Minnesota Health care News November 2013 by Minnesota Physician Publishing

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November 2013 â&#x20AC;˘ Volume 11 Number 11

Prevent heart attacks M. Nicholas Burke, MD

Winter bicycling Jason Tanzman

Affordable Care Act Kathleen Sebelius

Eating disorders are complex, and itâ&#x20AC;&#x2122;s not always obvious if and when to seek help. If you think you or someone you care about may be struggling with an eating disorder, the experts at Melrose Center can help you find answers.

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CO NTENTS

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November 2013 • Volume 11 Number 11

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News

People

CAlendar

MINNESOTA HEALTH CARE ROUNDTABLE

Insurance

Flexible spending account$

By Linda Heuer, MBA, RPA

PERSPECTIVE Kathleen Sebelius U.S. Dept. of Health and Human Services

10 QUESTIONS Israel Sokeye, MD PrairieCare

22 26 30

Take Care

Winter bicycling By Jason Tanzman

SPECIAL FOCUS: Cardiology

Caregiving How to obtain home care

By Jennifer Sorensen, MEd

Hospitals

Reducing readmissions By Howard Epstein, MD, FHM, Tania Daniels, PT, MBA, and Janelle Shearer, RN, MA

Policy

Cancer’s nonmedical challenges By Lindy Yokanovich, Esq.

Oncology

Testicular cancer

By Liangping Weng, MD

Heart attack warning signs By Elizabeth Klodas, MD

Prevent heart attacks By M. Nicholas Burke, MD

FOrty-First Session

Post-acute care Fixing cracks in the system

Thursday, April 17, 2014 1:00–4:00 PM, Symphony Ballroom Downtown Minneapolis Hilton and Towers

Background and focus: Postacute care is becoming an increasingly important component of health care delivery. It is also becoming increasingly community-based. Medical advances are dramatically expanding the range of access to these services and, at the same time, creating a larger number of problems providing them. Choppy access to electronic medical records and ensuing medication management complications, as well as problems with care team coordination, can impede the goal of improving outcomes while lowering costs.

Objectives: We will discuss the evolution of post-acute care and illustrate the dynamic potential it holds. From the hospital to the physician to skilled nursing, rehab, and home care, we will present perspectives from across the care continuum. We will investigate communication problems between care team members and present potential solutions. We will examine how elements of health care reform like ACOs and insurance exchanges can drive both improvement in and higher utilization of post-acute care. We will discuss the tools that are necessary for post-acute care to reach its full potential.

www.mppub.com Publisher Mike Starnes | mstarnes@mppub.com Senior Editor Donna Ahrens | dahrens@mppub.com ASsociate Editor Janet Cass | jcass@mppub.com Assistant Editor Jennifer Hollingsworth-Barry | jhb@mppub.com Art Director Alice Savitski | asavitski@mppub.com Office Administrator Amanda Marlow | amarlow@mppub.com Account Executive Iain Kane | ikane@mppub.com

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Minnesota Heath 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 are opinions expressed by authors of published articles are solely those of the authors and do publications. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business or other professional advice and counsel. No part of the publication may be reprinted or reproduced within written permission of the publisher. Annual subscriptions (12 copies) are $36.00/ Individual copies are $4.00.

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November 2013 Minnesota Health care news

NEWS

Campaign Targets Unnecessary Medical Treatment A campaign called Choosing Wisely Minnesota has kicked off efforts to spur conversations between health care consumers and providers about goals and treatment plans, in order to reduce unnecessary and costly medical tests and treatments. Choosing Wisely began as a national campaign two years ago, and was developed in Minnesota over the past year as a collaborative effort of the Institute for Clinical Systems Improvement, the Minnesota Health Action Group, and the Minnesota Medical Association. Collaboration partners include doctors, health policy experts, and large employers across the state. The collaborative group has identified 11 tests and procedures that may be overused, chosen from 135 that were determined by American medical associations to incur unnecessary costs and

risks. Recommendations cover areas such as inducing labor prematurely, removing benign artery blockages, and the use of antibiotics for sinus infections. “Over the years … we’ve focused on trying to achieve certainty about a diagnosis. The fact of life is that diagnoses are always at least a little bit uncertain … So, we have ordered lots and lots of tests without thinking about the downside, and the downside isn’t just the cost. The [tests] can actually be harmful,” says Thomas Kottke, MD, a cardiologist and HealthPartners executive who helped determine recommendations for the 11 tests/procedures. Members of Choosing Wisely believe that they will not see progress toward their goals unless they can get doctors and patients to talk candidly about their health care treatment and goals. A recent survey showed that 70 percent of doctors felt they had been pressured by patients to perform tests and procedures they wouldn’t have recommended otherwise, illustrating the need

for better communication and understanding in the doctor/patient relationship.

tion rate, while only 20 percent of ZIP codes with incomes below $35,000 reached that same rate.

The state coalition kicked off education efforts in October, offering a webinar to doctors about inducing premature labor and launching a campaign aimed at health care consumers to encourage them to make knowledgeable decisions, together with their providers, about tests and procedures.

Researchers say it is unclear why lower income Minnesotans were less inclined to receive the free vaccine, though speculations have been made that transportation limitations and not being able to take time off from work may have been deterring factors.

MDH Study: ZIP Code, Vaccine Use Associated People living in statistically wealthier Minnesota Zip codes during the 2009 H1N1 pandemic were more likely to have been vaccinated, according to researchers from the Minnesota Department of Health (MDH). Study results showed that 40 percent of ZIP codes with median family incomes above $50,000 had at least a 25 percent vaccina-

Kris Ehreseman, MPH, director of infectious disease at MDH, said of the vaccine, “As pandemics go, it was milder. If you’re in a situation … where you have competing priorities for your time and energy—your job or housing or food—and you’re not seeing people falling over from the disease, it may be more difficult for you to prioritize.”

New Blood Pressure Test May Increase Diagnostic Accuracy A new study by Allina Health tested the accuracy of 24-hour blood

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 November 2013

Researchers are seeing increasing evidence that routine, point-in-time blood pressure readings can lead to overdiagnosis of high blood pressure in up to 20 percent of patients whose numbers rise at their appointment due to appointment-related anxiety. Underdiagnosis is also occurring for those who have hidden hypertension that isn’t detected. “The reality is [that] your blood pressure fluctuates day to day, hour to hour, minute to minute. And those fluctuations are important,” says David Ingham, MD, of Allina’s Center for Outpatient Care. The new method has been used to test the blood pressure of more than 1,000 patients in the Twin Cities over the past year. Patients are equipped with a wireless monitor that takes their blood pressure every 20 minutes, for 24 hours, and tracks the scores for assessment by their doctors. For some patients, the new testing format has provided results that contradict those of their routine blood pressure checks at a health care facility, and either eliminate or confirm a need for medication. The U.S. Preventive Services Task Force is currently reviewing its stance on high blood pressure prevention and the role 24-hour monitoring could play. However, updated guidelines would not be announced for two to three years, says Karen Margolis, MD, MPH, a member of the task force’s blood pressure screening committee. If the device is recommended, the likelihood of its use in primary clinics will increase.

U of M Receives $5.7M Grant to Fight HIV The National Institutes of Health has awarded a $5.7 million grant to the University of Minnesota to test a new treatment for human immunodeficiency virus (HIV). Researchers at the university will perform clinical trials of the new approach over the next two years. An FDA-approved drug

called losartan will be used in an attempt to reverse inflammatory damage caused by HIV replication in lymphatic tissues. The hope is that the antifibrotic and anti-inflammatory properties of the drug will allow immune cell levels to be restored to what is necessary for normal immune responses. Losartan is currently used as a treatment for high blood pressure in selected patients. However, the drug was found to have rare anti-inflammatory properties that could lead to a breakthrough in HIV treatment. Officials say if the trial is successful, the new drug could boost immune function in patients with HIV and protect them from diseases associated with chronic inflammation such as heart attacks, blood clots, and cancer, leading to longer lifespans.

Antibiotic Resistance Urgent, Study Says A recent report by the Centers for Disease Control and Prevention (CDC) highlights an increasing threat of antibiotic resistance in the United States. The study found that more than 2 million people get sick, and at least 23,000 people die, from antibiotic-resistant infections each year in the U.S. “For the first time, we have a snapshot of antimicrobial threats that have the most impact on human health,” said CDC Director Thomas Frieden, MD, MPH. Seventeen antibiotic-resistant bacteria and one fungus cause the vast majority of these infections. The CDC categorizes drug-resistant superbugs as urgent, serious, or concerning, based on their current threat level. Three bacteria have been classified as urgent threats. Carbapenem-resistant Enterobacteriaceaem, or CRE bacteria, causes more than 9,000 infections in the U.S. each year and is fatal in up to 50 percent of patients. In Minnesota, 93 cases have been reported, half of which have occurred since December 2012, resulting in 12 deaths. Clostridium difficile causes up to 14,000 deaths and 250,000 hospitalizations in the U.S. annually. In News to page 6

Telephone Equipment Distribution (TED) Program

pressure monitoring devices versus that of conventional routine blood pressure tests, and says the new approach could give more reliable diagnoses to thousands of patients.

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

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

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PERSONAL to us.

Personalized Assisted Living goes a long way toward optimizing the daily quality of life for our residents. If you have a loved one that needs a friendly environment with a personalized care plan designed just for them, call or visit a Brookdale Community near you. Because caring for our residents is what we do, and it’s always personal to us.

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November 2013 Minnesota Health care news

News from page 5

central Minnesota, a surveillance project confirmed more than 1,400 cases of C. difficile, including 23 deaths from it, over a fouryear period. Neisseria gonorrhoeae infects up to 820,000 people each year and, according to state officials, its incidence is rising in Minnesota. Rates may be higher than reported, however. According to CDC officials, the numbers are purposely underestimated. The CDC’s findings are based on deaths that were a direct result of a drug-resistant bacterial infection. The report notes that overuse and misuse of antibiotics are largely to blame for this growing public health issue, with as many as half of all prescribed antibiotics deemed unnecessary or misused. State officials supported the CDC’s findings and endorsed its efforts to reduce the incidence of antibiotic resistance. In a press release from the Minnesota Department of Health, State Epidemiol-

ogist Ruth Lynfield, MD, noted, “We have worked extensively with our partners in public health and patient care to identify and control the spread of antibioticresistant infections. However, we need to continue to work on this issue aggressively, and we need everyone’s help.”

Fairview Announces New CEO Rulan F. Stacey, PhD, FACHE, has been appointed chief executive officer at Fairview Health Services. He previously was president of University of Colorado Health, which has a partnership with an academic medical center similar to the relationship between Fairview and the University of Minnesota.

Minnesota Fourth in Low-Income Care The Commonwealth Fund, a private research foundation, recently

released the Scorecard on State Health System Performance for Low-Income Populations 2013, which ranked states based on 30 indicators within four categories. The report ranked Minnesota fourth overall behind Hawaii, Wisconsin, and Vermont. These states ranked in the top 50 percent for most of the 30 indicators, particularly those in the areas of access, treatment, and prevention. They also had some of the lowest rates of uninsured adults, contributing to more positive health outcomes. Mississippi was the lowest ranked overall, and Louisiana and Oklahoma tied for 49th place. Between the highest and lowest ranked states, the report showed up to a fourfold disparity in performance on several key health care indicators for lowincome populations. Differences among states were most pronounced in the areas of affordable access to care, preventive care, dental disease, prescription drug safety, potentially preventable hospitalization, and premature death. Rates of hospital admis-

sions for diabetes complications or respiratory disease in lowincome adults were four times higher in the lowest ranked states. The report also showed more than an eightfold spread between the highest and lowest ranked states in rates of hospitalization for asthma in children living in low-income communities. The report also identified a strong correlation between states’ rates of hospitalization among nursing home residents and how well the health care needs of low-income populations were served. One indicator for the study analyzed the percentage of nursing home residents hospitalized within a 30-day period, in which Minnesota was ranked the highest for its rate of 7 percent. Researchers estimate that if all states could reach the standards set by leading states, 86,000 fewer people would die prematurely in the U.S., and tens of millions more adults and children would receive timely preventive care.

A One Stop Shop for Minnesota Seniors

Call to get helpp with: with s Planning for long-term care s Remaining independent in your community s Arranging for in-home services s Getting help from state agencies s Becoming involved in your community

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Minnesota Health care news November 2013

PEOPLE

Yun Shin Chun, MD

Yun Shin Chun, MD, FACS, has joined Allina Health’s Virginia Piper Cancer Institute, Minneapolis, as a staff surgeon and medical director of hepato-pancreato-biliary programs. Previously a staff surgeon and assistant professor at Fox Chase Cancer Center, Philadelphia, she earned a medical degree from New York Medical College, received general surgery training at Mayo Clinic, and completed a surgical oncology fellowship at M.D. Anderson Cancer Center, Houston.

Thomas Ortmeier, MD, board-certified in anatomic and clinical pathology, has joined Essentia Health–St. Joseph’s Medical Center, Brainerd. Ortmeier earned his medical degree and completed a pathology residency at the University of South Dakota School of Medicine, Vermillion. Kristin Knopke, MD, has joined the critical care department at Essentia Health–St. Mary’s Medical Center in Duluth. She earned her medical degree from the University of Minnesota and served a residency in anesthesia and a fellowship in critical care at the University of Iowa Hospitals and Clinics in Iowa City. Also joining Essentia is Ross Perko, MD, a boardKristin Knopke, certified pediatric hematologist and oncologist at Essentia’s MD Erick Peter Person Children’s Cancer Center, Duluth. He completed his medical degree and residency at the University of Minnesota and his fellowship in pediatric hematology and oncology at St. Jude Children’s Research Hospital, Memphis. Ross Perko, MD John Silkensen, MD, has been named medical director of the kidney transplant program at Hennepin County Medical Center (HCMC), Minneapolis. Silkensen graduated from the University of Arkansas College of Medicine, Little Rock, and completed an internal medicine residency and nephrology research fellowship at the University John Silkensen, of Minnesota. Christine Tompkins, MD, has joined HCMC’s pediatrics deMD partment. Tompkins graduated from the University of Nebraska Medical Center, Omaha; completed a residency in pediatrics at the University of Connecticut, Farmington; and completed a fellowship in pediatrics at Brown University, Providence, R.I. James Wetmore, MD, has joined HCMC’s nephrology department. He earned a medical degree from the University James Wetmore, of Texas Southwestern Medical School, Dallas; MD completed an internal medicine residency at the University of Alabama, Birmingham; and served a nephrology fellowship at the University of California, San Francisco.

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

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www.schellerlegalsolutions.com November 2013 Minnesota Health care news

Perspective

Your government at work Improving health through care delivery reforms

H ow is the Department of Health and Human Services (HHS) working to improve health care quality and patient safety while reducing the growth of health care costs?

Kathleen Sebelius U.S. Department of Health and Human Services Kathleen Sebelius is secretary of the U.S. Department of Health and Human Services (HHS). She is a former governor of Kansas and served as Kansas insurance commissioner from 1995 to 2003. She also served as a member of the Kansas House of Representatives from 1987 to 1995. Sebelius has overseen implementation of the Affordable Care Act, the largest federal health reform measure to be enacted since Medicare and Medicaid were signed into law nearly 50 years ago. As HHS secretary, Sebelius is overseeing a range of new regulations and taxes, expanded coverage through Medicaid and insurance exchanges, and sweeping new consumer protections. The health care law aims to bring health care coverage to 34 million uninsured Americans.

Under the health care law, we’re changing the incentives to reward providers who deliver the best quality of care, instead of just a higher quantity of care, and these changes are already making a difference. We’ve seen changes in care delivery on a broad scale.

Opportunities to eat right and exercise should be readily available to all Americans.

For example, after holding steady for years, hospital readmissions in Medicare have fallen significantly in the past year, resulting in an estimated 70,000 fewer return trips to the hospital with dangerous and costly complications. We’re starting to see health-care cost growth slow because of the Affordable Care Act and that’s something we’re going to continue to build on. P revention and wellness are topics at the top of HHS agendas. What are some outcomes of this focus? We know that a focus on prevention will offer our nation the opportunity to improve the health of Americans and control health care spending. To improve our health, the healthy choice should be the easy choice. Opportunities to eat right and exercise should be readily available to all Americans. Economic, social, and physical factors are all leading too many Americans to engage in behaviors that lead to poor health, such as tobacco use, poor diet, and physical inactivity. That is why we’re investing in prevention programs that meet Americans where they live, work, learn, and play. The Affordable Care Act creates a new Prevention and Public Health Fund designed to expand and sustain the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe. Through the fund’s Community Transformation Grants, communities nationwide are supporting core public health activities and implementing community-based strategies to address chronic diseases such as heart disease, diabetes, and cancer. Current projects are expected to improve the health of more than 40 percent of our citizens—about 130 million Americans. Projects supported by the fund include the “Tips from Former Smokers” media campaign, which

features people discussing the health effects they’ve experienced as a result of smoking. In 2012, calls to state smoking quitlines went up by 132 percent. The fund also supports the National Diabetes Prevention Program, a public-private partnership connecting people at risk of developing type 2 diabetes with a lifestyle coach in a group setting offered through community-based organizations, wellness centers, and faith-based organizations. The program’s goal is to reach 15 million people with prediabetes by 2020 and to prevent them from developing type 2 diabetes or to diagnose them early in order to avoid long-term health complications.

Minnesota Health care news November 2013

T ell us about some of the public-private collaborations HHS is promoting. One great example is Million Hearts, which was launched in 2011 with the goal of preventing 1 million heart attacks and strokes by 2017. It’s a national initiative that brings together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners to fight heart disease and stroke. We also have Partnership for Patients, a program working to improve the quality, safety, and affordability of health care for all Americans. This is a collaboration between hospitals, providers, patients, advocates, and the federal and state governments. There are over 3,700 participating hospitals in the program that are focused on goals like preventing hospital-acquired conditions and reducing readmission rates. H ow is HHS promoting adoption and meaningful use of health information (IT)? Health IT is critical to improving efficiency, promoting health, and especially lowering costs. Smart data and analytics help providers streamline care and avoid errors. Four years ago, just two in 10 doctors and one in 10 hospitals used electronic health records (EHRs), even though they’ve been around for years. Now, more than half of all doctors and other eligible providers have received Medicare or Medicaid incentive payments for adopting or meaningfully using EHRs. HHS has met and exceeded its goal for 50 percent of doctor offices and 80 percent of eligible hospitals to have EHRs by the end of 2013.

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Frequent Bathroom Trips? Men: Bell Ezee Flow Tea #4A is nature's nutritional support for urinary comfort, balance and ease. <Helps maintain urinary flow, frequency and comfort, with a good night’s sleep. <Guaranteed to make urine flow easier again.* Relief from dribbling, discomfort, burning, urgency, poor flow.* <Formulated using many herbs, such as chamomile, cranberry, willow flower, saw palmetto and many more. <We have had thousands of satisfied repeat customers. <Tastes great hot or cold! <I feel like another person with no more frustrations! It is phenomenal! It’s unbelievable. I'd like to thank Bell. I will get other Bell products. Thank you again! Richard Dorvilus, 55, Elmont, NY. <Ezee Flow tea gave back good sleep and health! I feel like I'm 30 years old. During the night I hardly have to go to the toilet anymore. What a feeling. Because I sleep well, I'm not tired anymore during the day. "Old age" was bearing down on me. Now I feel great again and healthy. Jerry H. Cole, 73, Lansing, IL. <I'm truly amazed and relieved. After just 2 weeks of drinking the Bell Ezee Flow Tea I no longer have to get up during the night. I'm enjoying a normal sex life. This product is so incredible. I enjoy drinking the tea. I hope that a lot of men with a pride issue give this a shot. It's difficult to express how delighted I am. Clarence A. Rehrig, 58, Allentown, PA.*

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SALES PERSON : Omar

Publication: Minnesota Health News

10 Q u e s t i o n s

Child and adolescent psychiatry Israel Sokeye, MD Dr. Sokeye is a board-certified psychiatrist specializing in treating children and adolescents. He practices with PrairieCare, an organization providing inpatient psychiatric care to children and adolescents and outpatient care to patients of all ages at three locations in the Minneapolis–St. Paul area.

What are some common reasons parents decide that a child needs to see a psychiatrist? One common reason involves behavioral issues at home or in school, such as a youth that becomes increasing irritable, easily angered, socially withdrawn, avoidant, and has declining academic functioning. Can you share some examples of how children benefit from psychiatric counseling? Counseling can help children manage anxiety and depression and build social skills. Children who’ve experienced trauma benefit from trauma-focused cognitive behavioral therapy that helps them process the trauma. Other therapies help children problem-solve stressful situations. Studies demonstrate that incorporating counseling into treatment hastens improvement of symptoms. How does child psychiatry differ from adult psychiatry? Children are treated with a developmental framework in mind: Certain symptoms may not be pathological at certain developmental ages. For example a hyperactive, impulsive, inattentive, aggressive five year old with developmental delays may not necessarily be diagnosed with ADHD despite having several symptoms of the disorder, due to the fact that developmentally, the child is at age two. Also, children metabolize drugs differently than adults and thus may require higher doses of drugs or more frequent dosing than adults. Lastly, information from school and other care providers is crucial for appropriate diagnosis and treatment because one of the most common responses from a teenager, when asked ‘Why you are here?’ is, ‘I don’t know!’ Please tell us about medication’s role in child psychiatry. Counseling plus medication is more successful than medication alone or therapy alone. Medications have been known to help children with significant self-harm and aggressive behaviors stay calm, as in the case of children with autism, thereby allowing them to learn skills. Historically, the advent of antidepressants coincided with fewer suicides. How does a child psychiatrist interact with counseling professionals available through school channels? We consult with school staff to help them problem-solve. We may observe youths in the classroom and provide recommendations to staff. Sometimes schools refer youths for counseling. The most comprehensive interaction is through a school mental health clinic. This allows the psychiatrist to evaluate the child in the school setting with collaboration from the school’s psychologist, social workers, and nurses, and to treat the child and family. We typically connect with a patient’s school to obtain information about the child’s functioning and academic struggles. After treating a child for a while, we ask the school for an update on his/her school progress. Please tell us how a youth’s family is integrated into therapy. Family involvement is crucial to the child’s participation and likelihood of success. It’s essential to build rapport with youth and family. Understanding family dynamics is integral to building rapport. If, for example, the patient is the family scapegoat, chances for therapeutic success are limited without integrating the family. We touch base with families regularly, especially for teen patients. Educating youth age 15 and older and their families about confidentiality is critical to successful therapy.

Minnesota Health care news November 2013

Some estimates place the number of children receiving psychiatric care as low as 20 percent of those who need it. What can you tell us about this? The Centers for Disease Control and Prevention (CDC) reported in May 2013 that annually, up to one in every five U.S. children experiences a mental disorder. Sadly, too few receive psychiatric care. Reasons range from poverty and lack of affordable health care to the shortage of children’s mental health providers. The Affordable Care Act made it easier for people going into this field to repay school loans. The number of advanced practice nurses in psychiatry has grown. However, there are approximately 7,000 child and adolescent psychiatrists in the United States, and to adequately treat the target population we need about 30,000. Child psychiatric services in this country are severely maldistributed. Rural children have significantly reduced access. The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.1 in Alaska to 21.3 in Massachusetts, with an average of 8.7.

specific setting (such as a community clinic oriented to specific cultural groups) are more likely to keep appointments and adhere to treatment. Please tell us about cutting-edge research in child psychiatry. There has been more focus on early, accurate identification of mental illnesses, with significant advancement in understanding autism and ADHD. There’s increasing use of touch screens, computers, and gaming systems to diagnose and treat these disorders. For example, research is exploring the use of a gadget that helps kids on the autism spectrum recognize facial expression. Another example is a gaming system whose ability to monitor the speed, rate, reaction time, and accuracy of response of a child playing a computer game may be used to diagnose disorders like ADHD, autism, and depression. This system may someday be used in intervention and treatment. Ongoing research also includes attempting to match an individual’s genetic information to specific medications and treatment that will be most beneficial.

Up to one in every five U.S. children experiences a mental disorder.

Help us understand the intersection of minority/cultural issues and behavioral problems in providing treatment. Treating minority children should be contextual and integrative, addressing psychosocial and cultural needs as well as psychological and biological ones. Clinicians should support parents in developing appropriate behavioral management skills in keeping with their cultural values and beliefs. It is important for providers to know the limits of their knowledge and skills rather than to reinforce damaging stereotypes and overgeneralization. For example, hearing the voice of a deceased relative, especially during bereavement, may be congruent with the patient’s cultural identity and should not be automatically misdiagnosed as auditory hallucination. In addition, misdiagnosis is not uncommon for certain cultural backgrounds. For example, studies show that clinicians who are not African American or Asian American may have a tendency to overdiagnose schizophrenia in people who are of those backgrounds. However, it is not clear if this represents a true difference among racial groups or clinician bias/cultural insensitivity. Youth treated by a clinician from the same culture and in a culturally

Please offer our readers advice to help them recognize if their children may need mental health care. Identifying mental illness early enhances successful outcomes. Children can become at risk for this disorder during periods of change, including divorce, school transitions, moving, a loved one’s death/bereavement, and after trauma. External symptoms can include irritability, anger, aggression, quickly changing moods, and hyperactivity. Other symptoms can be harder to identify: withdrawal, isolation, crying, guilt, and suicidal ideas. Be proactive by keeping communication channels open, especially with teenagers. It is important to try and understand the child, rather than seeking to be understood by the child. This means refraining from being overly reactive or quick to label the child. Be aware of the child’s change in functioning, monitor for safety concerns, and seek immediate help if you feel it’s needed. Call your primary care provider and request an evaluation whenever you’re concerned.

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Our Children’s Mental Health Clinic provides families the treatment and strategies they need when a child is stuggling emotionally. Psychological Testing & Consultation • Preschool Day Treatment Individual, Group & Family Therapy • Skills Training • and more

Learn more:stdavidscenter.org/mentalhealth • 952.548.8700

Questions? Please contact our Admissions Coordinator Kelly Emerson at 651-632-8842 3395 Plymouth Road, Minnetonka, MN, 55305

November 2013 Minnesota Health care news 11

Winter bicycling Ditch the car By Jason Tanzman Fear not. While it may be hard to see yourself as a winter cyclist, here’s the key: Barriers to cold-weather bicycling are more mental than tactical. The starting point is realizing that you can ride for most of the winter. Here are tips and techniques to help you stay safe and comfortable on your bike this winter. Equipment Lights Good-quality lights are critical for winter riding since you’ll be riding in the dark more often. Shorter days mean that the ride home from work at 5 p.m. that was in the middle of the afternoon last August takes place in darkness at the same time in December or February. Furthermore, usable road space shrinks in the winter as snow accumulates and cars park further into thoroughfares. This means cyclists and cars are in closer proximity, and you want cars to see you. Lastly, visibility is significantly decreased when it snows, even a little bit. Extra-bright flashing lights should be on the front and rear of your bicycle. Helmet lights enhance visibility too. There are many options for good-quality battery-powered lights. Check the lights periodically and be sure to recharge or replace batteries when they start to weaken, which happens more quickly in cold weather. Clothing Ironically, you’re more likely to overheat and become drenched in sweat than you are to be cold. To avoid sweat’s discomfort (and potential danger from hypothermia), dress in layers. Start by wearing a sweat-wicking base layer next to your skin, and end with an outer layer that is wind- and water-resistant. The number of layers in between will vary depending on whether it’s 30 degrees or zero degrees outside. After a few rides you’ll figure out how many layers you need. Wear a fluorescent outer layer to further increase your visibility. Avoid frostbite Protect extremities: fingers, ears, nose, and feet. Gloves or mittens should be warm enough for whatever temperature conditions you’re riding in, while allowing your hands enough dexterity to handle the

Minnesota Health care news November 2013

Cyclist photo courtesy Transit for Livable Communities, St. Paul, MN

hen I think about winter bicycling, here’s the image that comes to mind: an intrepid soul, nose dripping with icicles, grimly pedaling against a 20 mile-per-hour headwind with snow blowing and swirling across the road and giant snowdrifts piled high on sidewalks and parking lots.

bicycle safely and confidently. When the temperature goes below about 45 degrees, I wear a hat that covers my ears and fits underneath my helmet. Below about 20 degrees, I add a balaclava that covers my face and nose. Wool socks can help keep your feet warm. Doubling up your socks can provide extra warmth for those cold days, but make sure your boots are loose enough; too-tight boots restrict blood flow and put your feet at risk of frostbite. If you ride with toe clips, consider winterspecific cycling footwear. Many cyclists switch from toe clips to regular boots for winter riding.

therefore save you a sizeable sum. Not only that, it can benefit your health as well as your bank account.

The Midtown Greenway is plowed regularly throughout the winter.

Studded tires Studded tires help the bike grip the road under icy conditions and typically have between 100 and 300 steel or carbide studs inserted all around each tire. These tires are a good idea even for people who only ride a moderate amount in the winter. That’s because, even on a sunny, 25-degree January day, there may be patches of ice on the road. Studded tires aren’t cheap—they cost between $100 and $150 per pair—but gas savings and improved health will more than make up for the cost. However, no matter which type of tires is on a bike, a rider needs to adjust riding technique to manage ice and snow.

Commuting by bike burns up an average of 540 calories per hour (British Journal of Sports Medicine, 2007). Bike commuters report lower stress than car commuters, according to U.K. think-tank New Economics Foundation (2011). By 2017, residents of Portland, Ore., will have saved an estimated $64 million in health care costs due to bicycling (Journal of Physical Activity and Health, 2011). Bicycling significantly reduces the risk of dying from heart disease (European Journal of Preventive Cardiology, 2012).

And, commuters to McGill University in Montreal were more satisfied with their commute if they bicycled than if they drove or took mass transit—even during the winter (Transportation Research, 2013). So reduce your expenses and improve your health by riding a bicycle throughout the year! Jason Tanzman is the co-executive director of Cycles for Change, a nonprofit organization in St. Paul that promotes bicycling as a healthy, affordable transportation choice.

Technique Handling Whether you’re on ice or snow, it will take longer for you to stop. Start braking sooner than you would on dry roads, plan for an increased stopping distance, and take turns more slowly. Route planning You may need to vary your customary route based on specific weather conditions. For example, it can be worthwhile to go a bit farther out of your way to ride on a bike trail like the Midtown Greenway, which is plowed regularly throughout the winter and often is cleared more quickly after a snowfall than are many streets. Since side streets sometimes are not plowed promptly, it may make sense to ride more on main streets during the winter. Repairs Be prepared to address mechanical breakdowns or flat tires. Cold weather and reduced visibility makes roadside repairs a bit more difficult than during the summer, so make sure your bicycle is in sound working condition before riding, especially if you plan to bicycle in a comparatively desolate location. Be willing to put your bike on a bus and take it home or to a bicycle shop for maintenance, rather than trying to repair it when it’s zero degrees outside. Plan to reap benefits You can extend autumn bike riding a little bit longer into the winter without having to be a hard-core athlete, but it’s a good idea to build up to it slowly. Riding weekly through the summer into the fall is a great way to practice handling the seasonal challenges of cold rain, diminished daylight, snow, ice, and cold temperatures. The average car owner in Minnesota spends approximately $8,000 per year owning, maintaining, and fueling a vehicle, according to the U.S. Bureau of Labor Statistics (2011). Bicycling can November 2013 Minnesota Health care news

C a r d i o lo gy

Heart attack

war n i n g s i g n s Pay attention to your body By Elizabeth Klodas, MD

eart attacks come in many shapes and sizes. However, some symptoms are more common than others and should prompt immediate attention. This is especially true if you have risk factors for coronary artery disease or have been told by your physician that you have coronary artery blockages.

Common symptoms A “typical” heart attack is often described as producing one or more of the following symptoms. 1. U nrelenting pressure in the center or left part of the chest. Pressure can be quite severe, “like someone sitting on my chest.” 2. Left arm discomfort 3. Neck discomfort 4. Shortness of breath 5. Sweating 6. Nausea (or even vomiting) 7. A sense of doom or that something is not right

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Although many heart attacks produce these symptoms, variations can—and do—exist.

Uncommon symptoms 1. One variation is that someone does not experience all of the common symptoms. People can have just one of the symptoms, such as left arm pain or shortness of breath. Or, they might experience any combination of the common symptoms, with varying intensities of any of the individual symptoms. 2. Another variation is that someone experiences none of the typical symptoms, but rather, something quite different. This can include

Minnesota Health care news November 2013

pain in both arms, pain in only the right arm, upper back pain, jaw pain, heartburn, or profound fatigue with no other symptoms. Women and diabetics are more likely to experience these atypical symptoms. 3. Finally, some heart attacks are “silent.” This means that someone had no obvious symptoms even though heart muscle was damaged. Under these circumstances, the heart attack is discovered incidentally after the fact. Although diabetics are especially vulnerable to this situation, silent heart attacks are nevertheless quite rare.

Points to remember If symptoms represent a heart attack: 1. Symptoms are usually unrelenting. 2. All of the sensations are above the waist. 3. Symptoms are often accompanied by a sense of foreboding. That’s why chest discomfort that lasts for a few seconds is very unlikely to indicate a heart attack. Unrelenting pain below the belly button is also unlikely to represent a cardiac cause (but may still require medical attention).

Is it happening to me? Because fatigue, heartburn, and arm pain are pretty common, and because not every chest pain represents a heart attack, here are some additional things to keep in mind if you are concerned about what you are feeling.

toms p m y s Some prompt should attention. iate d e m they last m i

over 30 minutes, they are still unlikely to be due to a heart attack. Similarly, if you benchpressed a new personal record or chopped wood yesterday, today’s arm pain is unlikely to be heart-related. 6. Nevertheless, it’s better to be safe than sorry. Listen to the signals that your body is sending you. If what you’re feeling is different, worrisome, without an obvious cause, and unrelenting or recurrent, get yourself checked out. After all, what’s the worst thing that can happen? You could find out it’s not your heart.

When in doubt … People are sometimes reluctant to seek medical attention because they “don’t want to look stupid” or “don’t want to cause a fuss” or because they “can’t believe it could happen to me.” Heart attacks are life-and-death situations. If you’re at risk and you’re experiencing symptoms that are worrisome to you, the sooner you get evaluated, the better. Elizabeth Klodas, MD, is a board-certified cardiologist in private practice at Preventive Cardiology Consultants in Edina. MSA - MN Healthcare July 2013.pdf

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1. If you are someone who has experienced a heart attack before, chances are very high that another heart attack will feel very similar to your previous one. 2. If you already have symptoms related to known coronary artery blockages (like chest pain or shortness of breath with exercise), chances are very high that you will experience these same symptoms during a heart attack. The symptoms won’t go away like they usually do with rest or nitroglycerine use, and they may be more profound than usual and/or accompanied by additional symptoms (like nausea or sweating). 3. If you have risk factors for heart disease and you are experiencing new symptoms that are not going away (especially after 30 minutes), and especially if the sensations are above the waist and have you thinking that “something is just not right,” the symptoms may represent a heart attack and you should seek medical attention right away. 4. If you have no known risk factors for heart disease and you are experiencing new symptoms that are not going away (especially after 30 minutes), and especially if the sensations are above the waist and make you think that “something is just not right,” the symptoms are much less likely to represent a heart attack than in the above scenarios, but you should still seek medical attention for further evaluation. 5. All symptoms need to be put into context. If you are prone to heartburn, just ate a meal that typically upsets your stomach, and experience your typical heartburn symptoms, even if November 2013 Minnesota Health care news

c a r d i o lo gy

Prevent heart attacks What you can do By M. Nicholas Burke, MD

ant to avoid a heart attack? Good idea.

Cardiovascular disease, including heart attacks, D ta HealthCare News is the leading cause of death in the United States. er 2013 IssueAccording to the federal Centers for Disease Control and

Prevention (CDC), 24 percent of U.S. deaths in 2010 were attributable to cardiovascular causes. That’s almost 800,000 deaths annually, more than were caused by all types of cancer. So if you want to avoid dying early, focusing on preventing cardiovascular disease is a good bet.

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Minnesota Health care news November 2013

What is it? Heart attacks, also known as myocardial infarctions, are generally the result of plaque buildup in blood vessels. Plaque contains fat and cholesterol, and when it accumulates it causes vessels to narrow, which can impair blood flow. For reasons that are only partly understood, plaques can develop inflammation. When this happens, the plaque can break open, causing blood to clot. If a clot is large enough it will stop blood flow entirely, resulting in a heart attack. Who is at risk? Nationwide, in 2010, 225 men and 143 women per 100,000 people died from cardiovascular disease. In Minnesota, however, those numbers were substantially lower, at 155 men and 91 women per 100,000. In fact, only 18 percent of Minnesota deaths are due to cardiovascular disease, which is the lowest rate in the nation. We are the only state in the nation in which cardiovascular disease is not the leading cause of death. Risk factors Why is Minnesota doing so well compared to the rest of the country? There is no single reason for this; rather, it is likely a combination of several factors. Genetics play a large role, but this doesn’t explain our better chances when we are compared with our neighboring states. Factors in our favor include the fact that our population is relatively well educated, which correlates with better health. In addition, Minnesota has strong anti-smoking legislation and our health care, on the whole, is excellent.

The bad news is that for some people, the deck is stacked against them. There is nothing that can be done about two significant and related risk factors: genetics and family history. Nonetheless, you still can improve your odds significantly. As an individual, there is a great deal that can be done to lessen your chances of a heart attack and dying from cardiovascular disease. Some preventive steps can be taken on your own, while some might require the help of a health care professional. Prevention Lifestyle. First and foremost, DONâ&#x20AC;&#x2122;T SMOKE. Smoking dramatically increases your chance of developing cardiovascular disease AND it makes it occur at an earlier age. The reasons for this are many. Smoking damages the protective layer of cells that lines the inner surface of the blood vessels. This damage makes it easier for cholesterol to enter the walls of the blood vessel, which causes plaque buildup. Additionally, smoking makes the blood more likely to form clots. Diet. Eating a healthy diet is one of the main things that you can do to decrease your chances of cardiovascular disease. Most people have a general idea of what a heart-healthy diet looks like: rich in vegetables, fruits, whole-grain and high-fiber foods, fish, lean protein, and fat-free or low-fat dairy products. The American Heart Association (AHA) recommends five general dietary goals:

Blood pressure. High blood pressure, or hypertension, is a very strong risk factor for the development of cardiovascular disease. It is generally defined as resting blood pressure consistently higher than 140/85. High blood pressure becomes more common with increased age. Several lifestyle factors can affect blood pressure, including being overweight and a diet high in sodium. Frequently, it is impossible to lower blood pressure adequately without medications. Fortun-

Smoking dramatically increases your chance of developing cardiovascular disease.

ately, medical therapy for hypertension has been shown to decrease the risk of cardiovascular disease. Diabetes. As with high blood pressure, the risk for diabetes can be lowered by lifestyle modification, particularly by maintaining a healthy weight. Occasionally, if an obese person loses enough weight, his or her diabetes disappears without any other treatment. Prevent heart attacks to page 19

1. Eat more fruits and vegetables. 2. Eat more whole-grain foods: whole wheat bread, rye bread, brown rice, and whole-grain cereal. 3. U se liquid vegetable oils such as olive, canola, corn, or safflower, and use them sparingly. 4. Eat more chicken, turkey, fish, and beans. Avoid other meats. 5. Read food labels to help you understand what you are eating. Physical activity. The AHA also recommends some degree of physical activity every day. Research has shown you can lower blood pressure, lower cholesterol, and keep your weight at a healthy level by getting at least 30 minutes of physical activity on each of five or more days per week. However, some exercise is better than none. If youâ&#x20AC;&#x2122;re not exercising now, start out slow. Exercising as little as 10 minutes at a time may offer some health benefits. Studies show that people who have achieved even a moderate level of fitness are much less likely to die early than those who have a low fitness level. Weight. Maintaining a healthy weight decreases risk for cardiovascular disease in a number of ways. Being overweight or obese can cause elevated blood pressure and elevated cholesterol, as well as diabetes. People who are overweight also tend to exercise less. November 2013 Minnesota Health care news

November Calendar 7

Lung Cancer Awareness Month

Transition Age Mental Health Workshop

PACER presents a free, interactive workshop, Moving Toward Adulthood: Managing Your Mental Health Needs. Transition-age youth (ages 14–21) with mental health needs who are preparing for life after high school, and their parents, are invited to learn what changes to expect in the mental health system when transitioning to adult services. Attendees will also learn about practical guidelines and resources for post-secondary education, employment, and independent living. Visit www.pacer.org or call (952) 838-9000 to register. Thursday,

Nov. 7, 6:30–9:00 p.m., PACER Center, 8161 Normandale Blvd., Bloomington

Managing Tinnitus

Lakeview Health offers this educational session, “That Ringing in Your Ears: Managing Tinnitus.” According to the American Tinnitus Association, more than 50 million are affected by tinnitus nationally. We will discuss what tinnitus is, what causes it, and how to manage it. Free. Call (651) 430-4697 or visit www. lakeviewhealth.org to register. Thursday,

Nov. 14, 10–11 a.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Deaf and Hard-of-Hearing Multiple Sclerosis Group

TCdeaf.com and the Minnesota Association of Deaf Citizens offers a support group for those who are deaf or hard of hearing and are also living with multiple sclerosis. Join others who understand for lively discussion, valuable information, and to learn ways to cope with challenges. To sign up, contact Colleen at (651) 714-2314 or ckaldundeafms@yahoo.com.

Saturday, Nov. 16, 10 a.m.–12 p.m., Wentworth Library, 199 East Wentworth Ave., West St. Paul

Young Parkinson’s Disease Group for Women

Allina Health offers this support group for women aged 60 and younger who are affected by Parkinson’s Disease. Join this group for resources, opportunities to connect with others who understand, and to share information about living a healthy lifestyle despite the challenges of the disease. Free. To sign up, call (952) 888-1734. Tuesday, Nov. 19, 7–8 p.m.,

Byerly’s Community Room, 13081 Ridgedale Dr., Minnetonka

Each year, about 200,000 people are diagnosed with lung cancer in the United States and almost 160,000 people die from it. The second most common cancer in both men and women, its mortality rate is higher than that of colon, breast, and prostate cancers combined. According to Roswell Park Cancer Institute, between 60 percent and 70 percent of lung cancer patients are diagnosed too late for surgery that could help them. This illustrates the importance of early screening and diagnosis. Up to 90 percent of lung cancer diagnoses are attributable to smoking, says the Centers for Disease Control and Prevention. However, exposure to radon, asbestos, and air pollution, and a family history of lung disease, are also contributing factors. Although smoking is the leading risk factor, the American Lung Association emphasizes that patients should not be blamed for their disease. The best thing you can do to prevent lung cancer? Quit smoking. For free smoking cessation support, call (800) QUITNOW or visit www.smokefree.gov for more information.

Lung Cancer Education and Support Group

North Memorial offers a free support group for those who have been diagnosed with lung cancer. Join others to understand the challenges of a diagnosis and learn to make sense of the challenges. Educational topics include managing fatigue and pain, adjusting to a new way of life, the importance of communication, and coping with treatment. Visit www. northmemorial.com for more information or call (763) 520-5285 to sign up.

Tuesday, Nov. 26, 5:30–7 p.m. North Memorial Outpatient Center Education Center–Birth Room 3300 Oakdale Ave. N., Robbinsdale

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 amarlow@mppub. com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

18 Minnesota Health care news November 2013

Developmental Disabilities Waiver Overview

Hennepin County offers this free educational class for individuals under 65. Come get an overview of Developmental Disabilities Waiver services and the similarities and differences in services provided by licensed and traditional providers. An overview of Consumer Directed Community Support will be presented as well. Registration is required. Call (616) 596-6631.

Wednesday, Nov. 20, 5:30–7:30 p.m., Brookdale Library–Rooms A and B, 6125 Shingle Creek Pkwy, Brooklyn Center

Health Insurance Counseling for Seniors

Hennepin County Library hosts this free seminar in conjunction with the Metropolitan Area Agency on Aging. Certified state health insurance counselors will be available to assist with senior health insurance. Please bring a list of prescriptions and any questions you have related to Medicare, supplemental insurance, or the Part D drug plan. Limited to two couples per session. Register online at www.hclib.org, or call (612) 543-8375. Wednesday, Nov. 20,

12:30–2 p.m. and 2–3:30 p.m., Washburn Library, 5244 Lyndale Ave. S., Minneapolis

Dec.4

After Treatment: Is What I’m Feeling Normal?

Park Nicollet hosts this information session for patients who are nearing the end of, or have already finished, cancer treatment. Many at this stage feel they should be happy, but instead, have feelings of confusion and anxiety. Join others who are sharing similar experiences to learn about common emotional ups and downs, and discuss strategies to anticipate and manage these feelings. Significant others, family members, and caregivers welcome. Free, preregistration required. Call (952) 993-5700.

Wednesday, Dec. 4, 3–4:30 p.m., Park Nicollet Frauenshuh Cancer Center, Carlson Community Room–Ground Floor, 3931 Louisiana Ave. S., St. Louis Park

Dec.7

Food Allergy Resource Fair

The Food Allergy Support Group of Minnesota presents this resource fair, featuring allergy-friendly foods and products, allergy safety information, and doctors who will be available to answer questions. Free, no registration required. Visit www.foodallergysupportmn. org for more information. Saturday, Dec. 7,

9 a.m.–12 p.m., Eisenhower Community Center, 1001 Hwy 7, Hopkins

• Triglycerides: Less than 150 mg/dL

Prevent heart attacks from page 17

Weight is only part of the equation, however, and medications (pills and or insulin) are often required.

Dietary supplements. Many vitamin, mineral, and other supplements have been proposed as beneficial for heart and vascular health, including: Vitamins A, B6, B12, C, E, and D; selenium, calcium, co-enzyme Q10, garlic, and fish oil, among others. For most, there are plausible theoretical reasons why they should be beneficial. Unfortunately, none of these supplements have been proven to be effective.

Cholesterol. Elevated blood cholesterol can be modified by lifestyle modification as well. Both diet and exercise can significantly improve cholesterol levels. Diet can lower LDL (so-called “bad” cholesterol) and exercise can raise HDL (“good” cholesterol). Frequently, medical therapy is needed. Current AHA recommendations for cholesterol management are: • Total cholesterol: less than 200 mg/dL • LDL (bad) cholesterol:

Some exercise is better than none.

1. For someone at low risk for heart disease: less than 160 mg/dL 2. For someone at intermediate risk for heart disease: less than 130 mg/dL 3. For someone at high risk for heart disease (including those with existing heart disease or diabetes): less than 100mg/dL • H DL (good) cholesterol: 40 mg/dL or higher for men; 50 mg/dL or higher for women

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It raises many questions few of us are prepared to answer, such as: • How can I take time off from work? • Can I get help paying bills? • What is the difference between a health care directive and a power of attorney? • Can I keep my health insurance even if I lose my job? • And many others. If you or a loved one is facing cancer, we are here to help.

We are a nonprofit organization funded entirely through grants and donations. Your tax-deductible donations are welcome.

We provide free cancer related legal information on a wide range of topics.

Please visit our web site to find out more: www.cancerlegalline.org

educate.inform.empower

Managing risk pays off The risk of having a heart attack in Minnesota has fallen during the last several years. In 2000, 43 people per 10,000 per year were hospitalized for a heart attack. In 2010, that number was 30 per 10,000.

This decrease in the number of people hospitalized for a heart attack was largely the result of improved management of cardiovascular risk factors, particularly smoking and cholesterol. In fact, estimates the CDC, by paying attention to and managing your modifiable risk factors, you can substantially decrease your chances of developing and dying from cardiovascular disease.

M. Nicholas Burke, MD, is a board-certified cardiologist and the director of cardiovascular emergency programs at the Minneapolis Heart Institute.

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Locally owned and operated distribution Terri Rea – Brand Consultant 612-382-8148 • email terri@TerriRea.com www.terri.wellmedglobal.com November 2013 Minnesota Health care news

Flexible spending account

s the end of the calendar year approaches, your Health Flexible Spending Account (HFSA, sometimes called FSA) is likely the last thing on your mind. Life can get busy around this time of year and, before you know it, we’re watching the ball drop on TV and ringing in the New Year. It is easy to get caught up in the hustle and bustle of November and December, but this year, make a resolution to use up your hard-earned HFSA funds before December 31.

Minnesota Health care news November 2013

How HFSAs work If you have an HFSA, it means that you elected to have some of each paycheck deposited into this type of account. Can’t remember if you chose this? Your employer’s human resources department should be able to tell you. The way an HFSA works is this: You incur a health-related expense, pay for that expense, and submit the receipt to your employer. You are then reimbursed for the amount of the receipt with money from your HFSA. Money put into an HFSA is not taxed.

However, unlike other pre-tax reimbursement accounts such as Health Reimbursement Accounts (HRAs) and Health Savings Accounts (HSAs), an HFSA is a “use it or lose it” account. This means that at the end of the calendar year, whatever money hasn’t been used for eligible health expenses is forfeited and returned to the employer. (Some employers provide a grace period allowing receipts to be submitted through March 15 of the following year.) And while losing your funds may seem like bad news, the good news is that there are so many services and products that qualify for HFSA reimbursement that you should have no problem using up those account dollars.

for reimbursement. Dental care. Have you been putting off checking out that achy tooth because it may lead to an expensive filling? Waiting for the “right time” to get those braces for your child? Need to get family members in for their cleanings and checkups? If so, all those things, as well as any other noncosmetic work done by your dentist and orthodontist, can be paid for with HFSA dollars. Eye care. Have you been contemplating getting LASIK done? Are your kids in need of new glasses and contacts? Does your child need to get in for their eye exam? All prescription lenses and exams, as well as LASIK, qualify as eligible expenses for your HFSA.

There are so many services and products that qualify for HRSA reimbursement

How to use up an HFSA Ways to use up HFSA funds that you might not be aware of: Medical care. Do your kids have to get shots for school? Do you have a physical exam coming up that you can attend before the end of the year? Do you, your spouse, or any of your dependents have a prescription that can be renewed? Copays to your doctor can be reimbursed from your HFSA account, and most prescriptions can be bought with those same pre-tax dollars. How can you determine if a visit to a nurse practitioner, acupuncturist, or massage therapist, a prescription, or other health care service is eligible for HFSA reimbursement? If the visit or prescription has a copay, it is eligible

Alternative/complementary services. Are you or your spouse in need of a chiropractic adjustment or acupuncture? HFSA dollars can be used for both types of therapy. Pharmacy. Drugs must be prescribed to be reimbursable. Can you purchase several months’ worth of your prescription in advance? Do you need a flu vaccination or shingles shot that you can get at your pharmacy’s clinic? Pharmacy purchases can be paid for with HFSA funds because they all qualify as eligible expenses. Mileage. Keep a log of mileage that accumulated in order for you and your family to receive essential medical care. Mileage can Flexible spending account$ to page 25

Qualifies for FSA/HSA spending

November 2013 Minnesota Health care news

Caregiving

Multiple avenues, updated requirements By Jennifer Sorensen, MEd

Creative Care Art + Healing in the Twin Cities

ome care services are a wonderful alternative for people who need medical care but who want to stay at home. Because there are several types of this care and multiple ways to obtain it, read on to find out what you should do to get the help you need. Identify needs In order to obtain home health care of any type you must be under the care of a primary care physician. So, the first step to getting home care is to discuss with your physician what kind of help you need. It may be unskilled care, defined as care provided by a personal care attendant (PCA). This includes assistance with bathing or housecleaning. Or, it may be skilled care, explained below. Skilled care This includes, but is not limited to, having a registered nurse provide oversight and medication management; physical, occupational, or speech therapy; cardiac or pulmonary care; wound care; social services; and infusion therapy. Skilled care in the home that is paid for by Medicare requires that your physician designate you as homebound. “Homebound” means any of the following:

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•

eaving your home is not recommended due to your medical L condition or diagnosis.

•

our medical condition or diagnosis keeps you from leaving Y your home on your own; you need someone to help you in order to leave your home.

•

T he act of leaving your home affects your physical condition.

Determine how to pay There are four ways to pay:

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1. Use your own money (i.e., private pay) 2. Long-term care insurance 3. Medical Assistance/Medicaid

Minnesota Health care news November 2013

4. Medicare. With the exception of private pay, it is best to contact your insurance company to ensure that your insurance policy includes a home health benefit. Ask your insurer what you need to do to receive payment. Requirements For Medicare payment A law enacted Jan. 1, 2011, by the Affordable Care Act requires a face-to-face meeting with a physician before a person can be certified as eligible for Medicare home health care benefit. This certification is necessary for Medicare to pay for the care.

There are many avenues to care in your home. disabled and/or qualify for home health services, then call your local public health agency for an assessment.

How can you ensure this meeting takes place? Make sure to see your doctor within 90 days before starting home health care services or 30 days after home health services have started. The intent of this visit must include the reason(s) you need home health care.

This agency will send a representative to visit you and determine if you are qualified. Basic qualifications include having a minimum of an identified need in two activities of daily living and/ or a level 1 behavior (i.e., mental health condition, safety concern). If you qualify, a public health nurse will notify you of the number of hours and days per week you are approved for care.

At or after this meeting the face-to-face document will be completed, signed by your doctor, and faxed by the doctor’s office to the home health agency of your choice.

This nurse will also discuss with you the two options for finding care. One is to hire staff from a home care agency. The other is to hire your own caregiver, which can be a family member.

For non-Medicare payment Non-Medicare sources of home health care coverage require that your doctor certify your need for skilled care. However, they do not require you to have a homebound status or the face-to-face document. Choosing a home health care agency To have your care reimbursed by Medicare, the agency providing care must be Medicare-certified. After you’ve selected an agency, it will verify your eligibility. This means that with your permission, the face-to-face document and other certification documents from your doctor will be sent to the agency. If the agency does not receive the face-to-face document—signed by your physician—Medicare will deny payment for your services and you will be required to pay out of your own pocket. Therefore, be sure to meet with your physician and ask that this document be sent to the agency you’ve chosen, and follow up with the agency to make sure paperwork was received. Communication between you, your physician, and your home health agency is key to receiving timely services.

The first step to getting home care is to discuss with your physician what kind of help you need.

Unskilled care If you need unskilled services in your home, the first step in obtaining care is to determine if you are eligible for or are already on Medical Assistance, also called MA and Medicaid. Has your doctor determined that you are either disabled or have a diagnosis that may qualify you for services? If you are both Medicaid-eligible and your doctor has determined that you’re

Choosing unskilled home care The public health nurse will give you a list of providers. If you choose an agency to provide unskilled home health care, the agency will get orders from your doctor, help develop your plan of care, help hire staff, manage any human resource issues, bill for your How to obtain home care to page 24

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Sentinel Medical Associates 514 St. Peter Street, Suite 200 St. Paul 55102

612-287-8781 November 2013 Minnesota Health care news

How to obtain home care from page 23

services, and supervise the staff in your home. If you do not use the list of providers but instead hire your staff yourself, you are responsible for developing your care plan, managing human resource issues, billing for services, and paying your staff. A home health care staffing agency may provide a qualified professional to assist you in these tasks. PCA process Regardless of whether your PCA comes from an agency or you select a PCA yourself, the Minnesota Department of Human Services will issue an authorization for PCA care. The authorization is based on the public health agency’s assessment described above. Authorization is for one year. You’ll have a maximum number of hours of care that

can be used every six months during that year. Although these hours can be used throughout each six-month period as needed, once they’re used up you will not receive services until the next six-month period. Unused hours cannot be carried over from one six-month period to another. Supervising services If your PCA is provided by an agency, the agency will initially send you a supervisor or qualified professional to evaluate your plan of care and the PCA. Subsequently a qualified professional will visit you every 90 days to review the plan of care and the services. If you choose your own PCA, you will be required to provide a supervisor visit and you are responsible for supervising and evaluating your PCA staff.

The following resources can help you: Navigate the process of identifying your needs Determine the level of your needs Determine where money will come from to pay for your care Select a home health care agency • The Minnesota Homecare Association, www.mnhomecare.org • Senior LinkAge line, (800) 333-2433, www.minnesotahelp.info • Centers for Medicaid and Medicare, ww.cms.gov

Minnesota Health care news November 2013

Many choices There are many avenues to care in your home. The avenues can be confusing at times but the most important thing that anyone in need of services should do is to talk with his or her physician. Discuss your concerns, needs, and options. Jennifer Sorensen, MEd, is the executive director of the Minnesota HomeCare Association.

Flexible spending accounts$ from page 21

be submitted to an HFSA and is currently reimbursed at a rate of 23 cents per mile. Fill up the medicine cabinet. Have you exhausted your other health care options, and aren’t sure what to do with the rest of your tax-free HFSA money? Has your first-aid kit run low on bandages and other supplies? Are your kids always scraping their elbows and knees? Or do your kids use lots of medicine during the flu and allergy seasons? While many over-the-counter (OTC) items require a prescription or a doctor’s “note of medical necessity,” there are also many things that can be purchased OTC without a prescription. Simply submit OTC receipts for reimbursement or pay with your debit card, if that option is available to you through your HFSA administrator. (See the “Resources” sidebar for more information.) A note of medical necessity is given to an employee by his or her health care provider and is submitted with a claim for HFSA reimbursement. Check old receipts Another good idea is to look through receipts from earlier in the year for store coding that identifies HFSA-eligible items. Many stores, including Target and Walgreens, use this coding. Coding is sometimes printed as an asterisk or “F” next to eligible products; ask the store what it uses for coding. You can also call your doctor, dentist, chiropractor, and other specialists to request documentation of visits earlier in the year if you haven’t already submitted those for

Setting too much money aside in an HSFA can make it difficult to use it up. To more accurately plan how much to contribute to next year’s HFSA, use online worksheets. At www.eidebaillybenefits.com, for example, find worksheets under the “Participants” tab and at the “Plan Information”: “Participants” link.

the current year’s reimbursement. Notes of medical necessity Last, but not least, get to know your doctor, because a doctor’s note can make many otherwise ineligible products completely reimbursable. For example, if your doctor writes you a note of medical necessity for weight-loss supplements or for a weight-loss program, those expenses can be reimbursed. Another example is exercise equipment or specialized classes and therapies; with a doctor’s note these, too, can be reimbursed from your HFSA. You earned it Each year, hundreds of millions of dollars are forfeited simply because people don’t use up their HFSA dollars. If you don’t want to lose yours, be sure to use these ideas to spend down your account before December 31. Linda Heuer, MBA, RPA, is a principal with the accounting firm Eide Bailly LLP in its Minneapolis office and is the company’s director of employee benefits. She consults on health care reform, defined contribution health plans, private insurance exchanges, flexible benefit plans, COBRA, health reimbursements, health savings accounts, VEBA, and qualified transportation plans.

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November 2013 Minnesota Health care news

H o s p i ta l s

How to stay out of the hospital By Howard Epstein MD, FHM, Tania Daniels, PT, MBA, and Janelle Shearer, RN, MA

The problem

very year, Minnesota hospitals admit approximately 570,000 people at an average cost of $10,000 each. For some conditions, up to one in five patients is readmitted to the hospital within 30 days after being sent home (i.e., discharged). Many of these readmissions could be prevented by proper follow-up care. Causes There are five factors known to increase the likelihood that a patient will be readmitted within one month of discharge: inadequate discharge planning; a patientâ&#x20AC;&#x2122;s inability to manage medication; lack of patient/family engagement in self-care; insufficient transition planning; and poor transition communication between different settings of care, such as the hospital and an assisted living center. A hospitalâ&#x20AC;&#x2122;s attention to these factors helped one patient avoid being readmitted to the hospital. After being hospitalized with a leg fracture, worsening depression, and other chronic health problems, the patient left the hospital ahead of her scheduled discharge. The physician called in her prescription to the pharmacy but when the hospitalâ&#x20AC;&#x2122;s discharge advocate called the patient the following day to check up on her, he found that the patient was not doing well and had not started her medications. The discharge advocate strongly encouraged the patient to take her medications, to keep her doctor appointments, and to attend the transitions group meeting that was part of her medication therapy management program. The discharge advocate also visited the patient at her home, where he additionally encouraged the patient, reviewed her appointments, and made a referral for a visiting nurse to check up on the patient. Without this timely intervention, the patient likely would not have started her medications and her condition would have worsened. Without the follow-up phone call and home visit, she may have missed key follow-up appointments and have been readmitted to the

Minnesota Health care news November 2013

Asking Questions to Get the Care You Need. www.ahrq.gov/news/columns/navigating-the-health-care-system/video-questions/index.html Honoring Choices Minnesota. Downloadable advance health care directives. www.honoringchoices.org Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient. Guide for patients and families to use before leaving the hospital. http://www.patientsafetysummit.org/_assets/documents/checklists/Consumers Advancing Patient Safety - Hospital Exit Checklist.pdf Tips for Taking Medicines Safely. www.ahrq.gov/news/columns/navigating-the-health-care-system/video-medicines/index.html Minnesota Senior LinkAge Line (800) 333-2433, www.mnaging.org/advisor/SLL.htm

hospital. Efforts such as these are critical to helping patients spend more nights at home in their own beds.

The statewide RARE (Reduce Avoidable Hospital Readmissions) campaign, involving more than 80 hospitals and 95 community partners across the continuum of care, is working to lessen the burden that avoidable readmissions place on patients and their families. RARE is coordinated by the Institute for Clinical Systems Improvement (ICSI), the Minnesota Hospital Association, and Stratis Health (www.rarereadmissions.org).

whether prescriptions and other expenses for your care fit into your budget, and any other factors that affect your health and ability to stay out of the hospital. Share what quality of life means for you with your family and primary care doctor. Talk about your goals, like fishing at the lake next summer or dancing at your son’s upcoming wedding, and what you need to do for your health to achieve those goals. Discuss health-care treatment options: which options are right for you now and, in the event you can no longer make decisions for yourself, who is best able to make decisions that respect your life goals and personal treatment preferences. These thoughts should be recorded in a document called an advance health

Solutions

Reducing readmissions to page 28

Addressing the problem

The patient’s role. Visit your primary care physician within five days of being discharged. Ask your hospital if it offers a transition program or transition coaches to help ensure this follow-up visit happens. Coaches encourage patients to recognize their own needs, set their own health care goals, and access needed services. Patients are coached to understand the reasons to take, and possible side effects of, each medication they are prescribed. Coaching helps ensure patients have a reliable system to make sure medications are taken on schedule. In addition, coaching helps ensure that discharged patients keep a personal health record, schedule and keep follow-up doctor visits, can recognize if their condition is worsening, and know what to do so they don’t end up back in the hospital unnecessarily.

Ask how your current medications might interact with new ones.

Ask, share. Good care following a hospital stay takes teamwork. Your medical team will share a lot of health information that you’ll need to know in order to stay healthy. As part of the team, you need to ask questions until you understand your condition and how to better manage your health at home. It’s very helpful to have a family member or friend with you at the hospital who also can listen to instructions. Care is a two-way street, so you need to share information with your medical team. Share your medical history, diet, lifestyle, November 2013 Minnesota Health care news

Reducing readmissions from page 27

to doctor appointments, or picking up prescription drugs, make sure you have help ready—family caregiver, personal care attendant, etc.—and involve them in your self-care education so they understand your specific needs.

care directive (see Resources on page 27). A 2004 report in the Journal of the American Medical Association showed that hospitals that improve patient education at the time of discharge reduce the chance of a patient returning by 25 percent. While many hospitals have patient engagement and education programs, patients and their families who understand the patient’s condition and ask questions to better manage their own care can greatly decrease the risk of a quick return to the hospital.

Ask your health care provider to teach you and your caregiver any tasks that require special skills, like changing a bandage or giving a shot. Then, practice in front of the provider to make sure you can do these tasks correctly. Finally, write down a name and phone number of a contact person at the hospital whom you can call if you need help after leaving the hospital. Managing your own care after being in the hospital can be difficult. Your hospital, your doctor, and the rest of your care team want to help you care for yourself—so we all can sleep more peacefully.

Visit your primary care physician within five days of being discharged.

Medication management. Make a list of all the prescription drugs, over-the-counter drugs, vitamins, and supplements you were taking before you were admitted to the hospital. Review this list, as well as any new prescriptions you receive, with your doctor or other care provider. Make sure you understand three things about any new medication: what it is, what it is for, and how to take it. Ask how your current medications might interact with new ones. Know what to do if you have questions or problems.

Howard Epstein MD, FHM, is an internal medicine hospitalist and palliative care physician at Regions Hospital, St. Paul, board-certified in internal medicine and in hospice and palliative medicine, and is chief health systems officer at ICSI, Bloomington. Tania Daniels, PT, MBA , is vice president for patient safety, Minnesota Hospital Association. Janelle Shearer, RN, MA, is a Stratis Health program manager.

Self-care. Having a support system for daily activities is important. Ask your health care provider when you’ll be ready to do activities such as climbing stairs, cooking, shopping, and house cleaning. If you will need help bathing, dressing, using the bathroom, getting

October Survey results ... 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 October survey. 2. I have electronically accessed information pertaining to my medical records.

26%

50 40 30 20

20% 14%

10 3%

Strongly Agree agree

27%

25 20 15

17%

20%

5 0

37%

7% 3%

Strongly Agree agree

27% 23%

25 20 20%

15 10

7% 3% Strongly Agree agree

No Disagree Strongly opinion disagree

50 43%

37%

30 17%

17%

20%

17% 7%

No Disagree Strongly opinion disagree

7% 7%

5. I feel Internet search engine mining must be prohibited from analyzing data pertaining to personal medical issues.

Percentage of total responses

37%

No Disagree Strongly opinion disagree

37%

4. I feel that the ability of Big Data to mine my electronic records is superseding HIPAA protection.

Minnesota Health care news November 2013

Strongly Agree agree

0% No Disagree Strongly opinion disagree

3. As a result of Big Data mining, I may have received solicitations for products related to a medical condition that I have.

Percentage of total responses

57%

Percentage of total responses

1. I am confortable with the privacy of my medical records.

37%

35 30

27%

25 20 15

17%

20%

5 0

3% Strongly Agree agree

No Disagree Strongly opinion 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;? November 2013 Minnesota HealthCARE careNEWS news SEPTEMBER MINNESOTA HEALTH

29 33

Policy

Cancer’s nonmedical challenges Help is available By Lindy Yokanovich, Esq.

very year, an estimated 25,080 Minnesotans hear the words, “you have cancer.” A cancer diagnosis brings with it not only medical implications, but emotional and legal ones as well. While there is support from one’s health care team for medical decision-making and a growing network of options for emotional support during and

In the next issue...

• Medical record privacy • Ear infections

after treatment, help for cancer-related legal needs has been harder to come by. Those needs include employment, insurance coverage, navigating financial issues, and preparing planning documents such as guardianship elections, wills, powers of attorney, and health care directives. Legal guidance in those areas can improve a cancer survivor’s quality of life by assisting with the worrisome issues that can hamper survivors’ ability to focus on health and healing. Finances The overarching nonmedical concern most cancer patients have revolves around finances: What will happen to my family if I lose my job because of my cancer? How can I afford COBRA payments when I am not working? What if I can’t pay my mortgage? These concerns are not unfounded: More than 62 percent of all bankruptcies filed in 2007 were due to medically related situations, according to a study of medical bankruptcy conducted jointly by Harvard Medical School, Harvard Law School, and Ohio University in 2009. The study went on to show that 75 percent of people filing for medical bankruptcy had medical insurance and that most were well educated, owned their own homes, and had middle-class occupations. This shows that the seriousness of potential financial risks that accompany a cancer diagnosis cannot be underestimated. Insurance concerns

• Pneumonia

Minnesota Health care news November 2013

As the Harvard study revealed, even people with good health insurance can face a financial free fall as a result of a cancer diagnosis. Fortunately, the provisions of the Affordable Care Act (ACA) go a long way toward alleviating some of the main stressors faced by people living with a history of cancer. The ACA eliminates lifetime limits on essential benefits and extends benefits to young adults under their parents’ plan. And, as of Jan. 1, 2014, it will prohibit discrimination by health insurance companies due to preexisting

conditions and will ensure coverage for individuals who participate in clinical trials. The concerns of how to pay for such coverage or how to continue previous employer-provided insurance with COBRA—especially if an employee’s income is cut drastically—remain paramount. There are some national organizations that can help defer the cost of copays and deductibles. These organizations usually require the person applying for aid to meet certain income criteria or to have a certain type of cancer diagnosis in order to be eligible for assistance.

Often, a diagnosis of cancer, even if the prognosis is good, provides the impetus for people to engage in these conversations with their loved ones and, ultimately, to memorialize their wishes in legally enforceable documents. Most often these documents include a power of attorney for finances, a health care directive (sometimes called an advance directive) for medical decisions, and a will. Minnesota has recently approved the use of a transfer on death deed (TODD), which allows real property (i.e., land or buildings) to be transferred at death without going though probate. This can be especially beneficial for smaller estates.

The provisions of the Affordable Care Act (ACA) go a long way toward alleviating some of the main stressors faced by people living with a history of cancer.

Cancer survivors also must navigate short- or long-term disability insurance. Unlike Social Security Disability Insurance (SSDI), which provides a uniform standard for all who pay into the system via their payroll taxes, short- and long-term disability insurance coverage can vary widely among carriers and plans. Sometimes, longterm disability plans require full reimbursement from an insured’s SSDI benefit once received. It is imperative for people covered under one of these plans to understand exactly what they are covered for and how their private/employer-sponsored disability insurance benefits might be affected by receiving SSDI. Employment

Other concerns Other common areas of concern include housing and foreclosure, immigration, and family law. All of these areas are ones in which early action and investigation can lead to enhanced peace of mind for a cancer survivor and his or her family. No one would face the medical aspects of cancer without a doctor; similarly, no one should face the legal issues cancer brings with it without the help of an attorney. With options for pro bono legal help, no one should hesitate to get the help they need. Lindy Yokanovich, Esq., is the founder and executive director of the nonprofit organization Cancer Legal Line, www.cancerlegalline.org, (651) 472-5599. The National Cancer Legal Service Network (www. NCLSN.org) provides links to similar organizations across the country.

Minnesota workers with cancer are protected in the workplace by the federal Americans with Disabilities Act and the Minnesota Human Rights Act. These laws protect against workplace discrimination that is based on the disability of cancer. These laws also mandate that employers that have 15 or more employees must provide reasonable accommodation to an employee to allow that employee to perform the essential functions of his or her job. These laws work to keep an employee with cancer in the workplace. The Family Medical Leave Act (FMLA) provides job-protected leave for up to 12 weeks in a 12-month period for eligible employees of employers that have 50 or more employees within a 75-mile radius. The main purpose of the FMLA is to provide job protection for people so that they can temporarily leave the workplace to care for their own serious health condition or that of a parent, spouse, or child. During this time away from work, the employer is required to continue the employee’s benefits, such as insurance coverage, just as if the employee were actively working. Estate planning Everyone has an “estate” composed of assets and liabilities. Consequently, everyone should make a plan for his or her estate and loved ones. However, the last thing most people want to do is to sit down and think about estate planning. When people are facing a health crisis, this feeling is often amplified. Ironically, making estate-planning decisions is usually very comforting because it provides a great sense of accomplishment. People who plan know that they have created the means necessary to carry out their wishes and to provide guidance to their loved ones at an emotionally charged time. November 2013 Minnesota Health care news

O n co lo gy

Be proactive By Liangping Weng, MD

Don’t miss an issue...

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esticular cancer is rare; roughly 150–200 men in Minnesota are diagnosed with it annually. Even so, based on data from the federal Centers for Disease Control and Prevention, Minnesota was among the 10 states with the highest incidence of this cancer between 2000 and 2009. The higher incidence in this state is related to the disease’s higher occurrence among Caucasians compared with other ethnicities and the state’s relatively large Caucasian population. The good news is that the mortality rate for testicular cancer in Minnesota is among the lowest in the country; 21 men died from it between 2004 and 2008. Risk factors

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Nationwide, testicular cancer rates have more than doubled in white males during the past 40 years, and it is now the No. 1 cancer in men between the ages of 15 and 35. Although the exact cause of testicular cancer is unknown, several factors are known to increase the chance of developing it. Caucasian males are four to six times more likely to have this disease than are African American or Asian males. Risk is also higher in men who experience an undescended testicle, called cryptorchidism, or other abnormal testicular growth and development, as well as in those with a family history of testicular cancer. A man who has been diagnosed with this disease on one side has an increased risk of being diagnosed with it in the remaining testicle.

Minnesota Health care news November 2013

bath or shower. With one exception, there is no prevention for this disease because most known risk factors cannot be changed. The only exception is surgical correction of cryptorchidism early in life. Symptoms The most common sign of testicular cancer is a painless lump or enlargement in the testicle, typically found by the patient or by a health care provider during a routine exam. Some men may experience heaviness or swelling in the scrotum. Breast swelling or tenderness can also occur. Abdominal or low back pain, shortness of breath, or chest pain may occur if the disease has spread outside the testicle. These symptoms are not specific to testicular cancer and can occur in many noncancerous conditions. While a lump in the testicle is not always cancerous, it should be evaluated by a medical professional. Diagnosis Diagnosis begins with an ultrasound of the testicles and blood tests. An ultrasound helps to identify any abnormal structure and the nature of any lump within the scrotum. Blood tests are performed to detect tumor markers, which are substances that can be produced by cancer cells. Markers include alpha-fetoprotein, beta-human chorionic gonadotropin, and lactase dehydrogenase. Detecting markers aids diagnosis, helps to determine the treatment plan, and helps to monitor for disease recurrence after treatment. If these tests suggest that testicular cancer is likely present, the testicle is surgically removed, a procedure called orchiectomy. Biopsying the testicle by inserting a needle through the scrotum is never performed because this can spread the disease. Staging The removed testicle is analyzed to determine whether there is cancer and, if so, what type of cancer is present. There are generally two types of testicular cancer: seminoma and nonseminoma. Once a diagnosis of testicular cancer is made, CT scans of the manâ&#x20AC;&#x2122;s abdomen and pelvis, with possible CT or X-ray of the chest, are done to determine the stage of the cancer. Stage I means that the cancer is confined to the testicle. Stage II means that the cancer has spread beyond the testicle to the abdominal lymph nodes, but no further. Stage III means the disease has spread to other organs. Staging helps a manâ&#x20AC;&#x2122;s medical team determine the most effective treatment.

The mortality rate for testicular cancer in Minnesota is among the lowest in the country.

Treatment After diagnosis and staging are complete, a medical team that includes a urologist, medical oncologist, and radiation oncologist, plus support staff, work with the patient to

construct a treatment plan. This plan is based on the type of cancer, stage, and tumor marker results, as well as the patientâ&#x20AC;&#x2122;s overall health. The medical team will answer any patient concerns, including those about sexual functioning and fertility. Before making treatment decisions, patients should get as much information about testicular cancer as possible from reputable sources such as the National Cancer Institute and the American Cancer Society (see Resources on page 34). They should seek a second opinion from another health organization or provider if they have any uncertainty about their treatment plan. Testicular cancer is highly treatable and has a very high survival rate. The cure rate is 99 percent for early-stage disease and more than 70 percent for widespread disease. Surgery, chemotherapy, and radiation therapy are the three main treatment options. Orchiectomy is the primary treatment for all patients. Some men with stage I cancer may be offered post-orchiectomy surveillance without additional treatment if their risk of recurrence is very low and they comply with periodic medical follow-up. Most patients require orchiectomy and additional surgery to remove abdominal lymph nodes, in addition to possible chemotherapy and/ or radiation therapy to remove any stray cancer cells. Seminoma is less aggressive and more sensitive to radiation. This type occurs more often in older men and does not produce alphafetoprotein, so treatment for it is different than for nonseminoma. Testicular cancer to page 34

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November 2013 Minnesota Health care news

Testicular cancer from page 33

Cancers containing both cell types are treated as nonseminomas.

injury to kidneys or lungs. Some chemotherapy patients experience mental fogginess or “chemobrain.”

After treatment

Retain the name and phone number of your provider in case you need to transfer your care. Keep a record of other medical documents related to your diagnostic tests and treatment.

Testicular cancer may recur even when it’s caught at an early stage and when no cancer is detected after treatment. Consequently it is very important to keep follow-up appointments with your medical provider to detect any cancer recurrence and potential complications.

Caucasian males are four to six times more likely to have this disease than are African American or Asian males.

Possible side effects of treatment by chemotherapy, radiation, and surgery to remove abdominal lymph nodes include impaired fertility and sexual function. Men who want to father children should talk to their doctor about banking sperm before treatment. Chemotherapy and radiation can increase risks of cardiovascular disease and subsequent cancer, particularly leukemia. Chemotherapy may cause hearing loss or

The future Researchers are looking for genes associated with testicular cancer to find out how to prevent it. Clinical trials are under way to minimize the toxicity and complications from treatment in order to improve patients’ quality of life.

Finally, remember that you are not alone. Keep in touch with close friends and family, who can provide emotional support. Finding other testicular cancer survivors to share concerns can be very helpful. Ask your medical team or contact the American Cancer Society for a local support group. Liangping Weng, MD, is a board-certified oncologist who practices with Sanford Worthington Cancer Clinic.

National Cancer Institute (800) 422-6237, www.cancer.gov American Cancer Society (800) 227-2345, www.cancer.org

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Minnesota Health care news November 2013

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