Volume XXVl, No. 10
January 2013
The Independent Medical Business Newspaper
Cost, quality, and health care reform Opportunities to manage challenges By John E. Kralewski, PhD, MHA; Bryan E. Dowd, PhD, MS; David Knutson; and Yi (Wendy) Xu
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A
little over 10 years ago, South Country Health Alliance began working on new approaches to challenges of care that all health plans face. Over time, we have developed some unique and successful solutions to improving the health of our plan members. This new type of rural health plan is actually owned by the rural counties where its members live and is governed by elected
SOUTH COUNTRY to page 10
PAID
By Patrick Irvine, MD
PRSRT STD U.S. POSTAGE
A community-based health plan that works
officials. It focuses on serving vulnerable patients, using local health-care resources, and building healthy communities. Add that it coordinates health care and social services for its members, and you have a strong platform in rural Minnesota poised to help physicians practice quality medicine and achieve the triple aim of improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Since being established for Medicaid members by nine courageous Minnesota counties in 2001, South Country has evolved to currently serve about 23,000 members enrolled in Minnesota Health
Detriot Lakes, MN Permit No. 2655
Getting more with less
hile the changes proposed by the Patient Protection and Affordable Health Care Act (PPACA) may appear catastrophic to some health care providers, our research indicates that there are many opportunities to effectively manage the challenges. First, achieving affordable health care goals may not be as difficult as once thought. Our recent research found a $1,200 difference in permember per-year (PMPY) costs of care between medical group practices in the highest and lowest cost quintiles in Minnesota. These are costs of care when patient case mix and differences in payment rates are controlled. In other words, these are differences in the use of clinic visits, technologies, drugs, hospital days, and emergency department (ED) visPRACTICES to page 12
MINNESOTA HEALTH CARE ROUNDTABLE Page 20
NEW ICD-10 DEADLINE:
OCT 1, 2014
2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems. CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
CONTENTS
JANUARY 2013 Volume XXVI, No. 10
FEATURES Getting more with less A community-based health plan that works
1
MINNESOTA HEALTH CARE ROUNDTABLE
By Patrick Irvine, MD
Cost, quality, and health care reform Opportunities to manage challenges
1
T H I R T Y- N I N T H
SESSION
By John E. Kralewski, PhD, MHA; Bryan E. Dowd, PhD, MS; David Knutson; and Yi (Wendy) Xu
Minnesota Health Care Roundtable Health insurance exchanges
20
Patient engagement
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
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PREVENTION A high-stakes legislative issue
16
By Molly Moilanen, MPP
Blue Cross Blue Shield
Thursday, April 25, 2013 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers
PUBLIC HEALTH Birth defects in Minnesota
Patricia Riley
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By Kristin Oehlke, MS, CGC; Erica Fishman, MSW, MPH; and Barbara Frohnert, MPH
MEDICINE AND THE LAW Legislative preview 14 By H. Theodore Grindal, JD, and Nate Mussell, JD
Creating measures that work
PROFESSIONAL UPDATE: PEDIATRICS Alport syndrome 30 By Clifford Kashtan, MD
Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle choices into health care delivery is necessary, but how should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).
Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential. Panelists include:
The Independent Medical Business Newspaper
Vivi-Ann Fischer, DC, Chief Clinical Officer, ChiroCare Peter Mills, MD, CEO, nGage Health Sponsors: ChiroCare • nGage Health
www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com
Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name Company Address
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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.
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JANUARY 2013 MINNESOTA PHYSICIAN
3
CAPSULES
Minnesota COPD Rate Lowest in U.S. Minnesota residents have the lowest rate of chronic obstructive pulmonary disease (COPD) in the country, according to new data from the federal Centers for Disease Control and Prevention (CDC). The report shows that Minnesota’s rate, 3.9 percent, was matched only by Washington state, with the U.S. territory of Puerto Rico showing a 3.1 percent incidence of COPD. Nationally, COPD, which is a group of progressive, debilitating respiratory conditions, including emphysema and chronic bronchitis, is the thirdleading cause of death, according to data from 2008. The new report puts the national average of COPD at 6.3 percent, with southern states generally reporting higher rates of the condition. “COPD is a tremendous public health burden and a leading cause of death. It is a health condition that needs to be urgently addressed, particularly on a local level,� says Nicole Kosacz, MPH, a CDC epidemiol-
ogist and one of the lead analysts of the data. “This first-ever state-level analysis and breakdown is a critical source of information that will allow states to focus their resources where they will have maximum impact.�
Health Reformers Celebrate 20 Years Of MinnesotaCare Some of the top health reform advocates from the past two decades helped celebrate the 20th anniversary of MinnesotaCare on Nov. 27 in St. Paul. The event at the Minnesota History Center noted the history of the legislation, passed in 1992, that established Minnesota’s groundbreaking health insurance program for Minnesotans who do not have health insurance coverage. The program was designed for people not poor enough for existing public programs but who still could not purchase health insurance, officials note. “The enactment of Minnesota-
Care 20 years ago is certainly worth celebrating and remembering,� said Amy Crawford, regional director of Children’s Defense Fund–Minnesota (CDF–MN), and one of the event’s hosts. “This landmark piece of legislation provided critical health care coverage for hundreds of thousands of Minnesotans who had previously been caught in the health insurance dilemma—they earned too much for Medical Assistance but couldn’t afford coverage in the private market. MinnesotaCare contributed to Minnesota’s reputation as a national model for providing health care to its citizens.� Speakers at the event included Arne Carlson, former governor of Minnesota; Linda Berglin, former state legislator who also chaired the Senate Health and Human Services committee for several years; Nancy Feldman, CEO of UCare and a former assistant commissioner of the Minnesota Department of Health; Lucinda Jesson, commissioner of the Minnesota Department of Human Services
(DHS); and Jim Koppel, deputy commissioner of Health and former executive director of the CDF–MN.
Mayo Physicians Discuss Medical Futility Issues A recent article in Mayo Clinic Proceedings takes on the issue of end-of-life care and the tough discussions that families and providers face over continuing care. In the article, two Mayo Clinic experts, Christopher Burkle, MD, JD, and Jeffre Benson, MD, look at recent controversial cases that involve endof-life decisions, and then outline several steps that families can take to ease the difficulties of discussing such decisions. “Health care professionals in the United States have struggled with the importance of maintaining patient autonomy while attempting to practice under the guidance of treatments based on beneficial care,� says Burkle, the study’s lead author.
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MINNESOTA PHYSICIAN JANUARY 2013
The authors say the first key element is early and clear communication between families and providers. Secondly, they recommend choosing objective surrogates to represent patients who cannot represent themselves. Lastly, the article says when providers and patients or their representatives cannot agree on end-of-life care, turning to a third party may be necessary. They note that the Joint Commission has required hospitals to establish procedures for considering ethical issues, and many hospitals have ethics committees to resolve such issues. The article discusses “medical futility,” cases where medical professionals believe that life-saving treatment should not be continued. The authors say disputes between providers and patients or their families over this issue are the top ethical problem for U.S. hospitals today. “End-of-life care will continue to be an ongoing discussion within the medical community; however, it is important that medical care providers and patients/medical surrogates continue to dialogue,” Burkle says. “Only then can experts continue to offer insight into the effectiveness of systems used in countries that have moved to a more patient-centrist approach to end-of-life care treatment choices.”
MDH Campaign Promotes Imaging Best Practices The Minnesota Department of Health (MDH) is launching a ground-breaking campaign aimed at developing best practices for using medical imaging technology. There has been increasing concern that overuse of imaging may be exposing patients to more radiation than is necessary, increasing health risks. In the new campaign, state health officials will work with radiologists and other providers to determine how to minimize the risks from medical imaging. Officials note that MDH is the first state health agency to
endorse the ImageWisely and ImageGently campaign, national programs that promote safe medical imaging for adult patients and children, respectively. MDH will be working on the two campaigns with the Minnesota Radiological Society (MRS), the North Central Chapter of the American Association of Physicists in Medicine (NCCAAPM), and the Minnesota Society of Radiologic Technologists (MSRT). “Our partnership with these organizations is critically important,” says Minnesota Commissioner of Health Edward Ehlinger, MD. “They will play an essential role— along with the state’s health-care provider community—in implementing the best practices encouraged by ImageWisely and ImageGently.” According to Parham Alaei, PhD, of NCCAAPM, ImageWisely and ImageGently focus on two different aspects of medical imaging, in order to minimize the radiation dose needed to meet the patient’s medical needs. “The practices being encouraged through the two education campaigns emphasize, first of all, the importance of ensuring that the diagnostic procedures involved are medically justified,” Alaei says. “That means the medical practitioners ordering imaging procedures which utilize X-rays need to carefully balance the potential radiation exposure risks with the benefits gained from these procedures. “The other aspect focuses on the actual imaging process, where imaging professionals need to carefully balance actual exposure to ionizing radiation with the need to produce an acceptable image for interpretation and diagnosis,” he adds. MDH officials say the agency will continue to enforce current rules regarding radiology practices, and will mount an education campaign aimed at imaging professionals and facilities to help ensure that best practices are followed in using the equipment. CAPSULES to page 6
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MINNESOTA PHYSICIAN
5
CAPSULES Capsules from page 5
Essentia Health Launches ED Telemedicine Essentia Health has launched its second telemedicine program for emergency departments (EDs) in hospitals with the Duluth-based health system. The system announced that it has begun a telemedicine program that links the emergency department at Essentia Health– Sandstone to ED specialists at Essentia Health–St. Mary’s Medical Center in Duluth. Essentia created a similar system with the ED at Essentia Health–Northern Pines in Aurora earlier this year. The system uses two highend cameras, microphones, and a secure network connection to allow caregivers in the connected EDs to talk with each other and the patient as if they were all in the same room. “With telemedicine, our goal is increasing the ability of patients to stay in their community,” says Heather O’Brien,
David M. Aafedt (612) 604-6447 daafedt@winthrop.com
Sandstone’s director of nursing. “Now, a lone physician or advanced practitioner in a rural area can tap into the expertise of a larger trauma center. It’s great when you may be handling a complicated case and need to ask another opinion about treatment.” In addition to the ED services, Essentia has been using telemedicine technology to connect providers in the areas of dermatology, mental health, pharmacy, and congestive heart failure, officials say.
Minnesota Is Ranked Fifth in Annual Health Report Minnesota continues to be one of the top states in United Health Foundation’s America’s Health Rankings, an annual report on health measurements for all 50 states. Minnesota has traditionally been in the top five of the rankings, and ranked fifth this year after dropping to sixth last year. The foundation report says
Minnesota’s strengths include low rates of premature death and deaths from cardiovascular disease, low prevalence of sedentary lifestyle and diabetes, and a high rate of high school graduation, which is linked to better health outcomes. The foundation report says Minnesota’s challenges include a higher incidence of infectious disease, low per capita public health funding, and a high prevalence of binge drinking. In a press conference on Dec. 11, Reed Tuckson, MD, medical adviser, United Health Foundation, and executive vice president and chief of medical affairs, UnitedHealth Group (UHG), stressed that all states faced challenges in the area of health measurements. “It’s a good news story and a bad news story,” he said. “The good news—we’re living longer, life expectancy has significantly improved. The bad news—while we’re living longer, we’re living sicker from preventable illnesses.” Tuckson says the data show that medical care has been effec-
tive, giving people effective treatment for diseases and prolonging life. But, at the same time, chronic diseases such as diabetes are on the rise. “Why are these chronic illnesses increasing? Because the risk factors, the behaviors that people have that lead to those chronic illnesses, are worsening.” Rising obesity, sedentary lifestyle, and smoking are examples of unhealthy factors that are contributing to poor health, Tuckson says, and health-care reform efforts by state and federal governments will not be effective without a change in lifestyle. “Government alone cannot do what is needed,” Tuckson says, adding that the foundation would partner with states to identify progress being made in states and to promote best practices and prevention.
Christianna L. Finnern (612) 604-6435 cfinnern@winthrop.com
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MINNESOTA PHYSICIAN
JANUARY 2013
MEDICUS
Chris Yang, MD, has joined Children’s Hospital and Children’s Respiratory and Critical Care Specialists, PA, as a pediatric intensivist. Previously she was an assistant professor of pediatric anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, Baltimore, where she also was director for medical student and resident education in the Pediatric Intensive Care Unit and co-medical Chris Yang, MD director of Hopkins Outreach for Pediatric Education. Yang earned her medical degree from Drexel University College of Medicine in Philadelphia. Charles Oberg, MD, FAAP, has been elected vice chair of a division of the American Academy of Pediatrics (AAP). Oberg, an associate professor of pediatrics at the University of Minnesota and former chief of pediatrics at Hennepin County Medical Center, was elected by the group to a three-year term and will assist with duties including overseeing budget and fiscal operations and supporting chapter officers. He will be responsible for a geographic area that includes Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, and Wisconsin. Oberg’s work has included establishing clinics for newly arrived immigrants and refugees, developing primary care networks for the homeless, and creating a clinic for adolescent parents and their children. He also has chaired the Public Policy and Advocacy Committee for the Academic Pediatric Association, serving as liaison to the AAP Committee on Federal Governmental Affairs. Three new faculty members recently joined the Orthopaedics Department at Hennepin County Medical Center. Orthopaedic surgeon Nancy Luger, MD, completed her residency at the University of Minnesota and recently returned to Minnesota after completing a sports medicine fellowship in South Lake Tahoe, Cal. She specializes in sports medicine with a specific interest in shoulder and knee injuries for both the pediatric and the adult population. Jackie Geissler, MD, also completed her residency at the University of Minnesota. She completed the USC/Boyes Hand Fellowship, spending time at the University of Southern California, Los Angeles County Hospital, and Children’s Hospital Los Angeles. She has a special interest in upper extremity fracture care, arthritis, reconstructive surgery, elbow trauma, and peripheral nerve injury. Specializing exclusively in fracture care, Gudrun Mirick, MD, is an orthopedic trauma surgeon who completed her residency at the George Washington University in Washington, D.C., and an orthopaedic trauma fellowship at San Francisco General Hospital. Her interests are centered on pelvis and acetabular fractures, the use of external fixation for immediate fracture stabilization, and foot and ankle reconstruction. She will also coordinate HCMC’s pediatric fracture program. The American Medical Association has presented Peter Dehnel, MD, with its Benjamin Rush Award for Citizenship and Community Service. Dehnel is a practicing pediatrician in Minneapolis and is also medical director for utilization management at Blue Cross and Blue Shield of Minnesota. In the early 2000s, Dehnel testified before legislators and local community leaders about the effects of secondhand smoke on children. His efforts led to city ordinances that banned smoking in several cities and a county in the Minneapolis area, and later led to a statewide smoking ban in 2007. He has also partnered with the National Initiative for Children’s Healthcare Quality and the American Academy of Pediatrics to develop information for physicians to use in working with families to help their children lead healthier lives. Alicia Prahm, MD, has joined the Essentia Alicia Prahm, MD Health–Baxter Specialty Clinic. She received her medical degree from the University of North Dakota and completed her residency at the University of Minnesota. Prahm is board-certified in obstetrics and gynecology and has provided ob-gyn care in the Twin Cities for the past six years.
REQUEST FOR NOMINATIONS
2013 HEALTH CARE ARCHITECTURE & DESIGN
HONOR ROLL NOMINATION CLOSING: FRIDAY, MAY 10, 2013 PUBLICATION DATE: JUNE 2013
Seeking Exceptionally Designed Health Facilities Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2013 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any structure designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible.
In order to qualify for nomination, the facility must have been designed, built or renovated since January 1, 2012. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota or Iowa). Color photographs are required. If you would like to nominate a facility, please fill out the nomination form below and submit the form, three to eight 300-dpi-resolution color digital photographs, and a brief project description by Friday, May 10, 2013. For more information, call (612) 7288600.
2013 HEALTH CARE ARCHITECTURE & DESIGN HONOR ROLL NOMINATION FORM FACILITY NAME TYPE OF FACILITY LOCATION OWNERSHIP ORGANIZATION OWNER CONTACT NAME and PHONE OWNER ADDRESS CITY, STATE, ZIP ARCHITECT/INTERIOR DESIGN FIRM ARCHITECT CONTACT NAME and PHONE ARCHITECT ADDRESS CITY, STATE, ZIP ENGINEER CONTRACTOR COMPLETION DATE TOTAL COST SQUARE FEET NUMBER OF COLOR PHOTOS ENCLOSED [Note: Please include a caption for each photo] NOMINATION PROCEDURE: Submit the information on this form, along with a project description (150–250 words) and 300-dpi-resolution color 8”x10” digital photographs (no more than eight) to mmacedo@mppub.com For further information, please phone (612) 728-8600, fax (612) 728-8601 or e-mail comments@mppub.com.
JANUARY 2013
MINNESOTA PHYSICIAN
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INTERVIEW
Racing to implement health reform ■ Please tell us about the work you do.
Patricia Riley Blue Cross Blue Shield of Minnesota Patricia (Patsy) Riley is senior vice president of government programs, policy, and legislative affairs at Blue Cross and Blue Shield of Minnesota. Riley oversees the company’s government health program business; state and federal public policy initiatives; and interactions with elected officials and regulatory leaders. Before joining Blue Cross in 2006, Riley served as president and CEO of Stratis Health, the nonprofit health care quality improvement organization for the state of Minnesota. Riley has also held positions at United Healthcare Corporation and Aetna Health Plans, and has served on the board of Minnesota Community Measurement.
8
■ How does Blue Cross interact with federal and
My title is chief government officer, and I have responsibility for all of the government products that we run here at Blue Cross and Blue Shield. That’s about 560,000 enrollees in the state of Minnesota, between Medicare, Medicaid, and the federal employees program. In Medicaid, we participate with not only prepaid medical assistance, but also MinnesotaCare. In the federal employees program, we’re all around the state. We’re the largest market share of the federal employee program in Minnesota, about 70,000 enrollees or so. So postal workers and folks that work in federal agencies, we have a large share of that population. ■ Is lobbying involved with your position? Do you
work with legislators at the state Capitol? I now have the responsibility for the folks in our legislative and policy area, but I’m not a lobbyist and I don’t lobby. Typically my role is to help educate legislators about the importance of these programs and the importance of having predictable funding streams and making sure that we set up the regulatory environment in such a way that these plans can not only survive but thrive in our state and at the federal level. I work a lot with our trade associations, the Minnesota Council of Health Plans and the American Health Insurance Plans; I work on a lot of committee assignments for both of those organizations. My role is really more around influencing, but I do have responsibility now for the legislative policy area as well.
state regulators? It’s interesting. Minnesota already has taken on a lot of the improvements in the health insurance market. We already have a subsidized product for Minnesotans who are employed but either weren’t offered insurance or couldn’t afford the insurance that was there, so we have MinnesotaCare. We have one of the largest and highest-functioning high-risk pools, the MCHA [Minnesota Comprehensive Health Association]. A lot of what we’ve been trying to do at the federal level is working with members of Congress as well as with our trade associations to make sure that whatever gets designed at the federal level doesn’t disadvantage Minnesota and doesn’t take away from some of the innovations that we have already put into place. Minnesota is viewed as an innovator and has tackled some of the tough problems around covering as many folks as possible.
Minnesota is viewed as an innovator.
■ What are some of the biggest challenges you
are seeing in the area of government programs? Traditionally, in the years that I’ve been working in government programs, it was either the federal government doing a lot of changes or it was the state getting more innovative. Now we have both of them sort of going off at the same time. Obviously, you have to be very comfortable with change to be in government programs. I think sometimes people have the image that, “Oh, Medicare and Medicaid doesn’t change and they kind of just stay and do the same thing,”—that’s just not the case, certainly in our state, and I think now at the federal level as well. A lot of the testing of new ideas, new payment arrangements, and new ways to deliver care have been pushed at the federal level through Medicare. There’s been a huge emphasis on quality from the federal government, a huge emphasis from both state and federal governments on new payment arrangements and creating direct contracts with providers. Clearly that will engage physicians and hospitals in new ways as they become direct contractors to both the state and the feds.
MINNESOTA PHYSICIAN JANUARY 2013
■ What do you see as the biggest
issues around the Affordable Care Act (ACA)?
I would say that we are going to be on the fastest track. I compare this to the launch of Medicare Part D where, you may recall, they had a discount program that led up to the actual launch of Medicare Part D in 2006. They had a multiyear kind of runway ramp-up for that. We’ve had the same multiyear ramp-up for the Affordable Care Act, but it’s all being condensed; all of the regulations and all of the guidance coming at us gives us less than a year before open enrollment starts in October 2013. The actual start of the program will be in 2014. ■ Is that because of the legal challenges to the
ACA? Yes, part of it was, I think. Because of the Supreme Court ruling in June, there was kind of a slowdown of the release of some of the regulations to see what the Supreme Court was going to rule. After the ruling there was an election, so I think there was a lot of “wait and see.” Now that the election is decided, the Affordable Care Act is the law of the land, and I think we’re going to see, and already are seeing, a very rapid release of regulations that will guide the program. We’re going to have a very condensed period of time to actually get the products designed and up and on the exchange [by 2014] and make sure that they’re certified and meet all the state requirements. We’re not alone in this, obviously. All the insurance companies in Minnesota are facing the same condensed time frame. We have a great deal of confidence and respect in Commissioner Showalter and the exchange team that he has put together to try to get this implemented.
■ Do you think it’s realistic? Are they going
to be able to pull it off? What I have said to everyone around here and folks that have asked if we think there’ll be a delay, I don’t think so. It potentially won’t have everything that everybody wants at the very beginning, but, again, that was true with Medicare Part D as well. They didn’t have it perfect before they went ahead with the launch, and I think we’ll see the same thing here. A number of states around the country have already declared that they are going to build their own exchange, and Minnesota is one of those. The state has submitted their blueprint, so we have committed to building a state exchange. I predict that right at the beginning of the legislature, we’ll get a bill that will essentially set forth the requirements for the exchange in Minnesota. Obviously we will be working with our colleagues in the other health plans here to make sure that gets shaped in a way that is best for the individuals and the small groups that will be covered in the exchange. ■ What has expansion of Medicaid meant
for the private health plans that administer Medicaid programs? It increased enrollment, obviously, by going to up to 133 percent of the federal poverty limit. We, as a large insurer of Medicaid individuals, thought this was a very positive
action on behalf of the governor. The Medicaid expansion today is paid for almost exclusively with federal dollars. Even over time, as it shrinks down, about 90 percent of it is funded by federal dollars. ■ How did the health plan community
react to the competitive bidding for Medicaid plans? The state was in a budgetary cycle that required them to be as innovative as they could be to try to reduce their cost for this population. I think that they went through a very robust process to put in place competitive bidding. Even though we weren’t selected in as many counties as we would have preferred, we felt that the state’s process was fair. The transition was handled very well by the health plans. We had folks, at the end of the year during the holidays, Christmas and New Year’s, that were being transitioned over to new health plans, and all of the plans worked cooperatively to make sure those transitions were handled seamlessly. It was a two-year demonstration for 2012 and 2013. The state at that point will make a determination whether or not they want to continue to do competitive bidding in the metro area and/or potentially expand it to other parts of the state. That’s a conversation that I think is going on within DHS as we speak.
■ Is there another part of the state where
it may make sense to do a competitive bid process? Again, I don’t think we’ll see that in 2013, just given everything else that they have on their plate. After they’ve gone through the two-year competitive bid demo in the metro area, they’ll make that analysis. ■ What do you wish doctors knew about
the health insurance industry? Recently, as we have been rolling out our aligned incentive contracts, we have been working in a very strong partnership with several of the large care systems around the state to create aligned incentive contracts that try to move away from volume-based purchasing to looking at quality outcomes and total cost of care. We have found willingness and, in fact, enthusiasm on behalf of our provider partners, who have put several of these in place. We have nine or 10 aligned incentive contracts now in place that are multiyear contracts designed to encourage the same kind of innovation that we were talking about, and focusing on care transitions and the needs of the chronically ill population. We see this as how we work together to meet the health care needs of Minnesotans. This has been very well received by providers in the state.
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ClaimLynx is used by many national clearinghouses. You may already be using our services and not know it. Shorten your submission route and remittance time—go straight to the payer using ClaimLynx. Every practice is unique and whether a solo practitioner or large multi-specialty group (and everything in between) we can tailor a solution to your claims processing needs that will maximize your benefits.
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South Country from cover Care Programs administered by the Department of Human Services, such as Medical Assistance, MinnesotaCare, and home and community-based waiver programs. After a relatively easy first few years, the plan added five counties in north central Minnesota. The expansion had adverse financial consequences that caused two of the five new counties and one original county to withdraw. Since then, the financials have improved, staffing has expanded to meet the plan’s needs, and a change in leadership has given South Country
new energy. The current county owners are Brown, Dodge, Freeborn, Goodhue, Kanabec, Morrison, Sibley, Steele, Todd, Wabasha, Wadena, and Waseca counties (see Fig. 1). Owatonna-based South Country is one of three countybased purchasing plans in Minnesota. The other plans are PrimeWest Health, based in
The South Country members are often women and children receiving medical assistance; people of color and minorities; working people who do not have access to other coverage; and people who live with disabilities, chemical dependency, serious behavioral health con-
Without a balance between the medical and social concerns, health is often compromised. … Health care for these patients must be comprehensive, or it will fail. Alexandria, and Itasca Medical Care in Grand Rapids. While the three plans’ operations, finances, and relationships with providers and counties differ, they all share a commitment to serving disadvantaged and vulnerable people who enroll in the Minnesota Health Care Programs.
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Specialists for the disadvantaged
MINNESOTA PHYSICIAN JANUARY 2013
ditions, and unstable living environments. Language barriers, communication issues, and low health literacy are commonplace. Our members have different functional capacities, health needs, and insurance benefits, reflected in the “insurance product” they carry (e.g., Medicaid, MinnesotaCare, integrated Medicare/Medicaid programs). Members like these are well known to county nurses and social workers that have served them for decades. These county staff understand special programs available for persons with mental illnesses, developmental and physical disabilities, and varying housing needs, as well as waivered services programs that can offer greater independence and quality of life. These staff also perform most care coordination services for South Country members. Rather than conduct these services by telephone from a central office, they do so in person, in the home, or wherever the member lives. This local arrangement offers advantages for the plan, the members, and the communities. Integrating medical, behavioral health, and social aspects of care is especially important for these populations. In that spirit, South Country links primary care providers and clinics with care coordinators and case managers at the counties. Few primary physicians have working
knowledge of the specialized resources counties offer; as a result, important social and public health services sometimes go unused. Without a balance between the medical and social concerns, health is often compromised. For example, from the “whole person” perspective, patients are unlikely to manage their diabetes when they don’t have a safe place to live; food to eat; or transportation to shop, pick up prescriptions, or keep clinic appointments. Medical care may not be first on their list of priorities, so health care for these patients must be comprehensive, or it will fail. Links to medical care
County staff traditionally have worked closely with mental health providers because of the interrelated nature of county and mental health benefits and services. It is with medical services that stronger relationships are needed. Too many primary care colleagues are unaware of the major efforts counties invest in addressing the health and social needs of this population, often with relatively little input from the medical community. Particularly for people with mental illness and developmental disabilities, and for elderly people who need support to live independently, county nurses and social workers are involved on a daily basis. When county efforts are in sync with primary care, good things happen. Health plans like South Country don’t provide hands-on care, the most important aspect of health care. Clinicians do that. Instead, the health plans provide an organized context in which members can access needed care according to the benefits their insurance covers. The health plans
organize networks, monitor services, and pay providers for delivering the care. Using claims data, health plan staff follow the quality of services and the expenses while being alert for over- and underutilization patterns. Sometimes this involves working with members through care coordination and disease management; other times, health plan staff work directly with physicians and clinics to facilitate care, interpret insurance benefits, and smooth out an innately complex administrative process. As important as an organized system of care is, the core of quality still rests with handson clinicians. In that regard, South Country is fortunate to have an exceptional network of physicians, clinics, and hospitals. About 50 percent of clinical services are delivered through the Mayo Clinic Health System in southeastern Minnesota, with a few other high-volume providers such as Allina Health, and with many smaller local clinics and hospitals. Providers in smaller communities are often federally qualified programs and critical access hospitals, although many independent community practices remain. Without coordination of medical services with mental health and social services, efforts by providers in each of the three service domains are unlikely to reach their potential. When clinicians coordinate with county services, the health of patients improves. High-quality results
Attention to care coordination between practitioners and county staff has paid off in quality of care. South Country, as well as the other countybased health plans, has consistently achieved high scores for quality measures across its government programs. In 2011, for example, South Country received a 4.5 overall star rating from Medicare for its Minnesota Senior Health Options (MSHO) program, which integrates Medicare and Medicaid. South Country’s
FIGURE 1. South Country Health Alliance service area.
MSHO rating slipped slightly to four stars, which is still quite laudable, in 2012. Several individual clinical measures under Medicare rated five stars in 2012, including breast cancer screening (67.5 percent); controlling high blood pressure (73.6 percent); cholesterol screening after cardiac events (90.2 percent); and medication adherence for diabetes, hypertension, and high cholesterol. Results for Medicaid and other programs are comparable to results for Medicare. South Country also performed well in the state’s Lead Screening Program. About 80 percent of the high-risk population was screened through collaborative efforts of counties and primary care providers. Network providers and the county professionals are largely responsible for these and other outstanding results. South Country also conducts several performance improvement projects each year; a current project focuses on post-acute medication reconciliation. The three county-based plans collaborate on many of these projects. County integration
Two unique aspects of South Country have contributed to the health plan’s success: the South Country county integration model and the Community Care Connector program. Each approach is unique to South Country. As the plan has weathered ups and downs preparing for the future, these approach-
es have strengthened the local approach and relevance South Country brings to its members and their communities. County involvement is integrated into the governance of South Country. It starts with the Joint Powers Board (JPB), the plan’s board of directors. The JPB comprises one elected county commissioner from each owner county. Unlike most health plan boards, which
are composed of experts in health care, South Country’s JPB is populated by elected experts in local county affairs. They know human services and public health as well as related aspects of law enforcement and transportation. By virtue of the JPB’s composition, a strong connection with communities is built into the plan. This avoids any separation between the interests of health and health care from the community as a whole. And because the commissioners are elected, they are accountable to their communities every four years. In addition, county directors actively participate in the health plan’s management structure. County public health and human services directors meet bimonthly with health plan leaders to review county experiences, program progress, financials, and future plans. This level of engagement assures that the county point of SOUTH COUNTRY to page 38
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Practices from cover its used to care for similar patients. It appears that some physicians simply practice more cost-effective medicine than others. Consequently, costs could be reduced rather dramatically if physicians (or medical group practices) in the top cost quintile would adopt practice styles similar to those in the lower cost quintiles. Quality of care is unrelated to cost of care
Medicare enrollees. Again, these costs were risk-adjusted, standardized, per-member per-year costs of care. In fact, our national study showed that physicians can lower costs by increasing quality of care for patients with chronic illnesses. For each percentage point increase in the proportion of diabetic patients with appropriate A1c and lipid management, costs are reduced by $51 PMPY. Some of the practices on that study could reduce the PMPY costs for their diabetic patients by more than $5,000 if they would achieve recommended A1c levels for 90 percent of those patients. Another finding from our recent studies also provides good news for physicians. When the characteristics of medical group practices were entered into the analysis, medium-sized physician-owned practices (30 to
65 FTE physicians) were found to have lower costs and, in some cases, higher quality than the large care systems that include medical practices and hospitals. We don’t know why the physician-owned practices have lower costs, but it appears that it is not achieved at the expense of quality of care. Practice culture has been an area of research for us and a reasonable hypotheses would be that large care systems find it difficult to create a uniform culture that values wisely choosing the mix of services to care for patients. Ways of improving cost-quality performance
Our research also identifies some of the medical practice areas that physicians can focus on to improve cost/quality performance while maintaining a reasonable bottom line. Care management. We
Telephone Equipment Distribution (TED) Program
Some physicians may worry that lower cost implies lower quality. Our research also addressed that issue. We found that quality of care as measured by Minnesota Community Measurement is unrelated to costs. Higher-cost practices do not provide higher quality of care. We replicated our Minnesota study with a national sample of 265 medical group practices and found similar results. In that study, costs differed by more than $1,600 between high-cost and low-cost practices, and there was no correlation between costs and quality of care for more than 750,000
It appears that some physicians simply practice more cost-effective medicine than others.
found significant differences across practices in the inappropriate use of ED visits by their patients. We found that some practices had less than 3 percent of the ED visits classified as nonemergent, while others had over 13 percent in this category. Ambulatory care-sensitive hospitalization rates also varied from a low of 4 percent to over 20 percent of the hospitalized patients. Both of these areas of care have significant cost implications, and both often result from a lack of adequate care management for patients with chronic illnesses. High-cost technologies. Another practice-level cost issue identified by our research is the potential overuse of high-cost technologies and, especially, procedures that have no value. Our national study found that medical group practices with more technologies on site had higher costs even though the costs were adjusted to account for patient illness levels and payment differences. Since these practices did not have higher quality scores, it appears that costs could be
Do you have patients with trouble using their 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.
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MINNESOTA PHYSICIAN JANUARY 2013
reduced by a more thoughtful use of these technologies. The key words here are “thoughtful use.” No one wants to limit the use of imaging or other diagnostic services when they are needed and make an important contribution to care management. On the other hand, the list of wasteful practices developed by physicians and endorsed by several medical specialty societies presents a clear picture of procedures and practices that have no value and shouldn’t be done. [The list of these procedures is available at http://choosingwisely.org /?page_id=13.] Here is where significant savings can be achieved without attempting to influence medical judgment about appropriate levels of patient care or creating concerns about saving money at the expense of the patient’s health. Structure of primary care. Another area with significant cost implications is the structure of the primary care process. While our research indicates that the use of electronic medical record (EHR) technologies
increases patient-level costs, allegedly because more billable services are captured, the data indicate that practices with these technologies have slightly higher net financial operating levels. This demonstrates empirically that medical practices can gain more insight into resource use issues at the patient-care level from their EHR data and can also use that technology to improve the efficiency of the production of services. Both will serve them well as partners in accountable care organizations (ACOs) and other shared savings payment programs. The role of nonphysician clinicians also appears to be an issue both in primary care and multispecialty care practices. Our research found that having a higher number of nurse practitioners and physician assistants per physician in multispecialty practices increases patient-level costs. However, in some primary care practices, a higher ratio of these non-physician clinicians decreases costs. Ann Curoe, MD, a family medicine physician and a fellow health-services
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researcher, contends that this results from the differences in the roles the NPs and PAs have in these practices and that by reconfiguring these roles and using the optimal ratio of NPs and PAs to physicians, all of the practices could improve access to care and lower costs. Finally, we were able to include measures of net practice revenue in our national study and found that net revenue after operating costs was not related to patient-level PMPY costs. Consequently, the overall picture presented by these research findings is that medical group practices can achieve much lower PMPY costs of care than proposed by most health-care reform proposals—and can do so while increasing quality of care and maintaining a reasonable bottom line. John E. Kralewski, PhD, MHA, is professor emeritus at the University of Minnesota Division of Health Policy and Management and is senior research advisor at the Medica Research Institute. Bryan E. Dowd, PhD, MS, is a professor in the University of Minnesota School of Public Health’s Division of Health Policy
and Management. David Knutson is a senior research fellow and Yi (Wendy) Xu is a research assistant in the same division. This manuscript is based on data from several of our research projects and publications, including: Kralewski, J.E., Dowd, B.E., Knutson, D., and Xu, Y. The organizational characteristics of best medical group practices. Final Report to the RWJ/HCFO program 2011. Kralewski, J.E., Dowd, B.E., and Xu, Y. “Medical groups can reduce costs by investing in improved quality of care for patients with diabetes.” Health Affairs, August 2012. Kralewski, J.E., Dowd, B.E., and Xu, Y. Differences in the cost of health care provided by group practices in Minnesota. Minnesota Medicine, February 2011. Dowd, B.E., Kralewski, J.E., Kaise, A., and Irrgang, S.J. Patient satisfaction is not influenced by the intensity of medical resource use by their physicians. The American Journal of Managed Care, 15(5):e16-e21, 2009. Kralewski, J., B.E. Dowd, A. Kaissi, A. Curoe, T. Rockwood. “Measuring the culture of medical group practices.” Health Care Management Review, 30(3):184-193, 2005.
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MINNESOTA PHYSICIAN
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he election pendulum continues to swing in Minnesota, as 61 new legislators take office in January with new DFL majorities in both the House and Senate. After two years of Republican control of the Legislature, in November Minnesota voters flipped control back to the DFL, giving the Democrats a 73–61 majority in the House and a 39–28 majority in the Senate. The new DFL majorities, coupled with the DFL-held governor’s office, give a single party control of all three legislative bodies for the first time since the early 1990s, under then-Gov. Rudy Perpich. However, governing under one-party control is still no easy task; the legislative leaders in both caucuses will have to strike a delicate balance when it comes to balancing the state’s budget in the short term while trying to appease the interests of those groups that helped get them elected in the fall. The new majorities in the state House and Senate also bring a new set of committee
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Legislative preview Different cast of characters, same big issues By H. Theodore Grindal, JD, and Nate Mussell, JD
chairs and a few new faces to the forefront, particularly in the area of health and human services. Sen. Tony Lourey (DFL–Kerrick) will serve as chair of the Senate Health and Human Services (HHS) Finance Division, a role that former Sen. Linda Berglin had held for Democrats for more than 10 years before control of the Senate went to Republicans in 2010. Lourey is serving his third term in the Senate and has served as ranking minority leader on the HHS committee under Republican majority for the past two years. Sen. Kathy Sheran (DFL–Mankato) will serve as chair of the Senate Health, Housing and Family Security Committee. Sheran is also serving her third term, having served on the HHS committees in both of her previous terms.
MINNESOTA PHYSICIAN JANUARY 2013
On the House side, Rep. Tom Huntley (DFL–Duluth) returned to a familiar role as chair of the House HHS Finance Committee, a role he held from 2006 through 2010. Rep. Tina Liebling (DFL–Rochester) will serve as chair of the House HHS Policy Committee, a new role for her despite having served on both the Finance and the Policy committees during her previous terms in office. Finally, since all four of the HHS chairs are from Greater Minnesota, it will be intriguing to see what role, if any, outstate influence will play on some of the key pieces of legislation that move through the health committees this session. Big-ticket items—and a budget
The new legislative leadership and new HHS chairs will have no shortage of significant budget and policy issues to tackle in the upcoming legislative session. The November budget forecast projected a $1.1 billion budget shortfall for the 2014–15 biennium. The state’s budget officials added an asterisk to this number, as it could change dramatically depending on the outcome of the fiscal issues being tackled at the federal level. In December, the state went so far as to release a contingent forecast that would add almost $2 billion to the deficit if no agreement is reached at the federal level. However, one positive note from the forecast was an additional $1.3 billion surplus that will go directly toward repaying the $2.4 billion school payment shift that the state used to help balance last year’s budget. With a general target in place, much of the budget talk will shift to discussions of new tax revenue and tax reform. Gov. Dayton has been very public over the last two years about his desire to increase the effective tax rate on the state’s top 2 percent of income earners. Senate
Majority Leader Tom Bakk (DFL–Cook) and House Speaker Paul Thissen (DFL–Minneapolis) will look to balance the governor’s push for an income tax hike with desires to reduce statewide property and business taxes. One tax issue that has received considerable support in the health care community involves increasing the price of tobacco and in turn reinvesting those revenues in the state’s health care system, to help prevent further cuts to the health and human services budget. Medicaid, insurance exchanges, and MinnesotaCare
Following the November election, the state finally has a little clarity on the future of the Accountable Care Act (ACA). Now the question is how the state will deal with expansion of the Medical Assistance program, implementation of a state-based health insurance exchange, and the future of the MinnesotaCare program. Medicaid. Minnesota was one of the early states to expand its Medicaid program in 2010, so there is little question that the program will be expanded to 133 percent of federal poverty guidelines beginning in 2014. The eligibility expansion for single adults without children is projected to add almost 57,000 new individuals to the state’s Medical Assistance program, many of whom either had been covered previously through the MinnesotaCare program or were without coverage. As the negotiations over the fiscal cliff unfold at the federal level, legislators will be watching closely to see what impact potential federal cuts to Medicaid could have on the state’s budget and the federal matching funds the state is set to receive for these newly covered individuals. Health insurance exchange. The Medicaid expansion also fits into the larger, ongoing discussion of a state-based health insurance exchange. This discussion will take up considerable time in both the HHS and Commerce committees in 2013. Over the past 12 months or so, the Health Insurance Exchange Advisory Task Force has been
unpeeling the many layers of the state’s health insurance exchange. Two significant issues that remain for the legislature to tackle are governance and financing. The governance issue centers on the type of structure the exchange would take—i.e., public-private partnership, state agency, or nonprofit entity. The financing discussion is much more contentious. Although the federal government is set to finance the exchange over the first two years, the state needs to determine an ongoing financing mechanism that will cover the annual costs of nearly $55 million. Some of the options being discussed include a user fee for those accessing the exchange, a portion of premium for those policies sold on the exchange, or using a broader tax like the provider tax. In late November, the U.S. Department of Health and Human Services announced it would be assessing a 3.5 percent portion of premium on plans sold on the federal exchange. Whether this provides any basis
for a similar financing mechanism in Minnesota will be something to watch in 2013. Physicians and other health care providers should pay close attention to the insurance exchange discussions, as the exchange likely will become the platform through which a significant percentage of the state’s citizens receive health care coverage, both in the public and private market, starting in 2014. MinnesotaCare. The other big health-care eligibility issue that fits into both of the above discussions is how the state handles coverage on the exchange for individuals between 133 percent and 200 percent of federal poverty guidelines. Many of these individuals currently receive coverage through the MinnesotaCare program. However, with new federal subsidies available for these individuals, and the option of a basic health plan with 90 percent federal matching funds on the table, the question of the MinnesotaCare program remains to be answered. The discussions about MinnesotaCare have the close
ear of the provider community, given the future of the provider tax and its scheduled repeal in 2019. Nursing issues abound
Budget issues aside, there are several significant policy issues that both Sen. Sheran and Rep. Liebling will have to tackle as chairs of the HHS policy committees in their respective legislative bodies. From a hospital perspective, there is significant concern about legislation that would mandate statewide nurse staffing ratios. Both the Minnesota Nursing Association and the Minnesota Hospital Association are likely to make this their No. 1 priority in the upcoming session. In addition, legislators may well see a push by advanced practice nurses for independent practice. The APRNs are likely to put forward the APRN Consensus Model that emerged from the Institute of Medicine study a few years ago. In short, advanced practice nurses want to eliminate the current require-
ment to work under a collaborative management with a physician and to eliminate the requirement for written prescribing agreements. The APRNs’ efforts have drawn the attention of many of the physician practices affected by these changes and could bring to the table a greater discussion about prescribing, particularly in light of the growing prescription drug and opioid abuse problem in the state. Multiple layers of uncertainty
This is only the tip of the iceberg in what will likely be a very interesting session on the health care front. With the ongoing uncertainty at the federal level, the implementation of the ACA, and statewide reforms of the health care delivery model, it will be important for physicians to stay engaged in the legislative process throughout the 2013 legislative session. H. Theodore Grindal, JD, and Nate Mussell, JD, are with the Minneapolis law firm of Lockridge Grindal Nauen PLLP. They provide legal and government relations services to health care providers.
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MINNESOTA PHYSICIAN
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PREVENTION
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hysicians know better than most people about the impact that tobacco has on individuals. In your practice, you see firsthand the devastating results of smoking: death and disease, hospitalization, increased sick time, decreased productivity at work. You also understand the relationship between tobacco and health care costs, and how the hidden costs of smoking diminish your patients’ quality of life. You like to deliver good news to your patients. You likely have spoken to those who smoke about tobacco cessation. After all, there’s no better news to deliver to your patients than the improved health, longer life, increased energy, and fuller pocketbook that are the direct results of quitting. Research shows there is one clear way to motivate smokers to quit and prevent young people from starting: raising the price of cigarettes. Increasing prices on cigarettes is the top driver of smoking declines in our state and around the country. But Minnesota has fallen
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A high-stakes legislative issue Tobacco tax update By Molly Moilanen, MPP behind the pace in our cigarette taxation. Our state’s physicians are recognized thought leaders whose opinions can influence
Tobacco in Minnesota: Still a problem
Today, Minnesota’s adult smoking rate is 16 percent. That number may sound low compared to
Smoking costs Minnesota $3 billion per year in excess health care costs: This equals $554 for every man, woman, and child in the state. patients, policymakers, and the public. You can help make a tobacco tax increase a reality this year—and by doing so, help your patients and tens of thousands of other Minnesotans live longer, healthier lives.
MINNESOTA PHYSICIAN JANUARY 2013
20 years ago, and it is. But 16 percent still translates into 625,000 addicted Minnesota adults, and our kids are still using tobacco at alarming rates. The results are frightening. Each year 5,100 people die in our state from smoking and exposure to secondhand smoke. That’s more deaths than those resulting from alcohol, murders, car crashes, AIDS, drugs, and suicide—combined. And it isn’t happening by accident. Far from having been neutralized by regulations and lawsuits, tobacco companies are still spending millions targeting our kids. In Minnesota, 77,000 youths 21 and under are current tobacco users; they will buy or smoke 13.4 million packs of cigarettes this year. Further, the simple dollars and cents are a stark reminder of tobacco’s effects on our health care system and economy. Smoking costs Minnesota $3 billion per year in excess health care costs: This equals $554 for every man, woman, and child in the state, regardless of whether they smoke. Nor are employers immune from the excess costs of smoking. They end up paying the price through higher health insurance premiums and lost productivity of employees who are more likely than nonsmokers to miss work.
A clear solution: Raise the price
That’s the bad news. But there is good news, too. A new research study has taken the deepest-ever look into what tactics have actually reduced smoking here in Minnesota. Funded by tobacco control nonprofit ClearWay Minnesota, the Minnesota SimSmokeModel examined data to learn what fueled the 27 percent decrease in smoking prevalence our state experienced between 1999 and today. The results were clear. The price of tobacco was found to be the single most effective tool for influencing smoking behaviors in the state—responsible for 43 percent of smoking declines during the period studied. (Other helpful efforts included smokefree policies, media campaigns, youth access laws, and cessation programs.) You may remember some of the tobacco price increases that inspired this progress. In 2005, a health impact fee increased the cost of a pack of cigarettes in Minnesota by 75 cents, and motivated one-fourth of thensmokers to attempt to quit. In 2009, a 62-cent federal tax increase on cigarettes flooded cessation programs with requests for help. QUITPLAN Services, the free cessation program provided by ClearWay Minnesota, saw a 150 percent increase in helpline volumes in the first week the tax took effect. Nationwide, the 2009 increase prevented 220,000 American youth from using tobacco in just the first two months after implementation. The Minnesota SimSmoke findings reinforced previous research from across the country showing that cigarette tax increases were among the most effective strategies for reducing smoking. State cigarette taxes: Behind the times?
Minnesota is a leader in health care in many regards. In the fall of 2012, the state celebrated the five-year anniversary of the monumental Freedom to Breathe Act, our strong smokefree law. Minnesota is healthier because of the law, and support for it has grown, with an over-
Facts about tobacco use in Minnesota whelming number of Minnesotans—nearly 80 percent—now supporting the law. Considering the strong public support for health and policies that reduce youth tobacco use, it is surprising and very disappointing that our state has not increased its own tax on cigarettes since 2005. In fact, Minnesota’s tobacco tax now ranks in the bottom half of states nationally. States that have increased tobacco taxes have seen steep declines in their smoking prevalence as a result. Minnesota should follow suit— but political dynamics and shifts at the Capitol have presented challenges. The benefits for Minnesota: Thousands of lives, millions of dollars
Research projects many public health benefits for Minnesota if we succeed in increasing the cost of tobacco products. A $1.50-per-pack increase would result in nearly 18 percent fewer kids starting to smoke, saving 41,200 of them from a life of addiction. It could save 22,000 Minnesotans from a premature death. The health-care costs savings are also enormous. In the next five years, fewer lung cancer cases would save the state more than $4 million, fewer smoking-affected pregnancies and births could save $13 million, and fewer heart attacks and strokes could save more than $10 million. Minority populations and lower-income Minnesotans are disproportionately affected by smoking and smoking-related diseases. American Indians have the highest lung cancer rates in Minnesota, and African American men and women are 30 percent to 40 percent more likely to die of lung cancer than their white counterparts. Meanwhile, for nearly 50 years the tobacco industry has directly marketed its products to minorities, with campaigns in recent decades targeting African Americans, Latinos, the LGBT community, and other communities. Tobacco tax increases drive quitting among all smokers, but especial-
• 5,100 Minnesotans die each year from smoking and exposure to secondhand smoke. • Minnesota’s 77,000 middle and high school students who are current tobacco users will buy or smoke 13.4 million packs of cigarettes this year. • Smoking costs Minnesota $3 billion per year in excess health care costs: $554 for every man, woman, and child in the state. • The price of tobacco has been found to be the single most effective tool for influencing smoking behaviors in the state. • In 2005, when the cost of a pack of cigarettes in Minnesota rose by 75 cents, one-fourth of then-smokers attempted to quit. Sources: www.stillaproblem.com; www.clearwaymn.org/research; www.mnadulttobaccosurvey.org ly among lower-income individuals, who are the most likely to benefit, both economically and in terms of health improvement, from any increase in the price of tobacco. Bringing down the smoking prevalence rate will have a particularly positive effect on these populations and give them a better chance at health. It is undeniable that quitting improves individuals’ quality of life and happiness. At ClearWay Minnesota, we have heard many stories from those who used our QUITPLAN programs and promotions to quit. One woman wrote of the joy of running her first-ever 5K race after quitting. Another happy quitter saved the money he would have spent on cigarettes and eventually was able to buy a camper with those savings. And by extending life and improving its quality, quitting smoking also gives individuals more and better time with their families and loved ones. How can you help?
Raising the price of cigarettes seems like common sense, but in the realm of public policy there are always challenges. You can help—as a physician, you have a powerful voice, and your knowledge and experience give you an authority that is very meaningful to policymakers. I ask you to join the growing effort to make a new, significant tobacco tax increase in Minnesota a reality rather than a dream. There are many ways to do that. Consider communicating with your representatives at the Minnesota Legislature (to find contact information for your legislators, go to www.leg.state.mn.us/). At ClearWay Minnesota’s website,
www.clearwaymn.org, our Action Center makes contacting legislators easy and provides suggestions and data for letters to lawmakers and the op-ed pages of newspapers. You can also add your name to a database and receive email updates and alerts when your help is most needed. Raise it for Health (www.raiseitforhealth.org) is a coalition of leading health and nonprofit organizations that includes ClearWay Minnesota, Blue Cross and Blue Shield of Minnesota, the Minnesota Hospital Association, the
Minnesota Medical Association, the Twin Cities Medical Society, the American Lung Association, the American Heart Association, the American Cancer Society Cancer Action Network and many others, who have banded together to reduce tobacco use in Minnesota and advocate for a tobacco tax increase of $1.50 per pack. The stronger these organizations are, the more effective they can be in this fight, so your active membership will increase their clout on this issue. As doctors, you know too well the stakes of this problem. In recent years we’ve seen progress slowing, and we need your help. The cost of doing nothing is too great—to our economy and to the health of our citizens. Please join us in the fight for patients’ health and ask our state leaders to support raising the tobacco tax. Molly Moilanen, MPP, is the director of public affairs at ClearWay Minnesota and co-chairs the Raise it for Health Coalition.
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irth defects are a major public health issue in terms of morbidity, mortality, and cost. Major birth defects—conditions present at birth that cause structural changes in one or more parts of the body—can have serious adverse effects on health, development, or functional ability. Major structural birth defects occur in 3 percent to 5 percent of all live births. In Minnesota, an estimated 2,100–3,500 children are born each year with a major birth defect. According to the Centers for Disease Control and Prevention (CDC), treatment of birth defects in the U.S. results in 139,000 hospital stays per year, accounting for $2.6 billion in hospital costs. Birth defects are also the leading cause of death for children during their first year of life. Approximately 10 percent of birth defects are due to environmental factors, 20 percent are due to genetic causes, while the causes of 70 percent of birth defects are currently unknown or only partially understood.
Birth defects in Minnesota Monitoring helps reduce morbidity, mortality By Kristin Oehlke, MS, CGC; Erica Fishman, MSW, MPH; and Barbara Frohnert, MPH
History of birth defects monitoring in Minnesota
In 2002, the Minnesota Department of Health (MDH) received a grant from the CDC to establish birth defects surveillance and began collecting information on 45 structural birth
Information System (BDIS) was established in statute. As of November 2012, the BDIS was monitoring approximately 72 percent of Minnesota births, and it plans to monitor all Minnesota births by 2014.
Major structural birth defects occur in 3 percent to 5 percent of all live births. defects (see Table 1) among live births in Hennepin and Ramsey counties in 2005. In 2004, the Minnesota Birth Defects
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Monitoring and analysis of birth defects
The Birth Defects Information System is housed in the Birth Monitoring and Analysis Program (BDMAP) at MDH. The goals of the BDMAP, as defined in Minnesota statute, are to: 1. Monitor incidence trends of birth defects to detect potential public health problems, predict risks, and assist in responding to birth defects clusters 2. More accurately target intervention, prevention, and services for communities, patients, and their families 3. Inform health professionals and citizens of the prevalence of and risks for birth defects 4. Conduct scientific investigations and surveys of the causes, mortality, methods of treatment, prevention, and cure of birth defects Reports of babies with possible birth defects are received from hospitals and clinics approximately monthly. Abstractors visit facilities to review medical records and determine whether or not a case definition is likely to be met. BDIS case definitions are based on guidelines established by the National Birth Defects Prevention Network, a voluntary collaboration
of national, state, and population-based birth defects programs. Currently in Minnesota, a case is entered into the BDIS if the child’s condition meets the case definition and was diagnosed during the first year of life. Once the case is entered into the BDIS, nurse practitioners review the medical information for quality assurance. Physician consultants who specialize in neonatology, genetics, or pediatric cardiology also review abstractions when additional clarification is needed about specific diagnoses and/or when an infant with a confirmed birth defect has died. Parents or guardians of each infant identified are notified that their infant’s case has met the BDIS criteria. Parents also receive information on public insurance programs, the purpose of the BDIS, and information on how they may exercise their right to remove their identifying information from the BDIS (i.e., opt out of the program). Since most of the birth defects in BDIS are relatively rare, if a family opts out and their identifying information is removed from BDIS, the de-identified case remains in the BDIS in order to maintain the most accurate prevalence estimates possible. If the family does not choose to opt out, the child’s case is referred to their local public health agency for case coordination and connection to community services such as financial resources, Early Intervention Part C, Family Home Visiting, Early Childhood Family Education, Women, Infants and Children, Follow Along Programs, and parent support groups. How birth defects information is used
The BDIS data is used to develop prevalence rates of birth defects. Currently, prevalence rates are provided for live births in Hennepin and Ramsey counties. These rates identify the most common categories of birth defects in Minnesota that are included in the BDIS (see Table 2). Four of the most common birth defects are congenital heart defects (VSD, ASD). The
TABLE 1. Conditions included in the Minnesota Birth Defects Information System. Cardiovascular
Aortic valve stenosis, Atrial septal Defect, Coarctation of the Aorta, Common Truncus, Ebstein’s Anomaly, Endocardial Cushion Defect (AV Canal), Hypoplastic Left Heart Syndrome, Patent Ductus Cardiovascular Arteriosus, Pulmonary Valve Atresia and Stenosis, Single Ventricle, Tetrology of Fallot, Transposition of the Great Arteries, Tricuspic Valve Atresia and Stenosis, Ventricular Septal Defect, Total Anomalous Venus Return (New for 2013)
TABLE 2. Ten most common* birth defects in the Minnesota BDIS. Total Defects
Total # of Rate per defects 10,000 (4 yrs) live births 2,590 267.40
Defect
Body System Category
Atrial septal defect (ASD)
Cardiovascular
444
45.84
Ventricular septal defect (VSD)
Cardiovascular
324
33.45
Hypospadias and Epispadias
Genitourinary
248
25.60
Obstructive genitourinary defect
Genitourinary
196
20.24
Central Nervous Anencephalus, Encephalocele, Hydrocephalus, System Microcephalus, Spina Bifida
Patent ductus arteriosus (PDA)
Cardiovascular
171
17.65
Pyloric stenosis
Gastrointestinal
170
17.55
Chromosome
Down syndrome, Trisomy 13, Trisomy 18
Down syndrome
Chromosomal
143
14.76
Ear
Anotia / Microtia
Eye
Aniridia, Anophthalmia and Microphthalmia, Congenital Cataract
Cleft lip with and without cleft palate
Orofacial
97
10.01
Gastrointestinal
Biliary Atresia, Esophageal Atresia, Hirschsprung Disease, Pyloric Stenosis, Rectal and Large Intestinal Atresia / Stenosis
Pulmonary valve atresia and stenosis
Cardiovascular
56
5.78
Cleft palate without cleft lip
Orofacial
55
5.68
Genitourinary
Musculoskeletal
Oral
Bladder Exostrophy, Hypospadias and Epispadias, Obstructive Genitourinary Defect, Renal agenesis/ Hypoplasia Congenital Hip Dislocation, Diaphragmatic Hernia, Gastroschisis, Omphalocele, Reduction Deformity: Lower Limbs, Reduction Deformity: Upper Limbs Choanal Atresia, Cleft Lip and Palate, Cleft Lip Without Cleft Plate
other most common birth defects include genitourinary defects (epispadius and hypospadias, and obstructive genitourinary defects), the gastrointestinal defect pyloric stenosis, the chromosomal condition Down syndrome (trisomy 21), and the orofacial conditions cleft lip and cleft palate. Prevalence rates are calculated by sex, racial and ethnic group, and maternal age. The birth defects surveillance data reports may be accessed at www.health.state.mn.us/divs/eh/ birthdefects/index.html. These data also can be of use to improve newborn screening and prevention efforts. For example, BDIS data were used to estimate the prevalence of critical congenital heart defects (CCHD) in Minnesota as a basis for supporting the addition of CCHD to the newborn screening panel. Nationally, newborn screening for CCHD by pulse oximetry has been recommended by the secretary of the U.S. Department of Health and Human Services. MDH is adding these conditions to the newborn screening program in the near future. Currently, the BDIS monitors six of the seven CCHDs that are likely to be detected through screening. These
include hypoplastic left heart syndrome, pulmonary atresia, tetralogy of Fallot, transposition of the great arteries, tricuspid valve atresia and stenosis, and truncus arteriosus. The seventh CCHD, total anomalous pulmonary venous return, will be added to the BDIS in January 2013. Based on data in the BDIS, the CCHDs currently tracked affect about 17 children per 10,000 live births. A child may have more than one CCHD. Pulse oximetry screening soon after birth will identify most infants before symptoms develop and reduce the risk of additional disability and even death. Finally, BDMAP works with local public health agencies in 85 of 87 counties and one Native American tribe in Minnesota to assure that the families of children with birth defects monitored by BDIS have better access to available services. Local public health agencies are a vital link in helping families connect to services that may benefit the child and family. During 2011 and 2012, BDMAP conducted a survey to assess the use of services by families affected by a birth defect. In this situational assessment, BDMAP provided local public health agencies with
*Based on prevalence rates among live births in Hennepin & Ramsey counties, 2006–2009 the first notification about these children in 57 percent of cases. Public health nurses contacted 65 percent of these families to assess their needs and to offer assistance. Birth defects prevention
The BDMAP is focusing prevention efforts on primary and sec-
ondary prevention of birth defects. Primary prevention activities are aimed at reducing risk factors for birth defects prior to conception. The Preconception Health in Minnesota grant program is supporting six projects BIRTH DEFECTS to page 36
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MR. CHRISTENSON: What do we mean when we say “health insurance exchange?” MR. MUNSON-REGALA: A health insurance exchange is a facilitated marketplace where purchasers and sellers conduct transactions that connect folks with insurance coverage. It’s a place to shop for insurance products and public health programs like Medicaid in order to access insurance subsidies or tax credits. It provides consumers with information such as the quality, value, and cost of plans, whether or not they ever choose to purchase from the exchange. It is a place where the cost of connecting people to coverage gets reduced.
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About the Roundtable Minnesota Physician Publishing’s 38th Minnesota Health Care Roundtable examined the topic of accountable care organizations. Six panelists and our moderator met on Nov. 1, 2012, to discuss this issue. The next roundtable, on April 25, will explore the subject of patient engagement.
MS. MCMULLEN: Anyone employed by a large employer who is self-insured will not be eligible to purchase through an exchange.
MS. MCMULLEN: From the business perspective, the most important part of what an exchange can and should be is a place for consumers to have the ability to compare different products and enroll in them. DR. SAWYER: It’s a potential stepping-stone toward improving access to care because more consumers will be able to more effectively shop in a sophisticated electronic marketplace. We need to remember that insuring more people does not necessarily lead to universal access. It does not necessarily remove obstacles to receiving care. Will it be a good step forward? Potentially, yes, depending how it’s implemented and how the public receives it. DR. DEHNEL: Everyone wants more health care for a broader segment of the population at a better cost. It’s important to make a distinction between health, which is something we all want, and health care, which is something paid for by health insurance. You can have the world’s greatest health with very few health care services; likewise, you can have the world’s greatest health insurance without necessarily having access to health care services. In talking about the exchange, focusing on insurance is only part of the discussion. Access to care, that’s part of a broader discussion. MR. CHRISTENSON: What do we hope to accomplish with health care exchanges? MR. MAYNARD: To insure the uninsured. An exchange should be a one-stop shop for determining eligibility into government programs like Medicaid and CHIP (Children’s Health Insurance Program), alongside commercial products that can be funded partially
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thousand will be small employers and their employees, defined as groups of 50 or less. Some of those groups could change, dependent on policy decisions made next session. For example, should we expand “small employer” to include groups of 100 or less? Fundamentally, an insurance exchange is intended to serve individuals and small employers.
Health insurance exchanges Assuring they are meaningful through subsidies. The complexity of this is the complexity of all the different programs, plan designs, and products that have to be brought together to accomplish this. MR. SCHUYLER: An exchange will increase transparency around cost and quality, especially in comparing benefits. You’re comparing plans based on price, but in an exchange, you’ll also be able to compare plans and carriers by quality based on different metrics. Increased transparency will be valuable to consumers. MR. CHRISTENSON: Who will be eligible for coverage in health care exchanges? MR. MUNSON-REGALA: A study on the Department of Commerce website projects enrollment in a health insurance exchange to be 1.2 million Minnesotans. Of those, 700,000 are expected to be in Medicaid based on the assumption we’re going to expand Medicaid. We’ll see in the next legislative session if that assumption is accurate. Three hundred thousand individuals are expected to purchase health insurance products, potentially with the assistance of an advance premium tax credit. Two hundred
DR. SAWYER: Every two years, the Minnesota Department of Health publishes a report on insurance coverage. I think the last one reported over 500,000 uninsured Minnesotans. That’s larger than the population of St. Paul, and it’s been increasing steadily over the past several years. More shocking is that of those 500,000 uninsured, 70,000 are children. That’s double the enrollment of the entire Minneapolis school district. Those people often get care in the most expensive clinics we have—hospital emergency departments. Costs are being incurred, yet access to care is a challenge for these people because they lack affordable coverage. And these numbers don’t include people who have high-deductible insurance plans. They have coverage, but it’s not of much practical value to them. MR. CHRISTENSON: What important elements must be included in the health insurance exchange if the benefits that we’ve been speaking of are to be realized? DR. DEHNEL: First, make insurance more understandable to everyone by providing consumers with a much better understanding of what health insurance can and cannot do for them. Second, make it as transparent as possible. We want to make sure those choices lead to decisions that are as well informed as possible for people participating in the exchanges. MR. MAYNARD: A critical aspect for it to be successful is to have choice. To have choice, participation of the plans, employers, and consumers is critical. MS. MCMULLEN: I agree, a variety of options for consumers is important, as is ease of navigation. People assume that this may be like Travelocity, and you’re going to be able to go online and easily buy your ticket for health insurance like you do for travel. Insurance is
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going to continue to be a complicated decision-making process, so we need to focus on ease of navigation for consumers, whether they’re individuals or businesses.
employees pick that default plan because it’s what they were accustomed to. In the second year, we saw employees start to choose outside that default plan.
MR. SCHUYLER: Consumer decision tools and plan selection tools are the most important components of the exchange. If tools aren’t intuitive enough for consumers to make a choice that’s best for them, the exchange will fail. Plus, states like California include vision plans in their exchange, and I think you’ll see other states including other plans—vision, dental, pharmacy benefits—and making sure those are transparent and segregated.
MR. CHRISTENSON: Can a health insurance exchange encourage competition between health plans?
MR. MUNSON-REGALA: Choice and removing the nuisance factor of procuring insurance are important to consumers. The No. 1 concern consumers have is cost. An exchange should be designed to help moderate and manage cost. DR. SAWYER: There’s the argument for the exchange to have many insurance plan options in hopes that use by consumers would be straightforward, easy, and transparent, and another argument that the exchange should include a narrow range of options to ensure consumers can shop effectively. MR. MAYNARD: Technology under consideration will be able to narrow choices. As analytics are developed and the exchange matures postlaunch, use of the exchange will drive ability for plan selection to narrow and remove complexity. Plan designs offered on the exchange will mature, too. Over time, consumer purchases will drive change. DR. DEHNEL: For some people who are in the exchange for the first time, maybe those coming from an environment where their employer covered at least part of their premium cost, it’s going to be sticker shock when they’re suddenly responsible for the entire cost of the premium. For a lot of people there’s going to be a higher cost than they anticipate when they get into the exchange, regardless of the plan they choose. MR. SCHUYLER: That’s a great point. The Utah exchange allows the employer to pick a default plan to cover employees who don’t select a plan. Normally employers select a plan that their employees are most familiar with, a plan that they’ve chosen in the past. In the first year of the Utah exchange, we saw
DR. DEHNEL: Yes, if it is set up well. Competition has always been a good thing. It will put some burden on the payer community to provide information to attract and keep customers. MR. SCHUYLER: Unless there’s a good mix of plans in the exchange, I don’t know that you will get that competitive pressure. There has been some consideration to allowing countybased purchasing units in Minnesota to be members of the exchange. These units carry risk but are not traditional insurance companies or HMOs. They operate with a lean overhead and therefore can keep premiums low but still have robust options for the consumer. Unless they’re in the game, there may not be pressure on other payers. It would be like a discount airline not being able to operate in the Twin Cities. MR. CHRISTENSON: Should Minnesota allow for-profit companies to participate? MR. MUNSON-REGALA: Limiting participation to not-for-profit companies limits choices available to consumers. There are pros and cons to that decision. DR. DEHNEL: There has to be a level playing field for all participants in the exchange. If they are under the same set of rules, have the same state or federal fees and taxes, and as long as requirements for covered benefits are basically in the same area, then you’ll have a level playing field. The concern is that the playing field may not be level for both forprofit and not-for-profit companies. MR. MAYNARD: Participation is key. If there’s choice and participation by all health plans in the marketplace, it will create a competitive marketplace and drive costs down. One of the biggest concerns I hear from states is that not all plans will participate or will participate only in part. Employers and consumers alike won’t want a marketplace where there isn’t choice. It’s key, regardless of nonprofit or profit.
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A B O U T T H E PA N E L I S T S Peter Dehnel, MD, is president of the Twin Cities Medical Society and medical director for utilization management, Blue Cross and Blue Shield of Minnesota (BC/BSM). Trained as a pediatrician, he formerly served as the medical director of Children’s Physician Network of Children’s Hospitals and Clinics of Minnesota. In the latter capacity, he collaborated with other pediatric clinicians to improve care for children and teens in the Twin Cities area. His ultimate goal on behalf of BC/BSM is to optimize the interface between the insurance world and provider community, helping BC/BSM members get the right benefits and services within the context of their plan in order to deliver the best possible outcomes. Dan Maynard is president of Connecture, the leading provider of Webbased information systems used to create health insurance marketplaces and exchanges. The company grew from one he started in 1997, which was the first online broker for health insurance plans that allowed consumers to comparison-shop health plans. Connecture’s solutions are provided to health plans, state insurance exchanges, private exchanges, and insurance brokers. More than 25 million Americans shop for their health insurance through systems built by Connecture, and more than half the nation’s 20 largest plans rely on Connecture systems to sell, administer, and manage their plans and products effectively. Beth McMullen is health policy director for the Minnesota Business Partnership (MBP), an association of CEOs of Minnesota’s 100 largest employers. Since joining MBP in February 2002, she has worked with business executives and government officials to shape health policy in Minnesota through lobbying efforts at the state capitol. Prior to MBP, she worked for Associated Builders and Contractors, Wisconsin Manufacturers and Commerce, and then Congressman Scott Klug (R-Wis.). She has been honored twice by the Minneapolis-St. Paul Business Journal: In 2011 as one of its “25 Women to Watch,” and in 2005 as one of its “40 Under Forty.” Manny Munson-Regala, JD, is the assistant for health reform for the Minnesota Commissioner of Health. He was formerly deputy Exchange director at the Minnesota Department of Commerce, where he was responsible for business functions of the Exchange, including eligibility, enrollment, navigators/brokers, premium management, outreach, and marketing. His career includes public service with state agencies and the private sector, including service as vice president of strategy and partnerships at Ceridian; deputy commissioner at the Minnesota Department of Commerce; director of legal, regulatory, and government affairs at United Healthcare; vice president of government affairs at GeoVera Holdings, Inc., and Discover Re; and assistant vice president, senior corporate counsel at Travelers Insurance and St. Paul Companies. Charles Sawyer, DC, is senior vice president of Northwestern Health Sciences University, Bloomington, Minn. In that role, he serves on the Minnesota Chiropractic Association’s legislative committee and represents the university as a member of the Minnesota Provider Coalition, 15 diverse provider groups working together to affect change. At Northwestern, he has served as an associate clinic director, assistant dean of clinic development, dean of academic affairs, founding director of Wolfe-Harris Center for Clinical Studies, vice president for academic affairs and research, academic dean, and provost. In 2010, he and two Northwestern colleagues established the Center for Healthcare Innovation and Policy to advance complementary and integrative health care. Daniel Schuyler is a director at Leavitt Partners, a health-care intelligence business in Salt Lake City, where he helps to guide the firm’s health-insurance exchange practice. Prior to joining Leavitt Partners, he was the director of technology for the Utah Health Insurance Exchange, where he was responsible for defining technical goals and business processes associated with the exchange, the second of its kind in the United States when created in 2009. Prior to that position, he managed the department of environmental quality, National Environmental Information Exchange Network. There, he helped bring Utah from the bottom third in environmental exchanges to the top 10 percent in less than one year. Robert Christenson, with 40 years’ experience in health care policy and consulting, helps solo and small-group practitioners build a full practice of ideal clients and improve their net revenue.
MR. CHRISTENSON: Do physicians expect detrimental effects from a health insurance exchange? JANUARY 2013
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M I N N E S O T A DR. DEHNEL: There’s a distinction between health care services and health insurance. If the benefit and product design of your insurance plan has a strong detrimental effect on the delivery of health care services, physicians won’t like that. It’s going to disadvantage many good providers in this community if you have an insurance product design that excludes either the care they can give or participation with patients. DR. SAWYER: I don’t know that it’s a detriment per se. All providers are dealing with the challenges of a multipayer environment. The exchange won’t resolve that. When the Affordable Care Act (ACA) was being debated, a noted health economist testified in Congress that Duke University Medical Center, an acute access hospital with 900 beds, had 900 billing clerks. Not 900 physicians, not 900 nurses, but 900 billing clerks in a 900-bed hospital. We’re going to perpetuate complexity on the provider side of dealing with that multipayer environment. And not just multiple payers but multiple levels of benefit access within that payer. We have a huge administrative burden across the system that is unmatched in the world. We have to wrestle with that.
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DR. SAWYER: Might the exchange evolve over time to fulfill higher aspirations in the context of health reform? Right now, I think the temptation is to overpromise and not reach those expectations. MR. CHRISTENSON: States can create their own exchange or they can allow the federally traded exchange to go into operation. How would a state benefit from having its own exchange instead of participating in a federally operated exchange? MR. MUNSON-REGALA: Minnesota’s decision to build its own exchange gives us the opportunity to tie our exchange to the broader range of health reform initiatives that Minnesota has been working on for some time. That’s less likely to occur in a federal exchange. Another benefit of a Minnesota-based exchange is that exchanges will need to provide
spective, a lot of my members have employees in all 50 states. While it’s important for Minnesota to take advantage of advances we’ve made in health care, we need to pay close attention to what’s happening across the country so we have continuity in how employers communicate with exchanges. For example, we don’t want General Mills, based here but with employees all over the country, having to figure out how to communicate with exchanges in 50 different ways. It’s important for Minnesota to have its own exchange, but we need to make sure that we have some continuity across the country. DR. SAWYER: Control of the exchange should be at the state level, but there’s a price to pay for that control. Like-minded states, especially those that are contiguous, could collaborate and get economies of scale. Minnesota will probably spend $100 million just to get this thing built. Ongoing maintenance is another expenditure. MR. MAYNARD: Sustainability of the exchange will be borne by the exchange and the state, whether it’s a federal or state pro-
There has to be a level playing field for all participants in the exchange.
MS. MCMULLEN: For employers, one of the biggest concerns about the exchange as it is under the ACA is the amount of communication that must occur between employers and the exchange regarding human resource information. For example, how much an employee earns, in order to determine if they qualify for a subsidy or a public program. MR. MAYNARD: It’s daunting, the education and the timing associated with all of this. The program rollout is a fixed time frame, so we basically have a year to completely educate the entire population on how to purchase insurance. MR. SCHUYLER: Beth and Dan make a great point about outreach and education and how important it is to communicate how the exchange is going to work. This is a new way for employees and individuals to purchase insurance. Outreach and education are critical to ensure people understand how the exchange works and how they can make informed choices. The way we approached the Utah exchange was via a limited launch, addressing concerns that arose during that launch. That exchange is in its third iteration, learning from past mistakes and consumer feedback.
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a lot of customer service, and I’d prefer customer service relationships with folks in the state than with those outside Minnesota. That’s partially because there’s a connection to the marketplace that matters. Ultimately, states want a state-based exchange so that they can continue to control their markets and their health care environment. MR. MAYNARD: Every state would like a statebased exchange. If you take politics out of it, whether it’s a blue state or a red state, what it comes down to is taking control and having that access, as Manny said. I would be hardpressed to think that there are many states that would say, yeah, I would like to give that all up to the federal government. MS. MCMULLEN: From a large employer per-
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gram. Some forward-looking states are collaborating to create consistency in how programs will operate. MR. CHRISTENSON: When Utah made the decision to create their own exchange, what was in their minds? MR. SCHUYLER: Utah chose to build a small group exchange because employers were seeking ways to mitigate rising health care costs. Several stakeholders proposed defined contribution, which allows an employer to provide an employee with a set dollar amount every month. The employee could go into the Utah Health Exchange and purchase any product from any insurer in the exchange. In the first year of the exchange, we had 66 products and three insurance carri-
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M I N N E S O T A ers. Defined contribution allows the employer to forecast and predict costs on an annual basis because they can control the defined contribution that they allocate as part of their budget to the employees. It gives the employees greater choice instead of picking only one plan provided by the employer. They can go into the exchange and choose from what are currently 198 different plans. It builds loyalty between employee and carrier because now these products are portable. It doesn’t matter if the employee leaves and goes to work for another employer. As long as that employer is in the exchange, the employee can carry that health plan with them. Before, you didn’t have that. Defined contribution has been a big success with the Utah Health Exchange. MR. CHRISTENSON: If Minnesota has a statebased exchange, not a federal one, can we design our own essential benefits set?
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acute and chronic pain. They also provide that in an outpatient, ambulatory context. Will these providers be included in those benefit packages? MR. CHRISTENSON: The Affordable Care Act requires the financing of health care exchanges to be self-sustaining. Where should the money come from to operate Minnesota’s exchange? MR. MUNSON-REGALA: Exchanges need to be self-sustaining starting in 2015. Before that, Uncle Sam pays for design, development, and operational costs of an exchange. In 2015, we have several options. One is the Medicaid match. Some funding could come from our partner agency, DHS. Another source of funding could come from user fees, either on top of the premium or from the premium itself. In other words, consumers, insurance
MR. MUNSON-REGALA: Yes, until the feds implement one nationwide in 2016. If we choose to add additional benefits and/or
If there isn’t choice, if it isn’t affordable, you’re not going to get participation. Dan Maynard
mandates on top of that core set, the state of Minnesota picks up the cost associated with requiring additional benefits to be sold throughout the entire marketplace. DR. SAWYER: The Affordable Care Act requires 10 categories of essential benefits, including ambulatory patient services, rehabilitation, laboratory services, and preventive and wellness services. Which providers of those services will plans include in their benefit package? For example, chiropractic doctors are in many respects primary care physicians, certainly for musculoskeletal problems, and they do that in an ambulatory service capacity. They also provide preventive and wellness services. Second example: Acupuncturists are increasingly sought after, particularly for patients with
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companies, navigators, and brokers using the exchange may pay some fee to access it. General revenue—highly unlikely—could fund. Other possibilities include naming rights and advertising. It’ll probably be a blend of some of those rather any one mechanism. DR. SAWYER: Manny’s right; it’ll have to be a blend. According to documents from the Insurance Exchange Task Force, as of last week, it had not reached a conclusion about how this will be operationally paid for. MS. MCMULLEN: We believe there should be a market outside the exchange. You have to consider the impact of the cost of that exchange. You don’t want it spread across the whole market. It should be paid for by the users of an exchange.
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MR. MAYNARD: If you’re going to use user fees, I’d make them transparent versus making health plans pay an extra fee to be on the exchange. I’d make it as transparent as possible so that the competitive nature of it can play out without having administrative costs buried within. MR. SCHUYLER: Utah pays for the exchange strictly through a per-member, per-month administrative fee. That fee includes a $6per-month admin fee to pay for operation of the exchange. Brokers that facilitate enrollment for, I believe, about 93 percent of the employers that come through the exchange, get a $37-per-month commission on each transaction. DR. DEHNEL: In our own Minnesota experience, when the provider tax first came out there were prohibitions against being able to disclose that. Minnesota doesn’t necessarily have a great track record of transparency in these mandates. I second the notion that we have a transparent disclosure of wherever fees come from. MR. MUNSON-REGALA: Massachusetts funded its exchange with an initial loan from the legislature that had to be repaid. Massachusetts’ funding source was a percentage of the premium of the policy sold in the exchange. So they kept a cut off the top or the bottom. It started at 5 percent of premium. It’s now around 3 percent, scaled down relative to its predicted revenue and projected expenses. Percentage of premium, in a way, is a fee for insurers. Another way an exchange could fund itself could be in the form of an annual license to participate in the exchange: If an exchange is a farmer’s market, you pay rent on the stall you have in the farmer’s market. There’s disagreement about whether or not the exchange is useful to anybody other than the folks buying through it. I would say it does. If you come to the exchange to shop but you go to Blue Cross to buy directly, the exchange has served some benefit to you because it has given you validation that the price you get from Blue Cross is the best one you can get. The exchange provides validation for your purchasing decision. How much that’s worth to you and where the expense for providing that service comes from, I don’t know. Also, this will be a nonprofit exchange, so generating revenues through grants and donations is another option.
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M I N N E S O T A MR. CHRISTENSON: Federal dollars are going to be available for financing the Minnesota exchange. When do federal dollars stop and when do we have to pick up the entire bill for operating the exchange? Could Congress increase or extend that allocation? MR. SCHUYLER: The last deadline to apply for a grant is December 2014. It’s possible that HHS could extend deadlines. There doesn’t seem to be a limit right now on the size of the grant award. Allocations aren’t population dependent, judging by grant awards we’ve seen. Anywhere from $18 million to over $100 million grants have been awarded to states of various population sizes. A state determines the funding it needs to build an exchange. Population is a big factor in that. Then, the state submits its budget to HHS for review and approval. HHS approves it, denies it, requests clarification, or tries to amend the amount requested. I believe you can do this relatively inexpensively, for far less than states are being awarded. It depends how comprehensive an exchange a state wants to build. To me, it doesn’t require $100 million to build an exchange, but those are some of the awards being made.
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That reflects a different organizational choice by each exchange. Minnesota’s projected operational budget is around $30 million plus. DR. SAWYER: Manny, I understand that there’s a cost in the state budget for Medicaid enrollment and eligibility certification. We won’t know for some time if this will help the consumer. MS. MCMULLEN: I want to add one piece to this. There are a number of dynamic forces in health care insurance costs. Uncompensated care was mentioned. The cost of those individuals is shifted onto the rest of the market. We also have the market power of negotiating. Do large employers have a significant advantage in negotiating for payment of health care? We also have the government cost
MR. MUNSON-REGALA: The numbers depend on projected enrollment in the exchange. At some point you reach economies of scale, but there still will be incremental cost of providing service, particularly customer service, to more people. The other unknown that relates to ongoing operational cost is the role of agents and brokers. If the exchange is going to pay for them, that’s a cost that’s not currently in its budget. That would add to what we’d have to generate in the form of revenue to pay for that distribution channel. There are a number of unknowns as to what we expect an exchange will cost on an ongoing basis. Massachusetts’ exchange costs $30 to $40 million a year; Utah’s, less than $750,000.
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DR. SAWYER: Maybe the best configuration is a combination of agency and nonprofit. If the exchange is to be successful and respond to the needs of consumers who are patients, there needs to be a strong
A variety of options for consumers is important.
DR. DEHNEL: One opportunity with an exchange is to expand the number of people who have insurance. If you reduce the number of uninsured people, you reduce uncompensated care. Uncompensated care is something we’re all paying for through higher premiums or higher copays. An exchange would help reduce the cost of uncompensated care that you’re currently bearing in a nontransparent way. MR. CHRISTENSON: Have we set a budget for what we consider the basic necessities of operating our own exchange, Manny?
MR. MUNSON-REGALA: There are three options a state can select from in setting up the governing structure of their exchange. The first is a state agency, either an existing one or a new one. Another option: Some states have set up nonprofits to administer their exchanges. The third option is a hybrid of the two, a public-private entity. There are some of those in Minnesota already, such as the Minnesota Zoo, where public entities and private participants work together on the zoo board to administer the zoo. Such public-private entities are the preferred form in states that have passed exchange legislation. The word “hybrid” envisions a range of operational choices. One person’s hybrid could look remarkably different from somebody else’s.
Beth McMullen
shift where Medicaid pays at a lower rate. Now we add the exchange and how we pay for that, yet another complicating dynamic force. We’ve got a number of dynamic forces and we can’t pinpoint how they affect health care insurance costs. We need to consider that as we’re looking at adding another dynamic force, which is the exchange. MR. CHRISTENSON: How should our Minnesota health insurance exchange be governed? For point of reference, the health insurance exchange of Minnesota began at the Department of Health, moved to Department of Commerce, moved to Management and Budget, and then a piece of it moved back to Department of Health. It is currently an open question as to how this exchange will be governed.
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advocacy element representing patient needs. MS. MCMULLEN: We support a governing structure that is nonprofit outside of state agency. We have examples of those in Minnesota that have worked really well, and you can structure it to have stakeholders around the table as a nonprofit governing board. DR. DEHNEL: You need a broad range of stakeholders at the table. You also need people who have business, insurance, clinical expertise, all coming together, and certainly the consumer. If it’s independent of a state agency, that would be best. MS. MCMULLEN: A majority of people who sit on a governing board need to have some ex-
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M I N N E S O T A pertise in what the exchange is, and that is an insurance marketplace. That should include small employers who are purchasers through the exchange, as well as individuals. It gets difficult to have that level of expertise. We need to rely on our care providers, as well as the expertise that health plans that will be selling insurance through the exchange bring to the table. DR. DEHNEL: Physicians should be on the board. The reality is that health insurance does influence the delivery of health care services. In order to see how an insurance marketplace design influences health care delivery, it’s crucial to have that voice at the table. DR. SAWYER: I agree with Peter, as long as there are folks like me representing other provider groups. We have very similar per-
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MR. MUNSON-REGALA: Should health plans have a seat at the table? Including folks who have subject matter expertise tends to be counterbalanced by arguments that those same people have an inherent conflict of interest because their livelihoods depend on the operation of the exchange. The same observation has been made about providers and facilities. If they participate in the governing structure, they may be in the position to impact their own bottom line. I’m not saying that’s a bad thing; I’m just saying that those are pros and cons of allowing folks with perceived conflicts of interest on the board. DR. DEHNEL: As long as you fully disclose a conflict of interest position, you simply recuse yourself from the discussion. Boards that operate well accommodate those different interest positions.
Up to $750 billion in our health care system is wasted every single year. Charles Sawyer, DC
spectives regarding the need to look out for the interests of patients. I agree there has to be some understanding of how the insurance industry fits into this equation. There also needs to be a voice that is independent and cares less about revenue or profit and is devoted to what patients actually need and the quest for universal access. If you really want the consummate nonpartisan advocate, it would be nurses. So I would add a third group, and that is the nursing profession. MR. MAYNARD: It’s largely about consumer shopping and selection process. That expertise is essential to making sure the exchange provides a successful way to acquire insurance or government benefits.
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DR. SAWYER: Peter, you’re right. It depends on the ethics of folks that serve on an organization like this and their ability to distance themselves from conflicts. By its very nature, the governance structure of an exchange will have to be robust. The small business community has a stake in this. Consumers have a huge stake in this. You’re going to need a mix of people around the table that have one interest in mind, and that’s getting people access to care and affordable coverage. That’s got to be the guiding principle. The plans have to be there because that’s where technical expertise is going to be if we’re going to continue with a private insurance model. MR. SCHUYLER: Stakeholder engagement
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during development of the exchange is extremely important and needs to include a cross-section of experts from all industries. That philosophy should carry over to the governing structure. MR. MUNSON-REGALA: Inherent challenges in this enterprise are barriers to data sharing and data analytics. We fully anticipate the minute we go live that someone will attempt to hack us, because we’re going to have access to personal and financial information that could be of value to someone. That’s a data security concern we have to deal with. There’s a data-sharing dynamic inherent with the requirement that we do eligibility and enrollment in real time. The only way we can do that is by connecting to the federal data hub that accesses information from the IRS, Homeland Security, and Social Security. That might pose data-sharing challenges. At some point, we’re going to connect with the plans on information that they view as proprietary. DR. DEHNEL: There’s a distinction between proprietary versus protected information. That presents a huge issue in terms of what plans can work with as they collaborate with clinics and hospital systems. According to Minnesota law, there is a limited amount of information that health care providers can share with plans. Minnesota has gone above and beyond HIPAA statutes in terms of creating barriers to sharing information. As we construct this opportunity for enhancing care that’s called an exchange, looking at our data and enhancing our data analytics capabilities, we will have to revisit those barriers. Regarding data sharing, we’ll need to see what is possible, what is legal, and if there is a state statute that has to be modified in order for us to do this more effectively. MR. MUNSON-REGALA: Who should maintain, control, and disseminate that data? Should it be the exchange or some other entity? Speaking of conflicts of interest, a marketplace participant—which the exchange fundamentally is—has access to information that competitors may not. Do we prohibit the exchange from data mining their transactions to give information to their partners? Do we say that the exchange’s data should be maintained and safeguarded elsewhere? I suspect this dialogue’s going to occur during the next legislative session. MR. CHRISTENSON: What criteria should be used to determine the essential benefit set that
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M I N N E S O T A will be covered by insurance options available on the exchange? DR. SAWYER: The decision should be as evidence-informed as possible. The companion part of that decision is the value that patients place on certain therapies, care providers, certain ways of providing care, and settings of care. When it comes to essential benefits, there has to be a balance of those two factors. We waste a lot of money in this country, and all providers, regardless of the discipline, are guilty of that. Part of that waste occurs because we don’t know enough about what works and under what setting and for what reason. Plus, we’re all chasing another reimbursement dollar. If the goal is to keep costs down and improve the quality of care while responding to the desires of the consumer, we’ve got to be mindful of all of those considerations. MR. SCHUYLER: The EHB (essential health benefits) benchmark is a double-edged sword. While you’re trying to find a baseline that has a benefit level that can cover a vast majority of consumers, you also need to make sure that benchmark is affordable. Otherwise, you’ll price people out of the exchange, and then these subsidies won’t have the impact they should. That’s a struggle a lot of stakeholders are having with the EHB. MS. MCMULLEN: The discussion around EHB has been going for decades. This is not an easy question, and I was shocked when the ACA said it would identify the essential health benefit set. Really? Where did they find the answer? If you stop 100 people on the street and ask them, “What is essential for your health care coverage today?” you’ll get 100 different answers. We need to keep the consumer in mind because that is what this exchange is about: providing access to coverage, keeping the consumer in mind in terms of what options are available. If we have too broad an essential health benefit, you’re going to price people out. MR. MAYNARD: In order to meet every consumer’s need, affordability is what it comes down to. The lower cost side of the scale has to be considered, and if essential health benefits are too high, it’s going to create something that’s not affordable for one section of the economy. DR. DEHNEL: The broader and more inclusive you make that set of essential benefits, the more expensive you make it. That’s based on
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the cost of delivering that care. MR. MUNSON-REGALA: EHB applies inside and outside the exchange; it applies to our entire marketplace. Beth is right, this one’s going to be an ongoing conversation. Criteria for EHB say you must meet roughly 60 percent of actual value in every product. You can’t sell a product that pays for 20 percent of potential losses now. Going forward, 60 percent of projected claims have to be covered by this product. In addition, for you to be sold in an exchange, you have to meet network adequacy provisions, marketing standards, and quality standards. Those three elements are going to be subject to dialogue at the legislature. There are federal parameters in which those decisions are going to be made. We’re going to have a dia-
other modern economies, there’s a big cliff between the U.S. and the next highest country. Nobody’s projecting this cost curve will flatten anytime soon. Another statistic that’s staggering: A few months ago, the Institute of Medicine published a report that estimated that up to $750 billion in our health care system is wasted every single year. They also estimated that about $190 billion of that $750 is pure administrative excess. Fraud, unnecessary procedures, practice variation, and a host of factors add up to that $750 billion. We’re spending boatloads of money and not getting value, and we will have to wrestle with this question about what benefits are in, what kinds of providers are in, and what will patients have access to. It’s going to be a huge challenge. DR. DEHNEL: When a consumer has a portfolio of plans from which to choose, how are they going to decide which of the various options to go with? They will likely look at their health care needs and
An exchange will increase transparency around cost and quality. Daniel Schuyler
logue around what it means to have an adequate network, what it means to have a quality plan or an acceptable level quality, and what marketing standards should apply. One of the big policy questions I think we’re going to have is: should standards of network, quality, and marketing apply to nonexchange products? MR. CHRISTENSON: A current component of health insurance is preauthorization for a number of services and procedures. Would that be included in the exchange, or is there the opportunity to reject it? DR. SAWYER: I think that would be left up to the plans to determine, or for that decision to be made through another mechanism. To give you some context, we spend about 18.5 percent of our GDP on health care. When you look at where the U.S. ranks among
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ask, do you cover this? They may say, my child has autism; do you cover autism services? That’s going to be at a plan-specific level. It’s likely that you will have some variation on what plans cover. That may be the value of having choices. For example, I’m healthy. My BMI is 25. I don’t smoke. How can I get a more limited array of services because I choose to live healthy, versus someone with a BMI of 45 who says, “I like to sit around and watch Sunday afternoon football and Thursday night football and eat my Doritos and drink my beer and smoke my cigarettes at the same time”? You may have a different set of health care needs at that point, and you may choose a different plan based on what your needs are as a consumer.
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M I N N E S O T A MR. MUNSON-REGALA: Remember that an exchange’s fundamental role is to connect people with an insurance product. Our ability to utilize the exchange as a lever to do other health reform initiatives, modify environmental determinants of care, modify lifestyle choices, do this, do that, will have to be filtered through the connection between pocketbook—what you pay for a premium or copay—and insurance product. I propose that it’s a fairly limited type of tool. It’s not the only tool in the toolbox. When we consider what we can use the exchange to do, in a lot of these areas it will complement other initiatives. Where it is going to be the primary lever is in connecting people to access and potentially driving information around quality. MR. SCHUYLER: The exchange is not a silver bullet, it is a silver BB.
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than average populations. Risk adjustment smooths out that winner and loser perspective. We would take money from one plan and give it to another plan to reflect the fact that the plan that is receiving money is insuring a sicker than average population. It seems straightforward, but you can imagine the challenges of taking money out of my pocket and giving it to Dan, for example. I’m going to say, wait a minute, we’re not that different, or, you’re taking too much because his population isn’t that sick. That becomes the dynamic whenever you start swapping money around carriers. That’s the fundamental concept of risk adjustment: to eliminate risk selection as a reason for plans to participate in the marketplace and, hopefully, get them to compete around things like outcomes, quality, or other metrics. We’re relying on federal risk adjustment method-
An exchange’s fundamental role is to connect people with an insurance product. Manny Munson-Regala, JD
MR. CHRISTENSON: What risk adjustment methodology should be incorporated into an exchange to provide fair and transparent pricing once enough data has been collected to impact policy rates? MR. MUNSON-REGALA: First, what is risk adjustment; what does it accomplish? It stems from the tendency of people to act in their economic self-interest. If you know you can buy an insurance product whenever you want, the tendency would be to wait until the last moment to buy. That would mean insurance would be purchased by people who need it and prices would increase. In order to eliminate that, we require everyone to pool in order to purchase. Within that pool, there will be some winners and some losers with the plans because some plans will have sicker than average or healthier
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ology for the time being. We have no statutory authority to use the state source of data that would allow us to do a state-based risk adjustment mechanism. Our hope is to move toward a state-based risk methodology system that is prospective. Getting there involves technologic and political barriers. DR. SAWYER: The other piece of this that is probably under-recognized is accuracy and granularity of the data. For example, there’s a difference between a little back pain and a lot of back pain. If I’m not accurate as a clinician or if a physician isn’t accurate in diagnosing and coding a procedure, it can skew the math and characterize an individual or a collection of individuals as more severely ill when they’re not. There is a lot of gaming going on now in the form of upcoding. I don’t know how to resolve that. Using accu-
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rate data for risk adjustment is critical if this is going to work. The federal system is woefully imperfect, but that’s the one we’re going with for now. Would it be better to have a Minnesota-based formula? Clearly, but that’s going to mean a lot of diligence and resolve in terms of accurate information. MR. MAYNARD: There are big issues involved in sharing data so that you can monitor it from health plan to health plan. In order to tell whether people are complying or not, you have to look at the data. There are significant issues from a data aggregation standpoint as well as from a data sharing perspective that will make it difficult and complex to do that. MS. MCMULLEN: Risk adjustment should be invisible to the consumer purchaser, which means it needs to be fair. DR. DEHNEL: On the clinician side, there have been attempts at risk adjusting patient populations of clinics and hospital systems for the last 30 years because, as a physician, I’ll say my patients are always sicker and that’s why the cost of delivering care is higher. Right now, we have risk adjustment methods that may account for 25 percent to 30 percent of the true variation in disease cost. I’m not sure how we’re going to do that at an exchange level. Risk adjustment hasn’t been solved in the last 30 years or more; I’m not sure how we’re going to do it in a short time frame for this operation. MR. SCHUYLER: We don’t know who the pool of insureds will be. So although we can forecast the type of risk that will come from all of the new enrollees in an exchange, we won’t know until we have at least a year’s worth of data. I predict you’ll see different risk adjustment models state by state, a federal model, and models being distributed by other entities. MR. MAYNARD: Insurers have to deal with risk adjustment whether it’s coming from the exchange or not. MR. CHRISTENSON: At this point in time, who is eligible to use the Minnesota exchange? MR. MUNSON-REGALA: Legal immigrants and small businesses of 50 or fewer. People who are eligible for subsidies through the exchange includes individuals from Medicaid who are between 138 percent and about 400 percent of the federal poverty level. That translates to roughly $44,000 a year for an individual or $90,000 for a family of four. Eligibility for the small-employer
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M I N N E S O T A two-year tax credit is for employers of 25 or fewer. It’s a combination of the average salary your employees make and the size of you as an employer. So it’s not all small employers, it’s a subset of them. MR. CHRISTENSON: In order for the exchange to be successful, we need a lot of participants. What must be done to ensure that the eligible population uses the exchange? MR. MAYNARD: Education and choice. Participation is going to come from consumers and small businesses benefiting from the exchange. If there isn’t choice, if it isn’t affordable, you’re not going to get participation. If you don’t have participation, insurers aren’t going to want to be on it At the end of the day, you need affordable products on the exchange.
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MR. CHRISTENSON: Should a time period be set for accomplishing the process of setting up administrative processes and continuity of care? DR. DEHNEL: If a participant in the exchange says, I’m going to use this plan this year, but this other plan looks less costly for next year, that’s going to cause tremendous problems. If the insurance exchange says that you have to provide continuity of care with existing providers for X length of time, that may diminish your ability as an insurer to create a product that meets the needs of all of your stakeholders. I would get very concerned about this notion that people can
MS. MCMULLEN: Make sure that the exchange is easy to navigate and communicate to employers how an exchange might increase the purchasing power of a small business. MR. MUNSON-REGALA: Sixtyfive percent of small employers trusted their agents and brokers more than their spouses when it came to insurance decision-making. If we don’t involve agents and brokers, our ability to get small employers to participate will be nil. MR. MAYNARD: Small employers use brokers because they don’t have HR departments or benefits specialists. Somebody’s going to have to provide that service to small employers in order to draw them to the exchange. DR. DEHNEL: Physician and chiropractic communities can help people navigate insurance choices. DR. SAWYER: I work with the Harbor Light Center, the Salvation Army facility in downtown Minneapolis. There are homeless people who not only lack access to computers, but will need someone sitting with them to help them navigate a user-friendly navigation structure.
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move in and out of plans quickly. That will be a problem for their continuity of care. If they have significant chronic ongoing disease, it’s going to cause problems. MR. MUNSON-REGALA: I’ll argue the opposite. Think about a dynamic where consumers get to choose which product they want to purchase irrespective of who their employer is. If they find the product compelling enough, it doesn’t matter when they change jobs. If you are a carrier, you now have that consumer as a participant, potentially for the duration of their life. MR. CHRISTENSON: How should a health insurance exchange’s success be measured? MR. MUNSON-REGALA: Did it meet the minimum requirements required by law around enrollment, eligibility, and connectivity with Medicaid? Did it increase access to care? If we don’t reduce the number of uninsured, we haven’t done our job. Did individuals find their experience helped them understand how their decisions impact their health?
MR. MAYNARD: Getting the uninsured insured. That’s what this is all about. DR. DEHNEL: The term “Triple Aim” refers to improving the experience of care for the individual; improving the health of the population as a whole, in this case in Minnesota; and mitigating increasing health care costs. If the exchange helps to accomplish the Triple Aim, then it will have succeeded. MS. MCMULLEN: Does it increase access to coverage? Minnesota has a relatively low uninsured rate, but a significant number of uninsured are currently eligible. If we can reach them and get them enrolled, it helps the system as a whole. Does the exchange increase my purchasing power? “Am I able to get better value for my dollar that I’m bringing to the table?” is an important measurement for the exchange. MR. SCHUYLER: One metric I hope everybody takes away from this is that in the Utah exchange, 30 percent of employers using the exchange didn’t offer coverage to their employees prior to enrolling in the exchange. If we can provide greater access, reduce the number of uninsured, and make the process of choosing a health plan less painful, that would be a great benefit. DR. SAWYER: The Exchange Advisory Task Force set out six guiding principles. Three resonate very strongly with me: universal coverage, high quality affordable health care, and elimination of health disparities. It’s a necessary, high aspiration. The exchange will help, to some extent, accomplish those aspirations. Let’s reduce the immense complexity we have that creates barriers for patients to receive the care they need in a timely fashion.
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Spine Surgeons, join our team and set the standards for patient care. Orthopaedic Associates of Duluth is seeking a highly motivated passionate and experienced SPINE SURGEON to provide outstanding orthopaedic care to its patients. The successful candidate will be part of our expanding and growing, well-respected team that serves patients from Duluth to northern Minnesota.
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Medical Director Opportunity, Metropolitan Health Plan (MHP)-Hennepin County, Minneapolis, MN MHP, a state certified HMO, is seeking a Medical Director to provide oversight medical administration functions and assist the Director of Medical Administration in providing strategic leadership to enhance services to members. Hennepin County offers a comprehensive compensation package and an atmosphere that promotes dedication and commitment to public service. Hennepin County was listed in Minnesota Magazine as 1 of 48 “Great Places to Work”.
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Best Qualified Candidates will have: • Graduated from an accredited school of medicine with a Doctor of Medicine or Doctor of Osteopathic Medicine Degree and have completed an approved internship and an approved formal adult or child residency. • A valid license to practice medicine issued by the State of Minnesota, board certification in the appropriate specialty. • At least five years of related supervisory experience, of which at least two years were in the health care or insurance industry. To view the complete posting, learn more information, and access the online application process, visit our website at www.hennepin.jobs. This position is open until filled and may close at any time.
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JANUARY 2013
MINNESOTA PHYSICIAN
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PROFESSIONAL
A
lport syndrome, an important inherited cause of end-stage renal disease and sensorineural deafness that affects an estimated 30,000– 60,000 individuals in the United States, results from mutations in genes that encode members of the type IV collagen family of proteins. Stimulated by their fascination with the structure and function of glomerular basement membranes, investigators at the University of Minnesota, including Alfred Michael, Alfred Fish, and Robert Vernier, initiated studies of Alport syndrome pathogenesis in the 1970s that continue to this day.
Genetic mechanisms of Alport syndrome
Type IV collagen is the major structural constituent of basement membranes. Each of the six type IV collagen α chains (α1[IV] – α6[IV]) is encoded by a specific gene (COL4A1– COL4A6). The type IV collagen genes are arranged in pairs on three chromosomes: COL4A1 and COL4A2 are on chromosome 13; COL4A3 and COL4A4
U P D AT E :
P E D I AT R I C S
Alport syndrome Progress in treating a rare, progressive disease By Clifford Kashtan, MD
are on chromosome 2; and COL4A5 and COL4A6 are on the X chromosome. About 80 percent of people with Alport syndrome have Xlinked disease due to mutations in the COL4A5 gene. Approximately 15 percent have autosomal-recessive disease due to mutations in both alleles of COL4A3 or COL4A4. While rare families have autosomaldominant Alport syndrome resulting from a single COL4A3 or COL4A4 mutation, heterozygous mutations in COL4A3 or COL4A4 typically are asymptomatic or cause thin basement membrane nephropathy, a disorder that is genetically related to Alport syndrome but that usually has a benign outcome. Type IV collagen α chains
associate into trimers that combine with each other to form open networks; these networks interact with laminin, nidogen, and heparan sulfate proteoglycans to form basement membranes. Mammalian tissues express three type IV collagen networks that differ on the basis of the composition of the trimers that comprise the networks. A network composed entirely of αl(IV) and α2(IV) chains is found in varying amounts in all basement membranes. A network consisting solely of α3(IV), α4(IV), and α5(IV) chains is present in substantial amounts in glomerular basement membranes, some renal tubular basement membranes, and basement membranes of the cochlea and eye.
A third network made up of α5(IV) and α6(IV) chains is present in skin basement membrane and some renal tubular basement membranes. The effect of most mutations in COL4A3, COL4A4, or COL4A5 is to prevent or impair the deposition of the α3 α4 α5(IV) network into basement membranes. This network is not required for ontogeny of the kidney, cochlea or eye; consequently, these organs develop normally in people with Alport syndrome. The α3 α4 α5(IV) network does appear to be critical for maintaining the integrity of the mature basement membranes in which it resides, perhaps ameliorating the cumulative biomechanical stresses resulting from pulsatile blood flow (glomeruli), organ of Corti displacement by sound waves (cochlea), and changes in curvature of the lens with accommodation (eye). Features and progression of Alport syndrome
The timing and progression of the phenotypic features of Alport ALPORT to page 32
Minneapolis VA Health Care System The Minneapolis VA Health Care System is a 341-bed tertiary-care facility affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel. The Twin Cities offers excellent living and cultural opportunities. License in any state required. Malpractice provided. Applicants must be BE/BC. Opportunities for full-time and part-time staff are available in the following positions: • Chief, Radiation Oncology • Chief, Surgery/Specialty Care Director • Chief, Emergency Medicine • Chief, Ophthalmology • Cardiac Anesthesiology • Compensation & Pension Examiner • Emergency Medicine • Gastroenterology • Imaging o Resident Coordinator o Interventional Radiology o Neuro Radiologist
• Internal Medicine or Family Practice • Hematology/Oncology • Hospitalist • Outpatient Clinics: Internal Medicine or Family Practice o Maplewood, MN o Ramsey, MN o Chippewa Falls, WI o Rice Lake, WI
• Outpatient Clinics: Psychiatry o Superior, WI o Ramsey, MN o Rice/Hayward, WI–V-tel and on-site o Maplewood, MN –V-tel and on-site • Medical Director, Rochester Outpatient Clinic • Pathology • Radiation Oncology • Rheumatology • Spinal Cord Injury and Disorder
Competitive salary and benefits with recruitment/relocation incentive and performance pay possible.
For more information: Visit www.usajobs.gov or email Brittany.Sierakowski@va.gov EEO employer
30
MINNESOTA PHYSICIAN JANUARY 2013
Practice Well. Live Well. Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • Emergency Medicine
• Medical Oncologist • Pediatrics • Urology NP/PA
For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227
712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424 Lake Region Healthcare is an Equal Opportunity Employer. EOE © Paid for by the U.S. Air Force. All rights reserved.
AIRFORCE.COM/HEALTHCARE
www.lrhc.org
Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an out-patient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefit package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.jobs or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE
healthpartners.com
Emergency Medicine Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:
Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:
recruiting@epamidwest.com or visit our website at
www.epamidwest.com
Your Emergency Practice Partner JANUARY 2013
MINNESOTA PHYSICIAN
31
Alport from page 30 syndrome are determined primarily by age, gender, and genotype. In general, the phenotype advances with age and males are more severely affected than females. In males, the Alport nephropathy progresses through a predictable series of stages— isolated hematuria in childhood followed by the sequential development of microalbuminuria, overt proteinuria, declining kidney function, and, ultimately, end-stage renal disease (ESRD) —over the course of 15–60 years. Major rearrangements (deletions, duplications, inversions) and nonsense mutations of the COL4A5 gene are associated with relatively rapid progression of the nephropathy in males, usually resulting in ESRD by age 30, while missense mutations often result in more slowly progressive disease. The timing and severity of sensorineural deafness and ocular changes are similarly correlated with COL4A5 genotype. While most females with X-linked Alport syndrome will
In 2007 the Alport Syndrome Treatments and Outcomes Registry (ASTOR) was established at the University of Minnesota. not develop ESRD, the risk is nonetheless significant, with studies reporting a cumulative incidence of 8 percent to 30 percent by age 60 (the current expert consensus cites a risk of 15 percent to 20 percent). Females with X-linked Alport syndrome similarly have a lower but still significant risk of developing sensorineural deafness severe enough to require hearing aids. Patients with autosomal recessive Alport syndrome typically progress to ESRD by age 30 and exhibit sensorineural deafness during childhood, with no gender variation. Diagnosis of Alport syndrome
While the diagnosis of Alport syndrome is typically made by nephrologists during the course of evaluating patients with gross or microscopic hematuria, patients may be diagnosed by
alert hearing specialists or ophthalmologists who recognize the characteristic auditory and ocular manifestations of the disease. Hearing is normal at birth, so children with Alport syndrome will not be identified by newborn hearing screens. Reduced sensitivity to highfrequency sounds is often detectable during late childhood. The hearing deficit extends into the range of conversational speech over time but plateaus at levels that are responsive to hearing aids. Children with Alport syndrome acquire speech normally and retain good speech discrimination despite their hearing deficit. Ocular changes are usually not apparent until adolescence or adulthood and consist of anterior lenticonus, an alteration in lens shape that is pathognomonic of Alport syndrome but is found in only 15 percent to 20
percent of affected males and rare affected females; and a dotfleck perimacular retinopathy that is fairly common among both affected males and females but that has no discernible effect on vision. A suspected diagnosis of Alport syndrome can be confirmed by skin biopsy, kidney biopsy, and/or gene sequencing. The choice of diagnostic method is influenced by clinical findings and family history as well as insurance coverage. Treating Alport syndrome
Animal models of Alport syndrome have been employed extensively to study disease mechanisms and treatment. Both angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to slow the progression of kidney disease in transgenic Alport mice. The results of recent retrospective studies suggest that early treatment with such medications also delays ESRD in people with Alport syndrome. Current practice guideALPORT to page 34
Internal Medicine?
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Family Medicine?
NEW clinic in Mahtomedi, MN?
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32
MINNESOTA PHYSICIAN JANUARY 2013
Stillwater Medical Group is an 90+ provider multi-specialty group practice afďŹ liated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area. Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside avor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Lori Martin, Executive Assistant 1500 Curve Crest Blvd, Stillwater MN (651) 275-3305, lmartin@lakeview.org stillwatermedicalgroup.com
We’ll make it all better.
NEW POSITIONS:
Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •
Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned
Please contact or fax CV to: Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429 763-504-6600 • Fax 763-504-6622
St.Health Cloud VA Care System Brainerd | Montevideo | Alexandria
is accepting applications for the following full or part-time positions:
• Associate Chief, Primary & Specialty Medicine (Internist-St. Cloud) • Director, Primary and Specialty Medicine (Internal Medicine) (St. Cloud) • ENT (St. Cloud)
• Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud) • Pain Specialist (St. Cloud)
• Geriatrician (Nursing Home-St. Cloud) Visit our website at www.NWFPC.com
• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo)
• Hematology/Oncology (Part Time-St. Cloud) • Hospice/Palliative Care (St. Cloud)
Heart of Minnesota Lakes Country
• Psychiatrist (Brainerd, St. Cloud) • Radiologist (St. Cloud) • Urgent Care Provider (MD: IM/FP/ER) (St. Cloud)
Practice Opportunities Sanford Clinic North – Excellent practice opportunities in communities located in the ‘Heart of Minnesota Lakes Country’. Good call arrangements and modern well-managed community-owned hospitals. Alexandria • Dermatology • Family Medicine • Hospitalist/IM • Internal Medicine • Obstetrics/ Gynecology Detroit Lakes • Dermatology • Family Medicine • General Surgery • Internal Medicine • Pediatrics
East Grand Forks • Dermatology • ENT • Family Medicine • IM/Peds • Orthopedics Moorhead • Family Medicine New York Mills/ Perham • Family Medicine • Orthopedic Surgery
Thief River Falls • Family Medicine • General Surgery • Hospitalist/IM • Internal Medicine • Optometry • Podiatry • Urology
US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.
Excellent benefit package including:
Wheaton • Family Medicine
Sanford Health, serving western Minnesota, eastern North Dakota and South, is redefining health care. Sanford offers innovative technology, support of a multi-specialty organization and dependable colleagues. Our employment model includes: market competitive salary, comprehensive benefits, paid malpractice insurance and a generous relocation allowance. To learn more contact: Shannon Ellering, Physician Recruiter Email: Shannon.Ellering@sanfordhealth.org
Phone: (701) 280-4817 EOE/AA
Favorable lifestyle 26 days vacation CME days Competitive salary 13 days sick leave Liability insurance
Interested applicants can mail or email your CV to VAHCS Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618
JANUARY 2013
MINNESOTA PHYSICIAN
33
Alport from page 34 lines recommend initiation of treatment with an angiotensinconverting enzyme inhibitor in any Alport patient with proteinuria and in patients with microalbuminuria and an unfavorable COL4A5 genotype. Patients with Alport syndrome usually do very well after kidney transplant, with outcomes that are equivalent or superior to outcomes for patients with other diagnoses. Kidney donation by affected females is discouraged. Alport registry and patient/family support services
In 2007 the Alport Syndrome Treatments and Outcomes Registry (ASTOR) was established at the University of Minnesota. ASTOR’s primary objective is to maintain an electronic database of North American Alport families for the purpose of facilitating clinical trials of promising therapies. We hope that the existence of the registry will help reduce the barriers to testing innovative treatments of this orphan disease. ASTOR also
carries out natural history studies aimed at establishing biomarkers of disease progression. The ASTOR database currently contains detailed information on more than 500 participants. ASTOR receives support from the National Institutes of Health, the Alport Syndrome Foundation, the Kenneth and Claudia Silverman Family Foundation, and private donors, and conducts collaborative research with the Novartis Institute for Biomedical Research. ASTOR has formed a research network with centers of Alport syndrome research in Canada, France, Germany, and China. Rare disease registries can derive enormous benefit from establishing connections with patient advocacy groups, and these groups in turn can utilize registries to achieve their goals. ASTOR works closely with the Alport Syndrome Foundation (www.alportsyndrome.org), which also was established in 2007. The two organizations have cosponsored several events, including a symposium for families, physicians, and investiga-
tors at the Congress of the International Pediatric Nephrology Association in New York in 2010 and, more recently, a conference for Alport families at the University of Minnesota last July. The latter conference was attended by more than 100 Alport family members and included tracks for parents, teenagers/young adults, and young children. Parents attended talks on Alport syndrome genetics, treatment of Alport kidney disease and hearing loss, nutritional aspects of kidney disease and hypertension, the emotional and behavioral challenges of chronic kidney disease in teens and young adults, and current laboratory and clinical research in Alport syndrome. Parents were also able to meet individually and in small groups with Alport syndrome experts. The teen/young adult program provided these affected young people with an opportunity for facilitated discussion of their experiences and feelings with a peer group and establishment of a supportive community through social media.
In the past several years, advocacy groups for Alport syndrome have been organized in the United Kingdom, Europe, and Australia. University-based investigators and biotechnology companies are exhibiting increased interest in Alport syndrome as a model disorder for development and testing of innovative therapies for progressive renal diseases. Consequently, in the 25 years I’ve been involved in Alport syndrome research, I have never been more optimistic about the prospects for finding effective treatments for this disease. Clifford Kashtan, MD, is a professor of pediatrics and director of the Division of Pediatric Nephrology in the Department of Pediatrics at the University Minnesota Medical School and Amplatz Children’s Hospital. He is the executive director of the Alport Syndrome Treatments and Outcomes Registry (ASTOR). ASTOR is supported by grants and awards from private donors, the Alport Syndrome Foundation, the Kenneth and Claudia Silverman Family Foundation, the Novartis Institutes for Biomedical Research, and the National Institute of Diabetes and Digestive and Kidney Diseases.
VA Health Care System In South Dakota & North Dakota Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following locations. Sioux Falls VA HCS, SD
Black Hills VA HCS, SD
Fargo VA HCS, ND
Urologist Psychiatrist Hospitalist Family Practice
Psychiatrist General Surgeon Physician (Primary Care) Hospitalist (Internal Medicine) Urologist Podiatrist
Psychiatrist Hospitalist Family Practice Internal Medicine
Orthopedic Surgeon Cardiologist Internal Medicine
Sioux Falls VA HCS (605) 333-6858 www.siouxfalls.va.gov
Black Hills VA HCS (605) 720-7487 www.blackhills.va.gov
Fargo VA HCS (701) 239-3700 x2353 www.fargo.va.gov
Applicants can apply online at www.USAJOBS.gov
34
MINNESOTA PHYSICIAN JANUARY 2013
NEW POSITIONS:
Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •
Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned
Please contact or fax CV to: Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429 763-504-6600 • Fax 763-504-6622
The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Internal Medicine • Psychology • Family Medicine • Med/Peds Hospitalist • Pediatrics • General Surgery • OB/GYN • Pulmonary/ Critical Care • Geriatrician/Outpatient • Oncology Internal Medicine • Radiation Oncology • Orthopedic Surgery • Hospitalist • Rheumatology • Psychiatry • Infectious Disease For additional information, please contact:
Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366
Visit our website at www.NWFPC.com
Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community
An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000. Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org
Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052
www.acmc.com
Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We will be opening a new Urgent Care clinic in Hugo, MN in the spring of 2013! Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
AA/EOE - Not subject to H1B Caps
healthpartners.com JANUARY 2013
MINNESOTA PHYSICIAN
35
January is National Birth Defects Prevention Month
Birth defects from page 19 across Minnesota aiming to improve preconception health and care for non-pregnant, reproductive-age women through the use of evidencebased preconception health interventions that prevent and/or reduce the risk for birth defects. These projects will be evaluated and the most successful projects will be used to guide future MDH prevention efforts. Secondary prevention activities utilize the services of local public health agencies to provide case coordination and connection to local services to assure the best possible health outcomes, and to improve the quality of life for the child and their family. What’s ahead?
The mission of the BDMAP is to reduce the morbidity and mortality of birth defects in the population through monitoring, connection to services, prevention, and research.
The Minnesota Department of Health (MDH) is joining the National Birth Defects Prevention Network (NBDPN) to raise awareness of the prevalence of birth defects and strategies that reduce the risk of birth defects and their complications. This year’s theme is “Birth defects are common, costly, and critical.” Although not all birth defects can be prevented, the health care community can help all women (including teens) who could become pregnant or are pregnant to lower their risk of having a baby with a birth defect by encouraging them to follow some basic health guidelines throughout their reproductive years, including: • Take 400 mcg of folic acid daily from the beginning of menstruation through menopause. • Eat a healthy diet and aim for a healthy weight. • Keep diabetes under control. • Get a medical checkup before pregnancy and address specific health issues including weight control, control of diabetes, and any medications taken. • Stop smoking and avoid secondhand smoke. • Stop drinking alcohol prior to pregnancy or as soon as a pregnancy is known. • Do not take illegal drugs. • Plan carefully. Use contraception if taking medications that increase the risk of birth defects. • Know your family medical history, potential genetic risks and seek reproductive genetic counseling, if appropriate. January is a perfect time to call additional attention to the importance of folic acid in preventing certain birth defects. The United States Public Health Service recommends that all women of childbearing age consume 400 micrograms (400 mcg or .4 mg) of folic acid daily to prevent up to 50 percent to 70 percent of neural tube defects. You can make a difference in the lives of Minnesota families. Additional resources can be found on the NBDPN website at www.nbdpn.org/ bdpm2013.php. If you have questions or would like more information, contact Erica Fishman at Erica.fishman@state.mn.us or (651) 201-5141.
Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership. Currently we are seeking to add the following specialists: General Surgery
Pediatrics
Orthopedic Surgery
Obstetrics/Gynecology
Radiology/Oncology
Family Practice
Internal Medicine
Emergency Medicine
Hospitalist
Ophthalmology
Psychiatry
For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691. Dave.Dertien@avera.org Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258
www.averamarshall.org
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MINNESOTA PHYSICIAN JANUARY 2013
Birth defects monitoring and connection of families with community-based services continue to grow as more children with birth defects are covered as BDIS expands statewide. With more years of data, BDIS is poised to become a resource for researchers who study causes, outcomes, and prevention of birth defects. Kristin Oehlke, MS, CGC, is a genetic counselor and program supervisor, Erica Fishman, MSW, MPH, is the program planner and prevention specialist, and Barbara Frohnert, MPH, is an epidemiologist with the Birth Defects Monitoring and Analysis Program at the Minnesota Department of Health.
Opportunities available in the following specialties: Adult Psychiatry Child Psychiatry Southeast Clinic
Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.
Dermatology Southeast Clinic
Family Medicine Pine Island Clinic, Plainview Clinic
Hospitalist Rochester Hospital
Internal Medicine Southeast Clinic
Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
Sleep Medicine Rochester Hospital
Sports Medicine Orthopedic Surgeon Southeast Clinic
Orthopedic SurgeonJoint Replacement Southeast Clinic
Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622
www.olmstedmedicalcenter.org
EOE
Growth and Opportunity
For
Every Stage of Your Career
Over 700 physicians in more than 40 specialties. An award-winning hospital and network of primary/urgent and specialty clinics.
North Memorial is seeking driven providers to be part of our 2012-2013 growth initiatives. Opportunities exist in Family Medicine Internal Medicine Obstetrics Gynecology
and in multiple surgical or medical specialties
Optimize your education and leadership potential. To learn more, contact Mark A. Peterson, Physician Recruiter 763-520-1336 mark.peterson@northmemorial.com northmemorial.com
With Essentia Essentia He H Health, alth, yyou’ll ou’ll find group more a supportive supportive gr o of mor oup e than 750 medical 7 50 physicians physicians across across 55 55 me dical specialties. large spe cialties. Located Located in lar ge and small communities communities across across Minnesota, Minnesota,
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Wisconsin, North Dakota Idaho, Wis consin, Nort th D akota and Idah o, Essentia Health emerging E ssentia He alth h is emer ging as a leader cost-effective, le ader in high-quality, high-q quality, c ost-effectivve, patient-centered care. p atient-centered c are. EEOE/AA OE//A AA
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Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff
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JANUARY 2013
MINNESOTA PHYSICIAN
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South Country from page 11 view is incorporated into health plan programs and plans. Similarly, the county directors keep other county executives and commissioners informed to assure that the best interests of their communities are being addressed when the county boards act on matters related to South Country or health care. For example, a subcommittee of public health and human services directors focuses on care coordination, case management, and other clinical programs such as improving transitions and reducing readmissions. The group has guided a pilot intervention by county staff to decrease readmissions after hospitalizations. They have also guided two other innovations, the In-Reach Social Worker Program in Owatonna and the New Ulm Initiative in New Ulm, both designed to assist high utilizers of emergency departments. Both programs originated from their local communities, not
from the central office of a health plan. The Connectors
Community Care Connectors link members and providers to county services. Each member county has either a nurse or social worker who connects South Country members with health and social services, and works with the local providers (physicians, clinics, hospitals, and others) to facilitate appropriate care. Employed by counties and funded by South Country, these Connectors bridge the spectrum of care for new members, unstable or highrisk patients, and patients in transitions. This is a local service performed in communities by professionals who have relationships with providers, neighbors, and family members. Many Connector functions originally were designed into the South Country plan’s inception as “Community Resource Management Teams.” At that time, South Country supported a social worker and a public health nurse in each county
(the “team”) to assure that medical, behavioral, and social aspects of care were addressed. The teams evolved into Connectors, in part due to financial realities, while, in fact, county staff learned to work smarter and more collaboratively with health plan staff. While the Connector role continues to evolve, their value shows and grows. As representatives of South Country in the community, the Connector acts as a catalyst to strengthen relationships with clinics and providers; introduces physicians and clinics to county resources; facilitates care coordination for members; connects members to county services at home, in the hospital, or nursing home; and coordinates transitions home from hospitals and nursing homes. Connectors work closely with county staff and South Country’s clinical staff in Owatonna. They are available to physicians, clinics, and hospital discharge planners as a liaison to county services and South Country benefits.
Bridge to community health
South Country is a beginning. As public policy evolves from improving health care to improving health as is envisioned under health reform in Minnesota, the South Country model provides a new design platform for healthy rural communities. The model offers opportunities to unite local communities around accountable governance, integration of comprehensive local services, central performance measurement, and cost-effective payment strategies. It demonstrates that good things happen when clinicians, counties, and payers work together. Patrick Irvine, MD, is medical director of South Country Health Alliance.
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