Minnesota Health care News September 2013 by Minnesota Physician Publishing

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September 2013 â&#x20AC;˘ Volume 11 Number 9

Flu shots Jennifer Heath, RN

Erectile dysfunction Mathew Braasch, MD

Snoring and apnea Larry Zieske, MD

CONTENTS

4 7 8

SEPTEMBER 2013 • Volume 11 Number 9

NEWS

MINNESOTA HEALTH CARE ROUNDTABLE

Kelli Jo Greiner

PEOPLE

PERSPECTIVE April ToddMalmlov Minnesota Department of Commerce

INSURANCE Medicare changes in 2014

10 QUESTIONS

18 20

CALENDAR

SLEEP MEDICINE Snoring and apnea

TAKE CARE College health 101

CAREGIVING Long-term care Suzanne M. Scheller, Esq.

Larry A. Zieske, MD, FACS

Cary Mielke, MD Shriners Hospital for Children— Twin Cities

MEN’S HEALTH Erectile dysfunction

INFECTIOUS DISEASE Flu shots

Matthew Braasch, MD

Gary Christenson, MD, and Dave Golden

PATIENT TO PATIENT Navigating the unexpected Kim E. Nielsen, PhD

Jennifer Heath, RN, MPH

ORTHOPEDICS Bone spurs Lance Silverman, MD

FORTIETH

SESSION

Advance care planning Addressing end-of-life issues Thursday, October 24, 2013 1:00 – 4:00 PM • Symphony Ballroom Downtown Mpls. Hilton and Towers

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, and more. Advances in technology are extending life expectancies and require a redefinition of the term “end-of-life.” It now entails a longer time frame than one’s final weeks or hours, and provokes debate as to when life is really over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Objectives: We will discuss the significant infrastructure that supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontology, and hospice. We will review the elements that go into creating advanced directives, including societal issues that make having them necessary, and the difficulties encountered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improved in the future. Panelists include:

www.mppub.com

Ed Ratner, MD, University of Minnesota Center for Bioethics Suzanne M. Scheller, Esq., Scheller Legal Solutions, LLC

PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Jennifer Hollingsworth-Barry jhb@mppub.com

Cheryl Stephens, PhD, MBA, President, CEO, Community Health Information Collaborative Tomás Valdivia, MD, MS, CEO, Luminat Sponsors: Community Health Information Collaborative

ART DIRECTOR Alice Savitski asavitski@mppub.com

Luminat • Scheller Legal Solutions

OFFICE ADMINISTRATOR Amanda Marlow amarlow@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

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

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SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

NEWS

New Report Calls Bullying a Public Health Issue

Minnesota Facilities Do Well in “Best Hospitals” Rankings

Childrenʼs Hospitals and Clinics of Minnesota has released a new report on bullying’s health impact on children, calling bullying a public health issue. The report details how providers and parents should respond. “Any child is susceptible to bullying but, based on our experience, we also know that children who are sick or have special needs are even more vulnerable to bullyingrelated behavior and may suffer a setback in their health or development as a result,” says Children’s CEO Alan Goldbloom, MD. “Our clinical perspective drives us to dig deeper into what this dynamic means for kids and to explore how we as a medical community can help children navigate this threat.” The report notes that conflict is a normal part of childhood, and discusses how to determine what constitutes bullying.

Minnesota hospitals placed highly in the latest U.S. News and World Report “Best Hospitals” rankings. Mayo Clinic continued its tradition of being among the top three hospitals in the nation in the annual rankings, this year coming in at No. 3 overall. Its Rochester site ranked in the top five in 15 specialty areas and was No. 15 in ophthalmology. In all, Mayo was nationally ranked in 26 specialty areas. Allina Healthʼs Abbott Northwestern Hospital, Minneapolis, received a top-50 ranking for 10 specialty areas, with its highest ranking at No. 13 for orthopedics. Allinaʼs Mercy Hospital, Coon Rapids, was ranked No. 34 in gastroenterology. Minneapolis-based University of Minnesota Medical Center, Fairview, received top-50 rankings in one adult specialty area (No. 37, cancer). University

of Minnesota Amplatz Childrenʼs Hospital, Minneapolis, received top-50 rankings for four pediatric specialty areas. Childrenʼs Hospitals and Clinics of Minnesota, Minneapolis, received top-50 rankings in three specialty areas. Gillette Childrenʼs Specialty Healthcare, St. Paul, ranked among the top 50 in two areas. St. Johnʼs Hospital, St. Paul, ranked No. 36 in the ear, nose, and throat specialty. In all, U.S. News recognized 19 hospitals in Minnesota for either ranking among the nationʼs top 50 or receiving a “high performing” designation in at least one specialty area.

With Higher Cigarette Tax, More Seek Help To Kick the Habit Two groups dedicated to helping Minnesotans quit smoking say the stateʼs higher tobacco tax is making a difference. State lawmakers voted to increase the tax by $1.60 last spring, bringing the

cigarette tax to approximately $7.50 per pack. Both Blue Cross and Blue Shield of Minnesota and QUITPLAN, a program sponsored by the anti-tobacco group ClearWay, say that participation in their programs has increased dramatically. Officials with Eagan-based Blue Cross say enrollment in their Stop Smoking support program has nearly tripled since the tobacco tax increase took effect on July 1. The program enrolled 186 people in the first two weeks of July, compared to 69 people during the same period a year ago—a 170 percent increase. “Blue Cross advocated for this legislation because price increases have proven to be the most effective way to encourage people to quit using tobacco and ultimately live longer, healthier lives,” said Janelle Waldock, director of the Center for Prevention at Blue Cross. “While our members represent only a segment of Minnesota residents, this early surge in demand for

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

our cessation services is a positive indicator that the price increase is having its desired effect.” QUITPLAN, the Minneapolisbased service that provides smoking-cessation counseling and tools such as nicotine patches and nicotine gum, has noted a similar spike in activity. Officials there say during the first two weeks of July, 900 calls came through the QUITPLAN Helpline, an increase of 256 percent compared with the first two weeks of July in 2012. Visits to the quitplan.com website jumped 289 percent, with more than 5,600 visitors to the site during those two weeks. QUITPLAN is funded by ClearWay Minnesota, the antismoking nonprofit group created by the stateʼs 1998 tobacco settlement. Anti-smoking groups such as ClearWay pushed hard last spring for a tobacco tax increase. Health experts estimated at the time that the increase would save more than 25,700 lives in Minnesota and keep nearly 48,000 young people from taking up smoking. The American Cancer Society estimated that increasing the tax on cigarettes would cause more than 36,600 adult smokers in Minnesota to quit.

Franken Co-authors Bill to Regulate Compounded Drugs A significant update of regulations regarding compounded drugs, written in part by Sen. Al Franken (D–Minn.), is drawing bipartisan support in the Senate. The Pharmaceutical Quality, Security, and Accountability Act is designed to prevent a crisis such as the one in late 2012, when contaminated drugs distributed by New England Compounding Center were linked to a nationwide outbreak of fungal meningitis. The outbreak caused medical problems for more than 700 people in the U.S. and was responsible for 61 deaths.

In Minnesota, the federal Centers for Disease Control and Prevention and the Minnesota Department of Health found that 129 clinics received contaminated drugs, used mostly for steroid injections in patients with orthopedic conditions. In all, 12 Minnesotans were made ill by the medications, with one death reported. The legislation, introduced in the Senate By Sens. Tom Harkin (D–Iowa) and Lamar Alexander (R–Tenn.), includes a section coauthored by Franken and would increase FDA scrutiny of compounded drugs that are sold across state lines. Franken and other authors of the bill sit on the Senate Health, Education, Labor and Pensions Committee.

Insurers Consider Releasing MNsure Rates in September Minnesota health insurance companies are reacting cautiously, but positively, to the idea of publishing their rates for MNsure products in September rather than October. In a letter dated July 26, state officials asked health plans to publicly file the prices they will charge for health-exchange insurance products on Sept. 6, nearly a month earlier than the state law requires. Under state law, insurers working with MNsure, the stateʼs health exchange, had until the exchangeʼs enrollment period began on Oct. 1 to disclose their rates. However, state officials say an earlier disclosure will help consumers who qualify for MNsure. The letter, signed by the commissioners of Health and Commerce, said an earlier disclosure of insurance rates was in the public interest. “With that information, Minnesota consumers will have the time and opportunity to fully understand their options and make informed decisions on health insurance plans for themselves, their families, and businesses,” the letter

H2462_68051_CMS AAccepted H2462_68051_CMS ccepted 5/18/2013. 5/18/2013. PPlan lan pperformance erformance SStar tar RRatings atings aare re aassessed ssessed eeach ach year year aand nd may may change change from from oone ne yyear ear to to tthe he nnext. ext. HealthPartners HealthPartners iiss a health health plan plan with with a Medicare Medicare contract. contract. ©2013 © 2013 HealthPartners HealthPartners

When it comes to your child, getting help early is your priority.

It’s ours too. Our Pediatric Therapies partner with families to help children gain skills and improve functioning through: s Occupational Therapy s Speech and Language Therapy s Feeding Therapy s Music Therapy

Learn more:

stdavidscenter.org/therapies 952.548.8700

News to page 6 SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

News from page 5 says. The request might have been prompted by developments in other states, where public release of rates for products on insurance exchanges has shown those rates to be somewhat lower than expected. On July 18, the U.S. Department of Health and Human Services (HHS) publicized a report that found premiums for health exchanges will be nearly 20 percent lower in 2014 than previously expected. The HHS report found that in the 11 states that have made information available for individual insurance plans on exchanges, proposed premiums were 18 percent lower than HHS had previously estimated. In six states that disclosed information about small-employer premiums, HHS estimates costs also would be 18 percent lower, on average, than the amount small employers would pay for similar coverage outside the exchanges. Individual states have issued widely different estimates for

what premium rates will be under health insurance exchanges. New York officials estimate that costs will drop by approximately 50 percent for consumers who buy insurance on the exchanges. In contrast, Indianaʼs deputy commissioner for insurance released a statement saying that residents of that state who buy insurance through an insurance exchange will see an average 72 percent cost increase. With advocates on both sides spinning the data, officials may simply want to provide concrete numbers to consumers in this state before MNsure begins marketing the exchange later this summer. Regulations bar the state from releasing these numbers before the enrollment period begins, so officials have turned to insurers in hopes that they will voluntarily reveal their rates. Insurers seem receptive to the idea, though none have yet committed publicly to the Sept. 6 date. “We think this request from the Department of Commerce

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

makes a lot of sense,” said a statement released by Blue Cross and Blue Shield of Minnesota on July 26. “Health reform is bringing about a lot of change, and the more time Minnesotans have to understand their options, the more informed choices they can make.” The statement noted that any rates announced in September should be final and not subject to change. It added that Blue Cross is in discussion with state officials about the issue. A similar statement was released by Medica, saying, “It is important to get information to consumers in a timely way so that they can begin to consider their options. In concept, we support the request from Commerce and have worked with them to determine how to make this happen.” HealthPartners released a short statement saying they were in talks with the Department of Commerce about an earlier release of premium rates. But the statement also suggested that

insurers may be waiting for action from state officials. “We believe that the early release should occur after the Department of Commerce has completed approval of all of the products that will be available for 2014,” the statement said.

Collaborative Center At U of M to Address Health Disparities The University of Minnesota and the University of Alabama will share a $13.5 million grant from the National Institutes of Health to co-host the National Transdisciplinary Collaborative Center for African American Men’s Health, developing interventions for health care disparities affecting African American men, including violence-related injuries, cardiovascular disease, cancer, and stroke. The grant went into effect on July 1 and will fund five years of activity for the center.

PEOPLE

Children, St. Cloud, as the first and only certified community health worker in Central Minnesota. She assists the clinic’s Somali families and their infant to 5-year-old children with developmental screening and educates Somali expectant mothers about early brain development in infants and the importance of good nutrition. Imtiaz Mohamed, MD, has joined the Essentia Health-Duluth Clinic’s Digestive Health Center. He earned his medical degree from Maulana Azad Medical College in New Delhi, India, and completed a residency in internal medicine and a fellowship in gastroenterology at Nassau County Medical Center/SUNY Stony Brook in East Meadow, N.Y. Most recently, Imtiaz Mohamed, MD

Mohamed practiced in Hayward and Rice Lake, Wis. Thomas Moraghan, MD, has joined the

Essentia Health St-Joseph’s-Brainerd Clinic to provide endocrinology services. Moraghan earned his medical degree from the University of North Dakota School of Medicine in Grand Forks and served a residency in internal medicine and a fellowship in endocrinology at the Mayo Graduate School of Medicine in

Telephone Equipment Distribution (TED) Program

Fatumo Abdulkadir, CHW, has joined CentraCare Clinic-Women &

Do you have trouble using the telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud

Rochester. Cary H. Mielke, MD, has been appointed

Tho mas Mo raghan, MD

chief of staff at Shriners Hospitals for Children– Twin Cities, where he has served as assistant chief of staff since 2006.

The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

Mielke earned his medical degree from the University of Minnesota, completed an orthopedic surgery residency at Mayo Clinic in Rochester, and completed a fellowship in pediatric orthopedic surgery at the University of Utah/ Shriners Hospital for Children–Salt Lake City. Sheila Riggs, DDS, DMSc, director, Office of Community Engagement for Health at the Clinical and Translational Science Institute and chair, Department of Primary Dental Care at the University of Minnesota School of Dentistry, has been elected to the Hennepin Healthcare System (HHS) board of directors. HHS is a subsidiary corporation of Hennepin County that operates Hennepin County Medical Center. Twelve citizens with extensive experience in health care, business management, community development, finance, public health, and workforce development serve on the volunteer board. Riggs earned her dental degree (DDS) from the University of Iowa College of Dentistry and her doctorate of medical sciences (DMSc) in epidemiology from Harvard. Mary Story, PhD, RD, senior associate dean for academic and student affairs and a professor in the Division of Epidemiology and Community Health in the School of Public Health at the University of Minnesota, has been appointed to serve on the 2015 Dietary Guidelines Advisory Committee. The appointment was announced by the U.S. Department of Health and Human Services and U.S. Department of Agriculture,

Mary Story, P hD, RD

which jointly publish the guidelines. The Committee’s recommendations and rationale will serve as a basis for the eighth edition of the Dietary Guidelines for Americans, which is the foundation for national nutrition programs, standards, and education. SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

A better way to buy health insurance Steps to take now

April Todd-Malmlov, MPH MN Department of Commerce

April Todd-Malmlov, MPH, executive director of MNsure, has more than 15 years of experience in the public and private health care sectors. Before assuming her current position, she served as Minnesota’s state health economist. In that role she was responsible for monitoring the health care market and informing state health policy related to health care access, cost, and quality. ToddMalmlov has also served as the director of competitive intelligence for UnitedHealthcare and as the vice president of strategic analysis and communications for government affairs at UnitedHealth Group during the debate and passage of the federal Affordable Care Act.

ctober 1, Minnesota’s online health insurance exchange—MNsure—will open for business. It will be a one-stop online marketplace where individuals, families, and small businesses will be able to get quality health coverage at a fair price.They will be able to search for, select, and enroll in health insurance by comparing health plans in a side-by-side, “apples-toapples” comparison.

its services, and insurance options.

Savings

If you need help

Increased competition is one reason it’s predicted consumers and small businesses will save on premiums. Another reason is that MNsure will provide access to tax credits and low-cost and free coverage available through Medical Assistance and MinnesotaCare. MNsure will make real-time eligibility determinations for Medicaid, MinnesotaCare, and tax credits. Tax credits will be available for individuals below 400 percent of the federal poverty level, which is roughly $94,000 for a family of four. For individuals or families below 200 percent of the federal poverty level, which is roughly $47,000 for a family of four, MNsure will facilitate enrollment in Medical Assistance or MinnesotaCare. Tax credits also are predicted to offer additional savings for small businesses that have up to 25 employees who each make an average wage of $50,000 or less. In order to get insurance—and savings—follow these steps below.

People who want help figuring out which plan is right for them can contact the consumer assistance contact center, which opens Sep. 3, 2013. The contact center will be open M–F 7:30 a.m. –8 p.m., with weekend hours during high-volume times. Consumers can contact the center at (651) 284-4101 or toll-free at (855) 3MNSURE / (855) 366-7873.

Contact a Consumer Assistance Partner. MNsure will provide trained, certified Consumer Assistance Partners to help individuals and small businesses navigate the system. These partners will include community-based organizations, nonprofits, and insurance companies, and will be available for individuals or small businesses that would like to talk Individuals will be able to It’s predicted consumers to someone in person about choose the health insurance options available through and small businesses plan that best fits their MNsure. Consumers will be able needs from among an array to access Consumer Assistance will save on premiums. of public health options and Partners in late September plans offered by multiple through MNsure’s contact center private insurance companies. Small businesses, and website. defined as those with fewer than 50 employees, will be able to offer their employees a monetary What to do in October contribution toward employee premiums and the Open enrollment for coverage purchased though employees will be able to choose from among the MNsure begins Oct. 1, 2013 and lasts through insurance plans offered at MNsure. MNsure also March 31, 2014. This means that consumers have will manage premium payments to insurers on six months to shop on MNsure, compare health behalf of small businesses so that businesses can insurance plans, and find the coverage that’s right focus less on back-office work and more on their for them. Individuals also will be able to see if they bottom line. And, because this new marketplace are eligible for low-cost or free plans and if they will increase competition between health insurers, are eligible for tax credits to help pay for insurboth consumers and small businesses will benefit. ance coverage.

What to do in September Call MNsure’s contact center, which will open at 7:30 a.m. on Sep. 3, 2013 (7:30 a.m.–8 p.m., M–F (651) 284-4101 or toll-free at (855) 3MNSURE or (855) 366-7873). Consumers and small businesses will be able to call and talk to trained representatives, who can answer questions about MNsure,

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

If a consumer feels a specific determination by MNsure requires further review, that consumer may start the appeals process by calling the contact center or by contacting MNsure through its website (www.mnsure.org). MNsure’s marketplace can be accessed on its website starting Oct. 1, 2013. Benefits In addition to saving money on health insurance, MNsure will make it possible for people who currently can’t get insurance through an employer to obtain it. Native Americans will have specific opportunities through MNsure. It’s estimated that MNsure will enroll more than 1.3 million Minnesotans in health coverage by 2016.The more people who have health insurance coverage, the better everyone’s future can be.

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SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

10 QUESTIONS

Transforming children’s lives Cary Mielke, MD Dr. Mielke is board-certified in orthopedic surgery and is chief of staff at Shriners Hospitals for Children–Twin Cities. Please tell us about the history of Shriners Hospitals for Children. Shriners Hospitals for Children is a network of 22 nonprofit specialty hospitals across North America. Children with orthopedic conditions, burns, spinal cord injuries, or cleft lip and palate are eligible for care and receive all services in a family-centered environment, regardless of their families’ ability to pay. This hospital system was started in 1922 by Shriners International, a philanthropic organization. Shriners Hospitals for Children–Twin Cities opened in 1923 and provides orthopedic care for children from Minnesota, North Dakota, South Dakota, Nebraska, Iowa, Wisconsin, the Upper Peninsula of Michigan, and three Canadian provinces. Shriners Hospitals for Children–Twin Cities serves a specialized population. Please tell us about the kind of services you provide. We treat any condition of the muscles, bones, or joints. Typical conditions include hip dysplasia, clubfeet, knock-knee, bowleg, flatfeet, scoliosis, kyphosis, hand abnormalities, limb deficiency, cerebral palsy, spina bifida, brittle bone disease, rickets, arthrogryposis, and genetic or other neuromuscular disorders. We also see children with sports injuries, overuse syndromes, fractures, juvenile arthritis, and provide some plastic surgery services. For patients with cerebral palsy, we can perform rhizotomy, a neurosurgery procedure that helps reduce excessive muscle tone. How does a child become a patient at Shriners? Care is based solely on a child’s medical needs, regardless of the family’s ability to pay. Families should call our intake coordinator at (612) 596-6105. They will be asked a few questions to make sure we can treat their child’s condition, and then an initial appointment will be scheduled. What have been some of the most dramatic recent advances in the care you provide? For children with long bone deformities in their legs such as bowed legs (Blount’s disease, or rickets), guided growth with small plates and screws is used to straighten the bone. The way this procedure works is that the part of the bone called a growth plate is temporarily tethered with a small metal plate and two screws. Over the period of a year or so, the leg straightens. Guided growth is quite effective in most pediatric cases. It’s an outpatient surgery, and therefore much easier on the patient than the previous treatment for this condition, and permits quicker recovery. Previously, these children were treated by osteotomy, which involves cutting a wedge out of the bone and placing large plates and screws on the bone to straighten the leg. Also, in the past, a patient with multiple lower-extremity conditions caused by cerebral palsy would have had each condition treated by a separate surgery. Now, these procedures are all performed in one surgery. This allows faster recuperation and rehabilitation rather than multiple procedures over years.

Photo credit: Bruce Silcox

Some operations involve serious risk. How does Shriners help parents make difficult medical decisions? Our care coordination department and physicians educate families about every procedural option for their child’s condition, and the risks involved. Our social workers can provide additional counseling resources, including religious professionals. Shriners patients require care from a diverse team of providers. Tell us about this team. Surgeons, nurses, and social workers collaborate to explore treatment options for

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

Care is based solely on a child’s medical needs, regardless of the family’s ability to pay.

difficult cases. The entire medical staff meets weekly to discuss surgeries planned for the following week. Orthotics and prosthetic personnel build customized braces and prostheses. Occupational and physical therapists develop inpatient, outpatient, and home rehabilitation programs to maximize functional outcomes after surgery. Physical and occupational therapists discuss what kind of strengthening should be done before surgery and what the rehabilitation plan will be following surgery. Our hospital is a member of the Mayo Clinic Care Network, so our physicians can consult directly with Mayo Clinic specialists. We also have relationships with other health care facilities, including the University of Minnesota. Some patients need multiple procedures over time. What can you tell us about this? Patients who use orthotics or prosthetics have new devices built for them whenever they hit a growth spurt, often more than once a year. For patients who are here for an extended period of time during the school year, we hire teachers to come into the hospital. Children recover faster when they are able to return to their own homes and daily activities, so we work hard to get them home as soon as they’re ready. Our average length of stay is 2.5 days. What happens to kids who turn 18 but still need the types of services Shriners provides? Care may be extended to age 21 in some cases. If patients have

extensive equipment needs or if major surgery is anticipated during their late teens or early twenties, care will be continued at Shriners until these major needs are met. Once a patient is able to transition into adult care, our team assists the family with the transition. Please tell us about the medical research with which Shriners is involved. Current research projects include evaluating treatment for stiff muscles in hands; evaluating nonoperative vs. surgical treatment of spine conditions; assessing which types of operations for hand and wrist movement produce better results; and evaluating limb prostheses. Please share a success story with us. Alexis was born with proximal femoral focal deficiency. She virtually had no femur (the long upper leg bone above the knee) on her left side. But she had a knee, tibia (the inner, larger leg bone below the knee), and the bones of the ankle and foot. At age 6, Alexis underwent major surgery to convert her knee to a hip and her ankle to a knee joint. Using her ankle as her knee meant it had to be rotated 180 degrees so that it would bend the same way a knee bends; a prosthetic leg was built to fit her new knee. Alexis has had amazing success with the surgery and has led an active life ever since. Now 16, she competes on her high school swim team and tennis team and drives a car just like her peers. Alexis is a confident young woman who plans to become an orthopedic surgeon.

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

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

Appointments:

Online or Call 651-439-8807

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

SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

MEN’S HEALTH

Erectile dysfunction Common and very treatable By Matthew Braasch, MD

rectile dysfunction (ED) is described by the National Institutes of Health as a consistent inability to maintain an erection sufficient to permit satisfactory intercourse. This condition is quite common and affects up to 9 percent of men under age 40, 11 percent to 30 percent of men 50–59 years old, and around 35 percent of men over age 60.

Chemical dependency in older adults is hard to recognize We help them live a healthier life Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older. Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

Contact Us 713 Anderson Ave., St. Cloud, MN 56303 (320) 229-3762 • (800) 742-HELP toll-free www.centracare.com (Search: Senior Helping Hands)

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

Causes Causes of ED fall into two basic categories: organic and psychogenic. Organic causes originate from specific biologic impairment involving mainly the arteries and nerves to the penis. Psychogenic ED stems from lack of physical attraction or arousal in a relationship, partner conflict, poor mood or energy, lack of motivation, performance anxiety, or major life stress.

Quitting smoking, losing weight, exercising regularly, and improving diabetes control can improve erectile function.

Organic causes Medical. Erections are complex physiologic processes. Sexual stimulation causes the release of neurotransmitters that cause relaxation of the smooth muscle in the blood vessels of the penis. This increases blood flow that makes it become engorged and rigid. Consequently, many conditions that affect the vascular or nervous system may cause ED. This includes diabetes, high blood pressure, high cholesterol, cardiovascular disease, and cigarette smoking. Nerves required for erection originate from the lower spinal cord and travel near the bladder, rectum, and prostate. Some surgeries that involve those organs, as well as spinal cord injuries, can damage these nerves and cause ED. Parkinson’s disease, stroke, brain tumors, dementia, and epilepsy can also promote ED by affecting brain centers for sexual drive and erection. Psychological. Certain psychological illnesses can disturb the excitatory centers of the brain involved in erections. These include schizophrenia, bipolar disorder, substance abuse, and depression. Pharmacologic. Antipsychotic medications and antidepressants called selective serotonin reuptake inhibitors (SSRIs) may adversely affect erectile function by affecting certain neurotransmitters in the brain involved with sexual function. Several other drugs may cause ED through a variety of mechanisms. These include some blood pressure medications (thiazide diuretics, propranalol), statins used to treat high cholesterol, ulcer medication (cimetidine), opioids (when used chronically), and alcohol. Psychogenic causes Psychogenic ED is typically characterized by sudden onset, situational problems, and the presence of erections upon waking in the morning. Organic ED tends to be more gradual in onset, non-situational, and with poor or absent waking erections. Many men experience mixed ED, a combination of organic and psychogenic factors. Diagnosis Generally, ED must exist for at least three months for a physician to make a diagnosis. Evaluation by a physician typically includes patient and partner interviews and questionnaires, physical examination, and basic lab tests when appropriate. Sometimes ED can be the first symptom of other potentially more serious diseases. As such, a physician may order labs tests to screen for diseases such as diabetes, high cholesterol, heart disease, or low testosterone when appropriate.

attack, poor exercise tolerance, or very high blood pressure may need to consult a cardiologist before starting treatment for ED.

Treatment focuses on expectations and goals of the patient and his partner. The type of therapy prescribed can vary greatly from patient to patient depending on such factors as invasiveness, cost, motivation, and coexisting medical conditions. First-line therapy that is typically recommended includes education and lifestyle modification. Multiple studies have shown that quitting smoking, losing weight, exercising regularly, and improving diabetes control can improve erectile function. Psychological counseling or couples therapy may benefit patients with psychogenic ED. Pharmacologic therapy. Drugs categorized as phosphodiesterase inhibitors (PDE-I) are the most popular agents because of their convenience and non-invasiveness, and include sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). They lead to successful intercourse for about 50 percent–70 percent of the men with ED who try them. These medications must be prescribed by a physician and are typically taken about one hour before sexual activity and on a fairly empty stomach. Most of these drugs are taken as needed, although daily low-dose tadalafil exists. Possible side effects can include headache, stomach upset, facial flushing, backache, nasal congestion, and vision changes.

Erectile dysfunction to page 34

How will health care reform affect you? Get an answer to this question and more at medica.com/reform. Or call 1-855-HCR-8588. And get back to doing your thing.

Treatment Typically, a physician first assesses the patient’s cardiac risk and fitness for sexual activity. Patients with a history of chest pain, heart SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

INFECTIOUS DISEASE

Flu shots Why you need one By Jennifer Heath, RN, MPH

lu (influenza) season is just around the corner.

PSOR–2clr 211 767 08.07.13

Influenza usually circulates in Minnesota from October through March. Influenza is a respiratory disease caused by a virus that affects the nose, throat, and lungs. But make no mistake: Influenza is not just a bad cold. Last year was a reminder that influenza is serious. During the 2012–2013 influenza season, there were more

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than 3,000 people hospitalized with influenza and more than 200 influenza-related deaths in Minnesota. How to protect yourself To protect yourself, your family, and your community, getting your influenza vaccine is one of the best things you can do. A flu vaccination may not keep you from getting the flu, but it can lessen the severity and duration of symptoms. It can also decrease the risk that you’ll infect someone who can’t fight the flu very well, including the very old and very young. The Minnesota Department of Health recommends getting your influenza vaccine early in the influenza season. Your health care provider can tell you as soon as flu vaccine is available, which can be as early as August. But even if you get vaccinated later, you benefit. Since influenza often peaks in February or later, getting vaccinated in December or January still can protect you. Because the influenza virus changes its composition from year to year, influenza vaccines are created annually to protect against the subtypes of the virus—called strains—that are most common that year. This is one reason you need an influenza vaccine each year. In the past, influenza vaccines have protected against three strains of influenza virus. This year, some vaccines will be available that offer protection against four strains. Another reason for an annual shot is that protection you get from an influenza vaccination decreases during the course of a year. Several studies show that influenza vaccine is about 60 percent effective in healthy adults. Even though it’s not 100 percent, we know that we can protect about half of the population against influenza when they’re vaccinated. When you consider the severe complications of influenza, this is a huge benefit to our community. Everyone 6 months of age and older should get an influenza vaccine. But, there are some things that are important to know for different age groups. Infants and pregnant women

Call C all for for more more information information

952.848.2065 7700 France Ave., Ave., Suite 100, Edina, MN w w w. r a d i a n t r e s e a r c h . c o m www.radiantresearch.com Find Us On Facebook

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Getting sick with influenza during pregnancy puts both the woman and the unborn baby at risk for serious complications. Influenza vaccination during pregnancy is safe and helps protect both moms and babies because pregnant women who get vaccinated pass some of their protective antibodies to their baby. Antibodies tell our immune system to respond to a specific germ, like influenza virus.

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

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FIGHT THE FLU! • Cover your cough. These antibodies will protect your baby during the first few months of life before he or she can get vaccinated. Influenza vaccine is safe for women who are breastfeeding, so they should get vaccinated as well. It is also important for dads, grandparents, siblings, and other close contacts of infants to be vaccinated. Infants younger than 6 months old cannot be vaccinated, so they rely on their caregivers to be protected against influenza and not spread it to them. Children Influenza’s effects can be severe for children 5 years of age and younger, especially for those under 2 years of age. The single best way to protect them is through vaccination. Studies have shown that children’s immune systems respond well to influenza vaccine, typically giving them better protection than adults. This is great for protecting young children as well as the entire community. For children who don’t like needles, there’s good news: The nasal spray vaccine called FluMist has been shown to be even more effective than the shot in some studies. Healthy people age 2 through 49 years can get FluMist. Your health care provider can tell you if it’s right for you or your child. Some children need two doses of influenza vaccine to be fully protected. This depends on whether they received influenza vaccine in the past and on the strains contained in the vaccine this year. Your health care provider can tell you if your child needs two doses. Adolescents and young adults Minnesota data show that only about 25 percent of adolescents get influenza vaccine, fewer than any other age group. Being sick with the influenza can force them to miss school and sideline them from their extracurricular activities for several days or even weeks. Since healthy adults’ and adolescents’ immune systems generally respond well to flu vaccine, getting vaccinated can help make sure they stay healthy and active. Adults Even healthy adults can become very ill with influenza. Many adults can’t afford to miss work or other responsibilities, so spending a little time getting vaccinated can save days or weeks of missed work and fun later on. There are many places to get vaccinated, Get your influenza including a health care provider’s office, pharmacies, vaccine early in the and community and workinfluenza season. place influenza vaccination clinics. Many adults have chronic conditions that put them at higher risk for complications from influenza, such as asthma, diabetes, and heart conditions. Although you may have these conditions well controlled, influenza can worsen them suddenly and land you in the hospital.

tion as well, so influenza vaccine is less effective in the elderly. That makes it especially important that caregivers be vaccinated. This includes family members, long-term care providers, and health care workers.

• Wash your hands. • Stay home when sick. • Get vaccinated. Get more information about influenza at

www.mdhflu.com

There is a high-dose influenza vaccine for the elderly that contains four times the amount of antigen that is in a regular influenza vaccine. (The antigen is the ingredient that triggers your immune system to fight off the disease.) This high-dose vaccine is designed to elicit a stronger response from an elderly person’s immune system. Researchers are currently unsure if this vaccine protects older adults better than the regular influenza vaccine because the high-dose vaccine is relatively new, although research expected to be completed in 2015 will help clarify this vaccine’s effectiveness. Bottom line Everyone 6 months of age and older should get an influenza vaccine every year. Influenza vaccine protects you and those around you— especially those who may be at higher risk of complications if they get sick. Influenza vaccine might not be 100 percent effective, but it is the most specific tool we have against influenza.

Jennifer Heath, RN, MPH, is an immunization outreach nurse specialist at Minnesota Department of Health.

Health care reform answers for anyone and everyone. Right here. Get answers to how health care reform will affect you at medica.com/reform. Or call 1-855-HCR-8588. And do your thing.

Elderly The Centers for Disease Control and Prevention reports that 90 percent of influenza deaths and more than 60 percent of influenzarelated hospitalizations occur in people 65 years and older. This past influenza season was especially hard on the elderly. Unfortunately, as we get older our immune system isn’t able to respond to vaccinaSEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

INSURANCE

Medicare changes in 2014 Navigating open enrollment in 2013 By Kelli Jo Greiner

very January, Medicare changes. Each year, Medicare beneficiaries make decisions about those changes. Not all of 2014’s changes are known yet, but what is known is provided here to help you start planning for Medicare annual open enrollment, which begins Oct. 15, 2013, and ends Dec. 7, 2013. During that time, you can make changes to your Medicare Part D plan and Medicare Advantage plan; changes take effect Jan. 1, 2014. Before reviewing options for open enrollment, know that: 1. MNsure, the new Minnesota health insurance marketplace, will not include Medicare-related options. For help answering Medicare-related concerns, call Senior LinkAge Line, not MNsure. 2. Although people without Medicare will be able to purchase

Elder and Advocacy Services I am passionate about being an advocate for the elderly and disabled, including in maltreatment, injury and wrongful death claims.

Other services include: • nursing home litigation • health care agent appointments • elder abuse and neglect • elder mediation • nursing home resident rights • estate planning • speaker

Please contact: Suzanne M. Scheller, Esq. Scheller Legal Solutions LLC 6312 113th Place North Champlin, MN 55316

763.647.0042 suzy@schellerlegalsolutions.com

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

health insurance through MNsure without having to undergo health screening and cannot be denied health insurance due to a preexisting condition, this DOES NOT apply to Medicare supplemental policies. This means that Medicare beneficiaries who want to purchase a Medicare supplemental policy may be required to undergo health screening and may be denied a policy if applying for health insurance more than six months after enrolling in Medicare Part B. For information about exceptions, call Senior LinkAge Line. 3. You may hear that MNsure plan options are offered by companies with the same names that provide you with Medicare Part C and Medicare Part D plans. However, plans offered through MNsure are not available to people on Medicare. Be informed Medicare-related materials, including your Annual Notice of Change and Evidence of Coverage, must be mailed to you by Sept. 30, 2013. Read the information you receive from your plan, Medicare, and Social Security Administration to learn about upcoming changes to your current Medicare plan that take effect Jan. 1. This will help avoid potential surprises such as: • Going to the pharmacy only to find your prescription drug is no longer covered by your Medicare Prescription Drug Plan. • Discovering at the pharmacy that your Medicare Prescription Drug Plan has shifted a prescribed drug to a higher costsharing tier, increasing your out-of-pocket cost. • Being unprepared for Medicare Prescription Drug Plan cost-sharing changes such as monthly premium and deductible increases. • Finding out that you no longer qualify for Extra Help with

Medicare prescription drug changes in 2014 Plan changes become public information on Oct. 1, 2013 (www.Medicare.gov).

2013 Prescription Drug Costs (also called Low Income Subsidy, or LIS), which reduces out-of-pocket costs. â&#x20AC;˘ Learning that your Medicare Prescription Drug Plan is no longer a â&#x20AC;&#x153;benchmark plan,â&#x20AC;? so that even if you qualify for LIS, your monthly Medicare Prescription Drug Plan premium has increased.

Medicare-related materials must be mailed to you by Sept. 30, 2013.

Annual deductible Initial coverage limit

2014

$325

$310

$2,970

$2,850

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Coverage gap (Doughnut hole)

$2,970â&#x20AC;&#x201C;$6,733.75

Catastrophic coverage

Began after $6,733.75 in total prescription drug costs

Catastrophic coverage cost-sharing

â&#x20AC;˘ Discovering at the pharmacy that prescription drug coverage provided as part of your retiree plan has changed, either because of increased monthly costs or because your plan is no longer considered â&#x20AC;&#x153;creditable coverage.â&#x20AC;? Creditable coverage allows you to remain in your retiree prescription drug plan and avoid a premium penalty should you later enroll in a Medicare Prescription Drug Plan. Tips In addition to reading Medicare related materials you receive in the mail:

Definition

Doughnut hole amount in 2014 will decrease to $4,550

Doughnut hole amount in 2013 has been $4,750

You are responsible for copayments of $2.65 per generic prescription drug and $6.60 per brand-name prescription drug

Prescription drug costs from $320 through $2,850 are covered as follows: plan pays 75% of the cost and you pay 25% of the cost $4,550 is the amount that you pay out-ofpocket before having catastrophic coverage

Begins after $6,690.77 in total prescription drug costs You will be responsible for copayments of $2.55 per generic prescription drug and $6.35 per brand-name prescription drug

â&#x20AC;˘ Switch from a Medicare Advantage Plan that doesnâ&#x20AC;&#x2122;t offer drug coverage to a Medicare Advantage Plan that does offer drug coverage. â&#x20AC;˘ Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesnâ&#x20AC;&#x2122;t offer drug coverage. â&#x20AC;˘ Join a Medicare Prescription Drug Plan. â&#x20AC;˘ Switch from one Medicare Prescription Drug Plan to another Medicare Prescription Drug Plan. Medicare changes in 2014 to page 19

1. If you receive Extra Help (LIS), follow mailed instructions youâ&#x20AC;&#x2122;ll receive from the Social Security Administration (SSA) and/or the Centers for Medicare & Medicaid Services (CMS). This will help ensure you receive LIS in 2014. If you are asked to send in something, make sure to do so or your LIS eligibility could be revoked.

2. If you have retiree coverage, your insurer will inform you by mail of changes for 2014 and whether or not your retiree prescription drug coverage will be considered creditable coverage.

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3. Information you receive about other Medicare Prescription Drug Plan and Medicare Advantage options can help you decide which plan is best for you in 2014. 4. Beginning Oct. 15, 2013, call Senior LinkAge Line to receive the 2014 edition of Health Care Choices for Minnesotans on Medicare. This publication provides all open Medicare plan options available to Minnesota Medicare beneficiaries. Medicare open enrollment begins Oct. 15, 2013 and ends Dec. 7, 2013. Changes to your plan take effect Jan. 1, 2014.

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SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

September Calendar 9

Bariatric Gathering for All Part of Allina Clinics’ “Bariatric Gathering for All” series, this month’s session teaches skills for healthy eating. Free. Open to weight-loss surgery candidates, whether they are pre-or post-surgery, and their supporters. Register online (https://wellness.allinahealth.org) or by calling (763) 236-2068. Monday, Sept. 9, 5:45–7 p.m., Unity Hospital Education Center, 620 Osborne Rd. NE, Fridley

Living with Lynch Syndrome Conference Minnesota Oncology hosts the fifth annual conference for individuals and families affected by Lynch Syndrome. Topics will include medical management and updates, and there will be support and networking opportunities. Cost: $25 per person. Advance registration required; register online (www.livingwithlynchsyndrome.org). Saturday, Sept. 14, 8 a.m.–5 p.m., Minneapolis Airport Marriott, 2020 American Blvd. E., Bloomington

Immune Power for All Ages Vital Life Chiropractic hosts wellness-certified chiropractor Barbara Kaiser, DC, who will discuss natural solutions to chronic and acute health issues. Free. Register at www.vitallife.eventbrite.com or call (651) 757-5096 to reserve seats. Tuesday, Sept. 17, 6:30–7:30 p.m., Vital Life Chiropractic, 3470 Washington Dr., Eagan

Could My Cancer Be Hereditary? Park Nicollet genetic counselors will facilitate a discussion for cancer survivors and their families, caregivers, and supporters to explore what is known about familial and hereditary cancer. Preregistration required. Call (952) 993-5700 to register or for more information.. Wednesday, Sept. 18, 3–4:30 p.m., Park Nicollet Frauenshuh Cancer Center, 1st Floor Conference Room, 3931 Louisiana Ave. S., St. Louis Park

Back to School The early childhood years from birth to the start of kindergarten are an important time of rapid learning and growth. Screening children between the ages of 3 and 4 can detect possible health or learning concerns so that children can get theB help they need before they start school. Waiting to screen until a child is in school may be waiting too long. Screening is a brief, simple procedure to identify infants and young children who may need a health assessment, diagnostic assessment, or educational evaluation. It supports children’s readiness for kindergarten and promotes positive child health and developmental outcomes. The Early Childhood Screening Program is provided free and is available through school districts. At your child’s screening, a trained professional will check vision, hearing, height and weight; immunization status; functioning of large and small muscles; thinking, language, and communication skills; and social and emotional development. Some school districts may offer dental and nutritional review as well. In order for a child to start kindergarten in any Minnesota public school, his or her guardian must provide the summary form from the child’s early childhood screening as well as the child’s immunization record.

Sept. 1–30 Early Childhood Screening To register for screening at the nearest location, contact your local school district online at www.MNParentsKnow.info, search for the Early Childhood Screening programs available in your county using the link under the “Find a Program” box; or call (651) 5828412. Written forms are available in English, Hmong, Russian, Somali, Spanish, and Vietnamese. Interpreters may be available. The screening typically lasts about one hour. Siblings may attend, although childcare is not provided. When parents/guardians register, they will be told what materials they need to bring to the screening, such as an immunization record. Questions concerning child development, health, or other parenting issues can also be discussed at the screening appointment.

Introduction to Brain Injury The Minnesota Brain Injury Alliance sponsors this class, covering basic details about the brain, brain injuries, and living with brain injury. Participants also will learn about brain injury resources. A donation of $5 per person is appreciated. Registration is required, either by phone at (612) 378-2742 or (800) 669-6442 or online (www.braininjurymn.org). Thursday, Sept. 26, 6–8 p.m., Education Center of the Minnesota Brain Injury Alliance, 34 13th Ave. NE, Minneapolis

T.O.D.D Field Day Taking Opportunities, Defying Disabilities offers attendees of all ages, skills, and physical abilities the chance to try adaptive archery, rock climbing, golf, cycling, tennis, and hockey. Live demos of wheelchair basketball, rugby, and soccer. Convenient free parking, so come and go as you wish. Activities are inside and outside; dress for the weather. Free, but prereregistration required (www.toddfieldday13.eventbrite.com). For more information, email obuswebmaster@ottobock.com. Saturday, September 28, 10 a.m.– 3 p.m. Northern Star Base Camp, 201 Bloomington Rd., Fort Snelling

Break Up the Lunch Rut Whole Foods presents this class on healthy eating. Preregistration at least 24 hours in advance required. To register, call (952) 830-3500 or stop by the customer service desk in the store. Fee of $10 is required at time of registration; payment is nonrefundable but can be applied to store credit if you cancel at least 48 hours in advance. Monday, September 30, 6–7 p.m., Whole Foods Edina, 7401 France Ave. S., Minneapolis

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

America's leading source of health information online 18

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

Medicare changes in 2014 from page 17

• Drop your Medicare prescription drug coverage completely. Medicare Advantage disenrollment is from Jan. 1, 2014, through Feb. 14, 2014. During disenrollment, YOU CAN: • Leave a Medicare Advantage plan and switch to Original Medicare. Original Medicare coverage begins the first day of the following month. • Switch to Original Medicare. If you switch, you have until Feb. 14, 2014, to join a Medicare Prescription Drug Plan to add prescription drug coverage. This drug coverage begins the first day of the month after the plan receives the enrollment form. During disenrollment, YOU CANNOT: • Switch from Original Medicare to a Medicare Advantage Plan. • Switch from one Medicare Advantage Plan to another. • Switch from one Medicare Prescription Drug Plan to another. • Join, switch, or drop a Medicare Medical Savings Account Plan. 5-Star special enrollment period Medicare uses information from member satisfaction surveys, plans, and health care providers to rate plans to help you compare them based on quality and performance. A plan can be rated between one and five stars, with five stars considered excellent. 5-Star plans can be found in the Medicare Plan Finder tool at www.Medicare.gov, and are identified by a gold triangle with a star inside it with the number 5. You can switch to a 5-Star Medicare

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Advantage or Medicare Prescription Drug Plan once from Dec. 8, 2013, through Nov. 30, 2014. This is a special enrollment period available to most Medicare beneficiaries. For questions about star ratings, call Senior LinkAge Line. Health Care Choices 2014 The Minnesota Board on Aging will publish the 2014 edition of Health Care Choices for Minnesotans on Medicare in autumn 2013. This publication includes all Medicare Prescription Drug Plan and Medicare Advantage Plan options available in Minnesota. To obtain a copy, call Senior LinkAge Line after Oct. 15, 2013.

Contact Senior LinkAge Line Senior LinkAge Line is the federally designated State Health Insurance Assistance Program (SHIP) for Minnesota, providing free assistance to Minnesota Medicare beneficiaries of all ages in understanding all Medicare options. It also helps Minnesotans access programs providing free or discounted medications, and provides longterm care options counseling. Call (800) 333-2433 or visit www.MinnesotaHelp.info

Kelli Jo Greiner is team lead for the Minnesota Board on Aging Consumer Choices Team.

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CAREGIVING

Long-term care Prepare, research, and monitor By Suzanne M. Scheller, Esq.

anaging long-term care for an aging loved one is multifaceted. It includes drafting documents to appoint agents, paying for care, researching care options, monitoring care, and planning for end of life. Draft Documents. The inability to make financial and medical decisions often deteriorates with age. Elders retain the greatest control by appointing trusted agents to carry out their wishes in the following documents. â&#x20AC;˘ Financial Power of Attorney allows someone else power over financial matters, such as paying bills and performing financial transactions. The elder is the â&#x20AC;&#x153;principalâ&#x20AC;? and the person appointed is the â&#x20AC;&#x153;agentâ&#x20AC;? or â&#x20AC;&#x153;attorney-in-fact.â&#x20AC;?

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TIP. For the principal’s protection, require the agent to provide an accounting to the principal. Also consider prohibiting agents from transferring property to themselves, thus reducing the opportunity to “self-deal.” • Health Care Directive appoints a health care agent to make medical decisions if the elder cannot. Specific treatment wishes may be included as well. Other medical documents (see below) are also used to guide end-of-life treatments. Neither the financial power of attorney nor the health care directive strip the principal of acting on his or her own behalf, but merely appoint someone to act if the principal cannot. The documents do not involve court oversight. Any action of the agent must be in good faith, keeping in mind the best interest of the principal. Finance Care. Monthly costs for long-term care can be $4,000–$10,000. There are three main ways to pay for long-term care: long-term care insurance, Medicare, and Medicaid. For insurance, families should contact an insurance agent for options long before insurance is needed. Medicare does not pay for long-term care, but partially covers short-term rehabilitation in a facility for up to 100 days after a three-day qualifying hospital admission. If care is needed after 100 days, the elder often transitions to long-term care and pays for services from personal funds. Once funds are essentially depleted, the resident may qualify for Medicaid (“Medical Assistance”). Medical Assistance is complex, and families with questions should contact the county of residence and an elder law attorney. Research Care Options. The state of Minnesota issues several different licenses to provide care. Know the elder’s health needs and the care delivered based on the provider’s license. Below are care options, whether at home or in a facility: Nursing Home • Nursing Home • Boarding Care Home • Veteran’s Home

Housing w/ Services • Adult Foster Care • Supervised Living Facility • Memory Care • Assisted Living Title

Home Care

Adult Day Services

Independent Housing

• Supportive Services • Personal Care Attendant • Health-Related Services

• Family Adult Day • Adult Day

• Active Living • Board & Lodge • Community Support

Resources to consult when researching the quality of care for a facility or provider include: • State and federal database searches based on certain criteria: Nursing Home Compare http://medicare.gov/nursinghomecompare/search.html Nursing Home Selection www.health.state.mn.us/nhreportcard/ Minnesota Help Info http://longtermcarechoices.minnesotahelp.info/ • Survey and complaint information www.health.state.mn.us/divs/fpc/inspresults.html • “Annual Quality Improvement Report on the Nursing Home Survey Process” www.health.state.mn.us/divs/fpc/2011nhqifinalrpt.pdf

Visit a Facility. Gather information before admission: • Review a copy of admissions, housing, or services contract; policies; and surveys prior to signing documents. • For complex health needs, ask about staffing, training, and equipment for the needs of the elder. • Ask how the facility will assist with additional services as the elder’s health needs progress. • Determine if residents may bring in and pay for their own services and under what conditions. • Ask about the complaint process and how the facility responds. • Determine the cost of stay and the source of payments, such as Medicare or Medical Assistance. • Visit the facility at mealtime and bedtime to see how staff interacts with residents. Review admissions agreements. Read admissions agreements carefully prior to signing, particularly as to who is obligated to pay for care. The admission process can be stressful. Often the resident cannot sign the agreement and a loved one is asked to sign in one of the following capacities: • Spouse of the person receiving nursing home care • Legal representative: An agent of the resident in some capacity; this is often a family member • Responsible party: A person with access to the resident’s funds and who agrees to apply them to the resident’s care • Guarantor: A third party who voluntarily agrees to be personally liable for bills TIP. A long-term care facility cannot deny admissions based on the inability to secure a signature from the resident or another party. A “legal representative” is the broadest category and is usually sufficient. Signors may be required to pay the bill themselves if they sign as “responsible party” with access to the resident’s funds and don’t use them to pay for care or if they sign as “guarantor.” Admissions agreements may contain an arbitration provision that states that all disputes will be resolved by an arbitrator and not the court, which changes legal rights even before knowing the dispute. TIP. An arbitration provision may be rejected while keeping the remainder of the admissions agreement intact, such as by not separately signing the provision; crossing out arbitration language and initialing the change; or by objecting to the provision in writing within the number of days provided in the admissions agreement. Coordinate care With complex medical needs and the involvement of multiple health professionals, coordinating care can be difficult. A resident may retain his or her primary care physician and does not need to select the physicians used by the facility. Many facilities must have a “resident and family council” for residents and families to meet and address concerns. Minutes of council meetings are to be recorded, allowing the facility to track issues. Be watchful that the medical needs of the resident are met, such as proper transferring, Long-term care to page 32 SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

SLEEP MEDICINE

Snoring and apnea Life threatening but treatable By Larry A. Zieske, MD, FACS

pproximately 30 percent to 50 percent of the adult U.S. population snores. Children, too, can be affected by sleepdisordered breathing, which is associated with reduced school performance and behavioral disorders. Chronic loud snoring, however, may indicate the presence of obstructive sleep apnea (OSA), especially if the snorer also gasps for air or sounds as though he or she is choking or gasping. OSA is a potentially life-threatening condition that causes someone to temporarily stop breathing while asleep. Up to 30 percent of adults

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

have mild to moderate sleep apnea, which also affects up to 3 percent of children. Serious consequences OSA increases the risk of heart attack, stroke, high blood pressure, and daytime drowsiness that can cause car accidents. Because people with OSA usually donâ&#x20AC;&#x2122;t realize it unless they seek medical help for drowsiness or are prompted by a sleep partner to seek help for snoring, itâ&#x20AC;&#x2122;s important to consider whether you or a loved one may have any of the following causes.

Causes

Diagnosis

Anything that reduces airflow to a sleeper’s lungs can cause apnea, which triggers the brain to awaken the sleeper just long enough to resume breathing, which often sounds like gasping or choking.

Diagnosing children and teens relies initially on observation and judgment by parents, who should contact their primary physician if they are concerned about the child’s classroom performance, sleep, or behavior.

Obstruction of the upper airway can be caused by excess tissue such as large tonsils, a large tongue, or a long soft palate and uvula, which are anatomical structures at the back of the throat. Contributing factors can include jaw position, lax airway muscles that collapse during sleep, and being overweight, although normal and underweight people can have OSA. Nasal abnormalities also contribute to breathing difficulties. Environmental factors that irritate nasal passages and make them swell reduce space available for airflow. These can include fumes, chemicals, dust, pet dander and other allergens, exhaust, aerosol sprays such as room “fresheners,” and scented plug-ins. Tips to try first Weight loss. Overweight people who lose 10 pounds or more sometimes find that this makes snoring diminish or disappear.

Surgical treatment

Sleeping position. Sleeping on your back promotes snoring, so try sleeping on your stomach (best) or side. Avoid alcohol, heavy meals, and caffeine (including chocolate, cocoa, and soda pop) two or more hours before you plan to go to sleep. Avoid sedatives and over-the-counter sleep aids, because they can relax throat muscles, which therefore become more likely to collapse across the airway. This causes airway obstruction and promotes increased tissue vibration that causes snoring.

Disordered breathing in adults is generally diagnosed by a sleep study, during which the patient spends the night in a medically supervised sleep lab. The study records measurements such as the frequency of breathing stoppages that last longer than 10 Obstructive sleep seconds, oxygen levels, the apnea is a number of times the sleeper serious condition. awakes, leg movements, and snoring. The data that is collected allows the severity of the sleeper’s apnea to be graded normal, mild, moderate, or severe. Although snoring alone can merit treatment, moderate to severe apnea should be treated because of its associated health risks.

Tonsillectomy and adenoidectomy frequently solve or significantly reduce sleep problems and often benefit behavior and school performance as a result. Surgically correcting deviated cartilage and bone inside the nose may help, as can treating allergies. It’s best to delay nasal surgery for sports-active children until the child’s longterm involvement with athletics has concluded, to avoid reinjuring the nose. Soft palate and uvula surgery trim tissue from the soft palate Snoring and apnea to page 31

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College health 101 TA K E C A R E

Strategies to help students thrive By Gary Christenson, MD, and David Golden

our child is at college. No regular bedtime, nobody to wake them up or make sure they eat breakfast. They will figure it out.

You hope. School is more than academics and, sometimes, life gets in the way. When school doesn’t go well, it is often because of health-related issues like unmanaged stress, anxiety or depression, illness, lack of sleep, and alcohol or marijuana use. Health and academic success are intimately related, and data

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collected by University of Minnesota–Twin Cities Boynton Health Service provides insight into that relationship. Factors affecting school Good health is essential, and students need to see the links between their health and their academic success. Here are a few obvious links. Alcohol. Students who engage in high-risk, or binge, drinking (five or more drinks in one sitting during the previous two weeks) have lower GPAs than those who do not. Students who drink heavStudents who do ily with greater frequency have not smoke have even lower GPAs. This is probably obvious to you but may not be to higher GPAs. your son or daughter. At the U of M–Twin Cities campus, approximately 35 percent of the student population engaged in high-risk drinking one or more times during the past two weeks. You may want to share this information with your son or daughter even if you have already discussed alcohol use. That’s because they will be faced with choosing whether or not to drink once they’re at college. Going to college provides an opportunity to make sure your expectations are part of their decisions about alcohol. Marijuana. Higher marijuana use is associated with lower GPAs. When students use marijuana more frequently, it is associated with a steady decline in GPA. This makes sense: Marijuana is associated with short-term memory loss, and a well-functioning brain is essential to academic success. For some students, marijuana use also is associated with increased anxiety and depression. About 13 percent of U of M students used marijuana at least once during the past month. Stress. Some students find their first set of exams, a tight deadline for an assignment, or a college-level course with a lab to be stressful. New friends and a new living environment, perhaps with a roommate for the first time in their life, all can add to the stress of students’ first year. In contrast, some students find this sort of stress

exciting and challenging and many of them thrive in this environment. When students were asked to rate their stress level on a scale of one to 10, there was no relationship between their stress level and their GPA. However, when they were asked how effective they were at managing their stress, the relationship was significant. Students who reported that they were effective at managing their stress had much higher GPAs. Students need to be intentional about managing stress; getting enough exercise, a healthy diet, and enough sleep all help a student cope. In addition, most colleges provide many avenues to help students manage stress, and many schools offer yoga, meditation, or tai chi to do just that. Unmanaged stress can lead to a suppressed immune system and a corresponding susceptibility to illness. Unmanaged stress also can lead to difficulty concentrating and to depression. College students may have been able to handle stress in high school and still perform well in school or other activities, but some of their familiar support systems may not be available to them now that they have left home. Having a plan to help manage stress during college life will help them navigate difficult periods during their time at school. Safety. Students often feel invincible, but safety should be on their radar. Forty-one percent of students who bike regularly report they never wear a helmet, but protecting their brain should be a high priority. In addition to wearing a helmet when biking, students should pay attention to their surroundings, walk with friends while walking at night, and always protect themselves and their possessions. One in eight students at the University of Minnesota were victims of theft in the past 12 months. Safety must be a priority. Sleep. Lack of sleep is associated with a lower GPA. Health benefits of sleep are often underestimated, despite data showing that sleep improves memory, concentration, problem-solving abilities, immune system function, a feeling of well-being, and the ability to manage stress. Students may make the mistake of shortchanging themselves on sleep during the week and trying to catch up on weekends, but playing catch-up with sleep doesn’t work. When you check in with your college student, ask them if they are getting any sleep. They need to shut off the cell phone, stop texting, turn off the TV, and go to sleep! Smoking. Students who do not smoke have higher GPAs than those who do. It’s encouraging that U of M students 18–24 years of age have a daily smoking rate of 2.6 percent. However, despite this low rate, this age group still is susceptible to tobacco addiction. One quarter of students who smoke started smoking after the age of 18, and 18- to 24-year-olds have some of the highest smoking rates in the state. Tobacco use is a leading cause of death and correlates with a lower GPA—two good reasons to quit or to never start. Mental health. Approximately 30 percent of college students have been diagnosed with a mental health condition during their lifetime. Students who have had difficulties with mental health conditions while on campus have lower GPAs. Mental health conditions are common on college campuses and some students find that the new environment at college can aggravate their condition. Others become newly diagnosed with a condition such as depression or anxiety disorder after entering college life. Colleges often have mental health counseling services on campus and can provide

effective treatment for students. Getting help can be extremely important to a student’s academic success. One of the most common reasons cited for withdrawing from classes is related to mental health. Colds and flu. The number of days a student is sick is associated with a lower GPA. One case of influenza can mean four or more Health and days of missed class. To avoid getacademic success ting sick, students should get a flu are intimately shot, wash their hands, get enough sleep, and maintain a good diet. related. Send your college student an occasional text asking if he or she got a flu shot. Importance of parental advice It’s important for students to pay attention to the link between their health and academic success, and parents can help. Believe it or not, studies show college students do indeed listen to parental advice. You may not always see them follow it, but you have a big influence on what they do, so help guide them toward understanding the link between health and academic success. Gary Christenson, MD, is a board-certified psychiatrist and is chief medical officer and director of clinical services at the U of M Boynton Health Service, where David Golden is director of public health and communications.

In the next issue.. • Hypoglycemia • Concussion • How not to get sick SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

PAT I E N T T O PAT I E N T

Navigating the unexpected Facing a challenging diagnosis By Kim E. Nielsen, PhD

Obtaining the diagnosis Doctors eventually diagnosed transverse myelitis, a neurological disease that is nearly always initially misdiagnosed. Obtaining the correct diagnosis took more than six months, myriad tests, many doctors, and several hospitals. Including diagnosis and physical rehabilitation, we spent between two and five days a week at medical offices for more than a year. We experienced the very worst of medical practitioners, and some of the very best. My daughter missed more than a year of school and both my husband and I took significant leave time from work. But medical concerns were in no way the most difficult aspect of this journey. Potholes

ne day several Septembers ago, my teenage daughter and I headed to the doctor’s office for what we thought would be a routine childhood cold/flu visit. Within 90 minutes we were in a high-tech ambulance headed to a specialist pediatric hospital.

Navigating the health care and insurance systems was one of our most difficult and emotionally exhausting tasks. Despite the overabundance of graduate degrees in our household, and although we are native English speakers, we struggled to understand doctor-speak and to decipher health insurance forms and contracts. We struggled to deal with medical authority figures that considered our knowledge of our daughter and her body, and her knowledge of herself and her body, to be irrelevant. Equally difficult to steer through were relationships with family and friends, even though we needed them desperately. Despite good intentions, family and friends occasionally caused more stress and tears than they alleviated. Lessons learned

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Ask for a case manager. All medical insurance companies are required to provide case managers, but consumers need to know this and to ask their insurance company for one. This is especially important for people with long-term medical needs. Case managers are assigned to manage all of the paperwork and information for an individual for the duration of that patient’s medical condition. After asking for a case manager, our lives became easier. Whenever we called the insurance company, we spoke to one person—the case manager—who knew our case history. Not having to explain everything again and again meant less stress and much less time. Additionally, our case manager was a registered nurse, and her large-picture vantage point was very helpful: She knew what tests had already been done, remembered erroneous diagnoses when doctors did not, suggested questions we could ask of doctors and other specialists, and knew of regional resources. Doctors do not know everything, and they can be wrong. During the four years since my daughter’s rare and unpredictable condition was first assessed, I have never heard a doctor acknowledge that he or she did not know the answer to one of our questions. (Our family’s longtime primary care doctor was the only exception.) Nor, despite multiple initial diagnoses

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

and doctor disagreement about those diagnoses, did a doctor ever acknowledge that a diagnosis might be wrong. Additionally, the task of diagnosis blends both objective data and subjective analyses. Objective data like test results can be interpreted differently by different doctors; subjective data and analyses, even more so. Research has shown that a patient’s age, gender, race, and even clothing can influence a doctor’s perception of the situation. In my limited experience, there is no patient that physicians doubt more than an adolescent female. If we initially had been more skeptical of doctors and diagnoses, we likely would have gotten better medical care by being better self-advocates.

life and decision-making well during a crisis; don’t demand perfection of yourself. We also wish that we had taken better care of ourselves as parents. Indeed, nurturing oneself is sometimes the best medicine. Ice cream, movie marathons, occasional personal meltdowns, and 3 a.m. grocery store runs helped significantly.

Avoid late-night information searches. While self-education is important, never search the Web for medical information between 10 p.m. and 6 a.m. Being sleepless with worry is normal. Late-night Web searches, however, create a barrage of information when you are least able to process it. Read, clean cupboards—but do not search for medical information while sleepless with worry.

An unexpectedly large number of strangers feel it is appropriate to ask our daughter, “What’s a pretty girl like you doing in a wheelchair?” While it’s tempting to run over their toes with the wheelchair, we have found it helpful to giggle over possible responses that include everything from tigers to explosive chemistry experiments. Humor is our most useful coping mechanism.

Empower adolescents. As children near late adolescence, they need to be involved in their own medical decision-making, and their opinions need to be carefully considered. Once children are 18, they make their own medical decisions and parents have no legal right to access their child’s medical information unless the young adult wants them to do so. At age16, our daughter began what likely will be a lifelong regime of at least five daily prescriptions. She needed to learn to handle that on her own quickly, for at 18, she went off to college. There she has had to manage medications, make daily personal and medical decisions, deal with insurance paperwork, handle the immediate requirements of any additional medical complication, and advocate for herself in a society that continues to discriminate against and often denigrate people with chronic illness and/or disabilities. That only works if the teenager has been involved in daily medical and personal self-management prior to turning 18.

Coping

Transverse myelitis is a neurological disorder caused by inflammation on both sides of an area of the spinal cord. Which part of the cord is inflamed determines which body parts are affected. Initial symptoms can include a sudden onset of lower back pain, muscle weakness, or abnormal sensations in toes and feet, and can progress rapidly to include paralysis. No cure currently exists. One-third of people with this condition experience good or full recovery; one-third experience some degree of recovery with residual deficits; one-third show no recovery.

Whether you’ve received a serious diagnosis or are dealing with garden-variety medical concerns, navigating illness may not be your greatest difficulty. Navigating health care systems, insurance systems, and relationships may be the most difficult. Using these tips can help. Kim E. Nielsen, PhD, is a former Minnesotan and is a professor in the School of Disability Studies at the University of Toledo in Toledo, Ohio. MSA - MN Healthcare July 2013.pdf 1 6/12/13 15:23

Not everyone needs to know everything. Family members and friends cared about our child and our family and wanted to provide support. They also wanted to know what was going on. The lack of an initial diagnosis, our own traumatized reeling, and a teenager’s legitimate desire for privacy, however, meant that we could not share all information with those who desired it. Sometimes we didn’t have information, sometimes we were emotionally incapable of either discerning or sharing information, and sometimes it was not their business. Individuals and their immediate families are not obligated to share all medical and emotional information with those around them. A helpful phrase to use is, “We appreciate your concern and know that you care, but for our own well-being we need some privacy.” Ask for help. As stubborn Midwesterners, we found that asking for help was difficult. Minnesotans tend to pride themselves on giving, but rarely on receiving. Asking for assistance, however, is important. Family and friends want to help, and while they do not need to know all information, most are very receptive to specific requests: food, snow shoveling, lawn care, babysitting, someone to drive to and from appointments, books or movies, someone to spoil a nonhospitalized sibling, prayer, a cabin for a getaway, or someone with medical knowledge to translate doctor-speak. Ask for help—the more specific, the better. Forgive yourself. We wish we’d done some things differently. In particular, we wish that we had been more willing and able to challenge the all-knowing nature of some physicians. Few people handle SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

ORTHOPEDICS spurs become less noticeable after extensive physical therapy; at other times, surgery is necessary to address the problem. Causes

Bone spurs A closer look at a thorny problem By Lance Silverman, MD

one spurs (osteophytes) are a common ailment. A spur is a tiny, rigid outgrowth of bone that develops in the capsules (coverings) of joints and within tendons and ligaments. This condition occurs when individuals put wear and tear on their bodies over an extended period of time. That’s why spurs are common in athletes and people who are middle-aged or older. Sometimes, symptoms of bone

Bone spurs are the body’s response to repetitive stress and typically form along an area of bone where there is excessive pull on a tissue as it inserts into bone. When this tension is repetitive, eventually the tissue tears. Tearing tissue bleeds internally and forms a clot, which results in the formation of scar tissue. In a setting of repeated stress or recurrent injury, scar tissue tears. If scar tissue tears repeatedly, the body may make something it knows is more permanent and resistant to tearing: bone. There are several situations that make bone spurs develop. For example, muscles that are too tight can stress a tendon at the point where it inserts into a bone. This situation eventually makes the tendon tear. Calcifications (i.e., calcium deposits) subsequently develop within the tendon and ultimately become bone spurs. Another situation occurs when cartilage degenerates in a joint, and the space within the joint subsequently collapses. As a result, the joint becomes slightly loose. This looseness can lead to abnormal motion and stress on the connective tissue surrounding the joint (the joint capsule), causing small tears in the tissue. Eventually, those tears form spurs. Spurs develop rapidly when there are chronic ligament injuries

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

around a joint that cause the joint to move abnormally. Spurs also develop rapidly if rips in muscle or tendon make joints move in dysfunctional patterns because the resulting stress imparted to the joint capsule is abnormal. Symptoms Spurs themselves rarely hurt unless they press on soft tissue and cause pain, numbness, and/or weakness. They also have specific symptoms depending on where they develop. Knee. Bone spurs in the knee can make it difficult to fully extend the leg. Some spurs rub on tendons or ligaments that help support the knee joint. Spurs in the knee may cause further damage to ligaments or tendons near the affected area. Spine. These spurs can cause nerve or spinal cord damage. Spurs form in the cervical (neck) or lumbar (lower back) areas of the spine because of joint instability or from joint degeneration. If the spurs press on nerves that pass from the cord into arms or legs, they can cause radiating pain, numbness, and muscle dysfunction. If spurs in the cervical or lumbar spine take up space within the spinal canal, nerves become crowded, and symptoms of stenosis can develop: incontinence and/or persistent pain, numbness, or weakness in the back, legs, or arms. Shoulder. Spurs in the shoulder can injure muscles in the rotator cuff, a common condition affecting baseball pitchers and quarterbacks. Rotator cuff injury can cause spurs because if the rotator cuff doesnâ&#x20AC;&#x2122;t move perfectly, its abnormal motion puts stress on the joint and the deltoid muscle. Stress in these areas can lead to the develop-

ment of spurs that can further injure the rotator cuff, causing more abnormal motion. Heel. These spurs typically develop in two locations: the insertion of the Achilles tendon at the back of the heel, and just above the plantar fascia on the bottom of the foot. Symptoms at the first location include pain in the back of the heel that makes wearing shoes difficult. In contrast, a plantar heel Patients can help spur forms within the prevent spur formation muscle of the foot and by maintaining is rarely painful because it presses on no a healthy weight. other tissues. It is a sign, however, that the foot muscle has felt excessive stress, as the plantar fascia support has failed. This torn tissue forms a painful, thick scar that may cause additional symptoms if it presses on nerves in the foot. Ankle. In patients who develop flat feet as adults, spurs develop as the pressure in the ankle is distributed more to the outside, creating an imbalance. More commonly, spurs develop in the front of the ankle as a result of repetitive ankle instability. A bad sprain from childhood can come back to haunt someone 20 or 30 years later. Ankle spurs limit range of motion in the ankle, which may lead to an altered gait and contribute to tendon tearing. Toes and fingers. Bone spurs in these areas can lead to tenderness and a knobby appearance. Fingers and toes may look disjointed if spurs prevent them from fully extending or contracting. Abnormal Bone spurs to page 30

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www.mppub.com SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

muscle forces cause the toes to bend and form hammertoes, a condition in which toes resemble hammers. Spurs subsequently develop within the small toe joints. Diagnosis Most doctors can diagnose bone spurs in an affected region based on symptoms, but routine imaging techniques are used to get an idea of spurs’ size and cause. Common ways a doctor looks for bone spurs include X-rays, ultrasound, MRI scan, or CT scan. If spur symptoms interfere with a patient’s activity, goals, athletics, or daily comfort, treatment is recommended. Treatment If symptoms are minimal, a doctor may prescribe anti-inflammatory drugs to help manage pain. Physical therapy also is used to build strength and promote functional motion that may prevent the spur from creating or worsening symptoms. When anti-inflammatories or physical therapy don’t manage pain sufficiently or don’t return the patient to his or her desired level of function, surgical removal of the spur may be recommended. Surgical procedures differ based on where the spur is located. Many people focus on the spur as the source of the problem, but spurs, as discussed above, form for a reason. The body is trying to tell us something is wrong with a specific joint. Consequently, cutting spurs out is a short-term solution to a long-term problem. It is often not the best solution. However, simple surgical removal does make a patient feel better quickly without much downtime.

Consequently, doctors and patients are often drawn to this as a quick fix. In certain areas of the spine, for example, surgically removing a spur can relieve pain caused by the spur pressing on a nerve. However, it will not fix the dysfunctional motion that led to the spur formation; only physical therapy can do that. Sometimes, spinal fusion is performed to address pain caused by a spur. But fusion may create more stress on surrounding joints and make them develop spurs, necessitating more surgery. In the foot or ankle, removing a spur without addressing its cause similarly fails, typically within five years, and the spur recurs. Prevention Patients can help prevent spur formation by maintaining a healthy weight, as excess weight stresses joints. Every excess pound lost dramatically reduces force around the hip, knee, ankle, and foot. Undergoing a functional movement screen by a physical therapist can identify abnormal muscular patterns that promote spurs and that are correctable with simple exercises. Finally, patients who have had spurs are more likely to prevent their recurrence with physical therapy and surgical procedures that reconstruct ligaments or treating tendons rather than by spur removal alone.

Lance Silverman, MD, is board-certified in orthopedic surgery and sees patients at the three locations of Silverman Ankle and Foot, including Apple Valley Medical Center.

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

(651) 603-0720 • (800) 511-3696

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

Snoring and apnea from page 23

and uvula. This can reduce the likelihood of tissue collapsing over the airway (causing apnea) and/or vibrating (causing snoring).

People with OSA usually don’t realize it.

Palatal implants treat mild to moderate snoring that is associated with little or no apnea. Synthetic implants are inserted into the soft palate to stiffen the tissue at the back of the palate. This keeps the tissue from flopping over the opening to the airway. Implantation can be done in the physician’s office under local anesthesia for patients who tolerate dental work well, or under general anesthesia. This treatment works best for patients who are not overweight. Nonsurgical treatment Over-the-counter products—for snoring, not apnea—include aromatherapy, pillows or bed risers to elevate the back and head, and internal and external nasal devices. Overall, these products have not proven to be very helpful, but they may benefit certain individuals. Weight management and proper sleep habits include maintaining a healthy weight, setting a regular bedtime, and getting an adequate amount of sleep in a quiet, comfortable bedroom. In addition, the following approaches may help both snoring and apnea. A breathing mask worn during sleep delivers air pressure to keep the breathing channel open.

the airway. Generic mouthpieces are available online and at drugstores; custom-fitted ones from dentists cost more but may provide greater benefit. Multiple remedies

Some patients who do not get adequate help from the previously mentioned measures may be referred to a board-certified sleep medicine specialist and/or a sleep specialty surgeon. These patients include those who have growth problems with the face, skull, and/or jaw; very large tongues; and/or neuromuscular abnormalities. Additional medicines and surgeries are available that may help these patients. But no matter what other treatments a patient tries, it is always important to maintain a healthy weight. Obesity alone can undo benefits gained by other means. Obstructive sleep apnea is a serious condition. If you or a loved one snores loudly and sometimes wakes up gasping for air, consult a physician if maintaining a healthy weight and other lifestyle modifications do not solve the problem.

Larry A. Zieske, MD, FACS, is a board-certified ear, nose, and throat physician (otolaryngologist) practicing in Burnsville, Edina, Minneapolis, and Plymouth with Ear, Nose & Throat SpecialtyCare of Minnesota, PA.

Dental mouthpieces that make the lower jaw protrude can enlarge the breathing channel and keep the tongue from obstructing

SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

Long-term care from page 21

repositioning, and use of appropriate medications and dosages. Request medical records and addendums to the records when they are in error. With many providers addressing the needs of the resident, it is difficult to maintain consistency and errors can be perpetuated or issues unattended.

To report suspected maltreatment, call the Senior LinkAge Line at (800) 333-2433 or the “Common Entry Point” for Adult Protective Services in the county of residence (www.mnaging.state.mn.us/advisor/cepd.htm). The Ombudsman for Long-Term Care advocates for vulnerable adults and can be reached at (800) 657-3591.

Report maltreatment

Plan for end of life

Maltreatment in Minnesota is defined as abuse, neglect (including self-neglect), or financial exploitation of a vulnerable adult. Warning signs include (from S.A.F.E. Elders http://safemn.org/):

Conversations with elders about how they wish to spend their last days should occur before the need arises, such as when drafting a health care directive. Certain powerful medical documents may not be appropriate to draft for an otherwise healthy individual, but may be considered with terminal illness, age-related deterioration; or debilitating conditions. Consider drafting a Physician’s Order for Life Sustaining Treatment (POLST) or a Do Not Resuscitate/Do Not Intubate (DNR/DNI) document. The POLST is an order signed by a doctor that indicates what treatment the resident wishes to have if a life-threatening event occurs. It covers cardiopulmonary resuscitation (CPR), intubation (tube insertion for artificial breathing), antibiotic use and other treatments. The DNR/DNI generally covers CPR and intubation, but is generally not a physician’s order that clearly guides emergency personnel.

Abuse: physical and sexual

Bruises, pressure marks, broken bones, abrasions, and burns, with poor explanation Internal injuries

Neglect

Dehydration Malnutrition Poor hygiene and supervision Lack of necessary equipment or health aids

With preparation, research, and monitoring, navigating longterm care is manageable.

Financial Exploitation

Denied basic financial information

Suzanne M. Scheller, Esq., practices elder law and advocacy at Scheller Legal Solutions, LLC, Champlin.

Unpaid bills Abrupt asset transfers Abrupt changes to will or Power of Attorney

Minnesota

Health Care Consumer

August survey results ...

Association

1. I take OTC (over-the-counter) dietary supplements. 1. I take OTC (over-the-counter) dietary supplements.

40 30 22.86% 14.29%

Agree

Does not apply

Disagree

8.57%

11.43%

0% Strongly disagree

Every day Regularly Sometimes

Rarely

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

30 25 20%

20%

14.29%

Never

8.57%

Strongly agree

Regularly Sometimes

Rarely

Never

5. I trust and would (do) use OTC “diagnosis-in-a-box” 5. I trust and would (do) use OTCkits. “diagnosis-in-a-box” kits.

34.29%

60 31.34%

30 22.86%

20 15 10 5.71%

37.14%

4. When I visit my physician, I discuss the supplements take.I discuss the supplements I take. 4. When I visit my Iphysician,

Percentage of total responses

5.71%

5.71% Strongly agree

57.14%

Percentage of total responses

dietary supplements.

57.14%

Percentage of total responses

3. I believe the OTC supplements I take are improving mysupplements health. 3. I believe thesOTC I take are improving my health.

60 Percentage of total responses

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

2. I rely on an alternative care provider to advise me 2.inI relythe of dietary supplemtns. on anuse alternative care provider to advise me in the use of

51.43%

50 40 30 20

17.14%

20%

8.57%

10 2.86%

Everytime Regularly Sometimes

Rarely

Never

Strongly agree

Agree

No opinion Disagree

Strongly disagree

Minnesota

Health Care Consumer Association

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

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

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS

Erectile dysfunction from page 13

Testosterone supplementation to stimulate sexual drive is somewhat controversial because of its limited benefit and potential for serious risk. It provides marginal or no benefit to men who have normal testosterone levels and sex drive. Therefore, this therapy is appropriate mainly for men who have low sex drive and documented low serum testosterone levels. Testosterone replacement therapy can be effectively delivered by patches or gels applied to the skin or oral mucosa, injections, or slow-release pellets inserted under the skin. Oral pills, including over-the-counter “testosterone supplements,” generally do not work because they are metabolized by the liver and may lead to liver toxicity. Potential risks of testosterone supplementation in general include abnormally high red blood cell counts, prostate cancer, acne, elevated cholesterol, and liver dysfunction. Patients taking testosterone therapy must be followed closely by a physician. Self-injection of vasoactive agents into the penis are generally reserved for patients for whom PDE-Is are not an option or are not effective. These include single-agent drugs such as papaverine or alprostadil or specialized combinations. Self-injection should be prescribed only by a licensed urologist who can manage potential complications and who can properly determine doses. Patients should be leery of so-called “sexual” or “men’s health” clinics that lack on-site urologists, because non-urologists are not equipped to treat all forms of a potential complication known as priapism. This is a long-lasting and very painful erection that can lead to disfigurement of the penis and permanent, irreversible ED if not immediately cor-

rected. Moreover, many insurance plans cover physician appointments and injection instruction provided in a licensed urologist’s office. A non-pharmacologic option for ED is the vacuum erection device (VED). This is a vacuum cylinder placed around the penis to cause penile engorgement, which is maintained by placing a restrictive ring at the base of the penis, similar to the ring of a condom. This can also be used in combination with pharmacologic treatments. VEDs are covered by most insurance plans and by Medicare. Surgical implantation of a penile prosthesis is the gold standard in men for whom more conservative options don’t work or for patients with significant penile curvature called Peyronie’s disease. The device is implanted in the operating room by a urologist and requires minimal hospitalization. The satisfaction rate for this treatment is very high and the complication rate, fairly low. This procedure is paid for by most insurance plans and by Medicare. Solutions Treatment for ED ranges from nonpharmacologic (lifestyle and medication modification, and vacuum devices) to pharmacologic (oral medication or penile injections) to surgical to psychotherapy to couples counseling. Erectile dysfunction does not have to be endured. Matthew Braasch, MD, is a board-certified urologist practicing in Edina and Shakopee with Urologic Physicians PA. He has a particular interest in minimally invasive and robotic surgery, urologic oncology, prosthetic surgery for ED, and general urology.

Now accepting new patients

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

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

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

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

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

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2013

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

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

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

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

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

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

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

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

Model is used for illustrative purposes only.

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

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

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

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

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

Non-insulin • Once-daily