Minnesota Physician Oct 2015 by Minnesota Physician Publishing

Vo l u m e x X I X , N o . 7 O c t o b e r 2 015

Political malpractice A look at medical costs By Robert W. Geist, MD

hat are patients and doctors to make of the bevy of acronyms that seem to increase daily? HMO (health maintenance organization) has been a commonplace set of initials, as have HSAs (health savings accounts) and PBM (pharmacy benefit management). But now we have ACA (the Patient Protection and Affordable Care Act), which may be easily confused with ACOs (Accountable Care Organizations), one of the ACA’s means of cost control.

Infectious disease The value of physician reports By Richard Danila, PhD, MPH, and Ruth Lynfield, MD

urveillance for infectious diseases is a core public health function essential to prevention and control efforts. Since early in its creation in the 1880s, the Minnesota Department of Health (MDH) has mandated the reporting of selected infectious disease cases by physicians, laboratories, and other health care professionals. The reasons for surveillance are to assess the health of the population, and measure the burden of disease in Minnesota; i.e., how much Lyme disease, tuberculosis, West Nile

virus disease, or other infectious disease is there in Minnesota? What are the trends in these or other diseases over time? Are the numbers increasing or decreasing, and how are the characteristics of the cases and patients changing? What are the risk factors or sources of exposure for the cases? This information is used by MDH to inform prevention and control measures, and assess their effectiveness. In addition, other governmental and private sources can analyze trends and allocate and Infectious disease to page 16

So how did it happen that all of us are now subject to the ACA, its ACOs, and an alphabet soup of other acronyms, e.g., EHRs (electronic health records); P4P (typically pay for “value” performance, aka payment reform); FFS pay (feefor-service); or a threatening IPAB (the federal Independent Payment Advisory Board)? Recently, huge health insurance corporation mega-mergers have been featured in the news. Flying below the radar are mini-mergers between ACOs (hospital/medical staff insurance corporations) and HMOs. What happened, what’s going on, and how do all these things work…or not work? Political malpractice to page 18

L ife. We help people get back to it! Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.

To make a referral or for more information, call us at (866) GSS-CARE 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-G0933

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 because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe only if potential benefits outweigh potential risks.Â 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 of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. 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). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity.

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

Trulicity offers proven glycemic control* and once-weekly dosing in the Trulicity pen *In clinical studies, 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; the percentage of patients achieving A1C <7% ranged from 37% to 69% for 0.75 mg and 53% to 78% for 1.5 mg.1-5

Trulicity may be a good option to be used along with diet and exercise for adult patients with type 2 diabetes who need more control than one or more oral medications alone are providing.1 Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg.

To learn more about Trulicity and the savings card for patients, talk to your Lilly sales professional or visit www.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 because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe only if potential benefits outweigh potential risks. 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 • Trulicity

is contraindicated in patients with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2, and in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components.

• Cases

of medullary thyroid carcinoma (MTC) in patients treated with liraglutide, another GLP-1 RA, have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 RA use in humans. If serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging, the patient should be further evaluated.

• 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 therapies in patients with a history of pancreatitis.

• 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.

Minnesota Physician October 2015

Once-weekly Trulicity 1.5 mg demonstrated comparable A1C reduction* to once-daily Victoza® 1.8 mg at 26 weeks2 A1C reduction from baseline to week 262 8.2 8.0

LS mean A1C (%) ± SE

7.8 7.6

Victoza® (1.8 mg) (n=300; Baseline A1C: 8.1%) Injections: ~182

Consistent with product labeling, patients randomized to Victoza started at 0.6 mg/day in week 1, then were up-titrated to 1.2 mg/day in week 2 and to 1.8 mg/day in week 3.

Trulicity™ (1.5 mg) (n=299; Baseline A1C: 8.1%) Injections: ~26

Trulicity recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg.

7.4 7.2

6.8

†American Diabetes Association recommended target goal. Treatment should be individualized.7

85% fewer injections6

†

7.0

Most common side effects were gastrointestinal (GI). They were nausea, diarrhea, vomiting, and dyspepsia.

Victoza® is a registered trademark of Novo Nordisk A/S.

-1.36 -1.42

6.6 6.4

Week 0

Week 8

Week 12

Week 26

Once-weekly Trulicity delivered results* in clinical trials A1Creduction reduction from baseline A1C from baseline Add-on to metformin (26 weeks) Compared to Victoza®2

MeanA1C A1Cchange change from Mean frombaseline baseline(%)(%)

0.0

Add-on to metformin (52 weeks) Compared to Januvia®1,8,9

Add-on to metformin and Actos® (26 weeks) Compared to Byetta®1,10

Add-on to metformin and Amaryl® (52 weeks) Compared to Lantus®1,4,11,12

-0.2 -0.4

-0.39

-0.6

-0.46

-0.63 -0.76

-0.8

-0.87

-1.0 -1.2

-0.99

-1.10

-1.4

-1.30

-1.36 -1.42

-1.6

-1.08 -1.51

-1.8 Victoza (1.8 mg) (n=300; Baseline A1C: 8.1%)

Januvia (100 mg) (n=273; Baseline A1C: 8.0%)

Placebo (n=141; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=299; Baseline A1C: 8.1%)

Trulicity (0.75 mg) (n=281; Baseline A1C: 8.2%)

Byetta (10 mcg BID) (n=276; Baseline A1C: 8.1%)

Trulicity (0.75 mg) (n=272; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=279; Baseline A1C: 8.1%)

Trulicity (0.75 mg) (n=280; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=273; Baseline A1C: 8.2%)

™

Data represent least-squares mean ± standard error.

Trulicity (1.5 mg) (n=279; Baseline A1C: 8.1%)

•

26-week, randomized, open-label comparator phase 3 study of adult patients with type 2 diabetes treated with metformin ≥1500 mg/day

•

104-week, randomized, placebo-controlled, double-blind phase 3 study of adult patients with type 2 diabetes treated with metformin ≥1500 mg/day

•

Primary objective was to demonstrate noninferiority of Trulicity 1.5 mg vs Victoza 1.8 mg on A1C change from baseline at 26 weeks (-1.42% vs -1.36%, respectively; difference of -0.06%; 95% CI [-0.19, 0.07]; 2-sided alpha level of 0.05 for noninferiority margin 0.4%; mixed model repeated measures analysis)

•

Primary objective was to demonstrate noninferiority of Trulicity 1.5 mg vs Januvia on A1C change from baseline at 52 weeks (-1.1% vs -0.4%, respectively; difference of -0.7%; 95% CI [-0.9, -0.5]; multiplicityadjusted 1-sided alpha level of 0.025 for noninferiority with 0.25% margin; analysis of covariance using last observation carried forward [LOCF]); primary objective met

•

Primary objective of noninferiority for A1C reduction was met; secondary endpoint of superiority was not met

Lantus (n=262; Baseline A1C: 8.1%)

•

52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Byetta or blinded assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Actos (up to 45 mg/day)

•

78-week, randomized, open-label comparator phase 3 study (double-blind with respect to Trulicity dose assignment) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Amaryl (≥4 mg/day)

•

Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo on change in A1C from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [-1.2, -0.9]; multiplicityadjusted 1-sided alpha level of 0.025; analysis of covariance using LOCF); primary objective met

•

Lantus titration was based on self-measured fasting plasma glucose utilizing an algorithm with a target of <100 mg/dL; 24% of patients were titrated to goal at the 52-week primary endpoint

•

Primary objective was to demonstrate noninferiority of Trulicity 1.5 mg vs Lantus titrated to target on A1C change from baseline at 52 weeks (-1.1% vs -0.6%, respectively; multiplicity-adjusted 1-sided alpha level of 0.025 for noninferiority with 0.4% margin; analysis of covariance using LOCF); primary objective met

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

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 of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. 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). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components. Risk of Thyroid C-cell Tumors: Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist (GLP-1 RA), have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 RA use in humans. If serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging, the patient should be further evaluated. 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 therapies in patients with a history of pancreatitis. 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. Hypersensitivity Reactions: Systemic reactions were observed in patients receiving Trulicity in clinical trials. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice. 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. 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. 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 Trulicitytreated 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%).

DG97710

07/2015 PRINTED IN USA

Minnesota Physician October 2015

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 20APR2015 Trulicity™ is a trademark owned or licensed by Eli Lilly and Company, its subsidiaries, or affiliates. Trulicity is available by prescription only. Actos® is a registered trademark of Takeda Pharmaceutical Company Limited. Byetta® is a registered trademark of the AstraZeneca group of companies. Amaryl® and Lantus® are registered trademarks of Sanofi-Aventis. Januvia® is a registered trademark of Merck & Co., Inc. Other product/company names mentioned herein are the trademarks of their respective owners. References 1. Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC; 2015. 2. Dungan KM, Povedano ST, Forst T, et al. Once-weekly dulaglutide versus once-daily liraglutide in metformin-treated patients with type 2 diabetes (AWARD-6): a randomised, open-label, phase 3, non-inferiority trial [published correction appears in Lancet. 2014;384:1348]. Lancet. 2014;384:1349-1357. 3. Umpierrez G, Tofé Povedano S, Pérez Manghi F, et al. Efficacy and safety of dulaglutide monotherapy versus metformin in type 2 diabetes in a randomized controlled trial (AWARD-3). Diabetes Care. 2014;37:2168-2176. 4. Giorgino F, Benroubi M, Sun JH, et al. Efficacy and safety of once-weekly dulaglutide versus insulin glargine in patients with type 2 diabetes on metformin and glimepiride (AWARD-2) [published online ahead of print June 18, 2015]. Diabetes Care. doi:10.2337/dc14-1625. 5. Blonde L, Jendle J, Gross J, et al. Once-weekly dulaglutide versus bedtime insulin glargine, both in combination with prandial insulin lispro, in patients with type 2 diabetes (AWARD-4): a randomised, open-label, phase 3, non-inferiority study. Lancet. 2015;385:2057-2066. 6. Data on file, Lilly USA, LLC. TRU20140919B. 7. American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015;38(suppl 1):S1-S93. 8. Data on file, Lilly USA, LLC. TRU20150203A. 9. Data on file, Lilly USA, LLC. TRU20150203B. 10. Wysham C, Blevins T, Arakaki R, et al. Efficacy and safety of dulaglutide added onto pioglitazone and metformin versus exenatide in type 2 diabetes in a randomized controlled trial (AWARD-1) [published correction appears in Diabetes Care. 2014;37:2895]. Diabetes Care. 2014;37:2159-2167. 11. Data on file, Lilly USA, LLC. TRU20140912A. 12. Data on file, Lilly USA, LLC. TRU20150313A.

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 treatmentduration-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 of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. • 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). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity.

insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia in this setting. 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. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. ADVERSE REACTIONS

INDICATIONS AND USAGE Trulicity™ is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Risk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a doserelated 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 MTC, in humans, as the human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. 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). Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist, have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 receptor agonist use in humans. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the potential 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). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Such monitoring may increase the risk of unnecessary procedures, due to the low test specificity for serum calcitonin and a high background incidence of thyroid disease. Significantly 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 further evaluated. Patients with thyroid nodules noted on physical examination or neck imaging should also be further evaluated. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitis-related 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

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 42% 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 active-controlled 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

TrulicityTM (dulaglutide)

Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe Trulicity only to patients for whom the potential benefits outweigh the potential risk. 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

Trulicity DG HCP BS 20APR2015 Brief Summary 7 x 9.75

DG HCP BS 20APR2015

PRINTER VERSION 1 OF 2 October 2015 Minnesota Physician

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 patients 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 patients 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%) Trulicitytreated 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 dulaglutide-neutralizing antibodies, and 36 patients (0.9% of the overall population) developed antibodies 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 placebotreated 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%) Trulicitytreated 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). TrulicityTM (dulaglutide)

Trulicity DG HCP BS 20APR2015 Brief Summary 7 x 9.75 Minnesota Physician October 2015

DG HCP BS 20APR2015

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 nonsevere 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 has not been determined. 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 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, 2015, Eli Lilly and Company. All rights reserved. Additional information can be found at www.trulicity.com DG HCP BS 20APR2015 TrulicityTM (dulaglutide)

DG HCP BS 20APR2015

PRINTER VERSION 2 OF 2

October 2015

•

Volume XXIX, No. 7

Features Infectious disease The value of physician reports

MINNESOTA HEALTH CARE ROUNDTABLE

By Richard Danila, PhD, MPH, and Ruth Lynfield, MD

Political malpractice A look at medical costs By Robert W. Geist, MD

FORTyFOURTH SESSION

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Improving community health and wellness

Cardiology

Transcatheter aortic valve replacement By Santiago Garcia, MD, and Rosemary F. Kelly, MD

Physician/Patient Communication

New pathways to care

Thursday, November 12, 2015 • 1:00-4:00 PM 32

Jon L. Pryor, MD, MBA Improving infant immunization rates Hennepin County By Lynn Bahta, RN, PHN; Medical Center Margaret Roddy, MPH; and Anna Fedorowicz, MPH Behavioral Health 26 Early intervention in Health care psychosis By Michael O’Sullivan, MD professionals 34 Advanced practice providers By Kathleen Kieran, MD, MSc

Professional Update: Transplant Surgery Lung transplantation By Gabriel Loor, MD, and Gail Frankle, RN, DHA

Behavioral Health Integration

Downtown Minneapolis Hilton and Towers Background and Focus: Increasing evidence supports the link between access to mental health care and reducing health care costs. Primary care physicians often lack the expertise to diagnose behavioral health correctly and are not always able to easily refer a patient to a mental health care provider. Many initiatives nationwide are addressing this issue. It is so important that the ACA stipulated the development of the Behavioral Health Home in 2015. Some states, including Minnesota, are also creating Behavioral Health Home programs. Objectives: We will review numerous initiatives that support the development of new pathways to behavioral health care. We will introduce new ideas and discuss how to incorporate them into our health-care delivery system. We will examine the value they can bring and the challenges they will face. Our panel of industry experts will outline the steps that must be taken to increase the overall access to mental health care and the broad improvement in population health that this increased access will bring. Panelists include: • Sarah Anderson, MSW, LICSW, CEO, Psych Recovery, Inc. • Lee Beecher, MD, President, Minnesota Physician-Patient Alliance

Special Focus: Organized Medicine Advocating for change By Sue Schettle, and Ken Kephart, MD

Setting health care policy 24 By M. Tariq Fareed, MD, FAAFP

• Timothy P. Gibbs, MD, FAPA, DFAACAP, Chief Medical Officer, Natalis Counseling and Psychology Solutions • Martha Lantz, MSW, LICSW, MBA, Executive Dir., Touchstone Mental Health • Judge Kerry W. Meyer, Hennepin County Criminal Mental Health Court • Jane Pederson, MD, Medical Affairs Director, Stratis Health • Jeff Schiff, MD, MBA, Medical Director, MN Dept. of Human Services • L. Read Sulik, MD, Chief Integration Officer, PrairieCare Sponsors include: • MN Community Healthcare Network • MN Dept. of Human Services • Natalis Outcomes • PrairieCare • Psych Recovery, Inc. • Stratis Health

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; 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.

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Capsules

Thyroid Cancer Rates Rise Due to Increased Detection of Low-Risk Tumors A rapid rise in thyroid cancer diagnoses in the past decade is due to an increased detection of low-risk cancers that don’t have symptoms and could cause no problems in the future, according to results from a Mayo Clinic study. Researchers used data from the Rochester Epidemiology Project to study 566 men and women who had been diagnosed with thyroid cancer in Olmsted County between 1935 and 2012— specifically, they looked at the number of new cases, fatalities from the disease, and methods of diagnosis. They found that almost one-third of all recent cases were diagnosed when a provider used high-tech imaging even when no thyroid disease symptoms were present in the patient. “We are spotting more cancers, but they are cancers that are not likely to cause harm,” said Juan Brito Campana, MBBS, assistant professor of medicine at Mayo Clinic and lead author

of the study. “Their treatment, however, is likely to cause harm, as most thyroid cancers are treated by surgically removing all or part of the thyroid gland. This is a risky procedure that can damage a patient’s vocal cords or leave them with lifelong calcium deficiencies.” Researchers discovered that the number of new thyroid cancer diagnoses doubled from 7.1 per 100,000 people in the 1990 to 1999 time period to 13.7 per 100,000 people in the 2000 to 2002 time period. However, the number of new cases of thyroid cancer that presented symptoms stayed the same during those time periods, while the number of new cases of silent thyroid cancer, which presents no symptoms, increased almost fourfold. And the proportion of patients with thyroid cancer for whom it was fatal showed no change since 1935. The most common reasons for finding new cases of silent thyroid cancer were found to be reviews of thyroid tissue removed for benign conditions (14 percent); incidental discovery during an imaging test (19 percent); and investigations of patients with symptoms or palpable nodules

Minnesota Physician October 2015

that were clearly not associated with thyroid cancer but triggered the use of imaging tests of the neck (27 percent). Some of the suggested strategies include limiting the use of some imaging technologies and engaging patients in discussions about their treatment options to include the possibility of active surveillance for those with small, relatively benign cancers that don’t pose an immediate threat. Brito also suggests that using terms such as “papillary lesions of indolent course” in place of the word “cancer” to refer to the small, symptomless thyroid lesions could help reduce unnecessary treatments for patients because the term is less emotionally charged.

State Awards Grants to Improve Health Care Data Analytics The Department of Human Services has awarded 11 Minnesota health care organizations a total of more than $4 million in federal grants to increase data analytics efforts that will help them

be more proactive in preventing health problems. The organizations are all part of the state’s Integrated Health Partnership (IHP) demonstration. Some projects the funds will be used for include implementing training new informatics analysts, evaluating the integration of social determinants into care coordination and risk algorithms, and incorporating new software systems to help improve analytics. Each grantee received between $100,000 and $500,000. The grantees are Allina Health/ Courage Kenny Rehabilitation Institute; Children’s Hospitals and Clinics of Minnesota; Essentia Health; FQHC Urban Health Network; Hennepin County Medical Center; Lakewood Health System; Mankato Clinic; North Memorial Health Care; Southern Prairie Community Care; Wilderness Health; and Winona Health. “Data analytics serve a number of purposes,” said Michael Van Scoy, medical director of population management at Essentia Health. “We can access and analyze data to determine the health of any given population and we can identify specific patients or patient-types at high risk

of having a negative health event, and we can also compare data from our healthcare system to others’ health systems.” Essentia Health will use their grant funds to hire a data analyst who will focus on population health, as well as incorporating a software program from Epic called Healthy Planet that will improve analytics through Essentia Health’s electronic health record system. The data analytics grants are through Minnesota’s $45 million State Innovation Health Model grant, which is being used to test new ways of delivering and paying for health care using the Minnesota Accountable Health Model framework.

Pharmacy Benefit Spending Rose Last Year Net prescription drug costs increased 13 percent in 2014, according to the 2014 Report on Prescription Drug Costs from Prime Therapeutics. Traditional drugs showed a 4.2 percent increase, but specialty drugs accounted for the majority of the overall cost rise with an increase of 25.8 percent. According to the report, this was due to changing dynamics in the industry, including drug price increases across the board; new, high cost specialty drugs; less opportunity for members to switch to generic drugs; increased use across almost all drug classes; and the addition of 1.4 million health insurance marketplace members with greater health needs. Drug price increases were responsible for two-thirds of the increase in net prescription costs. And three therapeutics categories were responsible for more than 50 percent of all new drug spending in 2014—hepatitis C, diabetes, and anti-inflammatory drugs. Only 0.04 percent of members utilized hepatitis C drugs, but they were the highest contributor to increased pharmacy benefit spending in 2014, accounting for more than 25 percent of new drug spending overall and 40 percent of new specialty drug spending, partially due to new, high-cost drugs emerging into the market. Diabetes was the secondhighest contributor, however the rise in this case was largely due to price increases. Prices for the most commonly used insulins rose more than 20 percent on average.

Prime Therapeutics predicts that costs will continue to rise rapidly over the next few years. “The new dynamic in health care is characterized by extremes,” the report said. “Highly targeted, highly effective drugs with extraordinarily high prices will continue to intensify the pressure on already-tight health care budgets. Drug prices will continue to rise to record highs. Together, we estimate these forces will fuel annual pharmacy cost increases of 10 to 12 percent industry-wide.” However, they note that the new drug innovations, while costly, play a role in treating illness and improving patient health. Data for the report came from an analysis of almost 150 million commercial claims processed in 2014.

Carlton County Funded to Build Health Information Exchange Carlton County has received a $222,748 grant from the Minnesota Accountable Health Model project to develop a health information exchange (HIE). Duluth-based Integrity Health Network is leading a collaborative of area agencies to develop the HIE. The goal is to improve the overall health of the local populations by allowing providers across different health care settings to access information needed to coordinate patient care and keep healthy people out of the hospital. The collaborative is called Carlton County Connects, and includes Arrowhead Health Alliance (a partnership between the Health and Human Services agencies of Carlton, Cook, Lake, Koochiching, and St. Louis Counties); Augustana Mercy Health Care Center in Moose Lake; Carlton County Public Health and Human Services; Community Memorial Hospital and Sunnyside Health Care Center in Cloquet; Cromwell Medical Clinic; Integrity Health Innovations (an accountable care organization); Gateway Family Health Clinic in Moose Lake; Human Development Center in Cloquet; Mercy Hospital in Moose Lake; Min No Aya Win Clinic in Cloquet; Raiter Clinic in Cloquet; and Villa Court Senior Living in Cromwell.

Physician Driven. Patient Inspired.

“The time“The theytime save they me meeting save me meeting reporting requirements allows MS reporting requirements allows meatoCspend pprov me to spend more time ed more time with patients.”A C O with patients.” — Christopher Wenner, MD, Clinic Owner Integrity Health Network member, Cold Spring – Christopher Wenner, MD, Clinic Owner Integrity Health Network member, Cold Spring

Helping Independent Hospitals and Clinics compete:

Helping clinics facilities • Referral independent network of 215 primary and and specialty physicians

• Network of over 200 physicians, providers and •facilities QI/P4P Measurement development & reporting

• Competitive group purchasing contracts to control

• Q1/P4P Measurement development & reporting your costs

• •Competitive contracts to control Latest in EHRgroup & Webpurchasing Portal technology your costs • Partnering with health plans on new models of care Partnering with with select hospitals, clinics andon employers to • •Partnering health plans new models work on clinical integration and delivery of care Data Warehouse under development. Information is • •Partnering with hospitals, clinics, employers and key to competing and improving quality government entities to work on clinical integration •and Marketing, deliveryrisk management, clinic staff training • Developing strategies to leverage exciting new

• Grant-funded health information exchange (HIE) opportunities: Accountable Care Organizations, development Medical Home, Baskets of Care • Data analytics. Informationphysicians is key to competing and Our independent keep improving quality hometown healthcare where it belongs. • Marketing, risk management, clinic staff training • Developing strategies to leverage Jeff Tucker, CEO new opportunities (jtucker@ihnhealth.com) including Accountable Care Organization, medical home, episodes of care, bundled COO care, HIE and care Rachael Nyenhuis, coordination(rnyenhuis@ihnhealth.com)

Our Independent physicians keep 888.722.8802 hometown healthcare where it belongs.

JeffreyaL.network Tucker, CEO Delivering of solutions jtucker@ihnhealth.com

IntegrityHealthNetwork.com 218.722.8802.112 Melissa Larson, Vice President, Operations mlarson@ihnhealth.com 218.722.8802.115 IntegrityHealthNetwork.com Delivering a network of solutions

888.722.8802

Capsules to page 12 October 2015 Minnesota Physician

Capsules from page 11

CentraCare Health to Launch Teleneurology Program CentraCare Health will begin providing a teleneurology patient navigator program to post-stroke and transient ischemic attack (TIA) patients receiving follow-up care at its facilities beginning in October. The goal of the program is to improve access to care and health outcomes for CentraCare Health patients recovering from a stroke or TIA who live in Chippewa, Pope, Swift, Todd, Wadena, and parts of Stearns counties. It will begin in Long Prairie and expand to other locations in the coming months. Nine hospitals and eight home care agencies in central Minnesota will be involved in the program once it is fully operational. “There are two big benefits this program will provide to patients in these rural communities,” said Sarah Zastrow, RN, leader of the program. “First, I will help make sure they understand their discharge

instructions, medications, and follow-up appointments. I will also help them find the resources to obtain their medications, equipment, transportation, and anything else they need.”

U of M Awarded Grant to Create New Skin for Patients The Richard M. Schulze Family Foundation has awarded $2.4 million to the University of Minnesota to support research to create new skin that could be used to treat burns, repair congenital defects, heal injuries from accidents or those sustained in combat, and reconstruct skin damaged by cancer therapies. The funds will support three years of work for Jakub Tolar, MD, PhD, director of the University of Minnesota’s Stem Cell Institute. He and his colleagues have developed a process that takes cells from a patients’ skin, corrects errors in the gene if needed, reproduces the cells, and artificially creates three-dimensional skin to replace the skin the patient has lost. They have

worked out the details of most of the process, and next they will work to create a biological scaffold to fabricate the three-dimensional skin. They will also work to prove the safety and effectiveness of the process. “The gift will accelerate that process, so patients with burns, disfiguring injuries, or the need for surgical reconstruction won’t have to wait as long for treatments,” said Tolar.

State Institutions Recognized for Pancreas Care Two Minnesota institutions have been named National Pancreas Foundation Centers by the National Pancreas Foundation (NPF), which describes the centers as “premier healthcare facilities that focus on multidisciplinary treatments of pancreatitis, treating the whole patient with a focus on the best possible outcomes and an improved quality of life.” Mayo Clinic’s Rochester and Florida campuses and the University of Minnesota were three of 30 institutions in the U.S.

to receive the designation. Designated centers will work to advance research and lead the way for heightened awareness and better understanding of pancreatitis and related conditions among community physicians, allied health professionals, patients, families, and the general public. In order to be considered for this designation, institutions must meet several criteria, including having the required expert physician specialties such as gastroenterologists, pancreas surgeons, and interventional radiologists, along with more patient-focused programs such as a pain management service and psychosocial support. “NPF Centers will also help to increase awareness of important NPF programs such as the National Patient Registry, the Animated Pancreas Patient and be a vital cog in the sharing and development of best practices,” said Matthew Alsante, executive director of the National Pancreas Foundation. “In addition to pancreatitis, phase II of this project will also introduce NPF Centers with a focus on treating pancreatic cancer.”

Medical Malpractice defense

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Minnesota Physician October 2015

Medicus Michael Belzer, MD, medical director and chief medical officer and practicing oncologist at Hennepin County Medical Center, has received the 2015 Harold S. Diehl Award from the University of Minnesota for his professional contributions to the university, its medical school, and the community. Belzer has served in his leadership position at HCMC since 1990 and also serves as Michael Belzer, MD medical director for Hennepin County’s Community Health Department and as associate dean for the University of Minnesota Medical School. In addition, he is on the boards of directors for the National Public Health and Hospital Institute, the National Association of Public Hospitals Physician Leadership Advisory Committee, Hennepin Medical Association, Metropolitan Visiting Nurse Association, the Hospice of the Twin Cities, and many others. Belzer also received the Distinguished Alumni Award from the University of Minnesota Medical School in 2004 and is the only person to have won both awards. Kim McConnell, MD, neurodevelopmental pediatrician at Gillette Children’s Specialty Healthcare, has received the Family Voices of Minnesota Family Champion Award for her commitment to family-centered care. McConnell specializes in the early diagnosis and treatment of developmental conditions; cerebral palsy; abnormalities in muscle tone; developmental Kim McConnell, brain abnormalities; Down syndrome; autism MD spectrum disorders; behavioral and learning difficulties associated with children who have disabilities; and prenatal drug effects. McConnell graduated from the Medical College of Wisconsin and completed her pediatric residency at Children’s Hospital Medical Center in Cincinnati, Ohio. She completed her fellowship in child development and developmental disabilities at the Child Development Center at Rhode Island Hospital. Macaran Baird, MD, MS, professor and head of the University of Minnesota department of family medicine and community health, has received the Thomas W. Johnson Award from the American Academy of Family Physicians for his outstanding contributions to family medicine education in undergraduate, graduate, and continuing education levels. Baird has contribMacaran Baird, uted more than 30 years toward the advanceMD, MS ment of family medicine education locally, regionally, and nationally. He served on the Robert Wood Johnson Foundation’s Depression in Primary Care National Advisory Council and as co-chair for the Improving Diagnosis in Health Care report, and currently chairs the UCare Board of Directors. Baird also worked with a multidisciplinary team to develop the Patient Centered Assessment Method, a tool to assess the social determinants of health. Stephanie Krejcarek Childs, MD, has joined Radiation Oncology at the Maplewood Cancer Center. Childs earned her medical degree at Harvard Medical School, completed an internship at Brigham and Women’s Hospital in Boston, and completed a residency in the Harvard Radiation Oncology Residency Program. Childs was awarded a Fulbright Fellowship from Stephanie Krejcarek the Fulbright Foundation of Sweden. PreviChilds, MD ously, she was an assistant professor of radiation oncology at the Mayo College School of Medicine and senior associate consultant in the Mayo Clinic department of radiation oncology.

Your

Musical Home

for the

Holidays Home Alone in Concert

FILM + MUSIC

Sarah Hicks, conductor Nov 28 8pm / Nov 29 2pm

Merry and Bright

with Charles Lazarus* Dec 4 8pm

Messiah: Hallelujah!

with the Minnesota Orchestra Dec 11 & Dec 12 8pm

Messiah Sing-along Dec 13 2pm

An Evening with George Winston* Dec 17 7:30pm

Jingle Bell Doc

with Doc Severinsen Dec 18 8pm / Dec 20 2pm

A Scandinavian Christmas Sarah Hicks, conductor Dec 19 2pm & 6pm

A Joyous New Year: Beethoven’s Ninth Symphony with Osmo Vänskä and the Minnesota Chorale Dec 31 8:30pm (with after-party) Jan 1 2pm

612.371.5656 / minnesotaorchestra.org / Orchestra Hall * Please note: The Minnesota Orchestra does not perform on this program PHOTOS Home Alone: © 1990 Twentieth Century Fox, Sarah Hicks: Josh Kohanek Photography, Merry & Bright artwork: Garan Ipsen, George Winston: Joe del Tufo, Osmo Vänskä: Joel Larsen, Scandinavian, Doc Severinsen: Greg Helgeson, Chorale: Tim Rummelhoff

October 2015 Minnesota Physician

INTERVIEW

Improving community health and wellness ■■ Please tell us about the mission of the Hennepin County Medical Center (HCMC). Our mission statement captures who we are and what we do: “We partner with our community, our patients and their families to ensure access to outstanding care for everyone, while improving health and wellness through teaching, patient and community education, and research.” We added “community” and “health and wellness” two years ago to better reflect how we work in partnership with the community to improve health and wellness.

Jon L. Pryor, MD, MBA Hennepin County Medical Center Dr. Pryor joined Hennepin County Medical Center as CEO in April 2013. Before joining HCMC, he was CEO of the Medical College of Physicians, the Medical College of Wisconsin’s medical group of physicians, advanced practice providers, and other staff. He has an MBA from the Kellogg School of Management at Northwestern University and was awarded a Bush Medical Fellowship in 2005. A urologic surgeon, his education and training include a medical degree from the University of Minnesota School of Medicine, two years of residency in the Hennepin County Medical Center Surgery Residency program, followed by four years of urology residency, and an American Foundation of Urologic Disease Fellowship at the University of Minnesota.

Minnesota Physician

■■ Since the integration of Hennepin Faculty Associates (HFA), what is the relationship between the physicians and the hospital at HCMC?

■■ In 2013, HCMC had a $27.4 million deficit, but in 2014 reported a $7.2 million surplus. How did you accomplish such a dramatic turnaround? It was a combination of improved earnings from growth across our health care system and operational improvements that reduced expenses. I credit our entire organization for this work over the past three years. We identified significant savings in expenses without any layoffs of front-line staff. We grew our patient base, through strategic initiatives and expansion of our clinic system. We also continued to adopt Lean Systems Thinking, which looks to the front-line staff to identify ways to drive out waste and improve processes.

■■ HCMC is building a new We are unique because we are We value the work of ambulatory and specialty one of only two fully intecare clinic near the downgrated health care systems in our physicians and town hospital. Would you the Twin Cities. Our executive are honored to have share some of the details team includes many physicians about this project? them as colleagues who hold high-level leadership The new facility will conpositions while continuing to and coworkers. solidate primary care and practice in their specialties. Our specialty care clinics downservice lines and care rings are town that are currently spread across nine buildeach led by a dyad that includes a physician leader and administrative partner. This collaborative spirit ings owned or leased by the medical center. It will also include an outpatient surgery center and our is also evident across our system where physicians Cancer Center. It’s where we will deliver the next participate in improvement work at every level, generation of care at HCMC. The building will be side-by-side with their colleagues who may be nurses, pharmacists, health care assistants, or clinic located across the street from our inpatient hospiadministrators. We value the work of our physicians tal, in the middle of the fastest growing neighborhood in downtown Minneapolis with apartments, and are honored to have them as colleagues and offices, and hotel developments on all sides and coworkers, and I believe our physicians value the opportunity to have a real voice in the operations of the new U.S. Bank Stadium just two blocks away. The 367,000 square foot clinic and specialty center the Hennepin Healthcare System—we are all in the will meet the growing need for outpatient care same boat and rowing in the same direction. and specialty services, improve the patient/family ■■ Tell us how HCMC works with the Minneapexperience, realign our model of care, and improve olis Medical Research Foundation (MMRF) system integration. We will be seeing patients in and some of the exciting projects MMRF is the new building in about two years. After it is working on. completed, we will be able to reconfigure space in MMRF, and the research that goes on there, is an the current buildings to position HCMC to meet integral part of our mission. We are focused on the health care needs of the growing downtown four key areas of research that reinforce our areas residential population and employee base, as well of clinical strength: 1) HIV, 2) addiction medicine, as patients from across the region that use HCMC 3) emergent/acute care/trauma, and 4) health for specialty medical and surgical services. sciences research (improving care delivery and ■■ Some time ago, HCMC began expanding eliminating health care disparities). This summer service by opening neighborhood clinics. we welcomed internationally recognized researcher What has been the impact in their service and neurosurgeon Dr. Uzma Samadani as our first areas and what are your plans to continue Rockswold Kaplan endowed chair for traumatic this expansion? brain injury. She has developed a new technology Our clinic volume has been growing 6 percent that tracks the eye movements of patients as a a year for the past two years. Opening our new more accurate measure of brain injury than any neighborhood clinics has contributed to this other diagnostic measurements. She is receiving growth. More important, these clinics are becomworldwide coverage of her research and she will ing an integral part of their neighborhoods and are continue that research here. She also is a fine neurosurgeon and our community is fortunate to have serving a need. We now have clinics in Brooklyn Park, Brooklyn Center, St. Anthony Village, Golden her services. Valley, Richfield, and in Minneapolis in the Whittier October 2015

neighborhood, East Lake neighborhood, and downtown. We believe it should be convenient for people to get health care and services to stay healthy. That’s also why we are expanding hours in our clinics to include evenings and weekends. ■■ Recently, access to home care and hospice services through HCMC has increased. What experiences have you had with this level of care? Health care systems are increasingly responsible for managing the patient’s health across the full continuum of care that extends beyond the hospital bed and clinic walls into the patient’s home and community. Including MVNA and Hospice of the Twin Cities services among our offerings enables us to provide health care in the safest, most cost-effective setting for the patient. Through this partnership, we are now offering specialized services including home health care, community palliative care, family health services, and other specialty home-based and community health services. We see great potential in enabling our system to improve patient satisfaction by providing care to patients where they want to receive care; improve quality by reducing admissions and avoidable readmissions; and

making transitions to other care settings seamless. This can also reduce costs by expanding our ambulatory network to keep patients out of, or minimize length of stay in, the acute care hospital setting. It will enable our system to be more competitive in the emerging market for total cost of care contracts and we will become a more vertically integrated health system by continuing to develop a population health practice that allows us to provide care in the most appropriate setting to meet the needs of our patients and their families.

■■ What goals do you have as CEO of HCMC? We are dedicated to being a cost effective place to get health care with great services. We are working every day to be a place where our employees feel valued, and have an opportunity to learn, serve, and attain their dreams.

■■ What are the biggest challenges facing HCMC? We are an innovative health care system and we want to explore new and better ways to deliver care. We are doing this through our ■■ What are some of the ways the Afford- Center for Healthcare Innovation, along able Care Act (ACA) has had an impact with pilots and new models of care. Testing on the care you provide at HCMC? these new ideas requires significant fundHealth care reform has been good for raising efforts and we will continue to reach patients by extending coverage to more out to potential funders to engage them in Minnesotans, ending denials for pre-existing this work. What’s exciting is that we have evconditions, allowing young people to remain idence that our efforts to find more efficient on their parents’ insurance until they are and effective ways to manage the health of older, and encouraging providers to create populations is working, so the challenge is new models of care and new payment mod- to continue to refine the approaches that els. It is still too early to know if the newer work and apply what we learn to transform high-deductible plans will increase bad debt how we deliver care in a way that improves for systems, although we are seeing some outcomes, while reducing the total cost of early signs of that. We need to continue to care that we deliver. improve our own system and the overall health care system. The worst thing would have been to do nothing at all.

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october 2015 Minnesota Physician

Infectious disease from cover

target resources for treatment and prevention. The big picture Case data (without patient names) from Minnesota and other states are sent to the U.S. Centers for Disease Control and Prevention (CDC) for larger trend analyses and setting of national priorities. Are there infections that can be controlled through improved vaccinesâ&#x20AC;&#x201D;such as where we were with pneumococcal disease in children just a few years ago? Are diseases controlled in the past now re-emerging, such as syphilis and pertussis? With the massive changes in health care delivery and the move to decreased hospitalizations and hospital stays, coupled with invasive technologies, are we seeing increases in health-care associated infections? What is happening with antibiotic-resistant organisms? A single case report from a physician may

not seem important, but the reports add up locally, within Minnesota, and in the United States to provide a very important picture on the world of infections.

It is essential that physicians maintain their vigilance.

Tracking emerging diseases In the 1960s, physician leaders expressed the thought that infectious diseases had been largely controlled, and efforts needed to focus exclusively on chronic conditions such as cancer and heart disease. In fact, by the 1980s there was a realization that infectious diseases were emerging dramatically

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with the discovery of AIDS, the large increase in foodborne diseases, and outbreaks of previously controlled diseases such as measles. An increased population of humans on the planet, urbanization and

Minnesota Physician October 2015

crowding (including the juxtaposition of animals and people), with the explosion in the travel and movement of such people contributed to the spread of infections. In addition, the huge increases in shipping foods and products around the world, with increasing demands by U.S. consumers, led to increased exposure to pathogens and pests from elsewhere, which previously had been rarely encountered. The recent outbreaks of MERS-CoV in the Arabian Peninsula and H7N9 influenza in China highlight the risk of emerging infectious diseases. Early in the 20th century some physicians opposed the notion of reporting private information about their patients to the health department. In particular they were against reporting socially stigmatized diseases such as syphilis and gonorrhea. Even as late as the 1980s some physicians opposed reporting the names of HIV-infected patients. To improve reporting, the MDH made a concerted effort in the 1990s to involve physicians, infection preventionists, and laboratories as equal partners to address emerging infections. The key to successful relationships is good two-way communication about the data and usefulness of the data. Several examples are illustrative of the many successes that have been made. For some infectious diseases, a single case demands immediate action. For example,

close contacts of a case of invasive meningococcal disease are at high risk and should receive chemoprophylaxis. A call from a physician in an emergency department to MDH assures that prophylaxis is prescribed to close contacts including household contacts, daycare contacts, and others who may have shared oral secretions. In the last year, physicians have called MDH many times about patients they are evaluating who have recently returned from Ebola-endemic areas of West Africa. Collaboratively, we assessed the likelihood of Ebola virus disease and guided the diagnosis and infection control precautions. Clues to solving an outbreak In another instance, a physicianâ&#x20AC;&#x2122;s report may be put together with other reports and that information could lead to a public health breakthrough. For example, in November 2008, a cluster of 62 Salmonella enterica serotype Typhimurium isolates with three closely related pulsed-field gel electrophoresis (PFGE) subtype patterns was reported and investigated in more than 20 states. Local and state public health departments conducted routine case/patient interviews in November and December 2008. Unfortunately, no links among cases or large clusters were initially identified and the outbreak continued unabated. During December 2008, the medical directors of two separate long-term care facilities in the same northern Minnesota city independently called MDH to report five residents and one resident, respectively, ill with symptoms of salmonellosis with preliminary laboratory results indicative of Salmonella. With this information, and another report of two children from the same elementary school in the same city, MDH was able to identify the source of all the infections as being a peanut butter marketed to institutional food services. This enabled focus on this brand by other state and national investigators, quickly linking peanut butter and other peanut products

produced by the Peanut Corporation of America at their Blakely, Georgia, facility. This national outbreak of over 700 cases resulted in one of the largest food recalls in U.S. history with over $1 billion in lost peanut sales. The timely reports by the two physicians to MDH were invaluable to solving this outbreak expeditiously. Sometimes a report from a physician to MDH is analogous to “the canary in a coal mine.” In July 2013, a physician noted that two patients required knee surgery and were hospitalized at the same time with Staphylococcus aureus infections following knee injections by the same provider at a local chiropractic clinic. He instructed the infection preventionist to notify us and provided detailed information. Subsequently, MDH investigated the clinic, found additional cases, and discovered multiple egregious breeches in infection control practices that likely led to the infections.

Understanding new strains During the 2009 H1N1 influenza pandemic, rapid collection of information on individual hospitalized cases was critical to understanding the nature of the new strain of influenza, the severity of illness it caused, and who was most at risk for infection and severe outcomes including death. Initially at the start of the pandemic, Minnesota was one of only about a dozen states that collected detailed reports of hospitalized influenza cases, providing important data to the country. Early on, these data revealed risk factors that were different from those associated with seasonal influenza including pregnancy, obesity, American Indian/Alaska Native status, and younger age. Tracking unexplained diseases In another analogous warning event, in late August 2010, a hospitalized case of rapidly progressive, unexplained

encephalitis in a female aged 7 years was reported to MDH by the attending infectious disease physician. The presumptive diagnosis was bacterial meningitis. Despite antibiotic treatment, the patient’s condition declined rapidly, with increasing seizure frequency, and she required endotracheal intubation and mechanical ven-

Wright’s stain of a CSF (cerebral spinal fluid) sample from the day of admission showed ameboid forms. Additional testing confirmed the diagnosis as primary amebic meningoencephalitis (PAM) due to Naegleria fowleri. This case represented the northernmost documented occurrence of PAM in North America, approximately

A single case report from a physician may not seem important, but the reports add up.

tilation. Despite massive efforts, neurologic evaluation and cerebral flow study were consistent with brain death, and a decision was made to withdraw life-sustaining support. Permission for autopsy was granted, and a

550 miles north of the previous northernmost reported case in Missouri. Although the ameba is ubiquitous in water and soil in warmer climates, its distribution in cooler northern areas Infectious disease to page 42

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Tickets: $12-$50 October 2015 Minnesota Physician

Political malpractice from cover

Good intentions became inflationary U.S. cost-price inflation began abruptly after 1965 following the passage of Medicare and Medicaid laws. This was a tipping point: 85 percent of the population (employed workers since 1942, plus the old, poor, and disabled) suddenly had inexpensive tax-subsidized insurance—a piecemeal U.S. version of National Health Insurance (NHI). The good intentions behind using tax subsidies to artificially decrease the price of insurance meant that untaxed insurance dollars were used to prepay even affordable and expected medical care. As care appeared “free” (when actually the boss or government paid for it), unrelenting demand for services was met by a rise in prices to expand the supply of both clinic and hospital services.

When no one asked the price of care, wealth was transferred to medical sector expansion from other economic sectors and the market worked. Since repealing popular tax subsidies was considered political suicide, culprit economic sloganeering was invoked. “Market failure” was allegedly due to ignorant patients in the hands of profligate providers practicing in an inefficient “cottage industry” doing “sick care” instead of “well care.” Well-intentioned as it was to reduce the price of health care via subsidized insurance dollars, it was nonetheless economic political malpractice. The move toward corporate control—managed care (MC) 1.0 The political response to the first-ever medical inflation “crisis” was passage of the Health Maintenance Organization

Act (HMO) of 1973. The hype was that inflation would be controlled via profit-driven corporate efficiency to maintain health. Of more practical importance, could HMO corporations, MC 1.0, halt inflation by emulating the successful delay and denial regulatory strategies of socialized National Health Service (NHS) managed care organizations abroad? Since nationalizing industry was anathema in American politics, using the alleged efficiency of profit-driven corporations was palatable compared to using the presumed inherent inefficiencies of any nonprofit socialist system of managed care rationing. Health insurance corporation stocks sold on Wall Street gave a reassuring patina of free-market capitalism to HMO socialist-like rationing controls. These powerful controls legalized by the HMO Act gave medical insurers the perverse power to control the use of the benefits they insured—something not allowed any other casualty insurance companies. This is the same power used by NHS managed care organizations abroad to control the use and cost of open “free” care access. Following passage of the U.S. HMO Act of 1973 there was an accelerating transition from a professional medical marketplace, in which services were sold to patients, to a commercial marketplace in which populations (or “covered lives”) of HMO insurance corporations and government agencies (the mega “payers”) were sold at auction to providers for servicing—the essence of MC 1.0. Auctions of patients for services were most often for fees administered at progressively lower prices; negotiations were often “our way or the highway,” as HMO prices mimicked low government service prices. In addition, auctions of patient populations through capitation fees (sometimes coerced) transferred, to many clinics, the insurance risk of caring for a corporation’s clientele—many

Minnesota Physician October 2015

capitated clinics went broke as a result. By the late 1990s regulatory cost control panaceas had failed. Draconian HMO rationing of care tried in the early 1990s, such as drive-by deliveries and mastectomies, was a political bust. HMOs were seen to wear the black hat of rationing. The dilemma of managed care on a fixed budget was exposed: “Cost, access, quality—pick any two.” The failure of political panaceas was incomprehensible for those blissfully (or hypocritically) ignorant of NHI “free” care inflation. Admitting political malpractice or corporate incompetence was equally incomprehensible. The HMO industry promptly produced new scapegoats for public indignation: a self-indulgent, smoking, soda-drinking, obese population; greedy drug and technology companies; and, yet again, alleged profligate irresponsible providers. Doctors were (and are) speciously accused of practicing poor quality care, since supposedly driven by FFS profiteering avarice to do “too much.” The lack of FFS-driven inflation in any other industry is always ignored; equally ignored is the role of managed care’s fatal flaw. Why did MC 1.0 fail? All managed care organizations dispensing the appearance of free care, whether they are HMOs in the U.S. or National Health Services (NHSs) abroad, have a fatal flaw. As pointed out by the economist, John Cassidy years ago, no central authority, however brilliant (or good willed) the managers, can accomplish the functions of freely determined prices for the allocation of labor, capital, and human ingenuity. No panacea can fix a system with no real consumer prices to guide production and distribution of goods and services. Microeconomic systems (including medicine) where millions of transactions take place daily between millions of people with

millions of goals, have proved too complex to centrally plan and manage. For example, the fatal flaw of post-World War II experiments with mixed industrial socialism in Western European nations necessitated deregulation after 1980 to avoid economic collapse. Popular nationalized “free” care NHSs could not be touched politically; its inflation remained hidden in queues, subsidy props, and infrastructure deterioration. Meanwhile, in the U.S. the politically favored HMO industry, despite public distrust, was able to parlay decades of failed cost control into unparalleled profits, and profits into political power. With failure, a new panacea to control cost inflation was deemed a political necessity. The rise of cartels—MC 2.0 Our misfortune is that the story of many failed cost control

panaceas from 1965 to 2010 may be replicated by a more powerful, yet still fatally flawed, managed care panacea of government-protected corporate cartels following the passage of the ACA in 2010—MC 2.0. Public medical system cartels consist of government-managed care organization collusion

Private cartels on the other hand are regarded as sinister profiteering cabals intent on achieving only their own interests. Typical examples are the cronyism found in the Organization of the Petroleum Exporting Countries (OPEC) and in one-party nation states such as Venezuela, Cuba, the old Soviet Union, and the new Russia.

“Market failure” was allegedly due to … profligate providers.

aimed at the market control of prices, utilization of services, and franchising certain providers of goods, services, and insurance. Typical examples are the well-intentioned parliamentary-NHS cartels abroad. Their hope is to properly control access to “free” care.

Private domestic cartels have been outlawed by antitrust laws in most national jurisdictions, including the U.S. With implementation of the ACA the shift to a U.S. public medical cartel system consists of federal/corporate partnerships. The government man-

dates by law that we all buy the corporate partners’ insurance. To increase corporate power, massive corporate mergers and collusion are legalized through waivers of antitrust law and waivers of anti-fee-splitting and anti-self-referral laws—the essence of MC 2.0. The federal government has recently winked at rotating executive leadership roles between the public’s Medicare/ Medicaid regulator becoming the executive of the national medical insurance trade association and an HMO insurance executive being appointed as the government regulator. When does interlocking executive leadership cross the line into sinister state/private cartel collusion instead of proper public utility-like regulation and/or anti-trust enforcement? Specious, if not sinister, political/corporate arguments Political malpractice to page 40

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Professional Update: Transplant Surgery

he numbers are staggering. Close to 7,000 people die waiting for a lung transplant each year. Diseases like cystic fibrosis, idiopathic pulmonary fibrosis, and diseases caused by smoking, such as chronic obstructive pulmonary disease, all ruin a patient’s lung function. Most of these chronic lung diseases progress gradually over several years, slowly robbing patients of normal breathing patterns and sapping energy levels. The reduced lung function lowers blood oxygen levels, which can cause fluid retention in the legs and abdomen. With each flare-up, oxygen levels deteriorate further. Lung transplantation becomes the only option for survival. According to the 2014 Organ Procurement and Transplantation Network (OPTN), of the lungs donated for patients over an average of several years, just 20 percent were suitable for transplantation. Most donor lungs have inflammatory lung

Lung transplantation Improved outcomes By Gabriel Loor, MD, and Gail Frankle, RN, DHA

damage, making them unacceptable for surgery. In addition, attempted donor resuscitation or ventilator damage can ruin donated lungs. Even cold ischemia caused by contact with ice during the transport of lungs makes donated organs unusable for transplantation, which further reduces donor lung supply. While the shortage of suitable lungs remains a persistent challenge, the field of cardiothoracic surgery has made huge improvements since the first transplant in the early 1960s.

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Minnesota Physician October 2015

In the past, only about 30 percent of patients survived to five years and most experienced early death. Thanks to refined donor call models and transplant technology, surgeons have been able to lengthen organ vitality and improve the outcomes of lung transplantation. Currently, less than 3 percent of patients die within 30 days and close to 60 to 70 percent are alive at five years. A collaborative approach to matching All patients who are considered for lung transplant go through an extensive evaluation process. Each patient’s case is reviewed by a multidisciplinary team consisting of social workers, transplant coordinators, financial counselors, pharmacists, anesthesiologists, radiologists, pulmonologists, and transplant surgeons. These teams review the process and progression of the patient’s disease; their social situation and support network; the patient’s health insurance and means for preand post-op care; their ability to comply with health provider’s care regimens; and the risk/ benefit ratio for the patient. Though this process sounds arduous, it ensures that once a patient is added to the United Network for Organ Sharing (UNOS) national database, their likelihood of a successful transplant is higher. Like other transplantation processes, blood and tissue type, along with the recipient’s health, determine the viability of lung donation. Historically, lung size was also believed to be critical; however research published in the Journal of Cardiovascular Surgery shows

variations in lung size does not impact post-transplant survival or lung function. With a greater understanding of how to match donor lungs, the medical team has been able to streamline the donor call protocol. Previously, procurement organizations would call a surgeon directly when the lungs became available. This phone call may have been in the middle of the night or while a surgeon was operating on a patient, potentially taking hours to determine whether the lungs are suitable for transplantation. By working to develop collaborative protocols with specially trained donor coordinators, transplant programs can optimize lungs for transplant that would have previously been discarded. In the majority of programs, the transplant coordinator not only takes care of all care coordination for the patient and family, but also has donor call added to their responsibilities. They rotate through this 24hour call of being on for a week or several days at a time. Often, a transplant coordinator is unable to devote all of his or her time to assessing and collecting information on an organ. That’s when a procurement transplant coordinator steps in, whose sole job is to screen all local and import offers and work closely with Organ Procurement Organizations (OPOs), to guide the process and make sure the organ is optimal for the recipient. This leads to more transplants and better outcomes. The protocols include a detailed 20-point checklist to review oxygenation, size, viability, and potential cold time, among other criteria. The teams then look at all radiologic films. In the past, a surgeon would simply receive feedback from a radiologist who may not have been trained in lung transplantation. Data from this checklist provides a far more accurate picture for the surgeon and allows for a more informed decision and increases the odds of a successful outcome for the patient.

Recipient selection is another area of future importance. Since inception, the medical community has reserved lung transplantation for the sickest patients who are in the latest stages of their disease. But, we’ve learned that healthier patients have the most successful long-term results. Consequently, surgeons are now researching the ideal timing for transplantation to ensure the best outcome. Primary physicians have great power to lead this improvement by consulting with transplant centers as their patients’ lung condition progresses. Rejection Looking ahead, chronic rejection is a continued area for improvement in the field of transplantation, lung or otherwise. Among the most common post-transplant complication is bronchiolitis obliterans syndrome. This is a fibrotic process resulting from progressive narrowing of bronchiolar lumens and airflow obstruction is the manifestation of chronic allograft rejection. It renders donated lungs useless once in the body. Fortunately, scientists are now investigating the pathogenic mechanisms of bronchiolitis obliterans syndrome and other failure conditions, so the medical community can develop strategies to treat and prevent this complication. Transplant technology Beyond modifying donor call protocol, patient eligibility, and researching rejection, technology has drastically improved the field of lung transplantation. Traditionally organs are transported on ice. But, manufacturers can now make much smaller devices, providing transplant teams with small portable ventilators and pumps that keep the lung warm, ventilating, and perfused with blood. These tools maintain donor lungs in a nearly physiologic state. When the lungs are close to a body’s conditions, meaning 98.6 degrees with continually pumping oxygenated blood, the chances of success are far greater.

One of the biggest advancements that allow surgeons to achieve a near physiologic state has been the Organ Care System (OCS) Lung. This device pumps normothermic blood and oxygen through donor lungs to keep them “breathing” during transport. The device also contains sophisticated monitoring equipment, providing detailed information about oxygen levels, flow rates through the lungs, and compliance of the lung tissue.

Conclusion From November 2013 to July 2015 at the University of Minnesota Medical Center we have performed 79 transplants with seven lungs in the Inspire trial and 11 lungs in the Expand trial with the OCS Lung. All of these transplants have been successful with 14 transplants making use of organs that would not have initially met standard transplant criteria without conditioning and monitoring of the OCS Lung.

Close to 7,000 people die waiting for a lung transplant each year.

The University of Minnesota Medical Center performed the Midwest’s first breathing lung transplant in 2013. This procedure was part of the Inspire Trial, designed to compare standard donor lungs transported on ice to those transported using the OCS Lung. The medical center was also the first program in the world to transplant during the subsequent Expand Trial, which analyzed whether lungs that were previously thought to be unviable could be used in transplant after time spent on the OCS Lung. The university found that it was able to use lungs that would not have otherwise been suitable for transplant. In some cases, donor lungs have low oxygen levels as they’re placed into the breathing lung device. But, with time spent in the device, the oxygen levels increase. In addition, this technology is able to keep the organ viable for much longer, allowing the courier to travel longer distances and increasing access to donations. These preliminary benefits will undoubtedly prompt wider adoption of this technology for donor lungs once thought to be unviable. Such innovation will help cardiothoracic teams perform more lung transplants and reduce the number of patients who die waiting for an organ.

Thanks to a collaborative approach to caring for patients along with transplantation technology, the medical field has taken a once fringe science

and made it a standard treatment for those suffering lung failure. The medical community has an obligation to patients to continue its teamwork so that we may identify patients’ ideal transplantation time and minimize complications. Gabriel Loor, MD, is a cardiothoracic

surgeon with University of Minnesota Health and an assistant professor at the University of Minnesota Medical School. Loor accomplished the first breathing lung transplant in the Midwest in 2013 and the first Expand lung transplant in the world. Gail Frankle, RN, DHA, is senior director of Transplant Services at University of Minnesota Health. She has been a nurse for 28 years, with over 25 years in the transplant field and has been involved in direct patient care, nursing leadership, and 10 years in transplant leadership.

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October 2015 Minnesota Physician

Special Focus: Organized Medicine

he needs of practicing physicians are changing, and so too is the role of county medical societies. Not too long ago, nearly all physicians in the Twin Cities seven-county metro area were members of their county medical society. Physicians joined because there was a sense of duty and loyalty to their professional association. It was simply what physicians did. Clinics paid the membership dues, physicians joined committees, attended society events, and relied on their county medical society as a gathering place to share stories, foster collegiality, and network. County medical societies also served as a pathway for leadership opportunities with other associations, clinics, or within their hospital systems. Physician involvement Physicians were intimately involved in many aspects of their county medical societies

Advocating for change The new role of the county medical society By Sue Schettle, and Ken Kephart, MD

and helped lead the way in creating organizations such as the Midwest Medical Insurance Company (MMIC), the Center for Cross-Cultural Health, Physicians Health Plan (PHP), and the Foundation for Health Care Evaluation (now Stratis Health). Metro-based physicians also set in motion the Minnesota Clean Indoor Air Act—the first of its kind in the country to call for a no-smoking policy in hospitals. A metro-wide centralized credentialing program was established called Medical

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Minnesota Physician October 2015

Credentialing Services of Minnesota, which served as a model for other states. Work was accomplished through county medical societies, which empowered the state medical association to work toward changing laws and policies. It was a powerful time when physicians spoke with one voice. A drop in membership Over the course of time, however, things have changed. No longer are the majority of physicians in the Twin Cities metro area dues paying members of their county medical society. The membership of the Twin Cities Medical Society (TCMS) is now under 50 percent of the local market. There are many reasons for the drop in membership, including the emergence of specialty societies, the cost of membership dues, the value proposition (“What am I getting for my dues?”), and fewer physicians in independent practice. The largest issue that negatively impacts membership is the changing dynamic of the metro area health care scene. Many physicians are employed by large health care systems and their needs have changed. In addition, these employed physicians have seen their continuing medical education (CME) and medical organization membership allowance lumped together. Most physicians choose to join a specialty society, which includes CME and leaves little or nothing left to join other societies. At the same time independent physicians—those that are not employed by large health

systems—are becoming less and less prominent due to pressures and financial constraints that are real and difficult to manage. This trend is not just happening in Minnesota. It’s happening all over the country. Every state has a medical association and within that state there remains many county-based medical societies. The trend is that many county medical societies across the country are consolidating as membership remains flat or declines. There are pockets throughout the country where county-based medical societies are thriving (California and Texas for example) but the physician practice environment in those areas is different. Health care systems are large and powerful and have their own lobbyists and policy advocates on staff who advocate and work to change policy or laws on behalf of their “system.” Admittedly, some physicians find that having their health care system serve as their advocate is just what they wanted. Their system looks out for them and helps to advocate on their behalf so physicians can devote their time and attention to taking care of their patients. So, what should physicians expect their county medical society to do for them? Switching gears TCMS realized a decade or so ago that we needed to rethink how to better serve our members. How could we carve out a niche for ourselves that would provide value to physicians and the systems in which they work and ultimately the patients they serve? We needed to discover something that one health care system could not easily accomplish on its own. We asked ourselves tough questions. As a county medical society how can we effect change that would span health care systems? How can we engage physicians within large health care systems who are somewhat insulated from interacting

with their county medical society? How can we take what TCMS physician members have already prioritized as important public health priorities and do something more proactive than merely endorsing a policy, or supporting a law? How can we remain relevant? We decided to engage physicians in local policy work and advocacy, helping them to have their voice heard at the local level—e.g., testifying at city council hearings and talking to county commissioners and mayors. The goal was to enact public policy changes that would lead to changes in patient behavior, which leads to positive health outcomes. Restricting secondhand smoke in public places leads to decreased smoking and decreased exposure to known carcinogens. Enacting comprehensive public policy that spans health care systems, and is implemented at the community level, leads to positive health outcomes.

be working on in the coming years. Not surprisingly, tobacco use almost always ranks as one of the top priorities, followed by obesity prevention, among other public health issues. This helped us set our role as convener, coordinator, and catalyst in motion. We began to delve into areas that had an impact on the public’s health, and we served as the central point for physicians to become engaged in this work. During the past 15 years the physicians of TCMS have led public health initiatives that brought about remarkable public policy changes. These include:

Secondhand smoke prevention. In the mid-2000s TCMS engaged physicians in public policy discussions around the negative health consequences of prolonged exposure to secondhand smoke. Within one month, over 400 physicians had signed up to work with us by testifying at hearings, meeting with elected officials, We realized going through that our niche media training, was to act as a The role and advocating convener, coorpassionately for dinator, and catof the county ordinances to alyst for change. medical society restrict smokWe serve a has changed. ing in indoor unique role in places. The city the physician of Bloomingcommunity. ton passed the TCMS has access to physicians of all special- first metro area smoking ban. In 2004, the city of Minneapolis ties from all of the metro area, voted to enact a comprehenmany of whom have served as sive smoke-free ordinance that leaders of TCMS at one point in included bars and restaurants time. We had to capitalize on with other cities and counties that resource and engage our physician members, health care following suit. The physicians of TCMS served a crucial role systems and their physician in setting the framework for the leaders, and the community on statewide law that was enacted innovative public health priorin 2007. ities. It seemed like a win-win for everybody. Obesity Prevention. In 2008, Listening to our members We survey our members every other year to get their feedback on what TCMS’ priorities and concerns should be. We ask them which issues are important and use their feedback as a way to gauge what we should

CMS began an obesity prevention effort began in 2008 through TCMS. We established the Twin Cities Obesity Prevention Coalition and charged it to work with local municipalities to enact healthy eating and active living strategies by promoting community gardens

and connected bike paths, by phasing out transfats, and by labeling menus. Physicians were key in this work and provided much needed expert testimony. Physician Advocacy Network. The use of e-cigarettes and other tobacco products (OTP) are on the rise. We also know that these products are a gateway to using other products such as hookahs or flavored cigars. Physicians are educating themselves about the effects of e-cigarettes on their patients.

They are also being trained in the metro (and statewide) through the Physician Advocacy Network, a physician-driven advocacy arm of the Twin Cities Medical Society. The Physician Advocacy Network is an umbrella of sorts, and oversees all advocacy efforts at TCMS. The model that we created can be replicated to fit with any local public health initiative. First, we engage physicians in a particular idea, educate them Advocating for change to page 38

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October 2015 Minnesota Physician

Special Focus: Organized Medicine

ealth care is changing and physicians in general, and family physicians in particular, are living these changes every day. The U.S. has an extremely expensive health care system, which accounts for 17 percent of the gross domestic product. It is estimated that this percentage will inflate to nearly 20 percent by the year 2020, which is unsustainable. Compared to the rest of the industrialized world we continue to show poor health care outcomes, a higher morbidity and mortality rate, all incurred at a higher cost.

Primary care vs. specialty care Here in the U.S., we are facing an imbalance between primary care and subspecialty care. There is a significant shortage of primary care physicians. In 2008 in the U.S., only 32 percent of all practicing physicians were primary care physicians, with specialists comprising over 60 percent of all physicians.

Setting health care policy How family physicians can play a role By M. Tariq Fareed, MD, FAAFP

Here are some reasons for the increased interest in choosing a subspecialty. • Subspecialist salaries are higher than primary care salaries. • Medical students choose to pursue a subspecialty because it enables them to pay down their student debt faster. • Medical students are drawn to procedure-oriented specialties that often rely on advanced technology, which leads to higher reimbursement rates.

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Major health care policy is often left to the politicians. Legislators come from a variety of backgrounds and professions, but few have a medical background. This is why input from the medical community is imperative. It is our job as physicians to educate both our local and national representatives to help formulate policies and legislation to promote the Quadruple Aim as proposed.

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The Quadruple Aim? There is a move now to focus on patient wellness in order to reduce the cost of health care in the U.S. The patient population is aging, but also living longer, so there is an increased burden of managing chronic illnesses. The Institute of Healthcare Improvement proposed the Triple Aim as a framework to optimize health care performance: • Improving the patient experience of care (including quality and satisfaction); • Improving the health of populations; and • Reducing the per capita cost of health care. However, the shortage of family physicians means that there is often an overburdened work force. Physicians are striving to find a work/life balance and avoid burnout, which affects patient care. Since then a fourth component, clinician and staff satisfaction, has been proposed to make the framework a Quadruple Aim.

Minnesota Physician October 2015

From cradle to grave Nationwide the American Academy of Family Physicians (AAFP) is approximately 125,000 members strong. AAFP’s tag line “Strong Medicine for America” reinforces the belief that family physicians are the cornerstone of the U.S. health care system. Family

physicians are the only physicians that provide longitudinal, coordinated, and personalized care to people and their families, including patients of both genders and all ages. It is often said that family physicians provide care from cradle to grave or womb to tomb. Family physicians diagnose and treat illnesses, and provide preventive care including routine physical exams, health-risk assessments, immunization, screening tests, and counseling on wellness. Family physicians manage chronic disease and provide coordination of care through the medical home model. They also collaborate with those providing subspecialty and ancillary services. According to one estimate, nearly one in every five of all office visits are made to family physicians, which adds up to 192 million office visits per year. This number is nearly 66 million more than the number of office visits made to the next largest medical specialty. The majority of underserved and rural populations are served primarily by family physicians. The distribution of family physicians to the U.S. population is more proportional than any other medical specialty. Providing front-line medical care to people of all socioeconomic status and to all regions of the United States, family physicians are natural leaders in health care. This unique and comprehensive role that family physicians play in providing personalized, longitudinal, family, and community-based care earns them the trust and confidence of patients as their advocates for health. Family physicians can serve as a representative to their legislators and other stakeholders in formulating legislation, implementing policy, and making sound decisions for the betterment of health. The power of advocacy The AAFP aims to influence and shape health care policy by working with the government, the public, businesses, and the health care industry. Here are some important strategies that AAFP will focus on:

• Supporting health care for all • Advancing the patientcentered medical home (PCMH) • Improving payment equality for family physicians by reducing the income gap between family physicians and other specialties • Promoting family physician leadership in health care delivery • Increasing the family physician workforce

The Principles for the Reform of the U.S. Health Care System call for the following actions: • Health care coverage for all is needed to ensure quality of care and to improve the health status of Americans. • The health care system in the U.S. must provide appropriate health care to all people within the U.S. borders, without unreasonable financial barriers to care.

health services), medical education, and comprehensive health information technology infrastructure and implementation. • Sufficient funds must be available for public health and other essential medical services to include, but not be limited to, preventive services, trauma care, and mental health services. • Comprehensive medical liability reform is essential to ensure access to quality health care.

The Minnesota plan of action The Minnesota Academy of Family Physicians (MAFP), the largest medical specialty organization in the state, wants to ensure that the voice of its 3,000 members (including physicians, residents, and medical students) is heard. In service to its members, the MAFP recently approved a new three-year strategic plan in response to a rapidly changing and challenging health care environment. It allows for continued growth Setting health care policy to page 36

The shortage of family physicians is already impacting our patients.

The AAFP also wants to encourage family physicians to become more involved. Through its Key Contact program, the AAFP has advocated on behalf of its members and provided tools to empower them to become actively involved in the fight for family medicine. The program not only cultivates existing relationships with lawmakers, it also helps build new and long-lasting connections. Passion, enthusiasm, and the willingness to advocate are essential ingredients for success. AAFP provides tools and training for members to carry out the work of advocacy, updates about legislative issues confronting patients and family physicians, and health care in general (see www.aafp.org/ advocacy.html). The Minnesota Academy of Family Physicians (MAFP) plans to follow the format implemented by the AAFP and make it Minnesota focused. Reform principles Ten of the nation’s leading physician associations, including the AAFP, established principles to serve as a guide for Congress to improve both individual health and the collective health care system. (To see a list of the other nine participating associations go to: www.aafp.org/advocacy/track/ principles-for-reform.html.)

• Individuals and families must have catastrophic health coverage to provide protection from financial ruin. • Improvement of health care quality and safety must be the goal of all health interventions, so that we can assure optimal outcomes for the resources expended. • In reforming the health care system, we as a society must respect the ethical imperative of providing health care to individuals, responsible stewardship of community resources, and the importance of personal health responsibility. • Access to and financing for appropriate health services must be a shared public/ private cooperative effort, and a system that will allow individuals/employers to purchase additional services or insurance. • Cost management by all stakeholders, consistent with achieving quality health care, is critical to attaining a workable, affordable, and sustainable health care system. • Less complicated administrative systems are essential to reduce costs, create a more efficient health care system, and maximize funding for health care services. • Sufficient funds must be available for research (basic, clinical, translational, and

October 2015 Minnesota Physician

Behavioral Health

sychosis is a disorder impairing brain development and function leading to hallucinations, delusions, and cognitive impairment. It is a serious mental disorder affecting up to 3 to 6 percent of the population, and there are approximately 600 new cases each year in Minnesota. It is a major public health problem that develops in late adolescence/early adulthood. It is associated with increased suicide risk, poor quality of life for individuals and their families, and considerable cost to the health system. Psychosis can have multiple causes including substance abuse or withdrawal, exposure to severe stress, medical conditions or diseases, and mood disorders. However, more often than not, it signals the onset of schizophrenia or bipolar disorder.

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Early intervention in psychosis Radically improving outcomes By Michael O’Sullivan, MD

vocational development. Only 25 percent experience one episode and completely recover. Schizophrenia, the most common psychotic illness, is the most serious form of mental illness. With current mental health approaches, many of those with schizophrenia achieve symptomatic remission but few recover completely and most are left with secondary disabilities such as functional impairment, social exclusion, unemployment, and poverty. Early intervention Faced with this difficult-to-treat condition a new service, Orygen,

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Minnesota Physician October 2015

The National Centre of Excellence in Youth Mental Health (www.orygen.org.au), was piloted in 1992 in Melbourne, Australia involving preventive health approaches and phase-specific treatment. This service and others since (OPUS in Denmark, LEO in London, TIPS in Norway, PEPP in Canada, and EPIP in Singapore) continue to provide compelling evidence of the benefits of early intervention to patient outcomes. Early intervention services are no more expensive than traditional services and in fact may be more cost effective. First Episode Psychosis Programs or Early Intervention Programs are an integrated approach to the treatment of psychosis that emphasize the importance of both the timing and types of intervention provided to someone experiencing a first episode of psychosis. “Early” is as early as possible following the onset of psychotic symptoms; the “intervention” is comprehensive, intensive, phase-specific, and individualized. Early intervention should not be confused with “primary prevention” in which onset of an illness is prevented. Currently, with the long periods of untreated psychosis (on average one to two years) mental health services are often accessed after the most valuable time for treatment has passed. Research indicates that interventions at this late stage only achieve modest benefits and cost more. Conversely, early intervention transforms burden trajectory and achieves longterm health benefits. Minnesota currently has one pilot First Episode Psychosis Program at the University of Minnesota, which

is attempting to define a methodology for how these programs can be shaped in a state that is severely under-resourced. Duration of untreated psychosis “A stitch in time saves nine,” and “Prevention is better than cure,” are old sayings that also apply to people with psychosis. Longer duration of untreated psychosis (DUP) has been associated with increased suicide risk and poorer outcomes at six months, four years, and 15 years. The picture associated with long DUP is one of loss of functioning, increased likelihood of hospitalization, higher dosages of medication, treatment resistant symptoms, unemployment, and incomplete recovery. The treatment costs associated with this course of illness are, of course, higher than those associated with someone with a shorter DUP who is less unwell when he/ she first receives treatment and achieves a complete recovery in a short period of time. Analysis of over 4,500 patients who have participated in DUP studies around the world show that length of DUP and outcome are linked. In Norway, a project to reduce DUP was scientifically evaluated. This was done with an intervention area where an education campaign was carried out and a control area where no intervention was delivered. The activities (radio, newspaper, and bus shelter ads, etc.) were typical of a health marketing campaign and described on www.tips-info. com/?lang=en. The results were striking: the DUP in the education area dropped from 118 weeks to 26, where no significant change occurred in the control area. Patients presenting to services with the shorter DUP were less unwell and functioned better than those with the longer DUP and those in the control area. Patients with the shorter DUP were less likely to be admitted to the hospital. Norway is an example worth following!

First episode psychosis programs in Minnesota A virtually identical (culturally adapted) program was proposed in Minnesota based on the Norwegian program in order to reduce duration of untreated psychosis. This new and exciting clinical project was the first in mental health care in the Upper Midwest. It was to provide an evidence-based template for mental health systems across Minnesota to reduce unnecessary delays in accessing care and improve outcomes for people with psychosis. We had already developed a collaborative relationship with similar programs across the globe. Many people have asked where the First Episode Program is located. I usually borrow my answer from a colleague at the Columbia University First Episode Clinic: “It’s a state of mind, not a location.” The program is actually a network of social workers, family members, psychologists, psychiatrists, psychiatric nurses, and community organizations that work with young people with psychosis. Many patients are seen for medication management by community psychiatrists and attend various group therapies at the M Health Hospital. Treatment Optimal care consists of comprehensive, integrated biopsychosocial approaches (i.e., medication, psychosocial interventions, and patient and family education) tailored to the unique characteristics of each individual and the phases of their illness. Treatment is age appropriate and provided in a normalized destigmatizing recovery-focused context. Care is holistic and focused on the “whole person” including a patient’s ethnic and cultural background, rather than the signs and symptoms of psychosis. The person and the family are engaged as active collaborators in care from the start. Community-based supports are essential to treatment. Services and supports need to

be comprehensive and involve multiple sectors (e.g., vocational, economic, physical health, educational, and recreational). The First Episode Psychosis Program links the broad community-based services to assist patients and their families in recovery including peer support, family support networks, and other appropriate community-based resources.

Ideally, assessments take place in the most comfortable environment possible (e.g., home visits or through community outreach). Continuity of care is essential in preventing psychotic relapse. Patients can be seen in our clinic for five years, and then transition to a more general psychosis program if necessary.

Longer duration of untreated psychosis (DUP) has been associated with increased suicide risk.

The essential ingredient to the success of the program is Nancy Lindquist, RN, who is the First Episode Psychosis coordinator at the University of Minnesota. The coordinator links patients and their families in partnership with a psychiatrist to all of the individually-needed resources available. While the international standard of care would have a coordinator manage 25 to 35 patients at a time, Nancy has worked with as many as 180. Who benefits from treatment? First Episode Psychosis Programs aim to provide mental health services targeting ages 14 to 29 and integrate child, adolescent, and adult mental health services. These programs work in partnership with primary care, education, social services, youth, and other relevant services. We attempt to take patients who have not had treatment or just recently initiated treatment and provide a comprehensive assessment performed by a specialized professional or partner with a community physician. The emphasis of treatment is always on managing symptoms and role fulfillment rather than diagnosis. The focus is on the individual and his or her family. Part of the “state of mind” is providing services that are youth-friendly and flexible.

Program components Currently, these are the main established components of the M Health First Episode Psychosis Program. • Family education group is an eight-week information and support course on

Wednesday evenings at the University of Minnesota. This is not a billable service, and anyone is welcome to attend. • Caregiver support group is a monthly meeting of family members who have completed the family education group. • Young adult cognitive behavioral therapy/resiliency training group is offered weekly at the M Health Psychiatry Clinic. • Cognitive remediation is offered in the Fairview Riverside Day Treatment First Episode track. Group therapy here uses computer programs to enhance cognition, particularly working memory and possessing speed. • The Behavioral Emergency Center at Fairview Riverside is an emergency room for Early intervention in psychosis to page 30

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October 2015 Minnesota Physician

Cardiology

ranscatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), has emerged as an alternative to conventional surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) considered high-risk or inoperable. Since Alain Cribier, MD, performed the first in-man TAVR procedure in France on April 16, 2002 the technology has “gone viral” with over 200,000 implants performed in 65 countries around the world. The main reason for the rapid dispersion of this technology is that AS disproportionately affects the elderly, many of whom are unfit to withstand the rigors of a heart operation. After symptom onset AS is usually fatal within a few years without valve replacement. Unfortunately, multiple studies have shown that 40 percent of patients with symptomatic severe AS do not receive any treatment due to perceived or

Transcatheter aortic valve replacement By Santiago Garcia, MD, and Rosemary F. Kelly, MD

real risks associated with surgery. For example, in the U.S. approximately 270,000 patients have severe, symptomatic AS. Yet in 2014, only 70,000 SAVR and 18,000 TAVR procedures were performed leaving a large segment of the AS population untreated. Aortic stenosis in the VA system Degenerative aortic valve stenosis is the most common form of valvular heart disease

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among elderly patients and more than 9.3 million veterans are 65 years of age or older. By the year 2050, the number of people in the U.S. over age 80 will increase by 25 million. This increase in life expectancy will dramatically affect the management of valvular heart disease in the veteran population. A review of all veterans (n=7,142) who underwent isolated SAVR in the Veterans Health Administration (VHA) system between 1991 and 2007 showed that 7 percent were 80 years of age or older, 29 percent had chronic obstructive pulmonary airway disease, 15 percent had cerebrovascular disease, and 13 percent had peripheral arterial disease. Based on these data, a VA TAVR working group was formed to provide guidance and set program requirements to VHA facilities seeking to perform TAVR procedures in-house. It is worth noting that these procedures are performed

Figure 1. Veterans Integrated Healthcare Networks (VISN)

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Minnesota Physician October 2015

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The Minneapolis VA Health Care System (MVAHCS) serves as the referral tertiary hospital for the Veterans Integrated Healthcare Networks (VISN) 23 (see Figure 1). VISN 23 encompasses nine hospitals and 62 community clinics. It spans 394,134 square miles and serves 435,380 enrolled veterans. The projected growth for VISN 23 over the next five years is 4.6 percent. A review of 820 patients treated with SAVR from 2003–2013 at the MVAHCS showed that 154 patients (19 percent) had a predicted mortality of greater than 8 percent using the standard Society of Thoracic Surgeons (STS) adult cardiac surgery risk calculator, a well-validated and widely-used tool to estimate risk of mortality and serious complications with open cardiac surgery. In addition, 93 patients (11 percent) had a previous sternotomy, a factor that increases the risk of a second heart operation by a factor of 2 to 4. Therefore, a conservative estimate was that 30 percent of patients (or 27 patients per year) currently treated with SAVR at the MVAHCS would qualify for TAVR under current guidelines. In addition, we projected that

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in a so-called “hybrid” room: an environment that meets operating room standards and contains fixed radiographic imaging systems commonly used in cardiac catheterization laboratories.

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VISN 23 encompasses 10 hospitals (red stars) and 64 communitybased outpatient clinics (black asterisks[*]).

TAVR would also allow many patients (approximately 40 percent) that did not qualify for SAVR, because they were deemed inoperable, to receive treatment. The last potential source of TAVR patients to consider was comprised of veterans receiving treatment in the private sector. Although precise figures are hard to come by, many veterans rely on private insurance or Medicare when seeking care outside the VA. An estimate of 20–30 additional patients per year was reasonable based on our own referral patterns to the University of Minnesota. In summary, bringing TAVR to the MVAHCS would allow us to offer this life-saving therapy to 60–80 patients per year under current indications. This number could easily double in the near future if TAVR is expanded to intermediate-risk patients (i.e., STS scores between 4–8), as most experts in the field predict it would. In April 2015, the MVAHCS became the fifth VA hospital in the country to gain approval from the VA Central Office (VACO) to start performing TAVR procedures in-house. Other VAs performing TAVR procedures include San Francisco, CA; Dallas, TX; Houston, TX; Ann Arbor, MI; and Gainesville, FL. Initiation of a TAVR program required investments in physical infrastructure (i.e., hybrid rooms, imaging equipment, percutaneous valves, automatic contrast injection systems, dedicated software, etc.). In addition, extensive multidisciplinary training was required of cardiac surgeons, cardiac anesthesiologists, interventional cardiologists, cardiac imaging specialists, cardiac perfusionists, X-ray technicians, and nurses with different backgrounds and skill sets (operating room, cardiac catheterization laboratory, anesthesia, intensive care unit, and telemetry floors). These investments have paid off. We recently successfully implanted our first 17 transcatheter aortic valves with no mortality, strokes, or major vascular complications using various access sites

(transfemoral, transapical, and transaortic) and valves (Sapien XT, Sapien 3, and CoreValve). We have received referrals from places as far away as Omaha, NE; Rapid City, SD; Fargo, ND; and Waterloo, IO. We are on track to complete 40 TAVR

bought PVT, the company that Dr. Cribier and his colleagues had founded, for 125 million dollars. To put things in perspective, the global TAVR market has been projected to increase from $487.8 million in 2011 to $2.6 billion in 2018.

Forty percent of patients with symptomatic severe AS do not receive any treatment.

procedures by the end of 2015 as anticipated. One of the key factors in explaining the early success of our TAVR program is the close relationship we have with the University of Minnesota, which has provided training of key personnel and shared best practices with us.

Medtronic in Minneapolis has also received FDA approval for their self-expandable CoreValve and Evolut transcatheter valves. There are a multitude of percutaneous valves in various stages of development in the U.S., Europe, Japan, China, Israel, and South America.

From bench to bedside

The clinical evidence

It has been a remarkable journey of discovery, refinement, and translation of science from the animal laboratory to the hybrid operating room. The New York Times (June 20, 2015) recently chronicled the 20-year saga that led to this medical breakthrough. It all started in 1989 with a Danish cardiologist, Dr. Henning Rud Andersen, and a fairly simply proposition: “If you can put a stent in a coronary artery, you probably can put a valve in.” He bought pigs from a slaughterhouse, carefully removed their aortic valves, and mounted them on a handmade metal stent. He then put a deflated balloon inside the valve and manually crimped it down onto the balloon. After implanting 40 of these devices in pigs he patented it and tried to find a company to develop and refine his idea so it would be applicable to humans. In 2002, Dr. Cribier, who had implanted Andersen’s valve in sheep, performed the first in-man TAVR procedure in a 57-year-old patient with severe aortic stenosis and multiple comorbidities that made him inoperable. “Two hours later we were drinking champagne in his room,” Dr. Cribier said. In 2004, Edwards Lifesciences

In the landmark article, “Placement of Aortic Transcatheter valves (PARTNERS) A and B

Trial,” published in the New England Journal of Medicine, TAVR was compared with medical therapy in inoperable patients (cohort B) or to surgery in high-risk patients (cohort A). In PARTNERS B, TAVR associated with significant reductions in mortality, hospitalizations for heart failure, and cardiac symptoms. Of note, these inter-group differences were maintained at follow-up with no evidence of valve degeneration up to five years post-procedure, a critical consideration as this therapy is being applied to younger patients with longer life expectancy. In PARTNERS A, TAVR was equal to conventional surgery concerning mortality at one year. Post-hoc analysis of this landmark trial have shown that TAVR is cost-effective and significantly improves quality of life measures relative to conventional surgery, in particular with a transfemoral approach. Transcatheter aortic valve replacement to page 31

October 2015 Minnesota Physician

Early intervention in psychosis from page 27

people who need immediate psychiatric attention for medication management, acute exacerbation of symptoms, and suicidal or homicidal thoughts or actions. • The inpatient psychosis unit at Fairview Riverside accepts patients who are a danger to themselves or others. • Specialized/individualized medication management. These modules, however, are not sufficient to fully address the needs of a person recovering from a psychotic episode, possibly with a lifelong diagnosis of schizophrenia or bipolar affective disorder. Ongoing individualized psychological, family, and psychosocial interventions are required to help the person manage their illness effectively, return to work or school, and live independently.

The future that radically improved outcomes may be possible for As these services are developed young people experiencing and expanded to other health psychosis. Early psychosis systems, Minnesota will keep intervention represents a new pace with worldwide trends era of hope for those facing the in modern service delivery for challenges of those with serious menpsychosis. The tal illness. next stage will Spurred on be a multidisCommunityby this hope, ciplinary team momentum of trainers for based supports is building mental health are essential to across Minservice providnesota to treatment. ers developing provide early early intervenintervention tion in their services. health system/ community. Minnesota was To move forward producfortunate to have been a site for tively, it is crucial to ensure the research-based RAISE prothat concerned mental health gram (Recovery After an Initial professionals share a common Schizophrenia Episode) and understanding of the field. Earmany of the service providers ly psychosis intervention prinand trainers continue to work ciples and practices need to be in Minnesota. integrated into a comprehensive International efforts to intervene early in the course of psychotic disorders, suggests

Early Intervention services are now ready for prime time as evidenced by the results of the RAISE trial. It is time for this pilot program to expand into the community. I will be transitioning to Abbott Northwestern Hospital and initiating another First Episode Psychosis Clinic. To contact the First Episode Psychosis Program, call program coordinator Nancy Lindquist, RN, at (612) 273-9834.

Michael O’Sullivan, MD, is medical

director of the First Episode Psychosis Program at the University of Minnesota. He is board-certified in psychiatry and integrative and holistic medicine. He will begin work as a staff psychiatrist at Abbott Northwestern Hospital in November and plans on starting an integrative and holistic first episode psychosis program there.

policy in order to be consistent, coherent, and sustainable.

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Minnesota Physician October 2015

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Transcatheter aortic valve replacement from page 29

Technical advances continue to improve the valve and delivery system. The PARTNERS trial was done with a first generation device that was fairly rigid, as the frame was made out of stainless steel, and bulky; requiring a 22 French sheath for delivery of a 23 mm valve. In contrast, the third-generation Edward Lifesciences’ Sapien 3 valve is made out of cobalt chromium, which allows a 23 mm valve to be delivered through a 14 French delivery system, thereby reducing vascular complications, while increasing the proportion of patients that can be treated with a transfemoral approach as opposed to an alternative access (TAO- transaortic or TA-transapical). It also has several new features that improve procedural outcomes and valve performance; the most notable is an outer sealing skirt to minimize perivalvular leaks. With this

importance to the private new valve, mortality at 30 days sector where reimbursement is down to 1 percent and disabling stroke is down 2 percent. for this procedure is fixed at about $40,000, most of which More important, this is less is offset by the cost of the valve than a quarter of the expected mortality (5.3 percent with con- (approximately $32,000) and longer hospital stays mean ventional surgery in this group financial loss. The cost of the of patients (intermediate risk). valve should decrease as more For the self-expanding valve in players enter the U.S. pivotal the U.S. market. trial survival at Ongoing clinical one year was 4.9 trials will also percentage points Mortality inform whether higher for TAVR this technology relative to SAVR. at 30 days is appropriate This difference is down to for lower-risk increased at two patients without years (22 percent 1 percent. compromising for TAVR and 28.6 long-term valve percent for SAVR). durability. The future Transcatheter As most of these procedures are valves are also being introduced in other locations such as the being done using a transfemmitral, tricuspid, and pulmooral approach that facilitates nary space. From a VA perspecpatient recovery, many centers tive, the MVAHCS will continue are starting to shift from to be the tertiary referral general anesthesia to conscious hospital for complex cardiac sedation and early discharge and vascular procedures for (within 48 hours). This is of

A Diverse and Vital Health Service

patients in VISN 23. We have a talented and diverse workforce that takes pride in providing the best care to those who proudly served our country. Santiago Garcia, MD, is director of

the Transcatheter Valve Program at the Minneapolis VA Health Care System and assistant professor of medicine at the University of Minnesota. He is board-certified in internal medicine, cardiovascular medicine, interventional cardiology, and endovascular medicine. Rosemary F. Kelly, MD, is professor of surgery at the University of Minnesota and chief of cardiothoracic surgery at the Minneapolis VA Health Care System. She is co-director of the Lung Transplantation Program and associate program director of the Cardiovascular and Thoracic Surgery Fellowship Program at the University of Minnesota. Dr. Kelly is board-certified in general surgery and thoracic surgery.

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. Apply online at www1.umn.edu/ohr/employment, select “External Applicants” and then search for keyword: Gynecologist. Job ID#: 300363 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

October 2015 Minnesota Physician

Physician/Patient Communication

renatal providers play a vital role for their patients not just by providing care for them and their unborn baby, but for serving as a source of information—which vitamins to take, which foods to eat, and what items to have in advance of the baby’s arrival. One area where this trusted and influential relationship has been leveraged in Minnesota is the recommendation for pregnant women to get their influenza vaccine. In short, we’re doing a great job of vaccinating pregnant women. Recently published data from the Centers for Disease Control and Prevention’s (CDC’s) Pregnancy Risk Assessment Monitoring System (PRAMS) show that Minnesota providers vaccinated 75.9 percent of pregnant women against influenza in the 2010–2011 season—the highest rate among 21 states and a major city included in the PRAMS study. CDC has been monitoring immunization rates among this high-risk

Improving infant immunization rates Prenatal providers play a vital role By Lynn Bahta, RN, PHN; Margaret Roddy, MPH; and Anna Fedorowicz, MPH group since the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists (ACOG) recommended influenza vaccination in pregnant women in 2000. A provider’s recommendation Additional analysis of MDH PRAMS data released in 2011 demonstrates the importance of having a health care provider recommend vaccinations. Women who reported receiving a recommendation from their health care provider were twice as likely to get vaccinated when

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Minnesota Physician October 2015

compared to those who did not receive one (73.5 percent versus 32.8 percent). This analysis is supported by a recent national survey conducted by CDC that was published in their Morbidity Mortality Weekly Report (MMWR) in the fall of 2014, which showed a seven-fold increase in vaccination rates when a clinician offered and gave the vaccination. What if we capitalized on our state’s success with the maternal influenza vaccination to expand the provider/patient conversation to include the importance of infant immunization? Processing the information Expecting parents receive information on immunizations from an array of sources including their online and social networks. Unfortunately, some of this information is inaccurate or incomplete. Scary stories from what appear to be valid sources of information can skew a pregnant woman’s view on immunization before her baby is born. A 2006 qualitative study in the journal Pediatrics by Benin et al., found that many mothers immediately postpartum had already decided whether or not to immunize their infants or delay immunizations. This further supports the need for providing pregnant women with reassuring messages and reliable resources on immunizations during the prenatal period. Several studies have explored the characteristics of parents and immunizations. In a 2008 study by Gust, et al. published in Pediatrics, the authors found that the majority of parents were highly supportive of vaccinations (72 percent in contrast to the 1.6 percent who refused all vaccinations). In the middle of this spectrum are

parents who may reluctantly consent to vaccinations (9 percent) and those who pick and choose which vaccines to give their children (17.4 percent). Prenatal health care providers can support the norm of vaccination to parents who accept vaccination and may influence parents who are hesitant. Making a decision While social networks and the Internet are key sources of information for expecting parents, Kennedy, et al., in their 2013 article in Health Affairs found that the clinician plays a critical role in building confidence and support for vaccination. They also concluded that “the internet probably supplements, but does not replace, direct communication with a health care provider or other trusted individual.” Understanding how a parent makes vaccination decisions can also inform how prenatal health care providers should approach conversations about infant immunizations and offer medically accurate resources. Research by anthropologist Dr. Emily Brunson in the journal Pediatrics (2013) describes individual parents as being on a spectrum of the decision-making process. A parent is called an “acceptor” if they usually do what the provider recommends and follow social norms, in this case what parents usually do as far as vaccinating their infant. Having a basic brochure that supports established immunization recommendations prepares the parent for what to expect from birth on. On the other end of the spectrum is the parent “searcher” who wants to gather information and make decisions independent of recommendations from others. In Brunson’s 2013 article, she goes on to describe the middle of the spectrum parent as the “relier.” This parent makes decisions that are based on what their social network believes about a particular topic. A health care provider may still influence a relier’s decision-making process, especially if the intervention occurs when many expecting parents are formulating their beliefs on

immunizations. For both the “relier” and the “searcher” it is imperative to point them in the direction of reliable resources. MDH has an informational sheet called, Reliable Sources of Immunization Information (http://www.health.state.mn.us/ divs/idepc/immunize/safety/ imminfo.html), which compiles a number of trustworthy sources where you can direct patients in their quest for information. Important messages for your patients There are several infant immunization messages the clinician can incorporate into the prenatal visit when recommending maternal vaccination for influenza, and tetanus, diphtheria, and pertussis (Tdap). Getting vaccinated during pregnancy is just one more thing you can do to protect your baby. An expecting parent is typically doing everything she can to keep herself and her unborn child healthy, such as avoiding certain foods or drugs. Be clear that getting her influenza and Tdap vaccines is another step toward keeping herself and her baby healthy, even after the child is born. Protecting newborns begins by immunizing mom during pregnancy. There is growing evidence of the benefits of maternal vaccination to the fetus. These include studies by Eick in his 2013 article in Archives of Pediatric and Adolescent Medicine and the 2014 JAMA article by Munoz, which show that influenza vaccination and pertussis vaccination using Tdap during pregnancy protect the newborn—both potentially deadly diseases in early infancy. As a physician, it helps to use statements such as this one from a New York City health brochure, “The vaccine helps your body create antibodies that will be passed on to your baby before birth. These antibodies will help protect your newborn right after birth and until your baby gets his/her own whooping cough vaccine at 2 months of age.” Factual messages like this resonate with expectant parents.

In unpublished data that CDC used to develop Tdap and pregnancy materials, researchers found among focus groups comprised of pregnant women, that the concept of maternal vaccination protecting their

their questions—the prenatal health care provider may provide the upstream intervention that could make a difference in increasing childhood vaccination rates in Minnesota.

It’s never too early to think about immunizations for your baby. This message offers an easy opportunity to discuss the fact that childhood immunization begins in the prenatal period and continues throughout a person’s life. It is an opportune time to provide basic information and refer patients to reliable information about immunizations. In a 2006 Pediatrics article, Benin found that mothers had poor knowledge about vaccines whether they intended to vaccinate their baby or not. Concluding thoughts Discussing vaccines may raise questions or concerns. Your responses do not need to be long. You should acknowledge the parents’ concerns, provide accurate information, and encourage them to keep exploring reliable information. Consistency of message from the prenatal health care provider to the infant’s primary care provider supports the parent in vaccinating their child and maintaining confidence in vaccination. Because decision-making begins during the prenatal period—when parents have time to explore answers to

The Q & A factsheet — Too Many Vaccines: What you should know http://media.chop.edu/data/ files/pdfs/vaccine-educationcenter-too-many-vaccines.pdf For acceptors and reliers: • Keep them safe: Vaccinate • When to Get Vaccines, Birth to 16 Years

The clinician plays a critical role in building confidence and support for vaccination.

baby was the strongest motivator for them to get vaccinated. Using the statement, “born already immunized” was found to be especially reassuring. Additionally, research by Hendrix, et al. published in Pediatrics in 2014 supports the importance to the parent of focusing on the benefit of vaccination to the infant.

Resources to keep on hand at the clinic

Lynn Bahta, RN, PHN, is the immunization clinical consultant for the Minnesota Department of Health Immunization Program. Margaret Roddy, MPH, is the manager of the Vaccine Preventable Disease Section at the Minnesota Department of Health. Anna Fedorowicz, MPH, is the adult immunization coordinator for the Immunization Program at the Minnesota Department of Health.

For reliers and searchers: • Reliable Sources of Immunization Information • www.vaccine.chop.edu For the searcher: • Clear Answers & Smart Advice About Your Baby’s Shots • P lain Talk About Childhood Immunizations Both are listed in Reliable Sources but can be highlighted for searching parents

Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team. We currently have opportunities in the following areas: • Dermatology • Dermatology

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Visit fairview.org/physicians to explore our current opportunities, Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org

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October 2015 Minnesota Physician

Health care professionals

n 2010, there were approximately 176,000 advanced practice providers (APPs) in the United States, including physician assistants (PAs), advanced practice registered nurses (APRNs), and nurse practitioners (NPs) in primary care (from the Agency for Healthcare Research and Quality), and this number has almost certainly increased. While APPs are sometimes touted as the solution to a physician manpower shortage in primary care, in fact advanced providers work in a variety of acute (urgent care clinics and emergency rooms) and longitudinal (primary care) settings as well as medical and surgical subspecialty clinics, with varying degrees of autonomy. Advanced practice nurses, including nurse practitioners, may practice primary care independently in 18 states, while physician assistants must always have a supervising physician.

Advanced practice providers Defining a new role By Kathleen Kieran, MD, MSc Maximizing the benefits Despite the increasing numbers of APPs, in many cases their roles within medicine’s traditional physician-centric medical model remain poorly defined. Although many APPs work alongside residents and fellows caring for inpatients, assisting surgeons, and working in outpatient clinics, it must be remembered that APPs are fully trained medical professionals. Unlike physician training however, in which a four-year medical school curriculum segues into an internship, residency, possibly a fellowship, and then

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Minnesota Physician October 2015 Collision

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practice, physician assistants and nurse practitioners typically study for two years after a baccalaureate degree before entering practice. Because APPs do not have mandatory formal postgraduate training programs, most gain practical training through employment as well as continuing medical education. This flexibility is beneficial in that an APP can choose to gain specialized knowledge in particular areas of interest, but may limit the comfort that an APP or supervising provider has in the new APP graduate seeing and evaluating certain diagnoses. The impact APPs have Numerous well-conducted studies have shown that APPs reduce physician workload, enhance academic training programs (Kahn et al.), and have similar or better patient outcomes for common health conditions compared with physicians (Shah et al.). Moreover, APPs are more likely than physicians to educate patients regarding health conditions and management options (Ritsema et al.), and may provide increased continuity of care for patients since they do not rotate “off service” or graduate from residency training, and are less likely to be called away for emergencies (e.g., emergent surgeries or deliveries) than are physicians. Many APPs work alongside physicians, seeing patients with “bread and butter” issues, which frees the physician to see patients with more complex medical problems requiring subspecialized care. This not only increases patient access to health care

by enabling patients to more quickly be scheduled with a provider who can meet his or her needs, but also enables both physicians and APPs to spend more time with a given patient: a physician has more time to discuss a complex hernia surgery with one patient because the nurse practitioner is able to visit with a patient with hypertension and hypercholesterolemia. APPs often have more time to spend with patients at each visit, since the demands on their time are different from that of physicians. This is particularly useful for patients who require longitudinal care, those who are slow to warm up, and those with psychosocial considerations.

Numerous wellconducted studies have shown that APPs reduce physician workload.

Transitioning care to APPs Despite these clear benefits, many patients and physician providers express reservations about transitioning care from a physician to an APP. Because APPs often see patients with more straightforward medical problems, some patients or referring providers may perceive an APP visit as either inadequate management of the problem, or a tacit implication that the APP’s supervising physician does not consider the medical problem serious enough to warrant his or her time. Referring providers may avoid consulting APPs because they are uncomfortable requesting the expertise of a non-physician provider. Training for APPs To avoid this quandary, it is helpful to consider the differences in training and expectations for APPs compared with physicians. Nurse practitioner and physician assistant schools educate their students in a practical manner, with less emphasis on theory than

physician education (Giordano); as a result, APPs are most often called upon to manage straightforward medical complaints that often have a limited treatment repertoire or algorithm. However, the competencies expected of residents, NPs, and PAs are similar (American Urological Association statement on APPs). One urologist who (happily) employs two PAs alongside him in practice likens this to a scene from the movie “Patch Adams”: “It’s like my PAs can see the four fingers, but they can’t see the eight fingers. They’re not able to blur their vision and change perspective the way I can, because they just don’t have that training. But the important thing is that they know that they can’t see those eight fingers, and that’s when they come to me. It doesn’t make them less capable. It means that they know the limitations of their practice, which is a good thing for any practitioner.” Advanced practice nurses, unlike PAs and physicians, are educated in a nursing model, which employs a more holistic than problem-based approach compared to the medical model. For primary care patients, hospital inpatients requiring discharge planning, or patients with medical problems with prominent psychosocial or environmental components (e.g., school-age children with urinary incontinence), NPs may offer a novel perspective on diagnosis and management. An increased emphasis on the non-physiologic aspects of care may be especially valuable in settings like urology or gynecology clinics; many times these patients are frustrated, comprehensive history and examination is needed, and the sensitive nature of the topic means many patients do not wish to tell their stories to more than one provider. In the day-to-day management of inpatients with multidisciplinary conditions (e.g., pediatric oncology, ICU care), APPs can act as liaisons and care coordinators between multiple subspecialty services and provide a consistent resource to families and caregivers.

Referrals As with any interprovider referral, physicians who are considering referring patients to APPs should first consider the unique needs of the patient and skills of the APP, and establish expectations for the encounter. Referring providers should ensure that the receiving APP has adequate clinical experience and/or supervision

be addressed and clinical considerations that may be relevant to the visit. Similarly, patients should be prepared for the APP visit through a discussion of the unique role and skills of the APP and why an APP visit is right for that patient. Importantly, physicians should avoid calling APPs “mid-level providers” and other terms that suggest that APPs have incomplete

Referring providers should ensure that the receiving APP has adequate clinical experience.

to address the clinical problem in question. Equally important is an understanding of the local hierarchy, in particular the practice within which the APP is working. Is there adequate supervision? Most physicians view the APPS who work with them as integral members of the team, and allocate time and financial resources to train APPs in the specific skills needed at that practice. Unfortunately, this is not true in all cases and some APPs lack guidance and/or are assigned to see only those patients that are not deemed appropriate for physician care (e.g., patients deemed “difficult” or “challenging”). While, in some states, nurse practitioners and other APRNs are allowed to practice independently, PAs must always practice under the supervision of a physician (American Urological Association statement on APPs). Furthermore, there are presently no subspecialty certifications for APPs, and thus APPs to whom patients are referred for specialized care should work closely with subspecialty-certified physicians. Referring physicians should also take care to treat the receiving APP with respect, and as a colleague rather than as a subordinate. For new referrals, many physicians call the APP directly and discuss the patient and the clinical situation, including the specific questions to

training. Finally, as with any referral, physicians should follow up with individual patients to evaluate their experience with the APP; although Yelp and other online ratings engines have information, these evaluations

are anonymous. Knowing a patient personally and hearing his or her version of the visit gives the advantage of a more well-rounded perspective. Conclusion As the role of APPs in primary and subspecialty care continues to evolve, the responsibilities and visibility of APPs will continue to increase. Smooth integration of APPs into the patient care paradigm, with recognition of the unique skill set of the APP and the value that APPs add to health care delivery, is paramount to ensuring a positive experience for physicians, APPs, and above all, the patient. Kathleen Kieran, MD, MSc, is an

associate professor of urology at the University of Washington and Seattle Children’s Hospital. She has a special interest in communication skill teaching and development in surgical subspecialty trainees.

Family Medicine Minnesota and Wisconsin We are actively recruiting exceptional board-certified family medicine physicians to join our primary care teams in the Twin Cities (Minneapolis-St Paul) and Central Minnesota/Sartell, as well as western Wisconsin: Amery, Osceola and New Richmond. All of these positions are full-time working a 4 or 4.5 day, Monday – Friday clinic schedule. Our Minnesota opportunities are family medicine, no OB, outpatient and based in a large metropolitan area and surrounding suburbs. Our Wisconsin opportunities offer with or without obstetrics options, and include hospital call and rounding responsibilities. These positions are based in beautiful growing rural communities offering you a more traditional practice, and all are within an hours’ drive of the Twin Cities and a major airport. HealthPartners continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefits package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com, 952-883-5453, toll-free: 800-472-4695. EOE

healthpartners.com October 2015 Minnesota Physician

Setting health care policy from page 25

and success, and leverages the unique capabilities, perspectives, and talent of our members and organization. Our plan lists the MAFP’s core values, which are excellence, equity, leadership, knowledge, and service. Four strategic pillars identified in the plan form the backbone of actions for the future: 1) identity; 2) advocacy; 3) membership; and, 4) governance. The MAFP plans to follow the AAFP’s lead and develop a Key Contacts Program of their own. They recognize that creating a system that identifies and expands relationships with elected local, state, and federal officials who will support initiatives to improve health care is incredibly important. MAFP wants to provide strong leadership when it comes to advocating for quality health care and encourage physicians to focus on the following strategies to strengthen advocacy efforts:

• Meet with legislators or their staff at least twice a year to build and grow relationships. • Serve as a family medicine expert.

• Support and contribute to the PAC. • Participate in the MAFP Key Contacts Program. • Document your interactions with legislators for consistent messaging.

Nearly one in every five of all office visits are made to family physicians. • Stay current and informed about ongoing legislative issues that impact health care in general, and family medicine in particular. • Study MAFP’s discussion topics set by its legislative committee. • Share a patient’s experience or your own story with legislators so they better understand the issues. • Attend events such as “Day at the Capital” or town hall meetings, which MAFP will announce to its members.

MAFP is striving to address barriers and social disparities in health care access, delivery, and outcomes. Social determinants of health are increasingly recognized as a key component affecting the health of our patients. We want to engage all the stakeholders in collaborating organizations, as well as community leaders to overcome barriers and disparities. Conclusion The shortage of family physicians is already impacting our

patients. It is essential that we identify and champion methods and practices to increase the family physician workforce so we can continue to deliver high-quality care to our patients. We want to provide visible and valued leadership in establishing health care policy. All of this can be achieved through active participation in policy initiation, development, formulation, and implementation. MAFP and AAFP will regularly review our legislative plans and programs, and will identify areas where additional advocacy and leadership is needed. M. Tariq Fareed, MD, FAAFP, is board-certified in family medicine and practices at Park Nicollet Clinic in Plymouth and Methodist Hospital in St. Louis Park, Minn. He serves as president of the Minnesota Academy of Family Physicians and chair of the MAFP executive committee.

Join the top ranked clinic in the Twin Cities

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 • Sleep Medicine • 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 |

Minnesota Physician October 2015

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:

• 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.

Please contact or fax CV to:

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

763-504-6600 Fax 763-504-6622

www.NWFPC.com

Q&A WITH MARC MYER, MD

Addiction is a disease—and health care professionals aren’t immune But recovery outcomes are excellent for those who seek help Meet Marc Myer, MD, director of the Health Care Professionals Program at Hazelden in Minnesota. As a board certified addiction specialist, Dr. Myer specializes in helping physicians, nurses, and other health care providers find freedom from addiction. He is a Diplomate of the American Board of Addiction Medicine and serves on the executive committee for Physicians Serving Physicians in Minnesota. How prevalent is addiction in the health care profession? While the lifetime prevalence of addiction among health care professionals is similar to that of the general population—estimated at between 8-13 percent—there are some distinctions. Surgeons, especially female surgeons, have significantly higher rates of alcohol use disorders than the general population. The other dissimilarity relates to types of substances misused. Physicians are five times more likely to abuse opioid pain medications and benzodiazepine anti-anxiety drugs than the general population, which is attributable, at least in part, to greater access to and familiarity with those substances.

What barriers do health care professionals face in seeking help for addiction? Addiction is an illness driven by guilt and shame—even more so for health care professionals. The physicians and nurses I work with in treatment are wracked with guilt about having this disease. There are behavioral aspects of addiction that cause extreme

shame, which leads to deeper isolation. Fear is another powerful barrier. Fear about the consequences of admitting to addiction. Fear about loss of career, loss of license, and loss of respect among colleagues and patients. Health care professionals often feel like they have too much at stake to get help. The truth is, there’s too much at stake to not get help. In terms of personality profile, it’s not unusual for health care professionals to have taken on a caretaker role from a young age. That means many physicians and nurses are predisposed to caring for others, often at the expense of caring for themselves. It’s part of what draws many health care professionals into the field.

Are there unique treatment challenges or issues for health care professionals? Definitely. When you’ve spent your entire career taking care of patients, it’s difficult to adopt the patient role—to be vulnerable and willing to receive help. Health care professionals tend to enter treatment at a later stage of the disease because their denial structure is so fortified; the walls have been built up through the sacrifice and determination it takes to achieve a career in medicine. Being in a treatment environment with a cohort of health care professionals—colleagues who understand the workplace dynamics, pressures, and obligations—allows for those walls to start coming down.

Does stigma play a role in facing addiction, compared with other chronic conditions, such as heart disease or diabetes? Very much so. Stigma weighs heavily even though addiction has been recognized as a disease by the American Medical

The Hazelden Betty Ford Foundation is a force of healing and hope for individuals, families and communities affected by addiction to alcohol and other drugs. It is the nation’s largest nonprofit treatment provider, with a legacy that began in 1949 and includes the 1982 founding of the Betty Ford Center. With 16 sites in California, Minnesota, Oregon, Illinois, New York, Florida, Massachusetts, Colorado and Texas, the Foundation offers prevention and recovery solutions nationwide and across the entire continuum of care to help youth and adults reclaim their lives from the disease of addiction. It includes the largest recovery publishing house in the country, a fully accredited graduate school of addiction studies, an addiction research center, an education arm for medical professionals and a unique children’s program, and is the nation’s leader in advocacy and policy for treatment and recovery.

Marc Myer, MD, is director of the Health Care Professionals Program at Hazelden in Center City, Minnesota.

Association for decades. Like other chronic diseases, addiction can be treated and managed successfully. And for health care professionals, recovery outcomes are extremely impressive. Physicians who complete a treatment program and engage in ongoing monitoring and return-to-practice planning have recovery rates as high as 90 percent at three to five years post-treatment.

What advice do you have for health care professionals who think they might have a problem? You don’t need to self-diagnose. You can find help and answers, confidentially, from professionals who will assist with assessment, evaluation, and referral services. A starting place for many is the Minnesota Health Professionals Services Program, a state agency that coordinates diagnosis, treatment and monitoring services for health care practitioners. Addiction is an isolating disease, especially for health care professionals. But it’s safe to reach out for help. And it’s effective. The vast majority of health care professionals who complete treatment at the Hazelden Betty Ford Foundation are able to successfully restore their careers.

Call for a free, confidential consultation today, 800-257-7800. We answer the phone 24/7. Learn more at

HazeldenBettyFord.org/HealthCareProfessionals.

October 2015 Minnesota Physician

Advocating for change from page 23

on the topic, and invite them to advocate. Advocacy can mean talking to elected officials, policy makers, etc., but it can also mean being an advocate for their patients. Honoring Choices Minnesota. For the past eight years the Twin Cities Medical Society has served as the leader for the Honoring Choices Minnesota initiative that works to normalize the conversation about end-of-life health care choices. All metro area health care systems have partnered with us on this effort to varying degrees. Not surprisingly, physicians embrace the notion that we, as the collective health care community, can improve outcomes by talking with patients about their preferences for end-of-life choices prior to a health care crisis. Our goal is to promote this end-of-life discussion in Minnesota, take cultural differences into consideration, and

standardize the way people are trained to talk about advance care planning with patients. We are also standardizing patient education materials and health care directive documents that are available in hospitals, clinics, long-term care facilities, health and human services organizations, and on our website (www.honoringchoices.org). Honoring Choices is by far the

Conclusion Much of the work that TCMS is doing in the community is funded by grants. A significant amount of the funding comes from the health care systems that employ physicians. The systems know that patients can jump from one health system to another so, if we were going to effect change, we all need to look at the community as a whole.

TCMS has access to physicians of all specialties from all of the metro area.

largest public health initiative that TCMS has worked on, and it is why advance care planning has become one of the cornerstone initiatives of the Twin Cities Medical Society now and, we expect, for years to come.

Dues dollars support the core activities of TCMS. These include our membership journal MetroDoctors, medical student and resident outreach and engagement, educational programs, committee work, legislative and policy outreach,

our website (www.metrodoctors. com), the Foundation, the Senior Physicians Association, and our staff. The role of the county medical society has changed and TCMS has changed as a result. Responding to the needs of the medical community and the community as a whole has positioned TCMS to fulfill its mission to connect, represent, and engage physicians in improving clinical practice, policy development, and public health initiatives. To learn more about TCMS and the work we are doing, visit our website at www. metrodoctors.com.

Sue Schettle is chief executive officer

of the Twin Cities Medical Society. Ken Kephart, MD, is president of the

Twin Cities Medical Society.

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 October 2015

MAYO CLINIC HEALTH SYSTEM is a family of clinics, MAYO CLINIC HEALTH SYSTEM is a family of clinics, hospitals, and other healthSYSTEM care facilities serving more than 60 MAYO CLINIC HEALTH is a family of clinics, hospitals, and other health care facilities serving more than 60 Minnesota, Iowa,facilities and Wisconsin. Mayothan Clinic communities hospitals, andinother health care serving more 60 communities in Minnesota, Iowa, and Wisconsin. Mayo Clinic Health System the expertise of Mayo Clinic in practice, communities in links Minnesota, Iowa, and Wisconsin. Mayo Clinic Health System links the expertise of Mayo Clinic in practice, education and research with the health-delivery systems of our Health System links the expertise of Mayo Clinicsystems in practice, education and research with the health-delivery of our local communities. education and research with the health-delivery systems of our local communities. local communities. The Northwest Wisconsin Region opportunities include: The Northwest Wisconsin Region opportunities include: The Northwest Region opportunities include: Dermatology Wisconsin OB/GYN Dermatology OB/GYN Emergency Medicine OB/GYN Occupational Medicine Dermatology Emergency Medicine Occupational Medicine Family Medicine Ophthalmology (General & Glaucoma) Emergency Medicine Occupational Medicine Family Medicine Ophthalmology (General & Glaucoma) GeneralMedicine Surgery Orthopedics Family Ophthalmology (General & Glaucoma) General Surgery Orthopedics Hospitalist Psychiatry (Adult & Child) General Surgery Orthopedics Hospitalist Psychiatry (Adult & Child) Infectious Disease Pulmonary/Critical Hospitalist Psychiatry (Adult &Care Child) Infectious Disease Pulmonary/Critical Care Internal Medicine Urgent Care Infectious Disease Pulmonary/Critical Care Internal Medicine Urgent Care Neurology Urology Internal Medicine Urgent Neurology UrologyCare Neurology Urology action and equal opportunity Mayo Foundation is an affirmative Mayo Foundation is an affirmative action and equal opportunity employer and educator. Mayo Foundation is an affirmative action and equal opportunity employer and educator. employer and educator. If you wish to learn more or to express interest in these positions, If you wish to learn more or to express interest in these positions, please 800-573-2580; If you wish to learncontact more orus toat express interest inemail these positions, please contact us at 800-573-2580; email euphysicianrecruitment@mayo.edu; oremail apply at please contact us at 800-573-2580; euphysicianrecruitment@mayo.edu; or apply at http://www.mayoclinic.org/jobs/physicians-scientists euphysicianrecruitment@mayo.edu; or apply at http://www.mayoclinic.org/jobs/physicians-scientists http://www.mayoclinic.org/jobs/physicians-scientists

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

Neurologist

Endocrinologist

Orthopedic Surgeon

ENT (part-time)

Primary Care (Family Practice or Internal Medicine)

Emergency Medicine Gastroenterologist Geriatrician (part-time) Hospitalist

Psychiatrist Pulmonologist Urologist (part-time)

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

Join our team Join a primary care team where you can grow in your profession and partner with those who share your passion. From rural to urban settings, you’ll find a practice and community that is right for you. Explore our current openings on physicianjobs.allinahealth.org, including: Float pool physician (8840) Family Medicine or Internal Medicine/Pediatrics

Make a difference. Join our award-winning team. 1-800-248-4921 (toll-free) Katie.Schrum@allina.com

physicianjobs.allinahealth.org

FAMILY PRACTICE PROVIDER

Family or Internal Medicine Physician 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 more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334

Sioux Falls VA Health Care System

(with OB)

Our longstanding, independent clinic is recruiting! PRaCtiCE HigHligHts: • Employed by private group practice

COMMunity HigHligHts: • New high school (2013)

• Competitive base salary + production + full benefits package • Signing bonus, student loan repayment, relocation assistance • General hospital call 1:10 • Home financing assistance

• New (2014) 53,000-sq.-ft. Regional Wellness Center with indoor waterpark/aquatic center and modern fitness amenities • 18-hole championship golf course, lakes, parks, paved hiking/biking trails, hunting & fishing

For more information about these opportunities please call or e-mail:

Judy M. Erdahl, Provider Relations Coordinator Email Judy.erdahl@tchc.org • 218-631-7462 • Cell 218-639-4250

Email CV to: kirk.stensrud@glacialridge.org

4 NW Deerwood Avenue Wadena, MN 56482 www.tchc.org

www.glacialridge.org October 2015 Minnesota Physician

Political malpractice from page 19

have been successful in vilifying the medical workforce and technology companies. As a result, politicians have been convinced to mandate “payment reform,” the transfer of insurance risk from HMOs to ACO bedside gatekeeper doctors with “bonus opportunities” to those successful in restricting patient care, and “negative payment adjustments” for those ordering too much care (industry language, not mine).

potential for increased collusive rationing of care and profiteering mischief. Could this be the ultimate profit-driven, low-utilization, federally protected, big box medical home cartel system where patients and their physicians are seen and policed as annoying cost centers? If not deflected, ACA-favored government-corporate cartels can attain centralized power and size equal to socialized NHS cartels abroad.

A big box medical home cartel What might a cartel system of centralized power look like? Centralized state power abroad can be harsh in rationing care in order to control costs. Long queues (even care denials) in many nations are testimony to this fact. In the U.S., HMO/ ACO corporate cartels that are protected by the ACA have the

care is addressed. As long as the political command and control mindset is unchanged and mired in an alphabet soup of regulation, nations are stuck with various models of managed care organizations playing zero-sum rationing games to balance fixed budgets. Their strategies of political necessity include popular free “well care” for the many inexpensive healthy voters and queues for the few costly ill requiring “sick

Consumers were once kings in a professional medical market place.

Unsolved medical inflation Medical inflation will remain an unsolved policy maker’s problem of his or her own making until popular subsidized open (“free”) access to

care.” The ill were once the primary object of medical care. And consumers were once kings in a professional medical market place. Can patients regain their power? Maybe.

Conclusion It was political malpractice, when the U.S. government wrote prescriptions for the nation’s medical sector that caused the abrupt onset of tax-subsidized demand inflation after 1965. Political malpractice was compounded by futile efforts to ration subsidized open “free” access to care. Resolving the problem of medical inflation without resorting to Draconian managed care rationing will require a new medical marketplace prescription, where the consumer is king and where money (not political or corporate authority) is used to distribute goods and services.

Robert W. Geist, MD, is a retired

urologic surgeon.

Olmsted Medical Center, a 220-clinician 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: Anesthesiologist Hospital

ENT

Rochester Southeast Clinic

Family Medicine

Psychiatrist

Sleep Medicine

Rochester Clinics

Rochester Southeast Clinic

Rochester Northwest Clinic

Pain Medicine

Psychiatrist– Child & Adolescence

Urology

Rochester Northwest Clinic

Rochester Southeast Clinic

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 40

Minnesota Physician October 2015

Hospital

Seeking: Occupational Medicine Physician Specialists in Nonsurgical Treatment of Neck and Back Pain PDR Clinics is a spine specialty practice that is devoted to non-surgical care for neck and back pain patients. We use an active, biopsychosocial approach aimed at restoring functional goals through physical exercise and cognitive-behavioral therapies. Our outcomes support our model, and we have been recognized by several payors by winning innovation awards and recognition of our practice in meeting the triple-aim of patient satisfaction, quality outcomes, and affordability. We are looking for an individual to join our medical team and partner in expanding our service offerings to area employers and payor plans. Competitive salary and benefits available. No “on-call” requirements. Voted three years in a row a “Top 100 WorkPlaces” by Star Tribune. PDR Quality Outcomes

• 98% patient satisfaction • 71% of patients report a 50-100% reduction of headaches • 65% of patients report a 50-100% reduction in medication use • 101% increase in Lumbar Extension ROM & strength • 145% increase in Cervical Rotation ROM & strength

Interested?

www.PDRclinics.com

Contact Candi Dolan at Candid@pdrclinics.com or 952-908-2582

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

Opportunities for full-time and part-time staff are available in the following positions: • Associate Chief of Staff, Primary Care • Dermatologist • Internal Medicine/ Family Practice • Occupational Health/ Compensation & Pension Physician

• Physician (Pain Clinic)/ Outpatient Primary Care • Psychiatrist • Radiologist • Urgent Care Applicants must be BE/BC.

Family Medicine & Emergency Medicine Physicians

Great Opportunities

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

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV

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

Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 October 2015 Minnesota Physician

Infectious disease from page 17

was not well understood at the time. Therefore, it is rarely if ever considered as a possible cause of meningoencephalitis among patients whose exposures are limited to the northern United States. The child had been exposed through swimming in a small lake in Stillwater. A second Minnesota case occurred in 2012, also in a child exposed to that same small lake. The increase in median temperatures in the last 100 years is thought to be a reason for these two cases to have occurred. Isolating work-related diseases In October 2007, a physician from southeastern Minnesota notified the MDH of 10 patients, who worked at a swine abattoir and were experiencing unusual neurologic illness. The patients experienced significant sensory symptoms including numbness and tingling as well as limb weakness consistent

with polyradiculoneuropathy, and was initially referred to as progressive inflammatory neuropathy. Among those that had been evaluated, cerebrospinal fluid protein was elevated in the absence of pleocytosis and several had evidence of spinal nerve root or spinal cord inflammation on magnetic resonance imaging. The illness appeared to be associated with working at the specific abattoir and was unlike previously described occupational associated illnesses. Other calls were also received from the occupational health nurse and a clinician at a referral specialty clinic. MDH began an investigation of the plant where more than 19,000 hogs were slaughtered per day. Fifteen patients were eventually identified, and the cases all worked in the warm room, the area where hogs are eviscerated and initially processed. All cases worked at, or had close association with, the head table, the area within the warm room where skin, skeletal

muscle, and brain are removed from severed swine heads by compressed air. No toxic or infectious cause was identified despite a comprehensive exposure history interview, review of chemicals used in the abattoir, and extensive laboratory testing for infectious agents. Autoimmunity appears to be the likely pathogenic mechanism of their disease induced by exposure to aerosolized porcine brain matter. Cases were detected at two other abattoirs located in other states which had similar brain harvesting practices. Our findings indicate that swine abattoirs and other animal commodity abattoirs should not use compressed air to remove brains and should avoid any procedures that aerosolize CNS (central nervous system) tissue. So, starting with the call from the astute clinician, a previously undescribed disease was discovered and worldwide industry changes made to prevent further cases.

Three patients. Who is at risk for diabetes?

Conclusion As the epidemiology of infectious diseases continues to change, and as more infections emerge, it is essential that physicians maintain their vigilance and understand the critical nature of their role in public health. You are our partners, and our eyes and ears. We count on you to report cases and potential outbreaks to MDH. We are truly grateful for this partnership, and as a data-driven agency, we use reporting data to focus our efforts to improve the health of people in Minnesota. To report a case of disease, call 651-201-5414 (or 1-877-6765414). Additional information is on the MDH website at http:// bit.ly/1KxgqIo.

Richard Danila, PhD, MPH, is deputy

state epidemiologist at the Minnesota Department of Health. Ruth Lynfield, MD, is state epidemiologist at the Minnesota Department of Health.

When there are no signs or symptoms, you may not know until it’s too late. Act now. Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk. • Refer your at-risk patients to a proven lifestyle change program and help cut their risk of developing type 2 diabetes in half.

1 in 3 adults are at risk!

• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications. Find groups in Minnesota at www.health.mn.gov/diabetes/programs

Minnesota Department of Health DIABETES PROGRAM

Minnesota Physician October 2015

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