Minnesota Health care News February 2012 by Minnesota Physician Publishing

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February 2012 â&#x20AC;˘ Volume 10 Number 2

Psoriasis Bruce Bebo Jr, PhD

Dry eye syndrome Ralph Chu, MD

Audiology Jason Leyendecker, AuD

You call it â&#x20AC;&#x153;reminding mom to take her pills.â&#x20AC;?

We call it caregiving.

You or someone you know may be a caregiver. WhatIsACaregiver.org

CONTENTS

4 7 8

FEBRUARY 2012 • Volume 10 Number 2

NEWS

CALENDAR Seasonal Affective Disorder (SAD)

COMPLEMENTARY MEDICINE The art and science of acupuncture

MINNESOTA HEALTH CARE ROUNDTABLE

PEOPLE

PERSPECTIVE

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

SESSION

By John Pirog, MSOM, LAc Peter Bartling Professional Portable X-Ray

HEALTH CARE ROUNDTABLE Accountable Care Organizations

OPHTHALMOLOGY Intense pulsed light (IPL) for dry eye syndrome

10 QUESTIONS Jason R. Leyendecker, AuD Audiology Concepts, Inc.

By Y. Ralph Chu, MD

EMERGENCY MEDICINE Carbon monoxide poisoning By Jon B. Cole, MD

PUBLIC HEALTH Tobacco marketing to youth By Mike Sheldon

DERMATOLOGY Psoriasis By Bruce Bebo Jr., PhD

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com

Specialty pharmacy Controlling the cost of care Thursday, April 19, 2012 1:00 – 4:00 PM • Duluth 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 highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access. 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.

ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name

ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com

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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. 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.

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FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

NEWS

MHA Joins Nationwide Patient Safety Effort The Minnesota Hospital Association (MHA) is part of a $218 million effort to prevent injuries and complications at hospitals across the country. The Partnership for Patients initiative recently announced that 26 hospital systems and organizations will work together as hospital engagement networks to improve patient safety. The networks will develop collaborative efforts to train hospital staff and provide support and technical assistance to hospitals to improve patient safety and promote quality improvement goals. The efforts will be monitored by the Centers of Medicare & Medicaid Services (CMS) to ensure that the program’s goals are being met. MHA officials say the federal funds will allow the group to add three staff members to its patient safety team to provide members with training and technical assis-

tance to address hospital-acquired conditions, readmissions, and safety culture issues. The Partnership for Patients effort will build on patient-safety programs already in place in Minnesota, MHA officials say. They list the state’s Reducing Avoidable Readmissions Effectively (RARE) campaign; the Transforming Care at the Bedside (TCAB) program; and the work of the Minnesota Alliance for Patient Safety (MAPS) as three examples of programs that will gain from the educational and technical assistance that the new funding will provide. According to MHA communications director Jan Hennings, the new partnerships will ensure that Minnesota hospitals will continue to be at the forefront of delivering high quality care. “We in Minnesota have always had a very good working relationship with partners such as Stratis Health and ICSI (Institute for Clinical Systems Improvement). What this grant is going to help us with is to solidify and build upon those partner-

ships,” she says. “We’re extremely excited about it and I think that Minnesota is in good shape to use that grant money to the fullest.”

United Health Report Shows Increase in Diabetes, Obesity A new United Health Foundation report on the nation’s health raises alarms about the rise in rates of chronic diseases such as obesity and diabetes, saying that the increase in such conditions is undermining the country’s health. The annual America’s Health Rankings has consistently gotten attention for its grading of individual states’ health status. But it also presents an overall snapshot of the nation’s health, and foundation officials say they are concerned about trends shown by recent data. The report says areas of improvement, such as improved smoking cessation, reduced hospitalizations, and a decline in cardiovascular deaths, are offset by

increasing rates of obesity, diabetes, and the number of children in poverty. “While this year’s Rankings shows some important improvements, we also see some very alarming trends—particularly diabetes and obesity—that, left unchecked, will put further strain on our country’s already strained health care resources,” says Reed Tuckson, MD, United Health Foundation board member and executive vice president and chief of medical affairs of UnitedHealth Group. The rankings find Minnesota as the sixth-healthiest state in the nation. The ranking marks three years in a row the state has finished sixth, which is also the lowest grade Minnesota has received. Minnesota was ranked No. 1 in the nation for seven of the report’s 21 years. It was ranked in the top five every year until 2009. The United Health Foundation report says Minnesota’s strengths are its low rates of deaths from cardiovascular disease, its low rate of uninsured

Now accepting new patients

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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

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

residents, and the state’s high rate of high school graduation. Challenges include a high incidence of infectious disease, low per-capita public health funding, and a high prevalence of binge drinking. The report also finds that obesity in Minnesota has increased from 17.4 percent to 25.4 percent of the adult population, and that diabetes increased from 4.9 percent to 6.7 percent of the population in this state. Luke Benedict, MD, an endocrinologist at Allina Hospitals and Clinics and a board member of the American Diabetes Association–Minnesota, says the United Health Foundation report confirms what health experts have been seeing for some time. “We’ve been trumpeting this for years, that there’s a huge problem with obesity. It is a true epidemic and this report echoes that,” he says. “Minnesota is doing better than a lot of other states, but we’re still following the same general trend—we’re getting heavier.”

Decline in Youth Smoking Is Slowing, MDH Says State health officials say new data show that progress in reducing tobacco use and exposure to secondhand smoke among teens has slowed in Minnesota. The report says more than 50 percent of high school students in Minnesota are exposed to secondhand smoke, and the use of menthol cigarettes has more than doubled among teens since 2000. The study says tobacco use among teens is decreasing, but at a slower rate than in previous years. “We’ve made great progress in reducing tobacco use since 2000, but the most recent findings in this new report give us little to celebrate,” said Ed Ehlinger, MD, Minnesota commissioner of health. “We are failing our youth when you consider that they use tobacco at higher rates than adults and are still being exposed to secondhand smoke. We are setting them up for a future of tobacco-related illness

and premature death.” In addition to smoking and exposure to secondhand smoke, the report says, young people are trying other tobacco products, such as snus tobacco pouches. The state data show 14.3 percent of high school students report that they have tried snus in their lifetime, and 4.9 percent report using snus in the last 30 days. In addition, 28.6 percent of high school students and 6.8 percent of middle school students report that they have tried flavored cigars and little cigars at some point in their lives.

Fairview, Zipnosis Partner for Online Services Fairview Health Services has announced it will provide an online care service in partnership with St. Paul-based Zipnosis. Officials say the services will cover a number of conditions, including cold and flu symptoms, sinus infections, acne, seasonal allergies, yeast infections, and tobacco cessation. More serious conditions will be referred to a Fairview clinic. With the move, Fairview joins other health organizations like Blue Cross and Blue Shield of Minnesota and HealthPartners, who have also set up online health care services. “Together, Fairview and Zipnosis are making high-quality health care convenient and affordable for consumers,” says Terry Martinson, Fairview Medical Group executive regional medical director. “When patients need care for specific conditions, we are just a click away.”

SHIP Grants Help Communities Provide Health Programs The Minnesota Department of Health (MDH) will give grants totaling $11.3 million to communities throughout Minnesota for health improvement efforts, offi-

TThe he ffreedom re edom m to

ke e p yyour keep ou r d oc torr. doctor. IIt’s t ’s Me Medicare dicare w with it h o options. ptions. With HealthPartners Freedom, edom, you can choose linics like Park Nicollet, from hundreds of clinics Fairview u Fairview,, Allina and HealthPartners. And, you can likely keep yourr current doctor r, becausee doctor, we’d hate to break up a good thing. Shop and compare plans online. Or call us at 952-883-5601 or 800-247-7015, 00-247-7015, 8 a.m. t 8 p.m., seven days to d ys a week. k TTY users call 952-883-6060 or 800-443-0156.

healthpartners.com/medicare healthpartners.com/ partners.com/ ers.com/medicar ers.com/ medicarr e

Yes, you can! Take these steps: 9 Lose about 10 pounds if you are overweight 9 Move and be active at least 30 minutes a day 9 Eat low fat foods and smaller portions

You don’t have to do it alone! Check out a group program near you to help make these changes: YMCA www.ydpp.org or 612-465-0489 Other locations in Minnesota www.icanpreventdiabetes.org or 651-201-5435

Talk with your doctor to see if you are at risk for developing type 2 diabetes The Minnesota Diabetes and Heart Health Collaborative: Working together to keep you informed

www.mn-dc.org Minnesota Diabetes & Heart Health Collaborative

In partnership with the Minnesota I CAN Prevent Diabetes and YMCA Diabetes Prevention Programs

News to page 6 FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

News from page 5 cials announced last week. The grants are part of the Statewide Health Improvement Program (SHIP), which was created by the Legislature as part of health reforms passed in 2008. The grant programs will cover 51 counties, four cities, and one tribal government over the next 18 months, officials say. That is down from the first round of grants, which covered all 87 counties and nine tribal governments. MDH officials note that funding for SHIP was reduced in the 2011 legislative session, resulting in fewer grantees this year. “To improve health in Minnesota, we have to think in terms of prevention, not just treatment,” said MDH Commissioner Ed Ehlinger. “In Minnesota and nationally, the two main causes of chronic disease and premature death are obesity, caused by poor nutrition and insufficient physical activity, and commercial tobacco use. We must do something to address these problems as indi-

viduals, as communities, and as a state.” The SHIP program focuses on four areas: schools, health care, work places, and the community in general. State officials work with local communities on nutrition programs, increased opportunities for exercise, decreased exposure to second-hand smoke, supporting employer-based workplace wellness programs, and evaluation of local health promotion efforts.

Three Systems Join Federal ACO Project Three Minnesota health systems have been named as part of a pilot program to roll out accountable care organizations (ACOs), a key component of the health reforms passed as part of the federal Affordable Care Act (ACA). The Minnesota systems participating in the Pioneer ACO initiative are Allina Hospitals and Clinics, Fairview Health Services, and Park Nicollet Health System.

Nationally, 32 health organizations were chosen to take part in the program. According to U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius, the new program will encourage primary care physicians, specialists, hospitals, and other caregivers to provide better, more coordinated care for Medicare recipients. Officials say the Pioneer ACOs could save up to $1.1 billion in health care costs over five years. “Pioneer ACOs are leaders in our work to provide better care and reduce health care costs,” says Secretary Sebelius. “We are excited that so many innovative systems are participating in this exciting initiative—and there are many other ways that health care providers can get involved and help improve care for patients.” The ACO model has been discussed and debated throughout the health care reform process, and the new program is a further step to bring the concept to reality on a large scale.

HHS officials say the initiative will test the effectiveness of different payment models as systems move from paying for volume to paying for the value of care provided. The Pioneer ACO program will feature robust quality measurements, freedom of choice in choosing providers, and a coordinated approach to care. The Minnesota systems chosen for the program are among the largest in the state, and serve large populations in the metro area. Minnesota systems also have the advantage of being familiar with health reform innovations such as coordinated care, since such concepts are already being tested throughout the state. “Fairview Health Network is very well positioned to serve as a Pioneer ACO,” says Dave Moen, MD, president of Fairview Physician Associates, “because we have already made tremendous progress with implementing new care delivery models and care coordination processes. Our patients will enjoy better care and a better experience.”

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PEOPLE Two physicians were recognized in December

NOW hear this!

for their service to the community at the annual meeting of medical staff for Lakeview Hospital in Stillwater, Minn. Thomas Stormont, MD, was recognized for his long commitment to Lakeview Hospital, where he continues to serve as Surgery Department chair. He is a boardcompleted his residency at

Mayo Clinic. Andrew Dorwart, MD, was recognized for leadership commitment to Lakeview Health System. He has held many leadership positions in the past and currently serves as president of Stillwater Medical Group. Dorwart is a board-certified internal medicine physician who completed his residency at Hennepin County

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?

certified urologist who Thomas Stormont, MD

Andrew Dorwart, MD

Medical Center. Lakeview Hospital’s physician recognition awards are given annually by physician peers to recognize fellow physicians for their overall distinguished service to Lakeview Hospital, its patients, and the community. Aspen Medical Group has recently added three physicians at its clinics. Kang Xiaaj, MD, family medicine, will practice at the East Lake

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.

Street clinic. Xiaaj earned her degree at the The Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge.

University of Minnesota Medical School and comKang Xiaaj, MD

pleted her residency at

Regions Hospital. Josaleen Davis, MD, internal medicine and geriatrics, will see patients at the Hopkins clinic. Davis earned her degree at the University of Minnesota Medical School and completed her residency at Maine Medical Center. Heather Jensen, DPM, MHA, will see

Josaleen Davis, MD

patients at the Bloomington and Hopkins clinics and the Specialty Center in St. Paul. Jensen earned her degree at Des Moines University’s College of Podiatric Medicine and Surgery. The Minnesota Department of Health

Doo you D y experience p i nce i l flar flare-ups occasional casional e-ups -ups of

Gout? G out? t?

presented a Betty Hubbard Maternal and Child Health Leadership Award to Danielle Le Bon Gort of Superior, Wis. Le Bon Gort, the Maternal and Child Health team leader for the Fond du Heather Jensen, DPM, MHA

Lac Band of Lake Superior Chippewa, received the community award for her work within the

Fond du Lac community and Minnesota’s northeast region. She has been a public health nurse with the Fond du Lac band for 10 years, during which much of her work has focused on assuring women have access to the services they need to have healthy pregnancies and obtain positive parenting skills. She has initiated a doula program specific to American Indian women on the Fond du Lac reservation and in surrounding counties. She also has created a

Radiant Research earch is conducting ng a clinical dy of an investigational ational research study or Gout. medication for Qualified participants parrticipants will dy-related receive all study-related stigational care and investigational at no n charge and medication at nsated for time and travel.l. Call the may be compensated number below to see if you may qualify.

breastfeeding support program on the reservation. Le Bon Gort was instrumental in bringing the Nurse Family Partnership (NFP) model to the Fond du Lac community. NFP is a nurse-led, evidencebased maternal and early childhood health program that uses home visiting to foster long-term success for first-time mothers and their

Call Mon-Fri for more mo ore information

952.848.2065 2065 7700 France Ave., Suite te 100, Edina, MN www.radiantrese www.radiantresearch.com earch.com

Wee Can’t Do It Without W Without YOU!

babies. FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Toward solving the problems of senior care Elevating the discussion

y 2020, 950,000 Minnesotans will be 65 or older. By 2030, this number will grow to 1,300,000, an increase that threatens to overwhelm the capacity of the current health care system. Some in this growing demographic may need the skilled nursing facilities (SNF) that have traditionally been called nursing homes. However, SNFs are transitioning away from that role as they increasingly become settings that provide senior housing, assisted living, and related services, a change that will accelerate in the years ahead.

Peter Bartling Professional Portable X-Ray

Peter Bartling is the research manager at Professional Portable X-Ray, a Minnesota-based company that brings x-ray equipment to skilled nursing facilities and other locations for onsite x-rays. He has served in management positions in the banking and retail industries in addition to serving as CEO of Minnesota Oncology Hematology, PA, and other health care organizations.

accelerating crisis: increasing demand, no shortage of aging citizens, and declining resources. Albert Einstein said it best: “We can’t solve problems by using the same kind of thinking we used when we created them.”

Solutions to consider as the way forward 1. Rebrand senior care facilities. SNFs must be positioned as most of them currently are: Centers of Community Living that enhance and prolong life; staffed by caring professionals; and light and bright, not dark and drab. This transition will create a lack of access to skilled 2. Competitive bidding. Competitive bidding on nursing facilities. This concerns everyone; even every contract awarded by a SNF would ensure people who do not currently need senior care that vendors would be chosen on the basis of themselves have parents who may require a SNF quality, service, and price. Requiring contract disat some point. Given the rapid increase in our sen- closure to appropriate regulatory bodies would ior population, figuring out how to improve ensure compliance. access to senior health care must be proactive. If 3. End-of-life care planning. Senior care requires a we wait to deal with the future influx of senior range of decisions, which should be made, as needs, we’ll be trying to figure it out while in cri- much as possible, while each SNF resident enjoys sis mode. Finding solutions requires the involve- patient autonomy and the complete use ment of both consumers and service providers. of her or his mental faculties. The Great Debate “Honoring Choices Minnesota” is a superb example of an Hence “The Great Debate” takFiguring out how advanced-care planning model ing place in Minnesota and to improve access to (www.honoringchoices.org). across the country: Should we 4. Create a Senior Citizens spend less on senior care, or senior health care Corps. A Senior Citizens Corps tax more in order to spend must be proactive. made up of SNF residents more? Minnesota has 385 certicould enhance the quality of fied Medicare and Medicaid life of SNF residents. The corps nursing homes, with a combined total of 32,010 available SNF beds and an occupancy rate of 91 could develop a buddy system for residents who percent. The Medicare Five Star Quality Rating for lack access to family members; develop a technolMinnesota SNFs is 3.5 (out of 5), for a national ogy cadre to teach residents how to use the ranking of fifth highest among the 50 states. So Internet and social media; and serve as personal with such impressive numbers, why are Minne- trainers to encourage residents to exercise. sota SNFs facing ever-increasing costs and dimin- 5. Repeal Medicare’s three-day required hospital ishing resources? stay rule. SNFs should be encouraged as an alterReasons include a decline in federal Medicare native to hospitalization. A stay in a SNF transireimbursement rates, which decreased federal tional care unit is cheaper than hospitalization, funding for SNFs; a shrinking workforce as and should be encouraged by all physicians and employees leave SNFs for higher wages and ben- third-party payers whenever practical and possiefits elsewhere; and state legislation that repealed ble. Repeal of Medicare’s three-day required hosrebasing, which decreased state funding. pital stay is an absolute must. This rule penalizes (Rebasing periodically adjusted the cost of operat- SNFs for being efficient. ing an SNF, adjusted a facility's Medicaid reim- 6. Technology enhancements. Grants from busibursement rate, and enabled the facility to get ness and the government should be awarded to more state funding.) The net results of these neg- encourage SNFs to use lean-management principles, process engineering, and the use of robots, ative drivers: • There will be fewer skilled nursing facilities as where applicable. 7. Political participation. The SNF industry should time goes on. absolutely encourage staff and residents to partic• The cost of senior care will invariably rise in paripate in the political process.The aging of America allel with the rising cost of more expensive alteris not a Democratic or Republican issue. It is a natives to SNFs, such as hospitalization. demographic one. What to do? We now have conditions ripe for an

MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

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10 QUESTIONS

& Jason R. Leyendecker, AuD Dr. Jason Leyendecker is a licensed audiologist and practices at Audiology Concepts, Inc., in Edina. He also practices at the Tinnitus and Hyperacusis Clinic in Edina. Dr. Leyendecker is a member of the American Academy of Audiology, the Academy of Doctors of Audiology, and the Minnesota Academy of Audiology. What does an audiologist do? An audiologist diagnoses, treats, and counsels people on disorders of hearing and balance. What can you tell us about tinnitus? Tinnitus is a phantom auditory perception similar to that of phantom pain and affects more than 50 million Americans. It causes noises in the ear, which can sound like ringing, buzzing, clicking, or thudding. In people with tinnitus, damage to the organ of hearing has left the part of the brain that perceives sound unstimulated. In the absence of stimulation, the brain creates a signal that is perceived by the subconscious part of the brain as a sound. Tinnitus affects everyone differently and some individuals aren’t bothered by it, while some experience irritation or distress. Some people with tinnitus are affected to the point where it controls their daily routines, causing anxiety and loss of sleep. This happens in an area of the brain we cannot willfully control; therefore, we have no medical cure for tinnitus. However, there are several tinnitus treatments that help manage this symptom. Our job is to educate patients about these treatments and help them train their brain to disregard the sound. What are some of the most exciting advances in the field? Hearing aid technology involves many of the most exciting advances. Hearing instruments have improved tremendously over the last 10 years, with open-fit aids for more natural sounding amplification. Moreover, wireless communication between hearing aids and other audio devices using Bluetooth or Wi-Fi technology allows users to interface with their favorite devices. You can now hear your cell phone directly into both ears, with the signal amplified as needed for your hearing loss. This is ultimately the best way to communicate on the telephone. Other audio devices such as the television, music-playing machines, and the computer can be heard through hearing aids as well! What are some reasons an individual would make an appointment with an audiologist? Has your sound environment has lost its clarity? A frequent complaint from patients is, “I hear people fine, I just can’t understand what they are saying.” The most common type of hearing loss is a high frequency (pitch) loss. Patients are just missing the treble, or high-pitched sounds, which communicate clarity in speech. The earlier you come in for an appointment to address this issue, the easier it is for your brain to adjust to amplification. It is also important to rule out any medical issues that have hearing loss as a symptom, such as ear infections, middle ear growths, and unusual central brain abnormalities such as benign tumors.

Photo credit: Bruce Silcox

What concerns do earbuds raise for hearing loss in the young? In graduate school, we screen-printed fundraiser T-shirts with an image of an MP3 player and the words “job security” typed underneath. The American Medical Association released a recent study indicating a 20 percent increase in hearing loss among teenagers! That equals one in five teenagers with hearing loss! As a general rule, if someone next to you can hear

MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

“

”

Hearing instruments have improved tremendously over the last 10 years.

the music while the earbuds are in your ear, it is too loud. It is also important to limit the amount of time you spend wearing earbuds, as extended listening—even at a lower level—can cause hearing damage. The American Academy of Audiology created a campaign called “Turn It to the Left” to raise awareness of noise-induced hearing loss from personal listening devices. I encourage families to visit the website www.turnittotheleft.com for more information. When should a person consider using a hearing aid? It is important to consider amplification early, since the faster you address hearing loss, the easier it is for your brain to adjust to the sounds you have been missing. In our office, demonstration instruments are used for one week so the patient can evaluate the need for amplification. If the patient does not notice benefit from hearing devices, we recommend annual hearing evaluations to monitor existing hearing loss. In the future, if difficulty develops, the patient can return to assess hearing aids again. How does health insurance cover hearing-related problems? Typically, insurance companies do not cover amplification. It is important to look into your policy when selecting coverage, as it varies among companies and per policy; benefits can range from $500 to full coverage. Typically, private insurance covers hearing and balance evaluation from licensed audiologists.

Please tell us about some of the more unusual hearingrelated conditions. Some clinics, like ours, specialize in sound sensitivity. Sound sensitivity can range from hyperacusis (sensitivity to loud sounds) to soft-sound sensitivity syndrome (SSSS), which is a strong emotional reaction to specific sounds such as lip smacking or chewing. SSSS is a relatively newly diagnosed phenomenon (within the last decade). Very little is known about it and extensive research is needed to properly create widespread treatment of this population. We work with these patients to desensitize them to the sounds that are bothersome.

Please describe the process of hearing loss as we age. As they say, getting old is not for sissies. For instance, the hearing organ can break down over time due to poor blood flow and repeated sound damage to the inner ear structures. Young age will not protect you from hearing loss, so it is important to protect your hearing when working in noisy environments such as mowing the lawn and blowing snow. Truthfully, as we age our protective mechanisms don’t work as well and we even become more susceptible to breakdown of structures due to the normal aging process. What advice can you give our readers to best care for their hearing? The best care for your hearing starts with your primary care physician. They are the gatekeepers of your information and your general well-being. Have them refer you to an audiologist they trust and get your hearing tested early.

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FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

EMERGENCY MEDICINE

Carbon monoxide

POISONING Avoid itâ&#x20AC;&#x201D;know the symptoms

Carbon monoxide (CO) causes more sickness and death than any other poison in the United States. This deadly poison is an odorless, colorless, and tasteless gas responsible for over 50,000 visits every year to U.S. emergency care facilities. Exposure to this poison is often difficult to diagnose, as symptoms are quite vague and often mimic simple viral illnesses. Most CO exposures occur in the fall and winter, but can occur year-round. While specialized treatment is available for some selected cases, the most important treatment is to move away from the CO source as quickly as possible. If the exposure occurs inside, exiting the building is the most important step to take to keep safe. Where is carbon monoxide? Anywhere a combustion reaction occurs is a potential source of CO, including any gasoline- or propane-powered equipment. This includes everything from gas grills to forklifts to ice-resurfacing machines (Zambonis). Poisoning can be avoided by not operating such equipment in a confined space or, if necessary for work, by operating the equipment in strict accordance with guidelines from the Occupational Safety and Health Administration (OSHA). House fires are another common source of CO. Gas furnaces are also a frequent source for CO. Fall and winter are higher risk times for CO poisoning because furnaces go largely unused in Minnesota during the summer. The vast majority of CO poisoning occurs via inhalation. A far less common and somewhat surprising source of CO is methylene chloride, which is commonly found in paint strippers. When methylene chloride is ingested or absorbed through the skin, it is metabolized to CO by the liver. Thus it is important to wear gloves and work with proper ventilation when using paint strippers.

By Jon B. Cole, MD

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

www.mppub.com

Mechanisms of poisoning CO poisons both the blood and the metabolic system. Under normal circumstances, oxygen is supplied to all areas of the body by a protein in blood called hemoglobin. Unfortunately, the affinity of hemoglobin for CO is much greater than for oxygen. So, once hemoglobin binds CO, it can no longer bind oxygen. Oxygen delivery to all parts of the body is then compromised and can result in chemical suffocation. CO can also make brain cells initiate their own death by inducing a process called apoptosis. Lastly, CO is a potent poison of the cardiovascular system, impairing the heart’s ability to contract and causing blood vessels to dilate. All of these effects of CO can lead to dangerously low blood pressure, organ damage, and death.

this, data suggest children tend to fare better than adults. This may be due to their inherent ability to recover better. Pregnant patients are also theoretically at higher risk for poisoning, as some evidence exists that the hemoglobin of unborn children binds CO more tightly than in children or adults. Prevention

By Minnesota law, all homes in the state are required to have working CO detectors. Ideally, a CO detector should be placed in or outside every bedroom in the house. Fuel-burning appliances The most important should be maintained properly and aspect of treatment ventilated well. If a CO detector is to move away goes off, evacuate the house immediately and contact the fire departfrom the CO source ment. The Minnesota Poison immediately. Control System is available 24 hours a day, 365 days a year, to Symptoms answer any questions regarding CO Early symptoms of CO poisoning are very poisoning. Call toll free at (800) 222-1222. vague, including nausea, vomiting, fatigue, dizziness, and headache. Because poisonings are more common in the Jon B. Cole, MD, is medical director of the Minnesota Poison winter when the incidence of viral infections rises, it is easy Control System and Hennepin Regional Poison Center. to see how even an experienced clinician can misdiagnose CO poisoning as a viral illness or the flu. As poisoning becomes more severe, so do symptoms. Severe poisoning can result in confusion, loss of consciousness, stroke, heart attack, seizure, coma, and death. The higher the level of CO in the body, the more severe symptoms become. Survivors of CO poisoning are at risk for persistent neurologic The clinics of Northwestern symptoms such as amnesia, paralysis, dementia, difficulties with Health Sciences University offer speech, difficulties walking, or even symptoms of Parkinson’s disease. natural health care solutions at These symptoms are known collectively as three Twin Cities locations. delayed neurocognitive sequelae (DNS) We also partner to provide free and may show up in as many as 15 perFall and services at community clinics. cent of patients with severe CO poisonwinter are • Acupuncture ing. These symptoms typically show up and Oriental medicine higher risk after a period of two to 40 days of appar• Chiropractic ently normal behavior. times for

Health care …naturally

CO poisoning.

Treatment

The most important aspect of treatment is to move away from the CO source immediately. If you are inside when symptoms occur, get outside right away. If you are outside when symptoms occur, perhaps when you are standing next to a gas grill, move away from the grill or whatever you think is the source of the CO. Greater risk Any patient with underlying coronary artery disease, anemia, or respiratory disease such as asthma or chronic obstructive pulmonary disease is at a higher risk for a bad outcome from CO poisoning. Children are theoretically at a higher risk for CO poisoning because they have a higher metabolic rate that uses more oxygen. Despite

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FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

D E R M AT O L O G Y

he National Psoriasis Foundation estimates that of the 5.3 million people who live in Minnesota, about 128,000 have psoriasis, a chronic immune system disease that produces skin changes. That’s about the national average. As many as 7.5 million Americans—about 2 percent of the population— have psoriasis and/or psoriatic arthritis. Psoriasis cannot be cured, but it can be controlled. People who have psoriasis need proper medical care to keep their disease under control.

Of the five types of psoriasis, plaque psoriasis is the most common. People with plaque psoriasis develop raised red or pink patches of skin with thick silvery scales. The scales are a buildup of dead skin cells. These patches can appear anywhere on the body—arms, legs, trunk, hands, nails, or scalp—but knees and elbows are among the most commonly affected areas. The patches can be itchy and unsightly, but they are not contagious. Psoriasis can occur at any age, even in infants, although it is most common in adults. Most people get diagnosed between the ages of 15 and 35. Psoriasis affects men and women equally although women tend to show psoriasis symptoms at a younger age.

Psoriasis

Causes

We still don’t know what triggers psoriasis, but we do know that the immune system plays a key role. Research suggests that psoriasis occurs when a person’s immune system sends out faulty messages to The most common the skin. For some reason, the body thinks it is autoimmune disease fighting invaders and so it speeds up the producin the United States tion of skin cells. As new skin keeps being made, old, dead skin cells pile up, causing the area to By Bruce Bebo Jr., PhD become red and inflamed and to have increased blood flow. Psoriasis has a genetic component. In about a third of cases, psoriasis is inherited. It is not yet understood why some family members develop psoriasis and some do not. Environment may play a role as well. Environmental factors suspected of causing psoriasis in some people include trauma or injury to the skin, stress, smoking, and obesity. Some medications, including antidepressants, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors used for treating cardiovascular disease, may trigger psoriasis in some people. Strep throat is thought to be a trigger for a rare form of psoriasis called guttate psoriasis, especially in children and people under 30. Guttate psoriasis causes a rash of pinkish, tiny teardrop-shaped bumps that usually appear on the torso, arms, and legs.

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

Treatment is based on a number of factors, including which type of psoriasis the patient has, how much of the skin is affected, how the patient responds to initial treatments, other health conditions the person may have, and what medications he or she may be taking. Treatment may involve a combination of strategies. Psoriasis is considered mild if less than 3 percent of the body is affected and moderate if 3 percent to 10 percent of the skin is involved. When more than 10 percent of the body is affected, it is considered a severe case. (The area of a person’s hand equals about 1 percent of their skin.) • Most patients are given topical medications—medications applied to the skin—to try first. Some topical treatments are sold over-thecounter while others are by prescription only. Steroids, which reduce swelling and redness of lesions, are the most commonly used topical treatments. • Some patients find relief with light therapy or phototherapy, in which the skin is regularly exposed to ultraviolet light under medical supervision. Psoriasis to page 34

February Calendar 11

Reflex Sympathetic Dystrophy (RSD) Support Group If you are living with complex regional pain syndrome (CRPS), also known as RSD, this group is for you. We provide support, validation, and education. Meetings are held the second Saturday of each month. Contact Kate Healy at (763) 441-1641 or email Kate@rsdsmn.org. Saturday, Feb. 11, 10 a.m.–noon, Elk River Public Library, 13020 Orono Pkwy., Elk River

Pregnancy and Infant Loss While grieving is painful for everyone, the death of a baby represents a very special grief. Whether your loss was through ectopic pregnancy, miscarriage, stillbirth, or newborn death, please consider joining this group. Pre-register by calling Annette Klein at (651) 241-6206. Monday, Feb. 13, 5–6:30 p.m., United Hospital, 333 N. Smith Ave., St. Paul

Recovery Plus Event Are you recovering from alcohol or drugs? Bring your friends and family to fun-filled sober events. We meet the third Saturday of every month and plan a new activity each time. Everyone is welcome. For more information, call Bev at (320) 229-3760. Saturday, Feb. 18, 6–9 p.m., Recovery Plus, 713 Anderson Ave., St. Cloud

Overeaters Anonymous (OA) Join a program of recovery from compulsive eating that provides a fellowship of experience, strength, and hope where members respect one another’s anonymity. OA addresses physical, emotional, and spiritual well-being. Meetings are held each Monday. For more information, call (612) 273-9600. Monday, Feb. 20, 4:45–5:45 p.m., University of Minn. Medical Center, Fairview–West Bank, 2450 Riverside Ave., East Bldg., Board Rm., Minneapolis Heart & Vascular Lecture Charles Pinkerman, DO, will provide current information on congestive heart failure. The seminar is for people who have

had heart attacks, open-heart surgery, or other conditions affecting the heart. Family and friends are welcome to attend. Registration is not necessary. Questions? Call Patient Education at (952) 993-1909. Wednesday, Feb. 22, 7–8 p.m., Park Nicollet Heart and Vascular Ctr., 6500 Excelsior Blvd., Suite G-700, St. Louis Park

Seasonal Affective Disorder (SAD) If you notice periods of depression that seem to accompany seasonal changes during the year, you may suffer from seasonal affective disorder (SAD). This condition is characterized by recurrent episodes of depression—usually in late fall and winter— alternating with periods of normal or high mood the rest of the year. Symptoms of recurrent winter depression can include oversleeping, daytime fatigue, carbohydrate craving, and weight gain. Additionally, there are the usual features of depression, especially decreased sexual interest, lethargy, hopelessness, suicidal thoughts, lack of interest in normal activities, and social withdrawal. Bright white fluorescent light bulbs, encased in a box with a diffusing lens, have been shown to reverse the winter depressive symptoms of SAD. Studies show between 50 percent and 80 percent of users showing essentially complete remission of symptoms, although the treatment must continue throughout the difficult season in order to maintain this benefit. Antidepressants may also help, and if necessary can be used in conjunction with light. The optimum effect of light therapy requires that the dose be individualized, just as for medications. If your depressive symptoms are severe enough to significantly affect your daily living, consult a mental health professional qualified to treat SAD. He or she can help you find the most appropriate treatment for you. For more information about SAD or other mental illnesses, visit www.namihelps.org or call (651) 645-2948; toll free (888) NAMI-HELPS. 8 Don't Let the Winter Blues Get You Down Do you get the blues during the winter months but feel better in the spring and summer? You may have seasonal affective disorder (SAD). Dr. Jeff Virant, Stillwater Medical Group, will address SAD, its causes and what you can do about it—whether it’s you or someone you know. Free, but registration is required; call (651) 430-4697. Wednesday, Feb. 8, 6:30–7:30 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Minnesota Food & Nutrition Expo 2012 This event is designed to help every member of your family start eating healthier. Check out cooking demos, vendors with the latest healthy foods, and an expert dietitian to answer your toughest nutrition questions. Children can take a trip through the larger-than-life GI tract exhibit! Admission: $7 per family or free for each person donating a nonperishable food item. For more information, visit the Minnesota Dietetic Association at www.eatrightmn. org, email mda@eatrightmn.org, or call (952) 830-7022. Saturday, Feb. 25, 9 a.m–3 p.m., Minneapolis Convention Center, 250 Marquette Ave. S., Minneapolis

South Metro Moms Support Group Gather with other mothers of fetal alcohol spectrum disorders-affected children to informally share resources, insights, and support. Contact Tanya Weinmeyer at tweinmeyer@yahoo.com or (952) 8367182 for more information. Visit www.mofas.org for additional groups sponsored by Minnesota Organization on Fetal Alcohol Syndrome (MOFAS). Tuesday, Feb. 28, 9:45–10:45 a.m., Panera Bread, 15052 Gleason Path, Apple Valley

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 FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

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

The art and science of “I have always hated needles,” one of my patients—call her Katie— told me last week. “Yet here I am, looking forward to having them stuck into me.” It’s not the first time I’ve heard that statement: I’m an acupuncturist.

acupuncture Unconventional pain treatment finds increasing acceptance By John Pirog, MSOM, LAc

I practice a profession that is built on paradoxes, not least of which is the insertion of needles to relieve pain. In Katie’s case, the problem is particularly severe. A two-time cancer survivor, her pain is nearly constant and only partially controlled by medication. Her weekly sessions with me are the only times she’s free of pain. Performed more and more Acupuncture treatments like the one described above are performed every day in clinics across America, nearly 18 million a year by the government’s National Institutes of Health estimate. That’s triple the number performed 10 years ago. To obtain an acupuncture license in Minnesota, candidates must have graduated from an accredited acupuncture college, com-

pleted approximately 3,000 hours of study, and passed a national board examination. The Twin Cities has become a bustling hub of acupuncture activity, with nearly half the state’s 300 licensed acupuncturists practicing in the metro area. Some acupuncturists even subspecialize in areas such as fertility, cancer, and brain injury. Several of the state’s hospital systems now employ acupuncturists, including Allina, Fairview, HealthEast, and Mayo Clinic. All this growth begs a question: How is it that an ancient Asian healing art has become so popular in a civilization obsessed with modern science? In order to answer this question, we need to start with a few basics. The basics Modern acupuncture is performed with solid, ultra-thin needles, some no thicker than a human hair. The needles are presterilized and single-use—the only type approved for acupuncture by the U.S. Food and Drug Administration (FDA). And while acupuncture is not entirely painless, it is far less painful than the more familiar jab of a hypodermic needle. More importantly, following the insertion of the needles, patients usually experience an uncanny sense of relaxation and calm, the result of acupuncture’s unique effects on the nervous system. The total experience is usually quite comfortable and even pleasant. Yes, patients do look forward to their acupuncture treatments. Underlying philosophy Physicians who work with acupuncturists are often puzzled by our references to pre-scientific concepts such as “Qi” (pronounced “chee”). Our attachment to ancient Chinese medical theories deserves some explaining. In order to make sense of acupuncture’s complex effects on the body, acupuncturists long ago adopted simple, holistic explanations for how the body worked. These explanations and the ideas on which they rest are all the more useful nowadays because they cut through the intellectual barriers of reductionist science, which make it hard to imagine the body as a single, working whole. While modern medicine tends to imagine the circu-

MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

Bedside acupuncture is slowly being latory, nervous, and musculoskeletal systems as separate units demanding incorporated into modern hospital care. separate chapters in medical texts and even separate medical specialties, acupuncture envisions all these systems working as a contiguous totality, united through a single Numerous studies have shown that acupuncture helps control the all-important theme: Motion. The ancient term “Qi” is best nausea induced by surgery and chemotherapy, which is one of the understood as an attempt to relate to this motion and to reasons that bedside acupuncture is slowly being incorporated into communicate its role in sustaining life and restoring health. modern hospital care. And the alterations in brain chemistry proSince it is natural to think of currents flowing through duced by acupuncture suggest that it may help manage anxiety and pathways, the ancients imagined that Qi flowed through depression too. pathways called “meridians,” which appear on charts that Insurance coverage early practitioners devised and are still used today. Today, Although the number of insurance companies covering acupuncture we think of these meridians as functional diagrams rather in Minnesota has grown in recent years, most treatments in the state than anatomical entities in the strictest sense. They unite disparate regions of the body and help us predict, for exam- are paid for out-of-pocket. A number of clinics in Minnesota offer a ple, which points on the extremities should receive acupunc- “community” style of acupuncture, where treatments are performed in a group setting and the cost per session is significantly lower. If ture in order to treat a headache. you are looking for an acupuncturist in your area, the National How it works Commission for the Certification of Acupuncturists offers a listing In modern physiology, one type of motion seems to control all othof board-certified acupuncturists by ZIP code at www.nccaom.org. ers, which is the movement of electrical signals through nerves. Not If you wish to find a Community Acupuncture clinic, check surprisingly, contemporary attempts to understand acupuncture www.pocacoop.com. have focused on the nervous system. It is now believed that John Pirog, MSOM, LAc, has practiced acupuncture for 30 years and is a acupuncture’s pain-relieving effects are the result of subtle changes professor of acupuncture and oriental medicine at Northwestern Health induced in the routing of signals through the brain and spinal cord. Sciences University in Bloomington. While acute pain is necessary for survival, chronic pain is counterproductive: Cavemen being chased by tigers would have been illserved by low back pain. Evolutionary pressures have caused the development of an internal regulatory system that can switch off pain when needed. Referred to by modern research as the “Nerve Gate,” this system prevents pain signals from reaching the brain through the release of substances called neurotransmitters. One of these neurotransmitters, beta-endorphin, is thought to be 48 times more powerful than morphine. The unique stimulus produced by acupuncture needles seems to amplify the effect of the Nerve Gate, causing the release of neurotransmitters that not only switch off pain Right now, new students get a but also produce a natural sense of The insertion FREE WEEK of unlimited yoga. euphoria, a kind of “acupuncture high.” Switching off pain and producing a natuof the needles ral euphoria explain why an otherwise is usually needle-phobic patient like Katie might look forward to her weekly treatments. followed by In effect, acupuncture can turn the an uncanny body into its own medicine cabinet and sense of allow sufferers of chronic pain to avoid the need for pain-killing drugs that can relaxation lead to side effects and addiction. Even See you soon at any one of our 8 Minnesota locations and calm. more importantly, acupuncture can help Eden Prairie • Edina • Minneapolis • Minnetonka some patients who suffer from chronic St. Louis Park • St. Paul • Stadium Village • Uptown musculoskeletal pain to avoid surgery. Clinical trials have shown that acupuncture outperforms placebos in the treatment of tension headaches and migraines, as well as low back, neck, and knee pain. In one large trial on low back pain, acupuncture was twice as effective as guideline-based conventional care.

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FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

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Diabetes Chlorpropamide 100mg tab* ...........................................30 ........90 Glimepiride 1mg tab ..........................................................30 ........90 Glimepiride 2mg tab ...........................................................30 ........90 Glimepiride 4mg tab ..........................................................30 ........90 Glipizide 5mg tab .................................................................30 ........90 Glipizide 10mg tab* .............................................................60 ......180 Glyburide 2.5mg tab ...........................................................30 ........90 Glyburide 5mg tab (blue) ..................................................30 ........90 Glyburide 5mg tab (green)................................................30 ........90 Glyburide, micronized 3mg tab ......................................30 ........90 Glyburide, micronized 6mg tab ......................................30 ........90 Metformin 500mg tab ........................................................60 ......180 Metformin 850mg tab ........................................................60 ......180 Metformin 1000mg tab* ....................................................60 ......180 Metformin 500mg ER tab*.................................................60 ......180

Ear Health Antipyrine/Benzocaine otic (15ml bottle)†.....................1 ...........3

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 1/4/12

Heart Health & Blood Pressure Amiloride-HCTZ 5mg-50mg tab .....................................30 ........90 Atenolol-Chlorthalidone 100mg-25mg tab ................30 ........90 Atenolol-Chlorthalidone 50mg-25mg tab ..................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 ......180 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 ........90 Clonidine 0.2mg tab ............................................................30 ........90 Digoxin 0.125mg tab ..........................................................30 ........90 Digoxin 0.25mg tab .............................................................30 ........90 Diltiazem 30mg tab .............................................................60 .....180 Diltiazem 60mg tab .............................................................60 .....180 Diltiazem 90mg tab*............................................................60 .....180 Diltiazem 120mg tab ..........................................................30 ........90 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

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

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

........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 .....180 .......90 .....180 .....180 .....180 ........90 ........90 ........90 ........90 ........90

Prazosin HCL 2mg cap ........................................................30 Prazosin HCL 5mg cap ........................................................30 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 Terazosin 5mg cap ..............................................................30 ........90 Terazosin 10mg cap .............................................................30 ........90 Triamterene-HCTZ 37.5mg-25mg cap ..........................30 ........90 Triamterene-HCTZ 37.5mg-25mg tab ..........................30 ........90 Triamterene-HCTZ 75mg-50mg tab ..............................30 ........90 Verapamil 80mg tab ............................................................30 ........90 Verapamil 120mg tab .........................................................30 ........90 Warfarin 1mg tab .................................................................30 ........90 Warfarin 2mg tab .................................................................30 ........90 Warfarin 2.5mg tab ..............................................................30 ........90 Warfarin 3mg tab .................................................................30 ........90 Warfarin 4mg tab .................................................................30 ........90 Warfarin 5mg tab*.................................................................30 ........90 Warfarin 6mg tab ..................................................................30 ........90 Warfarin 7.5mg tab ..............................................................30 ........90 Warfarin 10mg tab ...............................................................30 ........90

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

Men’s Health

$9/30-day

Finasteride 5mg ...................................................................................30 $9/tablet

Levitra 20mg (limit 10 per customer per month) ......................1

Mental Health

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

Amitriptyline 10mg tab .....................................................30 .......90 Amitriptyline 25mg tab ......................................................30 ........90 Amitriptyline 50mg tab .....................................................30 ........90 Amitriptyline 75mg tab ......................................................30 ........90 Amitriptyline 100mg tab ...................................................30 ........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 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

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

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

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 1/4/12

*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

M I N N E S O T A

MR. CHRISTENSON: What is an ACO? DR. MOEN: ACO is a legislative construct that enables change in health care. The way I view it, it enables us to begin to balance individual health and population health appropriately in a system and drive accountability to both. DR. WECKWERTH: An ACO is a formless collaborative entity intending joint accountability for measurable quality improvements and to reduce rates of health care spending.

H E A L T H

C A R E

R O U N D T A B L E

About the Roundtable Minnesota Physician Publishing’s 36th Minnesota Health Care Roundtable examined the topic of accountable care organizations. Seven panelists and our moderator met on Oct. 13, 2011, to discuss this issue. The next roundtable, on April 19, will explore the subject of specialty pharmacy and its role in controlling the cost of health care.

MR. WATSON: It’s the latest way to bend the cost curve. MR. CHRISTENSON: What is a shared savings payment program? What does it mean? DR. MOEN: It’s a mechanism to allow a different style or type of contracting that rewards or allows alignment of incentives for managing cost care, not just producing volume of services. DR. THORSON: The intent of the shared savings program is to say, how do we reduce the waste and maintain the quality and allow for more efficient utilization of both limited resources and dollars? Is it really going to transition the payment from being hospital-centric to more outpatient-centric? MR. WATSON: It makes the assumption that there will be savings. The savings supposedly come from the elimination of episodic independent activities, and therefore you’re pooling something, and therefore it should cost less in the aggregate. That’s the assumption. Whether or not it’s true, I don’t know. DR. AINSLIE: One of the problems is, the regulations from CMS have an after-thefact payment. You don’t even know what patients are in your ACO, so you don’t know who you’re taking care of and how you’re taking care of them, and it will be decided after-the-fact by CMS who can arbitrarily say, you did a good job and we’ll pay you that money, or no, you’re getting nothing. It’s all controlled by CMS. MS. SORENSEN: I would also like to add that it is still considered voluntary. So patients will be passively enrolled into an ACO, which they may or may not be familiar with, or be forced based on demographics or where they live. If they choose to opt out, the ACO group may or may not know that patient has opted out.

Accountable Care Organizations Accountable to Whom? MR. CHRISTENSON: What is critically important for doctors to know about ACOs? DR. AINSLIE: I define an ACO as an HMO without the money. They are trying to save money, and that is the bottom line. It’s not to improve patient care, it’s not to improve physicians’ well-being. It’s for CMS to save money. I tell physicians that if they go into it, they certainly have a right to do so and a right to compete and a right to see whether this might work. What bothers me more than anything else is that if they do, their patients are going to automatically be included, and they have no say in the process. DR. KLODAS: The overwhelming thing that we need to come to terms with is how rapidly everything is changing. The way I practice medicine now may not be tenable in five years because these types of forces are making it almost impossible. I like to spend time with my patients, and have a practice style that is more preventative. We’re going to have a very difficult time existing independently. I think the thing that independent practitioners need to think about is a way to smartly consolidate within this marketplace. As far as specialists go, frankly, a

MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

lot of specialists are now part of ACO-type systems. They’re very affiliated with hospitals. Already, most cardiology practices in this environment here are owned. They already belong to systems. DR. THORSON: ACO is a technical change that has been made to try to drive cultural change at the delivery of health care. I think it is trying to get physicians to realize that the way we provide care needs to change. I don’t think there’s any question that we can’t continue to do what we’ve been doing and have a health care system that will stay afloat. The government is trying to do a technical change to force cultural change within clinics. And cultural change is hard. Technical change is a lot easier. The thing we talk about all the time is how we have to change the culture of how we deliver care. This is an awkward time because we’re trying to change culture before payment has been changed. It’s taking a very big leap of faith. DR. KLODAS: I think that a big thing not being addressed is that, as a society, we’re getting sicker. No amount of this piddling with the way we pay for health care really addresses some unbelievable statistics that we haven’t faced up to. I’m a cardiologist, so I know cardiovascular care. The current expenditure every year for cardiovascular care in this country, just care, is $270 billion a year. In 2030, on the current trajectory, it’s expected to reach $810 billion a year. That’s a stimulus package thrown at a disease year after year that is unsustainable. That’s a public health issue. It’s not necessarily how we pay for this. The ACO is projected to save $5 billion over the next eight years. That’s the CBO [Congressional Budget Office] estimate. That’s nothing in this giant pool of a problem. I totally agree with you. We need to refocus on how we truly deliver care, how we can truly impact this cost curve, because I don’t think this is going to do it. MR. CHRISTENSON: Vern, what are the best things we can say about ACOs? DR. WECKWERTH: The intents are very good. We are going to improve population health, and that’s to be done because everyone is supposed to have a personal health plan that will be intervened by the particular health care specialty most appropriate for it. Secondly, it’s therefore going to benefit individuals, and if individuals are benefited, the

group is. There will no longer be separate episodic care. The care that’s appropriate for the individual at that point in time takes the judgment of more than just a single discipline. If the ACO can pull it off, if we change the practitioner’s view of what collaboration means, then this will work. It isn’t clear to me what the incentives for collaboration are. MR. WATSON: They elevate primary care in our health care system up on the front end. I’m looking at our member community health centers, safety net clinics working together now among themselves and also looking to partner with mental health providers and with hospitals on a more formalized basis. I think with that communication and collaboration, it’s what we’ve been saying we have to do for the last 30 years, and we’ve never done it. I think it is forcing some of those discussions. MS. SORENSEN: It’s an opportunity for clients and patients to be served on a continuum of care versus a fragmented piece of care that we currently deal with. All of our systems are required to speak to each other, yet we don’t. Patients get lost time and time again. We need to talk to the other players across the table because this is part of the whole care plan, and yours is no more important than the other player. DR. MOEN: There might be an opportunity to decrease the number of regulations. If you could actually get into a population system that had a better goal and focused on an outcome, maybe you wouldn’t need some of the governors we have in place today. I think there’s an opportunity to reduce clinical variation, and there’s good research that demonstrates that a tremendous amount of the cost of health care is due to clinical variation, variation in decision making, variation in the types of things that people do for certain conditions. Some of that variability is hard to manage, but there’s really good evidence that a lot of variation in today’s system isn’t justified. There isn’t a great reason why Medicare costs so much more in New York than it does in Minneapolis or Davenport. How long are we going to pretend that it’s about how much we pay nurses instead of facing the fact that it’s about the variability and the practice and the incentives that are in place?

H E A L T H

C A R E

MR. CHRISTENSON: What are the three worst things about ACOs? DR. AINSLIE: The biggest problem is that it’s another command-andcontrol mechanism that will be imposed on physicians and will cause them to consolidate. I feel sorry for the primary care docs who are single practitioners in this state. They’re going to have to work with other people in other organizations. While it may cut down on individual variability, that’s fine, but most of the progress in medicine has been from people who are thinking outside the box, not inside the box, and this program and others will just make someone say, well, we’ve got to practice this way, or your computer tells me I’ve got to do this X, Y, and Z, and I’ll do that. It may tell me to have good diabetes control, since I take care of kids with diabetes. I can’t have anybody with an A1c over 8, for example, and every year it’ll be screwed down to 7 or 6. Well, what’s my first response? Get rid of the patients who are 12s and 14s because they’re screwing up my average? That’s not good patient care. I do much more for a 12 or 13, I feel, than for a 7 or 8, but that skews my statistics, and so I won’t like it if I’m paid on the basis of my A1c. The basic problem with ACOs is, it gets between the patient and the physician, and we’re not orienting ourselves to where the real problem lies—in the physicianpatient interaction. DR. KLODAS: The biggest thing to me that is amazing about this reform is that it completely leaves out the linchpin for success, which is the patient. There is no accountability on the part of the patient. You can do everything right, you can follow every single guideline, you can provide all the education, all the medications, everything—but ultimately, if that patient walks out of the door and doesn’t follow your advice, you’re the one who’s penalized, not the patient. None of this can succeed if patients are not accountable. I’m not saying it’s their fault, but they have to be part of the solution. MR. WATSON: There are really three kinds of problems we need to overcome with the ACOs. The first is the start-up cost, for nonprofits especially. You have to look at IT systems. You have to look at governance of your ACO. All sorts of changes to your practice in that sense that do cost money while you’re still trying to survive finan-

R O U N D T A B L E A B O U T T H E PA N E L I S T S

Michael Ainslie, MD, is a pediatrician and a pediatric endocrinologist with Park Nicollet Clinic, where he has practiced since 1977. He served as the chair of the Board of Trustees of the Minnesota Medical Association. He has served on Park Nicollet committees for salary and bonus, systems research, risk management, ethics, and recruitment. He was chief of pediatrics at Methodist Hospital from 1992 to 1998 and served on the Administration Committee for Methodist Hospital. David Moen, MD, is president of the Fairview Physician Associates (FPA) provider network (affiliated with Fairview Health Service), an integrated health system of more than 20,000 employees and 3,000 physicians. As FPA president, Moen leads the development of Fairview Health Network, an integrated multispecialty provider network. He and his team developed a team-based primary care model—the Medical Home Model—that is now deployed across 41 primary care clinics. Moen also is chief medical officer of NetClinic, a Web-based interactive health portal for clinicians to deliver virtual care to patients. Moen earned his medical degree from the University of Wisconsin and completed his residency in family medicine at the University of Minnesota. Elizabeth Klodas, MD, FACC, is a board-certified cardiologist with more than 15 years of experience treating patients with heart disease. Klodas completed fellowships at both the Mayo Clinic and Johns Hopkins University. She specializes in noninvasive cardiac imaging, including stress testing, echocardiography, nuclear, CT, and MRI imaging. Klodas founded Preventive Cardiology Consultants and sees patients at her independent practice in Edina. She has led several patient education initiatives at the American College of Cardiology (ACC) and spearheaded the formation of ACC’s patient education website, www.cardiosmart.org. Klodas is a medical editor for webMD, and also serves as director of the Heart Disease Prevention Program at General Mills. Jennifer Sorensen, MEd, is executive director of the Minnesota HomeCare Association (MHCA), which represents 250 members, including business affiliates and providers. Prior to joining the MHCA, Sorenson worked for the Mesa County (Colo.) Department of Human Services, overseeing programs including the Area Agency on Aging, Adult Protection services, Adult Resource for Care and Help, Community Services Block Grants, and Medicaid home and community-based services programs. She had a significant role in the collaborative development and implementation of programming for seniors, Care Transitions programming, and the regional Medicaid Accountable Care Organization. Sorenson has a master’s in education (guidance and counseling) from North Dakota State University. David Thorson, MD, is a board-certified family physician who practices at Family HealthServices Minnesota PA in St. Paul. He received his medical degree from the University of Minnesota Medical School, Minneapolis, and has a Certificate of Added Qualifications in sports medicine. He currently is chairman of the Minnesota Medical Association Board of Trustees. In addition, Thorson has served as chair of Family HealthServices Minnesota’s Neuromusculoskeletal Services Clinical Practice Committee, and as team physician for the St. Paul Saints baseball team, U.S. Ski Team, U.S. Freestyle Team, Mahtomedi High School, and the Twin Cities Marathon. He is a former president of the Minnesota Academy of Family Physicians. Jonathan Watson, MA, has worked with the Minnesota Association of Community Health Centers (MNACHC) since 1996, and currently serves as associate director and director of public policy. MNACHC represents 17 community health centers in Minnesota that serve more than 190,000 patients in medically underserved communities. Prior to joining MNACHC, Watson was a budget and policy analyst for the Wisconsin Department of Health & Family Services. He has also served on a number of statewide committees and task forces. Watson has a BA in economics from St. Olaf College in Northfield, Minn., and a master’s degree in public and international affairs from the University of Pittsburgh. Vernon Weckwerth, PhD, is a retired professor at the University of Minnesota, where, over a career of more than 50 years, he held joint appointments and taught in the School of Public Health, Medical School, School of Nursing, College of Pharmacy, Carlson School of Management, and Humphrey Institute. He earned his master’s and PhD in biostatistics at the U of M. His research specialties include effects of variables on health service delivery, design of research, inductive methods, and distance executive education. Weckwerth is director emeritus of the U of M’s ISP Off-Site Executive Study Programs in Healthcare Administration. He also serves on the editorial board of the Journal of Health Administrative Education. Robert Christenson has 40 years of experience in health care policy and consulting. He helps solo and small-group practitioners build a full practice of ideal clients and improve their net revenue. FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

Bruce Silcox Photography

M I N N E S O T A

M I N N E S O T A cially. Second, a lot of these ACOs that have been talked about and proposed are largely based on urban, highly integrated systems. How does this play in greater Minnesota? I don’t know. I see a lot of problems with that, given the different geographic distances between providers and small population base. That’s a problem for some of our health centers. Lastly, it’s silent on mental health and dental/oral health issues. In my book, that’s all part of someone’s health, and these ACOs are driven a lot just on the medical side. Incorporating more of those provisions would beef up the ACO model. DR. THORSON: Part of the problem with ACOs has been talked about earlier, which is the expected transform before payment changes. The one thing that we forget in Minnesota is we have a different perspective. [Mayo Clinic health care policy expert] Doug Wood has said that if everybody else in the country practiced medicine like it’s practiced in Minnesota, there would be $13 trillion saved over 10 years. So we look and say, gee whiz, an ACO doesn’t necessarily work well in some areas because we have a jaded perspective. We need to realize that the weakness in the ACOs is they're treating Minnesota like the rest of the country. If you start talking to them about shared savings, they’re going to start me out with where I am right now and have this be my baseline and measure me where I’m going to be in three years. I’d be better off waiting a year and getting a lot worse at what I do, because it’s going to be hard to do a lot better in some areas than we are currently doing. There are other parts of the country that are so far behind where we are in Minnesota that their ability to change is dramatically different. MR. CHRISTENSON: Another issue that frequently comes up when ACOs are addressed is that it puts the physician in the insurance business. How is that possible? DR. AINSLIE: ACOs are defined that way; that’s what they do. You don’t want to come to me for your insurance needs. We have professionals out there who do it a lot better than I do and know it a lot better. What insurance should do is to insure risk. We’ve gotten so far away from that definition that now we’re talking about insurance covering first-dollar things, and should it cover this or that or the other thing, without any appreciable looking at the risk and the cost of it. We’re trying to control those costs by this mechanism. And again, for those of you in

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practice in a large group like mine— Fairview and others—we can absorb some of those losses. Those of you out in Virginia, Minnesota, can’t do that. You have one catastrophe and you’re out of business. DR. KLODAS: There is some data about the fact that it doesn’t work. The demonstration projects were done with very large systems in an attempt to demonstrate how well this was going to all turn out—and this was done with Geisinger Clinic, very integrated systems. On average, they spent $1.7 million the first year just getting their organizations up to speed, so they had funding or had the wherewithal to put that type of resource in. Well, in the first year, eight of 10 of those participants didn’t get any savings. They got no return. The second year, it was only six out of 10. In the last year of the three years, only half had received any return on their investment. This is a big and expensive undertaking, and the way the savings were being calculated, I’m not sure it’s going to work for a lot of people. MS. SORENSEN: I would also say, here in Minnesota, we are the HMO capital. We have large HMOs that are integrated into our systems currently. You throw in an ACO concept, and then how does the HMO fit in within the physicianACO realm? I think that’s going to convolute our payment structure. The way it is, reimbursement issues and individualized contracts that outside providers currently have with certain HMOs, such as in the home health field, all of our providers end up having to do or sign up every year with one of the plans to make sure that they can see patients that are within that HMO realm. Now you’re bringing in a larger HMO system and this ACO piece. MR. CHRISTENSON: Do you see things within this ACO program that actually provide incentives for the withholding of care for financial gain? DR. THORSON: I’ve heard that criticism. I personally do not see that. I think that if we look at the relationships we have with patients, shared decision-making that we are going to be doing, it’s the shared decision-making that’s going to influence the cost of care. When you sit down and talk to

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people about the science of the care you’re proposing, the rationale for it, and have them participate in that decision, people often make the choice that is least expensive, not most expensive. I kind of joke [that] I have a biology degree and philosophy degree: I use my biology rarely and my philosophy every day in clinic, because it really is working on that shared decisionmaking and how you inform patients and reach that collaborative relationship of looking at how you deliver care. DR. MOEN: A question like that almost assumes that people are getting the care they want today. We overtreat people and kill them every day because of our system. That’s the reality. There’s almost an inherent belief that today’s system is ethical because people choose what they want. There’s an assumption that people are actually choosing to be in the ICU at age 87, intubated, just having a CABG [coronary artery bypass graft surgery], knowing what they were actually heading into. There’s great evidence that shows that we do a horrible job of engaging

Patients will be passively enrolled into an ACO. Jennifer Sorensen, MEd

people in understanding what they just signed up for. MR. WATSON: We’re trying to withhold care under ACO, the care that happens unnecessarily in the emergency room or in a hospital that doesn’t need to occur. That’s kind of the intent of the ACO. So it depends on how you frame that question: Is it necessary care or is it ineffective and should not have happened in the first place? That’s why I think I’m somewhat in support of the ACO model in terms of elevating that primary care and avoiding those costs, ER visits, and the like. MR. CHRISTENSON: The establishment and operation of ACOs would necessarily involve the creation of financial arrangements between

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M I N N E S O T A physicians and other entities that would otherwise be prohibited by current laws. How do you respond to this conundrum? DR. MOEN: That’s an issue that we’re discussing with the government almost every day. There are a number of things that need to change. Some of those rules were put in effect because of the abuse of the fee-for-service system. It’s fascinating that as we start to change incentives, some of those regulations don’t make sense because they are regulating something that’s no longer an issue. The question will be, what raft of new regulations will we have if this keeps going, which I’m sure it will. I also think that as physicians, we tend to—and I’m a victim of this—think either/or. We have to be perfect before we start. We have to have the answer before we do anything. We’ve got to get out of that mindset. This is an iterative process. An ACO is perhaps the beginning of a different system, but there’s a lot of work to be

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going to do those waivers as they say they are, because they would shoot themselves in the foot if they didn’t. We have to realize that transforming care is what this is about. We have to get critical mass so that the offices can afford to change how they do care. It’s not going to happen with 18 percent Medicare alone. This has to happen across the board. It has to happen with third-party payers. We have to recognize that this change has to happen. You have to embrace it and say, we can’t continue to do what we’re doing. DR. WECKWERTH: The irony is that nobody said collusion wasn’t effective. It’s just that collusion, by our terms, is what we didn’t want to do at that point in time. Now, under ACO, collusion is good because it will arrive at the intent—only we won’t then call it collusion. So here’s the irony. When you were on it for yourself, that was bad. Now if you’re on it being together, that’s good.

You don’t even know what patients are in your ACO.

MR. CHRISTENSON: Can we adjust for risk in these shared services programs? Is there a way to do that?

MR. WATSON: We do have to adjust for risk. This is No. 1A on my list of things for ACOs. Thirty percent of our patients who use a community health center don’t speak English. Seventy percent are not white. We have Somali immigrant clinics in the Cedar-Riverside neighborhood. This is a huge issue for us. The state right now is doing some risk adjustment on some their reporting, and it only looks at insurance status, which is unfortunate. We need to expand that to nonclinical issues— homelessness, poverty, English as your first language—all those sorts of variables fit into the patients we see every day and understand why they have troubles negotiating the system as it exists today. Again, this is probably the biggest issue for us in terms of risk adjustment, and getting to do it requires resources. I understand why the State of Minnesota only does it on insurance status at this point, because they don’t have the resources to go beyond that. There is a pretty heavy cost to doing this correctly.

Michael Ainslie, MD

done around regulation, payment, the way care is provided. We have to continue to transform over time. I think what I see is a sense or recognition that the time has come for us to change gears. DR. THORSON: As an independent singlespecialty group, there is no way that we could do an ACO without violating Stark regulations. The same thing came up three or four years ago. How many of you were involved in the baskets of care stuff that happened in the state of Minnesota? That was going to violate the same type of Stark [regulations], and we have to be able to think outside the box. I think we have to—it sounds hard—trust that the government is

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DR. MOEN: There is potential for some of our partners, such as academic health cen-

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ters, being penalized for caring for some of the most ill patients where there’s a ton of cost and there’s work that needs to be done, but the current risk stratification model doesn’t do a good job of characterizing that risk. MS. SORENSEN: You can do all the risk adjustment in the world, and at the end of the day you might not have met the mark. You could have spent all the time, all the resources, and invested a lot of dollars into risk adjustment and planning for the future, but we’re dealing with human beings. Human beings are not the square pegs that fit into a square hole. They are individuals, and they ebb and flow, and they change every day. We can’t set a perfect model to fit everybody. MR. CHRISTENSON: How will components of our health-care delivery system that are not physician groups be affected by ACOs? MS. SORENSEN: That is a very intricate piece that is missing in total care. How do we care for people in their homes at the time of their need? It’s completely wiped off the map in regard to this. We have all of these programs about reducing rehospitalization, transitions of care, and all of those things, but every time it’s discussed, home care is an afterthought. Maybe we should have pulled the home care agencies in to see how that would fit? They’ve had Mr. Smith for the last six years. We probably could have gotten some great information on how that family works. What are the social networks? What are the other ways that this patient can be served other than from a medical need and more from a holistic care need. A lot of my providers that are within my network don’t get paid for that, but they do it because it is in the best interest of the patient and their client. DR. AINSLIE: I think one of the basic philosophic problems we’re having is we’re moving from an acute care model, which is a fee-for-service model, to a chronic care model which has no model at this point. When you want to innovate or try something different such as keeping the patient in their home—probably much better than a hospital bed, I would suspect— there’s no reimbursement for that. They’re just kind of left out of equation. Unfortunately, I think CMS and some of the others that are putting down these regs for the ACOs are still in the acute care model. They want to control cost because the acute care model is

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I would love to see a transition to measurements around well-being. Dave Moen, MD move forward, will become unconstrained as we begin to really look at what’s optimal in the continuum.

going way up, and those of us in the chronic care model are getting nothing. MS. SORENSEN: As you know, home care is the smallest slice of the pie but the one that keeps getting cut the most. There are always concerns about fraudulent use and those types of things, and yet we are on the hook for faceto-face visits with CMS. It’s the physician we’re supposed to be communicating with, and it’s the physician who needs to sign off on the paperwork, but it’s the home care agency that gets nailed for the refusal of payment. That to me is a dysfunctional piece of the system, and I don’t know how to fix that right now until we start communicating. DR. MOEN: You have to have parts of the continuum that become part of the model and are rewarded for being part of the model. Home care, in my view, has been tremendously underutilized appropriately. In my background as an emergency physician, there were tons of people I could have sent home every day, but we didn’t get paid to do that so we put them in the hospital. I think there’s an opportunity, if we take it on and really try to serve a population, to develop different relationships with home care and other agencies such as the Courage Center, other kinds of community resources that absolutely are critical but today are not engaged in ways that are sustainable, and also they’re not leveraging all that they could offer potentially. They’re very constrained because of today’s payment and regulatory models, and hopefully, as we

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DR. KLODAS: One of the things that I’m really struck by in the definition and the goal for ACOs: It is reliant on bringing stuff together and making it bigger. Sometimes making things bigger isn’t necessarily better. I think this push sets up for too-big-to-fail systems where you get so large and it costs so much, but it can’t go out of business because it takes care of our entire community. Now that system holds a community or an area hostage, and you just have to keep feeding it. Sometimes bringing things together is not more efficient. DR. THORSON: The limitation with that by the federal regulations saying, you can only belong to one ACO—that’s why that part has to change. In a population area as an independent group, it would be to my benefit to participate in multiple ACOs because my choices will be better and broader, and my patients live in a big area. Our only choice, again, is to be our own ACO to prevent the problem of saying we can only belong to one, which will drive the alignment that will eventually prevent the groups from staying independent.

cians. It completely ignores other nurse practitioners or physician assistants, and that’s really the model the community health centers use a lot in terms of expanding access to care. It pretty much ignores those provider types in making that decision. That’s problematic from our end as well. MS. SORENSEN: The assignment process being at a CMS level is so far removed from the actual patient. It’s kind of like reading a piece of paper and making a complete judgment on an individual and saying, I think you need to go to Dr. A’s group versus Dr. C’s group. They don’t even know the patient; they’ve never seen the patient. It’s so arbitrary and not patient-centered. DR. THORSON: I think that attribution of patients is a struggle no matter who’s trying to do the attribution, if it’s the third-party payers, the government. They look at where the visits occurred, where more than 50 percent of the dollars were spent. When you’re a primary care doctor and you generate very few dollars taking care of a chronic disease patient, when they go in to have a very expensive procedure, that throws things off. MS. SORENSEN: This comes down to a fundamental piece of patient choice as well. As we live in a society of individual choices and being thoroughly informed of our choices,

There comes a point where personal accountability has to step in. Jonathan Watson, MA

MR. CHRISTENSON: What are the pros and cons of patients being assigned or attributed to an ACO by CMS? DR. WECKWERTH: CMS can’t even explain it. It should be pretty clear. They will tell you where you go. That’s step 1. As only first children do, that’s the way the world runs, and of course the back side of that is that nobody will be happy because who among you ever wanted the elder sibling to tell you what to do? That’s what I expect will happen. They’ll just do it. MR. WATSON: It’s based on claims for physi-

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what are the ramifications of an ACO that doesn’t show or explain someone’s choices? It’s easy enough to get an attorney and then sue the ACO because they weren’t provided the information and given patient choice or

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directive on their options. You come into another layer of care called case management in regard to making sure that everybody has their options laid out for them prior to being engaged into a program.

you’re in another bucket, you’ll be analyzed there.

DR. KLODAS: Patients may not know that they’re in an ACO, but they actually retain the right to go see other specialists that may not be part of the ACO. That can completely throw off the whole reason behind the experiment.

DR. WECKWERTH: That’s where the attribution comes in. You have those patients whom you then analyze and see what made them high use. And then you figure out which variables are associated with that and what then became high risk. I think we’re running under the assumption that there’s going to be a risk model, a multivariate one, by which you assign some kind of cumulative score and therefore you allocate it to different ACOs. Nobody said that was going to happen. It may, but it certainly isn’t in the works right now.

MR. CHRISTENSON: How should CMS address high-risk patients affecting utilization within an ACO?

MR. CHRISTENSON: In effect, a patient could be assigned to an ACO and never see any doctors within that ACO and get all their care elsewhere. But the effect that’s going to have on the shared savings program for that ACO will be manifested, is that right? DR. MOEN: Not necessarily. The attribution model is defined by where primary care takes place, and if the majority of it takes place within a certain system, then costs are attributed to that system. There are going to be a lot of people that aren’t attributed at all. There are going to be a number of people who change their attribution based on who they’ve decided to go see. DR. WECKWERTH: Assignment and attribution are totally different things. I never saw that assignment was something that was going to be done beforehand. Attribution is just an analytic way of taking a look to see

There is no accountability on the part of the patient. Elizabeth Klodas, MD, FACC

where people have been, to use that as one of many sets of multivariables for analysis. Assignment has nothing to do with where you are told to go. You can go wherever you want, show up, and if you’re in the right bucket you’ll be analyzed over there. If

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DR. AINSLIE: I’m sorry, but why would we have preexisting conditions? Why would we have people being dropped out of health plans when they’ve hit certain things? It’s because of the business model. The actuaries have figured out when to drop people off and how to make price products based on that information. The uninsured problem is due to the way health plans operate, the way they use analytics, and the fact that overall, the cost of care is not sustainable. The powers that be certainly like to blame the physicians for this cost overrun. There were about 42 to 45 million uninsured in 1965 before Medicare started, and today there are exactly about the same. Even places that tried to go from 94 percent to between 96 percent and 98 percent insured have had a tremendous cost increase to get that few percentages, in Massachusetts. I think that we can go to a different model and have insurance do what it’s supposed to do, which is to insure risk, and move to a different model where patients have control of some of that first-dollar coverage that they now enjoy without any thought of cost. What happens in economics when costs go to zero? Demand goes to infinity, and that’s what we’re seeing. DR. WECKWERTH: I think he used a critical term. We were talking about the insurance, the risk. When you have first-dollar coverage, you no longer have insurance. You have prepayment. It isn’t insurance; people are talking about prepayment. If, in fact, the events will occur with virtual certainty, that’s a prepayment of the service; that’s not insurance. For insur-

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ance to exist, it has to have a risk. If we don’t have a risk, then we aren’t talking about insurance. Really, prepayment is what goes on. MR. CHRISTENSON: What are the benchmarks of quality that are going to be measured in the ACO and determining shared savings? DR. AINSLIE: As with many things in medicine, they will measure what they can measure. I will be measured on my hemoglobin A1c values because you can measure that. I won’t be measured on how many carbs they take in a day, whether they take the appropriate insulin, all that. The idea is that if your A1c is good then you must be doing all the other stuff very well. That may be a fallacious argument and not be good quality care. The problem is, what’s your benchmark? I guess I’m going to have to have a terrible benchmark for the next three years before I get into it, because then I’ll look great when I improve all that. That’s terrible medicine. We’re measuring something that we can measure, but it has no sense in how we apply it. If the quality measurements are done correctly, they certainly can be, but physicians haven’t been involved in that much, and I think we need to look at that and how CMS comes up with these benchmarks. MS. SORENSEN: I think the other thing is, too, currently as it’s set up, there are 65 quality measures. You’re going to have to have a quality improvement team, which is another layer of management within your own organization just to be able to gather the data. I can’t even imagine the time that it’s going to take, one, to capture that data, and two, to get your patients to fill out the questionnaires that are required. And then how does it all fit within this magical formula that none of us really know yet? DR. WECKWERTH: This isn’t 65 things that you’re running out and doing that you aren’t doing now. They, in fact, are supposedly things that come because of the summary of care provision that is done. DR. MOEN: I would argue that the measurement actually reinforces the model of sickness. I would love to see a transition to measurements around well-being, which I think speak much more to the social connections people have in their lives, their financial stability, how they feel about their lives, the quality of their lives. The paradigm needs to shift, and I think it could be simpli-

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M I N N E S O T A fied as well if we engage patients in defining well-being. I think it would help orient the system toward a more holistic view of what actually constitutes health. DR. KLODAS: If we look at our community now, whatever we’re doing, and I don’t care how you measure it, it’s not working. We are getting sicker and sicker, and no matter how much money we’re throwing at this, it’s not working. This is beyond what an ACO can do. This is an entire community effort where you have food manufacturers who are stepping back and saying, wow, maybe we shouldn’t make so much of that, and you have communities getting together and saying, wow, we should probably build some more walking parks, and companies getting together and saying, hey, you know, maybe we should be giving people time during the day to go for a walk and do something. MR. CHRISTENSON: Who do you see being winners and losers when accountable care organizations are fully operational? Who are the winners going to be? DR. THORSON: My hope is the patients are the winners. I’m not sure that’s been proven yet, but that’s what my hope is, that the patients are the winners. I think if you talk about, in the health care professions, who are the winners and the losers, I think outpatient delivery of health care is going to be the winner. And I think the inpatient model of health care delivered through hospitalizations and emergency rooms will be the loser. DR. AINSLIE: I think the winners are going to be the CMS, because they rigged the system, and they will benefit from it primarily because that’s what they want. The losers, I’m afraid, are going to be the physicians and patients, especially in areas where we’re already doing a lot of this. As we’ve said, in Minnesota, we’re up on the ladder and I’m afraid that we’ll be judged. They’re going to look at the rate of change, of improvement. It’s going to look awful for Minnesota because we’re already pretty good. A place like Texas or Louisiana is going to look wonderful because they have a long way to go. I don’t think large groups or small groups or the whole state of Minnesota is going to come out [well] in this no matter how we set up an ACO. MR. WATSON: Highly integrated systems that exist now, that can understand the rules of the game as they’re entering the game,

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are going to be big winners. Small, independent, autonomous practices that are just trying to feel their way right now are going to be at a disadvantage. I see hospitals potentially being losers. Empty beds don’t translate to revenue. I see greater Minnesota potentially being a loser. I think who’s on the bubble, not a winner or a loser, are health plans. I really don’t see what the role of the health plan is exactly under an ACO model. I don’t know if they’re kind of backroom support or will transition to something else, but I think they’re on the bubble. DR. KLODAS: The winners are going to be administrators and compliance officers. I think this is going to have an awful lot of rules and regulations and new layers of bureaucracy that are going to employ an awful lot of people who will be doing an awful lot of paperwork. The losers are ultimately, at least in the near term and probably in most of my lifetime, are the taxpayers. I honestly don’t think this addresses true cost of care. The costs are because our population is changing, we’re getting older, the rates of diabetes and obesity are unbelievable. You can’t squeeze money out of a system when everybody’s sick. DR. MOEN: I hope my kids are winners in that they inherit a society that is actually sustainable. I would hope that we would all take the long-term view that this isn’t so much about accountable care organizations as it is about facing the things that we’re all alluding to. That is, we’ve got a public health problem that is unmanageable, and a health care system isn’t an adequate way to address much of what we’re talking about. If we don’t do this well, our whole society is at risk. We’re looking much different, and I don’t think in very positive ways. If I worry about one thing when I go home and go to bed at night, it is what kind of world we’re leaving for our children. MR. CHRISTENSON: How will allied health professionals be affected by this? DR. MOEN: They’re critical parts of the system. If we look at chiropractors and acupuncturists, which today are called

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complementary medicine providers, there’s good evidence that in some corridors those professions provide value. The trick is, how do you begin to define that value, and then how do you connect in ways that are meaningful to those groups of providers and professionals to help improve the health of a population. It starts with looking at the role of nursing and the changes that need to happen and the leadership we need out of the nursing community to actually drive to a different model. It starts with the chiropractic profession being honest with itself about some of the things that have gone on in that profession. MR. CHRISTENSON: How do you see health plans being affected by ACOs? Are they win-

The irony is that nobody said collusion wasn’t effective. Vernon Weckwerth, PhD

ners, are they losers, or neutral? DR. AINSLIE: Obviously, patients will need insurance, and obviously even the largest ACO in the state is going to need reinsurance for catastrophic risk, so they will provide that insurance—I’m sure, happily—at a cost. It will probably help them to some extent in the short term and perhaps in the long term also. What happened in the HMO model is that they were first developed by physicians, as you know, and pretty quickly morphed into health insurance models and consolidated and so on, and physicians lost control and lost their shirts. MR. WATSON: I think, quickly, health plans could potentially do a lot of the backroom claims processing. There seem to be a lot of analytics that need to occur in the ACO methodology. We talked about the 65 meas-

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M I N N E S O T A ures, you know, you need some sort of backroom office support for that. Secondly, health plans, I think, do a good job of setting up networks in terms of specialists. If you do set up your own ACO, your own primary care doctor, you’re going to need your network, and I think health plans can provide that expertise in terms of establishing those networks. DR. THORSON: I think that this past legislation has been more insurance reform than really health care reform. I think the insurance industry is somewhat vulnerable. I think you could imagine a world where accountable care organizations are big enough and cover enough patients that they can market directly to business. They can market directly to communities and bypass

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not going to be very successful with this process. Also, I think probably one of the biggest things that keeps resonating in our answers is that there’s no patient incentive for participation, and I think we really need to be looking at this through this developmental process. What is the incentive for the patient to participate in this? MR. WATSON: We need to have the ability to communicate across different systems and different care venues. I think the one aspect where you could pull the plug legitimately is if we have massive market consolidation that actually leads to higher prices and higher premiums. Then I think it’s clearly time to pull the plug. MR. CHRISTENSON: What will ACOs need to do in order to succeed in fulfilling the “triple

We have to realize that transforming care is what this is about. David Thorson, MD

aim” of better care for individuals, better health for populations, and reducing per capita costs?

insurance plans. The nature of insurance plans may well change from being insurance companies to become analytical companies where they will be administering stuff but not insuring risk. But to be honest, the insurance people haven’t been insuring risk, they’ve been trying to minimize risk and make money. I mean that somewhat seriously. They don’t pool risk anymore. They try to identify people who are high risk and exclude them. I think that’s where things are going to have to change. MR. CHRISTENSON: What are legitimate grounds for abandoning this whole ACO concept as a failed effort? MS. SORENSEN: At the end of the day, if we can’t all work together or all our common interests aren’t on the table and we’re willing to give in a little across the board, we’re

MINNESOTA

MR. WATSON: What they need to do is prevent folks from falling through the cracks. When they do fall through the cracks, identify them and case manage, whatever the terminology, carecoordinate their life. We need the interoperability, we need the flexibility, and we also need the proper risk adjustments. Those are my three big goals for an ACO to be successful. DR. THORSON: We need to have patient engagement. We can’t do this just as physicians or health-care delivery systems forcing it onto patients. We have to change the payment structure that allows for a wide variety of care delivery to happen on an outpatient basis and realize that we have a changing state of health of our population. We have to figure out how we’re going to fund the illness load that is going forward in a way that allows us to care for them as well.

DR. AINSLIE: We need to teach ACOs how to walk on water because that’s what they’ll have to do in order to succeed. My guess is that they won’t, and we’ll be onto the next iteration. And you heard it here first: It’s going to be a nice euphemism for “two weeks to live” because CMS has realized that they spend half of their money or more on the last two weeks of a patient’s life. If we can figure out what two weeks those are and do something about it, we’ll be all set. What the ACO has done is go in a retrospective payment model and a quality model that they set up and judge and pay for, and guess what, they’re going to do that for the last two weeks of someone’s life also. You will or won’t be paid for taking care of somebody with a terminal illness or other problems. DR. WECKWERTH: Public health has had the answer the whole time. We know in public health what to do. We know good and well that population is where the action is. In terms of individuals, they have to be accountable. The accountable party is the individual. That’s what it ought to be. We know what to eat, what not to eat, what to do, what not to do, everything else. I don’t know how we’re going to get people to do it that way, but the public health principles are there. The individual accountability has to be there, and that may sound strange from an academic. Finally, we know that 95 percent of the health status of anybody, by every analysis that’s ever been done, has nothing to do with the medical hospital establishment. That only accounts for about four percent of health status. The rest is diet. Of course, the most important thing is choosing your ancestors, so that’s what I think we should work on most. What are we going to do? Public health: Follow what we know, do it for yourself, don’t blame somebody else, don’t pass it off.

DR. KLODAS: I don’t think this is going to work, or anything is going to work, unless patients have skin in the game. I don’t know what that looks like, I don’t have a formula, but they have to be part of the solution. It has to be real, and they have to be accountable.

H E A LT H

CARE

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

OPHTHALMOLOGY Twenty million Americans suffer from the symptoms of dry eye syndrome, including blurred vision, itchiness, redness, foreign body sensation, and overall irritation. Nearly four out of 10 Americans (37 percent) experience symptoms on a regular basis. Unfortunately, because these symptoms can mimic other syndromes, chronic dry eye syndrome often goes undiagnosed, which can lead to serious ocular complications that include eye inflammation, infection, and even scarring on the surface of the cornea. Traditionally, the most common treatments have included eyelid hygiene, artificial tears, cyclosporine drops, steroid drops, nonsteroidal drops, topical and systemic antibiotics, vitamins, and eyelid shampoos. A relatively new treatment that uses intense pulsed light (IPL) gives patients another option. Understanding the problem

Intense pulsed light (IPL) for dry eye syndrome New treatment option By Y. Ralph Chu, MD

In the past, chronic dry eye was defined as a problem with the eye’s tear production, meaning not enough tears were produced. But research has changed this understanding. Today, ophthalmologists classify dry eye as an ocular surface disease because it has been found that many patients with this syndrome actually do produce enough tears. For those patients, the problem may be poor-quality tears, which result in a poor-quality tear film on the surface of the eye. The tear film is made of proteins and electrolytes that help minimize the symptoms of chronic dry eye. But when this film’s composition is unbalanced, dry eye symptoms can result. This is why many dry eye patients don’t find relief from over-the-counter artificial tear solutions such as eye drops. What causes dry eye syndrome? The natural aging process can exacerbate dry eye syndrome; a majority of people over the age of 65 experience some symptoms of it. Women are more likely than men to develop this syndrome because of hormonal changes during pregnancy and

WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.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 28

MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

menopause. Medications may also play a role, since antihistamines, blood pressure medication, and antidepressants can reduce the amount of tears the eyes produce. External factors such as exposure to smoke, wind, and dry climates also increase the risk of dry eye syndrome, as do refractive eye surgeries, LASIK, and long-term use of contact lenses. Another cause of dry eye is inflammation. During the last several years, ophthalmologists discovered that low-grade inflammation on the surface of the eye can damage the tissue that secretes material needed to keep the eye healthy. When that happens, dry eye symptoms can result. Inflammation can be cured by Restasis, prescription medication approved by the Food and Drug Administration (FDA) to reduce inflammation and prompt the natural production of tears. Abnormal secretion by the meibomian glands can also be a culprit. These glands are located at the base of the lashes on both the upper and lower eyelids and play an important role in maintaining the eye’s normally moist surface because they secrete a fine layer of oil that keeps the watery ingredient in tears from evaporating. (Tear evaporation contributes to dry eye.) Meibomian glands can become abnormal with age or because of medical conditions such as ocular

Dr. Chu performs IPL procedure on a patient with dry eye.

rosacea. Then, instead of producing normal secretions with the consistency of olive oil, the glands produce thick secretions with the consistency of butter or toothpaste. These abnormally thick secretions get stuck, resulting in a deficient tear film and deficient tear production, which lead to dry eye symptoms. The cause of abnormal meibomian gland secretion remains unknown. Lucky discovery In 2003, ophthalmologists began noticing that patients with chronic dry eye syndrome who received intense pulsed light therapy as a treatment for a skin condition called rosacea experienced a reduction in dry eye symptoms. Rolando Toyos, MD, of Memphis, Tenn., was the first to explore the relationship between IPL and chronic dry eye syndrome in several clinical studies. Dr. Toyos discovered this potential use of intense pulsed light by accident after opening an aesthetics clinic where he used IPL to treat patients with rosacea and acne. He recalls, “My rosacea patients who had the IPL treatment would return with their skin looking much better—but some also mentioned that their eyes Intense pulsed light to page 30

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Intense pulsed light from page 29

felt better. On examination, their eyes really were better, even though the IPL treatment wasn’t done directly on the [meibomian] glands.” Dr. Toyos subsequently received a research grant to study IPL and discovered that it can eliminate symptoms of dry eye. Through his research, Dr. Toyos learned that IPL treatment gently stimulates the meibomian gland, which improves the quality of its secretions and decreases dry eye symptoms. IPL treatment of dry eye is an off-label use of IPL, which means the FDA has not approved it as a treatment for dry eye syndrome; IPL is FDA-approved for dermatologic use. In most cases, insurance does not cover IPL treatment of dry eye syndrome.

IPL is a simple and painless outpatient treatment.

IPL procedure

IPL is a simple and painless outpatient treatment. The first step includes cleansing the face and placing shields on both eyes to protect the lids and lashes. A cooling gel is then applied to the eye area and surrounding skin. Next, the IPL hand piece is passed across the skin, allowing a pulse of energy to heat the meibomian glands. The treatment also seals the delicate blood vessels at the lid. The complete procedure typically lasts less than 15 minutes and is painless. Patients need between two and four treatments, separated by a month between treatments. Studies show an increase in tear function after the fourth or fifth treatment. The number of treatments needed depends on the severity of the patient’s dry eye condition. Once the

glands stabilize, patients may need maintenance therapy at least once a year. Patients seeking treatment for dry eye syndrome should be aware that the IPL machine used for treatment of dry eye uses lower energy settings than similar machines used for dermatologic treatments. There is less energy variability on the IPL machine, which protects dry eye patients while still ensuring the efficacy of the procedure. Side effects Although side effects and complications are rare, they include but are not limited to bruising, swelling, and blistering. Caution is advised for patients with a history of herpes simplex near the treatment area. Contraindications also include sun exposure two to four weeks prior to treatment, active infections, a compromised immune system, coagulation disorders, photosensitivity or allergy, use of aspirin or anticoagulants, pregnancy, moles, and tattoos. Because IPL was originally intended for dermatologic treatments, patients using IPL for dry eye syndrome may experience skin benefits from the procedure. For example, IPL helps to develop collagen, lighten dark spots, and tighten and plump skin. Dry eye syndrome is a common ophthalmic condition that can have serious effects on patients’ quality of life. The potential of intense pulsed light technology to treat this condition is an exciting development. Y. Ralph Chu, MD, is the medical director and founder of Chu Vision Institute and an adjunct associate professor of ophthalmology at the University of Minnesota, Minneapolis.

Minnesota

Health Care Consumer January survey results... Association

100

80 60 40 16.2%

13.5% 2.7% 100%

5.4% Over 50%

2.7% Does not apply

Under 50%

None

MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

21.6% 20

50 40 30 20

Very willing

0.0% Willing

13.5% 2.7%

2.7% Very satisfied

Satisfied

5.4%

78.4%

Does Unsatisfied Very not apply unsatisfied

60 50 40 30 20 10 0

8.1% None

8.1%

2.7%

Does Unwilling Very not apply unwilling

2.7%

75.7% Percentage of total responses

Percentage of total responses

50 40

5. If there were unanticipated side effects as a result of taking this medication, how would you describe them?

70 60

50 40

4. How satisfied were you with the improvement in your health this medication produced?

75.7%

10 Yes

73.0%

70 Percentage of total responses

Percentage of total responses

83.8%

3. How much of the cost of this medication was covered by your insurance?

2. How willing was your physician to give you a prescription for this medication?

1. Direct-to-consumer advertising was a factor in asking my physician for a specific prescription.

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 January survey.

5.4%

0.0%

Barely Does Very Required medical noticeable not apply noticeable attention

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;? FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

PUBLIC HEALTH In many instances, these populations may not realize how often they are being hoodwinked by the following Big Tobacco strategies.

ith tobacco taking the lives of more than 5,100 Minnesotans a year and costing nearly $3 billion annually in health care costs in Minnesota, it is clear that the battle against tobacco is far from over. ClearWay Minnesota, an independent nonprofit organization, is dedicated to reducing the harm of tobacco in Minnesota through action, collaboration with other anti-tobacco organizations, and research. Smoking continues to be the leading cause of preventable death and disease in Minnesota, and the use of smokeless tobacco, such as chewing tobacco and other products, is on the rise despite widespread education campaigns about tobacco health risks and despite strong anti-tobacco policies. Why? Partly because, more than a decade By Mike after the settlement against tobacco companies, the tobacco industry continues to target Minnesotans. In fact, the industry spends about $157 million a year on marketing in Minnesota (about $12.8 billion a year nationally). It’s true that tobacco product ads can no longer bombard consumers from billboards and television. But the industry continues to develop clever new ways to reach youth, nonsmokers, and minority communities and to keep current smokers hooked on its products.

Positioning tobacco as part of our culture

Tobacco marketing to youth

Historically, tobacco companies have worked to make tobacco a part of everyday life. From sending free cases of tobacco products to members of the military to utilizing product placement in youth-rated films and video games, the tobacco industry continues to insert its products into mainstream culture. Target marketing

Tactics to watch for

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

The use of pink cigarettes, “Cigarette Fairies” (young, attractive women hired by tobacco companies to go to bars and Sheldon promote tobacco products), and culturally specific images are just some of the ways tobacco companies are capitalizing on lucrative markets. Young women, minority communities, and youth are important—and successful—target markets. Point-of-sale product marketing (displaying products at the eye level of children) is another common marketing tactic. Portraying themselves as good corporate citizens In a single year, Philip Morris spent $100 million dollars on public relations to promote its corporate giving—more than the $75 million dollars it spent on the actual contribution itself. Tobacco companies routinely make charitable donations and pledge support to youth programs, suggesting that they are fighting youth The face of tobacco smoking, not causing it. But in Minnesota the actual dollars going to • 625,000 Minnesota adults charity pale in comparison to (16%) still smoke. the amount they’re spending • More than half of adult to promote their image. Minnesota smokers attempted to quit between 2009 and Getting around smoke-free 2010. laws with new, smokeless products • Minnesota is seeing an increase in smokeless tobacco Strong federal and state reguuse across all demographics, lations preventing direct youth especially among the 18- to marketing forced a different 24-year-old age group tactic by tobacco companies (28.4%). and have led to new products • Health care costs are that include fruit flavors, contributing to historic state “little cigars,” and colorful budget deficits. packaging, all of which are intended to attract youth. Though smokeless tobacco products now resemble candies, mints, and breath strips, they still contain the same addictive, harmful nicotine. Creating new markets abroad Developing countries across the globe are a new and profitable focus for tobacco companies. These countries have minimal regula-

tions on tobacco and limited knowledge about the dangers of tobacco use and the industry’s practices. The World Health Organ-ization predicts that the death toll from tobacco use by the end of the 21st century will exceed 1 billion people worldwide, with 80 percent of deaths occurring in developing countries. Making progress …

Minnesota’s ongoing efforts ClearWay Minnesota and the Raise it for Health coalition—composed of more than 30 leading Minnesota health, business, and nonprofit organizations—are working to keep state policymakers and community leaders focused on the threepronged approach that has proven successful in reducing the harm caused by tobacco: 1. Public education and awareness about the health risk 2. Maintaining access to stop-smoking programs, such as QUITPLAN Services 3. Increasing the price of all tobacco products and promoting other strong public policies against tobacco. Minnesota traditionally has been a leader in improving residents’ health by reducing tobacco use, but research shows that there is still room for improvement. The Raise it for Health coalition is pursuing a $1.50-per-pack increase in the price of cigarettes to reduce smoking, improve health, and help provide needed revenue for the state. According to the Campaign for Tobacco-Free Kids, a $1.50-per-pack increase would discourage 61,700 kids from becoming addicted adult smokers. Currently, Minnesota’s state cigarette tax, at $1.59 per pack, is the 22nd-highest in the nation. We can do better. Toward the end of the 2011 state legislative special session, the subject of a tobacco price increase surfaced in budget discussions as a solu-

Despite the tobacco industry’s marketing ploys, tobacco use in Minnesota is declining, thanks to proactive policies and programs to help people quit. According to the 2010 Minnesota Adult Tobacco Survey, cigarette-smoking rates have declined from 27.1 percent of adults in 1999 to 16.1 percent in 2010, and Minnesota’s adult smoking rate is consistently below the national average. A share of this progress can be credited to Minnesota’s comprehensive statewide smoke-free law. Since the law took effect in 2007:

• Secondhand smoke exposure in public has declined. • Hospitality workers are healthier. (A March 2008 study by ClearWay Minnesota and the University of Minnesota Cancer Center found that the statewide smoke-free law significantly reduced Almost half of U.S. states exposure to a tobacco-specific cancerare doing more than causing chemical in nonsmoking bar Minnesota to reduce and restaurant workers.) the impact of tobacco • Air in bars and restaurants is cleaner. But there is still work to do Unfortunately, Minnesota is a victim of its own success, making it increasingly difficult to keep the spotlight on reducing tobacco use. When you combine the new marketing strategies with Big Tobacco’s limitless resources to devote to enticing new customers, it becomes clear that we still need strong tobacco policy, education, and prevention. For more information about the tobacco industry’s marketing tactics, read ClearWay Minnesota’s report “Unfiltered: A Revealing Look at Today’s Tobacco Industry” at www.unfilteredmn.org.

tion to help fill budget gaps. Unfortunately, it was not included in the final budget deal. With new generations of tobacco products evolving and potential customers still targeted, the Raise it for Health coalition—whose members include the American Cancer Society, American Heart Association, American Lung Association, Blue Cross and Blue Shield of Minnesota, Minnesota Hospital Association, and Minnesota Medical Association—will continue its work in 2012 to remind Minnesotans about the lasting benefits of strong anti-tobacco policies. In addition to pursuing an increase in the price of all tobacco products, ClearWay Minnesota and the coalition are closely watching: • Efforts to weaken youth access to tobacco laws • Threats to Minnesota’s smoke-free law • Other ways that tobacco companies are seeking to exploit legal loopholes What can you do to help reduce tobacco use in Minnesota? • Learn more at www.raiseitforhealth.org. • Talk with your doctor about tobacco’s harmful effects. • Seek free smoking-cessation services at www.quitplan.com or from your employer or health care provider. • Get involved in the public policy discussion by contacting your elected officials.

In the next issue.. • Pediatric cardiology • Colorectal cancer • Dental care

Mike Sheldon is senior communications manager for ClearWay Minnesota.

FEBRUARY 2012 MINNESOTA HEALTH CARE NEWS

Psoriasis from page 14

• Patients who do not respond to topical treatments or light therapy may be given systemic medications, which are prescription drugs that work throughout the body. One type of this medication is called biologic drugs, a relatively new class of systemic drugs that is used to treat psoriasis and psoriatic arthritis. Biologics are given by injection or intravenous infusion. • According to the National Center for Complementary and Alternative Medicine (NCCAM) and the National Center for Health Statistics, nearly 40 percent of American adults are using some form of complementary and alternative medicine. Science has yet to confirm that complementary and alternative treatments are effective for psoriasis. However, some psoriasis patients report success reducing flare-ups by using meditation and massage to reduce stress and by eliminating wheat, red meat, and fatty foods from their diet. Associated health risks Studies confirm that people who have psoriasis are at greater risk for a number of serious, chronic, and/or life-threatening health conditions, particularly if their psoriasis is severe. These associated conditions include cardiovascular disease, stroke, diabetes, certain types of cancer, and mental health problems such as depression. New research shows that people who have any autoimmune disease are at increased risk for other autoimmune diseases, including Crohn’s disease and celiac disease, which requires a gluten-free diet. Because people with psoriasis are at greater risk for heart disease and diabetes, they should be encouraged to quit smoking,

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

612-624-7614 or email EXERT@umn.edu or visit EXERTstudy.org

EXERTstudy.org 34

MINNESOTA HEALTH CARE NEWS FEBRUARY 2012

People with psoriasis are at greater risk for heart disease and diabetes. exercise regularly, and maintain a healthy weight by eating a healthy diet rich in fruits, vegetables, and lean protein, and low in fats and sugars. Psoriatic arthritis About 30 percent of people with psoriasis also develop psoriatic arthritis, an inflammatory type of arthritis that affects the joints and tendons. Symptoms include joints that are red or warm to the touch, joints that are frequently tender or stiff, fingers or toes that swell to the point where they look like sausages, pain in and around the feet and ankles, changes to the nails that include pitting or separating from the nail bed, and lower back pain that is located above the tailbone. It is important that people with psoriasis watch for the signs of psoriatic arthritis because left untreated, it can cause joint damage and become debilitating. A recent survey of psoriasis patients by the National Psoriasis Foundation found that nearly one in four may have undiagnosed psoriatic arthritis. That number is in addition to the 2 million Americans who already have been diagnosed with this condition. This survey also revealed a delay of Psoriasis diagnosis for psoriatic arthritis patients. Forty-four percent of individuals expericannot be enced symptoms for at least a year becured, fore receiving a diagnosis from a doctor. For this reason, the Psoriasis but it can Foundation’s medical board recommends be controlled. that dermatologists ask their psoriasis patients at every exam whether they have joint pain or stiffness, back pain, or pain around their feet and ankles; whether they have experienced decline in their range of motion; and whether they have noticed any changes to their nails. Be sure to report any of these changes to your dermatologist. Living with psoriasis A diagnosis of psoriasis or psoriatic arthritis doesn’t have to be overwhelming. It’s important that those who have the condition learn all they can about it and their treatment options. It is also important that they regularly see a doctor who specializes in treating psoriasis and/or psoriatic arthritis. Patients also need the support of friends and family and to realize that they are not alone. The National Psoriasis Foundation is an excellent resource for people with psoriasis and their families and for medical professionals. It provides not only extensive patient education but also online communities, support networks, and mentorship programs to help people cope with their disease. It also supports research and advocates for better treatment and access to care for psoriasis patients. Bruce Bebo Jr., PhD, is director of research and medical programs at the National Psoriasis Foundation, www.psoriasis.org.

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