Minnesota Health care News April 12 by Minnesota Physician Publishing

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April 2012 â&#x20AC;˘ Volume 10 Number 4

Breastreduction surgery David Thao, MD

The changing role of nurses Marie Manthey, MNA

Psychotherapy for children Joel Oberstar, MD

We Have Exciting News!

Our new breast cancer survivors support project of the African American Breast Cancer Alliance!

The African American Breast Cancer Alliance is excited to present its new Breast Cancer Survivors Support Project! A community-based project to connect African American breast cancer patients and survivors with a culturally specific support organization and resources. • COMMUNITY – Build a vibrant network of communitybased organizations, resources and services. • CONNECTIONS – Breast cancer survivors work with their family, friends and healthcare providers to combat the challenges of breast cancer. • Be a Connection • Be a Survivor • Build a Community of Hope and Support

• SUPPORT – The best breast cancer care includes emotional and social support. • HOPE – Inspire healing, health, empowerment, faith and a passion for life for patients and survivors.

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(612) 825-3675

CONTENTS

4 7 8

APRIL 2012 • Volume 10 Number 4

NEWS

PEOPLE

By Pamela M. Dean, MBA

PERSPECTIVE Shiela Ugargol Keefe, MS Minnesota Department of Health

HEALTH PROFESSIONS Physician assistants

10 QUESTIONS

20 22

CALENDAR National Minority Health Month SURGERY Breast-reduction surgery By David Thao, MD

COMPLEMENTARY MEDICINE Massage therapy By Janelle Lyons, CMT

Patty Radoc, MS, CCC-SLP Courage Center

BEHAVIORAL HEALTH Psychotherapy for children By Joel V. Oberstar, MD

NURSING The changing role of nurses By Marie Manthey, MNA, FRCN, FAAN, PhD (hon.) Your Guide to Consumer Information

FREE

April 2012 • Volume 10 Number 4

Breast reduction surgery David Thao, MD

Psychotherapy for children

COMMUNITY HEALTH Disability safety net

SENTINEL

Laser Center Introducing a non-invasive treatment for Plantar Fasciitis

By Steve Larson

PRIMARY CARE The “medical home” By John Halfen, MD

Joel Oberstar, MD

The changing role of nurses

SENTINEL Laser Center is a unique medical facility focused on the philosophy…

Marie Manthey, MNA

“It is needless to do more when less will suffice” Call today for an appointment:

651-294-3232

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com BUSINESS DEVELOPMENT DIRECTOR Juline Birgersson jbirgersson@mppub.com

SENTINEL Laser Center

ACCOUNT EXECUTIVE John Berg jberg@mppub.com

Gallery Tower Office Building 514 St. Peter St., Suite 220 St. Paul, MN 55102

ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans.

www.burtonreport.com

www.sentinellasercenter.com

Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

APRIL 2012 MINNESOTA HEALTH CARE NEWS

NEWS

New HMO Enters Minnesota Market A new health plan was certified for the Minnesota market last week, as the Minnesota Department of Health (MDH) announced Gundersen Lutheran Health Plan Minnesota would operate an HMO in four counties. The health plan, based in Onalaska, Wis., will do business in Fillmore, Houston, Olmsted, and Winona counties in southeastern Minnesota. The Gundersen Lutheran health plan, which has 90,000 members in Wisconsin and Iowa, is the first to be certified in Minnesota since 1998. As with all health plans marketed in Minnesota, the new HMO will operate as a nonprofit. According to Allan Baumgarten, an analyst who regularly issues reports on the Minnesota HMO market, the three main areas of HMO enrollment in southeastern Minnesota are senior plans, Medicaid plans, and employer-based plans—with the last category seeing a significant

decline in numbers during the past 10 years. Baumgarten notes that Gundersen serves similar markets in western Wisconsin. “They could probably position themselves effectively in all three market segments, because they have a significant physician and hospital presence in the region,” he says. “I think they could leverage that to offer competitive prices, so the opportunities are potentially good for them.” There is also the possibility that the state will expand its competitive bidding process for Medicaid plans to cover areas such as southeastern Minnesota, Baumgarten says. “This could be an opportune time for a new entrant like Gundersen to make a proposal,” he says.

Mayo Study Examines Costs of Underage Drinking A study by Mayo Clinic researchers finds hospitalization

from underage drinking has an estimated total cost of $755 million per year in the United States. Of the 700,000 young people hospitalized in the United States for all reasons in 2008, approximately 40,000 of those cases were due to alcohol abuse, researchers say. Among all U.S. teens, roughly 18 of every 10,000 adolescent males and 12 of every 10,000 females were hospitalized after consuming alcohol in the year studied. “When teenagers drink, they tend to drink excessively, leading to many destructive consequences, including motor vehicle accidents, injuries, homicides, and suicides,” says researcher Terry Schneekloth, MD, a Mayo Clinic addiction expert and psychiatrist. The report drew on Nationwide Inpatient Sample and Census Bureau data. It found that in the United States, 36 percent to 71 percent of high school students report having consumed alcohol at least once, although the prevalence of heavy drinking (more than five drinks in a row within

the preceding two weeks) is lower (7 percent to 23 percent). “Alcohol use necessitating acute-care hospitalization represents one of the most serious consequences of underage drinking,” says Schneekloth. “Harmful alcohol use in adolescence is a harbinger of alcohol abuse in adulthood.” The average age of those with alcohol-related discharges was 18; 61 percent were male. Nearly a quarter of the alcoholrelated hospitalizations included an injury, most commonly traffic accidents, assaults, and altercations. Much of the hospitalization cost ($505 million) involved treatment of injuries. A total of 107 of those hospitalized died (.27 percent). Their average age was 18.6 years, and 82 percent were male. Seventy-three percent of the deaths occurred during hospitalization for injuries.

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MINNESOTA HEALTH CARE NEWS APRIL 2012

St. Scholastica Launches PA Training Program The College of St. Scholastica is launching a physician assistant (PA) training program. Officials with the Duluthbased college say the program will begin accepting students in 2016, pending accreditation. The program will be offered at the master’s degree level, with students becoming eligible for the program after completing a bachelor’s degree. The College of St. Scholastica currently offers a prephysician assistant program. State data shows the PA designation is the fourth-fastest growing occupation in Minnesota, officials with the college say. “ According to the Minnesota Department of Economic Development, the demand for PAs is expected to grow 43 percent by 2019,” says Rondell Berkeland, the College’s Dean of Health Sciences. “The PA program is a deepening of St. Scholastica’s longstanding strength in educating health care practitioners and leaders.”

MHD Grant Aims to Improve Health for Student Parents The Minnesota Department of Health (MDH) has announced $2.7 million in federal grant awards to aid student-parent help centers at colleges and universities in the state, which serve pregnant or parenting students. The grants, made available through Minnesota’s Young Student Parent Support Initiative, will range from $55,000 to $280,000 and will go to tribal colleges, universities, technical and community schools, and private colleges. “Having a college education is important to the health and economic well-being of the citizens of Minnesota. Pregnancy and parenting are major reasons why college women drop out of school,” says Commissioner of Health Ed Ehlinger, MD. “Student-parent

help centers provide the support that pregnant or parenting students need at a crucial time in their lives as they are building their future through post-secondary education.”

Mayo Clinic Reports Healthy Finances Mayo Clinic has nearly doubled its income since 2009, and its healthy financial results will lead to major capital projects in coming years, officials with the Rochester-based system say. Mayo Clinic is seeing total annual revenues of $8.5 billion, according to recent financial figures. After expenses, the system had $610 million in income in 2011, compared with $515 million in 2010 and $333 million in 2009. The annual report listed several areas of booming operations, including more than 1 million patients cared for at facilities in Arizona, Florida, Iowa, Minnesota, and Wisconsin. Mayo research programs brought in nearly $367 million in funding from outside sources such as government grants. Researchers were involved in close to 8,000 study projects in 2011. Mayo’s College of Medicine educated 2,446 medical students, with 1,491 residents and fellows also receiving training. Officials say Mayo Clinic’s operating margin of just over 7 percent will allow it to pursue its long-term objectives, including upgrading and expanding capital assets. “In 2012, Mayo Clinic will launch $600 million in capital projects. We estimate spending $700 million per year in capital projects for the next five years,” says Shirley Weis, the clinic’s vice president and chief administrative officer. “We anticipate that the next three to five years will be marked by higher-than-average job growth and continued capital spending as we execute a set of strategic initiatives designed to meet patients’ evolving needs.” News to page 6

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NOW hear this! D

o you know of family members, friends or neighbors who have difficulty using their telephone? Do they have trouble hearing, speaking or have a physical disability that prevents them from using a standard telephone? The Minnesota Telephone Equipment Distribution Program can provide special telephone equipment at NO CHARGE to Minnesota residents of all ages!! The equipment includes amplified (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment. To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663, (888) 206-6555 TTY. Eligibility requirements do apply.

The Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge. APRIL 2012 MINNESOTA HEALTH CARE NEWS

News from page 5

State Gets “C” For Dental Health Among Children Minnesota rated a “C” grade in a new ranking of children’s dental care by state according to a report by The Pew Center. The report finds that one in five children in America do not receive dental care each year. It scored all 50 states and the District of Columbia on a an A–F scale, using eight benchmarks on dental health and access to dental care. Six states received an A grade; nine states received a B grade. Minnesota was one of 20 states with a C grade. Six states and the District of Columbia received a D grade, and nine states were given an F grade. The study says that improving care and access issues can be done by states for relatively little cost. The report discusses fixes such as wider use of sealants, community water fluoridation, and improvements to Medicaid

dental programs. “Millions of children go without dental care each year but the good news is, it’s fixable,” said Shelly Gehshan, director of the Pew Children’s Dental Campaign. “By enacting a handful of effective policies, states can help eliminate the long-term health and economic consequences of untreated dental problems among kids. Several states are leading the way—but all states can and must do more to ensure access to dental care for the 17 million children left out of the system.” Minnesota’s C grade is a result of data showing it is behind the national average on use of sealants and slightly under the national average on the share of Medicaid-enrolled children who received dental care in 2007. The report finds that the state is well below the national average in the share of dentists’ retail fees that are reimbursed by Medicaid programs. The national average for this measure is 60.5 percent; Minnesota’s share is 42.9 percent. The report says Minnesota is

above average in fluoridation and says the state’s new program to license dental therapists could improve access to care.

State Receives Grant For Health Insurance Exchange As the Legislature continues to grapple with the idea of creating a health insurance exchange in Minnesota, the Dayton administration has secured a $26 million grant to continue to develop one. The grant comes from the U.S. Department of Health and Human Services and will be administered by the Minnesota Department of Commerce. “This grant provides the resources to continue the design and planning for technical infrastructure, program integration, operations, and outreach for a Minnesota-made exchange,” says Commerce Commissioner Mike Rothman. “It will further support ongoing work with all stakeholders to design an exchange that

meets the unique demands of Minnesota’s consumers, businesses, and health care marketplace.” The exchange concept has been staunchly opposed by many in the GOP since it became a key part of the Affordable Care Act (ACA), the federal health reform law. A bipartisan bill to create an insurance exchange was introduced in the Minnesota House of Representatives on Feb. 16. However, its prospects are uncertain, given strong opposition to the exchange concept by GOP leaders in the Senate. Senate Republicans have introduced their own health reform measures that they say will help increase access to health care without using an exchange. According to ACA rules, states must demonstrate their own health insurance exchanges will work by Jan. 1, 2013, and make them available to consumers by Jan. 1, 2014. ACA rules call for the federal government to implement an exchange for states that do not meet those deadlines.

Now accepting new patients

A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures.

Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.

We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health. Whether you have experienced any type of cardiac event, are at risk for one, or

are interested in learning how to prevent one, we can design a set of just-for-you solutions. Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions

To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

MINNESOTA HEALTH CARE NEWS APRIL 2012

PEOPLE John Estrem has been named CEO of Hammer

MINNESOTA HEALTH CARE ROUNDTABLE

Residences, Inc., a Wayzata-based nonprofit organization providing services for adults and children with developmental disabilities, with 36 residential sites and nine apartment programs throughout the western suburbs of the

T H I R T Y- S E V E N T H

SESSION

Twin Cities. Estrem has 24 years of service with local nonprofits, most recently as executive John Estrem

director of Episcopal Community Services. Prior

to that, he served as CEO of Catholic Charities of Minneapolis and St. Paul. He has a master’s of divinity degree from St. Paul Seminary and a master’s in nonprofit administration from the

Specialty pharmacy

University of Notre Dame in South Bend, Ind.

Controlling the cost of care

Gayle Mattson has been named chief operating officer of AgeWell, an Edina-based home

Thursday, June 7, 2012

health and life care management company. Mattson formerly was president of Allina Home

Gayle Mattson

and Community Services. In her new role, Mattson will support AgeWell’s plans to expand into other markets nationally and will be responsible for overall operations and development of its Life Services model. AgeWell also has named Julie Pitsenbarger general manager for the Twin Cities. Pitsenbarger will be responsible for leading and coordinating all site operations including sales, life care, life care navigation, staffing, and new programs and services.

1:00 – 4:00 PM • Symphony Ball Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing higher-cost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access.

Regan served as chair of the Child and Adolescent Intensive Services

Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care.

workgroup, helping to write a report to the Minnesota Legislature on

Panelists include:

service capacity and needs.

N Sara Drake RPh, MPH, MBA, Pharmacy Program Manager, Minnesota Department of Human Services

Mary Regan was among 11 individuals and organizations receiving DHS (Department of Health) Commissioner’s Circle of Excellence Awards in January. DHS Commissioner Lucinda Jesson honored professionals and organizations from across the state, citing their outstanding contributions to human services program clients. Regan is the executive director of the Minnesota Council of Child Caring Agencies, St. Paul. She has helped lead innovations and reform in children’s mental health and child welfare for more than a decade.

The Minnesota Association of Nurse Anesthetists (MANA) recently named Steven Hendrickson, CRNA, Coon Rapids, as president and John Hust, CRNA, MNA, Wabasha, as president-elect. MANA, with more than 1,500 members, represents the nurse anesthesia profession in Minnesota.

N Daniel Johnson, MEd, Vice President of Public Policy, National Multiple Sclerosis Society N Timothy Stratton, PhD, BCPS, FAPhA, Professor, College of Pharmacy, Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota—Duluth

Sponsors include: Daiichi Sankyo • Novartis

Connie Delaney, PhD, RN, FAAN, FACMI, was awarded an honorary doctorate by the University of Iceland. It recognizes her outstanding scientific and research contributions to the

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field of informatics in nursing and her contributions toward the development of post-graduate

Connie Delaney, PhD, RN, FAAN, FACMI

Company

studies in nursing at the University of Iceland.

Address

Delaney is professor and dean of the School of

City, State, Zip

Nursing at the University of Minnesota, Minneapolis. She also holds an appointment in the

University of Minnesota Institute for Health Informatics and, since 1998, has held an appointment at the University of Iceland, Faculty of

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informatics.

Email Please mail, call in or fax your registration by 05/31/2012

APRIL 2012 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Contaminants of emerging concern Understanding what’s in our drinking water

lean, safe drinking water is essential to human life. But reports that pesticides, pharmaceutical products, and fire retardants have found their way into the groundwater and surface water that provide drinking water may lead consumers to question the safety of their tap water. These chemicals are sometimes called “contaminants of emerging concern” (CEC) and are studied by the Minnesota Department of Health’s Drinking Water CEC program. This program is dedicated to understanding the public health impact of CEC and developing guidelines about how much of a given contaminant can be consumed without harming human health. What are CEC? CEC are chemicals that have been released into, found in, or have the potential to enter Minnesota waters. The Minnesota Department of Health (MDH) further defines CEC as chemicals that may or may not have Minnesota regulations or health guidelines governing their acceptable concentrations in water, pose a real or perceived health threat, or have new or changing health or exposure information.

Shiela Ugargol Keefe, MS Minnesota Department of Health

Shiela Ugargol Keefe, MS, is an environmental scientist with the CEC program within MDH’s Health Risk Assessment unit. This unit develops health-based guidance based on research designed to understand the fate and transport of CEC in the environment. The program receives funding from the Clean Water Fund, established by Minnesota’s 2008 Clean Water, Land, and Legacy amendment.

mine this safe amount. Once assessment is complete, MDH establishes a health guidance value for the contaminant. This value is typically expressed in “parts per billion” and describes the amount of the chemical in drinking water that we can safely drink over a period of time, whether that period is one day or a lifetime. MDH compares the guidance value to environmental levels. The insecticide DEET, for example, has been found in the Mississippi River at a level 900-fold lower than its guidance value of 200 parts per billion, and at much lower levels in drinking water.

Where do they come from? CEC come from varying sources, including pharmaceuticals and chemicals in personal care products. Other sources include household cleaning products, pesticides, industrial chemicals used in manufacturing, and food additives. Society continually develops new chemical products, which can enter the ground, air, and water through manufacturing processes, land-use activities, and use and disposal by individuals. An upholstered chair in a landfill, for example, may leach Sources of CEC fire-retardant chemical from its fabric into the ground below the landfill; this chemi- Pharmaceuticals cal may ultimately seep into potential sources of drinking water. Fortunately, science continually improves methods of detecting and measuring these chemicals in our environment, as well as improving Personal care methods of determining if and how much products of a chemical is harmful. CEC program The goal of the CEC program is to understand how much of a contaminant a person can drink safely. MDH uses a process called “health risk assessment” to deter-

Therefore, DEET is not expected to pose a concern in drinking water. If the amount of a contaminant in drinking water is not known, MDH may conduct small-scale monitoring in coordination with other agencies to determine the likelihood that Minnesotans would be exposed to the contaminant. Since the CEC program began in 2010, MDH has evaluated many chemicals and developed guidance values for 10 of them. Although these 10 may have been found in Minnesota waters in amounts exceeding some guidance values, they have not been found in drinking water at levels of concern. Reduce exposure Drinking water may not be the only way that people become exposed to CEC. Using products that contain CEC—herbicides we handle, cosmetics we apply to skin, etc.—may increase the concentration of these chemicals in our bodies and the environment. To reduce the possibility that chemicals enter your body, landfills, air, and waterways: • Read product labels; purchase products wisely. • Use products carefully and only as needed. • Dispose of products properly. To discard unwanted medications properly, follow Minnesota Pollution Control Agency disposal recommendations: www.pca.state.mn.us/index.php/livinggreen/living-green-citizen/householdhazardous-waste/pharmaceutical-wastedisposing-of-unwanted-medications.html

Keep your water safe It is important to understand where your drinking water comes from and how it is tested and treated for contaminants. MDH ensures that water utilities test and treat Examples of CEC community water supplies. People who Pain relievers (such as acetaown wells are responsible for their proper minophen), anti-seizure construction and testing. Bottled water is medications, birth control not necessarily free of contaminants, and pills, antibiotics, veterinary may not be inspected as thoroughly as medicines public water supplies. Fragrances, antibacterial chemicals (such as triclosan), Learn more about the CEC program by preservatives, detergents visiting www.health.state.mn.us/cec. You can find chemical-specific information by Insect repellents (such as Pesticides DEET), herbicides, fungicides clicking on a given chemical’s name in the table at www.health.state.mn.us/ divs/eh/ Industrial chemicals Paint strippers, flame risk/guidance/dwec/chemunderrev.html retardants, plasticizers Food additives

MINNESOTA HEALTH CARE NEWS APRIL 2012

Caffeine, parabens

APRIL 2012 MINNESOTA HEALTH CARE NEWS

10 QUESTIONS

& Patty Radoc, MS, CCC-SLP Patty Radoc is the adult rehabilitation program manager for Courage Center St. Croix in Stillwater. She has 19 years’ experience as a speech-language pathologist for children and adults, and is co-vice president of health care issues for the Minnesota SpeechLanguage-Hearing Association (MSHA). What does a speech-language pathologist do? Speech-language pathologists (SLPs) work with the full range of communication development and disorders. We evaluate, diagnose, and treat speech, language, cognitive-communication, and swallowing disorders in people of all ages, from infants to the elderly. “Speech” means the ways in which sounds and words are produced. “Language” refers to the understanding and expression of verbal messages. “Cognition-communication” refers to problem solving and reasoning. Swallowing disorders encompass each step a person makes during the swallowing process, from taking in food orally to successfully swallowing. How did speech-language pathology get started? Speech-language pathology in the United States dates to the 1870s. The first clinicians worked mainly with stuttering and articulation. “Speech doctors” at that time were already established in Europe. In the early 1900s, several special-interest groups formed in the United States and were known as speech correctionists. One of these groups became the American Speech-Language-Hearing Association (ASHA), the national association that certifies SLPs and audiologists. Where do SLPs work? We work in various settings, including schools, hospitals, rehabilitation centers, nursing care facilities, community clinics, private practice offices, state and local health departments, state and federal government agencies, home health agencies, adult day care centers, and research laboratories. What are some of the conditions that an SLP treats? We help clients who have had a brain injury or stroke re-acquire or improve the language and cognitive skills necessary for communication. We also treat children and adults with speech and articulation disorders caused by developmental delay, illness, or injury. One example would be children who make sound substitutions, such as saying “th” for “s.” The overall goal of therapy is to improve the intelligibility of a person’s speech. What conditions can an SLP help someone with that a person might not realize can be treated? Just because you can’t verbalize doesn’t mean you can’t communicate—we help people who might otherwise be unable to communicate to “find a voice.” We can educate clients to use adaptive devices that have pictures the client can point to and computerized systems that speak for the user. Some SLPs work with people who stutter. There are many different approaches to treating stuttering.

Photo credit: Bruce Silcox

MINNESOTA HEALTH CARE NEWS APRIL 2012

Does insurance typically cover the services of a speech-language pathologist? Insurance typically covers speech-language pathology services for rehabilitation. Rehabilitation includes improving, maintaining, or restoring communication skills after illness, injury, or surgery. This includes speech, language, cognition, and swallowing skills. Unfortunately, many insurance companies don’t cover habilitative services. Such services help a person learn, retain, or improve skills and functional abilities that may not be devel-

“

”

Just because you can’t verbalize doesn’t mean you can’t communicate.

oping normally. An example of this would be a child who is not communicating as expected for his or her age due to developmental issues or a medical condition such as cerebral palsy or Down syndrome. What are examples of how SLPs work with other health care providers? One example: In a rehabilitation setting as part of a multidisciplinary team that supports patients undergoing rehab, an SLP might help a physical therapist communicate effectively with a client who has aphasia, a neurologic disorder that decreases the ability to understand and produce language. In a hospital, we typically receive physician orders to evaluate and treat clients. While our licensure does not require us to have physician orders in order to provide therapy, many private insurance companies require these orders. What are some advances in speech pathology? Augmentative-alternative communication devices, including high-level voice output devices, help many of our clients communicate much more efficiently and independently. We also use computers or iPads with applications for speech, language, and cognition. We may also use pictures and voice output devices to augment a child’s verbal skills. One of the newest devices is a Dynavox EyeMax system. It scans the eyes of users, who thus need only to look at a word or picture to convey their thoughts, even if they do not possess the ability to point to or touch a device. It also affords users control over their environment because it can be programmed to operate other electronics in the home. This technology can even help very young children.

What does the future hold for the SLP profession? According to ASHA, the number of SLPs in the U.S. is expected to increase through 2014 at a rate faster than the field’s average growth rate due to the following factors. Baby boomers are now reaching retirement age, when the possibility increases for neurological disorders and associated speech, language, swallowing, and hearing impairment. Medicine is improving the survival rate of premature infants and people who experience trauma or stroke, who subsequently need assessment and treatment. Many states require that newborns be screened for hearing loss and receive early-intervention services. SLP support in schools and special education programs is expected to increase. Federal law guarantees special education and related services for all eligible children. Growing awareness of the importance of early identification and diagnosis of speech, language, swallowing, and hearing disorders is expected to continue. The number of SLPs in private practice is expected to rise due to increasing use of contract services by hospitals, schools, and nursing care facilities. What would you like people to know about speechlanguage pathology? When conversing with someone who has a speech-language problem, remember that communication is a twoway street and do not rush the other person. Instead of guessing what they are trying to say, clarify that you have heard their message correctly.

Supporting Our Patients. Supporting Our Partners. SupportingYou. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D. & Zawadi’s brother

Russ McGill, OPA-C & Zawadi

Appointments:

Online or Call 651-439-8807

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APRIL 2012 MINNESOTA HEALTH CARE NEWS

NURSING

The changing role of nurses Meeting a growing need By Marie Manthey, MNA, FRCN, FAAN, PhD (hon.)

Some things never change: Every year, a Gallup poll asks the public to rank more than 20 professions on ethics, honesty, and trustworthiness, and every year, nursing is No. 1 (except for 2001, when that spot went to firefighters). However, while the publicâ&#x20AC;&#x2122;s positive perception of the nursing profession remains unchanged, the role that nurses play has changed dramatically during the last 20 years. There has been a major expansion of the settings in which nurses work and the ways in which they help patients.

MINNESOTA HEALTH CARE NEWS APRIL 2012

Education-driven change

Nursing education shifted from hospital-based programs to academic settings.

One reason for this expansion is the increased number of ways in which education as a nurse can be earned. A nursing degree was formerly granted only to graduates of hospital-based programs that typically prepared nurses to work in hospitals implementing doctors’ orders: checking and recording patient temperatures, bringing medication to the bedside, handing a surgeon the requested tool during surgery, and so on. That started changing around the 1960s, when nursing education shifted from hospital-based programs to academic settings. Now, advanced academic degrees prepare nurses to assume roles involving greater responsibility and an increasing degree of independent decision-making. These degrees include a PhD in nursing, which prepares a nurse to teach and conduct research. Other graduate programs educate clinical nurse specialists and nurse practitioners, to name a few of what are called “advanced practice” roles. Nurse as health coach Some advanced practice nurses, or APRNs, work in settings that focus on health management rather than disease management. For example, growing employer recognition that healthy employees save company money means that nurses are increasingly employed to improve employee health via smoking cessation programs and other workplace wellness initiatives. Nurse-coaches are also employed by health insurance companies to proactively contact enrollees to ask if they are currently experiencing problems, and if so, to suggest solutions before those problems lead enrollees to seek expensive care that the insurer would need to pay for, such as a visit to an emergency room. Nurse practitioners Nurse practitioners are licensed to function autonomously as primary care providers in a variety of settings, including clinics and wherever chronic care is provided. They perform many functions previously performed only by physicians. A psychiatric nurse practitioner, for example, is allowed by law to diagnose, provide therapy, and prescribe medication for patients with psychiatric or substance abuse issues. Another nurse practitioner role is as patient care coordinator within long-term care facilities and hospitals. In this capacity, the APRN coordinates all aspects of patient care and oversees quality assurance for the team of professionals caring for a given patient—physician, respiratory therapist, bedside nurses, etc.—with support from a patient’s primary care physician as needed. Overseeing quality assurance includes reviewing patient data to ensure, for example, that the number of times a patient has fallen does not exceed nationally accepted standards for this type of accident, as well as working to eliminate falls.

adjust a patient’s insulin dose depending on the patient’s laboratory data and insulin dose parameters established by the patient’s physician. Internet-driven change Even nurses who aren’t APRNs and who serve primarily in the traditional role of bedside nurse are experiencing an expansion of their role to increasingly include patient advocacy. That’s because the Internet facilitates patients’ access to information about symptoms, which frequently leads patients to question what their doctor says. However, if patients do not know how to frame questions, the bedside nurse can help by asking questions on the patient’s behalf. This advocacy component involves assessing patients’ level of knowledge and involvement, making sure patients’ information is correct, and guiding patients through the process of owning their health. What’s next?

An emerging role is that of care navigator, typically an experienced nurse who is familiar with patient care pathways, both diagnostic and treatment. The care navigator works one-on-one with patients to help them navigate the often confusing and frustrating maze of health care decision-making. This includes identifying barriers to care, strategizing ways for patients to obtain necessary care, and The changing role of nurses to page 34

Leg Pain Study Do your legs hurt when you walk? Does it go away when you rest? Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health

To see if you qualify, contact the EXERT Research Team at

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Clinical nurse specialists APRNs in this role manage a patient’s disease within a hospital or clinic setting. A clinical nurse specialist in diabetes, for example, may counsel patients to make healthy lifestyle changes and may

EXERTstudy.org APRIL 2012 MINNESOTA HEALTH CARE NEWS

HEALTH PROFESSIONS

Physician assistants

innesota was the sixth-healthiest state in America in 2011, according to United Health Foundation. And for good reason: The state boasts low rates of death from cardiovascular disease, low rates of premature death overall, and one of the lowest rates of uninsured residents. But is all of this good health sustainable? Increasing demand Between 2010 and 2030, the number of adults in the state who are over the age of 65 is expected to double. Minnesota will then have significantly fewer residents of traditional work age to help financially support our health care system, at the same time as the aging population places a heavier burden on this system. On top of that, the Association of American Medical Colleges predicts a nationwide shortage of approximately 21,000 primary care physicians by 2015, a shortfall that experts predict will continue well into 2030 due to the needs of an ever-increasing aging population. So with more people needing care and fewer primary care physicians to provide it, will Minnesotans be able to get care when they need it?

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MINNESOTA HEALTH CARE NEWS APRIL 2012

By Pamela M. Dean, MBA Certified physician assistants (PA-Cs) are already helping to meet the growing demands on our health care system. The National Commission on Certification of Physician Assistants (NCCPA) reported in January 2012 that more than 1,500 of these highly trained health care professionals were employed in Minnesota. All physician assistants (PAs) must be certified by NCCPA to become licensed in Minnesota. The state does not require them to maintain certification to practice, but they must be certified to be granted and to maintain medication-prescribing privileges in Minnesota. What do they do?

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Easing the shortage of primary care physicians

PA-Cs obtain medical histories, examine and treat patients, order and interpret diagnostic studies, make diagnoses, and both recommend and implement treatment plans for a wide range of acute and chronic illness and injury. Minnesota law permits PA-Cs to perform minor surgery and to assist in major surgery; instruct and counsel patients; order or carry out therapy; and prescribe medications, including controlled substances, subject to the approval by the state licensing board of a delegation agreement between the physician and the PA-C. These duties are performed by PA-Cs within a scope of practice established by a supervising physician in accordance with state regulations, but generally speaking, PA-Cs can perform virtually any tasks delegated by the physician with whom they work. “The role of physician assistants is to become the right hand of the physicians they work with,” explains Katherine J. Adamson, MA, PA-C, a certified PA for more than 30 years who now serves as a medical consultant to

Becky Ness, PA-C, examines a patient during hospital rounds at Mayo Clinic Health System Mankato. Accompanying her is University of South Dakota student PA Randy Fite, learning what the job of hospitalist PA involves.

the NCCPA. “The relationship [between physician and PA-C] is very collegial, and it is from a team perspective that the physicians are comfortable entrusting their patients’ well-being to their PA colleagues.” “The role of physician assistant is very collaborative,” agrees Peter Lindbloom, PA-C, who works in emergency medicine with the Mille Lacs Health System in Onamia. “My PA team and I have the opportunity to work with the physicians in the ER and help make a difference in lives daily. The job is challenging but very rewarding.” Emergence of the profession The PA profession emerged in the mid-1960s in response to the shortage of physicians in the United States created by the post-World War II baby boom. The first PAs were Army, Air Force, and Navy medics returning from military service who had received medical and surgical training and experience in the field. However, there was no place for them within the civilian health care system until the PA profession was created. The PA profession still has close ties to its roots, with PA-Cs caring for the sick and injured in the Army, Navy, Air Force, and Coast Guard. They are also widely deployed by the Department of Veterans Affairs, the nation’s largest employer of PAs. Today, PAs work in most settings where there are physicians, including solo physician practices, large multispecialty clinics, hospitals, surgical centers, longterm care facilities, and prison systems.

PA-Cs since their ability to order lab work, make daily hospital rounds, write prescriptions, order diagnostic tests, perform therapeutic procedures, and instruct and counsel patients means faster, more efficient patient care by providing another pair of skilled hands. With more than 10 percent of PA-Cs practicing in emergency medicine, these specialists are an increasing presence in emergency rooms. This reduces the amount of time urgent-care patients must wait to be seen and, after discharge, wait for a follow-up appointment.

Benefiting physicians In a 2000 study conducted by the NCCPA, physicians who worked with PA-Cs affirmed the positive impact they had on medical and surgical practices. • 94.2 percent of physician assistant employers said PA-Cs helped increase the number of patients seen. • 92.5 percent said the presence of PA-Cs shortened the time patients waited for appointments. • 91.2 percent said the presence of PA-Cs allowed patients more time to ask questions during their office visits. Employers also give high marks to the quality of care provided by the profession, with more than 99 percent of respondents in this study reporting that PA-Cs provide high-quality health care, are compassionate clinicians, and are valuable members of the health care delivery system. Physician assistants to page 16

Training While the first PAs were informally trained in the military, today’s PAs are formally educated in accredited programs, most of which award graduate degrees. These programs include courses in medical and behavioral sciences and clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and geriatric medicine. To become a PA-C requires passing a comprehensive national exam, maintaining certification by earning continuing medical education hours, and passing a recertification exam every six years. In Minnesota, PA practice is governed by the Minnesota Board of Medical Practice. “Because PAs are trained as generalists and have to maintain a generalist fund of knowledge to maintain certification, we often are able to bring a broader range of care [to a] specialty practice,” says Randy D. Danielsen, PhD, PA-C, senior vice president of the NCCPA Foundation and emeritus professor and former dean of the Arizona School of Health Sciences at A.T. Still University, Mesa, Ariz. Benefiting patients According to a 2009 report by health-care consulting firm Press Ganey Associates, the average time patients spend waiting to see a health care provider is 22 minutes, with some wait times stretching as long as two hours. Waits can be shortened in settings that employ APRIL 2012 MINNESOTA HEALTH CARE NEWS

Physician assistants from page 15

Providing specialty care

PA training programs in Minnesota â&#x20AC;˘ Augsburg College, Minneapolis, currently offers the stateâ&#x20AC;&#x2122;s only PA program. For more information, visit www.augsburg.edu/pa â&#x20AC;˘ St. Catherine University, St. Paul, plans to inaugurate a PA program in the fall of 2012. For more information, visit www.stkate.edu/academic/mpas/ â&#x20AC;˘ College of St. Scholastica, Duluth, plans to inaugurate a PA program in the fall of 2016. For more information, visit www.css.edu

During the past decade, the physician assistant profession has trended steadily toward specialization, with todayâ&#x20AC;&#x2122;s PAs practicing in virtually every medical and surgical specialty. According to the latest data collected by NCCPA, approximately 33 percent of PA-Cs work in primary care, with the remainder practicing in a wide range of specialties. In recognition of this trend toward specialization, the NCCPA launched a Certificate of Added Qualifications (CAQ) program in 2011 to complement the existing certification process. The CAQ program provides a way for PA-Cs to document specialty experience, skills, and knowledge. This program requires licensure, continuing medical education, experience, and a specialty exam. It is available to those practicing in cardiovascular and thoracic surgery, emergency medicine, nephrology, orthopedic surgery, and psychiatry.

We're conducting a clinical research study for one of the known risk factors of heart disease and stroke...

The future

â&#x20AC;&#x153;With the growing strain on the health care system, the demand for physician assistants has never been higher, and it will continue to grow,â&#x20AC;? says Randy D. Danielsen, PhD, PA-C. â&#x20AC;&#x153;In my 38 years as a certified PA and a longPeter Lindbloom, PA-C, checks time educator, I have yet to a patient with an ultrasound machine at Mille Lacs Health see the demand for the proSystem, Onamia. fession met. Itâ&#x20AC;&#x2122;s incredible to watch the profession try to keep up.â&#x20AC;? According to the Accreditation Review Commission on Physician Assistant Education (ARC-PA), the professionâ&#x20AC;&#x2122;s accreditation authority, the number of accredited PA programs increased from 54 in 1991 to 159 in 2011. ARC-PAâ&#x20AC;&#x2122;s executive director, John McCarty, reports that there are more than 50 new programs in the process of seeking accreditation that could potentially be accredited by the end of 2015. With health care reform and inevitable changes to the U.S. health care system on the way, PA-Cs will undoubtedly play a larger role in providing care for current patients, as well as for the millions of new patients expected to enter the system. Pamela M. Dean, MBA, is vice president of operations for the National Commission on Certification of Physician Assistants (www.NCCPA.net). Since NCCPAâ&#x20AC;&#x2122;s inception in 1975 as a not-for-profit organization, it has certified more than 97,000 physician assistants.

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MINNESOTA HEALTH CARE NEWS APRIL 2012

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April Calendar 9

Free CPAP Check-Up Properly functioning equipment and a well-fitted mask are two key factors in successful sleep therapy. Bring in your CPAP machine: Expert staff will check your CPAP pressure, filters, hose, and mask, refitting as needed. For more information, call (952) 920-0460 or visit www.libertyoxygen.com for additional dates and times. Monday, Apr. 9, 2–6 p.m., Liberty Oxygen and Medical Equipment, 4820 Park Glen Rd., St. Louis Park First Steps Baby Expo First Steps Baby Expo provides expectant parents, new parents, and their support people with information that will help them prepare for pregnancy, their newborn, and preschoolers. The first 400 attendees receive an iTunes gift card for The O’Neill Brothers’ piano lullabies CD! General admission $3. Free admission for children 5 and under. For more information, visit www.firststepsbabyexpo.com. Saturday, Apr. 14, 9 a.m.–2 p.m., River’s Edge Convention Ctr., 10 4th Ave. S., St. Cloud

From Table to Ticker: Strategies to Improve Your Heart Health You and your friends will enjoy fine food by Crave, an informal style show, and a chance to win exclusive Galleria giveaways—all while participating in conversational health presentations. $25/person, with all proceeds to Abbott Northwestern Hospital Foundation. Call Galleria Guest Services, (952) 925-432, to register. Thursday, Apr. 19, 11 a.m.–1 p.m., Galleria Edina, 3510 W. 70th St., Edina

Hearing Loss Support Group The Hearing Loss Chapter of America support group meets the third Saturday of the month, Sept.–May. We often feature guest speakers who talk about issues affecting the deaf and hard of hearing. Meetings are real-time captioned. Contact Merrilee Knoll, (763) 537-7558 TTY, or rKnoll5200@aol.com.

Saturday, Apr. 21, 9:30 a.m.–noon, Courage Center, 3915 Golden Valley Rd., 2nd Floor Boardroom, Golden Valley

“The Celebration of Life” This special evening is for cancer survivors and their support persons. The free event includes presentations on topics of interest to cancer survivors. Light refreshments are served. No registration necessary. Call Jewel Butts at (763) 520-7383 with any questions. Tuesday, Apr. 24, 5–9 p.m., North Memorial Education Ctr. (Terrace Mall), 3500 France Ave. N., Bays A, B, and C, Robbinsdale

Lyme Disease: Be Your Own Advocate Learn how Lyme disease affects the body, become familiar with symptoms, avoid diagnostic pitfalls, and know how to protect yourself and your family. Sponsored by the West 7th Community Center. Please register by calling (651) 298-5493. Friday, Apr. 27, 10:15–11 a.m., West 7th Community Ctr., 265 Oneida St., St. Paul

National Minority Health Month: April 2012

Our health is based on more than just the ability to go to the doctor, what we eat, or where we live. Health equity is attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally, with focused and ongoing societal efforts to address avoidable inequalities and historical and contemporary injustices, and to eliminate disparities in health and health care. Celebrate Minority Health Month right where you are. Whether it’s one event or two dozen events, seize the opportunity to raise awareness and make a difference for the health of your community members and the future health of our nation. Find the ideas and tools you need by visiting online: minorityhealth.hhs.gov/actnow/. To request publications, articles, and database searches on minority health topics, call The Office of Minority Health toll-free at (800) 444-6472. Join with us! 14 Multiple Sclerosis (MS) Group for People of Color Learn valuable information about MS, ways to cope with challenges, and become inspired. Join us the second Saturday of each month. Questions? Contact Pam at (612) 664-0182 or Linda at (612) 290-9515, or email mitnlin@comcast.net. Saturday, Apr. 14, 10:30 a.m.–12:30 p.m., Sumner Library, 611 Van White Memorial Blvd., Minneapolis 21 African American Breast Cancer Alliance Support Group Black women and men diagnosed with breast cancer come together to encourage each other and learn how to be survivors. We meet the third Saturday of each month. For more information, call (612) 825-3675, email aabca@aabcainc.org, or visit www.aabcainc.org. Saturday, Apr. 21, noon–3 p.m., North Regional Library, 1315 Lowry Ave. N., Mpls.

May 7

Melanoma Monday: Free Skin Cancer Screenings Celebrate Melanoma Monday with a free skin-cancer screening! The screenings are first-come, first-serve; no appointment is necessary. Dermatologists will perform fullor partial-body checks. Please call (612) 626-4454 with questions. Monday, May 7, 8 a.m.–3 p.m., U. of Minn. Dermatologic Surgery and Laser Ctr., 516 Delaware St. S.E., Phillips-Wangensteen Bldg., Rm. 4-175, Minneapolis

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

America's leading source of health information online APRIL 2012 MINNESOTA HEALTH CARE NEWS

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Atropine Sulfate 1% op. soln* (5ml bottle)† ....................1 .........3 Erythromycin op. ointment (3.5gm tube)†* ....................1 ..........3 Gentamicin 0.3% op. soln (5ml bottle)† ............................1 .........3 Levobunolol 0.5% op soln (5ml bottle)† ...........................1 .........3 Neomycin/Polymyxin/Dexamethasone 0.1% op. ointment (3.5gm tube)† ........................................1 ........3 Neomycin/Polymyxin/Dexamethasone 0.1% op. susp (5ml bottle)†....................................................1 ........3 Pilocarpine 1% op. soln (15ml bottle)† ..............................1 ........3 Pilocarpine 2% op. soln (15ml bottle)† ..............................1 ........3 Polymyxin Sulfate/TMP op. soln* (10ml bottle)† ............1 ........ 3 Sulfacet Sodium 10% op. soln* (15ml bottle)† ............... 1 .........3 Timolol Maleate 0.25% op. soln (5ml bottle)† .................1 ........ 3 Timolol Maleate 0.5% op soln (5ml bottle)† ....................1 ........3 Tobramycin 0.3% op. soln (5ml bottle)† ............................1 ........3

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Fungal Infections Fluconazole 150mg tab ........................................................1 Nystatin/Triamcin cream* (15gm tube)† .........................1 Nystatin/Triamcin cream* (30gm tube)† .........................1 Nystatin/Triamcin ointment* (15gm tube)†...................1 Nystatin cream* (15gm tube)† ...........................................1 Nystatin cream* (30gm tube)†.............................................1 Terbinafine 250mg tab*.......................................................30

..........3 ..........3 ..........3 ..........3 ..........3 ..........3 .......90

Gastrointestinal Health Belladonna Alkaloid/PB tab*.............................................60 .....180 Cimetidine 800mg tab* ......................................................30 ........90 Cytra2 solution ...............................................................180ml 540ml Dicyclomine 10mg cap .......................................................90 .....270 Dicyclomine 20mg tab .......................................................60 .....180 Famotidine 20mg tab ..........................................................60 .....180 Lactulose syrup ..............................................................237ml 711ml Metoclopramide 10mg tab ...............................................60 .....180 Metoclopramide syrup ..................................................60ml 180ml Promethazine 25mg tab*...................................................12 ........36 Promethazine plain syrup*.........................................180ml 540ml Ranitidine 150mg tab .........................................................60 ......180 Ranitidine 300mg tab .........................................................30 ........90

Revised 3/2/12

Heart Health & Blood Pressure Amiloride-HCTZ 5mg-50mg tab .....................................30 ........90 Atenolol-Chlorthalidone 100mg ....................................30 ........90 Atenolol 25mg tab ...............................................................30 ........90 Atenolol 50mg tab ...............................................................30 ........90 Atenolol 100mg tab ............................................................30 ........90 Benazepril 5mg tab ..............................................................30 ........90 Benazepril 10mg tab ...........................................................30 ........90 Benazepril 20mg tab ...........................................................30 ........90 Benazepril 40mg tab ...........................................................30 ........90 Bisoprolol-HCTZ 2.5mg-6.25mg tab ..............................30 ........90 Bisoprolol-HCTZ 5mg-6.25mg tab .................................30 ........90 Bisoprolol-HCTZ 10mg-6.25mg tab ...............................30 ........90 Bumetanide 0.5mg tab ......................................................30 ........90 Bumetanide 1mg tab ..........................................................30 ........90 Captopril 12.5mg tab ..........................................................60 ........90 Captopril 25mg tab ..............................................................60 ......180 Captopril 50mg tab ..............................................................60 ......180 Captopril 100mg tab ...........................................................60 ......180 Carvedilol 3.125mg tab ......................................................60 ......180 Carvedilol 6.25mg tab .........................................................60 ......180 Carvedilol 12.5mg tab ........................................................60 ......180 Carvedilol 25mg tab* ..........................................................60 ......180 Clonidine 0.1mg tab ............................................................30 ......180 Clonidine 0.2mg tab ............................................................30 ........90 Digoxin 0.125mg tab ..........................................................30 ........90 Digoxin 0.25mg tab .............................................................30 ........90 Diltiazem 30mg tab .............................................................60 ........90 Diltiazem 60mg tab .............................................................60 .....180 Diltiazem 90mg tab*............................................................60 .....180 Diltiazem 120mg tab ..........................................................30 .....180 Doxazosin 1mg tab ..............................................................30 ........90 Doxazosin 2mg tab ..............................................................30 ........90 Doxazosin 4mg tab ..............................................................30 ........90 Doxazosin 8mg tab ..............................................................30 ........90 Enalapril-HCTZ 5mg-12.5mg tab ....................................30 ........90 Enalapril 2.5mg tab ..............................................................30 ........90 Enalapril 5mg tab .................................................................30 ........90 Enalapril 10mg tab ...............................................................30 ........90

Need to change your Pharmacy? Many large employers have recently dropped Walgreens and other Pharmacies from their Prescription Drug Benefit Plan, impacting where you can pick up your prescriptions. If this has happened to you please contact your local Walmart for assistance on our easy prescription transfer. $4, 30-day $10, 90-day

........90 ........90 ........90 ........90 ........90 Hydralazine 10mg tab ........................................................30 ........90 Hydralazine 25mg tab ........................................................30 ........90 Hydrochlorothiazide(HCTZ)12.5mg cap*.....................30 ........90 Hydrochlorothiazide (HCTZ) 25mg tab ........................30 ........90 Hydrochlorothiazide (HCTZ) 50mg tab ........................30 ........90 Indapamide 1.25mg tab ....................................................30 ........90 Indapamide 2.5mg tab .......................................................30 ........90 Isosorbide Mononitrate 30mg ER tab ...........................30 ........90 Isosorbide Mononitrate 60mg ER tab ...........................30 ........90 Lisinopril-HCTZ 10mg-12.5mg tab ................................30 ........90 Lisinopril-HCTZ 20mg-12.5mg tab*................................30 ........90 Lisinopril-HCTZ 20mg-25mg tab* ..................................30 ........90 Lisinopril 2.5mg tab .............................................................30 ........90 Lisinopril 5mg tab ................................................................30 ........90 Lisinopril 10mg tab ..............................................................30 ........90 Lisinopril 20mg tab ..............................................................30 ........90 Methyldopa 250mg tab*....................................................60 .....180 Methyldopa 500mg tab*....................................................30 .......90 Metoprolol Tartrate 25mg tab..........................................60 .....180 Metoprolol Tartrate 50mg tab..........................................60 .....180 Metoprolol Tartrate 100mg tab* .....................................60 .....180 Nadolol 20mg tab ................................................................30 ........90 Nadolol 40mg tab ................................................................30 ........90 Prazosin HCL 1mg cap ........................................................30 ........90 Prazosin HCL 2mg cap ........................................................30 ........90 Prazosin HCL 5mg cap ........................................................30 ........90 Propranolol 10mg tab .........................................................60 ......180 Propranolol 20mg tab ........................................................60 ......180 Propranolol 40mg tab .........................................................60 ......180 Propranolol 80mg tab .........................................................60 ......180 Sotalol HCL 80mg tab*........................................................30 ........90 Spironolactone 25mg tab*................................................30 ........90 Terazosin 1mg cap ...............................................................30 ........90 Terazosin 2mg cap ...............................................................30 ........90 Enalapril 20mg tab ..............................................................30 Furosemide 20mg tab ........................................................30 Furosemide 40mg tab ........................................................30 Furosemide 80mg tab ........................................................30 Guanfacine 1mg tab ............................................................30

Terazosin 5mg cap ..............................................................30 Terazosin 10mg cap .............................................................30 Triamterene-HCTZ 37.5mg-25mg tab ..........................30 Triamterene-HCTZ 75mg-50mg tab ..............................30 Verapamil 80mg tab ............................................................30 Verapamil 120mg tab .........................................................30 Warfarin 1mg tab .................................................................30 Warfarin 2mg tab .................................................................30 Warfarin 2.5mg tab ..............................................................30 Warfarin 3mg tab .................................................................30 Warfarin 4mg tab .................................................................30 Warfarin 5mg tab*.................................................................30 Warfarin 6mg tab .................................................................30 Warfarin 7.5mg tab ..............................................................30 Warfarin 10mg tab ..............................................................30

........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90

$4, 30-day $10, 90-day

Men’s Health

$9/30-day

Finasteride 5mg .................................................................................30

Mental Health

$4, 30-day $10, 90-day

.......90 ........90 ........90 ........90 ........90 Benztropine 2mg tab ..........................................................30 ........90 Buspirone 5mg tab ..............................................................60 ......180 Buspirone 10mg tab*...........................................................60 ......180 Carbamazepine 200mg tab*.............................................60 ......180 Citalopram 20mg tab ..........................................................30 ........90 Citalopram 40mg tab .........................................................30 ........90 Amitriptyline 10mg tab .....................................................30 Amitriptyline 25mg tab ......................................................30 Amitriptyline 50mg tab .....................................................30 Amitriptyline 75mg tab ......................................................30 Amitriptyline 100mg tab ...................................................30

Fluoxetine 10mg tab*..........................................................30 ........90 Fluoxetine 10mg cap ..........................................................30 ........90 Fluoxetine 20mg cap ..........................................................30 ........90 Fluoxetine 40mg cap ..........................................................30 ........90 Fluphenazine 1mg tab .......................................................30 ........90 Haloperidol 0.5mg tab ......................................................30 ........90 Haloperidol 1mg tab ...........................................................30 ........90 Haloperidol 2mg tab ...........................................................30 ........90 Haloperidol 5mg tab ...........................................................30 ........90 Lithium Carbonate 300mg cap* ......................................90 ......270 Nortriptyline 10mg cap .....................................................30 ........90 Nortriptyline 25mg cap ......................................................30 ........90 Paroxetine 10mg tab* .........................................................30 ........90 Paroxetine 20mg tab*..........................................................30 ........90 Prochlorperazine 10mg tab .............................................30 ........90 Thioridazine 25mg tab .......................................................30 ........90 Thioridazine 50mg tab .......................................................30 ........90 Thiothixene 2mg cap ..........................................................30 ........90 Trazodone 50mg tab ...........................................................30 ........90 Trazodone 100mg tab .........................................................30 ........90 Trazodone 150mg tab ........................................................30 ........90 Trihexyphenidyl 2mg tab ..................................................60 ......180

Skin Conditions Fluocinonide 0.05% cream* (15gm tube)†......................1 ...........3 Fluocinonide 0.05% cream* (30gm tube)† .....................1 ...........3 Gentamicin 0.1% cream (15gm tube)†.............................1 ...........3 Gentamicin 0.1% ointment (15gm tube)† ......................1 ...........3 Hydrocortisone 1% cream (28.35-30g tube)†................1 ...........3 Hydrocortisone 2.5% cream (30gm tube)†.....................1 ...........3 Silver Sulfadiazine 1% cream* (50gm tube)† .................1 ...........3 Triamcinolone 0.025% cream (15gm tube)† ..................1 ...........3 Triamcinolone 0.025% cream (80gm tube)† ..................1 ...........3 Triamcinolone 0.1% cream (15gm tube)† .....................1 ...........3 Triamcinolone 0.1% cream (80gm tube)† .......................1 ...........3 Triamcinolone 0.1% ointment (15gm tube)† ................1 ...........3 Triamcinolone 0.1% ointment (80gm tube)†.................1 ...........3 Triamcinolone 0.5% cream (15gm tube)† .......................1 ...........3

Thyroid Conditions Levothyroxine 25mcg tab .................................................30 Levothyroxine 50mcg tab .................................................30 Levothyroxine 75mcg tab .................................................30 Levothyroxine 88mcg tab .................................................30 Levothyroxine 100mcg tab ...............................................30 Levothyroxine 112mcg tab ...............................................30 Levothyroxine 125mcg tab ...............................................30 Levothyroxine 137mcg tab ...............................................30 Levothyroxine 150mcg tab ...............................................30 Levothyroxine 175mcg tab*..............................................30 Levothyroxine 200mcg tab*..............................................30

........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90

Viruses Acyclovir 200mg cap ...........................................................30 .......90

Vitamins & Nutritional Health Folic Acid 1mg tab ...............................................................30 Mag 64 64mg tab* ................................................................60 Magnesium Oxide 400mg tab0 ......................................30 Prenatal Plus qty 30*.............................................................30 Potassium Chloride 10% liquid ................................470ml Sodium Fluoride .25mg chewable (120ct bottle) †* ....1

........90 ........90 ........90 ........90 1419ml .....N/A

Women’s Health Estradiol 0.5mg tab .............................................................30 Estradiol 1mg tab .................................................................30 Estradiol 2mg tab .................................................................30 MedroxyprogesteroneAcetate 2.5mg tab ...................30 Medroxyprogesterone Acetate 5mg tab .....................30 Medroxyprogesterone Acetate 10mg tab ...................10

........90 ........90 ........90 ........90 ........90 ........30

$9, 30-day $24, 90-day

Alendronate SOD 35mg tab . ..............................................4 ........12 Alendronate SOD 70mg tab ...............................................4 ........12 Clomiphene 50mg tab ..........................................................5 ........15 Sprintec 28-day tab ..............................................................28 .....N/A Tamoxifen 10mg tab ............................................................60 ......180 Tamoxifen 20mg tab ...........................................................30 ........90 Tri-Sprintec 28-day tab .......................................................28 ....N/A

Other Medical Conditions Chlorhexidine Gluconate 0.12% soln (473ml bottle)† ...1 ...........3 Hydrocortisone AC 25mg suppositories* ....................12 ........36 Isoniazid 300mg tab ............................................................30 ........90 Lidocaine 2% viscous solution (100ml bottle)† .............1 ..........3 Megestrol 20mg tab*...........................................................30 ........90 Oxybutynin 5mg tab*..........................................................60 ........90 Phenazopyridine 100mg tab.............................................60 .....180 Phenazopyridine 200mg tab ............................................30 ........90 Prednisone 2.5mg tab .........................................................30 ........90 Prednisone 5mg tab ............................................................30 ........90 Prednisone 10mg tab .........................................................30 ........90 Prednisone 20mg tab .........................................................30 ........90

Revised 3/2/12

*Prices may be higher due to State restrictions. † Prepackaged drugs are covered only in unit sizes specified on Drug list. See Program Details or your Walmart Pharmacist for details. Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some covered generic drugs at commonly prescribed dosages. Higher dosages cost more and some restrictions may apply. PHARMACIES ARE CONVENIENTLY LOCATED IN EVERY MINNESOTA WALMART LOCATION

FOR MORE INFORMATION AND THE MOST CURRENT LIST OF DISCOUNTED DRUGS VISIT

WALMART.COM/pharmacy

SURGERY

ast week, a 35-year-old woman came into my office for a skin care consultation. After discussing treatment options for her age spots, she briefly complained of back, shoulder, and neck pain that she had been having for a long time. She also complained of her inability to exercise and of not sleeping well due to pain. Then, she pointed out the indentations caused by her tight bra straps and asked my opinion of available medical treatments. I realized that her pain and discomfort were probably caused by her overly large breasts, a condition called macromastia.

Breastreduction surgery How to decide, what to expect By David Thao, MD

Overly large breasts can cause both physical and emotional health problems. The weight of excessive breast tissue can cause physical discomfort and pain that restricts many physical activities and can limit a woman’s ability to lead an active, healthy lifestyle. Large breasts can be emotionally draining as well. Many women with macromastia become self-conscious and embarrassed about their breasts, in addition to dealing with frustration caused by the fact that this condition makes it difficult to find clothing that fits. According to the American Society of Plastic Surgeons, breast reduction, or

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Who is a candidate? A person—typically a woman—may be a candidate for breast reduction if: • She is healthy and has realistic expectations for the surgical outcome. • She experiences neck, back, or shoulder pain caused by the weight of overly large breasts.

Bigger isn’t always better

(Immediate availability)

reduction mammaplasty, is one of the most frequently performed reconstructive surgical procedures for women, although men also elect to receive this procedure. In 2011, 82,875 such procedures were performed in the United States, with about 24 percent of them performed on male breasts.

MINNESOTA HEALTH CARE NEWS APRIL 2012

• She gets deep indentations from bra straps.

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• Her skin is irritated around the breast crease. • Her breasts hang so low that the nipples extend below the breast crease. • Her skin is stretched all around the breast area and has caused the areola (nipple area) to become enlarged.

There is no age limit for obtaining reduction mammaplasty.

• She does not like the appearance of her overly large breasts. Procedure Before reduction mammaplasty, a patient obtains a preoperative exam from her primary physician to get clearance for surgery. This exam should be done no more than two to three weeks prior to surgery for the most up-to-date information, as this is needed for anesthesia clearance. The exam usually consists of physical examination, drawing blood, a pregnancy test, and any other medical tests appropriate for the patient’s health and age. The patient is also given specific instructions to follow in order to prepare for surgery. These include not smoking, eating, or using blood-thinning drugs such as aspirin and ibuprofen for eight to 10 hours before surgery. During the surgery itself, excess breast fat, tissue, and skin are removed to create a new breast size proportional to the patient’s body. The new, smaller breasts will look more aesthetically appealing and should help alleviate pain and discomfort stemming from overly large breasts. This procedure is performed by a board-certified plastic surgeon at an accredited outpatient surgery center or hospital while the patient is asleep under general anesthesia. It usually lasts from two to four hours, depending on the complexity of the individual case. Once the procedure is done and the patient is stable, she may be discharged to go home that same day, or an overnight stay in the hospital may be recommended. Oral medication is prescribed to control postoperative discomfort and pain, which typically subside within four to seven days.

How to decide

Reduction mammaplasty is a personal decision that patients should make for themselves. It should not be based on someone else’s desires. As with any surgery, reduction mammaplasty carries significant risks. Some of the common risks include pain, bleeding and blood clots, anesthesia-related complications, infection, resulting breast asymmetry, unfavorable scarring that can include thick and raised scars, breast-feeding limitations, and decreased sensation around the breast and in the nipple area. There is no age limit for obtaining reduction mammaplasty. Ideally, it should be done after the patient’s breasts have attained their full size or have stabilized after childbirth and breast-feeding. Many women, despite having all the known indicators for reduction mammaplasty, do not choose it. Reasons vary, but include a limited understanding of the procedure, fear of surgery, the cost to the uninsured patient, and the possibility of not being able to breast-feed after breast reduction. Those who think breast reduction may benefit them should discuss this procedure with a board-certified plastic surgeon to fully understand its risks and benefits. Making a well-informed decision increases the likelihood that the patient who chooses reduction mammaplasty will be pleased with its outcome.

David Thao, MD, is a plastic surgeon board-certified in general surgery and plastic surgery. He is a member of the American Society of Plastic Surgeons and practices in the Twin Cities area, specializing in cosmetic and reconstructive surgery.

Insurance coverage Because reduction mammaplasty is generally performed to relieve medical symptoms associated with large breasts, it may be covered by health insurance as a medical necessity. This is why a person considering this surgery should consult a board-certified plastic surgeon to determine if he or she is a candidate for breast reduction. However, pre-approval by the health insurance provider is required for coverage. Therefore, all those considering reduction mammaplasty should review their policy with their health insurance provider before surgery to make sure they understand the extent of coverage. For patients who do not have health insurance, the cost of breast-reduction surgery may vary depending on the complexity of the surgery and whether it is performed in an outpatient surgery center or a hospital, since the cost of procedures in those two settings can vary widely. Additional costs may include a preoperative appointment with the patient’s primary doctor, lab tests, postoperative garments for the first two weeks of healing, and oral pain medication to manage postoperative discomfort. Some plastic surgeons offer financing options.

Living with gout? Keep enjoying life’s simple pleasures.

Gout is the most common form of inflammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another. Learn more about managing this chronic illness at www.goutliving.org

APRIL 2012 MINNESOTA HEALTH CARE NEWS

C O M P L E M E N TA RY M E D I C I N E

Massage therapy

assage therapy has been shown to provide relief from certain disease symptoms, support the healing of injuries, and promote a feeling of well-being. It is provided by massage therapists, who are licensed professionals trained to manipulate muscles in a noninvasive and holistic manner.

Multiple styles, multiple benefits By Janelle Lyons, CMT

Massage is sometimes prescribed as part of a treatment plan for a medical condition, although a doctor should be consulted before using massage for any health condition. This therapy has been reported helpful in treating:

• Osteoarthritis: In the first clinical trial assessing effectiveness of the Swedish massage technique for knee osteoarthritis, participants who received a onehour massage once or twice weekly experienced improvement in pain, stiffness, and function. Peers that did not receive massage experienced no such changes, according to a 2006 report in the Archives of Internal Medicine.

• Back pain: The Annals of Internal Medicine reported in 2003 that massage was more effective than acupuncture or spinal modification at ameliorating persistent low back pain, and

Health care …naturally

• Acupuncture and Oriental medicine • Chiropractic • Healing touch • Massage therapy • Naturopathic medicine • Nurse practitioner Many treatments are covered by health insurance. Visit our website or call to find out more about locations, hours and services:

nwhealth.edu/patients • 952-885-5444

MINNESOTA HEALTH CARE NEWS APRIL 2012

• Premature babies: Newborns that received massage therapy gained more weight in the hospital and had shorter hospital stays than premature babies that did not receive massage, according to a study published in the Journal of Developmental and Behavioral Pediatrics in 2008. • Fibromyalgia: Patients reported decreased pain, depression, anxiety, stiffness, fatigue, and sleep problems after massage treatment, reported the Journal of Clinical Rheumatology in 2002.

Health benefits

The clinics of Northwestern Health Sciences University offer a variety of natural health care solutions at three Twin Cities locations. We also partner to provide free services at two community clinics.

reduced the need for over-thecounter pain medication by 36 percent.

• Anxiety: Massage lowered levels of cortisol (a hormone released by the body in response to stress) by up to 50 percent and increased levels of neurotransmitters that moderate depression, reported the International Journal of Neuroscience in 2005. • Asthma: Massage was found to be beneficial in reducing symptoms associated with asthma in children by reducing stress, increasing circulation, releasing muscle tension, and improving pulmonary function, according to findings published in the Journal of Pediatrics in 1998. • Cancer: The Journal of Nursing Scholarship reported in 2002 that massage helped reduce side effects of anti-cancer treatment, including pain, swelling, fatigue, nausea, and depression. Styles of massage Different styles use different methods of applying pressure, from static pressure to strokes, the latter ranging from long and smooth to short and percussive. Four of the most commonly used styles are: Swedish • Strokes are primarily long and involve light pressure • May include light tapping on the uppermost muscle layers • Intended to relieve muscle tension

• Can be both relaxing and energizing • May enhance recovery from soft tissue injury Neuromuscular • Static pressure is applied to specific points on the layer of connective tissue that covers muscles • Intended to relieve pain • Addresses trigger points, circulation, nerve compression, postural issues, chronic pain, and biomechanical problems • May enhance recovery from repetitive movement injury

order to take the examination, a candidate must have received 500 hours of supervised instruction and have graduated from an accredited massage school. Misperceptions

No pain, no gain. A common misperception is that massage must hurt to be effective. A therapist uses appropriate pressure for comfort and healing, and increases pressure of the massage strokes slowly over time. Massage is not a quick fix. Massage is However, it can be a useful Deep tissue antidote to society’s message sometimes • Slow, deliberate strokes focus pressure on musthat we should work harder prescribed as cles, tendons, or other tissues deep under the skin and faster with little regard for • Less rhythmic than other styles the body’s need to relax and part of a • Addresses chronic tension and muscle injuries recover. Massage is a therapeutic treatment plan such as a back sprain treatment that may take time to for a medical produce results in overworked Sports bodies. It is designed to train the • Promotes flexibility to help prevent injury condition. body to heal in a way that is nat• Used before, during, or after exertion ural and long-lasting. • May enhance recovery from muscle injury With more than 80 styles of massage encompassing a variety of Choosing a therapist techniques, this therapy can be customized for the recipient’s age Newcomers to massage might be nervous and not know what to and medical condition; even pregnant women and the elderly can expect, but obtaining referrals from health care providers and receive a massage safely pending their doctors’ approval. asking questions should provide reassurance. A therapist’s most Janelle Lyons, CMT, is a certified massage therapist and staff-training important concern should be client satisfaction. Ask a therapist: • How long have you been practicing massage?

associate with Massage Advantage, Inc., a national chain of massage clinics headquartered in Maumelle, Arkansas.

• Do you use a sheet or other covering for the client? • What types of massage do you provide? • Do you have references? Insurance and cost Massage is sometimes covered by insurance, especially if therapy is received following a motor vehicle accident or if it is prescribed. The likelihood that prescribed massage may be covered by insurance is also affected by the setting in which it is provided, with coverage more likely for therapy provided in a clinic or chiropractic office than in other settings. Check with Massage your insurance provider. As in most service industries, massage is sometimes price is influenced by demand, location, and covered by therapist experience. The price of a oneinsurance. hour therapeutic massage in the metro area currently ranges from $25 to $85 per hour; the average price is about $50. Be sure to ask the therapist what the price includes. Does a one-hour massage provide 60 minutes of actual therapy, or does it include paperwork and dressing time, leaving only 45 to 50 minutes for massage?

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Massage therapists practicing in Minnesota must pass a state licensure test and be additionally licensed by the city or county in which they practice. Before obtaining these licenses, a therapist must pass a certification examination from the National Certification Board for Therapeutic Massage and Bodywork. This allows the certified therapist to use the designation CMT (certified massage therapist). In APRIL 2012 MINNESOTA HEALTH CARE NEWS

P S Y C H I AT RY

Psychotherapy for children Many children and adolescents experience mental illness before reaching the age of 18. Indeed, approximately one in five youth are estimated to have a mental illness, according to a recent Surgeon General’s report. The consequences of untreated mental illness can be profound and include suicide. In Minnesota, suicide is the third-leading cause of death for

More than meds alone

youth ages 10 to 14 and the second-leading cause of death for those between 15 and

By Joel V. Oberstar, MD

34 years of age.

Need help to plan for aging at home?

Create a plan to stay at home for yourself, your aging parents, your partner or a friend. Get step-by-step help to find out how to stay in your home longer and find services near home. Who uses the navigator tool? People who are thinking about staying in their home while they get older. People who are trying to figure out how to handle yard work, groceries, help for an older parent, or assisting their partner and friends.

What areas does it assist with? t Home maintenance t Medications t Safety t Housing

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Who can I call for assistance? Senior LinkAge Line® at 1-800-333-2433 Monday–Friday 8 a.m. to 4:30 p.m.

To get started visit www.longtermcarechoices.minnesotahelp.info

MINNESOTA HEALTH CARE NEWS APRIL 2012

Treatment options Treatment for pediatric mental illness can include psychotherapy (talking with a therapist), pharmacotherapy (medication), or both, depending on the nature and severity of the illness and the preference of the patient and his or her family. While some controversy exists around prescribing psychoactive medication for youth—such medication is used to treat depression, anxiety, and other symptoms—numerous scientific studies demonstrate that many psychoactive medications are safe and effective when used appropriately. Admittedly, however, a primarily medication-oriented model of treating mental illness may overlook psychotherapy’s potential usefulness in uncovering the explanation for pediatric mental illness and in providing psychotherapeutic methods for treating it. Assessment Assessing and treating pediatric mental illness can involve individual or family psychotherapy, or both. During the initial assessment process, psychotherapists and social workers develop a comprehensive understanding of the psychological and social stressors that impact the child and the family. Factors such as parent-child conflict, parent-parent discord, school-related stress, and phase-of-life distress are identified through this process, which helps to define the patient’s illness and to identify one or more psychotherapeutic approaches to treatment. While each patient is unique, certain illnesses tend to make themselves known in children in often predictable ways. Consider the following hypothetical examples. • A 7-year-old girl is brought to her pediatrician because she is irritable, has nightmares, and has started bedwetting. These symptoms began after the death of the girl’s grandmother, who had lived with the family for several years. • A 12-year-old boy is brought to a therapist for evaluation of feeling “bummed out” and aggression. In the past year, he has lost friends and become somewhat socially ostracized because of his unusually intense preoccupation with dinosaurs, which he eagerly discusses at any opportunity. He behaves aggressively at home when household routines are not followed or plans are changed.

Psychotherapy can help guide parents.

In each of these fictional cases, medication may be appropriate either as the only therapy or as an addition to psychotherapy. However, each of these cases also suggests a role for individual psychotherapy, family psychotherapy, or both, as the primary way to address the mental health concerns raised. Therapy

One in five In the case of the 7-yearold girl, she may have youth are developed depression and estimated regression (bedwetting) in the context of her grandto have a mother’s death. Family mental illness. psychotherapy may help her parents recognize their daughter’s primary stressor (the death) as the source of concerns that produce her symptoms. Furthermore, this psychotherapy can help guide her parents to respond in a nurturing and supportive manner to the child’s sadness regarding the loss and any fears she may have or develop about potential future loss. The mood change and aggression demonstrated by the 12-year-old boy may represent emerging symptoms of Asperger’s disorder. In this case, individual psychotherapy may help the boy understand the reasons his peers are distancing themselves from him. This Psychotherapy to page 32

Hospital and Clinics

• A 14-year-old girl is observed by her school counselor to be becoming progressively more withdrawn and isolative. She has quit the soccer team, where she excelled, and her grades have declined from A’s to C’s. She has begun to engage in self-harming behavior by cutting herself. These behaviors started during a series of brief, intense relationships with boyfriends, all of which lasted several weeks and ended abruptly.

• A 17-year-old boy is brought to his family physician for evaluation of progressively worsening anxiety. Though he has been a “worrier” all his life, in the past six months he has become obsessed with cleanliness after seeing a video at school about HIV and AIDS. He fears anything he touches may be contaminated and spends two to three hours each day showering and washing his hands. APRIL 2012 MINNESOTA HEALTH CARE NEWS

COMMUNITY HEALTH

Disability safety net Resources for every age By Steve Larson

nly 60 years ago, Minnesotans with intellectual and developmental disabilities lived in institutions, with little contact with their communities. Since then, there has been a sea change in thinking about how best to support them, in recognition of the fact that Minnesotans with disabilities deserve to live, work, learn, and play in our cities and towns. As a result, a system of community-based services has taken root and is growing.

Support from birth People with disabilities need support throughout their lives, whether it’s health care, social services, or education. A child diagnosed with a disability may be able to receive support services as early as the day he or she is born, which may include physical therapy or medical care. And since disability impacts the family as well as the person with a disability, resources might also include train-

WHO’S A BIGGER BASEBALL FAN, YOU OR ME? You’ll find that people with Down syndrome have a passion for knowledge and learning that can rival anyone you’ve met before. To learn more about the rewards of knowing or raising someone with Down syndrome, contact your local Down syndrome organization. Or visit www.dsamn.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:

(651) 603-0720 • (800) 511-3696 26

MINNESOTA HEALTH CARE NEWS APRIL 2012

Thanks to programs in Minnesota’s schools, children with disabilities are more likely to learn and play with their peers without disabilities.

Support after high school

By the time people with disabilities graduate from high school, they will be prepared, ideally, to live as independently as possible in the community. They may live at home with parents and receive Courtesy The Arc Minnesota support from PCAs, home health aides, or staff who provide physical, occupational, or speeching that helps a family meet language therapy. If their parents can no longer the needs of their child. Such care for them, they may live in neighborhood early-stage services are often Minnesota’s programs can help group homes, supported by on-site, around-thedelivered by a partnership adults with disabilities live in clock staff. Or, they may live independently in their between the local school distheir homes. Courtesy The Arc Minnesota own residence with minimal support. Support for trict and the county and are people in this setting might include assistance for just a few hours typically provided in the family’s home. each week, helping with tasks such as budgeting, grocery shopping, Once a child is three years old, he or she is meal planning, and training to use public transportation. eligible for early childhood special education (ECSE) that lasts until the child enters kindergarten. Counties and school districts again partner to provide services tailored to the child’s needs, with services for this age range typically provided in a classroom. Additional support may be provided in the family home.

In-school support School districts assume most of the responsibility for providing disability services to children in kindergarten through high school. Each child with a disability receives services according to an individualized education plan, or IEP, geared to the child’s needs and shaped with parental input. For example, an IEP might stipulate that the child have a teacher’s aide alongside to help with classroom instruction and activities. An IEP could provide a student with assistive technology to handle school assignments. Or, an IEP might ask teachers to create a plan to manage a child’s behavior challenges so that the student can stay in the regular classroom.

Support outside school

Employment and health care Like all adults, people with disabilities need to feel useful. Programs exist that train individuals with disabilities in social skills, offer opportunities to volunteer, offer job training, and provide on-site support in the workplace. Disability advocates increasingly are putting a high priority on encouraging all employers to hire people with disabilities and to pay them competitive wages. Health care can be problematic when people with disabilities have the chance to be employed, since being employed can mean earning too much to qualify for Medical Assistance. To allow people with disabilities to continue to qualify for the health care and supports they need while they work, Disability safety net to page 33

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People with disabilities need support throughout their lives.

Additional support is available outside school for minors with disabilities, including medical care available for low-income families through Minnesota’s Medical Assistance (MA) program. Families that don’t qualify for MA can still receive medical and support services from MA through a program called TEFRA. This program charges sliding scale fees for therapies and medical services not covered by private insurance. TEFRA can also help families cover the cost of maintaining private insurance, which saves money for both families and the state. If expenses incurred by a family in caring for a child with disabilities aren’t covered by private insurance or MA, the family may be eligible for a Family Support Grant. This state-funded program helps pay for medication, respite care, and specialized clothing, diets, and equipment, as well as personal care attendants (PCAs). PCAs are inhome staff that assist with such daily tasks as grooming, bathing, eating, toileting, behavior management, and monitoring seizures.

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APRIL 2012 MINNESOTA HEALTH CARE NEWS

PRIMARY CARE

The “medical home”

ealth care providers have known for a long time that the existing model of health care, characterized by increasing physician specialization and decreasing focus on general care, needed to be improved, and that costs had to be contained as well. Health care providers in the United States have come up with a new model for health care delivery, one that delivers better care—and at a lower cost. This model is called the “medical home” model nationwide, although it has been renamed the “healthcare home model” by the state of Minnesota. When people hear this term, they usually think either of a nursing home or home-care nursing, but neither is accurate. Rather, the medical home model is a comprehensive approach to care that results both in high-quality health care and cost savings.

Crossing the chasm The medical home model got its start in 2004, when the Institute of Medicine issued a highly regarded report developed by top health care experts in the United States. (The Institute is a nonprofit, nongovernmental U.S. organization that analyzes issues in health and health policy.) This became known as the “Chasm Report” since it addressed the almost insurmountable chasm to be crossed in moving

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MINNESOTA HEALTH CARE NEWS APRIL 2012

A new patient/physician partnership By John Halfen, MD

Here, a medical home patient confers with Lakewood Health System medical director Dr. John Halfen during a typical office visit. Office visits are intentionally designed to be comprehensive so that all issues and needs can be addressed during the same visit.

from the existing system of health care delivery to a new and improved one. The Chasm Report stated that the only way to improve health care delivery in the United States was to change direction, philosophy, and incentives. Skeptics doubted that this was achievable, until medical home pilot projects began to show savings of up to 40 percent by preventing a significant number of emergency room visits and hospitalizations. Additional proof of this model’s viability came from the fact that patients and providers reported greater satisfaction with it than with the existing model.

Joint Principles for the Patient-Centered Medical Home Shortly after the Chasm Report was issued, a group of primary care organizations in the United States put together a set of simple principles called the Joint Principles for the Patient-Centered Medical Home, with the purpose of radically reforming primary care. This was to be a blueprint for building a new health care system that could deliver better quality and savings. It was based upon the fundamental principles of best medical practices, which are: • Coordinate care to eliminate misuse and waste. • Empower patients to become a real part of their care. • Use health care personnel to their maximum capabilities. • Utilize 21st-century technology to its maximum.

Medical providers have 30-minute visits with patients.

• Reestablish the relationship between patient and physician that was lost during the era of specialist care.

Increased complexity and specialization of care makes it almost impossible to establish a personal relationship with patients under the existing, fragmented model of health care delivery. But that personal relationship can be reestablished by using this new model of care, and by taking advantage of technologies such as electronic health records and email, which can be used to send lab results directly to a patient. These new medical home principles began being tested by pilot projects, individual providers, and various health care systems, including Lakewood Health System, based in Staples, Minn.

How the medical home model works

standard 15-minute visits, allowing them to review the entire scope of a patient’s health care and medical records. Each office visit is scheduled as a comprehensive visit so that all issues and needs can be addressed at one time. Medical home patients have quick and direct access to the team of people caring for them when questions or problems arise. Care coordinators are available 24/7 to answer questions, teach, and arrange proper care. Medical home patients can always get medical care when they need it. Medical home patients are included in all aspects of their care. Decisions are made with them, not for them. They, or the family members responsible for making decisions on their behalf, are not only given all information about their care, but are educated to the extent that they become active participants in determining and achieving their health care goals. Each patient is assigned a trained nurse called a care coordinator, who knows each patient personally and coordinates all aspects of care. The care coordinator functions as the patient’s advocate and oversees quality assurance for the team of professionals who provide care to that patient. The coordinator has access to that patient’s electronic medical record (EMR) and is available at all times (backed up by an on-call care coordinator) in order to answer questions and provide advice, supported by a primary care physician when needed. Each medical home patient also has a personal physician who works with the care coordinator and a team of other health care personnel as needed to assure the best care. As with the care coordinator this physician or a partnering physician on call is also available 24/7. The “medical home” to page 30

In the next issue.. • Wound care • Corneal transplants • Ovarian cancer

In this model, cross-departmental teams proactively treat health issues before those issues land a patient in the emergency room. Medical providers have 30-minute visits with patients instead of APRIL 2012 MINNESOTA HEALTH CARE NEWS

Medical home care coordinator Niki Worden, RN, center, confers with two medical home patients.

The “medical home” from page 29

Patients are not referred to specialists. Instead, their physicians consult with specialists as needed so that all the information remains at the medical home. A comprehensive EMR system includes automatic periodic review of each individual’s chart, with reports to the physician, thereby ensuring that no test, procedure, or treatment is unintentionally neglected. For physicians involved with the medical home model of health care delivery, there is a new sense of responsibility for each medical home patient. These patients get to see them whenever necessary. All health care information about the patient, such as test results, is reviewed by the patient’s own medical home Care provider. Better care can be provided coordinators because physicians are assured of havare available ing accurate, comprehensive information from the EMR, a care coordinator 24/7. available to assist them with patient communication, and patients who have been empowered to play a key role in their own care. Any changes to a patient’s care can be made knowing that any unexpected results can be reported promptly by the patient to the care coordinator.

Improved health, patient/ physician satisfaction Lakewood Health System has had a large number of medical home patients for over three years now. A review of Lakewood’s medical records shows that the health status of these patients improved dramatically during that period. Lakewood statistics show significant improvement in the cost of care, rates of hospitalization, need for emergency room visits, and medication usage by medical home patients. Surveys and individual discussions with patients and providers leave no doubt that both groups are extremely happy with the medical home model of care and believe strongly that it is an improvement over previous methods of health care delivery. Insurance companies indicate that using the medical home model to deliver health care reduces health care costs by up to 40 percent. Medical home represents 21st-century medicine at its finest. It is a key tool that can enable the U.S. health care system to provide optimal health care to the entire population while reducing costs. John Halfen, MD, is medical director of Lakewood Health System, an independent, not-for-profit integrated rural health care system based in Staples, Minn.

Minnesota

Health Care Consumer March survey results... Association

On a scale of 1-5, with 5 being more interested and 1 being least interested, please help us gauge interest in reading the following kinds of stories about health care.

Each month members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health care delivery system. There is no charge to join the association, and everyone is invited. For more information please visit www.mnhcca.org. We are pleased to present the results of the March survey.

40 30

25.6%

20 11.6% 4.7%

4.7%

27.9% 23.3%

20 10 0

4.7% 2

MINNESOTA HEALTH CARE NEWS APRIL 2012

30.2%

30 25.6%

25 20 15 10 5

4.7%

0.0% 2

30.2%

30 25.6%

25 20 15 10 5

4.7%

18.6%

20 15

11.6%

10 5

2.3%

5. Diseases and medical specialties 34.9% 35 Percentage of total responses

30 Percentage of total responses

Percentage of total responses

41.9% 40

2.3%

4. Health care policy (legal and legislative topics) 34.9% 35 32.6%

Percentage of total responses

53.5%

39.5%

3. Public health issues

2. New scientific advances

1. Cost of care (insurance and pricing of services)

4.7% 1

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

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

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? APRIL 2012 MINNESOTA HEALTH CARE NEWS

illness and develop different approaches to help him successfully combat it.

Psychotherapy from page 25

therapy may give him an opportunity to learn and implement social skills that can help him interact more successfully with his Valuable tool peers. Additionally, family psychotherapy may help his parents In each of the preceding cases, psychotherapy for the patient understand the reasons behind his cognitive and behavioral rigidity and/or the family may be a valuable tool. As the field of psychiatry at home and that increased predictability in household routine may continues to advance in step with increasingly detailed understandhelp decrease their son’s aggression. In the case of the 14Controversy exists around year-old girl, her symptoms suggest depression, a condiprescribing psychoactive tion frequently observed in medication for youth. teens. Individual psychotherapy may provide an opportunity for her to consider whether her relationships with peers and others are healthy. This ing of the development and functioning of the human brain, we therapy may also help her learn to manage extremes in her emomust continue to recognize the important role psychotherapy can tions and learn coping skills to avoid engaging in self-harming play in the treatment of pediatric mental illness. behavior. Family psychotherapy may help her parents learn how to Joel V. Oberstar, MD, is CEO and chief medical officer of PrairieCare, an emotionally support their daughter as she practices implementing organization providing mental health services to patients of all ages coping skills when distressed instead of cutting herself. through its inpatient and clinic facilities in Edina, Maple Grove, and Lastly, the symptoms of the 17-year-old boy suggest that he Woodbury. has obsessive-compulsive disorder. This illness is known to respond particularly well to intensive psychotherapy. His parents and family may be involved in the therapy as well, as they learn about his

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MINNESOTA HEALTH CARE NEWS APRIL 2012

gram may receive less money than they would if they used other disability programs, but in return, they have more control over spending that money. This gives them greater flexibility to hire the personnel and services they feel will best meet their needs.

Disability safety net from page 27

Minnesota created the Medical Assistance for Employed Persons with Disabilities program, which relaxed the strict income and asset limits normally required to qualify for MA. Most funding for disability services outside • Housing Access Services helps individuals schools comes through the MA program. On-the-job supports enable Minnewho are ready for more independence than a Minnesota is able to provide so many services in sotans with disabilities to work at group home. This program has only been in the community in part because of MA programs jobs in businesses across the state. existence since 2009 but has already moved that provide “waivered” services. These programs Courtesy The Arc Minnesota more than 370 Minnesotans with disabilities provide options for people with intellectual disinto residences where they have more freedom and control. abilities, Down syndrome, brain injury, mental illness, autism, or These support options are available through the state of Minneother disabling conditions so they can have the maximum level of sota or certain counties. Federal support includes Social Security and independence and stay connected to families and the community. Supplemental Security Income, with housing assistance available Waivers pay for services that include help with daily living skills, through the U.S. Department of Housing and Urban Development. technology that increases self-sufficiency, on-the-job support, training for parents, respite care, and staff to help with household chores.

Fostering independence In addition to supporting people with disabilities in their schools, homes, and cities, disability services continue being refined to allow people with disabilities and their parents more control over support services. Here are three examples. • Consumer Support Grants are available in certain counties. These grants give families more flexibility to use funding from the state of Minnesota as they see fit to pay for equipment, transportation, and modifications to the home that best fit their needs. • Consumer-directed support programs. Families in this type of pro-

Lifelong support Throughout their lives, people with disabilities and their parents may need support and information to help them navigate the service system, determine the services for which they qualify, and effectively advocate for their rights. To learn more about available support, find the chapter of The Arc nearest you by visiting www.arcmn.org. Steve Larson is senior policy director for The Arc Minnesota, a nonprofit agency that protects the rights of people with developmental disabilities and promotes their rights to be full members and participants in their communities throughout their lives. The Arc connects people with disabilities to resources, and provides advocates to work with them as needed.

“Multiple sclerosis upended the plans I had, forcing me to face uncertainty. I’ve learned to adapt and focus on what’s truly important to me.” — Susan, diagnosed in 1995

MS M S= ddreams reams llost. ost. dreams dreams rebuilt. rebuilt. What W hat does does MS MS eequal qual to to yyou? ou? Join Jo in th thee Movement Movement® aatt MS M MSsociety.org society.org APRIL 2012 MINNESOTA HEALTH CARE NEWS

condition requiring treatment, the universal human response is to feel vulnerable. interceding as needed on patients’ behalf to This vulnerability is, in my opinion, the reduce delays in receiving diagnosis and true explanation of the Gallup poll findtreatment. Nurses in this role are often ing. Because whatever the setting and employed by breast cancer centers or other role in which nurses function, they have specialty care settings. the knowledge, skill, position, and ability And it may happen that to interact with patients in a nurses assume ever more indeway that alleviates pain, pendent decision-making responNursing increases comfort, and sibility in parallel with ongoing decreases the feeling of vulroles efforts to deliver medical care nerability. And that is the more efficiently. Statistics continue privilege of nursing. released in January 2012 by the to evolve. Marie Manthey, MNA, FRCN, Centers for Disease Control and FAAN, PhD (hon.), received Prevention show that nationally, the first honorary PhD awarded by the the percentage of hospital outpatient deUniversity of Minnesota School of Nursing, partment visits during which a patient saw given in recognition of her contributions to an APRN or physician assistant increased the advancement of the nursing field. She is significantly from 1999 to 2009, the most one of only four U.S. nurses to have been elected a member of the United Kingdom’s recent decade for which such data are availRoyal College of Nursing, and is a member able. The changing role of nurses from page 13

Nursing may change, but … While nursing roles continue to evolve, what isn’t changing is the reality of patient vulnerability. Whenever our health is involved, and especially when we are diagnosed with a

of the American Academy of Nurses. She is the founder of Creative Health Care Management, a Minneapolis consulting firm specializing in the organization and delivery of health care.

For more than 60 years, protecting rights, creating opportunities, and providing hope. To find the chapter of The Arc nearest you, call 1-800-582-5256, or go to www.arcmn.org and click on “Minnesota Chapters of The Arc.” 34

MINNESOTA HEALTH CARE NEWS APRIL 2012

• Serious low blood sugar (hypoglycemia) may occur when Victoza® is used with other diabetes medications called sulfonylureas. This risk can be reduced by lowering the dose of the sulfonylurea.

Important Patient Information This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you. WARNING During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body. What is Victoza® used for? • Victoza® is a glucagon-like-peptide-1 (GLP-1) receptor agonist used to improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program. • Victoza® should not be used as the first choice of medicine for treating diabetes. • Victoza® has not been studied in enough people with a history of pancreatitis (inflammation of the pancreas). Therefore, it should be used with care in these patients. • Victoza is not for use in people with type 1 diabetes mellitus or people with diabetic ketoacidosis. ®

• It is not known if Victoza® is safe and effective when used with insulin. Who should not use Victoza®? • Victoza should not be used in people with a personal or family history of MTC or in patients with MEN 2. ®

• Victoza® may cause nausea, vomiting, or diarrhea leading to the loss of fluids (dehydration). Dehydration may cause kidney failure. This can happen in people who may have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. • Like all other diabetes medications, Victoza® has not been shown to decrease the risk of large blood vessel disease (i.e. heart attacks and strokes). What are the side effects of Victoza®? • Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath while taking Victoza®. These may be symptoms of thyroid cancer. • The most common side effects, reported in at least 5% of people treated with Victoza® and occurring more commonly than people treated with a placebo (a non-active injection used to study drugs in clinical trials) are headache, nausea, and diarrhea. • Immune system related reactions, including hives, were more common in people treated with Victoza® (0.8%) compared to people treated with other diabetes drugs (0.4%) in clinical trials. • This listing of side effects is not complete. Your health care professional can discuss with you a more complete list of side effects that may occur when using Victoza®. What should I know about taking Victoza® with other medications? • Victoza® slows emptying of your stomach. This may impact how your body absorbs other drugs that are taken by mouth at the same time. Can Victoza® be used in children? • Victoza® has not been studied in people below 18 years of age. Can Victoza® be used in people with kidney or liver problems? • Victoza® should be used with caution in these types of people. Still have questions?

What is the most important information I should know about Victoza®? • In animal studies, Victoza® caused thyroid tumors. The effects in humans are unknown. People who use Victoza® should be counseled on the risk of MTC and symptoms of thyroid cancer. • In clinical trials, there were more cases of pancreatitis in people treated with Victoza® compared to people treated with other diabetes drugs. If pancreatitis is suspected, Victoza® and other potentially suspect drugs should be discontinued. Victoza® should not be restarted if pancreatitis is confirmed. Victoza® should be used with caution in people with a history of pancreatitis.

This is only a summary of important information. Ask your doctor for more complete product information, or • call 1-877-4VICTOZA (1-877-484-2869) • visit victoza.com Victoza® is a registered trademark of Novo Nordisk A/S. Date of Issue: May 2011 Version 3 ©2011 Novo Nordisk 140517-R3 June 2011

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

and changed how I manage my type 2 diabetes. Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells. While not a weight-loss product, Victoza® may help you lose some weight. And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

Model is used for illustrative purposes only.

Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children. Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

If you’re ready for a change, talk to your doctor about Victoza® today.

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis. Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies. Please see Brief Summary of Important Patient Information on next page. If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088. Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily