residents of this region with first-rate health care. Currently, Carris Health is in discussions with Redwood Area Hospital. Although details have yet to be worked out, we are hopeful that definitive agreements will be finalized this summer, with an anticipated integration date of January 1, 2019.

What are the biggest changes you see coming in health care?

Disruptive change in health care is here. Consumer-oriented businesses have already announced plans to reinvent care delivery options by creating encounters that are highly convenient and done in a way that truly manages health and controls cost. All health systems face the challenges of recruiting and retaining high quality employees, as baby boomers retire and leave the workforce and the need for clinical staff steadily increases. These are just two of many changes impacting providers. The specific challenges mentioned above have unique aspects within the context of rural health care. CentraCare and Carris Health are both committed to our rural communities, patients, providers, and consumers. Our ability to innovate will be critical for success.

organizations ascribe to the Triple Aim of health, experience, and value, as stated by the Institute for Healthcare Improvement, and fully support a “people” strategy that delivers on these objectives. Certainly we will deliver on short-term accomplishments, but it will take years to measure and fully execute a robust plan. From an operations perspective, we are already taking steps forward in providing new resources to our communities, including the new Carris Health Surgery Center, which opened in Willmar in May, as well as access to a broader range of specialty services throughout the region. Ken Holmen, MD, a board-certified anesthesiologist, joined CentraCare Health on January 1, 2015, as the president/CEO. Dr. Holmen is responsible for providing leadership and strategic direction for CentraCare Health and its 12,000 employees and for the establishment, maintenance, and enhancement of quality health services in accordance with the

How will you measure the success of Carris

mission, philosophy, and values of the organization.

Health?

CentraCare Health includes seven hospitals and

Ultimately, the success of Carris Health will be based on the health of the populations we serve. Both

a network of primary and specialty care clinics throughout Central and Southwest Minnesota.

MANY FACES OF COMMUNITY HEALTH 13TH ANNUAL CONFERENCE

Thursday–Friday, October 25-26, 2018 • Hyatt Regency Bloomington, 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. Keynote Speakers: Dr. Michael Westerhaus and Dr. Roli Dwivedi of the Social Medicine Consortium The Consortium is a collective of committed healthcare professionals, universities, and organizations fighting for health equity through education, training, service, and advocacy, with social medicine at its core. This session will address the ways that structural and societal barriers faced by patients can often cause healthcare professionals to feel overwhelmed and isolated. Members of the Consortium will share tools that help us to rediscover agency, purpose, and collective impact in our work. Continuing Education Stratis Health designates the 2018 Many Faces Conference for 10 hours (6 hours on Thursday and 4 hours on Friday) of AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Attendees are responsible for determining if this program meets the criteria for licensure or recertification for their discipline.

For a complete list of speakers and times, visit the conference web site:

manyfacesconference.org

For more information: contact Shelby Maidl / shelby.maidl@mnachc.org / 612-253-4715 ext 10 MINNESOTA PHYSICIAN JULY 2018

3Minnesota’s price transparency law from cover 10 days, of the expected average reimbursement for a proposed service, including the amount that the patient may be personally liable to pay. If facility fees are to be charged, they must be disclosed in the estimate. 2. Health plans cannot prohibit, or “gag,” providers from disclosing their contractual reimbursement amounts in the good faith estimate.

consensus. This vote underscores the universal frustration with health care pricing and costs on the part of legislators and Minnesotans.

What is health insurance? While most of us in health care are vaguely familiar with the post-WWII origins of the health insurance industry in the United States, fewer of us are familiar with the intricacies of how this system functions today.

Insurance is a risk-redistribution strategy under which a pool of participants will pay some entity 3. Health plans must similarly provide a good premiums to guarantee compensation for a particular Increasing price transparency faith estimate if asked by an enrollee. eventuality. In practical terms, we insure against is critical to reducing uncommon or rare events that would be financially 4. Primary care providers (family medicine, health care costs. catastrophic. For example, a car is insured against internal medicine, pediatrics, and obstetrics/ theft or destruction in an accident, because it would gynecology) must maintain a list of their be financially catastrophic for most individuals to 25 most billed CPT codes—including their come up with tens of thousands of dollars to replace top 10 evaluation and management codes the vehicle. Theft or severe accidental damages are as well as their top 10 preventive service rare, so the insurance costs over a pool of participants codes—along with cash-pay (uninsured) remain reasonable. Insurance companies rate members of the pool based on their pricing, average commercial insurance reimbursement, Medicare individual risks—some folks crash more than others—and the characteristics reimbursement, and Medical Assistance reimbursement. This list of their cars, some of which are stolen more often or cost more to replace. As must be posted in waiting rooms and on the practice’s website. a result, different individuals in the insurance pool pay different amounts When the bill was heard in committee, I had the opportunity to testify for their insurance. Actuarial science, the study of these variable risk ratings on its behalf. It faced no overt opposition. Perhaps what is most striking ascribed to individuals or scenarios, is a critical component of the insurance about the bill is that it passed unanimously in the House of Representatives, business model. and in the Senate by a margin of 65–2. It is odd to see this level of bipartisan There are no car insurance products that cover oil changes or new tires. These maintenance costs are borne by the individual who operates the car. The reasoning is that these maintenance costs are clearly predictable and unavoidable, so there is no benefit to purchasing or selling insurance. Modern health insurance policies, particularly in a post Affordable Care Act (ACA) environment, do not constitute insurance in the traditionally accepted sense. The coverage against rare, unpredictable, and financially catastrophic events such as severe acute illness, cancer, or trauma fits the intent and design of insurance. However, limitations on the variability of premiums, coupled with mandatory coverage for maintenance care—some of which is lacking in evidence—results in elevated premiums for all individuals. Decades of additional lawmaking and lobbying have created fantastic market distortions that obscure the true costs of various treatments and increase treatment costs for health care purchasers, while profiting a network of middlemen and large health care systems.

Is health care a market? All markets need two things: a buyer and a seller. In health care, the buyer is the patient who seeks to maintain or restore health. The seller is a medical care provider, such as a physician or hospital. At the early part of the 20th century, this was the extent of the health care market. Patients paid their own bills directly when they needed care. The birth of health care insurance introduced a third-party payer, the insurer, and a third-party purchaser: the patient’s employer for the commercially insured, and the taxpayers for Medicare and Medicaid. The introduction of a third-party payer and purchaser necessarily obscures pricing information from the patient. It also introduces the potential for quality distortions when lowerquality health care providers were, unbeknownst to patients, substituted for high quality providers based solely on costs or other unknown factors.

JULY 2018 MINNESOTA PHYSICIAN

In efficient markets, the prices and qualities of various options are widely known. For example, when you purchase milk at the supermarket, you have your choice of milk products: standard, organic, and non-milk alternatives. Each has a price that is clearly marked. You may prefer to pay more for organic milk, but you make this decision knowing what you are purchasing, as well as the relative costs of alternatives. If you find organic milk too expensive at supermarket A, then you can leave and shop at supermarket B. Of course, obtaining health care is not like buying milk. Insured patients can choose neither their supermarket nor their type of milk. In fact, they only learn the price and type of the milk after they have consumed it.

Choosing your health care provider In the commercial market, choice of health care provider is driven by provider “network” status. Stay within your provider’s network, and you receive enhanced health care benefits. Venture out-of-network, and you risk being stuck with the entire bill. Physicians and other health care providers may petition to be included in a given network, but the decision on network status rests solely with the insurance company. Intriguingly, this issue still applies when patients spend their own money. Patients are essentially self-pay until they hit their deductible, but even predeductible patients are not free to apply their health insurance benefits to any provider they wish to see. In some cases, they may be forced to drive hours to an in-network provider, even if an out-of-network provider is closer. The commercial market also extends to Medicare Advantage plans, which are highly prevalent among Medicare-aged patients in Minnesota. Medical providers can be arbitrarily excluded without cause from provider networks despite being licensed and in good standing with the medical board.

Choosing your milk Even when patients are able to find an in-network provider for a given service, the relative costs of various treatment scenarios are rarely discussed. For example, if a patient presents with a low-risk skin cancer on their arm, there are four common treatment options: do nothing, destroy the cancer, cut out the cancer, or radiate the cancer. Clearly, option one—doing nothing—costs zero, but it is a worthwhile option to discuss if a patient has limited life expectancy. The other options can vary 10-fold in cost, even though their relative cure rates are within 5 percent of each other. Furthermore, the setting in which the treatment occurs—a doctor’s office or a facility—can further multiply the cost. Rarely are patients presented with even representative costs for given procedures prior to embarking on treatment. Hidden costs such as facility fees are almost never disclosed, even though they often double a bill. Further complicating this is the fact that insurance contracts are not on a per-physician basis, but rather on a billingentity basis. This means that a patient could see the same physician at two different offices for the same service and end up with different bills.

The price is wrong In Minnesota, we are fortunate to have some public pricing data. MN Community Measurement (MNCM)’s cost tool (mnhealthscores.org) provides information on what various health care providers are actually paid for a variety of services. That said, disclosure of the data is voluntary—for example, only one in 10 eligible providers list their colonoscopy prices—so it is incomplete. Further complicating the usefulness of the data are the insurance networks. A given clinic or hospital may be less expensive, but it might be out-of-network. Finally, certain datasets like the All Payer Claims Database, which showed massive variations in prices paid for common

services such as knee replacements and cesarean deliveries, are barred from identifying which hospitals are the most expensive. With that caveat in mind, the pricing information we currently have from MNCM reveals that the same health care provider could have high and low reimbursements that are 10-fold apart. Revisiting our milk analogy, we find that the price of milk is the same for all consumers at a given store regardless of whether they are old, young, rich, or poor. This is reasonable—the cost to produce that gallon of milk does not depend on who purchases it. For most health care services, the cost and risk remain constant across a broad swath of patients. Suturing an uncomplicated, one-inch laceration on a forehead or running a strep test have an easily predictable cost, and therefore price, across all patients. Why should the same health care provider get paid as much as 10 times more for performing an identical service for an identical patient? Presently, health care providers price their services based on what they are paid by third-party payers, not based on traditional determinants of price such as cost, risk, overhead, and profit margin. How does this work? For governmental payers like Medicare, Medicaid, and Tricare, the reimbursement for a given service, like an office visit, is fixed and nonnegotiable. An office visit may be reimbursed $50 from Medicaid and $74 from Medicare/Tricare. Nearly all health care providers agree that Medicaid reimbursement rates are set far below the actual costs related to the provision of that care. They are not sustainable or reasonable. Medicare does little better, but could be considered a reasonable floor for reimbursement for some services. A private insurer may provide contracted rates to in-network d

Minnesota’s price transparency law to page 354

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3The BME complaint review process from cover

nominations from various professional organizations, including the Minnesota Medical Association.

In addition to its licensing function, a key role of the Board is to investigate and resolve complaints against practitioners. This is crucial to ensure the quality of care provided by the Board’s licensed health care professionals.

Two other requirements are significant: 1) the Board’s makeup must reflect a geographic balance, and 2) the physician members must “reflect the broad mix of expertise of physicians practicing in Minnesota.”

In many ways, a Board complaint can seem even more threatening than a malpractice case. After all, the Board represents a jury of one’s peers and, unlike a malpractice case where an adverse judgment is covered by insurance, the Board’s actions can impact one’s ability to practice.

A Board complaint can seem even more threatening than a malpractice case.

Compounding this anxiety is the fear of the unknown. Most doctors know little about how the Board functions and what the likely outcomes might be. The goals of this article are to demystify the role of the Board and to provide enough information so that health care providers will be better able to navigate their way through the complaint review process. We will explain the process and offer some tips on how best to respond to a complaint.

The Board’s makeup First, a review of the Board’s makeup may be helpful. The Board is comprised of 16 members: 11 physicians (at least one MD and one DO) and five public members. The governor appoints members following

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The Board works largely through committees. Six members serve on two three-person Complaint Review Committees. Each committee consists of one public member and two physicians.

Complaints—many sources, many reasons

The complaint review process usually is triggered when an outside entity or person files a complaint or similar report with the Board. Patients and family members file approximately one-half of the complaints received annually. Other sources include malpractice insurers (which are required to report settlements or verdicts), various state agencies, other licensed professionals and health care facilities, pharmacists, and even licensees themselves. The types of complaints are almost unlimited, ranging from minor criticisms, such as long waits in a clinic, to very serious allegations, such as sexual abuse, incompetence, or fraud. The most common allegations include unethical/unprofessional conduct, prescribing practices, boundaries issues, improper management of medical records, and alcohol/substance abuse. The Medical Practice Act sets out more than 25 different classifications of misconduct justifying a disciplinary remedy. Some categories are narrow, such as the revocation of a license by another state or conviction for certain crimes. Other categories of misconduct are quite broad, such as engaging in “unprofessional conduct.” The majority of complaints are ultimately closed without public discipline or corrective action.

Triage screens complaints for investigative process Most complaints are processed through the Board’s triage system. Complaints are initially analyzed by staff members who obtain a written response and relevant records from the licensee. These materials are then reviewed by a Medical Coordinator or an Advisory Council, which makes recommendations to the Complaint Review Committee.

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One of the two Complaint Review Committees then evaluates each case. It may dismiss the complaint without any further proceedings, identify concerns to be addressed through an educational conference with a Medical Coordinator or Advisory Council representative, recommend further investigation, or conclude that disciplinary or corrective action may be justified. The committee may recommend a conference between the licensee and the full committee (discussed below) to more fully evaluate the complaint.

Medical Coordinator conferences If the committee believes that a licensee has technically violated the Medical Practice Act, but that the conduct does not justify disciplinary or corrective action, the committee may ask the licensee to participate in an educational conference with a Medical Coordinator. In such cases, the committee has tentatively determined that the complaint may be closed at the conclusion of the conference and is not likely to result in discipline. The primary purpose of the Medical Coordinator

conference is to confirm the accuracy of tentative conclusions and to provide guidance to the licensee to help avoid further complaints. The meetings usually last no more than 30 to 45 minutes. The Medical Coordinator does have the authority, however, to refer a complaint back to the Complaint Review Committee for more formal review and consideration. Thus, physicians should be well prepared for these conferences. More serious complaints are typically sent through the Complaint Review Committee conference process. This does not mean that licensees directed to appear for conferences with a Complaint Review Committee will necessarily be disciplined, but they may reasonably assume that the committee has identified fairly significant concerns.

Complaint Review Committee conferences The Complaint Review Committee conference is significantly more formal than the Medical Coordinator conferences. Licensees are given written notice approximately one month in advance of the conference and are entitled to be represented by attorneys. The conference usually lasts about one hour, depending on the number and seriousness of the allegations. The conference is audio recorded and closed to the public. The only persons present besides the licensee, the licensee’s attorney, and the three committee members are the committee’s attorney and usually four to five Board staff members, including the executive director.

$10,000 per violation, and placing conditions on a provider’s license. The primary purpose of Board disciplinary orders is to protect patients and the public, rather than to punish licensees. In other words, the Board does not discipline a licensee unless it is convinced that the discipline will help protect and serve patients and the public generally. Agreement for Corrective Action: A committee may propose that the licensee enter into an “Agreement for Corrective Action.” These agreements are settlement agreements, whereby the licensee agrees to complete an educational remedy, outlined in a public, non-disciplinary agreement, in exchange for the Board’s ultimate dismissal of the complaint. Although Agreements for Corrective Action are part of the Board’s public files, they are not considered discipline. They are not reported to the media or to the National Practitioners Data Bank, whereas disciplinary remedies are reportable. They are publicly available on the Board’s website. Referral program: Another option available in the case of impaired practitioners is referral to the “Health Professionals Services Program.” The Board may refer impaired physicians to a monitoring program as an alternative to discipline. This too is a non-public resolution, although such a referral may also be contained as a specific term of a public disciplinary action.

The licensee’s options If the committee recommends public disciplinary or corrective action, the licensee has the option of accepting or rejecting the recommendation. If The BME complaint review process to page 424

The conference is usually a question-and-answer session between the licensee and the committee members. The committee chair begins by asking the licensee about the allegations in the Notice of Conference. Other committee members also usually ask questions. Occasionally, a consultant or advisory council member may assist the committee in asking the questions, especially if the allegations center on a specialized practice area beyond the expertise of the committee members. At the end of the questioning, the committee excuses the licensee (and their attorney) from the room while it discusses the case. The committee then typically informs the licensee of its recommendation. If discipline is recommended and agreed to by the licensee, it is almost always adopted by the full Board.

Board options for resolving complaints The decision by the committee usually comes in one of five forms: Dismissal: It may dismiss the complaint, meaning that the case is closed and confidentiality is maintained. The committee has the authority to dismiss a complaint without action by the full Board. Further investigation: The committee may refer the case for further investigation or consideration by consultants, especially when the committee is concerned that the evidence is incomplete or believes an expert opinion from a specialist is needed. Disciplinary sanction: The committee may recommend some type of discipline against the physician. Sanctions may range from a simple reprimand to revocation of a license. While revocation is quite rare, the Board has almost unlimited discretion in fashioning other types of remedies, including requiring the licensee to attend courses on particular subjects (such as prescribing practices or patient boundaries), assessing fines of up to

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MINNESOTA PHYSICIAN JULY 2018

REGENERATIVE MEDICINE

Documenting outcomes A new national patient-reported registry BY ROGER HOGUE, MD, RVT

patient registry is an organized system that collects, analyzes, and disseminates data and information on a group of people defined by a particular health-related service, condition, disease, or exposure. Serving a predetermined scientific, clinical, or public health purpose, patient registries are classified according to how their population is defined. Along with clinical trials, these registries have played a key role in securing regulatory approval for allogeneic pancreatic islet cell transplantation as well as treatments for cancer, cerebral palsy, and numerous other conditions. Registries have helped secure reimbursement and bolster awareness of new treatment options among patients, physicians, insurers, and the FDA.

Paper or digital? Patient registries vary in sophistication, from paper-based data collection to complex electronic databases that are accessible online. Paper forms—completed and collected during and between clinic visits—often present logistical challenges. Web-based collection platforms, by contrast, can extend beyond the clinic, and can capture patient-reported outcomes (PRO) between visits.

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Electronic methods of PRO capture have been widely shown to be feasible in a variety of practice settings, disease states, and age ranges. Electronic collection of patient responses can provide both accurate and immediate time and date stamps for the responses. This facilitates real-time monitoring of response rates, and provides a built-in review mechanism to solicit missing data. Additionally, electronic platforms may provide a safer, more secure environment for information disclosure by patients. In general, electronic capture is preferred to paper because of its flexibility for data collection and for its ability to reveal a more accurate outcome.

Patient-reported outcomes The FDA defines PRO as information about the status of a patient’s health condition that comes directly from the patient, without amendment or interpretation of the patient’s response by a clinician or anyone else. Patient registries that collect PRO data to measure perception of pain, function, and quality of life serve to quantify the qualitative. Aggregating this data enables providers to perform original research at the practice level. Data stored in large registries provide national benchmarking, as well as measures of outcomes and trends within individual treatment centers and providers. By recognizing the critical role of the patient perspective, a PRO patient registry allows a venue for self-reporting of events and outcomes. This type of registry provides a foundation for continuous quality improvement by allowing measurement and comparison of patient-reported outcome measures across practices and providers. A PRO patient registry that allows for the assessment of symptoms, functional status, and health-related quality of life demonstrates the ultimate impact on outcomes experienced by patients.

Benefits of PRO registries PRO patient registries can also evaluate effects in a more “real-world” population, improving generalizability. A PRO patient registry can contribute information across the spectrum of registry purposes: determining effectiveness, measuring or monitoring safety or harm, and measuring quality. A patient registry intended to monitor safety offers the potential for a much more robust understanding of long-term safety than typical clinical efficacy trials. When coupled with data on effectiveness, such registries may help answer difficult questions as viewed from the patient’s perspective, such as “was your treatment successful?” and “if you could go back in time, would you still choose to have the same treatment done?” In the case of cellular-based regenerative medicine (RM) treatments, where established quality standards do not yet exist, a PRO patient registry can be used to establish realistic and acceptable standards. The process of patient self-reporting itself can improve symptom management, functional status, health-related quality of life, communication, and satisfaction with health care. As the ultimate end users of health care services, patients selecting an RM treatment center, provider, and specific treatment have an interest in outcomes based on previous reports of patients like themselves. Outcomes and analysis results will be meaningful to RM patients receiving an autologous cellular treatment for their same or similar degenerative condition.

JULY 2018 MINNESOTA PHYSICIAN

Hard data for an emerging specialty

traditional methods to treat and potentially cure a wide range of degenerative conditions. Over the years, scientific innovation has brought new tools and A PRO patient registry developed for the bourgeoning medical specialty methods to the specialty of RM for the isolation and deployment of autologous of RM has the potential to provide credibility to patients, medical communities, state medical boards, and regulatory agencies such as the cellular agents. The need for a national patient registry for a group of patients FDA. These entities are eager to be informed of receiving RM treatments with percutaneous the capabilities, successes, and shortfalls of RM injection of autologous cellular agents such as autologous cellular treatments. platelet-rich plasma (PRP), fat aspirate concentrate (FAC), bone marrow aspirate concentrate (BMAC), RM practitioners and national advocates in or a combination of these agents, prompted the their field have established and urged the expansion development of the RegenMedPOD patient registry. of patient registries. One such PRO patient registry Patient self-reporting itself can is RegenMedPOD (Regenerative Medicine Patient Outcome Data), an online, HIPAA-compliant, web-based collection platform with an electronic database that was co-developed in Minnesota in early 2018 by the author and Robert Wald for RM patients receiving autologous cellular treatments.

improve symptom management.

The new patient registry is designed for a particular patient population and treatment type, and is intended to provide meaningful information to advise future patients, as well as to establish best practices. Best practices are anticipated to evolve as evidence accumulates from this and other prospective PRO patient registries. Regenerative medicine is a relatively new medical specialty that uses specific treatments to augment, repair, replace, or regenerate tissues and organs. These treatments include cell therapies, gene therapies, tissue engineering, and biomaterials. For many, RM represents a more desirable, natural alternative to

The mission of this patient registry is to serve public health needs by building a community of RM providers that share a common desire of using autologous cellular agents to promote self-healing and tissue regeneration. PRO data is gathered post-treatment at one-, three-, six-, and 12-month intervals, then annually thereafter for 10 years. The gathered PRO data includes any patient-reported adverse events, along with percentage improvement in the following: pain scale, functionality for treated body area, health-related quality of life (QOL), activities of daily living (ADLs), and satisfaction regarding effectiveness of the RM treatment. This online patient registry also includes benefits for participating RM treatment centers and their providers. It offers built-in features to promote Documenting outcomes to page 404

MINNESOTA PHYSICIAN JULY 2018

CHRONIC PAIN

Minnesota’s medical cannabis program A new report on outcomes BY TOM ARNESON, MD, MPH, AND MICHELLE LARSON, PHD, MPA

n May 2014, Minnesota became the 22nd state to create a medical cannabis program. Distribution of extracted cannabis products in liquid or oil form to qualified, enrolled patients began July 1, 2015. The statute that established the program provided a list of conditions that qualified a patient for enrolling in the program, and it gave the Health Commissioner authority to add additional conditions. The statute also obligated the Commissioner to decide whether or not to add intractable pain as a qualifying condition before considering addition of any other condition. On December 1, 2015, the Commissioner announced his decision to add intractable pain to the list of qualifying conditions, effective August 1, 2016. For purposes of the program, intractable pain is defined as pain whose cause cannot be removed and, according to generally accepted medical practice, the full range of pain management modalities appropriate for the patient has been used without adequate result or with intolerable side effects. Minnesota’s medical cannabis program is distinct from those in nearly all other states, as the Minnesota Department of Health (MDH) Office of Medical Cannabis (OMC) collects and analyzes data to learn from the experience of program participants. Early in 2018, the OMC published a

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report drawing on data from patients enrolled in the program for intractable pain between August 1 and December 31, 2016. This article presents highlights from that report, which can be viewed in its entirety at www. health.state.mn.us/topics/cannabis/about/ipreport.html.

Key findings of the report From August 1 through December 31, 2016, 2,245 patients were certified for intractable pain and enrolled in the program for the first time. Most of the patients were middle aged (64 percent between ages 36–64), <1 percent were <18, and 87 percent were ≤65; 52 percent were female. Most patients (73 percent) lived within the Twin Cities metro region, based on the first three digits of their ZIP Codes. Only 8 percent had a registered caregiver (allowed to purchase, transport, and administer products for the patient), 2 percent had a registered parent or guardian, and 10 percent had either a registered parent, guardian, or registered caregiver. When certifying a patient for intractable pain, the health care practitioner indicates the primary cause of pain. The most common causes were axial (mechanical, localized) back pain (23 percent); radicular (nerve, extends into legs) back pain (14 percent); fibromyalgia/myofascial pain (10 percent); neuropathy (8 percent); and osteoarthritis (7 percent). A total of 268 health care practitioners certified the 2,245 patients for intractable pain—85 percent were physicians, 9 percent were advanced practice registered nurses, and 6 percent were physician assistants. The 2,245 patients purchased a total 28,800 products through 17,189 transactions during their first enrollment year at the eight single-purpose medical cannabis retail locations in the state, the only places where medical cannabis products are sold through the program. Products for inhalation (vaporized oil) accounted for 54 percent of purchases; products for enteral administration (swallowed—includes capsules and oral solutions) accounted for 39 percent; oromucosal products accounted for 6 percent; and topical products—which were introduced during the study period—accounted for <1 percent. The products are characterized by the ratio of two cannabinoids: delta-9tetrahydrocannabinol (THC) and cannabidiol (CBD). Very high THC:CBD products with a THC:CBD ratio ≥100:1 accounted for 57 percent of all purchases, followed by products with a THC:CBD ratio from 1:1 to 4:1 (33 percent). Products with a CBD:THC ratio from 1:1 to 99:1 accounted for 4 percent. Information on patient benefits comes from the required Patient SelfEvaluation (PSE) completed by patients prior to each medical cannabis purchase, from patient health care practitioner surveys (sent twice each enrollment year), and from pain scale information at certification by the health care practitioner. Results of analysis of these data indicate perceptions of a high degree of benefit for about half the patients. Among respondents to the surveys of patients (54 percent response rate) and health care practitioners (40 percent response rate), a high level of benefit was reported by 61 percent and 43 percent, respectively (score of 6 or 7 on a seven-point scale). Little or no benefit (score of 1, 2, or 3) was reported by 10 percent of patients and 24 percent of health care practitioners.

Data from the required PSEs were used to calculate the composite PEG scale, a validated three-item scale that asks the patient to assess, over the past week, pain intensity and its interference with enjoyment of life and general activity. Using the PEG scale data, 42 percent achieved ≥30 percent reduction, and 22 percent both achieved and maintained ≥30 percent reduction over four months. The ≥30 percent reduction threshold is often used in pain studies to define clinically meaningful improvement. Health care practitioners responding to the survey indicated a reduction in pain scale scores very similar to the change in PEG scores described above (41 percent achieved a ≥30 percent reduction).

• Authorized medical cannabis to be on school property;

Among patients taking opioid medications at baseline, 63 percent were able to reduce or eliminate opioid usage after six months.

• Permitted manufacturers to operate additional distribution facilities if fewer than the maximum number of manufacturers are registered and a region would otherwise be underserved;

By survey results, approximately 35–45 percent of patients experience at least one physical or mental adverse effect. The vast majority (approximately 90 percent) reported these effects as mild to moderate in severity. The most common adverse effects reported in the Patient Self-Evaluations are dry mouth, drowsiness, fatigue, and mental clouding/“foggy brain.” No serious adverse events—life threatening or requiring hospitalization—were reported for this group of patients during their first year of enrollment. However, among all the 10,000+ patients who have enrolled in the program to date, a total of three serious adverse events have been reported. All three were cannabinoid hyperemesis syndrome—episodes of severe nausea and vomiting that lasts for days. Each recovered fully after discontinuing cannabis.

Resources for health care providers Resources for clinicians are maintained on the Office of Medical Cannabis website (www.health.state.mn.us/topics/cannabis) in a section called “For Health Care Practitioners.” Clinicians can find:

• Increased the number of medical cannabis manufacturers from two to three; • Provided MDH with a greater array of enforcement options over the manufacturers and variable fine amounts proportionate to violations; • Clarified criteria for re-registration of manufacturers and established processes for a temporary suspension, revocation, or non-renewal of a manufacturer;

• Allowed destruction of medical cannabis if deemed necessary to protect patient health and safety; • Required manufacturers to use tracking software for products and give MDH read-only access; and • Notified MDH of any manufacturer ownership change of 5 percent+ and imposed background check requirements. For 2018, the Office of Medical Cannabis introduced a fiscal bill appropriation to be able to spend revenue (from paying patients) coming in and to support program growth. This funding is appropriated under the Special Government Spending Revenue (SGSR), an account that is typically funded by fees from program users. We are currently still under a 2014 Minnesota’s medical cannabis program to page 384

• Annotated listings of review articles and reports, including sections for each of the qualifying conditions in the Minnesota program. • Links to three organizations that offer medical cannabis continuing medical education courses and webinars online at reduced fees for Minnesota clinicians. • A review of medical cannabis clinical trials describing chemical compositions and dosages used in clinical trials for qualifying medical conditions. This report is updated annually and is organized by qualifying condition. • Information on how physicians, advanced practice registered nurses, and physician assistants can register themselves in the program so that they can certify patients for the program. Note that the clinician is able to view the products purchased and symptom scores reported by the patients they certify. In the late summer and fall of each year, clinicians and all members of the public have an opportunity to express their opinion on conditions petitioned for inclusion as qualifying conditions. There is a two-month window, June and July, when citizens can fill out a form requesting that a condition be added. In the following months, there are opportunities for both written comments and public testimony for each of the petitioned conditions. Information on the petitions and opportunities for comment will be posted on the OMC website in August.

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HEALTH CARE POLICY

The 2018 legislative wrap-up Much ado about nothing BY TOM HANSON, JD, AND JOHN REICH

f the 2018 legislative session were a Shakespearian play, it would be “Much Ado About Nothing.” The three-month session, which convened on Feb. 20 and adjourned on May 20, ended in fingerpointing and recriminations between DFL Gov. Mark Dayton and the GOP-controlled Legislature. While little substantive policy of any kind became law as the governor and the Legislature sparred over tax conformity and the supplemental budget, there were some bills that passed that will affect health care providers. This article describes what happened and details those legislative changes that will most affect health care providers.

Overview of session The 2018 legislative session could have been a productive and positive session. Bolstered by low unemployment, a strong economy, and increasing revenue collections, Minnesota Management and Budget announced, shortly after the session began, that the biennial budget was projected to have a surplus of $329 million.

Despite the positive economic and fiscal outlook, the relationships between legislative leadership and the governor were strained due to the contentious end to the 2017 legislative session, when the governor lineitem vetoed the Legislature’s funding over concerns with the tax bill. The Legislature sued the governor and lost at the Minnesota Supreme Court. Instead of spending the 2017 legislative interim working on issues of mutual interest, the Legislature and the governor spent the interim in court. The 2018 legislative session began on Feb. 20. The governor released his supplemental budget plan on March 9. Arguing that businesses fared very well in the latest federal tax overhaul, the governor provided tax breaks for lower- and middle-income tax payers. Among other spending proposals, the governor proposed $13 million for opioid treatment, a stewardship fee on opioid manufacturers, and opioid abuse prevention, and sought to open up MinnesotaCare for all Minnesotans. Republican legislators countered with a 989-page omnibus supplemental budget bill, which included numerous health and human services-related provisions. The governor delivered a letter with 117 objections to the bill. In response, legislators removed 71 items on his list and sent the revised supplemental bill to the governor a day before adjournment. After the Legislature adjourned, the governor vetoed this bill.

Telephone Equipment Distribution (TED) Program

What passed

Lawmakers passed these bills during the 2018 session:

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.

Step Therapy Override (HF 3196/2018 Minnesota Session Law, Chapter 162): This bill, supported by the National Multiple Sclerosis Society, creates a process by which an enrollee and prescribing health care provider can override a health plan company’s step therapy protocol. The bill language is effective Jan. 1, 2019, and applies to health plans offered, issued, or sold after that date. This bill enjoyed broad support in both the House and Senate and passed without a dissenting vote in either body. Regions Hospital Bed Expansion (HF 3202/2018 Minnesota Session Law, Chapter 199): This bill allows Regions Hospital in St. Paul to add 76 licensed beds to its existing facility in two phases. Due to the current moratorium on hospital construction in statute since 1984, it was necessary for Regions Hospital to pass an exemption to this moratorium into law. Regions initially requested 100 new beds, but legislators reduced this number to 76 after the Minnesota Department of Health determined that Regions overestimated their need.

Duluth • Mankato • Metro Moorhead • St. Cloud

Mental Health Provider Changes (SF 3066/2018 Minnesota Session Law, Chapter 128): This bill makes changes to the qualifications required for a mental health practitioner, case management service provider, mental health practitioner working as a clinical trainee, and mental health rehabilitation worker. The bill also adds certain mental health services that can be provided by a mental health practitioner working as a clinical trainee to the list of Medicaid-covered services.

The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

Health Care Price Transparency (SF 3480/2018 Minnesota Session Law, Chapter 168): This bill requires health care providers and insurers

1-800-657-3663 ted.program@state.mn.us mn.gov/dhs/ted-program

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to disclose the cost of medical procedures at the request of a patient within 10 days of the request. Any facility fees or other charges must be included in this disclosure. The bill, a priority of the Minnesota Chamber of Commerce, also required primary care providers to make publicly available price information for commonly billed services. Workers Compensation Hospital Outpatient Fee Schedule (HF 3873/2018 Minnesota Session Law, Chapter 185): This bill reflects the recommendations of the Workers Compensation Advisory Council, made up of labor and business representatives. The bill contains hospital outpatient fee schedules and requires the Commissioner of Labor and Industry to conduct a study of these fee schedules. The bill also establishes payment provisions for ambulatory surgical centers.

practitioners to make recommendations on non-pharmacologic pain management. • Mammogram Screenings Coverage Required (Article 36, Section 1): Requires insurance coverage of preventive mammogram screenings, including digital breast tomosynthesis, if the individual is at risk for breast cancer.

There were some bills that passed that will affect health care providers.

What did not pass While the bills listed below did not become law, they will likely be advanced in the 2019 legislative session. Physician required to notify women of opportunity to view ultrasound before abortion (SF 2849/Vetoed by governor): This bill would require a physician to notify a pregnant woman of her opportunity to view or decline to view an ultrasound of her unborn child. Minnesota Citizens Concerned for Life endorsed the bill, while the Minnesota section of the American College of Obstetricians and Gynecologists spoke against the bill.

• Facility Fee Disclosure Required (Article 36, Section 2): Requires a provider to notify patients about an additional fee that results from the provider’s affiliation with a hospital system and to inform patients that such a fee may result in a higher out-of-pocket expense to the consumer.

• Opioid Prescribing Continuing Education (Article 37, Section 48): Requires the Board of Medical Practice, among other licensing boards, to require licensees with prescribing authority to take at least two hours of continuing education on opioid prescribing by Jan. 1, 2023. • Opioid Prescription Dispensing Limitations (Article 38, Section 3): Prohibits pharmacists from filling a prescription for a Schedule II drug more than 30 days after the prescription date; prohibits pharmacists from filling a prescription for a Schedule II through The 2018 legislative wrap-up to page 364

Opioid Stewardship Fee (SF 730): SF 730 would have assessed a fee on opioid manufacturers and wholesalers based on the volume of product sold in Minnesota. The fee would have raised approximately $20 million, which would have been spent on addiction treatment, prevention, and county services. The pharmaceutical industry lobbied successfully against the measure. Despite the bill passing the Senate 60-6, the stewardship fee could not gain enough support in the House of Representatives. Minnesota Health Records Act Reform (HF 3312/SF 2975): HF 3312 would have conformed Minnesota law to HIPAA for purposes of authorizing the release of health records for treatment, payment, or health care operations. The Minnesota Hospital Association, Minnesota Chamber of Commerce, and Minnesota Business Partnership were among the groups pursuing this legislation. They argued that the efficiencies that providers would realize by conforming to HIPAA would benefit the health care system. Privacy advocates and certain legislators concerned with patient privacy adamantly opposed the bill and the bill did not pass. Omnibus Supplemental Budget (SF 3656/Vetoed by the governor): As stated earlier, the Omnibus Supplemental Budget contained a number of policy changes and funding items of interest to physicians. Brief descriptions of each appear below: • Minnesota Health Policy Commission Established (Article 34, Sections 3 and 19): A 14-member commission would be established, of which one member must be a primary care physician, to compare Minnesota’s market and its costs to other jurisdictions and make recommendations to the Legislature. • Pain Management (Article 34, Section 17): Requires the Health Services Policy Committee, established by the Minnesota Department of Human Services, to consult with certain

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MINNESOTA HEALTH CARE ROUNDTABLE

TH 49 SESSION

THE OPIOID EPIDEMIC:

Complex Problems, Complex Solutions Engaging doctors is key to fighting the opioid epidemic, but there are many other remedies we must pursue. A single silver bullet remedy does not exist. This is a complex problem with complex solutions. Let’s put some of the societal challenges into perspective. What should we know about the opioid epidemic? DR. SCHIFF: This is an epidemic where overdose results in death. We have

known for many years that the death rate from opioids well exceeds the death rate from motor vehicle accidents. We have about 10,000 people in this state who are in treatment for opioid addiction every year. On the prescribing side, we have over 5,000 people a year in Minnesota health care programs who become at risk because they have at least a 45-day supply, and they become new chronic users. We have a big population with the potential to move through that pipeline.

Minnesota Physician Publishing’s 49th Minnesota Health Care Roundtable focused on the topic of The Opioid Epidemic: Complex Problems, Complex Solutions. Eight panelists and our moderator, Minnesota Physician Publisher Mike Starnes, met on April 26, 2018, to discuss this topic. The next roundtable, on Nov. 1, 2018, will address Consolidation in Health Care: Examining Cost and Quality Issues.

DR. LEE: The populations we serve [at UCare] are a pretty representative

cross-section of Minnesota. Like other health plans, we have observed that, as the crisis has been recognized over the last couple of years and multiple stakeholders have taken action, the numbers are leveling off. We can only see, though, the opioids that are prescribed through the legitimate prescription mechanism. We also see the services that are utilized to treat the consequences of opioid use disorder and its related medical conditions, which everyone in this room would recognize: comorbidities, associated mental illness, accidents, and other kinds of medical events. MS. FORREST-PERKINS: Our residential programs [at Wayside Recovery Center] have waiting lists of 70 or more each week. We not only provide care to the individuals in our residential centers, but we also carecoordinate to get people who are on the waiting list into some other type of treatment option to deal with their complexity while they’re on the list. If they are on waiting lists too long, we miss a window of opportunity to work with them, and we could lose them to overdose. MS. BRIGNER: As a former ER nurse, I’ve seen, in Minnesota, an 83

percent increase in ER admissions due to opioids, and the hospitalization rate is going up dramatically. At PhRMA, we are committed to work with you and with other stakeholders, because this is not going away. MS. GOMEZ: It’s not just opioid deaths, but an issue with polysubstance

abuse. A patient who might be on an opioid is also on Ativan, they’re getting fentanyl from somewhere, or they’re getting benzo from another entity.

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That increases the rise in deaths, and you cannot always identify which patients might be at higher risk. We help deliver office risk assessments to help identify those at higher risk for polysubstance abuse or opioid abuse. DR. GEORGE: Prescription numbers have decreased, especially in Minnesota, since 2010. The dense data shows that very clearly, but, on the other hand, overdose deaths from heroin have also increased. In the last six months, most of my patients who said they used heroin actually had fentanyl in their urine. We prescribe them naloxone to ensure that they can survive those overdose episodes. In the last six months, there have been significant overdoses that have happened predominately because of fentanyl, in patients who do not have heroin in their urine.

Let’s look at how this epidemic started. Multiple factors led us to where we are today. Let’s start with FDA drug classifications and CDC guidelines around opioids. MS. GOMEZ: The CDC guidelines are very good, and people should be following them. I don’t know of many that are actually using them, but you also have to put it in the proper perspective for patients who do need more. It is perfectly okay to go against the standard of care as long as you document the rationale behind it, so that somebody else picking up what you have done will be able to read what you wrote and say, “That makes

SHARON BRIGNER, MS, RN, PhRMA

BETH GOMEZ, RN, BSN, JD, Coverys

Ms. Brigner is deputy vice president in state government affairs for the Pharmaceutical Research and Manufacturers of America (PhRMA), a trade association in Washington, DC. She provides clinical expertise and policy support for issues related to appropriate use of medicines, including prescription drug abuse/misuse efforts.

Ms. Gomez is a manager overseeing the Midwest risk management operations for Coverys. She previously served as a senior risk consultant for the University of Michigan. She graduated with a BSN from the University of Michigan, where she held a certification in critical care nursing during her tenure as an intensive care unit RN.

KARINA A. FORREST-PERKINS, MHR, LADC,

LARRY LEE, MD, FACP, MBA, UCare

Wayside Recovery Center Ms. Forrest-Perkins is CEO at Wayside Recovery Center (The Wayside House), a women’s chemical dependency and co-occurring treatment center in the Twin Cities. She is a national speaker on the adaptive impact of overwhelming stress and its intersection with substance use and abuse.

Dr. Lee is senior vice president and chief medical officer at UCare, where he has overall responsibility for clinical and quality practices, including medical policy, pharmacy, clinical services, and quality management. A board-certified general internist, he previoulsy served as a staff physician with the Veterans Health Administration in Minneapolis.

ASHWIN GEORGE, MD, MBA, Valley Pain Relief

LAURA PALOMBI, PHARMD, MPH, MAT,

and Wellness Center

University of Minnesota College of Pharmacy

Dr. George is addiction medicine director at Valley Pain Relief and Wellness Center, where he provides treatment for opioid dependency and heroin addiction, alcohol and chemical dependency, and addiction counseling services. He is certified in Suboxone treatment for narcotic addiction.

Ms. Palombi is an assistant professor at the University of Minnesota College of Pharmacy in Duluth. She has been involved in a variety of projects and collaborations, including Operation Community Connect, the Carlton County Drug Court, and the Carlton County Drug Abuse Task Force.

TODD GINKEL, DC, PDR Clinics

JEFF SCHIFF, MD, MBA, DHS

Dr. Ginkel is founder and CEO of Physicians’ Diagnostics & Rehabilitation Clinics (PDR) and a member of the American Back Society. He recently participated on the task force to review and revise the treatment guidelines for acute and subacute low back pain for the Institute for Clinical Systems Improvement (ICSI).

Dr. Schiff is medical director for Minnesota Medicaid at DHS. His work focuses on evidence-based benefit policy, improved care delivery models, and improvement of clinical quality. His interests include the role of social and family risk factors in health outcomes, integrated delivery systems, and quality measurement.

perfect sense. I know why you’re doing that.” That may be outside of the standard of care, given the present situation, but it still follows a good standard, and it is appropriate.

with a pain management ladder that called out opioids. The emphasis at that time was on controlling pain, and part of that effort was to emphasize measuring pain. It became a metric of quality. Pain scales were to be administered. Implied with that was that pain is bad. If the patient still has pain, then you’re under-treating. That was the prevailing philosophy. My point is that government policies—the products and programs that come out of our government agencies—often reflect the long-term priorities from that time. Government often reacts slowly, which has allowed the crisis to evolve and not be brought to attention.

MS. BRIGNER: Part of the build of the opioid crisis has been a real lack of

clinical evidence and guidelines. There is a public perception that using medicines is actually safe—70 percent of the medicines obtained that are misused and abused come from the family’s own medicine cabinet. A big piece of our messaging and education centers on how to use medicines exactly as prescribed, to not share them, to store them safely, and then to dispose of unused medicines in a proper way, such as your household trash, so they can disintegrate in landfills. We’ve seen a lot of the contributing factors for the opioid crisis being the lack of evidence-based guidelines, the perception of safety, that a doctor is prescribing it versus a shady person in an alley.

In 2001, the Joint Commission issued a report about pain being a fifth vital sign. We didn’t really need to live with pain, since there are ways around it. If we had a realistic perception of pain, it might have put the brakes on this rush to overprescribe opioids.

DR. LEE: During my medical training in the early to mid-1990s, clinical

DR. GINKEL: I’ve treated spine pain for almost 30 years. My position is

practice guidelines were coming on the scene. The Agency for Healthcare Policy and Research was the federal government’s effort to publish what were supposed to be regarded as national, definitive clinical practice guidelines. There was at least one guideline around pain management,

that pain is really a part of life and part of the healing process. To medicate away all forms of pain or all inflammation hinders the healing process, as well as the psychology of the person who goes through this process. When you have an injury, you experience discomfort, you work through that,

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MINNESOTA HEALTH CARE ROUNDTABLE

the body recovers itself, there is an inflammatory process, and you heal. Take away one of those steps, and maybe now all of a sudden you become a chronic pain patient. The medicated way, trying to remove all forms of the healing process, really does turn the person into more of a chronic pain patient. DR. LEE: Doctors have always recognized that opioids had the potential for addiction. It was always in their minds, but was it at the forefront or in the background, and what was the level of risk? I’ll keep referring back to the time when I was in training. The message that my classmates and I heard was that the new generation of opioid pain medication is a safe and effective way to treat pain. Doctors should feel confident in prescribing them because, while they are opioids, the label states that these medications have habit-forming addictive potential, so you don’t need to worry too much about it. It was promoted at the time that patients with chronic pain don’t become addicts. DR. SCHIFF: When we started the Opioid

but if it’s an ongoing pain problem or an ongoing medication, that’s when the risk of addiction starts. MS. GOMEZ: Just because patients are given opioids, that does not make

them dependent or necessarily at risk for being dependent. Social isolation and stigma contribute to dependency as well. You can stop prescribing opioids, bring the hammer down, and legislate against physicians who overprescribe, but what are we doing to address social isolation and stigma? Instead of incarcerating them, let’s put them in a treatment center. Also, we shouldn’t separate mothers from their children just because the mother has an issue. We need to keep them together and try to facilitate their movement into a more functional society. We need to keep the kids engaged in believing that they have self-worth, and we need to teach people better parenting skills. We need to keep them active in school, after-school programs, and churches. We have to look at more than just the prescribing. MS. PALOMBI: I do a lot of community education,

Prescribing Improvement Program, we made community forums throughout northeastern a strong statement that we did not find Minnesota, focus groups, naloxone trainings. We sufficient evidence that opioids were helpful for usually try to gather data on what the community Patients who are going through treating chronic pain. Dr. [Erin] Krebs at the believes to be the problem. Stigma is one thing legitimate pain need to have an Minneapolis VA Medical Center just came out that always comes up, which is not surprising. action plan and a plan to wean. with a landmark study that compared opioids Only 11 percent of people with substance use to NSAIDs for chronic pain. People did not disorder ever end up in treatment. Stigma is one — Sharon Brigner, MS, RN know that NSAIDs were equivalent and much of the reasons that happens, especially in our less harmful. We look at three distinct areas, rural areas, where people are afraid to admit that beginning with less opioid going out the door they have a problem. They’re in a community for the first prescription. You have to look at that isn’t very supportive of them. A lot of our that period of time—up to 45 days—because that’s when people go from communities are convinced that addiction is a moral failure rather than a being prescribed opioids for pain to being dependent. If you continue disease state. If I could work on one thing that would make a huge impact, it to prescribe during that interval, you need to make sure that you’re not would be reducing stigma in our communities. treating other kinds of patient suffering, such as mental health, anxiety, DR. GINKEL: Stigma is huge. From the physician’s point of view, at least the posttraumatic stress disorder, and other factors. After 45 days, how do ones that I work with, I don’t think we’re blaming. I think it’s a situation we make sure that folks who are on medicines for chronic pain are either that exists that we need to deal with. I don’t think our physicians enjoy weaned or are very safely prescribed? seeing somebody come in with a simple musculoligamentous strain/sprain To a certain extent, the opioid epidemic was created by the health care delivery system itself. How do we retool our idea of what an epidemic is to address the problems that opioids present? DR. GINKEL: First of all, we have to get the prescriptions under control—

how many prescriptions we have, and what we’re prescribing them for. It is one thing to help somebody with their pain immediately. That’s great,

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and is on opioids, but we’ve got to deal with it. MS. GOMEZ: Stigma runs both ways. There are many people out there who have cancer, and I’ve known a few who wouldn’t take opioids because they didn’t want to become addicted, even though they were terminal patients. It’s sad for these cancer patients, who do need relief from pain, and it wouldn’t matter if they became dependent during their short remaining lives. At least they would die comfortably and with dignity.

DR. SCHIFF: We also have to address cultural trauma. We have five times

the rate of opioid death in our Native American population, and twice the amount in our American-born African American population. Those are communities that talk about posttraumatic slave disorder, that talk about the Dakota Indian wars, that talk about trauma that still exists in their culture, and we have science around the epigenetics of how that affects multiple generations. We have to recognize the role of social determinants, but we also have to get to the culture. MS. BRIGNER: Addiction should be viewed as

a disease, just like diabetes or mental illness, and not as a moral failing. We need to look at multiple facets, including funding for addiction, mental health, and the comorbidities of patients who suffer from opioid addiction and other preexisting conditions. We would be remiss if we didn’t talk about patients with legitimate chronic pain. There are patients out there who will need to exceed dosage limitations as laid out in a guideline. A bureaucrat should not be the one making that decision, it should be a health care provider who knows that patient’s health history, knows their background, knows if they have an addictive personality, and knows that there are other options that the pharmaceutical industry might bring forth, such as abuse deterrent formulations that make it very difficult to abuse, snort, melt, or inject. DR. GINKEL: Funding for organizations is

into epidemics. For plague and cholera, we addressed environmental factors through public health measures. HIV was once an epidemic, but we addressed it though primary prevention, and it is now a chronic disease. How do we address the underlying emotional issues and social isolation that led to the opioid epidemic? How do we release patients from emotional trauma? We need intense education—not education at the doctor’s office, but at every person’s home, through intense media. This is not an infectious disease epidemic. This is the expression of modern disease. In the future, epidemics are not going to be infectious diseases, they are going to be some other form. Public health measures could go a long way. We’re trying to block small holes in the dam, but we need to focus on reducing the flood. What are the barriers to people seeking help for opioid use disorders? DR. SCHIFF: We have a choice to look at this

If we took opioids away, patients would still find a way to help themselves feel better. —Karina A. Forrest-Perkins, MHR, LADC

important, but I don’t know how you do it. We work in multiple platforms with different payer groups. Access to care is pretty good, although the duration of treatment may not be long enough. Interestingly, on the work comp side, a lot of payers now send patients out of state to get them away from the environment that they live in during their 30- or 90-day treatment. MS. FORREST-PERKINS: We could take away all opioid medications and stop prescribing, change how systems operate, and change how medical professionals are educated. But we still would not be addressing the underlying issue of a highly traumatized society that is seeking ways to mitigate emotional pain. If we took opioids away, patients would still find a way to help themselves feel better. If we do not address that as part of our overarching strategy, we will not be the causal factor that will leverage change in the way that we need to leverage change. DR. GEORGE: We’re talking about the opioid epidemic, but we’re not using

the word addiction. Addiction is a disease that is inherent in our genetics. Throughout history, environmental factors have turned certain diseases

as a moral deficiency—which I believe is still pretty apparent in many parts of our society— or as a use disorder. We have to get away from stigmatizing folks who have, unfortunately, gone down that path. It doesn’t mean that we don’t have to do urine drug test for folks who come in for treatment and make sure that we help people with tighter control of their drugs if they come in. It means that we have to be compassionate and see this as a disease, and we have to do that in all sectors—from the people who diagnose use disorders, to our legislators, to the people who treat, to law enforcement, and to incarceration folks.

MS. FORREST-PERKINS: The insurance payment structure—what they are

willing to pay for, what they are not willing to pay for, when money is cut off, and the complexity around what is currently in place—makes it difficult to look at what is needed to heal from a chronic disease condition like addiction that affects brain function. It takes five to eight months, at least, for the patient to build new neuropathways that wrap and myelinate. Treatment stays now are approved at between three and seven days for the most acute crises, and most addiction treatment programs are limited to 28 days. Even at 90 days or 108 days, patients have not even begun to build new neuropathways that can compete with the old neuropathways that have formed routinized ways of behavior. The neuroscientific evidence has not yet influenced the insurance industry or the payment mechanisms. This isn’t like a broken ankle, which you can treat in a primary care setting with very short and intense touchpoints.

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MINNESOTA HEALTH CARE ROUNDTABLE

DR. LEE: We finance health care in the United States through what I’ll call the

health service benefits administration chassis, a set of mechanisms meant to contract for, pay for, and—I’ll use the “R” word—ration medical services, recognizing that there is a finite amount of funding that has to provide for a long list of health service benefits that are articulated, either in contract or in regulation. When administering a finite resource, the only way to do it is with mechanisms that require services to be administered, covered, and metered out according to an objective mechanism. When it comes to intensity of different settings of care for substance abuse disorder or, even more generally, for behavioral health services, the industry administers those services according to criteria that drive what level of intensity and what setting of care is considered appropriate. During the transition from inpatient care to outpatient care, the industry applies criteria that have been developed with scientific evidence and consensus from the medical professional community. It’s not done arbitrarily. It is developed carefully and administered carefully.

reality is that it is polysubstance problem. It’s a very complex issue with a polysubstance component that may contribute to death when overdose takes place. MS. BRIGNER: Some people believe that there is some one-size-fits-all

solution or a magic bullet that we just haven’t found yet. That couldn’t be further from the truth. If there was one solution, we would have figured it out by now. One thing that is certain, we’re past the time for just talk. We need to come together with a unified, concerted effort by all stakeholders, plans, pharmacists, government, law enforcement officers, health care providers, and the biopharmaceutical industry. Everybody needs to be at the table. Finger-pointing can only take us so far. We need to start talking about serious solutions.

DR. GINKEL: Patients come in and say, “I need pain medication.” The more they want it, the more they need it. That’s probably more likely to be the person that you wouldn’t want to prescribe opioids to. They have anxiety around their pain, and are probably more likely to be dependent. When patients who are probably dependent or addicted come in, there is a What role can the pharmacist play to help brain chemistry change and a personality solve some of these challenges? Public education must focus on change. Their motivations are different. Their risk factors of opioids and on MS. PALOMBI: Community pharmacists have consistency in therapy is different. Their risky behaviors. an opportunity to engage with patients who motivation to try to recover is different. I’ve might be at risk of opioid use disorder or of had patients sit across from me with spine pain. —Ashwin George, MD, MBA overdose. At both the College of Pharmacy and They go through treatment, and I’ll ask them, the School of Medicine, students talk about “How’s your back? What do you have for spine substance use disorder and opioids. A survey pain?” “Nothing.” “What about the opioids?” of all pharmacists practicing in Minnesota “Don’t touch them.” At that point, they are still included questions on their attitudes toward substance use disorder and taking opioids, but not for pain. They get upset, maybe violent if you pharmacist utilization of the tools available to them, such as naloxone want to try to change that. There are also those that become very pain protocols, authorized take-back legislation, and syringe access. The vast focused, so whether they have pain or not, they can imagine they have pain majority agreed that there is a role for pharmacy in the opioid crisis. somewhere. You can create that in your brain. These inappropriate belief We also need to get our providers and our pharmacists used to having systems are alive and well in them. conversations about opioid usage in a professional manner. We give them DR. GEORGE: Our chronic pain and opioid addiction program attempts practice while they’re in school, so that we’re not hearing, later on, that to identify and help chronic patients who have an addiction issue. At the it’s an awkward conversation. It shouldn’t be an awkward conversation if same time, we try to contain this problem. For patients who may have the pharmacist calls the provider, or vice versa, to express their concern addiction issues, we need to understand that their neurobiological changes for the patient. are either persistent or permanent, and focus on a different pathway. I go back to the primary prevention perspective, where the public needs What are the biggest misperceptions around the opioid epidemic? to be educated that pain pills are not the solution to pain. Pain has to be MS. FORREST-PERKINS: From the treatment lens, it’s the misperception expected to certain levels, and there may be other ways to relieve it. I’m that the chronicity and acuity that we see is just from using opioids. The an addiction specialist, but I have multiple friends who work in primary

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care, and the underlying theme for them is, “I have five or 10 minutes, and I have a patient who is focusing on pain.” The physician, in the 10 minutes available, has no option other than to write a prescription and say, “Okay, I’m going to help you with your pain.” On the other hand, a different patient might walk into the primary care office already aware of the problems and perils of going on opioids and aware of other treatment modalities. If public education can help patients, the pressure on the primary care provider will be far less. DR. GINKEL: What are we treating, physiological

pain or psychological pain? Maybe that is what we have to be able to distinguish in the treatment room, and find out the right pathway for them. How can the media become more proactive in supporting efforts to bring the opioid epidemic under control? DR. GEORGE: I think the media should focus on

MS. GOMEZ: The media is a little too simplistic in their understanding of

how it all works. If you find somebody with a long history of polysubstance abuse and you hit them up with Narcan, that’s great, but then what do you do after Narcan? Twenty minutes later, if you haven’t called EMS or if you haven’t gotten help, the patient goes back into a stupor again and could still die. We do need Narcan out there, just as we need EpiPens for allergic reactions, but there’s got to be a followup. This happens in hospitals. You give them Narcan, you ship them back off to the floor, and after a while the nurse says, “He’s fine, he’s snoring.” He’s not snoring, he’s somnolent. Let’s face it, it’s kind of sexy for the media to talk about something like opioid deaths. They could do so much more by talking about projects that work well, if they did a little more research and told readers about a place to find grants if you need money to start a community organization for kids. Media could be part of the solution, instead of being part of the sensationalism.

more positive stories to create an environment MS. FORREST-PERKINS: The media could dispel where, as we’ve been saying, we could function some of the mythology around addiction in a more collaborative way, rather than in a by comparing it with other chronic health blame culture. Highlighting positive stories conditions, where you are in a relationship with would help patients to come forward and seek To medicate away all forms of pain your primary care partner for the rest of your help, knowing that there is something out or all inflammation hinders the life. People often believe that when you go to there that can make their lives better. Fairview treatment for addiction, you never need to go healing process. recently had a story about how opioid-addicted back, as if treatment should be a one-and-done patients and pregnant women were treated, and —Todd Ginkel, DC thing. I went to treatment 30 years ago, and no it was more focused on a couple of patients who one with diabetes would say that. People with had good outcomes and how the babies were diabetes go to the doctor on a regular basis and delivered without any problems. Stories like have their blood checked on a regular basis. that show patients that there is hope out there, versus all the stories that highlight death from opioids. MS. PALOMBI: I don’t believe this is just the media’s responsibility. One thing we can all work on is the language that we use when we talk about MS. BRIGNER: Another way is for the media to highlight the tremendous substance use disorder, even on the drug court teams that I’m a part of. research and development advances of the pharmaceutical industry. We We’ve been working with folks in recovery for a long time, and we still use have 40 medicines in the pipeline to treat addiction, and 40 medicines to words that are stigmatizing and moralizing: clean versus dirty, junky and help with medication-assisted therapy [MAT]. A few years ago, there were addict, urine drug screens that come back positive or negative. The words no medications to assist patients who are trying to wean off opioids and we use are important, and each of us should be aware of how we’re actually to get off their addicted patterns. Our industry spends, on average, $2.6 talking about the issue and whether we frame it as a medical issue or as a billion to bring a drug to market, and only 12 percent of them ever do moral failure. make it to market. Accountability is important, but we also need to ensure that organizations and industries are able to do what they do best. For my industry, it’s research and development to develop non-opioid alternatives and to make sure that we have other options, including medicationassisted therapies. For physicians, it’s focusing on the patient and making sure that they start low, go slow. Educate patients before they medicate.

MS. GOMEZ: The media will only run with articles that they believe will

bring in readers. You don’t hear about the housewife who overdoses. You hear about the young males, maybe those that have been in some kind of altercation or something, or about athletes. You don’t hear about how it affects a multitude of other people. You’ve got your big, important, sexy

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kind of articles, but you don’t have real life. They’re not really sharing what real life is all about, so I think it has become skewed. DR. SCHIFF: It really depends on your media outlet. Calling the media a

monolith is a little like calling doctors a monolith. There has been some coverage about the decrease in life expectancy in middle-aged folks who are Caucasian, based on opioids and suicides. That does get covered in different ways and in different places. I would like it if the media, as some of my colleagues have said, would cover the compassionate care more than the conflict. It would make a big difference. DR. LEE: I’m going to go out on a limb. Should certain kinds of behavior that are dangerous and irresponsible—such hoarding pills and leaving them unsecured in your home—be stigmatized in the media? Maybe that should be called out through public service announcements or other coverage as being just as reckless as leaving a firearm unattended in your house. Why not? Lying to your physician is, perhaps, a behavior that should be stigmatized and regarded as irresponsible. I believe that, in American society, we are too timid to convey messages, strong messages, about individual behavior and individual responsibility. DR. SCHIFF: There is a science behind public

the appropriate medication for my patient, then I will stand my ground and say, “Sorry, I cannot give you opioid pain medications, but I can definitely help you with other modalities for pain relief.” My patient has the right to accept my recommendation or to refuse my recommendation. Patients who do not agree with my recommendation can find another doctor, but at least they have been forewarned and understand the risks. This has happened multiple times, and six months, one year, two years later, I have the same patient coming back, now understanding that they have an addiction problem. I cannot stop patients from getting medications from somebody else, but at least I can educate them during my one encounter. DR. SCHIFF: The further along you get into

Who renders the standard of care in

prescribing, the more screening that should be done. Pain catastrophizing, anxiety, depression, and posttraumatic stress disorder are all things we should evaluate. We should find the folks who are at risk and then identify different mechanisms, rather than going down the line 45 days or 60 days or 90 days or a year later. We hope that the guidelines help our providers in Minnesota have some of these tough conversations. We also tell our providers how they compare to their peers.

medicine? It should be physicians,

DR. GINKEL: I had surgery about a year ago,

not the state.

and I left the hospital with 100 Percocet pills. I took three. The amount is really sensitive. —Beth Gomez, RN, BSN, JD After five days of use, your probability of being a one-year user is 6 percent. After 30 days, you’re at about 30 percent. When you look at prescribing to somebody, it’s important that you look at risk tools. In our office, we use a Keele [University] tool that DR. LEE: A quick example of a public health message being used right assesses for catastrophizing, anxiety, depression, and fear avoidance. We now that uses a negative message: texting while driving, distracted driving. can look at those traits or characteristics, and help work with the patient’s That’s being done right now, and it is using a very stark, even scary message inappropriate belief systems, versus treating with medications. If somebody about what could reasonably be interpreted as a public health issue— is really high on anxiety, opioids are probably not the recommended distracted driving. There are as many fatalities from that in Minnesota as therapy. My patients may demand opioids if they’re anxious, but I don’t from drunk driving. believe it’s the right medication for them, nor do I believe that clinicians are obligated to prescribe opioids. What are the most important things a physician should consider DR. LEE: I’d like to mention something coming down the pike, I believe before writing a prescription for an opioid-based pain medication? in 2019, in the health plan pharmacy PBM [pharmacy benefits manager] space regarding the 100-pill scenario after surgery. Seven days is going to DR. GEORGE: The first and most important thing would be to risk-stratify become the new CMS standard. The rules haven’t been finalized yet, but opioid assessment tools. If the patient has a history of addiction to some the Medicare program is going to allow for a restricted recipient kind of other substance or has severe mental illness, the provider should not program. Here in Minnesota, we’re familiar with in-state public programs prescribe opioids. If my risk assessment tool says that an opioid is not health messaging that says you can get the attention of some people by these negative messages, and they are sometimes effective. You have to be careful, though, because there is also the opportunity to go too far with that messaging and then turn people off.

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for opioid overuse and other kinds of utilization by the individual beneficiaries. A beneficiary can be placed on a restricted status, where they can receive their prescriptions from only one prescriber, use only one pharmacy, and go to only one hospital. To date, the Medicare program has not allowed for any kind of restriction to be placed on Medicare beneficiaries. That will change. What information should physicians tell patients before they prescribe opiods? DR. SCHIFF: There is the risk equation that doctors or other prescribers need to talk about, but the biggest thing is to say, “If I’m going to give this to you, it will be for a very short period of time.” I hope that all providers give that message across the board, because that’s the most important thing. We should stop thinking this is a chronic therapy, and start thinking of it as something that can be useful for a short-term level of acute pain.

prescription they write. In the Medicare program, all Medicare Advantage Plans and all Part D Medicare prescription drug benefit plans run the analytics by a company called Acumen, a contractor to CMS. Every Part D plan gets the reports back, and all part D plans are required to follow up on any questionable high dose or risky combinations involving opioids. One of my responsibilities at UCare is to do the outreach to prescribers based on those Acumen reports. It is sometimes hard to get prescribers on the phone. What tends to work is to tell the truth: “Your prescription was flagged by Medicare and that’s why I’m calling you.” I’ve never had anyone hang up on me when I say that. MS. FORREST-PERKINS: Practicing physicians

have long worked separately from behavioral health professionals. Integrated care models, with co-located providers in your wings of service, is really the optimum model. If not that, make sure that the physician has lists of resources in hand. Physicians may do a referral and worry that it will go into a black hole. They may not see the patient again to get an update, MS. BRIGNER: Seven days of pain medication or wonder whether they have referred to a may be great, but there have to be exceptions. quality behavioral health provider. Behavioral Not everybody responds the same way to pain health partners need to help physicians make medicines, just as not everybody responds the It was promoted at the time that sure they have the questions and point them same to the same surgery. I had a rare genetic patients with chronic pain don’t to a fast-tracker system. Minnesota has this cancer gene and had to have my stomach for mental health and addiction treatment become addicts. removed and have a double mastectomy. I now, allowing physicians to find resources in thought, “Oh, my God, I’m frightened. How —Larry Lee, MD, FACP, MBA their county. On the behavioral health side, am I going to handle pain and get back to we could also put together and vet packets of work?” My identical twin had the same genetic information. Some primary care clinics and cancer gene and had the same surgery. I had a hospital systems already have expert screens higher pain tolerance than she did. You asked and brief screens internally for the individuals seeking care, but we could what physicians should say to patients. For me, I need to hear that there go much further to give advice about symptoms that may come up in the is a treatment plan. I don’t want to hear, “Okay, Sharon, seven days of future, and that may manifest differently for different individuals. pills,” or, “In about two weeks, we’re switching you to Advil.” At that time, all I can handle is getting my drain changed or my dressing changed. I don’t want to think about going without pain medicine in two weeks. Patients who are going through legitimate pain need to have an action plan and a plan to wean. They need to hear, “This is going to be tough, but we’re going to get through it, and we’re going to do this, this, and this.” Remember that not everybody responds the same to pain medicines, and allow exceptions in prescribing. DR. LEE: We’ve all been patients at some point. The worst part is the fear.

It’s the professional responsibility of every clinician to address that as effectively as possible. Prescribers and providers also need to be aware that there are a lot of eyes watching their prescribing patterns, scrutinizing every

DR. GEORGE: Verbal or written pain contracts establishing patient

expectations have also helped immensely. In pain management, the verbal contract has turned into a written contract. You tell the patients when you will start them on pain medications and specify the risks of addiction and the risks of mixing other medications such as benzos with their pain medications. You can provide that information in a five-minute visit, and also give it in writing so they can read through it when they are back at home. Pain contracts help, but there are also some negatives. What do you do when somebody violates the contract? Do you just kick them out of the practice and leave them on their own, or do you find other ways to help them?

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MS. GOMEZ: Prescribing only seven pills after a procedure is the best way

to go, but the caveat then becomes when the government or the law says, “Okay, physicians, you can only prescribe ‘X’ amount.” What does that do in a medical malpractice case, when you’ve prescribed, or not prescribed, “X” amount? Who renders the standard of care in medicine? It should be physicians, not the state. I understand that we should be giving seven and not 100. It should be a reasonable number, and we have to determine what’s reasonable and what’s not. You should say, “Come back to me in seven days. If you still have pain, maybe there’s a secondary issue.” But I tell you, you’re going to be left in a quandary if you don’t follow the state law versus the standard of what your organization or your profession tells you is acceptable or unacceptable. You will be held to both standards, and you better be able to document and justify why you chose one route and not the other.

way in the healing process. We need to take the time to listen and to see why those disparities are occurring, and dig deep into that. DR. LEE: We are working on a project to accelerate the transition of

getting patients who present to the emergency department into a scenario where an opioid use disorder is recognized, accelerating their initiation of definitive treatment that includes MAT, and also getting the patient rapidly established with a community-based substance abuse treatment provider. Our model of embedding drug abuse counselors and being able to start MAT in the emergency department was piloted at Yale and written up in JAMA. The approach that Hennepin Healthcare is going to employ is built upon the Yale model, with some modifications to fit the way things are configured in our community. UCare is providing grant support, and also will be supporting the data collection and analytics for the project.

DR. SCHIFF: I’d like to talk about the state versus

DR. SCHIFF: The programs I’m most jazzed the doctors, since I am a doctor at the state. We about, in terms of supporting communities, follow the medical community and work with have been done for the tribal nations in the medical community, so I believe that there Ontario. These are programs where community are not two separate standards. In Minnesota, resources have surrounded MAT and the classic at least for the quality improvement portion treatment providers so that they have cultural Only 11 percent of people with of this, we’ve tried to create some leeway. We and community support and can wrap around substance use disorder ever end up know that there are going to be some patients other supports, including those involving in treatment. who need more than seven days, and we know dads and moms. These Ontario community that there are going to be some people who programs have had great success, and we’re —Laura Palombi, PharmD, MPH, MAT are going to be over 700 morphine milligram mirroring those in the moms program in equivalents. What we’ve tried to say is that if Minnesota’s White Earth Nation. We have you’re over that amount way more than your grants out to do similar work and to replicate peer physicians, then we’re going to tap you on that model with the other four northern tribes. the shoulder and ask you to do something. Not that we expect you to DR. GEORGE: I would like to add co-occurrence of mental illness. In always perform within a perfect standard, but when we see the gigantic communities where there is higher risk of addiction, they also have higher amount of variation we have, we’re really trying to bring down the rates of co-occurring mental illness. Addressing mental health, either through extremes of that variation first. If we can bring down the extremes, we still counseling, medication, or improved access to mental health in those leave room for some judgments. communities, where the rates of addiction are high, can make a difference.

How can issues of social disparities be best addressed when developing solutions to the opioid epidemic?

One final question: what are the most important things we need to do to bring the opioid epidemic under control?

MS. PALOMBI: We need to listen to what those populations have to say

MS. BRIGNER: Our energies are best served if we focus on prevention,

and understand that different populations have different ways of doing things. For example, in our work in northeastern Minnesota with some of our tribal nations, we put the power in the hands of the tribal nations. We ask them what they need, what they want to see. We work on the strengths in that community and the strengths of that culture. This has gone a long

education, and treatment. Those are the three areas where we have solid evidence. If we talk about the dangers of misuse and abuse of certain medications to patients, or even to teens, when that behavior starts early, they are 50 percent less likely to abuse medicines. Treatment is key. Despite stigmatization, and despite people who believe patients are just going to

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go back out and do it, we have to provide those rescue medicines and those medication-assisted therapies. It is our ethical responsibility and the right thing to do. Also, in my industry, to work on innovation. We cannot give up. We need to look at the regulatory pathways to expedite approval of generics, to expedite approval pathways for non-opioid alternatives. Even if you take away all of the opioids, you’re left with the behavior, you’re left with a real issue of what to do if patients just find something else to abuse. DR. LEE: I would emphasize two themes. First, that

each stakeholder has a part in this effort, and each stakeholder has accountabilities. Second, demand data and evidence so that we can objectively measure the effect of interventions to determine what works and what doesn’t, and also help to reinforce responsibility and accountability. Every sector, both in the health care space and beyond, has a role to play, and should want to hold itself accountable and responsible for its piece.

DR. GINKEL: I’d like to see more nonpharmacological approaches to treat

pain. Physical therapy, chiropractic, acupuncture, massage, and yoga are all tools that don’t have the side effects that opioids do, and they should all be the first line of approach. If you do need drug therapy, there’s also non-opioid therapy. We also need more screening. There is an opioid risk tool and other tools that should be used before prescribing opioids. The American Pain Society also has guidelines on pharmacologic and nonpharmacologic ways to address pain. Those are things that we should access, as well as ICSI [Institute For Clinical Systems Improvement] guidelines. MS. GOMEZ: The University of Michigan just

MS. PALOMBI: We must also look at the root

causes. We have a lot of people who have suffered a lot of trauma. Opioid use disorder has been called a disease of despair. Just as we’re not going to point fingers and say that this is any one group’s problem, we also need to know that we all need to be a part of the solution. It’s not just health care, it’s not just law enforcement, it’s not just public health, and it’s not just the community. It requires a multimodal and multipronged approach.

“This is about all of us.” We have to remember that.

DR. SCHIFF: In addition to the health care sector,

we need to involve law enforcement, child welfare, schools, and other sectors that want to play a part. We need to bring everybody together, and we’re working on getting funding to do that. I have two themes. One is around alignment across all the sectors. The second is that we all want compassionate care when we see our health care providers for any reason, and that’s even more important for folks who have opioid use disorder. At the state level and at the local levels, we need to make sure that all care is given compassionately. It’s more than just providing care without stigma, it’s also about caring. Caring is part of the cure here. There’s a tagline we started to use at DHS, which is, “This is about all of us.” We have to remember that. MS. FORREST-PERKINS: If we’ve ever been avoidant of change in the past,

we need to deal with that tension now and put it to bed. The ethics of finding a solution to this demand that we all do our work differently, collaborate differently, and think differently about solutions. People are coming to us with a life and death situation, and they deserve that priority.

—Jeff Schiff, MD, MBA

started a program called OPEN, which stands for Opioid Prescribing Engagement Network. They get everybody in the community together, including the police, and they look for the opioid-naïve, high-risk patients. Then they start developing programs in certain areas to try to engage. We also need to have candor. It is what it is, and we should talk about it without any bias, embracing it and discussing it in a loving manner. When patients have an issue, they have an issue. I don’t think an opioid addiction should be any more embarrassing for a person than, let’s say, a male who has impotence. Everything is what it is. Embrace it and talk about it in a nonjudgmental fashion. DR. GEORGE: If we want to turn the tide in this

disease as an epidemic, we need public health education that focuses on how to manage pain, as well as other modalities, including nonpharmacological modalities. We need to reach people before they have pain. Once you’re in the doctor’s office and you have pain or you’ve had surgery, no matter what the provider says, you’re not listening, because you have other stresses going on. Public education must focus on risk factors of opioids and on risky behaviors. This could be as simple as taking the Percocet from the cabinet that your husband or your wife was prescribed a couple of years back. I channel this based on how HIV was managed, and how we have successfully controlled the HIV epidemic based on public health measures. That involved similar approaches: general education and addressing risk factors. We changed the HIV epidemic into a disease, not just through improved treatment, but through public health approaches. We can do the same with the opioid epidemic.

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PEDIATRICS

Transitioning to adult health care Meeting the needs of children with medical complexities BY ROY MAYNARD, MD, FAAP

he prevalence of children with medical complexity in U.S. hospital systems has practically doubled over a decade, as advances in the understanding and treatment of previously life-limiting pediatric diseases have brought new hope to affected patients and their families. As children with medically complex conditions live longer, their health care will need to transition—not just transfer—from pediatric family health care to adult care. Despite this need, only 47.1 percent of Minnesota youth with special health care needs receive the services necessary to make appropriate transitions to adult health care, work, and independence, according to the National Survey of Children with Special Health Care Needs.

Extending lives We have made strides in many diseases and conditions that once took the lives of pediatric patients. For example: Infantile Pompe disease. Recipients of a disease-specific enzyme replacement therapy, available since 2006, now survive into their teenage years and, hopefully, beyond that age.

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Hypoplastic left heart syndrome (HLHS). Patients now commonly survive into adulthood without significant complications, but remain at risk for long-term complications associated with surgical palliation. Infantile spinal muscular atrophy (SMA1). Even before the development of nusinersen, many children with this disease survived into their adult years with the benefit of invasive mechanical ventilation and home care. Childhood cancers. While treatment of childhood cancers is one of the great successes in pediatric medicine, survivors will need a lifetime of follow-up for late effects. Neonatal and pediatric intensive care patients. There is an increase in neonatal and pediatric intensive care survivors, some of whom will require lifetime medical care for complex chronic conditions. Cystic fibrosis and sickle cell anemia. These and many other diseases now have improved survival rates, and former pediatric patients will transition into adult subspecialty care. Tracheostomy support. The prevalence of children receiving long-term tracheostomy support from Pediatric Home Service (PHS) has more than doubled over the last 13 years. Approximately two-thirds of these patients are ventilator-dependent. Many will never be liberated from this lifesustaining technology, and will survive into adulthood with an ongoing need for medical care.

Differences between pediatric and adult health care systems Generally speaking, pediatric health care tends to follow a model that is more holistic than adult health care. A team approach to the “whole child” is not unusual, and parents are an integral part of shared decision-making. A child’s disabilities are recognized, but the focus is on optimizing patient potential and quality of life. Pediatric providers may be more receptive to longer clinic visits to address the myriad questions raised by the patient or family. In an adult care system, health care responsibility shifts from a parent or caregiver to the patient. Also, emphasis for chronic conditions tends to be disease-oriented or disease-specific. Patients may need to assume the decisionmaking process for treatments without family support or participation. Recognizing these differences is paramount for providers on both sides of the health care continuum as they care for patients in transition.

Obstacles to a seamless transition It can be challenging to find care providers for children with medical complexities as they age out of pediatric systems. The focus of transition has typically been from the viewpoint of the pediatric provider, patient, or family, with less input from adult providers. A study looking at transition care from the perspective of the adult provider raised concerns about their medical competency to manage congenital and childhood illnesses. Additional issues for adult providers included a desire for continued family involvement, managing psychosocial problems, and financial considerations. There are pediatric providers willing to care for adults, but this opens their risk for medical liability when practicing outside the scope of their training.

Additional barriers to this transition include accessibility to waiver programs, health care workforce shortages, and financial disincentives to care for a labor-intensive population. Lastly, who should take the lead in transition—the primary care provider, medical home, or subspecialist?

The Got Transition/Center for Health Care Transition Improvement One of the best online resources for health care transitions is the Got Transition/Center for Health Care Transition Improvement (www. gottransition.org). This website provides information and tools for providers, clinics, or medical homes to develop their own transition program. There is even a query on readiness for transition to adult health care for adolescents and their families.

and most difficult group. She believes that the more complex the patient, the earlier the transition process should start. These patients will often have multiple providers and a need for community health care workers. Planning for adult health care may start as early as age 14, with transition of care completed between ages 20 to 22. Children with a single health problem such as diabetes, asthma, or ADHD generally don’t require community health services and comprise the second group of children, requiring a less complicated transition. Children without special health care needs comprise the third group. Important points emphasized by Dr. Hogan include: • Each pediatric provider at Hennepin Healthcare identifies their own patients in need of transition. • A warm hand-off is advised, with the patient and both pediatric and adult providers in attendance whenever feasible.

The fundamental framework in the Got Transition website involves Six Core Elements of Health Care Transition: 1. Transition Policy, which incorporates guidelines that best meet the needs of patients, families, clinics, and hospitals. The policy educates staff on a clinic’s approach to transition, which may identify youth at ages 12 to 14 to review the transition process.

It can be challenging to find care providers for children with medical complexities as they age out of pediatric systems.

2. Transition Tracking and Monitoring, which establishes criteria to identify patients in need of transition and uses tools to track the progress of transition. 3. Transition Readiness, which states that the timing of transition should not be determined by a patient’s chronological age, but by physical and cognitive considerations, medical status, and the readiness of the young patient. Assessments include the capability to make appointments, compliance with medications and provider visits, and self-care and advocacy. 4. Transition Planning, which provides a regularly updated plan of care that includes goals, legal decision-making and resources, and intellectual challenges. This planning identifies the optimum time of transfer and release of medical records. 5. Transfer of Care, which confirms the date for the first adult provider appointment. Plan of care, emergency care plan, and transfer package should be confirmed in this receipt of care from adult providers. 6. Transfer Completion, which offers consultation to accepting adult providers and calls for contact with the patient/family within six months to elicit feedback on the transition.

Minnesota transition programs Many Minnesota institutions are addressing transition care. The following list of transition programs is not meant to be exclusionary: Hennepin Healthcare. This program was spearheaded six years ago by Marjorie Hogan, MD, a specialist in adolescent medicine who recognized the need for a transition program to accommodate pediatric patients within the Hennepin Healthcare system. Since the inception of the Adolescent Transition Clinic, approximately 100 patients have successfully moved into adult health care. Dr. Hogan stratifies patients needing transition into three groups. Children with medical complexity (CMC) is the first

• A new primary care physician is identified for each transition patient. The program has evolved as the Adolescent Transition Clinic learns about the needs of the patients. Future elements of the program include modifications to their EMR to meet expectations for a seamless transition.

Children’s Minnesota. For a free-standing children’s hospital and its pediatricians, one of the obstacles to transition care is the lack of adult providers inherent in large health care systems with both pediatric and adult clinics. In 2008, Sheldon Berkowitz, MD, was part of a special interest group on transition that included parents, pediatric and adult physicians, and social and community advocacy workers. The impetus was to formulate a collaborative effort on how to transition patients that “age out” of pediatric care around age 21. The result was a roadmap to transition for complicated and uncomplicated patients. The latter is defined as a patient who has two or fewer straightforward problems, for whom finding adult providers is much less difficult. Patients with three or more providers, those who are technology-dependent, and those taking multiple medications are considered complicated. Again, the more complicated the patient, the earlier discussions about transition should occur. Ideally a warm hand-off is recommended, the least of which would be a phone call from the pediatric provider to the new primary care provider. This roadmap for transition care addressed issues such as insurance, guardianship, and the need to identify the health care resources and systems the patient and family want for adult care. Age restrictions in place at Children’s hospitals and their associated emergency rooms may affect timing of the transition process, so as not to impact health care access. Dr. Berkowitz also addressed that conversations may need to take place with some patients, including topics like menses, gynecological care, pregnancy, birth control, or sterilization. Gillette Children’s Specialty Healthcare. Robert Wagner, MD, has been integral in the development of the Transition Process and the Lifetime Clinic at Gillette Children’s Specialty Healthcare. Lifetime opened in 2002 with a focus on cerebral palsy, but expanded to include care for adults with spina bifida, progressive neuromuscular diseases, and other congenital or childhood-onset disabilities. The range of services reflects the needs of the patient population, Transitioning to adult health care to page 344 MINNESOTA PHYSICIAN JULY 2018

3Transitioning to adult health care from page 33

treatments. Karim Thomas Sadak, MD, MPH, director of the Childhood Cancer Survivor Program at MHealth, has recognized the need for and includes physical medicine and rehabilitation, urology, neurosurgery, a process to transition adolescent and young adult cancer survivors. and other disciplines. The Lifetime transition clinic was started by Kathy The University of Minnesota has received international recognition in Lindstrom, CNP, in 2015 to coordinate care for young performing complex organ and bone marrow adults new to Lifetime. Partnering with adult primary transplants in children. Children that benefit care providers, Gillette Lifetime provides disabilityfrom transplantation and that survive beyond related specialty care, including multidisciplinary adolescence also require lifetime care with adult clinics for spina bifida, neuromuscular disorders, and providers for potential complications from rejection The more complex the patient, complex movement disorders. Gillette works closely or immunosuppression. the earlier the transition with Regions Hospital for adult inpatient care.

process should start.

University of Minnesota Masonic Children’s Hospital. The current focus on transition has been on specialty-centered care within the same institution. Adolescents with a history of congenital heart disease transition to an adult cardiac specialist, which is important for longitudinal follow-up of potential morbidities. The average life expectancy for cystic fibrosis patients in the U.S. approximates 40 years, with most of these patients now being identified by newborn screens in the neonatal period. As their disease progresses, sharing the same health care record within the University of Minnesota provides a smooth transition between pediatric and adult pulmonary specialists. Transition care for childhood cancer survivors also emphasizes the need for longitudinal care into adulthood. Pediatric oncology patients are at risk for late-onset chronic conditions as a sequela of their life-saving

Making transitions possible

Thoughtful processes and preparedness from the patient and pediatric and adult providers ensure that the transition into adult health care can be purposeful and beneficial. A seamless transition benefits all parties involved and maintains access to care for the patient. The outlined resources and health care systems have provided great assistance in building the framework for success within our communities. Roy Maynard, MD, FAAP, a retired neonatologist and pediatric pulmonologist, is medical director for Pediatric Home Service (PHS). He serves as PHS’s clinical leader, working with the team to provide consultation and advice to ensure quality and effective pediatric home care to patients and their families in their own homes. He also leads implementation of clinical policies, procedures, and programs to further enhance the best possible care for each child.

Regional Medical Director MINNEAPOLIS, MN HealthPartners Medical Group, based in Minneapolis, Minnesota, is actively recruiting a Regional Medical Director (RMD) to oversee our urgent care services and our in-house primary care physician float pool. The RMD will coordinate and oversee the clinical, operational and financial performance of all HealthPartners Urgent Care clinics. RMDs will partner across the care group to provide a consistent care model and experience for patients. The RMD will report directly to the senior Medical Director, Primary Care. To accomplish the intended outcomes, the RMD must maintain effective working relationships with patients, leadership, clinician and staff colleagues across the care group. Requirements: • Effective in leading physicians and advanced practice clinicians, including coaching, team building and development. • Effective, efficient and articulate communication skills; ability to effectively cooperate, collaborate and communicate with all disciplines and levels of professionals within a large multi-specialty organization • Actively participate in care group initiatives to achieve desired outcomes • M.D. or D.O. degree and current Minnesota medical license, or ability to obtain a Minnesota medical license • Two years of leadership and management experience. Preferred candidates will have five years’ experience as a practicing physician, with experience in ambulatory care settings. • Board certification in Family Medicine or Internal Medicine/Pediatrics is required. HealthPartners offers a competitive salary and benefits package and a commitment to providing exceptional patient-centered care. For more information, please contact diane.m.collins@healthpartners.com or call Diane at 952-883-5453, or 800-472-4695 x3. Apply online at healthpartners.com/careers, Job ID# 48701. EOE

JULY 2018 MINNESOTA PHYSICIAN

3Minnesota’s price transparency law from page 13 providers that can be as high as 300 percent of Medicare rates—an almost unreasonable amount over the true costs to provide services. Health care providers set their “list” price at some amount over the maximum amount they are paid by their highest-reimbursing payer. This is the “price” in health care. Rarely does this “price” reflect the actual costs involved in the provision of health care services. In scenarios where patients have no insurance, they may be liable for this “list” price. This is unfortunate for these self-pay patients, as every other payer gets a contractual discount on the list price. Moreover, the self-pay patient was, until the passage of the price transparency law, unaware of the discounts provided to most other payers. In fact, most commercial insurance contracts provided to health care providers contained gag clauses that forbade the disclosure of actual reimbursement amounts, called allowable amounts, to any other party.

The tide is turning We have viewed the issues related to the current health “insurance” marketplace and described the decoupling of costs from price in the pricing of health care services. A doctoral dissertation could be constructed on each of these issues. With that in mind, there are issues on the horizon that will force a rethinking of how we price and purchase health care services. In the private sector, health care spending continues to rise, but with a greater proportional burden on employees. While employers still cover the majority of health insurance premiums as a benefit for employees, the Kaiser Family Foundation reports that, between 2006 and 2016, the increase in health insurance spending has been led by a 78 percent increase in employee contributions,

with only a 58 percent increase in employer contributions. Moreover, there is additional cost shifting to employees via an increase from 4 percent to 29 percent of employees enrolled in high-deductible insurance products over the same period. Employees purchasing these types of plans are essentially self-pay until they hit their deductible, which may be nearly $14,000 for a family. This movement towards cost shifting to employees will help drive the movement towards price transparency in health care. As patients become the health care purchasers for the first few thousand dollars of their health care expenses—the maintenance costs in our car analogy—they will start to ask, “How much will this cost me?” SF 3480, while not complete or perfect, is a good first step toward empowering patients to receive that information before making decisions. Employers should also begin to ask, “What are we getting in exchange for our premium dollars?” They may find that by seeking out low-cost, high-value health care providers, and directly contracting with those providers, they can reduce administrative costs as well as their total health care costs. Unfortunately, what’s good for patients and health care purchasers may not be good for some insurers or large health care systems. The challenge will be fighting that powerful lobby, which benefits greatly from price opacity and the status quo. Nonetheless, after the passage of SF 3480, I remain cautiously optimistic that the tide may finally turn when it comes to health care pricing transparency and the reigning in of runaway health care costs. Neil A. Shah, MD, FAAD, is a board-certified dermatologist in private practice and a founding member of the Minnesota Independent Physicians Association (mnipa.org).

Urgent Care Physicians HEAL. TEACH. LEAD.

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 VAHCS is currently recruiting for the following positions:

Cardiologist Endocrinologist Neurologist PACT

Physiatrist Psychiatrist Psychologist Pulmonologist

Emergency Medicine (part-time) ENT (part-time) Gastroenterologist (part-time) Urologist (part-time)

apply online at www.USAJOBS.gov

(605) 333-6852 ·

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE

www.siouxfalls.va.gov MINNESOTA PHYSICIAN JULY 2018

3The 2018 legislative wrap-up from page 21 V drug more than 30 days after the prescription was written; and prohibits refills more than 45 days after the date of the prescription. • Prescription Monitoring Program (PMP) (Article 38, Sections 4-6): Requires that the Board of Pharmacy contract with a vendor to provide a service to providers to access data related to health records or pharmacy software; imposes certain restrictions and requirements on the vendor; allows the Board of Pharmacy to charge an annual fee, not to exceed $50, to pharmacists and prescribers who access the PMP.

3. If either of the aforementioned points do not apply, then the quantity prescribed shall not exceed a seven-day supply for an adult and a five-day supply for a minor under 18 years of age.

Learn more

An enrollee and prescribing health care provider can override a health plan company’s step therapy protocol.

• Opioid Quantity Prescribing Limits (Article 38, Section 12): Puts limits on the number of opioids for acute pain; allows for prescriptions above the limits listed below if, in the practitioner’s professional clinical judgment, it is warranted. The limits are:

Most of the bills passed during the 2018 session take effect Aug. 1, and will be compiled at the website of the state’s Office of the Revisor of Statutes (www. revisor.mn.gov). To learn more about an individual House or Senate bill, or to track bills that may carry forward during the 2019 session, visit www.leg.state. mn.us/leg/legis. Tom Hanson, JD, an attorney with Winthrop & Weinstine, represents clients before the Legislature and regulatory bodies. Prior to joining the firm, he worked for the Republican Caucus in the Minnesota House of

Representatives for eight years and served for eight years in Gov. Pawlenty’s administration, including four years as the Commissioner of Minnesota

1. For the treatment of acute dental pain or acute pain associated with refractive surgery, the quantity prescribed shall not exceed a fourday supply;

Management and Budget.

2. For practitioners who are practicing in an emergency department, urgency care clinic, or walk-in clinic, a prescription shall not exceed a three-day supply;

extensive experience in lobbying and strategy management. Prior to joining the

John Reich, director of government relations at Winthrop & Weinstine, has firm, he worked for the DFL Caucus in the Minnesota House of Representatives for five years and served for four years in Gov. Dayton’s administration.

Change Lives Boynton Health is a national leader in college student health. We serve the University of Minnesota, delivering comprehensive health care services with a public health approach to campus well-being. Our patients are motivated and diverse undergraduate, graduate and international students, faculty and staff. On campus, you will have access to cultural and athletic events and a rich academic environment. Boynton is readily accessible by transit, biking and walking. With no evening, weekend or on-call hours, our physicians find exceptional work/life balance.

PHYSICIAN Boynton Health is seeking a full-time physician in Primary Care and Urgent Care Clinics. We have in-house mental health, pharmacy, physical therapy, lab, x-ray and other services to provide holistic care of your patients. This position offers a competitive salary, comprehensive benefits, CME opportunities and a generous retirement plan. Professional liability coverage is provided.

To learn more, contact Michele Senenfelder, Human Resources at 612-301-2166, msenenfe@umn.edu Apply online at http://www1.umn.edu/ohr/employment and search Keyword 324537. 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

JULY 2018 MINNESOTA PHYSICIAN

& Coming together to care for you.

with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Join our family of physicians Fairview Health Services is an award-winning, nonprofit health system, providing exceptional care across the full spectrum of health care services. Joined by HealthEast in June 2017, Fairview is one of the most comprehensive and geographically accessible systems in the state, serving the greater Twin Cities metro area and north-central Minnesota. 12 hospitals – including an academic medical center and long-term care hospital 56+ primary care clinics and 55+ specialty care clinics

Apply online at www.mankatoclinic.com

30+ retail pharmacies and specialty pharmacies

Helping physicians communicate with physicians for over 30 years.

Call 1-800-842-6469 Email recruit1@fairview.org Visit fairview.org or healtheast.org

Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: • Recruit a new physician associate • Share new diagnostic and therapeutic advances • Develop and enhance referral networks

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MINNESOTA PHYSICIAN JULY 2018

3Minnesota’s medical cannabis program from page 19

patients certified for intractable pain indicates most patients perceive a high level of benefit and their certifying clinicians generally concur.

appropriation of $733K, which was enough for a program with fewer than The medical cannabis products obtained through the program continue 5,000 patients. At over 10,000 patients and quickly growing, the fee revenue to have a relatively good safety profile, though some patients discontinue is needed to keep up with the Patient Registry and use of medical cannabis because of side effects call staff processing patients. Program revenue and a few patients have experienced serious bouts has more than doubled, but is not allowed to be of persistent and/or cyclic nausea and vomiting. spent without legislative approval, and is now just The Office of Medical Cannabis will continue to sitting in an account, earning interest. Not being gather, analyze, and publish reports on patients Sixty-three percent were able able to support program growth creates delays in certified for each of the qualifying conditions, to reduce or eliminate opioid patient applications. including intractable pain. In early 2019, OMC Unfortunately, no legislation passed for the Office of Medical Cannabis in 2018, thus causing further problems for the Office to keep pace with program growth.

usage after six months.

will publish its first report on patients certified for post-traumatic stress disorder. Tom Arneson, MD, MPH, is research manager at the Office of Medical Cannabis at the Minnesota

Conclusion Adding intractable pain as a qualifying condition has significantly increased enrollment in Minnesota’s medical cannabis program, increasing the average age of participants. As of May 18, 2018, there were 10,230 patients active in the program; 66 percent were certified for intractable pain. The number of health care providers who have registered themselves in the program continues to grow steadily. As of May 18, 2018, there were 1,207 registrants: 77 percent physicians, 16 percent advanced practice registered nurses, and 7 percent physician assistants. The program was created to help patients cope with serious medical conditions. Data collected from enrolled

Department of Health, where he provides a clinical and research perspective to implementation of the state’s medical cannabis program and oversees research on the program’s impact. He received his MD from Mayo Clinic School of Medicine and his MPH from the University of Minnesota.

Michelle Larson, PhD, MPA, is director of the Office of Medical Cannabis at the Minnesota Department of Health. She received her PhD and MPA from the University of Minnesota.

Carris Health is the perfect match “I found the perfect match with Carris Health.” Dr. Cindy Smith, Co-CEO & President of Carris Health

Carris Health is a multi-specialty health network located in west central and southwest Minnesota. Carris Health 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: • Dermatology • ENT • Family Medicine • Gastroenterology • Geriatrician • Hospitalist

• Internal Medicine • Nephrology • Neurology • OB/GYN • Oncology • Orthopedic Surgery

• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urology

Loan repayment assistance available.

FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | Shana.Zahrbock@carrishealth.com | (320) 231-6353 | acmc.com We are pleased to introduce Carris Health, a new entity launched in January to deliver high quality health care to West Central and Southwest Minnesota. Carris Health is a partnership between ACMC Health, Rice Memorial Hospital and CentraCare Health. This partnership allows us to reach beyond our individual capabilities to combine the talent and skills of all three organizations. Visit www.carrishealth.com for more information.

JULY 2018 MINNESOTA PHYSICIAN

Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice

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

Opportunities for full-time and part-time staff are available in the following positions: • Physician (Internal Medicine/Family Practice) • Physician (Pulmonologist) Part-Time

• Physician (Hospice & Palliative Care) • Psychiatrist (Mental Health)

• Physician (IM/FP) Brainerd MN

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

• Physician (IM/FP) Montevideo MN

PRACTICE WHERE BEAUTY SURROUNDS YOU

Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.

WORK-LIFE BALANCE: • Competitive salary • Significant starting & residency bonuses • 4-day work weeks • 51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. 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 Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

MINNESOTA PHYSICIAN JULY 2018

3Documenting outcomes from page 17

may reside with the gathering and aggregation of patient-reported outcome data using national PRO patient registries. History demonstrates that there was once reluctance to the general acceptance of what is now considered standard best practice involving treatments such as endovenous laser ablation v. surgical vein stripping, balloon angioplasty or intracoronary stents v. coronary artery bypass grafting (CABG), and the role of oral antibiotics targeting H. pylori in gastric ulcers—all of which were initially resisted and questioned by long-time practitioners.

marketing and advertising, such as Provider Chat (a HIPAA-compliant chat service to promote communication between providers and current or potential patients); provider directories; “Find a Treatment Center” lookup; and “Patient Testimonials,” which are patient-editable on a longitudinal basis to strengthen the testimonial’s significance and relevance. Patients play an active and critical role in this PRO patient registry through self-reporting of events, participation Registries have played a key role in research, advancing patient advocacy, and increasing in securing regulatory approval. community awareness of the RM specialty. The vision of our new online registry is to establish the specialty of RM as a safe, effective, and credible alternative treatment method for those choosing selfhealing over traditional methods by using autologous cellular agents derived from their own blood, fat tissue, or bone marrow.

Over time, we may find that the missing data is provided by patients to promote general acceptance of RM autologous cellular treatments as standard best practice or as acceptable alternative treatment methods for specific degenerative conditions and cosmetic concerns.

Roger Hogue, MD, RVT, is founder and CEO of Hogue Clinics, comprised of

The intent is nationwide participation of RM treatment centers and providers to harness the power of “real-world” data that can provide the evidence from patient-reported outcomes to allow for long-term monitoring of the safety and efficacy of autologous cellular treatments. Ensuring that the patient voice is present, patient engagement in the RegenMedPOD patient registry can greatly enhance and improve this specialty.

four specialty clinics: Minnesota Regenerative Medicine, Hogue Vein Institute, Hogue Cosmetic Surgery, and HCS MedSpa. He is also founder and CEO of Hogue Surgical LLC, a privately owned medical device company located in Maple Grove. A graduate of Stanford University School of Medicine, he is a Diplomate of both the American Board of Venous & Lymphatic Medicine and the American Board of Laser Surgery.

The future and the past The path to general acceptance of autologous cellular treatments in RM

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Nephrology • Cardiologist • Internal Medicine/Family Practice • Urologist • Psychiatrist • Tele-ICU (Las Vegas, NV)

Ely VA Clinic

Hibbing VA Clinic

Current opportunities include:

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

JULY 2018 MINNESOTA PHYSICIAN

•

www.minneapolis.va.gov

MINNESOTA PHYSICIAN JULY 2018

3The BME complaint review process from page 15 the licensee chooses to reject a recommendation, he or she has the right to a hearing before an administrative law judge. This hearing is similar to a court trial and enables the licensee to present evidence and witnesses, and to cross-examine the opposing witnesses. The licensee has the opportunity to learn the identity of the complaining person or persons and has access to some of the Board’s previously confidential files affecting the case. A licensee also has the right to challenge the Board’s final decision through an appeal to the Court of Appeals, but courts typically defer to the Board’s decisions even if the court might believe that discipline is not justified.

Reporting requirements The Board is required by law to periodically publish a summary of all disciplinary actions to the Legislature and the news media. Disciplinary decisions must also be reported to the National Practitioner Data Bank.

Strategy tips In order to be as well prepared as possible, there are a number of guidelines that a licensee should keep in mind when faced with a Board complaint. First, learn as much as possible about the process. Just as when a patient receives medical care, the more information you have, the better your odds of a successful outcome. There are relatively short deadlines in which to respond and you will likely need all the time available to prepare your response. It is important to act quickly as soon as you find out about a Board investigation. While this article discusses the basics of the complaint review process, there is a great deal more information you can obtain. Study the Board’s website, learn about the participants in the process, and seek out competent legal representation. While you must cooperate with the investigation, the complaint review process is fundamentally an adversarial process. Licensees would be well advised to act promptly to protect their interests. Second, learn as much as possible about the specifics of the complaint. This is not always as easy as it may seem. Sometimes the allegations focus on conduct that happened months or years before. Whenever possible, obtain the medical records and any other documentation that might help refresh your recollection of the details of the complaint. If this is an area of medicine with which you are not familiar, it is a good idea to get up to speed. For example, if it is a prescribing case, learn about the latest trends in prescribing practices. The Board will have access to experts in the field; you should, too. JULY 2018 MINNESOTA PHYSICIAN

There is no “one size fits all” approach that works best in responding to the Board. It is important to try to understand where the Complaint Review Committee is coming from and how it views the case. Perhaps it is a simple misunderstanding where the most important thing you can do is to explain what actually happened. In that case, a very cooperative approach would certainly work best.

But perhaps the committee’s view of the appropriate treatment under the circumstances is very different from your view. In that case, while you certainly want to cooperate, you will have to work to persuade the committee that your treatment was reasonable and appropriate. This can be a challenge, obviously, and will require a substantial effort by the licensee. You may need to consider retaining an expert witness Most complaints are dismissed to support your treatment. In any event, the key is to without any public action. evaluate where the committee is coming from and decide how best to respond.

There are two exceptions to the public reporting requirement. Discipline imposed because a licensee is impaired by illness or addiction and unable to practice medicine with reasonable skill and safety is not reported to the media, although these decisions are in the Board’s public files. Also, Agreements for Corrective Action are not reported to the media. These agreements, too, are in the Board’s public files. (A pending or dismissed complaint is classified as confidential or private and is not public.)

It is important to adopt the right approach in dealing with the Board investigation. You have a duty to cooperate with the investigation. Your demeanor and attitude in dealing with the Board does matter. While the facts of the complaint cannot be changed, the Board is affected by the way the licensee responds to the complaint.

Finally, it is important to understand the potential consequences of the outcome of the complaint process. Discipline can have serious long-term consequences. Depending on the circumstances, discipline could restrict your ability to be credentialed or find employment elsewhere. It might affect your ability to obtain a license in another state. It may impact insurance rates and a variety of other factors. Do not assume that the consequences cease after you resolve the complaint. Moreover, whether it is a corrective action or some form of discipline, the way the agreement or order is drafted can make a difference going forward. You and your lawyer should attempt to have input into the wording of any such document.

Conclusion A licensee is well advised to take seriously all Medical Board investigations. Even though most complaints are dismissed without any public action, there is too much at stake for a licensee to participate in the process without careful preparation and advice. Ruth Martinez, MA, is executive director of the Minnesota Board of Medical Practice. She has a long career in public service and has been with the Board since 1988, including 12 years as supervisor of the Board’s Complaint Review Unit.

David Bunde, JD, an attorney with Fredrikson & Byron, PA, has significant experience in complex administrative litigation, before both federal and state agencies. He has defended medical professionals in court and before professional licensing bodies for over 35 years.

STAY FOCUSED AMONG THE DISTRACTIONS.

Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E  A N A LY T I C S  R I S K M A N A G E M E N T  E D U C A T I O N

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is for an end to joint pain. University of Minnesota Health Cartilage Restoration and Joint Preservation Program We use surgical, biologic and rehabilitative techniques, as well as leading-edge research. This preserves and improves joint health, reduces joint pain, delays and prevents joint replacement surgery, and improves surgical outcomes for patients. Our integrated team of orthopaedic surgeons, sports medicine physicians, physical therapists and researchers continually pioneer new treatments, always offering the latest care for patients with complicated joint conditions. Itâ&#x20AC;&#x2122;s the kind of care every joint pain sufferer deserves.

Visit: MHealth.org Call: 612-676-5505

The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ÂŠ 2018 University of Minnesota Physicians and University of Minnesota Medical Center. *U.S. News & World Report