Minnesota Health care News March 2011 by Minnesota Physician Publishing

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March 2011 â&#x20AC;˘ Volume 9 Number 3

Pain medicine Alfred Anderson, MD, DC

Anxiety disorders Craig Vine, MD

Fetal care Jeffrey Schiff, MD, MBA William Block, MD

One Heart, One Mind, One Universe May 8, 2011 at Mariucci Arena, University of Minnesota Medicine Buddha Empowerment: A Tibetan Cultural and Spiritual Ceremony Promoting Personal and Societal Healing featuring His Holiness the 14th Dalai Lama 9:30 - 11:30 a.m. Peace Through Inner Peace: A Public Address featuring His Holiness the 14th Dalai Lama 2:00 - 3:30 p.m. May 9, 2011 at University Radisson Hotel Second International Tibetan Medicine Conference: Healing Mind & Body 9:00 a.m. - 7:30 p.m. (* His Holiness is not expected to be in attendance.)

2 Days Only, 3 Events

The Minnesota Visit 2011 His Holiness the 14th Dalai Lama

A special invitation to health professionals: The Second International Tibetan Medicine Conference May 9, 2011 This event will bring to the Twin Cities the foremost practitioners of Tibetan medicine from the Men-Tsee-Khang, the Tibetan Medical Institute of His Holiness the Dalai Lama, in Dharamsala, India. By the end of the conference, participants will be able to meet the following objectives involving Tibetan Medicine: Examine the relationship between ethics, spirituality, and healing. Investigate participants' own unique constitution. Determine what lifestyle choices to make, based on participants' own constitution. Explain how to heal from the source and develop health through balance. Describe research about Tibetan medicine, as well as propose additional research needed. Apply teachings of Tibetan medicine personally and professionally.

etan Ame Tib r

Minnesota of

For tickets and more information, visit www.dalailama.umn.edu or call 612-624-2345

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CONTENTS

4 7 8

MARCH 2011 • Volume 9 Number 3

NEWS

CALENDAR National Nutrition Month

MINNESOTA HEALTH CARE ROUNDTABLE

PEOPLE

PERSPECTIVE

T H I R T Y- F I F T H

Tim Nelson, MA, LISW Hammer Residences

COMMUNITY CAREGIVERS Making a difference in Minnesota and the world By Scott Wooldridge

10 QUESTIONS Alfred Anderson, MD, DC Medical Pain Management Clinic

PSYCHIATRY Common anxiety disorders By Craig J. Vine, MD

SPECIAL FOCUS: FETAL CARE All in good time

26 28

TAKE CARE Smoking cessation tools

HEALTH POLICY Fixing our broken health care system

By Pat McKone

AGING The coming storm By George Schoephoerster, MD

By David Feinwachs, JD, PhD

Jeffrey Schiff, MD, MBA, and Trudy Ohnsorg, MPH

Perinatal partnership By William Block, MD, and Brad Feltis, MD

SESSION

Background and focus: Until recently, when the word wellness came up in organized medicine it was regularly dismissed as pseudo-science. Our health care delivery system, or as many call it “sick care delivery system,” evolved in a way that doctors were not paid to keep patients well and thus wellness strangely fell outside the purview of medicine. Obviously it is better to stay healthy than try to fix complex and sometimes avoidable medA changing focus in health care ical conditions. Selling services supporting this approach was often criticized for lack of ranApril 28, 2011 domized clinical trial research; 1:00 – 4:00 PM • Duluth Room inadequate licensing, credentialDowntown Mpls. Hilton and Towers ing, and oversight for practitioners; and many other concerns. Wellness as an industry, with its wide diversity of methods and approaches, was kept at arm’s length by the medical establishment. Economics have forced this to change.

The Wellness Revolution

Objectives: We will explore the definition of wellness, why today there is a wellness revolution, and why doctors now embrace the concept. Examining multiple collection methodologies and sets of data, we will discuss how and why employers are driving this new approach to health care. We will consider privacy issues and many other challenges to an already overburdened administrative process posed by collecting and storing individual health care data in places such as work sites and health clubs. We will discuss the breadth of wellness initiatives, their pros and cons, and how they can lower the cost of health care while improving individual health status. Panelists include: N Karen L. Lawson, MD, Director Health Coaching, U of M Center for Spirituality and Healing

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com

N William Litchy, MD, Chief Medical Officer MMSI, Mayo Clinic N Mark T. Zeigler, DC, President, Northwestern Health Sciences University Sponsors: Pfizer • Mayo Clinic Health Solutions Northwestern Health Sciences University

EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Martha Malan mmalan@mppub.com 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 ACCOUNT EXECUTIVE Sharon Brauer brauer@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 Company Address

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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; e-mail 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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MARCH 2011 MINNESOTA HEALTH CARE NEWS

NEWS

Grants Awarded For Fetal Alcohol Syndrome Education The Minnesota Organization on Fetal Alcohol Syndrome (MOFAS) recently awarded grants to 10 Minnesota groups to help educate women about the dangers of drinking during pregnancy. The 10 grants went to four county public health departments and six clinics throughout the state. The money will be used to implement a screening program designed to create more open dialogue between providers and patients about alcohol use during pregnancy. “We as health care providers play a critical role in advising our pregnant patients not to drink alcohol during their pregnancy,” says Lydia Caros, director of the Native American Health Clinic and co-creator of the screening program. “Oftentimes, we are the first touchpoint, and can be a big influence on moms-to-be.” According to data from the

Centers for Disease Control, as many as 8,500 babies are born every year in Minnesota with prenatal alcohol exposure. MOFAS officials note the lifetime cost for an individual with fetal alcohol syndrome is estimated at $2.9 million.

Adverse Events Report Says Hospital Leaders Can Do More The annual report on adverse events in hospitals in Minnesota found that the number of such events overall held steady between 2009 and 2010, with a jump in medication errors. Officials with the Minnesota Department of Health (MDH) say the stagnant numbers are a concern, and add that a new focus on patient safety from hospital leadership is needed. Overall, the number of adverse events in Minnesota hospitals went from 301 in 2009 to 305 in 2010. In 2009, there were four deaths; in 2010, there were

MINNESOTA HEALTH CARE NEWS MARCH 2011

10, including two deaths from medication errors, an area that increased from four events in 2009 to 13 in 2010. Other areas such as the numbers of falls, serious bedsores, and adverse events related to surgery remained roughly the same, the report found. “The system has helped us to learn so much about why these events have happened and continue to happen,” says Diane Rydrych, assistant director of MDH’s health policy division. “As a result, we have dedicated staff all around the state working on implementing new solutions. But when we see that we’re holding steady from where we were last year, that’s not where we want to be. We think that the numbers can and should be lower than they are.” Rydrych says MDH is putting a new emphasis on leadership from hospital boards and CEOs. “Leaders at that level really need to send a strong message that safety is the primary focus of the organization and that everybody

is going to be held accountable for compliance with best practices,” she says. “It’s all part of developing a culture of safety. No matter how many dedicated frontline staff you have, if you don’t have a culture that is focused 100 percent on safety, you’re not going to be able to make progress.” MDH will continue to work intensively with frontline staff on embedding best practices on safety, Rydrych notes. “But what we also hear is that it can be difficult to make those changes happen when you get pushback from certain areas,” she says. “It can be really tough for the staff trying to make it happen if they don’t have complete support.” Some of the strategies being recommended by MDH include telling patient stories of preventable harm at every board meeting, training hospital board members on patient safety, and requiring board members to participate in “leadership rounds” that put them in contact with frontline staff and patients.

CDC Will Join Groups In Studying Autism Among Somalis A national autism advocacy group and the Centers for Disease Control and Prevention (CDC) will collaborate to study the rate of autism among Somali children in Minneapolis. Autism Speaks, a New Yorkbased group that funds research and advocacy in the area of autism, announced Jan. 18 that it would collaborate with CDC and the National Institutes of Health (NIH) to investigate what seems to be an unusually high rate of autism among Somali children in Minneapolis. In 2009, the Minnesota Department of Health (MDH) reported that Somali parents in Minneapolis had raised concerns about a disproportionately high number of Somali children participating in autism programs. A MDH report on the issue said that the state does not have the public health surveillance tools to adequately study the issue, since there is a lack of baseline rates for children with autism spectrum disorder (ASD). The MDH report found that a higher percentage of Somali children were enrolled in ASD public school programs, but it cautioned that the data were limited and incomplete. The Minneapolis-based Somali American Autism Foundation, a group that was started by Minneapolis parents of autistic children, brought their concerns to the Interagency Autism Coordinating Committee (IACC) in October of last year. Idil Abdull, a parent of an autistic child and a co-founder of the Somali American Autism Foundation, asked the committee to conduct a systematic investigation of the issue in Minneapolis. Officials with Autism Speaks say that the group has the resources to move quickly to investigate the issue. “There have been concerns about higher prevalence of ASD in Minneapolis’ Somali population. We believe it is important to verify if a true increase in

prevalence exists and, if so, why it exists,” says Autism Speaks’ chief science officer Geraldine Dawson, PhD. “In this circumstance Autism Speaks has both the resources and facility to allocate a budget to initiate this effort in a timely manner.”

MDH Promotes Pertussis Booster State and federal health officials are recommending wider use of a vaccine to fight whooping cough. The Minnesota Department of Health (MDH) last week called on physicians and patients to make wider use of the booster vaccine that protects against whooping cough, or pertussis. The booster, called Tdap (tetanusdiptheria-acellular pertussis) is seen as an important tool to fight the nationwide rise in pertussis cases. MDH officials say Minnesota is in its third year of a peak pertussis wave, with more than 1,000 cases reported each year from 2008 to 2010. This represents about 20 cases per 100,000 people in Minnesota. The Centers for Disease Control and Prevention (CDC) recently released new recommendations on the use of Tdap, expanding the range of adults and children who may receive the booster. “We want all Minnesotans to be aware that the pertussis booster vaccine can help protect them and others from this disease, which can be most serious for young children and infants,” says Kristen Ehresmann, MDH director of infectious disease. Officials say patients should ask their health care provider to give them the pertussis-containing tetanus-diphtheria shot, if needed, at their next clinic visit.

NOW hear this! D

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

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

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

State Will Reapply For ACA Grant Minnesota will reapply for a $1 million grant to help the state plan for health insurance News to page 6

EXERTstudy.org MARCH 2011 MINNESOTA HEALTH CARE NEWS

News from page 5 exchanges, a key component of the Affordable Care Act (ACA). Insurance exchanges would allow consumers to shop for the best plan and figures to be an important part of the reformed insurance market once they are implemented in 2014. After the ACA passed, all but two states, Minnesota and Alaska, applied for the grant to help in planning for the exchanges. Gov. Tim Pawlenty, who proposed similar insurance exchanges in his 2007 budget, changed his position and opposed the exchanges, saying they were a big-government intrusion on the free market. He issued an executive order directing state agencies not to apply for the federal grant. The move sparked protests from health groups around the state, including the Minnesota Medical Association and the Minnesota Council of Health Plans. Those groups went so far as to forward preliminary

studies to federal regulators, saying that they did not want the state to be disadvantaged by not giving input as the exchanges were developed. With a new governor in St. Paul, the insurance exchange issue has been reopened. Gov. Mark Dayton announced recently that after discussions with Health and Human Services (HHS) Secretary Kathleen Sebelius, Minnesota will be given a new opportunity to apply for the federal grant. State officials say the grant will help the state create a strategy for implementing an exchange to maximize competition and simplify Minnesota’s health care system. “It is a high priority to get the health insurance exchange for Minnesotans back on track,” says Mike Rothman, commissioner of the Minnesota Department of Commerce. “These funds help kick-start our planning process to develop the insurance exchange.”

Ramsey County Joins Long-term Study of Children’s Health Officials with the University of Minnesota Study Center announced recently that residents of Ramsey County will play a role in the largest and longest study of children’s health ever conducted in the United States. The National Children’s Study (NCS) was originally launched in 2000, with funding provided by Congress and directed by the National Institutes of Health. The latest phase will include 105 counties across the U.S., which were chosen because of the diversity of their residents. The study will look at environmental health factors that affect children, such as air pollution, nutrition, schools, neighborhoods, and family history. Residents in Ramsey County will be contacted through letters sent by the U of M Study Center. The researchers will contact eligi-

ble households in 16 neighborhoods across St. Paul and suburban Ramsey County, and will invite pregnant women, women considering becoming pregnant, and, eventually, fathers in those neighborhoods to join the study. The study will follow hundreds of children and their families from before birth until age 21, with the goal of gaining new insights into factors that influence children’s health. “By joining this study, women and their families can contribute to improving the health of children not only here in Ramsey County, but across the United States,” says Pat McGovern, PhD, MPH, principal investigator for the NCS in Ramsey County and professor at the University of Minnesota. She adds that the information gathered will be confidential and private.

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

David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi

Appointments:

Online or Call 651-439-8807

Providing P roviding care care at at multiple ultiple modern modern clinics in Minnesota Minnesota esota and Wisconsin Wisconsin

MINNESOTA HEALTH CARE NEWS MARCH 2011

PEOPLE Glenace Edwall, PhD, PsyC, LP, MPP, has been elected to a four-year term on the board of directors of the National Register of Health Service Providers in Psychology. The national register is the largest credentialing organization for psychologists. The independent, nonprofit organization was created in 1974 with the help of the American Psychological Association and the Glenace Edwall, PhD, PsyC, LP, MPP

Nationally recognized. Patient-focused.

American Board of Professional Psychology.

Edwall has been director of the Children’s Mental Health Division of

Areas of Expertise

the Minnesota Department of Human Services since 2000. She over-

Artificial Disc Replacement Disc Degeneration Disc Herniation Discectomy Fractures Fusion Kyphosis (hump) Minimally Invasive Surgery Pediatric Curvature Sciatica Scoliosis - Juvenile - Adult

sees Minnesota’s county-administered children’s mental health service system and works on public policy issues regarding mental health benefits for children provided through Medicaid. Edwall is also the chair of the Minnesota Child Psychologists and chair of the Children, Youth, and Families Division of the National Association of State Mental Health Program Directors. Paul Terrill, MD, received the community-nominated “Physician of the Year” award for 2010 from the Lake Superior Medical Society. The award is given in recognition of “consistently demonstrating qualities recognized as defining excellence in medical care delivery.” Terrill joined Sawtooth Mountain Clinic in Grand Marais in 1991 as a board-certified family practice physician. Other award recipients were also announced: David Luehr, MD, from the Raiter Clinic in Cloquet, received the Thomas A. Stolee Exceptional Dedication to the Practice

Spinal Arthritis Spinal Cord Injury Spondylolisthesis (shifted vertebrae) Stenosis Tumors/Infections Pain Treatment & Diagnostics - Injections - Radiofrequency Neuroablation - Spinal Cord Stimulators - Vertebroplasty

of Medicine Award. Jay Knuths, MD, from St. Luke’s Internal Medicine Associates, received the John B. Sanford Community Service Award. Gail Baldwin, MD, from Lake Superior Community Health Center, received the 2010 President’s Award. Roger Waage, MD, from the Duluth Family Practice Center, received the 2010 Educator Award. Kenneth P. Kieffer has been appointed vice president of collections, recruitment, and product planning for Memorial Blood Centers. Kieffer is a 25-year veteran in the blood banking industry, serving in leadership positions with the American Red Cross at the national and regional levels. Most recently an independent consultant working with various independent Midwest blood centers, Kieffer had served as a consultant for donor recruitment at Memorial Blood Centers since September 2010. Steven Kottke, DDS, joined Lake Superior Dental Associates in Duluth in January. Kottke

Stefano M Sinicropi M.D. (spine surgeon), Glenn R. Buttermann M.D. (spine surgeon), Louis C. Saeger M.D. (interventional pain physician), Daniel W. Hanson M.D. (spine surgeon), Thomas V. Rieser M.D. (spine surgeon) Seated - Mark A. Janiga M.D. (interventional pain physician), Mark K. Yamaguchi (interventional pain physician)

earned a doctorate in dental surgery from the University of Minnesota School of Dentistry in 2001. He worked in Denver in a private practice for three years and then spent seven years in a group practice in Minneapolis.

Kenneth P. Kieffer

The Minnesota School Nutrition Association has presented Ron

Physicians specializing in restoring lives affected by spinal injury and disorder

Strasburg with its Silver Friend of Child Nutrition Award. The award recognizes an outstanding supporter or advocate of school nutrition programs. Strasburg was honored during the School Nutrition Association’s Child Nutrition Industry Conference on Jan. 16 in Seattle. He is a senior account executive with Upper Lakes Foods Inc. in Cloquet. He worked with the Minnesota Department of Education

Locations throughout the Twin Cities and Western Wisconsin

Food Distribution Pilot and Rebate programs to change the way Minnesota schools purchase and use USDA commodity foods. He also has participated in the School Nutrition Association’s Legislative Action Conferences in Washington and in Minnesota’s State

800.353.7720 / 651.430.3800 / fax 651.430.3827 MidwestSpineInstitute.com

Legislative Conference. MARCH 2011 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

A world of possibility Broadening participation benefits people with disabilities

Tim Nelson, MA, LISW Hammer Residences

Tim Nelson is the CEO of Hammer Residences, a nonprofit agency founded in 1923 that serves people with developmental disabilities. Nelson has a bachelor’s degree in education and a master’s degree in psychology, and is a licensed independent social worker. He is president of the board of directors of The Arc of Minnesota, past board member and current committee member of the Association of Residential Resources in Minnesota (ARRM), and a board member of the Council on Quality and Leadership (CQL), based in Towson, Md. Nelson had a brother with developmental disabilities who died in 2009.

magine being told when your baby girl is born that you should give her to complete strangers who will place her in an institution with several thousand people. She would live her life wandering in a large, open room with up to 100 other children, half-dressed, sometimes naked, wet from urination, and dirty with feces. Her caretakers might do medical experiments on her or give her major tranquilizers to calm her. Sound far-fetched? This was a common scenario for people with intellectual/developmental disabilities in the United States as recently as the 1970s.

Self-advocacy. Organizations such as ACT (Advocating Change Together) and SABE (Self Advocates Becoming Empowered) have empowered people to take control of their lives. In 2010, ACT successfully obtained an apology from the Minnesota Legislature for past treatment of people with disabilities in our state institutions. Self-determination. Having choices about where to live, with whom to live, where to work, where to spend one’s money, what hobbies to pursue, what services to utilize, whether to marry, and whom to vote for are slowly but steadily becoming a reality for people with disabilities.

Large institutions became the norm for the disabled in the U.S. during the latter part of the 18th century. Technology. Technology is increasingly being utiIn 1900, there were 11,800 individuals with intellec- lized to help people with disabilities be more indetual disabilities living in institutions; this number pendent. Sensing devices that monitor people peaked in 1967 at 194,650. Minnesota had institu- remotely for safety and health concerns are freeing tions in St. Peter, Hastings, Rochester, Fergus Falls, people from constant supervision, increasing Moose Lake, Willmar, Faribault, their self-esteem, and reducing and Owatonna. At the height of staffing-related expenses. Other institutional care in Minnesota, Life choices—where exciting technologies are rapidly in 1962, about 6,200 people with to live, with whom to emerging. developmental disabilities were Challenges and hope live, whether to warehoused in these facilities. Many challenges remain for peoCompassionate visionaries like marry, where to ple with disabilities. In MinneAlvina Hammer spearheaded the sota there is a waiting list of work—are slowly but move away from institutional about 4,000 people who are care in Minnesota. In 1923, while steadily becoming a seeking residential-related servworking as a nurse in one of ices and supports. People curreality for people Minnesota’s large institutions, rently receiving services often Alvina had a vision for supportwith disabilities. are living in settings and with ing people with disabilities in a people not to their liking. Many more humane manner. As a people still work in segregated settings doing work result, she created Hammer, the second oldest that is not meaningful or satisfying to them. A high community-based residential program in percentage of people with disabilities in Minnesota Minnesota. Additionally, family-led organizations are unemployed. Isolation and loneliness are still such as Arc, founded in the 1950s, along with dediprevalent. Finally, government funding constraints cated professionals and politicians, utilized advocawill be a major concern in coming years, and some cy, education, and support to improve the lives of are again proposing institutional models to deal people with disabilities. Minnesota’s last state instiwith these shortfalls. tution was closed in 2000. But people with disabilities, supported by their famPositive trends ilies and dedicated professionals, now hold a Today people with disabilities in Minnesota gener- new vision for their lives—one in which they are ally experience a much-improved quality of life as afforded their full rights, they are respected and valdemonstrated in these relatively recent significant ued for the gifts they bring to the community, and trends: their desires and dreams for self-direction are honLiving situations. Most individuals with intellectu- ored. The hope for the future is that this vision will al/developmental disabilities live in settings that not be lost, but built upon. mirror the regular population (their family homes, All our lives are richer when we embrace people single-family homes, and apartments). who are “differently abled.” We learn from their Employment. People with intellectual disabilities increasingly desire and are finding employment in the community—from office work, to janitorial jobs, to technology-related careers (e.g., document scanning).

MINNESOTA HEALTH CARE NEWS MARCH 2011

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10 QUESTIONS

& Alfred Anderson, MD, DC Dr. Anderson, medical director of the Medical Pain Management Clinic in Minneapolis, is a member of the Minnesota Board of Medical Practice and president of the board of directors of the American Academy of Pain Management. How does a doctor become a pain medicine specialist? In the broad term, a “specialist” in medicine would be one who has limited his or her practice to a specific area of medicine. Among subspecialties in the various fields of medicine, specializing in pain is one. So far, the American Board of Medical Specialties has not sanctioned a specialty in “pain medicine.” Practitioners who restrict their work to the treatment of pain are doing so by their experience and acquired education in the field. What determines the need to see a pain medicine specialist, and are referrals primarily through another physician? Pain that persists for more than three to six months, and is unresponsive to accepted medical practices, would be considered chronic. Patients who suffer from chronic pain are typically referred to practitioners who specialize, or are comfortable, in treating long-term chronic pain patients. Physicians who are not comfortable with treating persistent chronic pain would typically refer to a doctor who would have the confidence and skill to treat a chronic pain patient. What are the differences between chronic and acute pain? Acute pain is the protective mechanism that warns us of a problem or an injury. If pain persists for longer than three to six months, it is considered chronic, which is physiologically different from acute pain. Acute pain is helpful, whereas chronic pain can be harmful. Patients suffering from chronic pain tend to be less active, which leads to physical deconditioning, which then reduces the person’s ability to cope with pain. There is evidence in the literature that chronic pain affects the immune system, the disposition, other body functions, and even cognitive function. Chronic pain may also increase the brain’s perception of pain. How do you assess the severity of a person’s pain? An individual’s ability to function is the primary determinant of the severity of pain. There are instruments, or questionnaires, that help to estimate the function of an individual. Each visit to a pain physician includes an estimate of perceived pain based on a scale of 1 to 10, with 10 being the most severe pain that the patient could imagine, and 1 being minimal pain. There are several systems of estimating the patient’s pain level, but each system is simply an indication of the patient’s perception of pain and cannot be compared to other patients’ pain levels. What can you tell us about the differences in people’s tolerance for pain? The literature proposes that an individual’s ability to tolerate pain may be based on various factors in genetics. Some individuals can tolerate very high levels of pain and still function normally. Other individuals may be totally debilitated with their perception of pain. However, it should be noted that each individual has his own interpretation of pain that must be respected by the practitioner in assessing that individual’s pain level. Photo credit: Bruce Silcox

How about for medications? The initial goal of the treatment of pain should involve an increase in the ability of the person to function. Conservative measures should be considered initially, such as physical rehabilitation to enhance the strength and endurance of the patient. Medications such as acetaminophen or nonsteroidal anti-inflammatory medications

MINNESOTA HEALTH CARE NEWS MARCH 2011

“

”

An individual’s ability to function is the primary determinant of the severity of pain.

may be considered. However, if conservative measures are ineffective, then the more potent medications should be considered. If medication is not successful in enhancing an individual’s ability to function, then interventional procedures should be offered as an option. From the least powerful to the most, describe the kinds of medications a pain management physician prescribes. Medications cannot be considered according to whether they are more or less powerful. The response to medication is primarily mitigated by factors such as genetics. Whatever medication helps the patient to increase function, with minimal or absent side effects, would be considered an appropriate medication for that patient. Patients may be allergic to a certain medication, limiting the choices one has for treatment. Possible severe adverse effects with medication such as anti-inflammatory medications and even acetaminophen must also be considered. High doses of these medications have been shown to cause potential severe health problems. Every medication must be considered a potential hazard to an individual’s general health. For a patient who is in very severe, chronic pain, it is considered appropriate to use medications such as opioids to help the patient function. What are recent advances in research into pain? The most significant advances in pain research have emphasized the mechanism of pain, its transmission, and how acute pain can become chronic pain. The findings in these research studies may ultimately be helpful in developing pharmaceuticals that will be effective in the treatment of pain, or may even prevent the development of chronic pain.

Why are some people reluctant to see a pain medicine specialist? I do not think most people are reluctant to see a pain management specialist, particularly if they have suffered with pain for a long period of time with no relief. Many people have fears about taking narcotic medications. However, if opioid medications are necessary to treat a patient’s chronic pain, accurate education and monitoring of the patient will usually alleviate fears the patient may have regarding opioid medications. Some patients fear the pain associated with invasive procedures, which would subsequently influence their decision. There is also the effect of perceived fear of pain associated with rehabilitation exercise programs. The success of the treatment depends on the ability of the practitioners to educate the patients regarding the options available and the benefits of treatment. What advice do you have for our readers who are in chronic pain themselves or who have family members with chronic pain? I would recommend approaching the issue with an open mind relative to treatments that would help the patient achieve a higher level of function and improved quality of life. There are many different systems of treatments. Unfounded beliefs and fears about opioid medications are detrimental to the potential benefit of patients with intractable pain. Opioids can be used safely in the management of severe chronic pain if the patient is monitored regularly for increased quality of life as well as potential adverse effects.

MARCH 2011 MINNESOTA HEALTH CARE NEWS

P S Y C H I AT RY more commonly in women than men. Possible explanations for the difference could include differing personality traits as well as genetic and hormonal factors. People who see a primary care provider for any reason have double the rates of GAD compared to the general population. People with untreated GAD have high rates of co-existing medical illness, and go to their doctors more frequently. The majority of people with GAD also have other coexisting psychiatric illnesses such as depression, other anxiety disorders, and substance abuse. Generalized anxiety disorder GAD is theorized to involve Generalized anxiety disorder (GAD) is maladaptive response to stresscharacterized by excessive anxiety and worry ful stimuli primarily involving Vine, MD By Craig J. about multiple events or activities, occurring chemicals in the brain called more days than not for at least six months. neurotransmitters—norepinephrine, seroThe worry is way out of proportion to the tonin, and gamma-aminobutyric acid (GABA). Hormonal systems likelihood or impact of the feared events. People with GAD may have may be involved as well. Brain imaging studies have shown differphysical symptoms, such as fatigue, muscle tension, memory loss, and ences in regional brain activity, with higher metabolic rates in multiinsomnia. GAD is common. At some point during their lives, around ple brain areas of people with GAD compared to control subjects. 4 percent of Americans will experience GAD. Twice as many women Treatment with medication resulted in a significant decrease in metaas men have GAD. It’s unclear why many anxiety disorders appear bolism in the brain cortex. Genetic factors appear to play only a modest role in causing GAD, much less than for depression. Early environment—including childhood adversity and witnessing trauma— is thought likely to be more influential than inheritance on the development of GAD.

nxiety disorders are among the most common of the psychiatric illnesses. According to the National Institute of Mental Health (NIMH), anxiety disorders affect about 40 million Americans adults. That’s almost one in five. The anxiety disorders include panic disorder, generalized anxiety disorder, phobias (persistent, abnormal fear of certain things or situations that leads to avoidance of them), obsessive-compulsive disorder, and posttraumatic stress disorder. This article will focus on two of the most common disorders: generalized anxiety disorder and panic disorder.

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Treating GAD

The Penny George Institute for Health and Healing seeks volunteers who: • are 55–75 years of age • take at least one medication for high blood pressure • have high systolic blood pressure and normal or low diastolic blood pressure. Subjects will be reimbursed for time and travel. Physical exams, blood tests and training will be provided at no cost.

MINNESOTA HEALTH CARE NEWS MARCH 2011

Treatment of GAD may consist of psychotherapy (such as cognitive behavioral therapy or supportive, problem-focused therapy), medication, or both. A brief series of primary care office visits can be effective in alleviating symptoms of anxiety. Many people are more receptive to this mode of treatment than to a psychiatric referral. While benzodiazepines (minor tranquilizers such as diazepam or Valium) and tricyclic antidepressants or TCAs (such as imipramine) were commonly used drug treatments for GAD in the past, current first-line treatments include selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft), selective serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor XR), and buspirone (BuSpar). These medications have fewer side effects and lower risk for tolerance. GAD is often a chronic disorder. People with GAD experience periods of severe symptoms and periods of few or no symptoms. GAD can be provoked by stressful life events. Long-term recovery in GAD is achieved in about one-third of patients. Many patients will need chronic treatment with medication to prevent relapse; others may be treated with intermittent courses of acute treatment. Panic disorder Panic attacks are characterized by the sudden onset of intense anxiety or fear accompanied by physical symptoms that can include chest pain, racing heart, headaches, dizziness, faintness, shortness of breath,

and gastrointestinal distress. The symptoms often last for several minutes to an hour. Of patients who seek treatment for panic disorder from primary care providers, 55 percent complain of physical symptoms. People with panic attacks can develop agoraphobiaâ&#x20AC;&#x201D;anxiety about and avoidance of places or situations that might precipitate a panic attack, such as being in a crowd or using public transportation. People with agoraphobia also fear and avoid unfamiliar, distant places or being alone, without help, should a panic attack occur. In panic disorder (PD), people experience recurrent, unexpected panic attacks, and one month or more of at least one of the following: worry about future attacks, phobic avoidance of situations that could trigger an attack, or other change in behavior due to the attacks such as frequent medical or emergency room visits. People with new-onset PD may repeatedly seek care for continuing frightening symptoms. The cause of PD is believed to involve a combination of underlying predisposition and life stress. Vulnerability factors include specific genetic factors, childhood adversity, and several personality traits, including sensitivity to anxiety. Current stressful life events in association with one or more of these vulnerability factors often precipitate development of panic attacks. Several areas of the brain and several brain chemicalsâ&#x20AC;&#x201D;including serotonin, norepinephrine, and GABAâ&#x20AC;&#x201D; are likely involved in the cause of panic. People with PD may inherit specific brain areas that are hyperexcitable, making them susceptible to unprovoked panic symptoms when exposed to mild physical stressors such Over a lifetime, as an increased heart or respiratory rate. about 5 percent of Also, they may have higher sensitivity to various chemicals, including carbon dioxAmericans will ide and caffeine. experience panic During their lives, about 5 percent disorder at some of people will have PD. Primary care point and patients have double the rates of the 4 percent will face general population. PD is approximately twice as common in women as in men. generalized The onset of PD peaks both in late adoanxiety disorder. lescence and again between the ages of 35 to 50. People with PD often have coexisting depression, bipolar disorder, and alcohol abuse. They may also use alcohol or sedative hypnotics in an attempt to control panic symptoms. Unfortunately, alcohol and sedatives have a short-lived anxiety-reducing action and are subsequently associated with rebound worsening of anxiety and panic attacks when blood levels decline. Recurrent withdrawal can lead to a kindling effect on central controls of the sympathetic nervous system, resulting in more frequent and severe panic attacks.

For more information People interested in additional information about anxiety disorders can refer to the NIMH website: www.nimh.nih.gov/health/topics/anxiety-disor ders/index.shtml or the Anxiety Disorders Association of America (ADAA): www.adaa.org. vokes a greater increase in heart rate and respiratory rate. Medications that are effective for PD include: SSRIs, SNRIs, tricyclic antidepressants (TCAs), benzodiazepines, and the older MAOI antidepressants. SSRIs are generally the first-line treatment for PD. Patients typically improve within four to six weeks. If there is no response by eight to 12 weeks at a maximum therapeutic dose, the patient should be given a second trial of another antidepressant (e.g., a different SSRI, SNRI, or TCA) or should be referred to a psychiatrist. Benzodiazepines with longer half-lives such as clonazepam (Klonopin) may have less between-dose rebound of panic symptoms. Because of the potential for abuse, however, benzodiazepines should be used with caution or avoided in people with drug or alcohol abuse, chronic pain disorders, and severe personality disorders. PD can usually be stabilized (i.e., alleviation of panic attacks, avoidance, and agoraphobic behavior) within four months. Drug treatment should be continued for at least one year and then reassessed. Relapse during or after medication dosage is reduced is less likely if coexisting psychiatric and medical conditions have been optimally treated and psychosocial stressors have been significantly reduced. Craig J. Vine, MD, is a psychiatrist in St. Paul.

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Treating PD Treatment of PD resembles that for GAD, with psychotherapy and medications demonstrating effectiveness. Cognitive behavioral therapy focuses on correcting false or inadequate thoughts or perceptions that play a role in amplifying normal bodily sensations so that they are no longer experienced as frightening or uncontrollable. For example, increased heart rate after walking up a flight of stairs may provoke thoughts that one is having a heart attack, which in turn pro-

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S P E C I A L F O C U S : F E TA L C A R E

All in good time State seeks to end elective induction of early-term labor By Jeffrey Schiff, MD, MBA, and Trudy Ohnsorg, MPH

hances are, if you are an adult today, you controlled the timing of your own birth. After 39 or 40 weeks of growth and development, you sensed it was time, and initiated the complex sequence of hormonal and physical changes that culminated in your delivery. Back in the security of the womb, you didn’t consult your mother’s calendar. You didn’t think about her ability to get child care for your siblings while the two of you were in the hospital. You certainly didn’t consider your doctor’s schedule. You were going to be born when you were good and ready, and not a minute sooner. Things have changed for today’s baby. In the last 20 years, deliveries using induction (artificially starting labor) have more than tripled nationally. While there are some valid medical reasons for inducing labor, some inductions are done for convenience: convenience for the mom, convenience for the doctor, convenience for the hospital. Convenience for everyone, it seems, except the baby. Induction can complicate labor, endanger baby Over the years, there has been a disturbing trend of electively (without medical reason) inducing labor a week or two before the baby is

39 or 40 weeks old, or “full-term.” The period during the 37th and 38th weeks of gestation is called “early-term.” This is a period when the baby is close to maturity but has not yet fully developed. Research has shown that early-term babies are seven to 22 times more likely than full-term babies to have respiratory distress syndrome (RDS), a condition where the baby cannot get enough oxygen into its body because its lungs are not fully developed. Complications of RDS include metabolic and heart disorders, chronic lung changes, and even death. Inductions tend to be more complicated labors, requiring medical interventions such as the placement of an intravenous line, continuous use of electronic fetal monitoring, and the use of drugs to stimulate labor contractions and ripen the cervix. Interventions like these have their own risk for complications, to both the mother and the baby. Research has shown that infants born at 37 weeks tend to end up in the neonatal intensive care unit of the hospital more frequently than do babies born at full term. In addition, induced labors tend to take longer and be more painful, requiring additional pharmaceuticals to alleviate pain. Because the labor is so much longer, babies who are induced are twice as likely to end up as cesarean deliveries. Why are unnecessary, early-term inductions still done? More than 90 percent of American board-certified ob/gyns are affiliated with the American College of Obstetricians and Gynecologists (ACOG). For more than 10 years, ACOG has stated that elective inductions should not occur before 39 weeks’ gestation. And yet they still happen. Why? One issue is that it can be difficult to accurately measure the gestational age of the unborn baby. All babies start out as a single cell, but they grow to very different sizes by the time they are born. The best time to measure the gestational age of a baby is at 20 weeks; at this age, babies tend to be about the same size for their age. If gestational age is not accurately captured, a woman may think she is giving birth to a full-term baby when, in fact, the baby may be a week or two younger than she thought. Another factor is that many women are confused about when a pregnancy is full-term. A study of women who had recently given

MINNESOTA HEALTH CARE NEWS MARCH 2011

birth found that a quarter of these women thought that 34 to 36 weeks’ gestation was full-term. Half of the women in the study thought that full-term occurred at 37 to 38 weeks, while only a quarter of the women considered full-term to be at 39 to 40 weeks. Also, the final weeks of pregnancy are uncomfortable for many women. They may ask their doctors to schedule an induction before 39 weeks, not realizing that it is in their baby’s best interest to wait. A matter of policy, quality In Minnesota, about 38 percent of all births are paid for by the Medicaid program. That makes Medicaid the largest payer of deliveries in the state. Because of this, the Minnesota Department of Human Services (DHS) formed a clinical advisory group to study best practices related to deliveries. As it turns out, a number of hospitals in Minnesota were already developing policies and quality programs aimed at eliminating elective inductions before 39 weeks. According to a DHS survey, hospitals that had policies in place tended to have fewer early-term inductions, and fewer inductions in general. Across the country, as the potential for infant harm associated with early-term delivery has become more recognized, more and more hospitals are putting policies in place to stop early-term elective inductions. However, just having a policy in place at a hospital does not guarantee that early-term elective inductions will stop at that institution. A recent study compared 27 hospitals that had recently implemented policies to reduce elective early-term deliveries. The rate of early-term elective deliveries fell the most among hospitals that instituted a “hard stop” approach, where hospital staff was empowered to refuse to schedule any such deliveries and questions about the medical appropriateness of scheduled inductions were handled in a standard manner by accessing the chain of command. For example, if a physician wanted to perform an elective delivery for a woman who was at 38 weeks’ gestation, and the reason was that the child’s grandparents were in town, the physician would have to seek special permission from the chief of obstetrics at the hospital. Hospital nursing staff would be empowered to refuse to schedule the delivery unless the chief granted permission. In most cases, the physicians would not seek permission from the chief, but instead would tell the patient that she needed to wait because the hospital’s policy had been developed to protect the health of babies. Hospitals with policies that left compliance up to individual physicians did not see as much of a decrease in elective early-term induction rates. Hospitals that relied solely on provider education around the subject had even smaller decreases in elective early-term induction rates. Across all hospitals that did anything to change the rate of induction, the rate of neonatal intensive care admissions went down by 16 percent after they implemented policies. Even though some babies were born later than they would have been without the policies, there were no increases in stillbirths, the most feared outcome from letting pregnancy progress to completion. Policy recommendation for Minnesota The DHS advisory group recommended that hospitals adopt policies and quality review processes to prohibit elective inductions before 39 weeks’ gestation. In addition, the recommendations encouraged providers of prenatal care to identify gestational age by 20 weeks’ gestation, and to inform expectant mothers of the risks of early-term induction. The Minnesota Department of Human Services is in the process of turning these recommendations into action, and has

teamed up with the Minnesota March of Dimes to help hospitals across the state adopt policies and quality improvement processes that will reduce their elective early-term induction rates. Deliveries in Minnesota are about to get safer for our newest and most vulnerable populations, and will cost taxpayers less because they will not have as many complications, such as respiratory distress syndrome. The Department of Human Services, because of its role as the largest payer of births in the state, has an opportunity to positively affect the health of the next generation of Minnesotans. Jeffrey Schiff, MD, MBA, is medical director for Minnesota Health Care Programs at the Minnesota Department of Human Services. Trudy Ohnsorg, MPH, is on the staff of the Minnesota Health Services Advisory Council. The authors would like to acknowledge the contribution of the provider community in developing and supporting this change.

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MARCH 2011 MINNESOTA HEALTH CARE NEWS

S P E C I A L F O C U S : F E TA L C A R E

Perinatal partnership

Coordinating care for the tiniest patients By William Block, MD, and Brad Feltis, MD

my Allen was only seven weeks pregnant when she learned that her unborn child was already fighting for her life. A routine ultrasound revealed that her baby was facing life-threatening complications too severe to be treated at her hometown health care facility 45 minutes from the Twin Cities. Only a few years ago, Amy would have been faced with two options: Try to synchronize specialized care at multiple Twin Cities facilities or seek care at a comprehensive perinatal facility in a city thousands of miles away from her family and friends. Fortunately for Amy, she didn’t have to go far from home to receive world-class care. In response to the needs of patients such as Amy, Abbott Northwestern Hospital, Children’s Hospitals and Clinics of Minnesota, Minnesota Perinatal Physicians, and Pediatric Surgical Associates joined forces to develop a better, more coordinated approach for high-risk perinatal care. In 2008, they opened the Midwest Fetal Care Center, which seamlessly treated Amy through her pregnancy, and today treats hundreds of patients per

Cancer Summit 2011 Looking Forward During Changing Times

year with complications ranging from chest abnormalities to neurological disorders. Harmonizing care

The driving force behind the creation of the Midwest Fetal Care Center was the need for a comprehensive perinatal services center in the Upper Midwest. Although Twin Cities clinics offered a broad range of advanced perinatal services, they lacked coordination to successfully manage highly complex cases. The Midwest Fetal Care Center allows patients who otherwise would have had to see doctors at clinics in cities like Boston or Houston to manage their care right here in Minnesota. The center coordinates the expertise of perinatologists with the pediatric subspecialties of cardiothoracic surgery; neurosurgery; general surgery; urology; genetics; ears, nose, and throat surgery; and neonatology. These physicians consult with each other to develop the best treatment approach. Together, they determine if it’s best to employ fetal surgery, fetal laser ablation therapy, or newborn surgery after birth.

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Keynote Speaker: Dr. Lawrence Wallack Dean, College of Urban & Public Affairs, Portland State University March 24, 2011 8am-4:30pm Minneapolis Airport Marriott, 2020 American Boulevard East Bloomington, MN 55425 For more information www.mncanceralliance.org (763)712-7636 or (800)782-1878 Ext.167

MINNESOTA HEALTH CARE NEWS MARCH 2011

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One of the biggest advantages of merging these resources is that it provides one-stop service for the family. The team works to coordinate all aspects of care so patients are able to see different specialists during one trip, instead of having to travel back and forth for

The team works to coordinate all aspects of care so patients are able to see different specialists during one trip. multiple appointments. Streamlining care leads to better care. Very few centers across the country are structured in this manner.

Working together

Among the most exciting things for the doctors at the Midwest Fetal Care Center has been the opportunity to unite fields that traditionally don’t work together and see how they can bring better patient outcomes. For example, perinatologists and pediatric surgeons seldom united to coordinate prenatal care. However, in operative fetoscopy, the two specialists possess the ideal combination of skills to generate the best outcomes. The pediatric surgeon has advanced expertise in minimally invasive procedures, and the perinatologist has advanced training in ultrasound interpretation and in-utero procedures. Working as a team allows these specialists to determine the best strategy for the patient. This alliance of multiple specialties provides patients with seamless, coordinated care from diagnosis to treatment—an approach that ensures that mother and baby receive the best care possible. From a critical delivery to a thriving little girl

Amy Allen’s doctor referred her to the Midwest Fetal Care Center for further tests, where physicians determined that Amy’s baby had a large congenital cystic adenomatoid malformation (CCAM), an L-shaped mass over its left lung. Amy traveled the 45 minutes to the Twin Cities for monthly ultrasounds that were monitored by multiple specialists until she reached 30 weeks in her pregnancy.

High-risk pregnancies require coordinated care

According to the American Pregnancy Association, every year 875,000 women experience at least one pregnancy complication and more than 150,000 children are born with birth defects. Although some birth defects are caused by genetic or environmental factors, more than 60 percent of birth defects are caused by unknown factors. One factor that increases the risk of complications is multiple gestations. The National Center for Health Statistics reports that over the past two decades, twin births have increased 74 percent and births of three or more offspring from a single pregnancy have increased fivefold, largely because of advances in fertility treatment technology. As the number of multiple gestations increases, so does the risk of fetal abnormalities. One high-risk abnormality is twin-to-twin transfusion syndrome (TTTS). It can occur when identical twins share a single placenta and abnormal blood vessels form that connect the twins’ circulatory systems, resulting in one twin having insufficient blood flow, the other getting too much, and endangering the health of both. The preferred treatment for TTTS is laser coagulation of the shared placental vessels. This is accomplished via operative fetoscopy, a procedure where a tiny camera is inserted into the gestational sac and a laser fiber is used to directly coagulate the shared blood vessels. Until the development of the Midwest Fetal Care Center, operative fetoscopy for TTTS was not available in the Midwest. Instead, perinatologists referred TTTS patients to other centers in Houston, Providence, Miami, and Seattle for this procedure. Today, the Midwest Fetal Care Center sees dozens of patients annually for TTTS.

Perinatal partnership to page 19

Independent Practitioners ... freer to give you: More Attention More Choices And be your best Advocate

Thank you for choosing independent medical care. www.midwestipa.org • 952-883-3133 MARCH 2011 MINNESOTA HEALTH CARE NEWS

March Calendar 8

Adult Hematology Support Group This group combines education and group discussion for patients or family members who have had blood cancer or a blood disorder. Free refreshments will be offered. Meetings are held the second Tuesday of each month. For more information, call 320-229-5199, ext. 70659. Tuesday, March 8, 6–7 p.m., Great River Regional Library, 1300 W. St. Germain St., Bremer Rm., St. Cloud Margie’s Group: Chronic Pain Have you been diagnosed and treated for chronic pain? These classes will help you recognize factors that contribute to your pain and learn skills to alter your pain experience. We provide a supportive, fun environment for learning, healing, and living life to its fullest. Classes are free and meet the second Wednesday of each month. For more information, call Fairview on Call at 612-672-7272. Wednesday, March 9, 4–5:30 p.m., Riverside Park Plaza Auditorium, 701 25th Ave. S., Lower Level, Minneapolis

Tai Chi for Parkinson’s and Wellness This class helps people with Parkinson’s improve balance, coordination, concentration, physical strength, and mental wellbeing. It can be done standing or seated. $5 per session. Classes are held every Monday. To register, contact Capistrant Parkinson’s Center at 651-232-2098. Monday, March 14, 10:30–11:30 a.m., Bethesda Hospital, 559 Capitol Blvd., St. Paul

Pre-Diabetes Class This one-session class will provide practical information to help you understand prediabetes. Participants will learn about the diagnosis, identify personal barriers and goals for making changes, and learn about community resources for management. Cost: $20 (A support person may attend for free). Call 952-993-3454 for more information and to register. Wednesday, March 16, 3–4:30 p.m., Park Nicollet Clinic, 1885 Plaza Dr., Conference Rm., Eagan

National Nutrition Month Eat Right with Color While the trees may be bare in March, there are still plenty of colorful and nutritious foods to fill your plate. “A rainbow of foods creates a palette of nutrients, each with a different bundle of potential benefits for a healthful eating plan,” says registered dietitian Karen Ansel of the American Dietetic Association. Ansel offers ways to brighten up your plate in every season with this quick color guide. And for additional options in the color palette, choose frozen or dried fruits and vegetables available throughout the year. Green produce indicates antioxidant potential and may help promote healthy vision and reduce cancer risks. • Fruits: avocado, apples, grapes, limes • Vegetables: artichoke, asparagus, broccoli, green beans, leafy greens Orange and deep yellow fruits and vegetables contain nutrients that promote healthy vision and immunity, and reduce the risk of some cancers. • Fruits: apricot, cantaloupe, grapefruit, mango, papaya, peach, pineapple • Vegetables: carrots, yellow pepper, yellow corn, sweet potatoes Purple and blue options may have antioxidant and anti-aging benefits and may help with memory, urinary tract health, and reduced cancer risks. • Fruits: blueberries, plums, raisins • Vegetables: eggplant, purple cabbage, purple-fleshed potatoes Red indicates produce that may help maintain a healthy heart, vision, immunity, and may reduce cancer risks. • Fruits: cherries, cranberries, pomegranate, red/pink grapefruit, red grapes • Vegetables: beets, red onions, red peppers, red potatoes, rhubarb, tomatoes White, tan, and brown foods sometimes contain nutrients that may promote heart health and reduce cancer risks. • Fruits: banana, brown pears, dates • Vegetables: cauliflower, mushrooms, onions, parsnips, turnips, potatoes Visit www.eatright.org for a variety of helpful tips, fun games, promotional tools, and nutrition education resources.

Lyme Support and Education Minnesota Lyme Association–St. Anthony/ New Brighton Chapter is starting a support group this month. Come and learn about the prevention, diagnosis, and treatment of Lyme disease. For more information, contact Laurie Gross at 612-865-1796 or lauries.rhythm@comcast.net. Sunday, March 20, 4–5 p.m., Faith United Methodist Church, 2708 33rd Ave. N.E., St. Anthony

Your Painful Shoulder Common shoulder problems such as rotator cuff injuries and arthritis will be discussed. Non-surgical treatment options, as well as the latest advances in shoulder arthroscopy and joint replacement surgery, will be included in the discussion. Free, but advance registration is required. Call 651-430-4697. Wednesday, March 23, 6:30–7:30 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Behavioral Interventions for Children This workshop provides a practical road map for families in assessing what the best intervention fit for their child might be. We will review the principles of Applied Behavioral Analysis (ABA). The role of school-based, community-based, and home-based interventions working together will be discussed. Workshop is for adults only; childcare is not provided. Cost: $30 per individual; $50 per couple. Register online at www.fraser.org, call 612-7988331, or e-mail workshops@fraser.org. Thursday, March 24, 9:30–11 a.m., Fraser Child & Family Center, 3333 University Ave. S.E., Minneapolis

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to 612-728-8601 or e-mail 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 18

MINNESOTA HEALTH CARE NEWS MARCH 2011

Perinatal partnership from page 17

At that time doctors planned for an EXIT (exutero intrapartum treatment procedure) to ECMO (extracorporeal membrane oxygenation) procedure that would take place during a planned cesarean delivery. The EXIT procedure is used to deliver babies whose airways are compressed. It allows ventilator access while the fetus’ blood is still being circulated through the placenta. Once delivered, the ECMO technology does the work of a patient’s heart and lungs, giving the body time to heal. The day before the cesarean delivery, Amy and her husband checked in and met with their team of doctors, including an anesthesiologist, the doctor who would be doing the delivery, and the doctor who would be handling the baby. On the day of the delivery, 31 doctors and nurses were assigned to help with the delivery. Amy’s case was extremely rare and had never been treated in Minnesota. The procedure did not go entirely as planned. The baby, a girl the Allens named Elyn, came out with her umbilical cord wrapped twice around her neck. Doctors had to resuscitate her before hooking her up to the ECMO machine. Elyn was stabilized on ECMO for two days before the pediatric surgeons performed a surgical procedure to remove a 2-pound benign mass on

REGENCY

The alliance of multiple specialties provides patients with seamless, coordinated care from diagnosis to treatment.

H OSPITAL

top of her left lung. After five more days on ECMO, Elyn was taken off the machine. Within six weeks, she was home with her parents. Today, though Elyn has only two-thirds of her left lung and breathes a little faster than some kids her age, she is a healthy 1-year-old. She will go back to Children’s Hospitals and Clinics of Minnesota for a checkup at 18 months. In this medical scenario, it was imperative that multiple providers be able to take part in determining the best treatment strategy. Instead of having to travel to another city, away from home and family, Amy and her husband were able to live at home and travel into the Twin Cities to meet with doctors at the Midwest Fetal Care Center as necessary. Once the diagnosis was made, the doctors were able to coordinate the delivery and make a plan together, without having to refer Amy to any other clinics. This ensured a much smoother process and care plan for Amy, her husband, and Elyn throughout the entire pregnancy through delivery to Elyn’s checkups. Their experience underscores the advantages of coordinating care to achieve optimal care for high-risk mothers and the tiniest patients. William Block, MD, is medical director and Brad Feltis, MD, is surgical director at the Midwest Fetal Care Center.

M IN N EAPOLI S

Giving People Their Lives Back Regency Hospital of Minneapolis is an intensive critical care hospital serving the needs of medically complex patients that require acute level care for a longer period of time than traditional hospitals are set up to provide. We are a national network of hospitals with a different way of thinking, a different way of caring, and a different way of treating, and it shows in everything we do.

R E G E NC Y PRO G R A M S A N D SE RV IC E S Pulmonary/ventilator program Medically complex/multi-system failure program Wound care program (stage III and IV decubitus) Low-tolerance rehabilitation services Regency Hospital of Minneapolis 1300 Hidden Lakes Parkway Golden Valley, Minnesota 55422 Main: 763.588.2750 Referral: 763.302.8340 MARCH 2011 MINNESOTA HEALTH CARE NEWS

COMMUNITY CAREGIVERS 2011

Making a difference in Responding to disaster

Recognizing Minnesota’s volunteer physicians Each year, Minnesota Physician Publishing honors physicians who have volunteered medical services in recent years. In volunteer medical activities that span the globe, Minnesota’s volunteer physicians have provided medical care and medical education and expanded cross-

In the days following the devastating earthquake in Haiti on Jan. 12, 2010, medical groups from all over the world scrambled to offer assistance in different forms. One of these groups, an orthopedic practice from St. Paul, managed to get a team on the ground in Haiti just days after the earthquake, and for weeks they worked tirelessly to save lives and mend broken bodies in the Haitian capital of Port au Prince. Summit Orthopedics had a previous relationship with Nuestros Pequenos Hermanos (NPH), a charity group that runs nine orphanages in South and Central America. NPH has a children’s hospital in Port au Prince called St. Damien. When the 2010 earthquake struck, the hospital’s founder, Father Richard Frechette, called Summit orthopedic physician Peter Daly, MD, and asked him to come immediately and help with the injured people who were flooding into the hospital. Daly organized a team that flew first to the Dominican Republic, because it was impossible to fly directly into Haiti’s capital at the time, then drove overland more than 8 hours to Port au Prince. Joseph Perra, MD, a Summit Orthopedic physician who had worked with NPH before, arrived with a second group of health care workers from Summit about three weeks after the earthquake. According to Perra, that first team faced chaos when they arrived.

“At first we had no census, we had no numbers or names, it was just ‘the kid in the fourth bed of that room.’” Joseph Perra, MD

cultural skills and understanding. Their compassion, commitment, and generosity reflect deeply held values of Minnesota’s medical community. Story by Scott Wooldridge

“This is a children’s hospital, built to hold about 120 patients, and they had 500 patients on the grounds surrounding the hospital who had been dragged in there by families, including 80 with femur fractures,” he says. Perra recalls that the first team worked around the clock, collaborating with a team of Italian physicians there. “The Italian team would run the operating room during the day from about 8 a.m. to 5 p.m., and the American team would take over from 5 p.m. until 2 or 3 in the morning,” he says. “They slogged day and night for the first couple of weeks. Shortly after I got there, the deci-

MINNESOTA HEALTH CARE NEWS MARCH 2011

sion was made that we needed to slow down to some kind of controllable pace. We relied on local staff, and these people had to have a break. They had to have a chance to go home and to take care themselves, too.” By the time Perra arrived, teams of physicians were working 12 hours a day to treat earthquake casualties. “There was kind of a rotating staff of physicians and nurses coming from different aid groups in the States, and most people would just stay for five to seven days and have to leave. Every week, we had new people coming in,” he says. “At first we had no census, we had no numbers or names, it was just ‘the kid in the fourth bed of that room.’ At first we had 75 patients; by the time we left, we had it down to 25 postoperative patients because we were getting some people discharged, getting them home. But home was a tough question. How do you send somebody home when home is a tent on the side of the road? It was very difficult to find a safe place for people to go after they left the hospital.” The physician team that went to Haiti from Summit, in addition to Daly and Perra, included Paul Donahue, MD; Mike Forseth, MD; Mark Holm, MD; and Daren Wickum, MD. The team brought their own equipment and even their own food, since basic supplies were so short and the demand for incoming relief supplies was so great. The Summit physicians did amputations and after-care for amputations, applied fixators and casts to broken bones, and provided other types of surgical and medical care. Perra says the trip was difficult in some ways but he is proud of the way the team responded to the disaster. And, he says, there were some bright spots. “The children, once they got through the worst of things and weren’t in bad pain anymore, were still children,” he says. “They may have one leg amputated; they may have a big fixator sticking out of their thigh; but they still could smile and laugh and play some games. So seeing the bright faces on the children was uplifting. And the Haitian people themselves are very tough, very stoic people who put up with a lot of adversity and did amazingly well.”

Minnesota and the world A different view Practicing medicine in a country that is hot, crowded, and desperately poor comes with many challenges. But Steven Rousey, MD, a physician with Minnesota Oncology, says his two medical missions to Bangladesh not only have made him grateful for the resources we have here but also have given him a new appreciation for the basics of medical practice. “It was exhausting and it puts you out of your comfort zone, but that’s OK,” he says. “It is quite rewarding to get rid of all the other stuff around you and just focus on what is the right thing to do for people in very difficult circumstances.” Rousey’s trips were sponsored by Lutheran Health Care Bangladesh (LHCB). He has traveled twice to Dumki, a small, rural community in southern Bangladesh. The LHCB missions bring American physicians to the Dumki hospital, a 15-bed facility that was originally built to provide care for women and children, although in recent years that has changed to include men. With only basic health services being provided by the hospital, there is not much work for an oncologist, so Rousey assisted with primary care and providing support to the Bangladeshi physicians. “The physicians in

Bangladesh are trained by two years of studying books, some of which are out of date, and then they are asked to go out and practice medicine,” Rousey says. “The professional isolation for many physicians is profound. One of the things that was most helpful was to be in

“The professional isolation for many physicians is profound.” Steven Rousey, MD outpatient settings with them and be someone of whom they could ask questions—[someone] who would have a different perspective.” Rousey is quick to say he respected the cultural differences that exist between Bangladeshi and American providers. “Like anywhere else, there is professional pride,” he notes. “You want to respect their way of doing things and then respond in a way that says, ‘Well, this would be another way you could do it.’ There was a lot of learning about how you communicate to other people. There are solutions we might think of in the United States

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that simply do not work there.” The typical day at the Dumki hospital would find American physicians, teamed with Bangladeshi staff, seeing more than 30 patients. The medical mission physicians saw a wide range of conditions, with Rousey noting an alarming rate of diabetes. “It appears to be type 2 diabetes, which in the U.S. would ordinarily be associated with someone who is overweight,” he says. “These are rail-skinny people with type 2 diabetes, which does not fit the stereotypes.” Rousey says it’s unclear why so many have the condition, though he thinks changes in diet may be playing a role. One challenging part of this particular mission is the long hours in the air and further traveling by road to get to Dumki, Rousey notes, but he adds that the welcome the American providers received from the local staff made the travel worthwhile. “It must have been 11 or 12 o’clock at night when we got there, and the entire hospital has shown up, all of the staff, the employees, and the children of the employees—all singing songs and with flowers to greet us—talk about getting blown away! They had been there all day waiting for us. We were received in a very wonderful fashion.” Caregivers to page 22

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COMMUNITY CAREGIVERS 2011 would be graduated and put in hospitals and told, ‘You are a pediatrician’ or, ‘You are an obstetrician.’“ Quirk adds that the Health Frontiers Hospitalists Rosemary Quirk, MD, and Jon White, MD, are a husband programs have now advanced to the point where Laotian physicians and wife team who have trained hundreds of residents, both in the are taking over the training and beginning research projects, something Twin Cities and in Vientiane, the capital of Laos. Since 2005, the two they lacked the capability to do until recently. have played an important role in helping to rebuild a medical educaWhite notes that for 12 years, Laos was bombed by American tion system that was destroyed during the Vietnam War and is only forces and its allies to the point where it was the most-bombed counnow getting back on its feet. try, per capita, in history. However, he says there is no remaining Quirk and White joined Karen Olness, MD, a Minneapolis native animosity toward Americans. “There should be,” he says. “[Laotians] who has been running the Health Frontiers program in Laos since 1991. are moving on. In the Lao culture, the role of teacher is really one of Health Frontiers has worked with the Laos University of Health Science the most highly respected roles in society. It was a to create medical residency programs in pediatrics low-paying job, but the emotional feedback from and internal medicine. The programs have greatly all the people we worked with was always extremely expanded the rudimentary medical training that positive.” Laotian physicians had previously received. Since returning to the U.S., Quirk and White “Education is the main problem in a country have worked as hospitalists at Regions Hospital in like Laos. The communist revolution in 1975 meant St. Paul. They continue to make yearly visits and supthat most of the educated class left the country,” port the Health Frontiers program out of their own White says. “It has taken 30-some years to even try pockets. The two contribute $15,000 to $20,000 a to replace those educated levels of society.” year to the program, not including their travel Quirk and White arrived in Laos in 2005, after expenses. “When you realize what physicians here in a stint providing health care in Indonesia in the the States make, and that a physician in Laos makes aftermath of the 2004 tsunami. They worked for 16 probably $40 to $50 a month, … you feel so grossly months in Laos and have continued to support the overpaid that it seems like absolutely nothing to Health Frontiers program by returning for one commit some of your wealth to really changing the “It has taken 30-some month every year, as well as contributing financially. educational infrastructure of a capital city, and hope“The medical school in Vientiane was in a build- years to even try to replace fully someday it will filter down to the more rural ing that, a few years ago, before it was renovated by those educated levels of places,” White says. the World Bank, was a crumbling building with Quirk and White also teach here in the Twin society.” Jon White, MD chalkboards, no computers, and no medical books Cities by training medical students at Regions and by written in the Laotian language,” says Quirk. volunteering at the Phillips Neighborhood Clinic, “People would go to school, [sometimes taught] in where they oversee medical students who care for languages the students could not understand. They underserved patients.

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tant step was completing an 18-month program with the Stratis Health Cultural Care Connection, which gives providers around the state tools For Deborah McCarl, MD, the benefits of medical missions don’t end for communicating effectively with patients from different cultures. She with the friendships and good memories that come from working in a has also taken Spanish language classes and has studied immigration foreign country. McCarl has taken several trips to Guatemala and medicine at the University of Minnesota. worked on the Navajo-Hopi Reservation in the southwest United States. The extra training is helpful in a community that is seeing an She says that working in other cultures has given her skills that she uses increase of immigrants, McCarl says. Among the key things she has on a daily basis in her practice, especially when dealing with patients learned in working with patients from different cultures is the imporfrom other cultures. tance of listening and keeping an open mind, she adds. “It’s being able “I’ve always been interested in cross-cultural experiences,” says to listen and be open to other ways to approach problems that is helpMcCarl, an ob/gyn physician at CentraCare Clinic in St. Cloud, noting ful, and it takes some learning to do that,” she says. “The models of that she has spent time in Japan and India over the years. She has been practice that we have now in the U.S., with the constriction in time, do on several medical missions to Guatemala with HELPS make it a little bit difficult.” International, which has its northern U.S. office in St. Cloud. The need for cultural competency in health care has On her most recent trip to Guatemala, in 2009, McCarl grown, not only in the Twin Cities but in greater Minnesota was part of team that set up a temporary clinic and hospital communities such as McCarl’s hometown of St. Cloud. in Tejutla. She says the medical staff, which included a “During the last 15 to 20 years or so, we’ve had a real range of specialties, focused on basic procedures that could influx of immigrants in our community,” McCarl says. “First be done on a short-stay basis. Her work covered a range of we had Southeast Asian immigrants, and then more recentobstetric and gynecological issues such as ovarian cysts, ly we’ve had Somali and some other African immigrants uterine fibroids, and some cesarean deliveries. arriving, and I found working with [the different groups] to Guatemala’s history of civil war is fading into the past, be very similar.” McCarl says, with little danger to medical mission staff, but McCarl says she has enjoyed watching generations of psychological scars remain among the people who lived immigrants become part of the St. Cloud community. “I’ve always through it. She notes that the repercussions of war are “They’re just great people, and very dedicated to this been interested something she has seen not only in her mission work in place, to making our community a good community,” Guatemala but also in caring for Somali immigrants in her in cross-cultural she says. “I had always envisioned that I was going to go practice in St. Cloud. The patients from both Somalia and out somewhere and do cross-cultural medicine in some experiences,” Guatemala may have been through traumatic experiences other country. What’s actually happened is that enriching in war and can have issues that arise from that, she says. Deborah McCarl, MD experiences have come here to my community, and that’s In addition to what she’s learned from medical mismade me very happy. I think really we all are benefiting sions, McCarl has taken steps over the years to increase from this.” her communication skills and cultural literacy. One impor-

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COMMUNITY CAREGIVERS 2011 these kids and they undergo full evaluation, including chest x-ray, EKG, echocardiogram. Then we contact the hospitals to see if we can get the If providing medical charity work for groups on four continents is surgery done,” she says. stressful, you couldn’t tell by talking to Shanthi Sivanandam, MD. The trust was formed because Sivanandam saw a tremendous need Sivanandam chats pleasantly over the phone, discussing her work in for this kind of medical treatment in India. “There are hardly 10 conBrazil, India, Minnesota, and—via e-mail—for patients in Africa. The genital heart surgeons in India—for a billion people, there are 10 CHD electrocardiographer and pediatric cardiology expert has done medical surgeons,” she says. With the CHD screening program, she hopes for missions, participated in cross-cultural clinics, and started her own foun- the first time to start recording the numbers of children who have the dation, but she seems at ease juggling the various tasks, saying the disease, something that is not being monitored now. work makes her feel “peaceful.” “We are trying to establish a database in south India that we can Sivanandam is a native of India who received her medshow to the government,” Sivanandam says. “There are ical degree there and then did a residency in pediatric carvery few pediatric cardiologists available. If I showed the diology at the University of Minnesota. She currently is the incidence, the prevalence, … the government will start director of fetal cardiology at the University of Minnesota thinking about more training programs and working with Amplatz Children’s Hospital Heart Center. international organizations.” Since 2009, Sivanandam has been a volunteer physiThe trust also hopes to bring children from Africa to cian with Children’s Heartlink, traveling to Brazil that year India for treatment at some point. Sivanandam has volunas part of a team that treated children with congenital teered to read echocardiograms of African children over the heart disease (CHD). In January, on a second trip to Brazil, past two years, and some of those children may end up she taught physicians in that country about using imaging being candidates for surgery. scans during heart surgery. The effort also requires fund raising, and Sivanandam Sivanandam has also participated as a volunteer at “This is why I says she is fortunate to have people willing to contribute to health clinics at the Maple Grove Hindu Temple. The wanted to be a the cause. Poverty in south India is widespread, and there clinics have a preventive care and educational format, are few options for poor children who may have heart physician, to go defects. “It’s fee-for-service in India; there is no insurance and Sivanandam says a lot of the work is simply talking with families about good lifestyle choices and preventive back and help company that is paying for anybody,” Sivanandam says. health topics. out-of-pocket is not imaginable.” She adds that some people.” “Paying Sivanandam has also started her own group in India, the trust is a result of “a lot of people helping me out,” called the Narasimhan Family Trust. The group’s goal is to Shanthi primarily family and friends in India. screen for CHD and provide financial support for diagnosis, Sivanandam, MD “They said, ‘We will support you,’” Sivanandam says. treatment, and surgery. The organization paid for two suc“And I really wanted to do it, because the health care is not cessful heart surgeries last year and will screen 700 children there. I thought, ‘This is why I wanted to be a physician, to in south India this year for CHD. “This is free—we pick up go back and help some people.’”

A global approach

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. Your privacy is completely assured; we won’t even ask your name. Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

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Join now. We want to hear from you! 24

MINNESOTA HEALTH CARE NEWS MARCH 2011

Fairview facility in the former St. John’s Hospital in Red Wing. As medical director, Heilman oversees 23 volunteer providers. In addition, more than Dann Heilman, MD, needed some convincing about the necessity of a 200 volunteers from the community help with registration, resource free clinic in his community. Heilman, a pediatric physician with Fairview coordination, and other jobs. The clinic, open one night a week, sees Red Wing Health Services, also serves as the medical director for the free approximately 20 patients a night. CARE Clinic in Red Wing. But at first he wasn’t sure there was a need for Heilman says the CARE clinic treats a range of uninsured patients, a clinic serving the uninsured. with an income requirement of 250 percent of poverty level or less. The “I knew from working at the [Fairview] clinic and hospital that any- clinic has worked with some General Assistance Medical Care (GAMC) one who needed health care could come in and be seen,” he says. “We patients, as that program has struggled under cutbacks, but Heilman didn’t turn people away because they couldn’t pay.” notes those patients tend to be complicated and present a challenge to However, as he learned more about the issue, he found that there a free clinic. were an estimated 3,000 people in Goodhue County without health Being open one day a week also means that the clinic is limited in insurance. “I knew we weren’t seeing 3,000 patients in our taking acute-care cases, but Heilman notes that they see Fairview Red Wing clinic who weren’t insured,” he says, “So cases of strep, sinus infections, skin conditions, and other that woke me up a little bit.” ailments that primary care clinics see on a regular basis. And As he began talking to people about the CARE clinic, since the clinic represents the first care that some patients which opened in February of last year, Heilman says he have seen in a long time, the clinicians diagnose a number revised his earlier opinion. “I realized from talking to people of chronic illnesses. “Our three most common diagnoses are that many who couldn’t afford health care didn’t come in hypertension, diabetes, and depression,” Heilman says. The because they were proud,” he says. “I began to realize that clinic can refer patients not only to medical specialists but people were staying home with some serious problems to psychiatric providers as well, and has a program for promore out of pride than total inaccess to care.” viding low-cost prescription medications. The free clinic, he came to realize, was a way for people With changes to state programs such as GAMC and the “We provide to access the health care system in a low-pressure setting, ongoing rollout of health reform legislation, Heilman says an easier entry the long-term future of the clinic is uncertain. “We feel quite and possibly find that they needed more specialized care.”I think we provide an easier entry point into the system for point into comfortable that we’re funded well enough through 2012, people,”he says. For people without insurance, dealing with but after that we just don’t know,” he says. “I think we all the system the health care system can be intimidating, and a free clinic went into this not knowing what the future would be.” for people.” seems less daunting, Heilman says. “A lot of these patients In the meantime, Heilman says there is an enthusiastic end up going to Fairview Red Wing Clinic, but it is a way for Dann Heilman, MD volunteer base and strong support in the community for the them to be seen and for someone to tell them, ‘It’s OK for project. “I run into people every week that go out of their you to go in and get this checked out by a specialist.’” way to say how glad they were to see Red Wing doing someThe CARE clinic was developed by a coalition of comthing like this,” he says. munity and health care groups. The clinic is housed at a

A gateway to care

Minnesota

Health Care Consumer February survey results... Association

30 20 10

33.3%

25 20

16.7%

11.1%

10 5 0

Agree

No opinion

Disagree

Strongly disagree

Agree

No opinion

5.6%

3.7%

29.6%

30 20 11.1%

9.3%

Disagree

1.9% 0

Strongly disagree

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

5. I have put off necessary dental care due to cost concerns. 30

3.7%

40.7%

1.9% Strongly agree

Strongly agree

7.4%

50.0%

37.0%

5.6%

4. I am satisfied with my access to dental care.

Percentage of total responses

38.9%

Percentage of total responses

48.1%

44.4%

3. I feel confident that care recommended by my dentist is necessary.

2. I am satisfied with how my dental care is paid for.

1. I am satisfied with the quality of my dental care.

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

27.8%

25 20

20.4% 16.7%

15 10

7.4%

0.0% Strongly agree

Agree

No opinion

Disagree

Strongly disagree

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

MARCH 2011 MINNESOTA HEALTH CARE NEWS

TA K E C A R E

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• If nobody smoked, one in three cancer deaths in the United States would be prevented. U.S. Surgeon General Regina Benjamin, MD, MBA, reported in December that a person’s risk of having a heart attack drops sharply after being smoke-free for a year. Stroke risk can fall to about the same as a nonsmoker’s after two to five years. Quitting smoking also significantly reduces a person’s likelihood of developing and dying from various types of cancer. All of this saves lives and health care costs. Despite all of these statistics, smokers continue to light up many times a day, damaging their health (and that of others around them) with every puff. Most people who smoke wish they didn’t. An astounding 70 percent of smokers want to quit. Instead, they continue smoking because they have not found the right resources or support system to help them succeed at quitting once and for all. For the seven of 10 smokers who want to give up the habit, there is help to make it happen. Smoking-cessation resources As a society, we know one of the best ways to help people quit smoking is to make sure they have access to effective smoking-cessation tools. Research has shown that smokers who get help are twice as likely to succeed in quitting, and those who use a combination of medications and counseling are the most likely to quit. Few people succeed in quitting without getting some kind of help. More and better treatment options are available today than ever before, from prescription medications to over-the-counter aids to cessation counseling. Individual, group, telephone, and online counseling options are widely available. Counseling has proven effective for many smokers, and many achieve success by using a variety of these options. One online option—so that people who are trying to quit have access to help 24 hours a day—is the American Lung Association’s Freedom from Smoking (www.ffsonline.org) program. It offers help for smokers to address their psychological and behavioral addictions to smoking, which are increasingly recognized, along with physical

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addiction, as powerful barriers With no action, both the program available to any Minnesotan who wants to quit to quitting smoking. health and economic burdens smoking. For more information, call 888-354-7526 According to the surgeon of smoking will continue to or visit www.quitplan.com. general’s December report, scienmount for all of us. Nationtists know more today about wide, smoking costs more than why the brain craves nicotine. Like cocaine and heroin, nicotine $193 billion each year in health care costs and loss of productivity. changes how the brain works and causes a smoker to crave more and Smoking cessation benefits represent money well spent. Let’s more nicotine. These mental cravings make it hard for a smoker to make that commitment as a society, so that smokers committed to think of anything besides that next cigarette. quitting are in the best position to go from one of the seven in 10 To make matters worse, the report says, new research suggests who want to quit, to one of those who has succeeded in quitting. that tobacco companies have altered cigarettes to make them more Even if you have tried and failed in the past, try again. Perhaps addictive. The design and contents of today’s cigarettes make them you weren’t using the most effective quit aid. You may have had an more effective at delivering nicotine quickly and efficiently than cigaimproper dose. Or maybe you have never tried a combination rettes made many years ago. That is one of the many reasons why of medication and counseling. Today’s smoking-cessation quitting smoking can be so difficult. treatments and approaches to quitting are well worth trying. But the design and contents of today’s smoking-cessation treatWhether you get help through your health insurance plan at ment options have improved just as much. We just need to make work or through community-based quit assistance, there’s never them as accessible as possible. been a better time or better resources than now. For smokers who want to quit—and for the rest of us who care Pat McKone is director of tobacco about smokers in our workplaces, families, and circles of friends— control and policy for the American we can start by asking: Do insurance benefits include coverage of Lung Association in Minnesota. smoking-cessation treatments? To determine whether smoking-cessation coverage is part of your insurance plan, ask your insurer these questions: • Does my insurance plan cover medications or counseling to help me stop smoking? • If so, what exactly does it include? – What is the counseling benefit (individual, group, phone and/or online)? – Which prescription medications are covered? – Which over-the-counter medications are covered? • What is my copay? • How many attempts at quitting does my coverage include? (Quitting often requires multiple attempts.) • Is there a time limit on how long I can use quit aids or go to counseling? Best-practice guidelines from the Centers Few people for Disease Control and Prevention (CDC) succeed in and the U.S. Department of Health and quitting Human Services recommend access to counseling and all FDA-approved over-the-counter without and prescription medications, multiple quit getting attempts, and reduced or eliminated copays to give people the best chance of success. some kind In Minnesota, however, benefits vary of help. from one employer to the next. Benefits can also vary within companies that offer open enrollment. If you have open enrollment, review the plan options available to you and check the smoking-cessation benefits provided by each plan. If your insurance coverage does not include smoking-cessation assistance, talk to your employer. Paying for tobacco-cessation treatments is the most cost-effective health insurance benefit an employer can offer. Every dollar Minnesota spends on providing smoking cessation treatment will yield a potential average return of $1.32.

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AGING

The coming

storm Alzheimer’s escalates as America ages By George Schoephoerster, MD

met my mother-in-law, Dorothy, in 1978 when I was a medical student and she was the chief x-ray technologist in a small-town hospital in Iowa. She soon introduced me to her daughter Jeanie, who later became my wife. Dorothy was brilliant, conversational, and fun-loving, with a wide range of interests. She often vacationed with Jeanie, our children, and me. In 1998, when she was 70, we were heading west on just such a trip to the Rockies when Jeanie and I noticed that Dorothy no longer seemed to be able to figure out schedules on a calendar, manage her checkbook, or even drive safely. By the end of 1998, her neighbors had helped us realize she could no longer manage safely alone in her home, so we moved her to an assisted-living facility near our hometown of St. Cloud. Within two years, she moved into our home, because she now required assistance with bathing, dressing, and other activities of daily living. She continued a very rapid decline and died about 10 months later. The stress of caring for her 24/7, even with the help of hospice during the last

two months of her life, was exhausting for my wife. The growing impact of Alzheimer’s Our family’s story is typical of the course of dementia and its impact on family caregivers. And the emotional, social, and economic toll of Alzheimer’s disease (AD) will only continue to increase for the foreseeable future. The population of the United States is aging. In 2000, there were 35 million people over the age of 65— about 12 percent of the population. By 2030, the number of Americans over the age of 65 will double to about 70 million, representing 20 percent of the population; and by 2050, there could be as many as 85 million people over the age of 65. The biggest risk factor for getting dementia is aging itself. So we know that with this aging of the population, the number of Americans over 65 with dementia will increase. Current estimates are that 5.1 million Americans (13 percent of the U.S. population over 65) have Alzheimer’s, and that number is expected to increase to 13.5 million (16 percent) by 2050 (see Fig. 1).

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FIGURE 1. Number of Americans age 65 and older with Alzheimer’s disease, 2010–2050

FIGURE 2. Costs for care of people with Alzheimer’s disease

Cost in billions of dollars

$1.078 trillion

$906

$717

$547 $408 $307 $172

The cost of care for dementia is staggering. A recent report by the Alzheimer’s Association estimates that the direct costs of care to payers of health care—Medicare, Medicaid, private insurance, HMOs, out-of-pocket costs to patients and families, and uncompensated care—will rise from the current level of about $172 billion to a staggering $1.08 trillion by 2050 (see Fig. 2). And this figure does not include the value of unpaid care by families as caregivers, currently estimated to be around $144 billion and likely to increase in a similar manner. Another financial concern is that having AD has been shown to increase the cost of care for any other chronic disease a person might have by nearly tenfold. A disease we can’t prevent, delay, or cure What makes dementia different from other chronic diseases? Advances in the care of many chronic diseases, such as heart disease, cancer, and HIV, over the last couple of decades have reduced the number of deaths from those diseases. Data published by the Alzheimer’s Association in 2009 showed that from 2000 to 2006, the number of deaths from breast cancer declined by 2.6 percent, from prostate cancer by 8.7 percent, from heart disease by 11.1 percent, and from stroke by 18.2 percent. During that same period, the number of deaths from Alzheimer’s disease increased 46.1 percent. Currently there is no known way to prevent, cure, or even delay the progression of Alzheimer’s. Medications like Aricept and Namenda may temporarily delay functional decline, but they do not appear to change the progression of the underlying disease. Research has shown, though, that we can reduce the dementia patient’s suffering by reducing disability There is no known beyond that which would be way to prevent, cure, expected from dementia alone, improving behavioral sympor even delay the toms, and optimizing the qualiprogression of ty of life for patients and their Alzheimer’s. What we caregivers. If we could further reduce the cost of medical care can do is reduce being provided, it might make the dementia even more resources available to allay that suffering. patient’s suffering. We know that 95 percent of those with dementia have at least one other chronic disease and that those with dementia develop difficulty in managing their other chronic diseases. Having dementia, especially as it progresses, also affects the risks and benefits from any

2010

$202

2015

$241

2020

2025

2030

2035

2040

2045

2050

treatment options for those other chronic diseases. For example, I recently heard of a woman taking her husband, who had a diagnosis of moderate Alzheimer’s, to a physician who suggested inserting a pacemaker to treat an abnormal heart rhythm. Fortunately, the patient’s spouse responded, “Why would we do that? He’s dying from dementia!” and quickly laid that idea to rest. When dementia remains unrecognized, both cost and quality of care for that patient are affected. A case in point that I have seen often happens when a caring daughter or son, visiting on a weekend from a distant community, notices that a parent seems “weak” and decides to take him or her to the emergency room. Thus can begin an The coming storm to page 30

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The coming storm from page 29

FIGURE 3. Impact of a 5-year delay in onset on costs, Americans age 65 and older with Alzheimer’s disease, 2010–2050

expensive evaluation and perhaps a hospital stay where many things might be tried to address the “weakness,” often leading to even more complications, including more confusion, all of which can lead to a nursing home stay—but still with no clear diagnosis of a cognitive deficit, which was the real cause of the “weakness” in the first place. What research tells us Despite the absence of a cure for Alzheimer’s, there are many ways we can lessen the impact of the disease on patients, their families, and society in general. One model for this is the Dementia Demonstration Project, developed at the Minneapolis Veterans Affairs (VA) Medical Center. In this cost-saving prototype, an advanced-practice registered nurse functioned as a care coordinator, leading an interdisciplinary team in the early identification, evaluation, diagnosis, and management of cognitive impairment of all patients 70 and older who visited outpatient VA clinics in the Upper Midwest. Work by Mary Mittelman and colleagues in 2006 showed that improving caregiver well-being delayed the nursing home placement of patients with Alzheimer’s. And a sophisticated cost-benefit analysis in 2009 by David Weimer and Mark Sager at the University of Wisconsin suggested that early diagnosis of Alzheimer’s disease pro-

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MINNESOTA HEALTH CARE NEWS MARCH 2011

vides measurable cost savings not only in terms of the social aspects of the disease but also in terms of the cost of the medical care itself. Research in dementia holds a key to solving the issues raised by the escalating incidence of the disease. The Alzheimer’s Association’s 2010 report showed the financial impact of any future treatment breakthrough that would either delay the onset of the disease or slow its progression (see Fig. 3). Cost savings over the next 40 years of their model ranged from 10 percent to 40 percent, in addition to its positive impact on patients and caregivers. Early screening is vital Despite the absence of a cure for Alzheimer’s, there are many ways that we can, and must, ameliorate the impact of the disease on patients and their families. Research has shown that we can have a positive impact on dementia by getting better at early diagnosis and management of dementia, supporting caregivers both emotionally and financially, and supporting more research that could lead to delaying the onset of the disease and/or slowing its progression. Because early diagnosis is so important for managing dementia, anyone 65 or older, or anyone else who has concerns about their memory, should ask their health care provider to screen them for Alzheimer’s and other forms of dementia. Since Jan. 1, Medicare has been paying for an annual wellness exam for all Medicare recipients, which includes screening for dementia. At least five studies have demonstrated that patients prefer to know about a diagnosis of Alzheimer’s as soon as possible in the disease’s course. This allows them to plan for their future while they still can, and it gives their family members the opportunity to learn about dementia and their role as caregivers. In our family, knowing Dorothy’s diagnosis was extremely important as we worked with her doctor to develop management schemes for her. In Alzheimer’s disease, it’s the surprises, the things that you don’t know, that hurt you the most. Screening for cognitive impairment is quick and easy. The Mini-Cog (a composite of three-item recall and drawing a picture of a clock) takes only a few minutes to administer and can be done by whoever escorts a patient to the exam room. So what do you do if your cognitive screen is positive? Your doctor can help you begin to manage this chronic disease and any impact it may have on you and on any of your other health problems. The Alzheimer’s Association can provide valuable support for you and your family. Call our helpline at 800-272-3900 or visit our website at www.alz.org/mnnd. We can provide educational materials and/or referral sources and other options to help you and your family plan for the future while living your best for today. George Schoephoerster, MD, practices with CentraCare Clinic, Geriatric Services of Minnesota/ St. Cloud. He is medical director of the Early Intervention Project for the Alzheimer’s Association Minnesota–North Dakota.

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HEALTH POLICY

Fixing our broken health care system What the heck happened? By David Feinwachs, JD, PhD

veryone agrees that our current health care system needs fixing. While people may disagree on what changes are needed, we can all agree that there’s no fixing the system if we don’t understand how it works. We don’t know how our current system works—even though a huge part of it in Minnesota is funded with state and federal tax dollars. Minnesota health maintenance organizations (HMOs) need to answer some simple questions: 1. What did you buy with the public money that was given to you? 2. Whom did you buy it from and what did you pay for it? 3. Most importantly, how much did you keep for yourself? The reason we haven’t been able to get answers to these questions makes for an interesting story. At one time, state employees administered public health care programs in Minnesota, paying claims from a fee schedule and incurring a modest overhead cost of about 4 percent to run the system. Then, just over 20 years ago, the state undertook a pilot project

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outsourcing large parts of its Medicaid program to private HMOs on the theory that they could deliver better health care at a lower cost while relieving the state of an administrative burden. This pilot project was to be evaluated for cost effectiveness and health care outcomes to demonstrate the soundness of the outsourcing theory. Twenty years later, that has never occurred.

The HMOs argue that their conduct is a trade secret and that this secrecy must be maintained to protect their competitive advantage.

Prepaid Medical Assistance Program

In 1992, the state created MinnesotaCare (MNCare), a publicly subsidized program for Minnesota residents who do not have access to affordable health care coverage. At the same time, it bundled together all Minnesota health care programs that received public funding— Medical Assistance (Minnesota’s Medicaid program), MinnesotaCare, the now-defunct General Assistance Medical Care (GAMC), workers’ compensation, and the health care program for state employees. With this bundling the state told providers that, to participate in any of these programs, they must participate in all of them. The idea was that this would assure patients adequate access to providers and would assure providers reimbursement for all programs by leveraging the better-paying programs (such as workers’ comp and state employees’ health care) against the poorly paid programs (such as MNCare and GAMC). Although no data were available to justify the decision, in 1995 the managed-care Medicaid pilot became a permanent program, called the Prepaid Medical Assistance Program (PMAP). With the outsourcing of the medical assistance program on a permanent basis, the state also outsourced to the HMOs the all-ornothing participation requirement. This significant economic benefit has been in the hands of PMAP HMO vendors, unchecked for many years now, and there is no real way of knowing if it is being used primarily to benefit the state, or also for the economic advantage of the HMOs themselves. The Prepaid Medical Assistance Program is an incredibly good deal for HMOs. They are compensated for any and all administrative expenses. There is no definition of what constitutes “reasonable” or “appropriate” administrative expense. Their contracts with the state guarantee the HMOs a minimum profit (approximately 2 percent), but there is no limit on maximum profitability or expense recovery. A common misconception regarding this program is that because HMOs receive set, per-patient fees that do not take into account the treatment required, they are assuming some sort of insurance or managed-care risk. In fact, the HMOs hold virtually no risk. The Minnesota Department of Human Services (DHS) sets rates based on the health plans’ total expenses and expenditures. Their actual experience for the prior year becomes the justification for certifying rates in the subsequent year. Because there is no competition and all HMOs are permitted to participate as PMAP vendors, the only risk to the

HMOs would be if the state of Minnesota ceased to exist before they recovered all their expenses and costs for the previous year. Not likely. So each year the HMOs receive increases to the contractual price for reasons that are less than apparent. Lack of transparency, accountability

The lack of transparency in our PMAP program causes many problems. It is impossible to determine who is being paid for what and whether there is any economic or quality justification for payments that are higher or lower than usual. How can we consider any proposals to repair or improve our health care system without this kind of information? How can we fix it if we don’t know how it works? Why would we ever allow vendors receiving public money to be exempt from this kind of commonsense disclosure? In addition, the competitive advantage argument has no application, when every HMO is allowed to participate with no competitive bidding. Legislative action (and inaction)

During the 2010 Legislature, legislators introduced bills that would have required HMOs to actually keep books using the generally accepted principles of accounting and to make those books available for audit. The legislation also would have required the HMOs to spend a majority of health care money they received from the state for health care. These proposals were defeated, after arguments from the Minnesota Department of Human Services (DHS) that any failure to pay HMOs for any and all of their expenses would violate established principles of actuarial soundness. These arguments persuaded the Fixing our broken health care system to page 34

In the next issue.. • Pediatrics • Food safety • Spinal stenosis MARCH 2011 MINNESOTA HEALTH CARE NEWS

Fixing our broken health care system from page 33

The Prepaid Medical Assistance Program is an incredibly good deal for HMOs.

Legislature not only to defeat the legislative proposals described above, but to amend existing law to add language statutorily legitimizing rates paid to managed care plans. The amendment stated that in order to justify federal matching dollars, PMAP vendors would have to “… be certified as meeting the requirements of federal regulations by actuaries who follow the practice standards established by the American Academy of Actuaries and … the Actuarial Standards Board.” Legislators were assured that this statutory change would provide security that all was well in our public programs. At the time these assurances were being made, some health care providers expressed concern that the standards proposed for incorporation into Minnesota law in fact did not exist. Their concerns went unanswered. On Aug. 4, the U.S. Government Accountability Office (GAO) issued a report to congressional committees criticizing oversight by the Centers for Medicare & Medicaid Services (CMS) of state ratesetting. Most notably for Minnesota, the report stated: “… There is no Actuarial Standard of Practice (ASOP) that applies to actuarial work performed to comply with CMS’s regulations.” In addition, the GAO report noted that in 2005 the American Academy of Actuaries had issued “nonbinding guidance” describing what its standards would look like if indeed they existed. This guidance recommended that “… rates do not have to encompass all possible costs that any health plan might incur.” This view is completely contrary to current Minnesota DHS and health plan practices.

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We are still waiting for answers. The HMOs are in the process of making deals with big hospital systems to create what are called “accountable care organizations,” per the federal Affordable Care Act. Nobody really knows how these organizations might actually work, but it’s pretty clear that the HMOs will provide financial incentives for hospital system participation. These organizations will not provide services solely to tax-funded programs; they will, in fact, become the mechanism by which all of us receive our health care. Shouldn’t we know how they work? Health insurers, meanwhile, are preparing bids to run privately managed Medicaid plans for the states. Winners will be in position to benefit from the expansion of Medicaid in 2014. Gail Boudreaux, UnitedHealth executive vice president, was quoted in the Dec. 29, 2010, Wall Street Journal as telling investors: “The Medicaid space is a significant long-term growth opportunity for us.” It’s clear that the HMOs are now targeting the elderly and disabled and demanding that their medical care be swept into this invisible and unaccountable system. Shouldn’t we know what they do with the money we currently give them before we decide to hand over our most vulnerable populations? For the 2011 Legislature

What needs to be done immediately, i.e., in the 2011 legislative session? We must demand answers to our questions. We must insist on understanding exactly how the current system works before the HMOs are permitted to make any additional changes. Here’s what we need to do: • The state and the taxpayers must have information. Minnesota should require HMO vendors to maintain segregated accounts for public programs and money. • There must be a way for the state to audit these accounts in order to maintain transparency and accountability on the part of our HMO vendors. • Most importantly, in light of the health plan/hospital system business collaborations, full disclosure of any and all financial incentives or arrangements must be made public so that health care consumers understand how these financial incentives are aligned and how they might work against them as patients.

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We must now confront a critically important issue: What if HMOs are one of the largest cost drivers in our health care system? What if they are overpaid and largely unnecessary brokers connecting very willing sellers with desperate purchasers? Wouldn’t we want to know whether this was true? If we fail to demand data regarding our tax-funded programs and neglect to answer these questions, then we forfeit any right to complain. David Feinwachs, JD, PhD, served for 30 years as legal counsel to the Minnesota Hospital Association. The association fired him last fall after he made video presentations for a group advocating PMAP reform. The videos described the PMAP system as a “black box” with no realistic accounting oversight. Feinwachs teaches courses in health law and policy at the University of Minnesota.

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