Minnesota Physician May 2015 by Minnesota Physician Publishing

Vo l u m e x X I X , N o . 2 M a y 2 015

International medical graduates Minnesota’s untapped physician workforce By Edwin Bogonko, MD, and Edward Ehlinger, MD, MSPH

hat if Minnesota had a resource that could simultaneously reduce health disparities, health inequities, and health care costs? And what if that resource could also help the state catch up with huge demographic shifts, replenishing and diversifying the health workforce with clinicians capable of providing primary care where it is needed most?

Prior authorization Why legislation is needed By Sen. Melisa Franzen, MPP, JD

first heard about the challenges with prior authorization (PA) at the home of some of my physician constituents. They, and soon many others, told me that the prior authorization process was time-consuming, frustrating, and costly. Although a necessary process in some cases, prior authorization is too often a roadblock and headache for delivering effective care for those who need it the most; patients. The current prior authorization system is unclear and difficult to understand.

Doctors are often left scratching their heads when they prescribe medications that are covered by insurance plans, but require the additional step of prior authorization. They must then scramble to find medication the health plan will cover, or start the process to convince the plan that this is the best drug for the patient. For patients, they are caught in the middle and unable to get the medications they need. In some cases, patients have their current Prior authorization to page 16

We have such a resource. It’s the state’s numerous international medical graduates who come to the U.S. as refugees, asylees, or other immigrants and find they cannot practice in their new home. Even the most highly qualified— those fluent in multiple languages, and with years of experience delivering care in a variety of settings and with a passion for serving those in need—run into impenetrable roadblocks that no amount of expertise, effort, or drive can surmount. We have a ready asset base we ought to tap into. International medical graduates to page 18

rehabilitation services from P ost-acute the Good Samaritan Society. Post-acute care is designed to heal and assist patients with care and support following a hospitalization from serious illness, injury or elective surgical procedure. Multiple in-patient and out-patient post-acute locations are located throughout the Twin Cities metro area and state of Minnesota. To learn more about our post-acute services, call us at 866-GSSCARE or visit www.good-sam.com/minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. ÂŠ 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G0066

An approach to consider for type 2 diabetes therapy starts here

Trulicityâ&#x201E;˘ is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Select Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, and Brief Summary of Prescribing Information on following pages. Please see Instructions for Use included with the pen. May 2015 Minnesota Physician

Trulicity offers proven A1C reduction* and once-weekly dosing in the Trulicity pen â&#x201E;˘

*In clinical trials, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose.1

Trulicity may be a good option for adult patients with type 2 diabetes who need more control than oral medications are providing.1 To learn more about Trulicity and the savings card for patients, talk to your Lilly sales representative or visit Trulicity.com.

Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

DG95134

02/2015 PRINTED IN USA

Minnesota Physician MAY 2015

Trulicity is contraindicated in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components. Risk of Thyroid C-cell Tumors: Counsel patients regarding the risk of medullary thyroid carcinoma and the symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Patients with elevated serum calcitonin (if measured) and patients with thyroid nodules noted on physical examination or neck imaging should be referred to an endocrinologist for further evaluation. Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected discontinue Trulicity promptly. Do not restart if pancreatitis is confirmed. Consider other antidiabetic therapy in patients with a history of pancreatitis. Please see Important Safety Information continued on following page.

Important Safety Information, continued

Once-weekly Trulicity 1.5 mg showed significant A1C reduction1

Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia.

Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg for additional glycemic 1-3 control.

A1C reduction from baseline

8.4

Hypersensitivity Reactions: Systemic reactions were observed in clinical trials in patients receiving Trulicity. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice.

Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients.

8.0

Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree. Pregnancy: There are no adequate and well-controlled studies of Trulicity in pregnant women. Use only if potential benefit outweighs potential risk to fetus. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. A decision should be made whether to discontinue nursing or to discontinue Trulicity taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age. Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen. DG HCP ISI 12NOV2014 Trulicity™ is a trademark of Eli Lilly and Company and is available by prescription only. Other product/company names mentioned herein are the trademarks of their respective owners.

Byetta® (10 mcg BID) (n=276; Baseline A1C: 8

7.8 7.6

-0.5

7.4

Trulicity™ (0.75 mg) (n=280; Baseline A1C: 8

7.2 7.0

‡

-1.0

6.8

-1.3* † -1.5*

†

6.6 6.4

93% fewer injections3

Trulicity™ (1.5 mg) (n=279; Baseline A1C: 8

6.2 Baseline

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. The most common adverse reactions reported in ≥5% of Trulicity-treated patients in placebo-controlled trials (placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%).

Placebo (n=141; Baseline A1C: 8

8.2

LS mean A1C LS mean A1C(%) (%)

Renal Impairment: In patients treated with GLP-1 RAs there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions.

1-3

Week 13

Week 26

Placebo (n=141; Baseline A1C: 8.1%) Byetta® (10 mcg BID) (n=276; Baseline A1C: 8.1%) Trulicity™ (0.75 mg) (n=280; Baseline A1C: 8.1%) Trulicity™ (1.5 mg) (n=279; Baseline A1C: 8.1%) Data represent least-squares mean ± standard error. * Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C. † Multiplicity-adjusted 1-sided P value <.001 for superiority of Trulicity vs placebo for A1C. Mixed model repeated measures analysis. After 26 weeks, placebo-treated patients were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg. ‡ American Diabetes Association recommended target goal. Treatment should be individualized.4 •

Data represent least-squares mean ± standard error.

52-week, randomized, placebo-controlled phase 3 study

*(open-label assignment to Byetta or blinded assignment to

Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C.

Trulicity or placebo) of adult patients with type 2 diabetes Multiplicity-adjusted 1-sided P value <.001 for(≥1500 superiority of Trulicity vs placebo for A1C. treated with maximally tolerated metformin mg/day) and Actos® to 45 mg/day) Mixed model(up repeated measures analysis. • Primary objective was to demonstrate superiority of Trulicity After 26vsweeks, placebo-treated were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg. 1.5 mg placebo on change inpatients A1C from baseline at 26 ‡weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% American Diabetes Association recommended target goal. Treatment should be individualized.4 CI [-1.2, -0.9]; multiplicity-adjusted 1-sided P value <.001; analysis of covariance using last observation carried •forward); primary objective met †

52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated 1. Trulicity [Prescribing Information]. tolerated metformin (≥1500 mg/day) and Actos (up to 45 mg/day) Indianapolis, IN: Lilly USA, LLC; 2014. References assignment

2. Data on file, Lilly USA, LLC. TRU20140910A. • Data Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo o 3. on file, Lilly USA, LLC. TRU20140919C. 4. American Diabetes Association. Standards from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [ of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80. adjusted 1-sided P value <.001; analysis of covariance using last observation carr

objective met

References 1. Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC; 2014. 2. Data on file, Lilly USA, LLC. TRU20140910A. 3. Data on file, Lilly USA, LLC. TRU20140919C. 4. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.

May 2015 Minnesota Physician

TrulicityTM

(dulaglutide) Brief Summary: Consult the package insert for complete prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS • In male and female rats, dulaglutide causes a dose-related and treatment-durationdependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. • Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors. INDICATIONS AND USAGE Trulicity™ is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise. Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not recommended in patients with pre-existing severe gastrointestinal disease. The concurrent use of Trulicity and basal insulin has not been studied. CONTRAINDICATIONS Do not use in patients with a personal or family history of MTC or in patients with MEN 2. Do not use in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components. WARNINGS AND PRECAUTIONS Risk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. Glucagon-like peptide (GLP-1) receptor agonists have induced thyroid C-cell adenomas and carcinomas in mice and rats at clinically relevant exposures. It is unknown whether Trulicity will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of this signal could not be determined from the clinical or nonclinical studies. One case of MTC was reported in a patient treated with Trulicity. This patient had pretreatment calcitonin levels approximately 8 times the upper limit of normal (ULN). Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the risk for MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). The role of serum calcitonin monitoring or thyroid ultrasound monitoring for the purpose of early detection of MTC in patients treated with Trulicity is unknown. Such monitoring may increase the risk of unnecessary procedures, due to the low specificity of serum calcitonin as a screening test for MTC and a high background incidence of thyroid disease. Very elevated serum calcitonin value may indicate MTC and patients with MTC usually have calcitonin values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Patients with thyroid nodules noted on physical examination or neck imaging should also be referred to an endocrinologist for further evaluation. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitisrelated adverse reactions were reported in patients exposed to Trulicity versus 3 in non-incretin comparators (2.7 cases per 1000 patient years). An analysis of adjudicated events revealed 5 cases of confirmed pancreatitis in patients exposed to Trulicity (1.4 cases per 1000 patient years) versus 1 case in non-incretin comparators (0.88 cases per 1000 patient years). After initiation of Trulicity, observe patients carefully for signs and symptoms of pancreatitis, including persistent severe abdominal pain. If pancreatitis is suspected, promptly discontinue Trulicity. If pancreatitis is confirmed, Trulicity should not be restarted. Trulicity has not been evaluated in patients with a prior history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia with Concomitant Use of Insulin Secretagogues or Insulin: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia. Hypersensitivity Reactions: Systemic hypersensitivity reactions were observed in patients receiving Trulicity in clinical trials. If a hypersensitivity reaction occurs, the patient should discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75 Minnesota Physician MAY 2015

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. ADVERSE REACTIONS Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg) nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions : In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 43% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and activecontrolled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia : Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials: Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), TRULICITY 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5 mg: 5.0%; Severe: all 0. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. Documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented symptomatic hypoglycemia occurred in 85% and 80% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Severe hypoglycemia occurred in 2.4% and 3.4% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Heart Rate Increase and Tachycardia Related Adverse Reactions : Trulicity 0.75 mg and 1.5 mg resulted in a mean increase in heart rate (HR) of 2-4 beats per minute (bpm). The long-term clinical effects of the increase in HR have not been established. Adverse reactions of sinus tachycardia were reported more frequently in patients exposed to Trulicity. Sinus tachycardia was reported in 3.0%, 2.8%, and 5.6% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Persistence of sinus tachycardia (reported at more than 2 visits) was reported in 0.2%, 0.4% and 1.6% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Episodes of sinus tachycardia, associated with a concomitant increase from baseline in heart rate of ≥15 beats per minute, were reported in 0.7%, 1.3% and 2.2% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Immunogenicity : Across four Phase 2 and five Phase 3 clinical studies, 64 (1.6%) TRULICITY-treated patients developed anti-drug antibodies (ADAs) to the active ingredient in Trulicity (ie, dulaglutide). Of the 64 dulaglutide-treated patients that developed dulaglutide ADAs, 34 patients (0.9% of the overall population) had dulaglutideneutralizing antibodies, and 36 patients (0.9% of the overall population) developed antibodies TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

PRINTER VERSION 1 OF 2

against native GLP-1. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, the incidence of antibodies to dulaglutide cannot be directly compared with the incidence of antibodies of other products. Hypersensitivity: Systemic hypersensitivity adverse reactions sometimes severe (eg, severe urticaria, systemic rash, facial edema, lip swelling) occurred in 0.5% of patients on Trulicity in the four Phase 2 and Phase 3 studies. Injection-site Reactions : In the placebo-controlled studies, injection-site reactions (eg, injection-site rash, erythema) were reported in 0.5% of Trulicity-treated patients and in 0.0% of placebo-treated patients. PR Interval Prolongation and Adverse Reactions of First Degree Atrioventricular (AV) Block : A mean increase from baseline in PR interval of 2-3 milliseconds was observed in Trulicity-treated patients in contrast to a mean decrease of 0.9 millisecond in placebo-treated patients. The adverse reaction of first degree AV block occurred more frequently in patients treated with Trulicity than placebo (0.9%, 1.7% and 2.3% for placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively). On electrocardiograms, a PR interval increase to at least 220 milliseconds was observed in 0.7%, 2.5% and 3.2% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Amylase and Lipase Increase: Patients exposed to Trulicity had mean increases from baseline in lipase and/or pancreatic amylase of 14% to 20%, while placebo-treated patients had mean increases of up to 3%. DRUG INTERACTIONS Trulicity slows gastric emptying and thus has the potential to reduce the rate of absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are concomitantly administered with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to any clinically relevant degree. USE IN SPECIFIC POPULATIONS Pregnancy - Pregnancy Category C: There are no adequate and well-controlled studies of Trulicity in pregnant women. The risk of birth defects, loss, or other adverse outcomes is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes to maintain good metabolic control before conception and throughout pregnancy. Trulicity should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In rats and rabbits, dulaglutide administered during the major period of organogenesis produced fetal growth reductions and/or skeletal anomalies and ossification deficits in association with decreased maternal weight and food consumption attributed to the pharmacology of dulaglutide. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for clinical adverse reactions from Trulicity in nursing infants, a decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established in pediatric patients. Trulicity is not recommended for use in pediatric patients younger than 18 years. Geriatric Use: In the pool of placebo- and active-controlled trials, 620 (18.6%) Trulicity-treated patients were 65 years of age and over and 65 Trulicity-treated patients (1.9%) were 75 years of age and over. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Hepatic Impairment: There is limited clinical experience in patients with mild, moderate, or severe hepatic impairment. Therefore, Trulicity should be used with caution in these patient populations. In a clinical pharmacology study in subjects with varying degrees of hepatic impairment, no clinically relevant change in dulaglutide pharmacokinetics (PK) was observed. Renal Impairment: In the four Phase 2 and five Phase 3 randomized clinical studies, at baseline, 50 (1.2%) Trulicity-treated patients had mild renal impairment (eGFR ≥60 but <90 mL/min/1.73 m2), 171 (4.3%) Trulicity-treated patients had moderate renal impairment (eGFR ≥30 but <60 mL/min/1.73 m2) and no Trulicity-treated patients had severe renal impairment (eGFR <30 mL/min/1.73 m2). No overall differences in safety or effectiveness were observed relative to patients with normal renal function, though conclusions are limited due to small numbers. In a clinical pharmacology study in subjects with renal impairment including end-stage renal disease (ESRD), no clinically relevant change in dulaglutide PK was observed. There is limited clinical experience in patients with severe renal impairment or ESRD. Trulicity should be used with caution, and if these patients experience adverse gastrointestinal side effects, renal function should be closely monitored. Gastroparesis: Dulaglutide slows gastric emptying. Trulicity has not been studied in patients with pre-existing gastroparesis. OVERDOSAGE Overdoses have been reported in clinical studies. Effects associated with these overdoses were primarily mild or moderate gastrointestinal events (eg, nausea, vomiting) and non-severe hypoglycemia. In the event of overdose, appropriate supportive care (including frequent plasma glucose monitoring) should be initiated according to the patient’s clinical signs and symptoms. PATIENT COUNSELING INFORMATION See FDA-approved Medication Guide • Inform patients that Trulicity causes benign and malignant thyroid C-cell tumors in rats and that the human relevance of this finding is unknown. Counsel patients to report symptoms of thyroid tumors (eg, a lump in the neck, persistent hoarseness, dysphagia, or dyspnea) to their physician. • Inform patients that persistent severe abdominal pain, that may radiate to the back and which may (or may not) be accompanied by vomiting, is the hallmark symptom of acute pancreatitis. Instruct patients to discontinue Trulicity promptly, and to contact their physician, if persistent severe abdominal pain occurs. • The risk of hypoglycemia may be increased when Trulicity is TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75

used in combination with a medicine that can cause hypoglycemia, such as a sulfonylurea or insulin. Review and reinforce instructions for hypoglycemia management when initiating Trulicity therapy, particularly when concomitantly administered with a sulfonylurea or insulin. • Patients treated with Trulicity should be advised of the potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid fluid depletion. Inform patients treated with Trulicity of the potential risk for worsening renal function and explain the associated signs and symptoms of renal impairment, as well as the possibility of dialysis as a medical intervention if renal failure occurs. • Inform patients that serious hypersensitivity reactions have been reported during postmarketing use of GLP-1 receptor agonists. If symptoms of hypersensitivity reactions occur, patients must stop taking Trulicity and seek medical advice promptly. • Advise patients to inform their healthcare provider if they are pregnant or intend to become pregnant. • Prior to initiation of Trulicity, train patients on proper injection technique to ensure a full dose is delivered. Refer to the accompanying Instructions for Use for complete administration instructions with illustrations. • Inform patients of the potential risks and benefits of Trulicity and of alternative modes of therapy. Inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and advise patients to seek medical advice promptly. • Each weekly dose of Trulicity can be administered at any time of day, with or without food. The day of once weekly administration can be changed if necessary, as long as the last dose was administered 3 or more days before. If a dose is missed and there are at least 3 days (72 hours) until the next scheduled dose, it should be administered as soon as possible. Thereafter, patients can resume their usual once weekly dosing schedule. If a dose is missed and the next regularly scheduled dose is due in 1 or 2 days, the patient should not administer the missed dose and instead resume Trulicity with the next regularly scheduled dose. • Advise patients treated with Trulicity of the potential risk of gastrointestinal side effects. • Instruct patients to read the Medication Guide and the Instructions for Use before starting Trulicity therapy and review them each time the prescription is refilled. • Instruct patients to inform their doctor or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens. • Inform patients that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and HbA1c levels, with a goal of decreasing these levels towards the normal range. HbA1c is especially useful for evaluating long-term glycemic control.

Eli Lilly and Company, Indianapolis, IN 46285, USA US License Number 1891 Copyright © 2014, Eli Lilly and Company. All rights reserved. Additional information can be found at www.trulicity.com DG HCP BS 12NOV2014 TrulicityTM (dulaglutide)

DG HCP BS 12NOV2014

PRINTER VERSION 2 OF 2 MAY 2015 Minnesota Physician

The 2015–2016 Season

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Minnesota Physician May 2015

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May 2015 • Volume XXIX, No. 2

Features Prior authorization Why legislation is needed

By Sen. Melisa Franzen, MPP, JD

International medical graduates 1 Minnesota’s untapped physician workforce By E dwin Bogonko, MD, and Edward Ehlinger, MD, MSPH

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Dawn Ellison, MD, CPC Influencing Healthcare

Neurology

Otolaryngology

Research

Wellness and Prevention

The Brain Health Registry By Michael Weiner, MD

Accelerating the preventive agenda By Peter Mills, MSc, MD

Time is brain By Irfan Altafullah, MD, FAHA

Balloon dilation of the sinuses By Theodore O. Truitt, MD

Special FoCus: Physician Support Services Child and adolescent 24 psychiatry By Todd Archbold, LSW, MBA

Transitioning complex 28 pediatric patients By J udy Schloss, RRT-NPS, AE-C, and Rebecca Long, RRT-NPS

Professional Update: Women’s health Alcohol use disorders in women 32 By Pamela J. Shultz, MD

10th ANNUAL PAIN CONFERENCE Please plan to join us for a full day educational conference that includes the latest interventional pain management treatment options, appropriate opioid prescribing information as well as many other pain related topics.

Utilizing a

Multidisciplinary Approach in Pain Management

Pain Psychology Protocol Based Prescribing and Opioid Safety

Diagnosis and

Treatment for the Headache Patient

Healthcare Reform /

Patient Engagement Strategies

Emerging Therapies: The Direction of Pain Management

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

Conference registration and CME programs: www.painphysicians.com 888.901.7246 (PAIN) / 608-604-4659

For more information contact Ginny Cairns at ginny.cairns@apmhealth.com

May 2015 Minnesota Physician

capsules

State Hospitals Fare Well on Medicare Star Rating System Twelve Minnesota hospitals were awarded the top rating of five stars on the new Centers for Medicare and Medicaid Services (CMS) star rating system based on patient reviews. Results from hospitals’ patient satisfaction surveys have previously been listed on the Medicare website, but this is the first time a star rating has been applied to those scores. Ratings were posted on April 16. Nationally, 251 hospitals, or about 7 percent of the 3,553 hospitals rated, received a five-star rating. About 34 percent received four stars, 40 percent received three stars, and 16 percent received two stars. More than 1,100 hospitals did not receive a star rating because not enough patient surveys were completed within the designated timeframe. The highest average ratings were in Maine, Minnesota, Nebraska, South Dakota, and Wisconsin, while the lowest average ratings were in California,

Florida, Maryland, Nevada, New Jersey, New York, and the District of Columbia. There were 34 states that had no one-star rated hospitals and 13 states that had no five-star hospitals. Of the hospitals in Minnesota, 86 had enough patient surveys to receive a star rating. Out of those, 53 received four stars (about 62 percent); 19 received three stars (about 22 percent); and two received two stars (just over 2 percent). The Minnesota hospitals that received five stars are Big Fork Valley Hospital; Fairview Northland Regional Hospital in Princeton; HealthEast Woodwinds Hospital in Woodbury; Lakeview Memorial Hospital in Stillwater; Lakewood Health System in Staples; Mayo Clinic Health System–New Prague; Municipal Hospital and Granite Manor in Granite Falls; New Ulm Medical Center; Redwood Area Hospital in Redwood Falls; Riverwood Healthcare Center in Aitkin; Sanford Luverne Medical Center; and Sleepy Eye Municipal Hospital. Some experts are concerned that the ratings won’t accurately

Minnesota Physician May 2015

reflect a hospital’s quality or will be misleading because they are only based on patient reviews. “There’s a risk of oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons,” the American Hospital Association said in a statement. Others don’t think it’s likely that the ratings will have much effect on consumers. “It’s nice they’re going to try to be more consumer friendly,” said Evan Marks of Healthgrades. “I don’t see that the new star rating itself is going to drive consumer adoption. Ultimately, you can put the best content up on the web, but consumers aren’t going to just wake up one day and go to it.”

HCMC to Consolidate and Expand Downtown Campus Hennepin County Medical Center (HCMC) will move forward with plans for a new clinic and special-

ty building after it received approval from the Hennepin County Board on April 14 for the project, the scope of which is larger than originally planned. The project will consolidate HCMC’s downtown clinics and specialties into one six-story, 367,000-square-foot building to be located in east downtown Minneapolis. The total project cost will be $224.6 million. The original plan was to construct a 322,000-square-foot building for $191.7 million with the possibility of future expansion. Hospital officials determined that this would not create the space needed to accommodate consolidation of all the clinics and specialty buildings. “As we completed a careful analysis of our current needs and the volume growth that we’ve seen in the past two years, it has become clear that we would not be able to consolidate all of the clinics and services that are today spread across nine buildings downtown in the square footage originally proposed,” said Scott Wordelman, vice president of ambulatory services at HCMC.

Hospital officials expect to break ground on the project in November and open to patients in December 2017. “Understanding the changing needs and development in the east downtown area, this plan gives us the greatest flexibility for the rest of the campus as we take a fresh look at our facilities,” said Wordelman.

Heart Failure Patients See Improvements with Palliative Care Palliative care for hospitalized heart failure patients is associated with improvements in depression symptoms, quality of life, and symptom burden, according to results of a study by Allina Health. The study, “Inpatient Palliative Care for Patients with Acute Heart Failure,” was published in the Journal of Palliative Medicine. Palliative care has previously been known to help with these issues for cancer patients, and Allina researchers wanted to determine if the same would be true for heart failure patients. “Heart failure patients are good candidates for palliative care because heart failure is associated with high symptom burden, functional impairment, increased caregiver burden, and high rehospitalization rates,” said Hallie Richards, MD, palliative care physician with Allina. “However, despite consensus statement recommendations by national cardiology groups, heart failure patients rarely receive services from palliative care providers compared to cancer patients.” Abbott Northwestern Hospital Foundation funded the study, which included a randomized control trial testing inpatient palliative care services for acute heart failure patients. Researchers looked at 232 patients over a 10-month period. Half received palliative care intervention and half did not. Outcomes were measured at one and three months. At one month, quality of life improved by 12.92 points in the intervention group and 8 points in the control group, and symptom burden improvement was 8.39 in the intervention group and 4.7 in the control group. “There were noticeable, meaningful differences between the intervention and control groups at

one and three months after hospitalization from an intervention that took place during generally short inpatient stays, and with 80 percent of patients receiving only one visit with a palliative care provider,” said Abbey Sidebottom, MPH, senior scientific advisor at Allina Health Hospitals & Clinics and lead author of the paper. “Patients with palliative care visits had larger improvements in symptom burden, depression symptoms, and quality of life.” Participants in the study were also three times as likely to complete an advanced care planning process within six months after hospitalization, according to Sidebottom. THE 5 BROWNS

HealthPartners to Support National Prevention Priorities HealthPartners has announced it will be working more in-depth with the National Commission on Prevention Priorities (NCPP). The NCPP is comprised of leaders of federal agencies, private industries, public health, and health care who help decision-makers choose preventive services that maximize the impact of their investments. Previously, HealthPartners has analyzed clinical rankings for the NCPP. Now, it will also provide administrative services, help secure funding, and contribute to strategic direction of the NCPP. “The NCPP is well-positioned to help shape key national discussions in the realm of clinical and community prevention using rigorous data from the evidence-based modeling conducted by the Institute,” said Eduardo Sanchez, MD, MPH, chair of the NCPP and chief medical officer for prevention at the American Heart Association. “As an integrated organization that provides both health services, financing, and research, HealthPartners has a unique opportunity to advance efforts to improve population health and disease prevention on a national scale,” said George Isham, MD, MS, senior advisor for HealthPartners.

ANDRÉ WATTS

GARRICK OHLSSON

LIVE AT ORCHESTRA HALL

The 5 Browns

Fri May 15 8pm When The 5 Browns sit at their 5 Steinways and play arrangements from Gershwin to Rachmaninoff, you won’t believe your ears. No wonder the famed Juilliard School admitted them all—simultaneously. Please note: The Minnesota Orchestra does not perform on this program.

Garrick Ohlsson Plays Brahms

Thu May 21 11am / Fri May 22 & Sat May 23 8pm Stanislaw Skrowaczewski, conductor / Garrick Ohlsson, piano The extraordinary Garrick Ohlsson plays the youthful and vigorous Piano Concerto No. 1 by Brahms; this exhilarating program concludes with Beethoven’s dance-infused Symphony No. 7.

André Watts with Osmo Vänskä

Thu May 28 11am / Fri May 29 & Sat May 30 8pm Osmo Vänskä, conductor / André Watts, piano Brahms called his Piano Concerto No. 2, “a tiny, tiny, pianoforte concerto" but it is anything but that, especially when played by the legendary André Watts. Then Osmo Vänskä brings his inimitable touch to Sibelius Symphony No. 3.

Singin’ in the Rain*

Film with the Minnesota Orchestra Thu Jul 9 11am / Fri Jul 10 8pm Sarah Hicks, conductor Short of dancing down a rain-splattered street, there’s no better way to recapture the magic of this classic MGM musical than to see it on a big screen with a live orchestra performing songs from the timeless soundtrack.

minnesotaorchestra.org 612.371.5656 / Orchestra Hall All programs, artists, dates, times and prices subject to change.

Capsules to page 12

PHOTOS Watts: Steve J. Sherman, The 5 Browns: Bryan Hernandez-Luch, Ohlsson: Paul Body

Media Partner:

May 2015 Minnesota Physician

LETTERS Capsules from page 11

Methodist Hospital to Undergo $140 Million Renovation Park Nicollet Health Services has announced plans for a $140 million project to expand and renovate Methodist Hospital in St. Louis Park. The project includes adding two floors to the hospital’s east tower, making it a six-story facility. It will also build a 60,000-square-foot addition and renovate the surgery center. Once completed, almost all of the currently semiprivate patient rooms will become private, and most will have private showers. “We do have an older building,” said Roxanna Gapstur, senior vice president and chief operating officer at Methodist Hospital. “Our room sizes and things are probably not as spacious as what you would see in many of the other Twin Cities hospitals. And then, we do have a lot of semiprivate rooms.” Hospital officials expect the project to be completed in 2019.

To the editor: In your March 2015 article titled, “Health exchange transparency,” Candace DeMatteis posed the question, “Are we there yet?” In response, I would say “Not yet, but we’re starting to make progress.” I am on the MNsure board of directors and share the concerns she described. Recently, a board workgroup made three recommendations to the MNsure board to address a number of issues, including the concerns DeMatteis described. In December 2014, a series of stakeholder group meetings with board members was held to identify the priorities of our consumers and partners. Many great ideas came out of these sessions, and at the MNsure board of directors meeting on April 15 three recommendations were passed: • Create process transparency: Making

the workflow of an application visible to the public to improve understanding and expectations. • Consumer assistance tools: Options

for shopping and improved enrollment experiences are being developed. This will include online comparison tools.

• Innovative health insurance products:

The board will provide the health plans with the priorities for product and benefit design desired by our consumers and partners. We will invite the health plans to respond with new products and benefits to meet these priorities. Products that meet criteria will be highlighted on the website. It is our intention that some new products will begin to address some of the affordability issues, as one of the desired outcomes. These actions are the initial steps of a plan to address the goals listed at the beginning of the MNsure enabling legislation and the goals identified by MNsure consumers and partners. While it is true that more is needed, these are critical first steps and we will continue to address these needs as the business and IT system improvements make that possible. The focus of the organization has to be on making the IT and business systems stable and robust to serve our public program and qualified health plan customers. With that as our first priority, we are addressing other priorities as effectively and economically as possible, while not jeopardizing the vital infrastructure work. Kathryn Duevel, MD, MS MNsure board member

WE ARE EXCITED TO ANNOUNCE... The integration of St. Croix Orthopaedics and Twin Cities Orthopedics!

The integration allows for us to expand the services we offer across the entire metro area and into western Wisconsin with a team of more than 100 orthopedic surgeons and 35 locations. Both St. Croix Orthopaedics and Twin Cities Orthopedics share a similar vision of providing exceptional care and outstanding service. Visit TCOmn.com or stcroixortho.com to learn more

Minnesota Physician May 2015

Medicus Thomas Bracken, MD, of Onamia-based Mille Lacs Health System, has been named the 2015 Family Physician of the Year by the Minnesota Academy of Family Physicians. The award is given to a family physician who represents the highest ideals of family medicine, including caring, comprehensive medical services, community involvement, and service as a role model. Physicians across the state are nominated for the award by paThomas Bracken, tients, community members, and colleagues. BrackMD en’s peers praised him for his commitment and tireless attention to the people in the community. Bracken has worked as a family physician for more than 30 years. He earned his medical degree at the University of Minnesota Medical School and completed his residency at Hennepin County Medical Center. He also teaches one day each month at the Hennepin County Medical Center Family Medicine Residency, mentors premed and physician assistant students at the clinic, and travels to Haiti annually as a volunteer physician. Mark Traynor, senior vice president and general counsel for UCare Minnesota, has received the Minnesota Law Review’s 2015 Distinguished Alumni Award for his legal and leadership achievements in the health care sector. The publication, published six times a year by University of Minnesota Law School students, gives the award annually to alumni who “have made extraordinary contributions to the legal profession and the greater good Mark Traynor of society.” Traynor is the only recipient this year. Traynor has been with UCare since 1999 and became its first general counsel in 2002. He acts as the main lawyer for UCare, leads its legal team, and oversees its antifraud, internal audit, and compliance functions. He earned his master’s degree in public affairs from the Uni-

versity of Minnesota–Twin Cities Humphrey Institute of Public Affairs and graduated with honors from the University of Minnesota–Twin Cities Law School. Mark Sannes, MD, MS, of the Park Nicollet Infectious Disease Clinic, is one of two recipients of the American Academy of HIV Medicine’s (AAHIVM) fourth annual AAHIVM/Institute for Technology in Health Care HIV Practice Award for his innovative use of technology in the HIV care setting. He plans to share the code for the HIV registry with other HealthPartners Park Nicollet clinics to add more patients to the registry, resulting in it tracking about 20 percent of HIV-positive patients in Minnesota. If other systems get involved, the registry has the potential to track almost 75 percent of HIV-positive Minnesotans. Sannes graduated from the University of Minnesota Medical School and completed his residency at Hennepin County Medical Center. Peter Igarashi, MD, head of the department of medicine at the University of Minnesota Medical School, is one of two researchers in the U.S. to receive the Lillian Jean Kaplan International Prize for Advancement in the Understanding of Polycystic Kidney Disease (PKD). The award is given annually to a medical professional or researcher whose work on PKD research has greatly improved knowledge and treatment of the disease. Before stepping into Peter Igarashi, MD his role at the University of Minnesota, Igarashi served as chief of the nephrology division at the University of Texas Southwestern Medical Center. Much of his 30-year research in kidney development, stem cells, and PKD was conducted during that time. Igarashi earned his medical degree from the University of California, Los Angeles; completed a residency in internal medicine at the University of California, Davis Medical Center; and completed a nephrology fellowship at the Yale University School of Medicine.

OBJECTIVE, INNOVATIVE HEALTHCARE REAL ESTATE SOLUTIONS For more than 25 years, the CWN Healthcare Real Estate Advisory team has exclusively represented healthcare clinics and systems, delivering unbiased and uncommon real estate solutions tailored specifically to your unique priorities, not ours. Call or visit us online, and take the first step toward a healther practice through real estate.

952.837.8517 healthcare.cushwakenm.com May 2015 Minnesota Physician

Interview

Improving communication in health care T ell us how Influencing Healthcare was started.

Dawn Ellison, MD, CPC Influencing Healthcare Dr. Ellison is board-certified in emergency medicine, holds a CPC (Certified Professional Coach) certificate from the College of Executive Coaching, and served as a crucial conversations instructor with Mayo Health Systems. She spent her 2006–2007 Bush Medical Fellowship learning to build collaborative medical cultures. Dr. Ellison is the president and founder of Influencing Healthcare, LLC (IHC).

In 2005, I was working in the ED one afternoon, when I needed to order an MRI for a patient. The protocol at the time required that I get permission to do an MRI. I had the choice of calling a radiologist, neurologist, or neurosurgeon. I noticed that the new neurosurgeon was on, so I decided to take this opportunity to introduce myself to him. I got him on the phone, welcomed him to the community, and presented my patient. The first thing that the neurosurgeon said to me was, “Just because you have a surgeon on call, doesn’t mean you call me for every medical patient you have in the ED.” After a pause I replied, “Doctor, this is the first time we have ever spoken and this is how you talk to me?” After another pause he proceeded to discuss the case. I didn’t hear a thing he said, because I was so angry. I got off the phone and thought, “This guy needs charm school!” I wondered what, if anything, I could do to improve my skills and my colleagues’ communication skills. I began to realize how important collegial interactions are. Not only did I feel better at the end of the day if I was treated well, but I realized that talking to difficult doctors often delayed a patient’s care. I noticed that doctors avoided conferring with difficult doctors and would end up calling someone who didn’t know the patient well or was only tangentially related to the patient’s problem. The tragedy about the rude neurosurgeon was that he only stayed at that hospital for a few months. He didn’t get along any better with anybody else. This epiphany prompted me to seek a Bush Medical Fellowship. In 2006 I became a Bush Fellow and my company, Influencing Healthcare, was created as a result.

 Please share some experiences you have had so far with Influencing Healthcare. I have had the opportunity to coach intelligent, compassionate providers who care deeply for their patients. Often, their perfectionism gets in the way of treating staff and patients with respect because they don’t tolerate errors or “noncompliance.” I find it very rewarding to help these clients figure out how to enjoy practicing medicine again. With a new outlook, these clients are enthusiastic and willing to navigate through the nuances of their organizations. I am often a mentor as well as a thought partner for them. One of the skills I have honed in my work at Influencing Healthcare is bringing groups together to collaborate and innovate. In 2012, at the invitation of the Clinical and Translational Science Institute at the University of Minnesota, my colleagues and I hosted

Minnesota Physician May 2015

140 health care innovators from around the state. It was an inspiring and energized event. The participants self-organized into 20 different groups and each group discussed a different topic. Despite competing for the big CMS (Center for Medicare & Medicaid Services) innovation grants that year, the participants engaged in frank discussions that are still shaping health care today. That same year, thanks to a sponsorship from the Bush Foundation, I was asked to project manage a daylong event for foreign-trained physicians. These doctors face significant barriers to becoming physicians in the U.S. and yet there is a shortage of physicians in Minnesota. In addition to foreign-trained physicians, we invited stakeholders from government, higher education, and communities experiencing physician shortages. Many important connections were made that day and it was an opportunity to hear the stories of these well-trained physicians.

 What are some effective tools that physicians can use to motivate patients?

The most important skill in a physician’s toolkit is active listening. When physicians take the time to listen and understand why good health is important to patients they can help patients keep that goal in mind. By understanding what prevents patients from achieving their health goals, physicians and their team can help patients develop good habits rather than poor habits.

 What can you tell us about empathizing with patients? Empathy for patients builds a therapeutic relationship that is a powerful influence on a patient’s ability to get well and stay healthy. Physicians should not only help patients set achievable goals but keep them accountable.

 What is social technology, especially as it applies to health care?

Social technologies are methods and theories used to engage people in collaborative and innovative conversations. The World Café is a good example of this technique and offers guidelines for how participants are expected to relate to one another. The process begins with groups seated at several tables with large pads and markers in the center so people can jot down notes. Participants are invited to discuss a question related to the purpose of the gathering. After about 20 or 30 minutes people switch to another group and discuss the same or another question. As they move from table to table, they bring bits and pieces from previous

noticed that county health surveys had not uncovered this gap. Many in the community wanted to emphasize inclusiveness for all residents.

conversations. Social technology is designed to be fun, to leverage diversity, and to tap the collective intelligence in the room. Imagine if medical staff meetings used fun engaging ways to have conversations and make decisions.

 What can you tell us about the importance of engaging communities in the decision-making process concerning health care issues?

merely arguing over strategy. This will require leaders to give up control and trust the intelligent, caring providers with whom they work so they can make decisions together.

 Why is it important for phy-

The most important skill in a physician’s toolkit is active listening.

The solution for healthier communities lies within the communities themselves. The challenge is how to engage communities in these efforts. A couple of years ago I was asked to organize an event about health in a rural community. We chose a small community in southern Minnesota that had an abundance of health care options, a fantastic food cooperative, and a community recreation center as well as several parks. While working with some community members who helped us organize the community conversation, we learned that they were concerned about new community members from Somalia and Mexico who were not making use of the many opportunities offered to improve their health. As a result, our event focused on building an inclusive community rather than on how to leverage all the health assets in town. We

 Please share some of your thoughts on physician burnout.

I agree with a program of self-care, resilience, and mindful practice. My unique perspective is drawn from the consistent story I hear from physicians about how they are not listened to. On the flip side, administrators complain that they can’t get physicians involved in committees where decisions are made. If decisions were made using the social technology technique that physicians would feel respected and valued, and they wouldn’t be using EHRs that weren’t designed by them, seeing patients every 15 minutes, and being asked to see more people for less money every year. We need to collaborate with our business partners so we understand each other’s point of view without

sicians to keep in mind how patients view health care?

In order to partner with patients for better health, it is important to understand how they view health care. Physicians often assume that patients want imaging studies and labs, when they really just need to understand that their abdominal pain is most likely from a lack of fiber in their diet and that they should increase their fluid intake. Asking, “What brings you here today?” and “How can I help you with that?” could open up the lines of communication.

 What are the most important things

that can be done to optimize the physician/patient relationship?

Patients expect that their doctors are medically competent. Partnering with patients, empathizing with them, respecting them, and legitimizing their concerns all strengthen the therapeutic relationship. These require the important skill of listening.

University of Minnesota - Continuing Professional Development Education is essential to achieving and sustaining quality healthcare. Through partnership with healthcare leaders, our educational activities help advance quality improvement and patient care initiatives.

2015 CPD Activities

www.cmecourses.umn.edu

(All courses in the Twin Cities unless noted)

LIVE ACTIVITIES Bariatric Education Days: Advances in Bariatric Care May 27-28, 2015 Workshops in Clinical Hypnosis June 4-6, 2015 Topics & Advances in Pediatrics June 4-6, 2015 Pediatric Orthopaedic Trauma Summit 2015 September 24-25, 2015 Twin Cities Sports Medicine Conference 2015 October 2-3, 2015

ONLINE CE ACTIVITIES www.cme.umn.edu/online

Psychiatry Review 2015 October 5-6, 2015 NPHTI Pediatric Clinical Hypnosis Workshops October 15-17, 2015 Practical Dermatology 2015 October 16-17, 2015 Donald Gleason Conference on Prostate and Urologic Cancers October 23, 2015 Internal Medicine Review and Update 2015 November 11-13, 2015

• • • • •

Adolescent Vaccination Nitrous Oxide for Pediatric Procedural Sedation Preventing Chronic Pain - A Human Systems Approach Honoring Choices Across Cultures Global Health - To include Travel Medicine & Refugee Health - Family Medicine and Pediatric Specialties

For a full activity listing, go to www.cmecourses.umn.edu

Office of Continuing Professional Development 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

May 2015 Minnesota Physician

Prior authorization from cover

treatment regimens disrupted when a medication is suddenly withdrawn from coverage. Already a burdensome process, prior authorization can have dire consequences for the health and even the life of the patient. Time is money Physicians tell me that the prior authorization process not only takes time away from treating their patients, but it also increases costs. Prior authorization is among the most significant portion of time physicians spend interacting with insurers—it is estimated that a physician spends, on average, 2.8 hours per week; nursing staff spends 16.9 hours per week, and clerical staff spends 5.6 hours per week. That equals an average of $68,274 annually per physician per year.

If you consider that the prescribing physician population in Minnesota is roughly 12,000, that is over $800 million spent annually on health plan interactions, of which the prior authorization bureaucracy adds questionable value to the patient. With these requirements adding

The bill Two of the largest pharmacy benefit managers (PBM), Express Scripts and Prime Therapeutics, are located in my district. I also have countless providers and a health plan presence within or bordering my district. I represent a

Not surprisingly, PBMs and insurers are concerned about the ramifications of this legislation. However, I have heard countless stories where inconsistent rules get in the way of

Most prior authorization reviews end with the prescriptions being approved.

to inefficiency and rising costs in health care, it was evident to me that we needed to address this issue.

district that is uniquely positioned to engage in this debate so I took the lead in the Senate by introducing SF 934. In this unique position, I can hear the perspectives from all parties involved, and facilitate dialogue and a solution to deliver on our biggest concern: quality and affordable care for patients. The prior authorization legislation I authored is an important step in improving the ability of patients to get the right medications to treat their conditions. As proposed, the bill calls for: • Improving transparency of medication coverage • Limiting changes to such coverage during an enrollment year • Ensuring ongoing coverage when patients transition to new insurance policies • Disclosing cost-sharing arrangements with patients • Reducing timelines for approving or denying a prescribed drug • Using prescribing data to support improved prescribing practices Ultimately, the bill removes barriers from the time a physician prescribes a medication to a patient, to the time it takes

a patient to pick it up at the pharmacy.

Minnesota Physician MAy 2015

patients receiving the medications they need. While the original intent of prior authorization was to ensure that a prescribed medication was safe and medically appropriate for a patient, it has morphed into an uncontrolled process that is often at odds with scientific evidence; disruptive to patients’ care; and the cause of higher health care costs in the form of emergency visits, lab tests, and hospitalizations. Additionally, most prior authorization reviews end with the prescriptions being approved anyway—only delayed with added administrative costs for the prescribing physician. It is important to note that this legislation would not do away with prior authorization, but instead would create muchneeded guidelines for its use. When used effectively, prior authorization can play a role in ensuring appropriate, cost-effective treatment. Inconsistencies in the system We need a system that ensures that patients get the prescriptions they need, consistent with medical evidence and an insurer’s formulary. In data analyzed by the Minnesota Medical Association (MMA) the group found almost no similarities among insurers in terms of the drugs they subject to prior authorization require-

ments. The MMA found that of the more than 1,000 medications for which Minnesota’s six largest insurers required prior authorization, only six drugs were common among these insurers. This suggests that authorization requirements are not being used to steer patients to the best medications for patients on the basis of clinical rationale. If prior authorization is about patient safety and efficacy, then why do only six out of 1,000 drugs consistently need prior authorization across all insurers? One could infer that other factors such as cost or drug company rebates to insurers may be more compelling in driving PA decisions. The bill’s progress There’s an old saying in politics, “Laws and sausage are two things you don’t want to see being made.” Right now, SF 934 is going through the process that all bills go through. It is being heard in committee and is receiving a thorough review from legislators that includes testimony from both supporters and opponents of the bill. I strongly encourage thorough scrutiny of any piece of legislation, particularly when we are dealing with people’s health and well-being. New information can come to light, new perspectives can add important elements that may have been missed in the initial drafting, and the bill can be improved upon. The bill has already passed through various committees and currently awaits a final stop in the Health and Human Services Budget Committee, before going to a floor vote by the full Senate. However, the bill has stalled in the House of Representatives for reasons that can’t be described in full fairness, but let’s just say politics is to blame. Even though the bill has bipartisan support, opponents claim that if the bill became law premiums would rise. However, they provide no supporting data and cannot articulate where these alleged costs would come from. The debate should not center on unsubstantiated claims, but

on efficacy and patient safety. Certainly we want drugs to be affordable to the patient, but not at the expense of patients who don’t get their medication on time and consequently end up in the emergency room or worse yet, the criminal justice system. A consistent medication schedule is key to ensuring quality care and treatment. Prior authorization can upset this schedule, threatening the health of the patient through delays in obtaining medication and disruptions in ongoing therapy.

make the prior authorization process more transparent for all parties involved. When you consider the fact that the

In Minnesota … over $800 million [is] spent annually on … prior authorization.

That is why a coalition of dozens of patient advocates including the MMA, the Minnesota Pharmacists Association, and countless patient groups support the bill (see a full list on www.fixPAnow.com). SF 934 puts the patient first in ensuring that they have access to the medications and care they need, without having to go through unnecessary obstacles. Streamlining the prior authorization process would also increase the time physicians can actually spend with their patients.

process has not been updated since the mid-1990s when prior authorization was conducted on paper, it is about time we standardize and streamline the process to give individuals the

opportunity to make informed health care decisions and to provide much needed stability and predictability to matters around medication access. This legislation is a necessary reform, and we need to make sure that policy makers and the general public understand the undue burden being placed on patients trying to access the medications their physician prescribes. I encourage the public, and in particular, physicians who spend countless hours on PA to call your legislator today to voice your support for this necessary reform. Sen. Melisa Franzen, MPP, JD, is

vice chair of the Health and Human Services Budget Committee in the Minnesota Senate. She represents Senate District 49, which includes the communities of Bloomington, Eden Prairie, Edina, and Minnetonka and has served in office since 2013.

A necessary reform We look forward to Jan. 1, 2016, which is the effective date under current law when automatic electronic PA will become the norm for physicians to submit all PA requests. However, submitting PA requests in electronic form will not address the inherent problems caused by the lack of transparency and standardization in the process moving forward. We need to tackle these issues today. This legislation aims to strike a balance between patient safety and efficient access to treatment and therapies prescribed by their physician. I’m working diligently to MAy 2015 Minnesota Physician

International medical graduates from cover

This past year, at the request of the Minnesota Legislature, an unprecedented combination of individuals and organizations came together to address this vexing challenge. Together they formed the Task Force on Foreign-Trained Physicians (see the sidebar on page 19), which tackled key questions such as the number of unlicensed immigrant physicians (see the sidebar on page 21) in Minnesota, the barriers preventing them from practicing, and how we can effectively address those barriers without compromising standards and competency. In addition, the task force considered the costs and benefits of creating a pathway to practice for these physicians. In the end, the Task Force on Foreign-Trained Physicians answered these ques-

Table 1. M innesota immigrant populations compared to Minnesota licensed physicians

Country

Estimated foreign-born populations in Minnesota, 2010–2012

Number of MN-licensed physicians educated in these countries7

Number of MN-licensed physicians born in these countries7

Mexico

70,9881

878

Laos

24,408 –66,200

Somalia

21,2271–77,0002

Vietnam

18,5481

Thailand

15,0141

Liberia

12,216 –35,000

Ethiopia

12,5031–45,000 4

Burma (Myanmar)

4,1831–8,2005

109

159

El Salvador

7,2331

Honduras

4,5341

Cambodia (Kampuchea)

3,0451–8,0006

The Task Force concludes that the imbalances between Minnesota’s population and its physician workforce are significant and warrant new and innovative action. Minnesota Compass Project, 2010. 2 Arrive Ministries. 3 Organization of Liberians in Minnesota. 4 Ethiopian Community in Minnesota, 2014. 5 Karen Organization of Minnesota, 2014. 6 Minnesota State Demographic Center. 7 Minnesota Board of Medical Practice, 2014. 8 Includes a significant number of non-Mexican individuals who attended medical school in Mexico. 9 Personal correspondence from Mimi Oo, 2014. 1

Source: Task Force on Foreign-Trained Physicians

tions and more, delivering to legislators a set of potentially groundbreaking strategies. We are confident that these recommendations could fortify the state’s physician pool for years to come—and make Minnesota, once again, a national leader in health workforce innovation. Minnesota physician facts At the Legislature’s request, the task force examined the demographics of the Minnesota physicians who are licensed and how they compare to the state’s population. It found the following: • The licensed physician workforce skews older than Minnesota’s general population. A greater proportion of MDs are over age 55. • The physician workforce does not mirror the state’s racial and ethnic composition.

• Licensed foreign-trained physicians represent 16 percent of the physician workforce, but most of Minnesota’s largest immigrant and refugee comMinnesota Physician MAy 2015

munities are significantly underrepresented. These findings are important when we consider two powerful forces already transforming Minnesota. The first is an “age wave” that is increasing demand by adding more senior patients, while more physicians are aging out of the workforce. The second trend is the state’s rapidly growing immigrant population. Minnesota’s foreign-born population is increasing faster than the national average, with refugees in particular representing 8.9 percent of the state’s immigrants. This is a far greater portion than the national average of 1.7 percent. Here are a few examples of how underrepresented these immigrant communities are among licensed physicians: Although Minnesota has one of the largest Somali populations in the nation, with some estimating it as high as 75,000, the state has only 28 Somali-born physicians licensed to practice. Similarly, despite being home to a Liberian population estimated as high as 35,000 and a Hmong community over 66,000, the state has only 8 Liberian-born and 19 Laotian-born licensed physicians (see Table 1 on this page). Making Minnesota home The task force estimated that Minnesota is currently home to 250 to 400 immigrant physicians who are not able to practice because of barriers to licensure. The task force based its estimate on information from organizations that have long worked with immigrant health care professionals and a statewide survey the task force conducted. The survey results revealed a richly diverse and skilled pool of potential Minnesota physicians: • The 69 survey respondents were from 37 countries and the group spoke over 30 languages. • Respondents on the whole were younger than the current population of licensed physicians in Minnesota, with only 6 percent over

the age of 55. • Most have trained as general practitioners, but over a third have credentials in specialties and these span a large range of practice areas. • Just over half (55 percent) have been fully certified by the Educational Commission for Foreign Medical Graduates (ECFMG), and many have also gone on to pass Step 3 of the United States Medical Licensing Examination (USMLE), which is technically not required for ECFMG certification and is usually taken during residency. Most passed on their first try. • Eighty-seven percent were interested in entering medical practice or other health careers in Minnesota. Perhaps the most significant survey finding was this: Just over half of respondents were eligible to apply for medical residency, but only a small minority (17 percent) had been accepted into a residency program. Barriers facing immigrant physicians To practice in the U.S., foreign-trained physicians must complete an intensive process that takes an average of three to five years (sometimes as long as 10) and costs roughly $7,500 to $15,000, not including the cost of residency. The process includes four major stages:

have clinical experience acquired in the U.S., but such hands-on experience is nearly impossible to obtain outside of medical school or residency.

The Minnesota Task Force on Foreign-Trained Physicians The task force convened in July 2014 with the charge of developing strategies to integrate refugee, asylee, and other immigrant physicians into the Minnesota health-care delivery system. Members of the task force included representatives from the following:

• Complexity and costs of testing and other steps needed to qualify for residency. Foreign-trained physicians often need assistance in medical English proficiency, exam preparation, and navigating the path to licensure.

• Higher education (including the medical schools at the University of Minnesota and Mayo Clinic, the nursing schools at the University of Minnesota and MnSCU, and the physician assistant program at St. Catherine University) • Health care organizations (including Essentia Health, the Minnesota Medical Association, and the Minnesota Safety Net Coalition) • Community-based organizations (including New American Alliance for Development and the Women’s Initiative for Self Empowerment)

The task force also found that policies and processes within the current graduate medical education system have unintended consequences that advantage U.S. medical graduates and create structural inequities for immigrant physicians.

• Workforce organizations (including Workforce Development Inc. in Rochester, and the International Institute of Minnesota) • The Federal Reserve Bank of Minneapolis • Foreign-trained physicians themselves

Canada. 3. Passing Step 3 of the United States Medical Licensing Exams. 4. Application for a Minnesota license. Only a small fraction of immigrant physicians who attempt the path to licensure are able to complete it, regardless of how often they try and how experienced they are (see Figure 1 on page 20). For them, the path is blocked, often for reasons beyond their control. The task force identified multiple barriers to explain this, with the following most significant:

• Growing competition for limited residency spots. This is likely to get even tougher with the “residency bottleneck,” in 1. Certification from the Email – Clinic@whla.net which increasing numbers Educational Commisof medical graduates comsion for Foreign Medical pete for a capped number Telephone-651-426-6995 Graduates (ECFMG). This of residency slots. requires verification of the • “Recency” of graduation physician’s diploma and from medical school. Most transcripts from medical U.S. residency programs school, which must be consider only those who included in the Internahave recently graduated tional Medical Education from medical school Directory. It also requires (within three to five years). passing Steps 1 and 2 of Consequently, many of the USMLEs. the most highly qualified 2. Completion of at least two immigrant physicians— years of graduate clinical those who have practiced medical training (most extensively since medical commonly, a medical school—are essentially residency) in the U.S. or

disqualified at this point in the path to licensure. • Lack of recognized clinical experience. Most American residency programs prefer or require that applicants

For example, residency programs receive up to 100 applications for each residency position, which can mean 2,000 applications for a 20-resident International medical graduates to page 20

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International medical graduates from page 19

Figure 1. Pathway requirements for an immigrant physician to obtain a physician license in Minnesota Educational Commission for Foreign Medical Graduates certification

U.S. or Canadian graduate medical education (GME) Secure and complete medical residency

Obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG) Primary-source verification of medical education Diploma from school in IMED (International Medical Education Directory

Transcripts

Key barrier point

Apply to residency programs through the Electronic Residency Application Service (ERAS)

Pass Steps 1–2 of the U.S. Medical Licensing Examination (USMLE) (or certain older equivalents) Can be taken in any order but all within 7 years. Minnesota law also requires that they be passed in no more than three attempts.1 NAAD recommends that IMGs take Step 3 at this stage as well. USMLE Step 1

USMLE Step 2 CK

USMLE Step 2 CS

(Clinical Knowledge)

(Clinical Skills)

Costs of tests and test preparation, English proficiency

Key barrier point

AMA recommends that IMGs apply to at least 25 programs. (Most U.S. graduates apply to 5–10)

Not a recent medical graduate, lack of clinical experience in U.S., limited residency spots

and/ or

Interview with residency programs (when invited) Residencies offered Obtain residency permit from MN Board of Medical Practice

Complete required residency minimum

Pass Step 3 of USMLE

MN law requires that IMGs have a minimum of 2 years U.S. or Canadian graduate clinical medical training (residency)2

Per MN law, must be passed within 5 years of Step 2 or before end of residency.3

(U.S. graduates need minimum of 1 year)

Source: Task Force on Foreign-Trained Physicians

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program, and need efficient approaches to screen out all but the most competitive candidates for interview invitations. Residency programs often set a preference for recent medical school graduates, for instance, as a screening criteria. The effect of this screening is that the experience of immigrant physicians may be automatically excluded from consideration, and these applicants don’t have the opportunity to communicate their unique abilities to admissions personnel. That’s another roadblock, and one that too often ends a physician’s career. Recommendations These barriers are significant and embedded in a complicated, long-standing system of graduate medical training and licensing. However, the task force concluded that adapting that system to overcome these barriers is both possible and necessary. The task force’s full report to the Legislature lays out its recommendations in detail. Here

are three key actions Minnesota should pursue: 1. Create a comprehensive system of linked strategies, coordinated by a statewide coordinating council in partnership with all stakeholders including the residency training programs, social services, and as appropriate, the Board of Medical Practice. This system would provide multiple pathways into the health workforce depending on a physician’s qualifications, interests, and level of readiness to practice. The council would also ensure that all pathways include competency assurances comparable to Minnesota physician licensing requirements. 2. F acilitate movement through the current pathway to licensure. This should include a focus on expanded support services to prepare immigrant physicians as fully as possible for the daunting

MN Licensure Apply for license Includes verification of diploma, ECFMG certificate residency training and exam scores

Maintain license Includes continuing education reqs. Some exceptions for physicians who are licensed in other states and are board certified (they are allowed four attempts in any one step of the USMLE).

Does not apply to an applicant admitted as an immigrant under certain conditions on or before October 1, 1991 as “a person of exceptional ability in the sciences or as an outstanding professor or researcher.” Also does not apply to applicants licensed in other states under certain conditions. Minnesota Statutes Section 147.037, subdivision 1, paragraph (d).

Combinations of FLEX, National Board, and USMLE may be accepted only if approved by the Board of Medical Practice as comparable to existing exam sequences, and all exams are completed prior to the year 2000. Minnesota Statutes Section 147.02, subdivision 1, paragraph (c).

challenge of getting into residency. It also suggests that medical residency programs be encouraged or required to revise their “recency” guidelines, to take into account other measures of readiness. 3. Explore new licensing options. This is the set of recommendations that proposes developing new pathways, beyond the current route that disqualifies so many without ever giving them a true chance at demonstrating their qualifications. Among the options recommended is to create a standardized assessment that would determine a physician’s clinical abilities. This assessment would determine if he or she: • Needed more hands-on clinical experience (in which case they could apply to a clinical preparation program). • Was ready for residency (in which case the assessment

results could strengthen an application). • Could practice under supervision (in a proposed apprenticeship program) or practice independently (if a new path to licensure were to be developed). The task force’s recommendations were introduced as legislation during the 2015 session of the Minnesota Legislature, which is still underway at this writing. Provisions to create an apprentice physician status and take other action beyond improving the movement of immigrant physicians into traditional residency proved controversial and were dropped, and instead the legislation calls for further study of new licensing options.

Immigrant physician versus foreign-trained physician The task force decided to use “Immigrant International Medical Graduate (IIMG)” or “immigrant physician” rather than “foreign-trained physician” to describe more precisely the population of physicians intended by the legislation. Foreign-trained physicians, also known as International Medical Graduates (IMGs), are defined as individuals who obtained their basic medical degree outside the U.S. and Canada. IMGs in the U.S. include several distinct subsets: 1) American-born citizens who obtained their medical degree overseas (most commonly in the Caribbean or Central America), 2) IMGs who are foreign-born and reside in the U.S. on non-immigrant visas (such as J-1, O-1, or H1-B visas), and 3) IMGs who are immigrants to the U.S. classified as either permanent residents (“green card” holders), U.S. citizens, asylees, or refugees. The task force focused on the third category and specifically immigrant physicians not licensed to practice medicine in the U.S.

We know these recommendations are ambitious. We also know they will require continued collaboration and consensus building across many interests. We encourage Minnesota’s physicians to take advantage of this opportunity and take action. The task force has shown us we can achieve this. There is a path forward and the positive impact could be enormous. One study has suggested that Minnesota could save over $63 million by tapping foreign-trained physicians to address shortages in areas designated as medically underserved. The impact on health disparities and health inequities, one of Minnesota’s greatest health challenges, would likely be far greater. Edwin Bogonko, MD, is the chair of the state’s Task Force on Foreign-Trained Physicians. He is board-certified in internal medicine and practices at St. Francis Regional Medical Center, Shakopee. Dr. Bogonko completed his medical degree at the University of Nairobi, Kenya and an internal medicine residency at Hennepin County Medical Center. Edward Ehlinger, MD, MSPH, was appointed by Gov. Mark Dayton in 2011 to serve as the commissioner of the Minnesota Department of Health, the state’s lead public health agency. Commissioner Ehlinger is board-certified in both internal medicine and pediatrics.

MAy 2015 Minnesota Physician

NEUROLOGY

troke was recognized over 2,400 years ago by Hippocrates, the father of medicine. However, it was only in 1995 that the first FDA-approved treatment for acute stroke became available. rt-PA (Alteplase) sparked a revolution in acute stroke care. Clinicians quickly realized that in order to deliver rt-PA quickly and safely, systems of care would have to be established similar to trauma centers. The American Stroke Association, the Brain Attack Coalition, the National Stroke Association, and several professional societies set up criteria, and stroke centers were established all across the country. “Time is Brain” became the mantra since it seemed obvious that the sooner the patient was treated, the better the odds of recovery. Although there has been much progress in acute stroke care over the past two decades, it has been a challenge on many fronts. Public awareness of the symptoms and signs of stroke and the need to seek urgent medical attention remains subopti-

Time is brain Mobile stroke units By Irfan Altafullah, MD, FAHA mal. When patients do get to an emergency room (ER) within the window for treatment, appropriate evaluation can take a while including clinical history gathering, physical examination, blood tests, and imaging. As a result, the national median door-to-needle time (DNT) in the American Heart Association’s Get With the Guidelines (GWTG) stroke registry is 75 minutes. Only 6.7 percent of the hospitals in the U.S. that treated more than 10 patients per year with IV rt-PA, reported a DNT of less than 60 minutes. The number needed to treat (NNT) to achieve a good outcome with little or no residual symptoms has been estimated at 4.5 when treatment is initiated within 90 minutes of symptom onset. The NNT rises to 9 when treatment is started from 90 minutes to three hours from

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symptom onset. Treatment is even less effective when a stroke victim is treated three to four and a half hours after onset resulting in the NNT rising to 14.1. Improving the DNT A handful of centers around the world have been able to achieve remarkably low door-to-needle times. In 2011, a group from Helsinki University Central Hospital in Finland published a median DNT of 20 minutes with 94 percent of patients treated within 60 minutes of arrival in the ER, using multiple concurrent strategies. In 2010, The American Stroke/Heart Association launched a national quality improvement initiative to improve DNT, which resulted in significant improvements in the median DNT and in the proportion of patients receiving rt-PA within 60 minutes of arrival. Notably, there was also improvement in clinical outcomes including reduced rates of intra-cerebral hemorrhage and in-hospital all-cause mortality. Concurrently, there has been increased focus on the prehospital evaluation and care of patients with acute stroke. Jeffrey Saver, MD, director of the UCLA Stroke Center, and others demonstrated the feasibility of paramedic evaluation and ambulance-based care in the FAST MAG trial of administration of magnesium sulfate in the field. While the trial did not demonstrate a statistically significant benefit of magnesium sulfate, it was groundbreaking in that nearly three-quarters of patients were treated in the “golden hour,” the first 60 minutes after the onset of stroke symptoms. Two groups in Germany went a step further and decided to take stroke care to the patient’s doorstep. They installed a portable CT scanner in an ambulance and had either onboard stroke expertise or a telemedicine link along with point-of-care testing. Ebinger et al. published the results of the PHANTOM-S trial last year, in

which a STEMO (Stroke Emergency Mobile) was dispatched 1,804 times every other week over a 21-month period and 177 patients received rt-PA prior to transport to an ER. Compared to non-STEMO weeks, this intervention resulted in a 25-minute reduction in the time to give rt-PA from when emergency medical services (EMS) was activated. Fifty-eight percent of patients were treated within 90 minutes of symptom onset, compared to 37 percent of controls. By way of comparison, the median onset to treatment times in the best hospitals in the GWTG cohort is 110 minutes. In the Berlin study, more patients also ended up receiving rt-PA (33 percent versus 21 percent of ischemic strokes) and the rate of symptomatic intracerebral hemorrhage was low (2.2 percent). Is ultra-fast treatment better? While ultra-fast treatment of stroke with thrombolytic therapy appears feasible using a number of approaches, there are still many unanswered questions. Is there truly a clinical benefit in treating a patient within 60 minutes of symptom onset compared to 60 to 90 minutes? If so, what is the magnitude of the benefit and is it cost-effective when applied to large groups of patients? Clearly, major changes will be needed in acute stroke care delivery if we are to achieve ultra-low symptom to treatment times. There are several reasons to think that a more rapid treatment with rt-PA could lead to better clinical outcomes. Earlier evaluation and treatment should result in more patients being treated within the currently recommended 4.5-hour time window from symptom onset. Patients might also receive earlier care for acute hypertension and get faster endovascular care. Recent results of several trials have shown a statistically significant benefit of mechanical thrombectomy and clot removal compared to intravenous rt-PA only, especially in patients with large arterial occlusions that are typically not reopened with rt-PA. While there is general consensus that faster treatment is

The Houston MSU The first mobile stroke unit (MSU) in the U.S. became operational in Houston, the result of an academic/private partnership between the University of Texas–Houston, Memorial Hermann Hospital, Houston area EMS, and private philanthropy. The Houston team is under the leadership of James Grotta, MD, a neurologist at Memorial Hermann Hospital and a pioneer in thrombolytic stroke therapy. The MSU is a modified ambulance equipped with a portable CT scanner and staffed by a nurse, radiology technician, and a stroke neurologist. The team responds to EMS calls for suspected stroke in a specified section of the Houston metropolitan area, sometimes reaching the patient’s home, sometimes meeting first responders who might already be transporting the patient. When the team reaches the patient, the neurologist obtains a clinical history and examines the patient. Concurrently, a second neurologist remotely evaluates the patient via a telemedicine link. Appropriate point-of-care blood testing and a non-contrast head CT is performed in the ambulance. The images are reviewed on a laptop in the ambulance by the neurologist and remotely by a radiologist. If the patient meets the criteria and is felt to be an appropriate candidate for thrombolytic therapy, rt-PA is mixed in the ambulance, the bolus dose is administered, and infusion is started. The patient is then transported to one of several comprehensive stroke centers in the Houston area where the patient might go on to have further advanced imaging such as perfusion studies, angiography, and, depending on clinical circumstances, mechani-

cal thrombectomy. Presently, the MSU is operating in the context of a clinical trial, attempting to answer several questions: 1) How much can an MSU speed up and increase treatment of ischemic stroke patients with rt-PA compared to routine management? 2) Is it feasible to replace the onboard neurologist with a remote neurologist using telemedicine?

The Cleveland MSU Similar results have been reported by the Cleveland Clinic group in Ohio, which has also been operating an MSU since May 2014. Their average arrival to treatment time is 19 minutes. In comparison, the average DNT time at the main campus is about 60 minutes. The MSU was recently voted No. 1 on the Top

preparation with many challenges including obtaining funding, licensure, documenting radiation safety in the ambulance, and setting up and implementing protocols with local EMS providers. If in fact, there is a significant clinical benefit from ultra early treatment of ischemic stroke with thrombolytic therapy as anticipated, MSUs should prove to be cost-effective because the average lifetime cost of stroke has been estimated to be over $150,000. MSUs may also serve as models for ultra-fast management of other medical emergencies.

Thirty-one percent of patients got treatment within 60 minutes of onset of symptoms.

3) What is the cost-benefit case for MSU? The Houston MSU went into service May 2014. Data were collected during an 8-week run-in period, prior to commencing the study. During this 8-week period, the MSU was dispatched, on average, 2.7 times per day. Of the total 130 calls, 24 patients were initially felt to be potential candidates and 13 eventually received IV rt-PA in the MSU. The rest were excluded for a variety of reasons including intracranial hemorrhage, seizures, etc. On average, it took 24 minutes from MSU arrival at the scene to rt-PA bolus. Thirty-one percent of patients got treatment within 60 minutes of onset of symptoms and another 31 percent between 61 to 80 minutes from onset. These numbers are all the more impressive when viewed in the context of existing data. In the seminal National Institutes of Health-funded rt-PA study, only two subjects out of 302 were randomized within 60 minutes of symptom onset; both into the placebo group. Less than 1 percent of 58,353 patients in the American Heart Association’s Get With the Guidelines stroke registry got rt-PA within 60 minutes of symptom onset. There were no rt-PA-related hemorrhages, CT scanner malfunctions, or other complications in the MSU. Three of the 13 patients went on to have endovascular treatment. There was 91 percent agreement between the onboard neurologist and remote neurologist using a telemedicine link.

10 list of medical innovations for 2105 at the Cleveland Clinic’s Annual Medical Innovation Summit. The cost of setting up the MSU has been reported to be around $650,000 by the University of Texas, Houston team and approximately $1 million by the Cleveland Clinic group. It took the Houston group about a year of

Telephone Equipment Distribution (TED) Program

better, there are little data to demonstrate the magnitude of such a benefit. In large part, this is because most of the existent data from randomized controlled trials of rt-PA is on patients treated within 80 to 90 minutes of symptom onset. There are many theoretical and physiological reasons to believe that ultra-fast treatment with rt-PA might have a disproportionate benefit because of the susceptibility of brain tissue to ischemia.

With several centers around the country planning on deploying ambulance-based thrombolysis and recent data from trials of mechanical thrombectomy, the future of acute stroke care looks promising. Irfan Altafullah, MD, FAHA, is board-certified in neurology and vascular neurology and is director of the Comprehensive Stroke Program at North Memorial Health Care.

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May 2015 Minnesota Physician

Special Focus: Physician support services

he shortage of child and adolescent psychiatrists (CAPs) and other specialized mental health practitioners has resulted in the challenge of meeting the overwhelming mental health needs in communities across the country. These needs include managing chronic illnesses like depression, anxiety, and other mood disorders, to triaging and treating acute disorders like suicidality that rise to the level of a psychiatric emergency. The CAP shortage has shifted the burden of providing mental health care to primary care clinicians, many of whom feel ill equipped to manage complex psychiatric illnesses during brief office appointments with little or no psychiatric support. All the while the use of psychotropic medications has increased, with a significant majority being prescribed in the primary care setting. The lack of CAPs is compounded by an uneven distribution nationwide in relation to population. The state

Child and adolescent psychiatry Improving primary care’s access to services By Todd Archbold, LSW, MBA with the most CAPs per 100,000 children is Massachusetts with 21.3, while Alaska has the least with 3.1. Minnesota ranks among the lowest distribution with only 5.8 CAPs per 100,000 children.

symptoms will begin before the age of 14. A vast majority of these illnesses are highly treatable with appropriate evaluation and intervention. In the state of Minnesota there are

early identification results in further social developmental problems and significant worsening of symptoms, not to mention increased financial costs for families, hospitals, and taxpayers. Numerous studies, including some within PrairieCare, have shown evidence that a significant proportion of children in need of treatment for psychiatric disorders, many of them severe, never receive the treatments they require.

Psychiatric consultation models Since early 2000, nearly 32 states have experimented with psychiatric consultation The child programs mental to increase Successful consultation can mitigate health crisis access from costs of up to $3,500 per phone call. Nearly one primary care out of five settings. In children will many cases, suffer from pediatricians symptoms of a diagnosable and other pediatric primary approximately 75 board-cermental illness, and approxcare providers can be considtified CAPs, not all of whom imately 70 percent of those ered the most suited to assess are actively practicing. It is and provide care for behavioral estimated that the state needs health issues. Although there closer to 350 to adequately are limitations in their training manage youth suffering from and comfort in treating these the most complex psychiatric conditions, they have the folconditions that are currently lowing advantages: they genermanaged in the primary care ally enjoy positive and trusting setting, or not at all. Twenty-five years have passed since relationships with children and Dr. Seuss’s final words to us were families; they are on the “front Access to child and adolespublished. His last book—with cent psychiatry is often attained lines” for most health issues; its powerful images—are truly they have extensive practical only after enduring lengthy the capstone of his career. knowledge of normal developwaitlists in the outpatient ment, which allows them to desetting, or when psychiatric This exhibition artistically highlights tect problems at an early stage; conditions spiral into emergenthe scores of places and eras Dr. and they have a reduced stigma cies. Reallocating the already Seuss takes us with his incomparable associated with behavioral limited CAPs simply means collection of artwork. health treatment and settings. depriving another setting of their expertise. For example, Today is your day. Since 2011, the Minnesota moving a psychiatrist from a You’re off to Great Places! Department of Human Services hospital setting to an outpatient (DHS) has provided grant fundYou’re off and away! clinic will add availability for ing to support primary care clinic patients, but reduce the access to child and adolescent Special Opening Reception Saturday June 6, 4pm–8pm. number of hospital beds availpsychiatry, as required by legisShow Runs Through June 20. able thus shifting those acute lation passed in 2010. The Minpsychiatric cases to emergency nesota Psychiatric Assistance rooms. Nationwide, hospital Line (PAL) offers free clinical emergency rooms are becoming triage and child and adolescent more crowded with patients psychiatric phone consultations in psychiatric emergencies. to pediatricians across the Many of these emergencies can 612.338.4333 | 800.336.9924 entire state. PAL is staffed by a be prevented if early access to www.jsgalleries.com full-time clinical social worker psychiatrists or psychiatric con- who has immediate access to 4811 Excelsior Blvd., St. Louis Park, MN 55416 sultation is available to patients a CAP. This service is funded ™ & © 2015 Dr. Seuss Enterprises, L.P. All Rights Reserved. and primary care. The lack of by DHS and augmented by the access to care and failure of

Minnesota Physician May 2015

Figure 1. Identification of caller type

Pediatrician

13%

Nurse Practitioner

73%

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Family Practice Physician

5% 3%

Edina 952-908-2700 Chanhassen 952-908-2730 Burnsville 952-908-2710 Coon Rapids 952-908-2580 Maplewood 952-908-2727

Mental Health Provider Parent/Guardian

• 98% patient satisfaction

Source: Psychiatric Assistance Line Analysis, PrairieCare 2015

• 71% of patients rate their headache reduction between 50-100%

Figure 2. Diagnoses reported in consultations

• 65% of patients rate their use of

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Substance Abuse Comorbid Developmental

ASD/PDD

ADHD

Depression

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Source: Psychiatric Assistance Line Analysis, PrairieCare 2015

Fast-Tracker online mental health database. The service is available Monday through Friday from 8:00 a.m. to 5:00 p.m. via a toll-free number; online options for access are available as well. While one of the primary goals of psychiatric consultation services is to help manage and support evidence-based prescribing practices, almost every case that involves psychotropic medications usually requires psychology and psychotherapy intervention as well. A pilot study done in 2012 in Massachusetts found that nearly half of referrals made to community mental health providers were not completed. An overarching goal of any child psychiatry access program

should also be to develop a full continuum of behavioral health services that includes comprehensive resources as well as a network of providers and organizations with the capability to effectively and efficiently collaborate with cases. The Minnesota Psychiatric Assistance Line (PAL) The purpose of PAL is to support primary care providers so they can treat youth with mental illnesses in a safe, effective, and expeditious way. Previously, children with complex psychiatric conditions would either be referred to a child and adolescent psychiatrist and have to endure lengthy Child and adolescent psychiatry to page 26

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Analysis of sample data PAL conducted an analysis of 100 voluntary consultations (n=100) completed within

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30 25 20 15 10

Discontinuation

ED referral

Diagnostic evaluation

Dosage decrease

Dosage time/ frequency change

Medication addition

Source: Psychiatric Assistance Line Analysis, PrairieCare 2015

the first six months. Over 60 percent of the providers called PAL directly, while 40 percent accessed the service online by either scheduling directly or submitting a secure online inquiry. Almost all callers cited multiple reasons for calling PAL, with a majority asking questions about a medication protocol for a specific patient.

The PAL sample data (see Figure 1 on page 25) shows that 73 percent of the consultations were from pediatricians, 13 percent from nurse practitioners, and 6 percent from family practice physicians. The remaining 8 percent was comprised of other mental health providers and a parent/ guardian. PAL has also been accessed by a small number of nonmedical providers (psychologists and psychotherapists) as well as parents or guardians of children with mental illnesses.

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The patient ages ranged from 3 to 39. Seventy-seven percent of the cases were between the ages of 3 and 21, where 59 percent of the patients were male and 41 percent female.

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Figure 3. Recommendations for consultations about medications

Dosage increase

PAL is designed to be convenient by offering both on-demand phone and online services. Primary care providers can submit online inquiries that are answered by secure email. They can also schedule their own appointments online, and a PAL triage social worker will call them when it is convenient. PAL is beneficial to patients and families by allowing the assessment and management of mental illness to take place in their primary care provider’s office. This means more kids are getting help sooner and avoiding the cost and trauma of

Before launching PAL in 2014, administrators at PrairieCare Medical Group surveyed pediatricians in the Twin Cities metro area to gather input to help them design the service. Nearly 90 percent of survey respondents reported wanting help with questions about specific psychotropic medications and 83 percent wanted help with dosing. Another 66 percent wanted help with diagnosis or assessment and 44 percent wanted help with triage and referrals for other behavioral health services. About half of the respondents reported either “never” or “rarely” having access to CAP services, and 89 percent said they would be more likely to manage psychiatric conditions if access to a CAP was more readily available.

Therapy recommendation

waitlists, or the pediatrician would simply do his or her best to manage the case with limited training. While a few pediatricians are adept at managing diagnoses such as ADHD and depression, many are not comfortable treating those conditions and have to make referrals elsewhere.

untreated mental illnesses.

Medication change/alternative

Child and adolescent psychiatry from page 25

Each patient case had a stated primary working diagnosis relevant for each consultation (see Figure 2 on page 25). The top working diagnoses are

anxiety, followed by depression and ADHD. These three diagnoses comprised 68 percent of all consultations. This data is congruent with the overall prevalence of mental illness in the United States, with the Centers for Disease Control ranking ADHD (6.8 percent) and behavioral or conduct problems (3.5 percent) as the most common. Anxiety disorders are reported to affect 3 percent of children aged 3 to 17 and depression to affect 2.1 percent. Most medication consultation phone calls lasted approximately 10 to 20 minutes and included multiple suggestions for ongoing medication regimens from the CAP (see Figure 3 on this page). The most common suggestion was a medication change or alternative to the current treatment plan. Also, a type of therapy was recommended in almost every case where a therapist was not currently involved in treatment. Other recommendations for medication consults included medication titrations, tapers, and changes in dosing times or frequency. Two cases included the triage social worker recommending a crisis referral to an emergency department. Every CAP consultation supported the primary care

provider’s treatment plan and offered helpful suggestions for ongoing treatment. Although careful consideration of each element of the treatment plans were considered, the CAP in every case was not negatively critical or uncollaborative with the primary care provider. The purpose of PAL is to support treatment in the primary care setting or augment the treatment plan, but not to deter treatment or create adversity between specialists. The triage social worker provided triage or referrals in 37 percent of the cases. Sixty-five percent of the referrals were to a mental health agency, 13 percent to an advocacy group, and 11 percent to another type of provider. Conclusion PAL has provided valuable clinical expertise that has empowered primary care providers to treat psychiatric conditions in a timely and cost effective way.

Each of the 100 sample cases that PAL analyzed found that patients received timely and quality care in a familiar environment without the costs and waiting involved in accessing

We also know that there will be lost productivity when parents have to take time off from work and travel to a new clinic, that may not be near their area of residence. These costs add up

Service is available to every child across the state.

a CAP. The ability for primary care providers to manage behavioral health cases in the primary care setting, can prevent the child and family from having to wait for an appointment with a CAP who is already overwhelmed with complex patient cases. These referrals not only take a lot of time, but are costly to the guarantor and/or insurance plan through extra copays, evaluations, labs, office consultations, and more.

quickly and can be avoided through psychiatric consultation to primary care. It is estimated that each successful consultation can mitigate costs of up to $3,500 per phone call. Barriers to receiving timely consultation increase the risk of symptoms worsening in the meantime. Over 140 children have been served, and the service is available to every child across the state. The total costs for supporting PAL including

administration, technology, outreach, and clinical time is now available for just 34 cents per child in Minnesota. The results that are derived from successful psychiatric consultation to primary care are invaluable. PAL has been able to provide services to 74 primary care providers in 41 clinics in the first six months, and its trajectory is to provide over 300 consultations in the first year. For children to have adequate and timely access to quality behavioral health care, innovative and collaborative services like PAL must be made available, and its value will grow exponentially over time. Todd Archbold, LSW, MBA, is a licensed social worker, the chief development officer at PrairieCare, and the practice manager of PrairieCare Medical Group. He served on the Executive Committee of the Minnesota Collaborative Psychiatric Consultation Service.

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reland spent her first six months in the hospital. Born with an esophagus that wasn’t connected to the rest of her digestive tract, she has undergone multiple surgeries, has a tracheostomy tube, feeding tube, and is at increased risk of infection. She is one of a growing number of children in the U.S. who have complex medical conditions that sometimes require prolonged hospitalization. Yet most kids, like Ireland, are able to live at home and receive the care they need, thanks to advanced health care technology and treatment. Helping these children successfully transition home—and maintain a safe care plan to meet their complex needs—requires extensive coordination among the many individuals involved in their care. Sending a child home with the appropriate support includes: • Assessing a patient’s needs and planning for home care • Selecting and setting up equipment, supplies, medication, and therapies

Transitioning complex pediatric patients Coordinating care from hospital to home By Judy Schloss, RRT-NPS, AE-C, and Rebecca Long, RRT-NPS • Ensuring that parents and other caregivers are adequately trained • Beginning therapy and interventions in the hospital on a schedule that can be maintained by the family at home • Establishing opportunities for ongoing communication across settings as needed, even after hospital discharge

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Integrated care is better Research has revealed that collaboration of care results in positive outcomes, including improved quality of care, increased patient satisfaction, fewer patient errors, lower mortality rates, less redundant care, and improved outcomes (Sullivan, 1997). Improving hospital to home collaboration also has the potential to lower aggregate economic and human costs, by reducing avoidable readmission, unnecessary hospital days, and preventable emergency care—all of which add cost to our health care system and adversely impact patients (Greines and Knebel, 2003a). This is particularly true for pediatric patients with complex needs. As the number of children with special health care requirements continues to grow and they transition home, so does the need for a standard model of integrated, collaborative care.

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Minnesota Physician May 2015

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One such joint care delivery model is the result of a partnership between the University of Minnesota Masonic Children’s Hospital (UMMCH) and Pediatric Home Service (PHS), two organizations with extensive experience in caring for pediatrics with highly acute medical needs. Multidisciplinary staff members from both entities have been working together to transition complex young people from hospital to home for 25 years. This longtime collaboration has led to the development of an efficient, effective, and integrated transition process. Based on best practices developed through years of experience, the model outlined in this article incorporates a series

of closely coordinated steps and lays out five areas that are critical for a smooth transition home. A smooth transition requires engaged participants on both the hospital and the home care teams to safely bring a child with medical complexities home.

How the transition works Communication between UMMCH and PHS begins at the moment a child’s need for home care has been identified. The conversation among multidisciplinary staff from both organizations is ongoing throughout the process, and continues after hospital discharge with plans at the ready for emergency management in the home or readmission, if needed.

Focusing on five critical areas While the hospital and home care teams coordinate services and efforts throughout the transition process, collaboration in the following five areas is critical to maintaining safe and integrated care once the child is safely at home. These areas include: 1. S electing durable medical equipment (DME) for hospital and home use 2. Meeting the needs for effective individual care plans 3. P reparing for care at home 4. P roviding home equipment stabilization in the hospital 5. T raining caregivers prior to discharge Here is how interdisciplinary teams can collaborate in these five areas throughout the discharge process to execute seamless transitions, deliver comprehensive care, keep readmissions low, and maintain safe care plans for children with medical complexities. 1. Selecting DME for hospital and home use. If it is necessary to bring new or different DME into inventory to be used on patients, the decision by both the hospital and home care company must be carefully considered because machines are more complex, with many brands, models,

options, and features from which to choose. It is imperative that hospitals choose acute care ventilators that meet the needs of patients throughout their stay in the hospital. When extubation is not in the foreseeable future for a patient, hospitals need a small number of home care ventilators they can put patients on to help them transition into moving home. Once the patient is discharged into the home setting, they will be on similar equipment provided by the home care company. Partnerships between hospitals and home care companies can save significant time as hospitals rely on a home care company’s evaluation and knowledge of the equipment. Often, the hospital purchases the same machines that are used in patients’ homes to ease the transition for these children and to assure that hospital-based clinicians are proficient in the use of home care equipment. Training hospital staff on home care equipment is important because it means they are ready to use that equipment when a patient is re-hospitalized and admitted with their home care DME. When home care companies bring on new equipment they must evaluate portability, durability, and ease of use for the families who will use the equipment. A multidisciplinary group consisting of a medical director, clinicians, biomedical technicians, customer service reps (who provide insight on equipment from a patient perspective), and billing/coding people (who understand insurance coverage) should be gathered to evaluate equipment and supplies for safety and cost-efficiency for their patient population. Once the DME passes this test group with the home care company, it’s moved into a voluntary patient use analysis phase to gather real-life feedback. When patient analysis is complete and if feedback is positive, collaboration with the hospital begins to see how the DME can best be implemented in the community. In some cases, a DME piece, such as a ventilator, can’t be used in

the hospital setting until staff has been trained on it to ensure they understand its functionality. 2. Meeting the needs for

effective individual care plans. In preparation for a patient’s discharge, hospital and home care teams meet to discuss current DME and best practices to be

model, where clinicians are assigned based on patient needs. A team could include a respiratory therapist, an infusion nurse, a pharmacist, a home care nurse, a dietician, and a clinical social worker. Hospital staff may help identify additional services to be

• The geography of the home (whether it’s in an urban or rural area) • Nursing support

Collaboration of care results in positive outcomes. used in the home, aligning the needs and goals for the child. This ensures that the hospital provider (who is expert in providing inpatient care) and the home care provider (who is expert in providing DME for children with medical complexities), each have a role in deciding what will work best for the child outside the hospital setting.

• The physical home environment (is there sufficient electricity and properly grounded outlets to sustain the equipment’s electrical needs; are there any environmental concerns; and are smoke/carbon monoxide detectors in place, etc?)

• Other community support (family, friends, church, school) • Primary care and emergency response in the area

coordinated with other agencies as needed. These clinicians (RT, RN, RD [registered dietician], and MD) review the patient’s history and physical condition, discuss clinical requirements, and establish realistic goals for the child.

4. H ome equipment stabi-

lization in the hospital. Once the home care plan is established, the hospital staff begins to integrate that plan into the care they deliver. Using the example of a ventilator-dependent patient, it is important to

Success factors considered prior to discharge include: • Parents or caregiver’s ability to care for the child at home

Transitioning complex pediatric patients to page 36

This collaborative step: • Ensures that the hospital is confident their patients have safe, high-quality home care plans. • A llows a stabilization period, helping ease transfer to the home setting. • Provides an opportunity to create a proactive plan that sets guidelines for a patient’s baseline status, when a physician should be consulted, and patient and family preferences. For example, selecting the best home ventilator requires the expertise of skilled respiratory therapists (RTs) familiar with various modes of ventilation and brand-specific terminology. They assess a patient’s needs, as well as set ventilation strategies and determine which machine is the best match overall. 3. Preparing for care at home. On referral, teams meet to ensure that the best technology and backup support is selected for a patient’s individual care plan. The home care company may use a primary care

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May 2015 Minnesota Physician

Otolaryngology

ccording to the CDC, chronic sinusitis is the second most prevalent chronic condition with an annual average of 33.7 million U.S. patients or about 13 percent of the adult population. The cost of office copays and treatment can be expensive. Sinusitis also accounts for patients missing work or school. Medications are helpful but present their own challenges including cost, increased antibiotic resistance, and side effects. As we focus more on the cost of care, we need to be open to new, cost-effective treatments for sinusitis other than the current gold standard. Acute sinusitis Treatment of sinusitis starts with medical therapy. Antibiotics, decongestants, topical and systemic steroids, sinus rinses, and smoking cessation are all helpful in treating acute sinusitis. If the problem becomes re-

Balloon dilation of the sinuses A less invasive option By Theodore O. Truitt, MD current (more than four to five infections per year) or chronic (longer than three months in duration), then a referral to an otolaryngologist seems appropriate. There may be hesitation on the part of the patient or sometimes even the primary physician in seeking a surgical option. Patients often hear negative stories about the surgery. But, not all sinusitis and its treatments are the same. Some patients show isolated, mild disease on a CT while exhibiting severe symptoms, and some have severe inflammation with nasal polyps involving all of the sinuses with relatively mild

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symptoms. Failing to medically manage sinusitis is frustrating for patients and physicians. Sometimes nothing seems to help much. Prescribing multiple antibiotics with increasingly wide microbial coverage and high cost generally offer minimal relief. Endoscopic surgery Functional endoscopic sinus surgery (FESS) is the most common surgical procedure for sinusitis. It focuses on the natural drainage pathway. The mucosa of the nose and sinuses are lined with cilia, which work to remove mucous out of the nose and sinuses and down the back of the throat. FESS widens the natural opening (ostium) by removing tissue with cutting instruments. It’s not clear to otolaryngologists just how much tissue needs to be removed, especially in relatively mild radiographic disease. If a blocked or narrow sinus has its own ostium tripled in diameter, is that enough? The surgeon decides during surgery when to stop removing tissue. He or she will try to remove enough to be assured that the surgical ostium will scar closed but leave enough to keep normal sinus physiology including mucociliary clearance. Technological and surgical advancements with a greater knowledge of the anatomy and physiology of the sinuses have led to improvements in symptomatic, long-term outcomes, lower risks, and quicker recovery. If a CT shows narrowing or blockage of the sinus outflow tracts then the option of sinus surgery is considered. Patients may have severe sinus symptoms but show little to no

sinus inflammation on a CT scan. Those patients likely have allergic rhinitis, vasomotor rhinitis, or viral upper respiratory infections causing the typical symptoms. Sinus surgery is less likely to help these people. Sometimes, the problem comes from severe inflammation or polyps from environmental irritants or unknown causes. The sinuses may become blocked secondary to this and antibiotics are helpful to treat the acute sinusitis. Surgery helps these patients but the medical management of the sinonasal inflammation is really the key to treatment. Put simply, the goal of sinus surgery is to improve drainage. The risks of sinus surgery include bleeding and the need for nasal packing, eye injury, cerebrospinal fluid leak, and the need for more surgery. Often, at the time of surgery it is difficult to know how the tissue at the surgical site will respond to FESS. Surgery can, however, lead to scarring and the introduction of irritants to other areas of the sinuses causing new inflammation. The frontal sinus is one of the more common sinuses to become inflamed again after surgery. Scarring in this narrow region after a technically successful FESS can lead to more blockage and the need for more surgery. Balloon dilation of the sinuses Less invasive balloon dilation of the sinus outflow tracts has gained acceptance as an attractive alternative to endoscopic sinus surgery for many sinusitis patients. Patients benefit from the low cost, lower procedural risks, less pain, a quicker return to work, and minimal scarring with the in-office balloon procedure compared to endoscopic sinus surgery. The natural physiology of the sinuses is preserved. In the REMODEL, RELIEF, and BREATHE prospective studies, safety and statistically

significant efficacy with balloon dilation is shown. When compared head-to-head with the surgical gold standard, FESS, balloon dilation of the ostia is just as efficacious at six months post procedure. Bleeding complications and postoperative in-office debridements are significantly less. The symptomatic improvement using the validated symptom score, Sino-Nasal Outcome Test (SNOT-20), persists for greater than two years with no indication of decreasing over time. This questionnaire asks about the severity of the 20 most common symptoms present in sinusitis and the patient also ranks his/her five most important. Balloons work by remodeling the outflow tracts. There are thin bones near the ostia that, if enough pressure is applied, move and heal in a more open position. A normal sinus drains out of small channels lined with mucous membranes with the assistance of cilia. When the mucous gets thick or narrowed from processes such as allergies, upper respiratory infections, or sinus infections, the sinus fills and the fluid becomes infected. By adding more room in the outflow tract, mucous can be transported out of the sinus more effectively and the sinus becomes better ventilated. It can then withstand inflammatory changes within the nose. A relatively small change to the volume of the tract can bring large results. Balloon dilation of the sinus drainage tract is well tolerated and minimally invasive. The primary attraction of a simple, well tolerated, less invasive procedure with low risks is when it can be safely done in the office under local anesthesia. The procedure is done with the patient sitting in an exam chair where the nose is anesthetized topically and then by injection. The drainage pathway is accessed either through the nose or by directly accessing the maxillary sinus. A balloon is in-

serted into the natural opening to the sinus, inflated and then removed. The patient may hear some of the surrounding bone moving out of the way and may feel some slight sinus pressure. The bones then heal in a more

out sedation or has minimal anxiety with nasal endoscopy. There is little discomfort from the procedure but some patients tend to become anxious anyway. Balloon dilation can be done under general anesthesia

Balloon dilation of the sinus drainage tract is well tolerated and minimally invasive.

open position. Because no tissue is removed, patients don’t experience bleeding, and they will notice immediate improvement, and often immediately return to work. Not all patients are candidates for balloon dilation. Recurrent sinusitis and chronic sinusitis patients are initially considered and a CT scan helps us ultimately decide. The natural pathway needs to be carefully inspected and the patient’s history taken into account. The key areas for obstruction are the frontal recess, ethmoid infundibulum, and the sphenoethmoid recess. These drain the frontal, maxillary, and sphenoid sinuses respectively. Patients who are not candidates for sinus balloon dilation are those with recurrent polyps, multiple sinus surgeries when the physiology of the sinuses have been severely altered by removal of too much tissue, allergic fungal disease, and a mycetoma (fungal ball). It is not a treatment for allergies but it can help prevent sinus infections in those patients. Patients will still need to manage their environment post procedure by avoiding allergens and irritants, and must continue to take their allergy medications as needed. Patients need to be able to tolerate simple in-office procedures. The nose is anesthetized but the patient is still awake. A good gauge for me to tell if a patient will be comfortable with an in-office procedure is whether a patient can tolerate a simple dental procedure with-

but the cost of the anesthesia, facility, surgery, and device becomes a factor in the decision-making. By avoiding the operating room and choosing a less invasive and equally efficacious option, payers save money and patients notice immediate improvement and return to work sooner. The addition of a less invasive option will likely help alleviate the fears that have

prevented patients from having surgical treatment for years. Medicare and many Minnesota payers will cover the procedure in the office, but some insurance companies are still holding out on coverage. Across the nation, balloon dilation has asserted itself as a viable option to less invasively treat patients with sinusitis. Patients have benefited greatly from this new procedure. Otolaryngologists feel more comfortable with this procedure after seeing the economic and clinical benefits. Patients who have suffered with recurrent bouts of sinusitis or constant sinus symptoms may benefit from this novel, minimally invasive office approach.

Theodore O. Truitt, MD, is board-certified in otolaryngology and practices at St. Cloud Ear, Nose & Throat.

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May 2015 Minnesota Physician

Professional Update : Womenâ&#x20AC;&#x2122;s Health

ase study: A 31-year-old female was admitted for her second residential treatment for alcohol dependence. She first began drinking at age 21 and her use has gradually increased since then. Her most recent use has been about a fifth of hard liquor per day. She has had multiple detoxes for alcohol and has suffered several seizures during alcohol withdrawal. About four years ago she was diagnosed with alcoholic liver disease. Over the past two years she has had multiple GI bleeds from esophageal varices and has required several peritoneal taps for ascites. Recent abdominal ultrasound and CT scan confirmed the diagnosis of cirrhosis. Despite these consequences, she has been unable to stop drinking alcohol. This unfortunate young woman demonstrates the rapid and devastating consequences that alcohol can cause in women. The 2012 National

Alcohol use disorders in women A look at the latest data By Pamela J. Shultz, MD Survey on Drug Use and Health (NSDUH), found that 47 percent of American females over 12 years of age reported drinking at least one drink in the last month. This equates to about 124.8 million girls and women. While the prevalence of alcohol use remains greater in males than females, this gender difference has been shrinking over the years. In fact, in the 12 to 17 age group the rate of current alcohol use has become equal between genders, as has the age of first use. This is an alarming change, in that females have been found to progress to complications from alcohol use more quickly than

men. Furthermore, alcohol use in pregnant women can lead to significant medical and mental health issues for the child. Alcohol binge use and poisoning Not only is alcohol use increasing, but the rate of binge drinking is also increasing in girls and women, according to the Centers for Disease Control and Preventionâ&#x20AC;&#x2122;s Morbidity and Mortality Weekly Report (MMWR) from January 2013. In 2011, about one in eight women drank more than four drinks on any one occasion, which is defined as binge drinking for women. In girls

and women that reported binge drinking, the average number of episodes was 3.2 per month and they averaged 5.7 drinks per episode. The prevalence of binge drinking was highest in the 18 to 24 age group and in non-Hispanic whites. Contrary to some views, women with at least some college education and coming from households with a greater than $75,000 annual income had the highest prevalence of binge drinking. Girls in high school reported a current alcohol use rate of 38 percent and a binge drinking rate of 20 percent. Binge drinking increased with each grade in high school, and was 62 percent in 12th grade girls. In adolescent and adult females, binge drinking has been shown to increase the risk of breast cancer, heart disease, sexually transmitted diseases, unintended pregnancies, and many other health problems, according to a report to the U.S. Congress by the National

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Minnesota Physician May 2015

t i y r T r o f E FRE ths n o m 3

Institute on Alcohol Abuse and Alcoholism in 2000. Binge drinking is also associated with a higher risk of being a victim of sexual assault and domestic violence, injuries from automobile accidents and falls, as well as homicide and suicide. Binge drinking is also one of the risk factors for alcohol poisoning. Alcohol poisoning deaths accounted for over 500 deaths per year in women from 2010 to 2012, or about 4.4 per 1 million women in the U.S. (CDC MMWR, January 2015). The highest age-adjusted rate of alcohol poisoning deaths for both men and women was in the 45 to 54 age group, followed closely by 55 to 64 and 35 to 44 age groups. However, given the increasing rate of binge drinking in high school seniors, the alcohol poisoning death rate may be expected to peak at lower age ranges in the future. Alaskan Native/American Indians had the highest rate of alcohol poisoning deaths, while

non-Hispanic whites had the second highest rate. It has been observed that young women and girls are targeted by marketing strategies aimed at encouraging them to behave more like young adult

Chronic Disease Prevention and Health Promotion developed a fact sheet on binge drinking among women and girls that can be distributed through clinics, schools, and other community programs to educate people about the risks of

Females have been found to progress to complications from alcohol use more quickly than men.

women in terms of their use of alcohol. States with higher rates of adult women who binge drink, tend to have higher rates of high school girls who also binge drink. Lack of education about the risks of binge drinking for girls and young adult females is also a concern. In an attempt to address this issue, the Centers for Disease Control and the National Center for

binge drinking. The fact sheet is available at http://www.cdc. gov/vitalsigns/pdf/2013-01-vitalsigns.pdf. Alcohol use disorders Alcohol use disorders, also known as alcohol abuse and dependence, are more common in men than women. However, over the last 30 years, the variance has narrowed between

A Diverse and Vital Health Service

genders. In the early 1980s, the Epidemiologic Catchment Area Survey found a 5:1 male to female ratio for alcohol abuse and dependence. The National Longitudinal Alcohol Epidemiology Survey (NLAES) conducted in the early 1990s, showed a male to female ratio of 3:1 for alcohol abuse and 2:1 for alcohol dependence. More recently, in 2001, the National Epidemiologic Survey on Alcohol and Related Conditions found a male to female ratio of 2.3: 1 for abuse and 2.4:1 for alcohol dependence. While these studies had different methodologies and surveyed different populations, when taken together they suggest that the gender differences for alcohol use disorders is decreasing and it appears to be due to an increase in the rate of alcohol use disorders in females. Furthermore, the age of first use of alcohol, which is a known risk Healthalcohol Service factor forBoynton developing Alcohol use disorders in women to page 38

Boynton Health Service

Welcome to Boynton Health Service Located in the heart of the Twin Cities East Bank campus, Boynton Health Service is a vital part of the University of Minnesota community, providing ambulatory care, health education, and public health services to the University for nearly 100 years. It’s our mission to create a healthy community by working with students, staff, and faculty to achieve physical, emotional, and social well-being. Boynton’s outstanding staff of 400 includes board certified physicians, nurse practitioners, registered nurses, CMAs/LPNs, physician assistants, dentists, dental hygienists, optometrists, physical and massage therapists, registered dietitians, pharmacists, psychiatrists, psychologists, and social workers. Our multidisciplinary health service has been continuously accredited by AAAHC since 1979, and was the first college health service to have earned this distinction. Attending to over 100,000 patient visits each year, Boynton Health Service takes pride in meeting the health care needs of U of M students, staff, and faculty with compassion and professionalism.

Gynecologist/Clinical Supervisor Boynton Health Service is seeking a gynecologist or primary care physician with extensive experience in women’s health to serve as Assistant Director of Primary Care in charge of the Women’s Clinic. The Assistant Director will provide clinical services, ensure staff adherence to relevant regulations, assure the highest professional and ethical standards, and work with the Director of Primary Care and Chief Medical Officer to formulate long range planning and policies. This position offers a competitive salary and a generous academic status retirement plan. Professional liability coverage is provided. To learn more, please contact Hosea Ojwang, Human Resources Director 612-626-1184, hojwang@bhs.umn.edu. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer

410 Church Street SE • Minneapolis, MN 55455 • 612-625-8400 • www.bhs.umn.edu

May 2015 Minnesota Physician

RESEARCH

s the aging population grows, physicians are seeing more and more patients with brain disorders such as Alzheimer’s disease, Parkinson’s disease, depression, and post-traumatic stress disorder. Alzheimer’s disease alone affects one in eight older Americans and is the sixth-leading cause of death in the U.S. The impact on patients and their families is devastating. Yet, despite the prevalence of brain-related disorders among the growing elderly population, we still don’t have effective treatments for Alzheimer’s and other neurological diseases. This is unacceptable. We simply must find ways to accelerate research that will lead to effective therapies. If we don’t, the terrible toll on patients and their families will continue. In the case of Alzheimer’s, we know that the major risk factor for the disease is age:

The Brain Health Registry Accelerating the path to cures By Michael Weiner, MD the older you get, the greater the risk. Genetics also plays a very important role; the second major risk factor is family history. For people whose parents or grandparents had dementia to Alzheimer’s disease, their risk for developing Alzheimer’s increases three- to fourfold. Some of this risk is due to the gene APOE4, but other genes also seem to be involved. There are still a lot of questions left to be answered. There is great work going on in this area in Minnesota. The physicians and scientists in the Alzheimer’s Disease Research Center at Mayo Clinic are at the

Olmsted Medical Center, a 220-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: Family Medicine

Pain Medicine

Spring Valley Clinic

Rochester Northwest Clinic

Nursing Home Physician

Psychiatrist – Child & Adolescence

Rochester and Surrounding Communities

Rochester Southeast Clinic

OB/GYN

Hospital – New Women’s Health Pavilion

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904 email: dcardille@olmmed.org Phone: 507.529.6748 • Fax: 507.529.6622

www.olmstedmedicalcenter.org

Minnesota Physician May 2015

forefront. Ronald Petersen, MD, PhD, is world famous for his recognition that mild cognitive impairment is a clinical stage on the continuum between normal aging and development of dementia due to Alzheimer’s disease. Many other scientists at Mayo Clinic have also made significant contributions to the field. At the University of Minnesota, the Center for Magnetic Resonance Research led by Kamil Ugurbil, PhD, has also been a world leader in developing the most advanced, state-of-the-art MRI imaging techniques. Furthermore, “functional MRI” was first performed at this center, leading to the development of an entire field that is impacting research and diagnosis of Alzheimer’s disease. Therefore, investigators from Minnesota have produced and continue to come forth with some of the most outstanding research advances in the field. The research challenge Despite progress, there is an urgent need to speed research into neurological diseases. But one of the biggest impediments is the difficulty of finding people willing to enroll in studies and clinical trials. Recruiting study participants is both expensive and time-consuming, with recruitment accounting for about a third of the total cost of running a clinical trial. It is particularly difficult to recruit patients for studies of neurological diseases. Among the major challenges are identifying at-risk cohorts of sufficient size. The problems in recruitment are several fold. First, large numbers of subjects need to be recruited, because many subjects who volunteer

will fail to meet the criteria of the specific study and will be screened out. Second, each clinical trial or neuroscience study currently recruits subjects separately. Third, when subjects are recruited and screened, the only data that is available is the data obtained at the time of recruitment. There is no longitudinal data available that might help determine eligibility. In summary, the needs are to recruit large numbers of subjects at low cost, to obtain screening information, and to obtain longitudinal information prior to entry into a treatment trial. Given the significant hurdles in recruiting study participants, my colleagues and I thought long and hard about potential solutions, and we came up with a website called the Brain Health Registry (www.brain healthregistry.org). The primary goal for this web-based effort is to recruit as many as 100,000 people into studies of neurological diseases by the end of 2017. Our goal is to recruit, assess, and longitudinally monitor subjects and refer them into clinical trials including treatment studies. If we can do that, we can speed up research on brain diseases and thereby accelerate the development of effective therapies. How it works The Brain Health Registry is designed to find potential study participants more quickly and at less cost, thus reducing the time and costs associated with clinical trials for brain disorders such as Alzheimer’s disease. Simply put, the website gathers cognitive testing data online from registered members who complete questionnaires and tests on the site. Anyone 18 and older can register to participate in the Brain Health Registry, whether or not they have a family history of brain disease or neurological risk factors. The registry is designed to detect changes over time in a person’s cognitive brain health, which is why it

The project was launched in 2014 and is overseen by UCSF Medical Center. Every aspect of the project is reviewed and approved by the UCSF Institutional Review Board (IRB). Ensuring that safeguards are in place to protect participants’ privacy is a high priority. Those who sign up to participate on the site are first asked to sign a consent form. Next, they complete a series of questionnaires about their personal and family medical history and about their diet, sleep, exercise, and lifestyle. Once the questionnaires are completed, participants are asked to take some neurological tests in an online game format. Given the important role of genetics in brain diseases, we also have plans to collect DNA from willing participants. Participants are asked to revisit the site every three to six months to engage in these online cognition games. Participation takes an estimated one and a half hours per visit or about three hours each year. Data from the online assessments is collected over time and analyzed to identify potential candidates for clinical trials and other studies on brain-related diseases. My colleagues and I think the Brain Health Registry will become an important tool to speed outreach to candidates for clinical trial recruitment and for other research purposes that involve data collection and analysis. Similar to the Stand Up 2 Cancer model, which was created to accelerate innovative cancer research, the Brain Health Registry is partnering with researchers across the country to collaborate in finding treatments and cures for brain diseases. Based on the needs of the research community, the Brain Health Registry may use infor-

mation collected on the website to identify potential participants for clinical trials to test diagnostic tools and potential therapies for brain disorders. Participants will only be con-

partnerships with Cogstate and Lumos Labs (both of which provide online cognitive tests) and Johnson & Johnson, which is funding a validation study. We’re off to an exciting start.

Anyone 18 and older can register to participate in the Brain Health Registry.

tacted about participating in clinical trials already approved by UCSF’s IRB. Once given the opportunity to participate in a clinical trial, the choice to participate or not will always be up to the patient. Another advantage of the Brain Health Registry is that it will reduce the need for individual recruitment efforts. We are very interested in helping genetics studies recruit, assess, and monitor subjects longitudinally. The more members who join the Brain Health Registry and who continue their participation over time, the more data can be collected to help find viable candidates for clinical trials. This normally is a process that can take years to accomplish. We think the Brain Health Registry can help streamline that process and help recruit more diverse, but underrepresented populations including ethnic and socio-economic segments. Progress so far During the past year, more than 12,000 people have enrolled in the Brain Health Registry. About half of those who have signed up have returned for a six-month follow-up visit. The initial data is very exciting and is of high quality. We have found significant effects of age, gender, sleep, depression, and memory complaints on cognitive functioning. We have reported the findings at international meetings, and papers are being prepared for submission to scientific journals. We have

But more needs to be done to make this a success. We need to continue to grow the number of members and to encourage them to continue revisiting the site. We are building partnerships with organizations such as the Alzheimer’s Association and Alzheimer’s Prevention Initiative. We are starting to seek enrollees outside of the San Francisco Bay Area, including the Minneapolis/St. Paul area and surrounding counties.

How you can help We hope you will join the Brain Health Registry and also encourage your patients to join. It only takes about an hour a few times a year. It’s a practical way, without cost, to help advance scientific research leading to effective treatments for brain disorders, including Alzheimer’s disease. The website gives people a chance to participate in meaningful research aimed at developing effective therapies for devastating brain disorders. Also, their participation may lead to access to clinical trials they may want to participate in. We believe the Brain Health Registry will lead to faster cures for brain disorders. We ask you to join our effort. Michael Weiner, MD, is founder and principal investigator of the Brain Health Registry and professor of radiology and biomedical engineering at the University of California at San Francisco.

Join our team At Allina Health, we’re here to care for the millions of patients we see each year throughout Minnesota and western Wisconsin. From rural to urban settings, you’ll find a practice and community that is right for you, with ideal staff support and the widest range of clinical practice options, physician leadership opportunities and competitive benefits. EO M/F/Disability/Vet Employer

Make a difference. Join our award-winning team.

is important for people of all ages to participate. But we are particularly hoping for sign-ups from the over-50 population.

1-800-248-4921 (toll-free) Katie.Schrum@allina.com

physicianjobs.allinahealth.org

May 2015 Minnesota Physician

Transitioning complex pediatric patients from page 29

transition to the home ventilator at least two weeks before the anticipated discharge date so that the child and their family can become more comfortable with the schedule and equipment. One last step in this process involves having a home care RT bring the same ventilator, tubing, and equipment to the hospital that the patient will use at home. The hospital and home care company communicate while the patient is put on this new ventilator for the remainder of their time in the hospital to confirm that the ventilator is functioning for the patient before discharge. 5. Training the caregivers prior to discharge. While a child is still hospitalized, parent and caregiver training is usually provided through a patient learning

center and by a bedside clinician, focusing on the disease process along with the current plan of care and what to expect in the future. Many disciplines may be involved depending on the diagnosis and disease management specifics, and training may be provided for topics such as basic life support, tracheostomy care and changes, central line management and medication administration, and enteral therapy. The training for care at home always starts with collaboration between hospital and home care staff, later involving the patient caregiver in home care training as the child is prepared for discharge. Staff work together to identify patient-specific supplies needed to transition home and arrange for appropriate training. This training on equipment and care, provided by a home care clinician, may include:

• How hospital care is different from home care • Emergency response • Equipment use • Supply management • Infection prevention

A safe trip home Before discharge, respiratory therapists often conduct a car seat trial for babies leaving the NICU. They make sure that the baby will tolerate the ride and can be safely positioned in the seat. Car seat trials may also be considered for older pediatric patients with known airway issues. When children go home, it is anticipated that they will be involved with their family and entire home community, which is why the care plan includes plans for transportation, school, and other family activities.

Continuing collaboration Overall service collaboration has no real beginning or end. It is an ongoing process for a child

with medical complexities that focuses on the best interests of patients, families, and health care professionals. An Institute of Medicine report (Greine and Knebel, 2003a) has challenged interdisciplinary health care teams to improve safety and quality by focusing on effective, efficient, timely, equitable, and patient-centered care management. Complex populations improve when health care teams collaborate to transition patients from hospital to home, and by limiting or preventing readmissions, all parties become good stewards of health care resources. Judy Schloss, RRT-NPS, AE-C, is a cardiopulmonary education specialist, ECMO technician, and education coordinator for the University of Minnesota Medical Center and the University of Minnesota Masonic Children’s Hospital. Rebecca Long, RRT-NPS, is director of therapies with Pediatric Home Service, a Minnesota pediatric home care company offering respiratory therapy, infusion nursing and pharmacy, home care nursing, and clinical support services.

Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.

Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258

Currently we are seeking to add the following specialists: • Psychiatrist

• Family Medicine

• Psychologist

• Internal Medicine

• Orthopedic Surgeon

• OBGYN

• General Surgeon

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org

www.averamarshall.org 36

Minnesota Physician May 2015

Sioux Falls VA Health Care System Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Cardiologist

Orthopedic Surgeon

Endocrinologist

Podiatrist

ENT(part-time)

Primary Care (Family Practice or Internal Medicine)

Emergency Medicine Geriatrician (part-time) Nephrologist Oncologist/Hematologist

Psychiatrist Pulmonologist Urologist (part-time)

(605) 333-6852 www.siouxfalls.va.gov Applicants can apply online at www.USAJOBS.gov

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

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

F O R M O R E I N F O R M AT I O N :

Kari Lenz, Physician Recruitment | karib@acmc.com | (320) 231-6366 www.acmc.com |

Family Medicine

St. Cloud/Sartell, MN

with Clinic OB

We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.

Physician-owned Gateway Clinic seeks a family medicine physician to join our new Hinckley clinic. 3 or 4-day week practice with shared hospital call. Full-scope primary care and clinic OB practice (prenatal and postpartum care in clinic, option for colleagues to cover OB call and deliveries). Generous salary with sign-on and retention bonus, outstanding benefit package, 15% retirement contribution. Shareholder opportunities available. Gateway Clinic has locations in Moose Lake, Sandstone and Hinckley. Centrally located between Mpls/St. Paul and Duluth, the area provides an excellent family focused, quality of life opportunity in a rural setting with good public schools and abundant with lakes, rivers, state parks, and ideal hunting - all within an hour to metropolitan conveniences.

Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

For additional information, contact Dr. Kathy Brandli, President, at kbrandli@gatewayclinic.com or Eric Nielsen, Administrator, at enielsen@gatewayclinic.com or 218.485.2000

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care.

www.gatewayclinic.com

Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

MN Physician 4" x 5.25"

May 2015 Minnesota Physician

Alcohol use disorders in women from page 33

abuse or dependence, is now the same for girls and boys, whereas in the past boys began using at a younger age. The reason for this is not completely clear, however the cultural views in the U.S. may be more accepting of girls’ and women’s use of alcohol than in previous generations. Increases in binge drinking and heavy alcohol use are also likely contributors to the increase in alcohol use disorders in females. Females are known to metabolize alcohol differently than men. In females, very little alcohol is absorbed in the stomach, whereas in men, about 10 to 20 percent is absorbed there. This may mean that recent eating may have little effect on alcohol absorption in women, as opposed to men. More important, the volume of distribution of alcohol in women is smaller than in men, due to the higher body fat to water ratio in women.

This results in higher blood alcohol concentrations (BAC) in women for the same amount of alcohol ingested. For example, a female and male both weighing 160 pounds who ingest three standard drinks over one hour, can be estimated to have a BAC of 0.09 percent and 0.07 percent respectively. In Minnesota, that means that the female would be over the legal limit to operate a vehicle, whereas the male would not be. It has been hypothesized that these higher levels of BAC may contribute to the telescoping effect of alcohol in women. Telescoping refers to the observation that women progress from social use to regular use and first treatment episode more quickly than men, demonstrated by multiple published studies. Also, by the time females enter treatment, the severity of their substance use is generally higher than their male counterparts, according to Hernandez-Avila in 2004, as

Family Medicine & Emergency Medicine Physicians

Great Opportunities

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

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com 38

Minnesota Physician May 2015

well as others. Evidence has also shown that women experience complications from their alcohol use within a shorter period of time and with lesser amounts than men. These complications can include alcohol-related dementia and cirrhosis (as described in the earlier case study). Psychiatric and social problems also seem to have this telescoping effect in women, as compared to men. There is increasing evidence that estrogen and progesterone may play a role in the increased risk of alcohol-related complications in females. Overall, these findings support that alcohol use is more risky for females than males. It is also risky for unborn children of pregnant women who drink. The NSDUH reported that in 2010–2011, 8.5 percent of pregnant women reported current use of alcohol (use within the last month) during their pregnancy, while 2.7 percent reported binge use and 0.3 percent had heavy alcohol use. Exposure of a fetus to alcohol, even in small amounts, may result in premature births, low birth weight, miscarriages, sudden infant death syndrome, ADHD, and fetal alcohol spectrum disorders. Fetal alcohol spectrum disorders may range from mild hyperactivity to severe retardation. Women who are pregnant, or attempting to become pregnant, should be instructed to avoid all alcohol intake. Treatment and outcomes for women Compared to men, women are less likely to enter treatment for substance use. Factors such as perceived cultural bias against women with addiction, as well as lack of insurance coverage, difficulties in arranging child care, and financial constraints, likely contribute to these differences. Furthermore, women are more likely to have co-occurring disorders, such as anxiety, depression, or PTSD, which complicate their recovery from alcohol. Often, women with alcohol use disorders present to their primary care provider with complaints of worsening

mental health symptoms. A chemical use history is essential in determining whether these patients may have co-ocurring issues. Several studies have demonstrated better outcomes for women and pregnant mothers who were treated in gender-specific programs, especially for those with co-occurring PTSD and substance use. Cognitive behavioral therapy, particularly programs such as Seeking Safety, in conjunction with Twelve-Step Facilitation, seem to provide the best outcomes at one year for these women, according to studies by Morgan-Lopez et al. in the Journal of Substance Abuse Treatment (2013). Summary Adolescent girls are beginning alcohol use at an earlier age and the percent engaging in binge drinking is at least as high as boys of the same age. Binge drinking is known to be a risk factor for alcohol poisoning and alcohol dependence, and can lead to many physical and psychological complications. Furthermore, alcohol use can lead to medical and social consequences at a faster rate in women than men. Adolescent girls and women should be educated regarding the risk of alcohol use. Treatment can be effective, but unfortunately, women tend to not seek treatment as often as men and may have more severe addiction by the time they attend their first treatment. Screening to identify risky drinking in girls and women should be routine in primary care and women’s health clinics. Earlier intervention may reduce the development of serious alcohol-related consequences in women. Pamela J. Shultz, MD, is medical director at Hazelden Betty Ford Foundation in Center City, Minn. and is board-certified in internal medicine and a diplomate of the American Society of Addiction Medicine. She is an adjunct professor at the Hazelden Graduate School of Addiction Studies and is an adjunct faculty member at the University of Minnesota Department of Family Medicine and Community Health.

Urgent Care

Family or Internal Medicine Physician

We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites.

For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

For more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to: kirk.stensrud@glacialridge.org

www.glacialridge.org

MN Physician 4" x 5.25" 4-color

Join the top ranked clinic in the Twin Cities

Family Practice with OB

A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

Our independent, physician-owned clinic is seeking a BC/BE physician with OB for our family practice facility. 1:9 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental insurance, 401(k), CME and more.

• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

It’s your life. Live it well.

Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally performed plays, concerts and the arts; community festivals; dining and more.

Send CV to: jturonie@raiterclinic.com 218.879.1271 • www.raiterclinic.com 417 Skyline Blvd. • Cloquet, MN 55720

763-504-6600 Fax 763-504-6622

www.NWFPC.com May 2015 Minnesota Physician

WELLNESS AND PREVENTION

enjamin Franklin’s expression, “An ounce of prevention is worth a pound of cure,” is probably just as relevant today as it was almost 300 years ago. Preventive health interventions have, at least in part, been responsible for the dramatic and sustained improvements seen in life expectancy over the last century. So why are so many physicians ambivalent about integrating a preventive health strategy within their practice? Part of this paradox comes from the perverse incentives that govern how physicians are remunerated. For all the services that physicians bill for, only a handful are preventive. This model, together with the ever-increasing demands on doctors’ time, has distracted them from trying to prevent significant disease in their patients. There are two options for getting the country’s preventive agenda back on track; either make appropri-

Accelerating the preventive agenda Improving population health By Peter Mills, MSc, MD ate, evidence-based preventive services and interventions fully reimbursable across the board, or move away from the often divisive fee-for-service model of health care delivery. It is the latter that appears to be gaining momentum. More providers are entering into risk-sharing arrangements with payers and are concerned about outcomes and containing costs rather than worrying about how many procedures they deliver. Although attenuating health-care cost inflation is a major reason for change, the U.S. languishes well below many other developed nations in terms of health outcomes

WORK-LIFE BALANCE

SURROUNDED BY LAKES POSITIONS AVAILABLE: INTERNAL MEDICINE– No call EMERGENCY MEDICINE FAMILY MEDICINE – Full-scope practice avail. (ER, OB, C-Section, Hospitalist, Clinic)

Erik Dovre, OB/GYN

Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with ﬁve primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and beneﬁts. Relocation and sign-on bonus available.

Visit www.lakewoodhealthsystem.com, or contact Brad Anderson at 218-894-8587 or bradanderson@lakewoodhealthsystem.com.

www.lakewoodhealthsystem.com

Minnesota Physician May 2015

for most major conditions. It’s time to fully integrate a robust preventive strategy into the mix if physicians truly want to help their patients and not merely manage their decline. An ounce of prevention The U.S. Preventive Services Task Force (USPSTF) does an admirable job in reviewing evidence and publishing guidance on appropriate, cost-effective preventive interventions. What is quite staggering though is that the USPSTF is run by only 16 volunteers, which speaks volumes about the current importance attached to prevention. What’s more, despite the USPSTF publishing their care recommendations it is clear that many patients are still not receiving all of the services they are entitled to. To a certain extent this is not surprising. Throughout a physician’s training they are taught how to treat, and sometimes cure, disease. Very little time, or attention, is spent on prevention and health promotion. Only recently have physicians begun to understand that helping patients modify their lifestyle and behavior in a sustained fashion improves their overall health. I recently attended a smoking cessation training workshop for physicians and nurses. As a pulmonologist I often advise my patients to consider quitting smoking. I took the workshop to better understand the most effective way of discussing smoking cessation with my patients. Research has consistently shown that smoking cessation advice from a physician, even a brief discussion, has a significant additive effect to other interventions on quit rates. This is likely to be the case for other lifestyle-related

risks as well. Many physicians don’t have the time in their daily schedule to include lifestyle and wellness discussions with their patients, especially because no one is paying them to do it. It is sad to think that physicians have gotten to the point where they expect payment for doing the right thing. The question that doctors should be asking themselves is why wouldn’t I do this if it has a potentially huge impact on an individual’s health? Health risk assessment Thankfully, it seems that the “system” may be coming to the rescue. Of the many different facets of the Patient Protection and Affordable Care Act the one that caught my eye was the full coverage of an annual wellness visit for all Medicare beneficiaries. This is something that a number of private health insurance plans have offered for years, but to make it a fully reimbursed benefit for retirees shows a renewed focus on prevention. Prior to attending the wellness visit an individual is asked to complete a health risk assessment (HRA). The CDC has a framework for what the HRA should contain and has recommended that the provider review this data before seeing patients. This is a positive step toward engaging individuals in their own health care needs and establishing a dialogue where health recommendations and suggestions can be discussed. As a profession, medicine is often dismissive of patient self-report data, sometimes to the extent of discounting it all together. This attitude is rather curious, because at the end of the day a significant portion of the information added into health records comes directly from patients during face-toface consultations. Well-structured self-report data (such as from an HRA or similar tool) can add significantly to the overall understanding of both the patient and the population as a whole. By merging regularly updated self-report data Accelerating the preventive agenda to page 42

Join the Leader in Correctional Health Care FEDERAL BUREAU OF PRISONS

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Accelerating the preventive agenda from page 40

with the more clinical elements contained in the EHR there is an opportunity to create a view that is better than the sum of its parts. This can only be of benefit in this new era of accountable care. Focusing on prevention and wellness To a certain extent, focusing on preventive care is what employers have been doing for the best part of two decades in order to help their employees stay healthy. Employers, and to a certain extent insurers, have long known that they need to engage individuals in health management initiatives to manage downstream costs. Much of the early focus was on chronic condition management, but by early 2000 wellness was included in the portfolio of initiatives offered by increasing numbers of employers across the nation.

The work done by Dee Edington, PhD, from the University of Michigan showed how the humble HRA could predict future health care costs within a population with a high degree of accuracy. In addition, he showed how shifts in risk status (as measured by the HRA) also predicted changes in medical

companies big and small are betting the farm on the need for health care providers to be better connected with their patients and to understand what their patients are doing in real time.

quo. Many private insurers are entering into risk-sharing agreements similar to those that the Centers for Medicare & Medicaid Services (CMS) has negotiated with providers. As yet, the proportion of fees “at risk” is still small. It doesn’t require a crystal ball to see that this will only get larger, and

Conclusion It often seems that health care is the last “unmodern” industry in the world. Everything from financial services to travel and retail has embraced technology to better understand the needs of their clients, and to stay close to them. So far we have rejected this approach in health care, and, in fact have actively discouraged such change. But we do appear to be at a tipping point and I see a very different health care landscape in five year’s time.

Providers are entering into risksharing arrangements with payers.

care cost utilization. One of the criticisms of the workplace health promotion movement is that it doesn’t involve the provider in the mix. This has largely been because providers have been unwilling to get involved, but with health care reform comes a whole new ball game, and with it the opportunity to change the status

with this will come the need to proactively manage the health of populations in a much more sophisticated fashion than we do now. The explosion of digital health initiatives, especially in the U.S., is a testament to this change in how health care is reimbursed. Health technology

Peter Mills, MSc, MD, is a pulmonologist practicing at The Whittington Hospital in London in the U.K. He is director and co-founder of nGage Health in Bloomington, Minn.

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