Volume XXVl, No. 12
March 2013
The Independent Medical Business Newspaper
American Tax Relief Act of 2012 Putting a patch on health care reform By Timothy Johnson, JD, and Greg Larson, JD
M
Big-picture patient care An expanded role for physicians By Peter Mills, MD
H
ealth care reform is happening at an increasingly rapid pace, and whatever your thoughts on the pros and cons of health care reform, one central fact is undeniable: As a nation, we cannot afford the inexorable rise in health-care delivery costs that we have seen over the past two decades. A recent report from the Kaiser Family Foundation highlights the fact that
in 1991 we spent a little over 12 percent of gross domestic product (GDP) on health care; in 2011 this figure was 18 percent. Over the same period, the GDP of the United States almost tripled, so in real terms we’re spending almost four times as much on the delivery of health care today as we were 20 years ago. It doesn’t take an economist to work out that the current health care system must change; the alternative is literally a bankrupt nation. Yet, it is easy to understand why some physicians are unhappy with the way change is unfolding. The health reforms of the Patient BIG PICTURE to page 10
ost Americans are aware that when President Obama signed the American Tax Relief Act (ATRA) on Jan. 1, 2013, the United States was able to avoid, at least temporarily, the “fiscal cliff” disaster that would have resulted from a combination of significant individual and business income-tax rate increases and spending reductions. However, many people are not aware that ATRA also made numerous changes to federal programs, including extensions and modifications to energy tax credits, various agricultural and unemployment programs, and, most significantly, health care programs. Twenty-nine sections of ATRA’s Title VI address changes to Medicare and other government health programs, functioning as a kind of software patch to the Patient ProtecSPECIAL FOCUS: tion and Affordable GENETICS/ Care Act (ACA), deliverGENOMICS ing, in essence, “bug fixes and various other Page 20 improvements.” TAX RELIEF to page 12
We protect your peace of mind. And we do it in lots of ways for physicians, facilities and hospitals. Whatever your situation, we’ve been there, and will be there. We’ve gotten good at it. Excellent, actually, with a proven success rate. It’s a peace of mind movement. And we’d love to have you along. Join the Peace of Mind Movement at PeaceofMindMovement.com,or contact your independent agent or broker.
CONTENTS
MARCH 2013 Volume XXVI, No. 12
FEATURES Big-picture patient care An expanded role for physicians
1
MINNESOTA HEALTH CARE ROUNDTABLE
By Peter Mills, MD
American Tax Relief Act of 2012 Putting a patch on health care reform
1
By Timothy Johnson, JD, aand Greg Larson, JD
T H I R T Y- N I N T H
SESSION
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
8
PROFESSIONAL UPDATE: PSYCHIATRY Pediatric bipolar disorder 16 By Joel V. Oberstar, MD
PROFESSIONAL UPDATE: PSYCHIATRY Billing update on psychiatric consultations 18
Gary Oftedahl, MD ICSI
By Linda Vukelich
PRACTICE MANAGEMENT Staying on top of technology 14 By Derek Kosiorek
PROFESSIONAL UPDATE: EPIDEMIOLOGY Chlamydia 28 By Candy Hadsall, RN
Patient engagement Creating measures that work Thursday, April 25, 2013
ONCOLOGY Toward “nontoxic” cancer therapies
1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers
32
By Christopher Moertel, MD
SPECIAL FOCUS: GENETICS/GENOMICS Genomic medicine
20
By Catherine A. McCarty, PhD, MPH
From bench to bedside
24
By Christopher G. Chute, MD, DrPH, and Iftikhar J. Kullo, 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:
Insurers and genetics By Patrick Courneya, MD
22
Genetic counseling
26
By Barbara Kunz, MS, CGC
Vivi-Ann Fischer, DC, Chief Clinical Officer, Chiropractic Care of Minnesota, Inc. Peter Mills, MD, CEO, nGage Health
The Independent Medical Business Newspaper
William Nersesian, MD, MHA, Chief Medical Officer, Fairview Physician Associates Pam Van Zyl York, MPH, PhD, RD, LN, MDH Health Promotion and Chronic Disease Division 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
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MARCH 2013 MINNESOTA PHYSICIAN
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CAPSULES
Medicaid Expansion Bill Signed by Dayton A measure that would expand the state’s Medicaid program was approved recently by Gov. Mark Dayton. The bill, HF9, officially adopts a Medicaid expansion for Minnesota under the Affordable Care Act (ACA). It will also change how eligibility for the program is calculated from Minnesotans’ income. An estimated 35,000 low-income adults will gain health care coverage under the bill, and Dayton’s office estimates that other changes to the Medical Assistance program could bring coverage to as many as 145,000 Minnesotans over time. The expansion will move thousands of impoverished Minnesotans from primarily state-based programs to Medicaid coverage, which is run jointly by the state and federal government. Under the new ACA rules, the federal government will pick up 100 percent of coverage costs for childless adults earning less than $15,414 annu-
driven by your
ally for the first few years, and in the future would fund 90 percent of those costs. Officials say the bill will provide $129 million over the next two years. This is in addition to the $1.3 billion Minnesota is already expected to save by 2015 as a result of the ACA. “Minnesotans who will be covered by this legislation desperately need better quality health care,” says Gov. Dayton. “Instead of taking their health crises to emergency rooms, thousands of low-income children, families, and individuals will be able to see doctors sooner and live healthier lives.”
Serious Adverse Events Rise in Latest Report The latest adverse events report from the Minnesota Department of Health showed that 2012 saw an increase in death and serious harm occurring in health care settings. Overall, the number of adverse events stayed about the same from 2011 to 2012.
Most of the increase in deaths and serious harm was related to falls, state officials say. There were 14 deaths in 2012 compared with five in 2011, and 89 serious injuries compared with 84 in 2011. The report found hospitals and surgical centers improved during 2012 in a number of areas. These include the number of total pressure ulcers (bedsores), which declined by 8 percent. This is the first decline of this magnitude in the nine years of reporting, officials say. Medication errors dropped by 75 percent from the previous year and were at the lowest level in all nine years of reporting. “This year’s report shows that as a state we really need to redouble our efforts to reduce falls in hospitals,” says Minnesota Commissioner of Health Ed Ehlinger, MD. “While falls in health care settings can be very difficult to prevent, we also need to look at all opportunities to prevent injury when falls do occur, by focusing interventions on each patient’s specific risk factors.”
CDC Names Mayo As a TB Center In an effort to fight complacency about a disease that remains the second most deadly infectious disease worldwide, the Centers for Disease Control and Prevention (CDC) has named five new tuberculosis centers, including Mayo Clinic in Rochester. The new Regional Tuberculosis Training and Medical Consultation Centers will be funded by the CDC and will be responsible for training and technical support to fight TB over large geographic areas. Mayo Clinic’s center will serve a 12-state area comprising Ohio, Michigan, Indiana, Iowa, Illinois, Minnesota, Wisconsin, North Dakota, South Dakota, Wyoming, Montana, and Idaho. The centers will be responsible for providing training and technical assistance to providers, including developing educational materials and providing consultations. Although the rate of TB cases in the U.S. is at an historic low, there is concern about new,
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drug-resistant strains of the disease. Over 10,000 new TB cases were reported in the U.S. in 2011, and TB remains the second leading cause of death from infectious disease worldwide, with more than 1.5 million deaths from the disease reported in 2010. “This is a great opportunity for Mayo to continue its long tradition of tuberculosis research and patient care, by ensuring that providers everywhere have the latest information and training,” says Zelalem Temesgen, MD, director of Mayo Clinic’s Center for Tuberculosis.
Report Examines Adverse Childhood Experiences A report by Minnesota Department of Health (MDH) says that adverse childhood experiences (ACE) have happened to more than 50 percent of Minnesotans. These experiences can include a divorce or separation of parents; an incarcerated household member; a mentally ill parent; domestic violence against a parent; a household member with an alcohol or substance abuse problem; or verbal, physical, or sexual abuse. Public health experts say these kinds of experiences can have lifelong health impacts on people. A 2011 MDH survey of 13,520 Minnesota adults found that 55 percent of them reported having at least one ACE. The most common ACE events reported were verbal abuse (28 percent), a drinking problem in the household (24 percent), mental illness in the household (17 percent), and physical abuse (16 percent). “The significance of this study is that it shows that these experiences, which can significantly affect the health and wellbeing of adults decades later, are much more common in Minnesota than one might expect,” says Ed Ehlinger, MD, Minnesota commissioner of health. “Our task now is to learn from this information and use these insights to better identify and support children and families
at risk.” Minnesota is one of 18 states that have surveyed residents in an effort to better understand the impact of adverse childhood experiences on the health of adults. Officials say the Minnesota data contributes to a growing body of research that shows a strong link between ACE and toxic stress, changes in brain chemistry, and health outcomes. However, MDH officials say ACE do not, by themselves, define individuals. “Though this research shows that adversity increases risk, it is also clear that adversity is not destiny and many people with high ACE scores overcome challenging childhoods,” says MDH Assistant Commissioner Jeanne Ayers. “Part of the value of this research is that we can let people know they are not alone in these experiences, and that they can break the cycle and prevent ACE instead of dealing with their impact later.”
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No “July Effect,” Study Finds There is no “July Effect,” says a new study from Mayo Clinic in Rochester. The notion that July is a dangerous time to have surgery because that’s the month new residents and fellows arrive at teaching hospitals seems to be a myth, researchers say. The report, published in the Journal of Neurosurgery: Spine, looked at seven years of data and found that surgeries in July did not have a significantly higher rate of deaths and postoperative complications. In addition, no substantial July Effect was observed in higherrisk patents, those admitted for elective surgery, or those undergoing simple or complex spinal procedures. “We hope that our findings will reassure patients that they are not at higher risk of medical complications if they undergo spinal surgery during July as compared to other times of the year,” says study co-author Jennifer McDonald, PhD. “While we only looked at spinal surger-
Savvy and practical legal solutions by attorneys with decades of health care experience
CAPSULES to page 6 MARCH 2013
MINNESOTA PHYSICIAN
5
CAPSULES Capsules from page 5 ies, we think it’s likely we’d find similar outcomes among other surgeries and procedures.�
DHS Partners with Systems on New Payment Model The state of Minnesota has announced a partnership with six health systems to test a new payment model designed to improve quality, promote preventive care, and reward providers for meeting health goals. Gov. Mark Dayton says the state’s Department of Human Services (DHS) will oversee the effort. Health systems taking part in the program are Children’s Hospitals and Clinics of Minnesota, Essentia Health, CentraCare Health System, North Memorial Health Care, Federally Qualified Health Center Urban Health Network, and Northwest Metro Alliance (a partnership between Allina Health and HealthPartners).
Combined, these providers will serve over 100,000 Minnesotans enrolled in publicly-funded programs. The new system is expected to save the state’s Medicaid program approximately $90 million over three years. “Minnesota is the first state in the nation to implement this results-based payment model,� Dayton says. “This new payment system will deliver better health care at a better price. By changing the way we pay health care providers we can incentivize reform, help Minnesotans live healthier lives, and slow the rising cost of health care in our state.� The reform measure will change Minnesota’s payment system for publicly-funded health programs, including Medicaid. Officials note that the current system pays providers for the volume of care delivered, rather than the quality of care provided. Under the new payment system, providers will receive financial incentives for reducing the total cost of care for Medicaid enrollees while
maintaining or improving the quality of care. Providers and the state will negotiate targets for cost and quality, and if quality targets are met, any shared savings will be divided between providers and the state. Under the plan, as time goes on, providers and the state will begin to share the responsibility for any losses as well.
New Toolkit Available To Treat Depression MN Community Measurement has introduced a new online toolkit to help health care providers deliver evidence-based treatments for depression. The Help and Healing toolkit aims to help people with depression by fostering collaboration between the patient and the provider. The toolkit includes treatment planning, self-management techniques, and information to help providers measure treatment outcomes. The toolkit was developed
collaboratively by MN Community Measurement, a Minneapolis-based healthquality improvement group, and the Minnesota Health Action Group (formerly BHCAG), a nonprofit coalition of public and private employers based in Bloomington. Clinicians and medical experts, including patient advocates and employer representatives, worked together to design the toolkit. Officials say the materials have been used and proven successful in Minnesota clinics, and were reviewed and approved by a team of experts. “We believe the successful treatment of depression depends on the collaboration between the provider and the patient,� says Diane Mayberry, a nurse and director of business development at MN Community Measurement, who co-managed the toolkit creation. “The tools included for this project have been demonstrated to help address depression.�
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MARCH 2013
MEDICUS Jon Pryor, MD, MBA, has been named the new chief executive officer of Hennepin Healthcare System, Inc., the public subsidiary corporation of Hennepin County that operates Hennepin County Medical Center, a Minneapolis trauma center and public hospital and clinic system. Pryor previously was CEO of the Medical College of Wisconsin Medical College Physicians, a clinical practice group of physicians and advanced practice providers who are the medical staff for Froedtert Health System in Wisconsin. He is a former chair of the Department of Urologic Surgery at the University of Minnesota and is a graduate of the University of Minnesota Medical School. Pryor earned an MBA from the Kellogg School of Management at Northwestern University, in Evanston, Ill., and has worked for McKinsey & Company, a leading national business and strategic consulting firm. Tacjana Friday, MD, has joined the Noran Neurological Clinic. She graduated from St. George’s University School of Medicine in Grenada, West Indies. Friday completed her neurology residency at the University of Minnesota, and completed a fellowship in clinical neurophysiology and epilepsy at the U of M, followed by a second fellowship in sleep medicine at Hennepin County Medical Center/U of M. Tacjana Friday, MD Lakeview Hospital, Stillwater, recently presented Physician Recognition Awards to Lawrence Morrissey, MD, and Theodore Haland, MD. Morrissey, a board-certified pediatrician, practices at the Stillwater Medical Group Main Campus. He was recognized for his long commitment to Lakeview Hospital as well as his commitment to patient-centered care and to the St. Croix Valley community. Haland is a board-certified family medicine physician who practices as a hospitalist at Lakeview Hospital and is the hospital’s medical director for both hospice and information systems. He was recognized for his commitment to Lakeview Hospital leadership and the community. Daniel Rubin, MD, has been named UCare health plan’s associate medical director, joining the nonprofit’s Clinical and Quality Management Department. Rubin most recently was director of clinical development for Wolters Kluwer Health in Minneapolis. He has practiced part-time as an urgent care physician at Park Nicollet Clinic since 1999. Daniel Rubin, MD Edwin N. Bogonko, MD, was installed as the 2013 president of the Twin Cities Medical Society (TCMS) in January. Bogonko received his medical degree at the University of Nairobi, Kenya. He worked as an ICU physician and served as the secretary of the Kenya Medical Association for two years. He immigrated to the United States in 1999 and completed a residency in internal medicine at Hennepin County Medical Society. Bogonko currently is the clinical director of medicine and lead physician, hospitalist program, at St. FranEdwin N. Bogonko, MD cis Regional Medical Center in Shakopee. The following physicians join Bogonko on the 2013 TCMS Executive Committee: Lisa Mattson, MD, president-elect; Peter Dehnel, MD, immediate past president; Ken Kephart, MD, treasurer; Carolyn McClain, MD, secretary; Matthew Hunt, MD, at-large member; and Nicholas Meyer, MD, at-large member. Drew Rosielle, MD, program director for the Hospice and Palliative Medicine Fellowship at the University of Minnesota Medical Center, Fairview, has been named one of five recipients of the 2013 Hastings Center Cunniff-Dixon Physician Award, which recognizes excellence in caring for patients near the end of life. Rosielle was honored for his commitment to evidence-based palliative and end-of-life care and education. The Hastings Center, based in Garrison, N.Y., is a nonprofit institution dedicated to bioethics and the public interest.
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INTERVIEW
Thinking differently about patient engagement ■ Tell us a little bit about your role at ICSI.
Gary Oftedahl, MD ICSI Gary Oftedahl is the chief knowledge officer at Bloomington-based Institute for Clinical Systems Improvement (ICSI). He works with ICSI clients and other health care stakeholders on health-care redesign initiatives and quality improvement efforts. Oftedahl helped develop the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project. This groundbreaking effort at improving depression treatment in the state provides a new care model and payment approach. Prior to joining ICSI in 2002, Oftedahl was medical director at Olmsted Medical Center in Rochester, Minn. He has also served in executive positions at Blue Cross and Blue Shield of Minnesota and at the Mayo Clinic.
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At ICSI, I serve as chief knowledge officer, which of course sounds like a great job title. It builds upon my past 26 years of experience in health care. It’s my job at ICSI to work on identifying and learning about new ideas, connecting with people who have different ideas, and working across our membership to bring some of our members—who are primary health care providers of all different sizes and locations in the state—to the table to work collaboratively at improving care. I’m not in a direct operational role. I’m more of a convener and more of an integrator, thinking of how we can bring ideas and concepts and translate them into real activity.
you’re a physician or a nurse means that you don’t really think like most people do.” We need to understand that as we’re talking with patients. You have to understand what’s driving their behavior. ■ Why has this topic become important to health
care delivery?
It’s important, as I said before, because we need to have patients being active participants in their health care. I think broadening the impact is the fact that we are going to be seeing, at some point in the future, a change in the way health care is paid for. Today we look more at traditional outcomes of how many patients got preventive services, how many diabetics have their blood sugar under ■ We hear a lot about the terms patient engagecontrol, their cholesterol under control. Those are ment and patient activation. What do they important, but we may be seeing a move more mean and what is the difference, if any? toward how many patients are better able to manage their health. Is their activation level higher I think the difference may be subtle but probably because of the role we play? How many patients depends upon the person with whom you’re talkactually feel they have a better ing. Patient engagement is “how quality of life? How do they feel do we do a better job of engaging Patients are the about their functional capabilities? our patients?” in several areas. We If we start looking at those biggest untapped need to engage patients in how as measurements, that’s going to we design and craft the way we resource that require us to think differently deliver care. We talk about the about how we interface with we have. need to become more patientpatients. centered, which means that we focus our efforts around the patient rather than around the institution. Patients do not live in the clinic or hospital, they live in the real world. While we can certainly interface with them for very brief periods of time, they have to go out and engage in the behaviors that are going to be necessary to improve health. One only has to look at the rising rate of obesity to know that we have a major problem. “Patient activation” is a term that we use. It’s a little different, but I think it’s important to look at. Patient activation reflects how we’re able to meet patients at the level of their ability to manage that care. In other words, we can present a patient with a laundry list of things they need to do. But if we do that without knowing their ability to understand that, without knowing if they have the resources to do that, if they are motivated to do that, and whether it fits in with their values, then we just as well could be talking to the wall. If we just come at them with a list of things to do and we can’t customize it to their activation, then if they’re overwhelmed they won’t do it and we get to call them noncompliant. If they feel hamstrung because they’re way above what we want them to do and they feel like we’re holding them back, they may disengage from working with us and we never get to call them noncompliant. A person I know who works in the coaching area—not in a health care setting—says, “Physicians and nurses think other people think like you do. You need to realize that the mere fact that
MINNESOTA PHYSICIAN MARCH 2013
■ How can the role health care providers play in
patient engagement be improved? I think there are probably several ways to do that. The first is that in health care in general we need to have a better understanding of what drives human behavior. There’s an expanding body of knowledge to help us understand how we make decisions. That area has made us recognize that humans often behave in illogical, emotional ways that really make it very difficult to follow what may be logical advice. Many of us got into health care because we wanted to help people, we wanted to help make them better, we wanted to help solve problems and fix things. Yet in today’s world a lot of things are chronic and ongoing and require longitudinal support. In today’s world of exploding knowledge and complexity, the role of the physician may be more to help support the coaching. I hear physicians say, “Well, I don’t have time to do all the coaching.” I’m not sure physicians often are best equipped to be coaches; I’m not sure they’re being paid to be a coach. But they may be paid to help support and understand the value of coaching. The other thing that I think is going to be a challenge is, how do we incorporate the patient and his or her family as part of the team? I think they need to be part of the team. These are significant changes in longstanding beliefs and values that are going to be a real challenge to many of us.
■ What tools or technologies do you see
being most effective for encouraging patient engagement? I think there’s an opportunity with evolving technology to use different applications that can help people to become involved in managing their health and give them feedback. I think that there’s a very good likelihood that technology is going to become really astonishing. The analogy I use is that when you’re in your car, if the check engine light goes on you check the engine. What about the day when somebody with chronic illness gets a message on their iPad or phone because an internal sensor—believe me, the technology is there—pops up and says, check your blood sugar. Weight Watchers has created a small thing you can wear, it’s a pedometer, but you put it on like clothing. What’s fascinating is the instant feedback. You push on it, and it’ll sort of light up around it, and if it goes all the way around and lights up to green, you know you’ve done your 100 percent of activity for the day. It seems subtle, but these kind of things start to have an impact on getting people engaged. I think you’re going to see people forming virtual organizations, virtual clubs, sharing information. One example of this is called Patients Like Me, a virtual commun-
2013 CME Activities
(All courses in the Twin Cities unless noted)
MARCH - SEPTEMBER 2013 Fundamentals of Critical Care Support March 18-19, 2013 Advanced Critical Care for Hospitalists March 18-21, 2013 Maintenance of Certification in Anesthesiology (MOCA) Training March 23, 2013 June 15, 2013 Integrated Behavioral Healthcare Conference April 12, 2013 Chronic Pain: Challenges & Solutions for Primary Care April 19-20, 2013
Patients do not live in the clinic or hospital, they live in the real world. ity of people with different diseases. It’s actually used by the research community because there are patients talking to each other, sharing notes in a way that never would have been done before. The iPhone is just a little over five years old. Think about what’s happened in five years. Experts in the field of technology suggest that in two to three years, we will all be using a technology on a regular basis that we currently don’t even know exists. How do you plan for that? That’s part of our challenge in health care. ■ What are the best things that can be
done to maximize the potential offered by increased patient engagement? One, bring patients to the table, engage them in a conversation. Two, consider them as a resource to improve your care rather than as the recipient of your care. Think about them differently. Three, recognize that if they’re not involved, you’re not going to have a chance to succeed. The things we’re
being asked to do are going to require that they be active participants. Four, increase understanding of the importance of relationships. If a relationship means that I’m an equal partner, then I certainly have more ownership in that. Patients are the biggest untapped resource that we have. In fact, a lot of my work has been done with HELP [Hospital Elder Life Program, at Park Nicollet Methodist Hospital], which is a program that uses citizen volunteers who go into hospitals and visit patients who are at risk for developing delirium. It doesn’t require any medical expertise. It doesn’t require a license. Yet it dramatically reduces the amount of delirium and confusion in hospitalized patients through using relationships and human contact. There’s going to be a need for engagement at the community level. You know, health care systems live in a community, but sometimes they may not even be aware of the resources that are available in the community. I think a large part of the work about patient engagement going forward is going to go on at a community level. I think there are going to be more conversations occurring than we’ve ever thought about, and that they will bring different people to the table.
www.cmecourses.umn.edu Cardiac Arrhythmias: An Interactive Update for Internal Medicine, Family Medicine, & Pediatrics April 26, 2013 Integrative Medicine Conference: Healthy Eating & Lifestyles May 3, 2013 Global Health Training (weekly modules) May 6-June 2, 2013 Topics & Advances in Pediatrics in cooperation with MN-AAP May 30-31, 2013 (NEW DATES!) Midwest Cardiovascular Forum: Controversies in CVD June 1-2, 2013
ONLINE COURSES (CME credit available) www.cme.umn.edu/online U Fetal Alcohol Spectrum Disorders (FASD) - Early Identification & Intervention U Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health
Update in Gastrointestinal Surgery & Bariatric Education Days June 5-8, 2013 Workshops in Clinical Hypnosis June 6-8, 2013 Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners September 5-6, 2013 (NEW DATES!) Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: cme@umn.edu
Promoting a lifetime of outstanding professional practice MARCH 2013
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Big picture from cover Protection and Affordable Care Act (ACA) not only represent a major change to the operational side of health care delivery, but also potentially take us out of our comfort zone. In medical school, we were taught to deliver care on a patient-by-patient basis—to elicit signs and symptoms from a patient and use appropriate investigations to reach a diagnosis. From there,
organizations that will feature shared savings among physicians, hospitals, and other health care providers, the ACA reforms shift away from the traditional fee-for-service model toward a greater emphasis on total population health and on cost of care. These changes to the health-care delivery system offer physicians the opportunity to put ourselves at the center of
trust of the vast majority of the population. To shape health care in the 21st century, we need to capitalize on this trusted relationship. In order to do this, physicians will have to be much more involved in all of the health care needs of our patients. It is no longer enough to interact with them only when they are sick; we need to expand our role and engage
Physicians will have to be much more involved in all of the health care needs of our patients. we planned the most effective treatment based on what was appropriate for the individual. Nowhere in that process were we instructed on how to place that very individualized interaction into the context of the broader patient population for which we are responsible. But that’s what we need to do now. In addition to establishing accountable health care
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managing the health of everyone while continuing to focus on the individual patient. However, we need to drive this change in a direction that plays to our strengths—and one of those strengths is the relationship we have with our patients. In a society that no longer trusts its politicians, bankers, or captains of industry, we are privileged to still retain the
MINNESOTA PHYSICIAN MARCH 2013
them in an ongoing dialogue about their health, lifestyle, and behaviors. Only then can we hope to effect sustainable improvements in health status. Layering technology into medical practice
Over the past 20-plus years, government, employers, and health insurers all have tried, with limited success at best, to manage existing diseases and reduce lifestyle risk among their constituents. I think the main reason these approaches have not been as effective as they should or could have been is not that the approaches were without merit, but rather that physicians have not been involved in their implementation and coordination. The time is right to change this. Research has shown that even an unstructured, brief intervention from a physician on a patient’s lifestyle choices has a profound and sustained impact on behavioral modification. How much more could we achieve if we structured this type of approach throughout our patient populations? Almost every industry in the world, with the exception of medicine, has embraced modern technology to create meaningful connections with their customers. Technology has transformed the way we buy goods, do our banking, and book our travel. Yet in medicine, the only connection most of us have with our “customers” is still the faceto-face office visit. We need to
change this if we are to establish a true ongoing dialogue with our patients. Given the almost universal penetration of the Internet and mobile phones in our society, we have an opportunity to harness this ubiquitous connectivity to get closer to our patients. At a very basic level, even simple email and text communications, when used appropriately, have been shown to be effective tools to engage and motivate individuals. But we now have so much more at our fingertips. Data from the Pew Internet Foundation highlights the fact that of the 95 percent of the population that own a cell phone, more than 50 percent have a smartphone. The last few years have seen an exponential rise in the development of health apps and devices that can help individuals track and monitor their health conditions or their lifestyle and behavior. Harnessing this patient selfreport data is key to better understanding, and therefore better managing, the health of our populations. An example
The annual wellness visit is a good example of how new technology can benefit us in medical practice. Medicare, as well as many private insurers, now fully covers an annual wellness visit. The objective is for physician and patient to co-create an annual wellness and prevention plan for the year ahead. This is the ideal scenario for layering technology into the mix. According to the Centers for Disease Control and Prevention, the online health assessment needs to focus on current medical diagnoses, family history of disease, preventive services received, current symptoms, and lifestyle and behaviors. Ideally, this assessment should be easy to navigate and intuitive to complete. Here’s how it could work. The most scalable and easy-toadminister scenario for this activity would be to have the assessment form accessible to patients via the Internet. The physician, or another practice member, communicates the availability of this service to all
patients and invites them to complete a health assessment. Those few patients without ready access to the Internet are invited to arrive slightly earlier to their appointment and complete the assessment on a tablet device in the waiting room. Upon completing the questionnaire, the patient immediately receives a report that highlights the areas where he or she is doing well and the areas to discuss in more detail with the doctor. The beauty of the modern Internet is that the patient no longer has to wait for this sort of thing—a report can be generated instantaneously once the patient has completed the assessment. In addition, data from the patient’s responses can be made available to the physician in real time. The physician can quickly and easily see the areas that require further attention and intervention. In the office, the doctor and patient agree on which areas to focus on during the coming year, set goals, and select the best means of track-
ing the patient’s progress (commonly used apps and devices can be easily connected and used for tracking progress). All of this information becomes available to the patient on a dedicated portal where the patient posts updates on his progress in the days and months ahead. This data is also viewable by the physician, who can also periodically send messages of advice and encourage-
sages about relevant local initiatives and interventions that can help them improve their health, establishing an ongoing physician-patient connection outside of the office. Data from this sort of ongoing interaction also can be used to segment the population and target individuals for more hands-on intervention. Research from the employersponsored health management
high-cost utilization. This is the very basis of the new accountable-care approach to health care delivery. Change as opportunity
We all went into medicine because we wanted to make a difference. I believe that we have a great opportunity to make a huge and sustained difference—but we need to grasp the opportunity for change,
Harnessing this patient self-report data is key to better understanding, and therefore better managing, the health of our populations. ment to the patient. On a macro, populationhealth level, the data from all of the physician’s patients can be rolled up into a population view that can inform likely future care requirements for the population and also demonstrably show progress and outcomes— something we will all increasingly need to do. Segments of the population can be sent mes-
field has repeatedly shown that self-reported health assessment data is a valid and accurate way of predicting future short- to medium-term health care utilization and costs. Targeting individuals at high risk with more frequent face-to-face interactions with a physician, nurse practitioner, or physician assistant could potentially lower risk and mitigate against future
rather than fear it. “With change comes opportunity” is a much-quoted adage, but it is as true as it ever has been when we apply it to health care reform in America. Peter Mills, MD, is founder of Minneapolis-based nGageHealth, which provides technology-driven patient engagement and health management solutions for health care providers.
Are you satisfied with your claims processing? You will be with ClaimLynx! Every medical practice depends on cash flow. Very few people understand the required processes between when a doctor sees a patient and how/when insurance reimbursement is disbursed. We make these steps simple for you. Among the services we offer: • Direct, real time verification of eligibility • Secure online access to claims tracking • Secure online access to claims correction • Never miss a payment due to late filing • We handle every kind of insurance and every medical specialty • Less time on paperwork, more time with patients
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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Tax relief from cover While a majority of the provisions in Title VI impose technical or minor changes, a few significant changes, discussed below, may have an impact on many, if not all providers.
ATRA includes a series of Medicare offsets and other spending cuts that are expected to save slightly more than $25 billion over a 10-year period. Hospitals are hit hardest by these ATRA cuts.
Extension of Medicare physician payment update
doc fix that included an increase. However, ATRA merely extends the current MPFS for an additional year (through 2013), with no increase. Congress will have to consider the doc fix again next year. It appears that in order to get agreement on the extension of the doc fix, which costs approximately $25 billion, ATRA’s drafters had to find offsetting cost savings. ATRA includes a series of Medicare offsets and other spending cuts that are expected to save slightly more than $25 billion over a 10-year period. Hospitals are hit hardest by these ATRA cuts, with Medicare cuts to hospitals covering approximately half the cost of the doc fix. These cuts come in
two forms: • Reduced Medicare disproportionate share hospital allotments; and • Reduced inpatient prospective payment system (IPPS) payments to correct for changes in the coding or classification of discharges associated with the 2008 transition to Medicare severity diagnosis-related groups (MS-DRGs), which the Centers for Medicare & Medicaid (CMS) has determined resulted in overpayments to hospitals. Collection of overpayments
ATRA lengthens the statute of limitations period during which regulators can recover Medicare overpayments from three years to five. This change is in keeping
Telephone Equipment Distribution (TED) Program
As a result of the Balanced Budget Act of 1997, the annual update to the Medicare Physician Fee Schedule (MPFS) was to be tied to a complex calculation referred to as the Medicare Sustainable Growth Rate (SGR). However, to prevent significant reductions in the MPFS, the annual MPFS update necessary to meet the target SGR has been suspended or adjusted by Congress on a regular basis, commonly referred to as the “doc fix.” The latest doc fix was due to expire at the end of 2012 and, if allowed to expire, would have reduced the MPFS by about 27 percent on Jan. 1, 2013. Since physicians have not had an across-the-board increase to the MPFS for a couple of years, they were hoping for a permanent
with the health-care reform law’s general theme of expanded enforcement efforts and recoupment of overpayments. Physician quality reporting
ATRA includes a provision potentially making it easier for physicians to qualify for incentive payments under the Physician Quality Reporting System (PQRS). PQRS uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. Historically, physicians have been required to submit this quality information directly to CMS or a qualified PQRS data submission vendor. ATRA adds a provision allowing physicians to satisfy PQRS obligations, and thus receive the Medicare incentive payments, by participating in a qualified Physician Quality Reporting registry. The requirements for what constitutes a “qualified Physician Quality Reporting registry” will be established by the Department of Health & Human Services (HHS).
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.
1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services
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National Quality Forum funding
ATRA also continues funding of the National Quality Forum (NQF). The primary goal of NQF is to review, endorse, and recommend use of standardized health-care performance measures. In addition to extending the funding of NQF, ATRA requires the HHS Secretary to develop a strategy to provide performance improvement data to providers, including utilization data and feedback on quality data, and to publish this strategy on the CMS website and seek feedback from stakeholders. Changes in long-term care coverage
ATRA officially repeals the Community Living Assistance Services and Supports (CLASS) voluntary long-term care (LTC) benefits program. The CLASS program was enacted as part of ACA, with the goal of developing a program to provide individuals with a self-funded and voluntary long-term care insurance choice where workers would pay premi-
ATRA merely extends the current Medicare Physician Fee Schedule for an additional year (through 2013), with no increase. Congress will have to consider the doc fix again next year. ums in order to receive a daily cash disability benefit. The benefits to individuals would be covered solely by the premiums paid, and no taxpayer funds would be used under the program. However, in October 2011, the HHS Secretary suspended all activities implementing the CLASS program since it was determined that the premiums under the program would never raise enough revenues to pay for the benefit. In conjunction with repealing CLASS, ATRA calls for the formation of an LTC Commission to develop a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality system that ensures the avail-
ability of LTC services and supports for individuals in need of them. ATRA provides details on the establishment, composition, and meetings of the commission, as well as requirements for a report from the commission. Other ATRA provisions
Outpatient therapy services. ATRA extends through Dec. 31, 2013: • The Medicare outpatient therapy cap exceptions process • The requirement that Medicare perform manual medical review of therapy services when an exception is requested because the beneficiary has reached a specified dollar aggregate threshold • The therapy caps and manual
medical review thresholds to services furnished in hospital outpatient department settings • The requirement that outpatient therapy services furnished in a critical access hospital count toward the therapy caps and manual medical review thresholds Extension of current floor for physician work component geographic adjustment. Medicare adjusts the relative value unit (RVU) for the component of physician work, practice expense, and professional liability insurance to reflect geographic cost differences. Since 2004, as directed by Congress, CMS has maintained a floor on the work component that results in none of the 89 designated geographic areas having an adjustment factor below average (designated numerically as 1.0). ATRA extends the current 1.0 floor through Dec. 31, 2013. Hospital payment extensions. ATRA extends through 2013 an add-on payment available to qualifying low-volume TAX RELIEF to page 38
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PRACTICE
A
s a medical technology consultant, I always have fun wandering the vendor halls at conferences and trade shows. What better place to take the pulse of the industry, where you can find innovative solutions and new companies, and see demos of the “toys” you will be using in the years to come? Recently, though, medical conference vendor exhibits have been dominated by one category: information technology (IT). At the 2012 Medical Group Management Association Annual Conference last October, fully half of the booths on the floor listed “Information Management and Technology” as their category. In the medical field, advances typically occur slowly. The industry is very methodical about introducing new techniques, tools, and processes— which makes the speed at which technology is advancing the business of health care all the more staggering. A technology unheard of one year may be a staple of medical offices the next. Across the country, for
MANAGEMENT
Staying on top of technology Common IT problems and challenges— and how to resolve them By Derek Kosiorek
example, physicians are asking when they can begin to carry their iPad from room to room— even though the first iPad was introduced to the public just under 36 months ago, in April 2010. On the other hand, today’s hot new technology may turn
overwhelmed by the options. Should they purchase the hottest new equipment, stick with their existing technology, or upgrade it? And with products being discontinued nearly as fast as they’re launched, sizable investments in time and
Health-care IT staff often have greater responsibility than their counterparts in other industries. out to be an expensive flash in the pan. In this constantly evolving technological environment, it’s easy for physician groups to feel
money are at risk if they choose the wrong path. So, how can medical practices determine the best course of action with regard to computer technology? Let’s start by looking at some of the most common technology problems and challenges in health care. Keeping abreast of the IT industry
Before you can judge whether a technical advancement is right for you, you have to know what it is (or isn’t) and what it does (or doesn’t do). Should you buy that fancy new module the EHR vendor is trying to sell you, or will it be obsolete within a year? Is the cloud a more efficient way of handling data storage? What are the risks that come with server or workstation virtualization? These are just a few examples of questions practices are facing today. How do you know which option is best for you or your practice? And are you sure you understand what, in plain English, those options are and what implications they have for your daily tasks? User group meetings, societies, and even discussion boards are the best places to dig into current best practices in
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EHR technology. Have your IT staff or key users keep up with the advances by attending at least one computer technology meeting a year. A great place to start is your EHR vendor’s annual user’s conference. Many practices send their senior partners or managers to these conferences, but the people who get the most out of them are the hands-on support staff that better understand how the system fits into the business. At the very least, designated medical staff should explore online societies and discussion boards for groups that have the same or similar products or setup. LinkedIn has a number of professional discussion boards on a variety of topics, including most EHR vendors. Finding the right experts
Because there hasn’t been as much investment in IT talent in health care as in other settings, health-care IT staff often have greater responsibility than their counterparts in other industries. For example, where a standard law firm may have a full team of dedicated IT people on staff, the median multispecialty practice has only one IT person for every 10 FTE physicians, according to the Medical Group Management Association (MGMA) 2011 Cost Survey. In addition, for an IT person to be effective in a health care setting, he or she needs to be able not only to communicate effectively with a layperson, but also to be able to speak medical language, which comes with its own set of acronyms and jargon. (Would a general IT person know key concepts such as CPT codes, HCFA forms, HIPAA compliance, or even what the Meaningful Use program is?) One common complaint among medical practices is that the IT person or contracted vendor doesn’t understand how technology can be a tool to help the business. Instead, they tend to simply react to technology problems rather than proactively identifying ways to leverage the technology. For example, fixing a broken printer is important, of course; but what if your IT staff sat with the nursing staff and helped them improve the way they use the EHR’s messaging
functionality or document management? The best way to ensure that the IT staff understand the difficulties your office staff is experiencing is to put the IT people to work in the office. Have them shadow the administrative or clinical staff one day a week for several weeks. You will be surprised at how quickly the IT people can identify the inefficiencies that regularly occur in your office. Their understanding of how the technology should be used, combined with an understanding of the tasks the staff is trying to accomplish, can raise the level of office efficiency. If you feel you don’t trust the judgment or expertise of your IT staff or consultants, bring in another set of eyes. There are a number of healthcare technology consulting firms that can evaluate the infrastructure or staffing in place and recommend improvements. Rethinking your IT investment
Studies have shown that there is a direct correlation between IT investment and IT satisfaction at medical practices. In other words, groups that spend more on technology tend to be more satisfied. If your group is still using computers running Windows 98, you should expect to have problems, as you have crossed the line from stretching your dollar to costing more in time, IT support, and general office-staff stress. It doesn’t take a tech guru to tell you that older equipment tends to be slower and needs more attention, while newer equipment tends to be more reliable. One way to gauge whether it’s time to update your equipment is by looking at where your IT people are spending their time. If they spend more than half their time working on reactive support, rather than future planning, you can help by investing in new equipment. According to the 2011 MGMA cost survey cited above, better-performing multispecialty practices spend about $20,000 per FTE physician annually on IT. But money isn’t the only thing involved in technology investment. If staff members (including physicians) fail to
Among the concerns providers face in the near future are EHR interoperability, patient engagement through technology, and ensuring data privacy and security. take the time to learn how to use the systems, they are costing themselves and the practice considerable efficiency. Some of the better-performing EHR systems insist on setting aside a certain number of hours with each physician during implementation to make sure the clinicians are properly trained. A few hours of lost productivity at the beginning can easily make up for years of using a system poorly. Maximizing efficiency, staying competitive
Among the concerns providers face in the near future are EHR interoperability, patient engagement through technology, and ensuring data privacy and security. Interoperability. One of the great promises of federal and state EHR “meaningful use� incentive programs is increased interoperability among health care systems, allowing them to exchange information and use the information that they exchange. The success of electronic prescribing has demonstrated how interoperability can benefit health care organizations. As the Meaningful Use program proceeds through its three stages, the ability to transfer data between organizations will become more standard. Patient portals. While provider-to-provider interoperability is being sorted out at the federal, state, and vendor levels, there are opportunities to improve how your practice interacts with another important stakeholder—the patient. Patient portals are fast becoming an important factor in choosing which provider(s) to use for care. According to a 2012 Harris Interactive poll, only 17 percent of patients reported having online access to their medical information, but 65 percent rated it as either very important or important. Patients have already started choosing
providers based on how technologically advanced they are, and a portal is one of the most basic ways to inform and engage patients. You can be sure that if your medical group doesn’t have plans to offer a patient portal, your competition does. Security. Not a month goes by without a news report about a health system that was forced to contact patients because of a security breach that involved their health information. The Hollywood version of a breach of this nature involves a teenager or foreign government infiltrating your network and downloading data. In reality, however, the vast majority of cases involve mishandling of equipment that has patient information on it. Medical practices can take simple steps to minimize this risk. They should implement
protocols that stipulate who can access certain data. Also, they should clearly state how the information is kept secure. A username/password is standard for in-office computers, but is there also the same security in place if staff is working from their personal laptops at home? Do the smartphones or iPads that access the information have passwords? Regular review of the security systems and policies is needed. But more important than that is an analysis that shows whether they are actually being followed. When it comes to health care technology, there’s much uncertainty. The one thing we can be sure of, however, is that the world will never get less technical. Keeping on top of advances in health information technology can help your office maximize efficiency, improve patient care, and stay competitive in an increasingly complex world. Derek Kosiorek is an Eagan-based principal in the MGMA Health Care Consulting Group.
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PROFESSIONAL
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ithin the past decade, the topic of pediatric bipolar disorder has garnered considerable attention in the scientific community and in the public eye. A 2007 study suggested that in the period from 1994 to 2003, diagnosis of pediatric bipolar disorder in adults rose two-fold, while similar diagnoses in children and adolescents increased 40-fold (Moreno C, et al., National trends in the outpatient diagnosis and treatment of bipolar disorder, in Youth Arch Gen Psychiatry, 2007). This dramatic difference between populations suggests that either there is an epidemic of pediatric bipolar disorder sweeping the nation or there is some shift in the criteria used by clinicians to diagnose pediatric bipolar disorder. Much of the disagreement on this issue centers on the strict application of the existing diagnostic criteria.
Diagnosing bipolar illness
The current edition of the DSM (American Psychiatric Association, 2000, “Diagnostic and
P S Y C H I AT RY
Pediatric bipolar disorder Fact or fiction? By Joel V. Oberstar, MD
Statistical Manual of Mental Disorders�) indicates that a diagnosis of bipolar illness is predicated on the identification of a mix of one or more mood episodes: major depressive episode, manic episode, hypo-
euphoria and grandiosity typically lasting one week or longer, while hypomania is of less intensity and shorter duration. Finally, a mixed episode typically lasts one week or longer and involves a patient meeting
Accurate early diagnosis provides an opportunity for intervention—medication and therapy—that can mitigate or even ameliorate symptoms entirely. manic episode, and mixed episode. A major depressive episode is a period of depression lasting two weeks or longer. Mania consists of
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criteria for both manic and major depressive episodes. Frequent symptoms of each episode type are presented in Table 1. Patients with bipolar I disorder are those who have suffered at least one manic or mixed episode. Those with bipolar II disorder have experienced at least one episode of major depression and one episode of hypomania. Lastly, those patients who experience multiple symptoms of one of these four episodes at varying times, but whose symptoms do not meet full criteria for I or II, may be classified bipolar disorder not otherwise specified (NOS). Many youngsters do not meet “full criteria� for I (in particular) or II, partly because they do not exhibit symptoms of sufficient duration (e.g., seven days for mania or four days for hypomania). Additionally, many young patients (in particular) present with a constellation of symptoms that are not easily classified into one specific illness. Consider a 10-year-old boy with a history of intrauterine exposure to alcohol, adopted from an orphanage (where he may have experienced neglect and/or abuse) at age 5, who exhibits dramatic mood swings from rageful
aggression to weeping hopelessness. Is this pediatric bipolar disorder, a fetal alcohol spectrum disorder, reactive attachment disorder, post-traumatic stress disorder, some combination of these, or something else altogether? Such cases can be quite difficult to accurately diagnose. For other kids—adolescents in particular—the diagnosis of bipolarity is crystal clear. Consider a 16-year-old male with no previous psychiatric history who, after a heated debate with another teenager, slips into a five-day period of sleeplessness, racing thoughts, pressured speech, psychomotor agitation, and grandiose delusions of being Jesus Christ. His behaviors are of such a dramatic nature that he is psychiatrically hospitalized. He has no substance use in his history and has a paternal uncle whom every family member characterizes as having classic bipolar I disorder. This patient undoubtedly is experiencing acute mania, for which a diagnosis of bipolar I disorder is quite appropriate. Treating bipolar illness
In cases of bipolar I disorder, a treatment parameter from the American Academy of Child and Adolescent Psychiatry suggests that treatment with one of several second-generation (aka atypical) antipsychotics such as risperidone or olanzapine is appropriate, as are the traditional mood stabilizers lithium and valproic acid (American Psychiatric Association, 2000, DSM 4th ed., text rev.). Patients with psychotic symptoms typically require an antipsychotic agent. After a period of stabilization lasting on the order of several months, during which the patient undergoes psychotherapy and psychoeducation about the importance of chemical sobriety and maintaining healthy sleep patterns, consideration may be given to dose reduction or medication discontinuation. Close monitoring by the patient, family, and clinician is quite important, as the patient is clearly at risk of a subsequent mood episode. Some patients will not experi-
TABLE 1. Mood episode and associated symptoms ence another episode for years, while others may slip into “rapid cycling,” wherein they experience four or more episodes within one year. In some respects, treatment of bipolar depression is even more challenging than mania, as use of traditional antidepressant agents poses the risk of activating the bipolarity or “flipping” the patient into mania. In such patients, consideration is frequently given to lithium, lamotrigine, a secondgeneration antipsychotic, or gentle addition of bupropion or a selective serotonin reuptake inhibitor. Bipolar illness in the long term
As is the case with many other physical and mental ailments, patients with chronic conditions must be vigilant regarding flare-ups of their illness. Such episodic worsening may require resumption of pharmacotherapy or increased dosing of medication. With each recurrence of a mood episode, increased consideration is given to longer-
Major depressive episode • sadness • irritability • hopelessness • suicidal thinking Manic episode • grandiosity • euphoria • pressured speech term maintenance medication treatment. That being said, many patients suffering bipolar illness can and do go on to lead very fruitful, fulfilling, and productive lives. As a local example,
• flight of ideas • decreased need for sleep Hypomanic episode • increased goal-directed activity • decreased need for sleep • highly productive behavior • irritability
ence with the disorder, he said, “My episodes are pretty much under control these days. I have good days and bad days just like anybody. I take my medication religiously. I go to my doctors. I get my blood tested. I
Many patients suffering bipolar illness can and do go on to lead very fruitful, fulfilling, and productive lives. television meteorologist Ken Barlow revealed last fall that he had been diagnosed five years previously with bipolar I disorder. In talking about his experi-
Pediatric bipolar disorder: It’s a fact
While there are cases in which the diagnosis of bipolar disorder is questionable, there are certainly instances in which the diagnosis is accurate. In either case, consultation with a child and adolescent psychiatrist is advisable, particularly earlier rather than later. As with most illnesses, accurate early diagnosis provides an opportunity for intervention—medication and therapy—that can mitigate or even ameliorate symptoms entirely. Joel V. Oberstar, MD, is CEO and chief medical officer of PrairieCare, which provides inpatient and outpatient psychiatric care to patients of all ages at three locations in the Minneapolis–St. Paul area. Oberstar is board-certified in psychiatry and in child and adolescent psychiatry, and is an adjunct assistant professor of psychiatry at the University of Minnesota Medical School.
do what they tell me to.” (Gustafson, AC, “KTSP’s Ken Barlow goes public with his struggle with bipolar disorder,” Pioneer Press, Oct. 4, 2012)
Chemical dependency in older adults is hard to recognize We help your patients live healthier lives Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older. Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.
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rimary care physicians who prescribe can now bill for their time while obtaining a psychiatric consultation. Minnesota’s public health care programs already allowed reimbursement for the time spent by a primary care physician while obtaining a psychiatric consultation (billing code 99499 plus modifier). However, the number of billings has been low because of difficulties in arranging for psychiatric consultation and a cumbersome requirement for joint PCP/psychiatrist billing. In response to the growing need for these services and limited child and adolescent psychiatric resources, the state applied for, and received, permission to simplify the previous consultation code, which required a standing contractual and business relationship between the primary care provider seeking the consultation and the psychiatrist providing the consultation. In many cases, this contractual
U P D AT E :
P S Y C H I AT RY
Billing update on psychiatric consultations A simple change with far-reaching benefits By Linda Vukelich
relationship was not part of the physician’s or clinic’s normal operations, and meant that a lawyer or business manager needed to be engaged to de-
proved to be a deterrent for both parties. The new consultation code simply allows both parties to code separately. In addition, the
The lessons shared will help improve the system of care, one patient at a time. velop the business system to support the process. In many cases, the cumbersome billing process was too much for the smaller clinics to manage, and
new code expands the definition of primary care providers (PCPs) to include general adult psychiatrists who see children and adolescents, allowing them
to enhance their knowledge and apply it to those pediatric patients. Psychiatrists are a scarce commodity in the rural areas of our state, and child and adolescent psychiatrists even more so. This change offers Minnesota providers another new tool in the ongoing effort to improve integration and access to quality psychiatric care. On Nov. 15, 2012, the state’s Department of Human Services received federal approval to allow the PCP (including any prescriber of psychotropic medications) and the psychiatrist to each bill separately for psychiatric consultation. Retroactive to April 1, 2012, Minnesota Health Care Programs (MHCP) reimburses psychiatric consultations with separate rates for the primary care physician (including APRNs, PAs, pediatricians, prescribing psychiatrists receiving consultation from another psychiatrist, and any other prescriber), and the consulting psychiatrist’s components of the consultation.
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TABLE 1. CPT codes to bill for psychiatric consultation services to primary care providers Proc code
Psychiatric consultation to primary care providers Modifier Provider Brief description Unit Service limitations
99499
HE AG
99499 HE AM
1 Primary Communication Care between a conProviders sulting psychiatrist and a primary care provider, for consultation or medical management of a recipient
Add the U4 modifier if not face-toface Add the U7 modifier if provided by a Physician Extender
1 Communication between a consulting psychiatrist and a primary care provider, for consultation or medical management of a recipient
Add the U4 modifier if not face-toface
Consulting Psychiatrist
Legal References: MS 256B.0625 subd., 48 The new billing procedures are highlighted in the sidebar. If you have questions, call the MHCP Provider Call Center at (651) 431-2700 or (800) 366-5411, or go to
www./mn.gov/dhs. From there, enter Psychiatric Consultations to Primary Care Providers in the search bar and click on “MHCP Provider Manual.”
ONE ON E WEEK WEEK ON ONLY LY
Billing procedures • The primary care provider and consulting psychiatrist may bill separately for this service. • Use the MN–ITS 837P online claim form to bill for physician and nonphysician services. • Primary care providers are allowed to bill an office visit and a consultation if appropriate. • Providers should bill for services provided on the same day using the appropriate modifier (see Table 1). Improved communication and collaboration
The new coding option simplifies the consultation initiation and reimbursement process; and by doing so, may improve engagement for consultation in primary and psychiatric care. This is a shift in how providers share and co-manage patients with chronic and even acute care and/or crisis management needs. In addition, eliminating the barriers that have complicated consultation in the past may result in more collaboration and fewer referrals to specialty care. Access to consultation will improve communication, enhance collaboration, and support shared learning opportunities.
The lessons shared will help improve the system of care, one patient at a time. Working together, primary care and psychiatry may improve treatment at every stage, from identification to maintenance, and, if needed, even the initial point of crisis management. The new consultation code is a simple change that could have far-reaching benefits. Linda Vukelich is executive director of the Minnesota Psychiatric Society.
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SPECIAL Since the Human Genome Project was completed 10 years ago, the field of genomic
FOCUS:
GENETICS/GENOMICS
Genomic medicine The state of the science, or “When will it be ready for prime time?”
medicine has advanced,
By Catherine A. McCarty, PhD, MPH
as researchers strive to achieve the goal of translating genomic data into clinical practice. This special focus looks at two research efforts in Minnesota that are participants in a nationwide genomics research network. Our feature also discusses “moving target” issues of insurer reimbursement for genetic tests, and the growing need for genetic testing and genetic counseling.
T
he director of the National Human Genome Research Institute has identified the following imperatives for genomic medicine: making genomics-based diagnostics routine; defining the genetic components of disease; characterizing cancer genomes; developing practical systems for clinical genomic informatics; and determining the role of the human microbiome in health and disease. The Electronic Medical Records and Genomics (eMERGE) network (www.gwas .net), funded by the National Human Genome Research Institute of the National Institutes of Health (NIH), is helping to address a number of these issues, including iden-
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tifying the genetic components of disease and translating genetic research into clinical care. The eMERGE network, phase 1
The eMERGE network has good representation in Minnesota, where two health care organizations (Essentia Institute of Rural Health and Mayo Clinic) are among the network’s nine participating sites. The eMERGE network is in its second round of funding. To apply to be a funded eMERGE member, investigators had to have access to DNA biobanks with linked electronic medical records (EMRs). In phase 1, eEMERGE researchers conducted genome-wide association studies (GWAS), and also engaged with communities on the ethical, legal, and social issues associated with broad data-sharing with the research community. The GWAS analyses in eMERGE phase 1 helped us to identify the strengths and limitations of current EMRs for genomic research. The strengths for integrated health-care delivery systems include availability of information for the majority of health care for an individual, and electronic accessibility. The limitations tend to be specific to specialty. For example, in specialties such as dermatology and ophthalmology, much of the information, even when captured electronically, is re-corded using “ink-over” forms that allow health care practitioners to draw pictures of any lesions that they visualize on clinical examination. Interpretation requires manual review of the digital forms rather than less labor-intensive electronic extraction. Also, very specific diagnostic codes are typically not used in any specialty because there is no incentive to use them. In fact, it could be argued that there is a
financial disincentive to using more specific diagnostic codes if it takes more time (which it often does) to search for the codes even though the reimbursement is the same regardless of code. Precision in disease classification is necessary for research. EMR challenges for genomic research
The large-scale genomic research undertaken in eMERGE could not occur without the existence of extensive EMRs. Although Minnesota is ahead of many states in EMR development and use, the health records for a significant number of patients are not maintained electronically. Electronic records are needed to support the genetic discoveries being made now and, ultimately, to support translation of research into clinical care. Personalized medicine that incorporates genetic information will not be possible with print records. Some of the main challenges to the use of EMRs in genomic research are briefly discussed below. Data-sharing rights. There are four different EMRs in use across the eMERGE network and many more EMRs are available commercially. In the network’s phase 1 research, that made data sharing challenging for a number of reasons. First, it was necessary to have data-sharing agreements in place, as well as procedures to ensure that the confidentiality of the data would not be compromised. In a recent study published in the journal Science, researchers demonstrated that they were able to identify subjects with genetic data in a database by linking information on birthdates and surnames from publicly available sources. Further research is needed to determine the policies that need to be in place to adequately protect individual privacy. Merging data. After securing data sharing rights among eMERGE sites, the next challenge was to merge the data. Data are collected and stored differently in the various EMRs. We quickly discovered that much of the wealth of the clini-
Useful websites cal information can be found in the dictated notes—and electronically extracting the information from the records required natural-language-processing tools. We are now developing new tools to allow structured entry of some of the information in the medical records. As an example, for ophthalmic records, ophthalmic measurements that are taken at most visits could be entered routinely in the EMR. In addition to aiding research in the future, this type of structured entry will facilitate the development of tools to visually display trends, such as intraocular pressure measurements over time. Data storage. Data storage issues also need to be resolved. There are 20,000 to 30,000 genes and 3 billion base pairs in each strand of DNA. Current EMRs do not have the capability to store, much less manage, this quantity of data. Risk identification. Disease is caused by a combination of genetic and environmental “risks.” Much research has been done to identify personal and environmental risk factors for disease and, more recently, to identify genetic markers that predict disease outcomes and response to medications. The research to quantify gene/ environment interactions that increase risk of disease is in its infancy. As we have discovered in eMERGE, standardized collection in EMRs of environmental exposures, other than smoking, is rare. We need simple tools that can be completed by patients and that can feed the information into clinical decision-support tools—in order, for example, to issue an alert for a patient who may need a behavioral med consultation. The eMERGE network, phase 2
In phase 2 of eMERGE, researchers are conducting GWAS analyses with the existing genetic data and additional health outcomes derived from the EMRs. Discussions with the community are focusing on the return of genetic results to patients, and the discussion has expanded to include physicians and their needs for education
American College of Medical Genetics, www.acmg.net American Society of Human Genetics, www.ashg.org Clinical Pharmacogenetics Implementation Consortium, www.pharmgkb.org/page/cpic National Coalition for Health Professional Education in Genetics, www.nchpeg.org National Human Genome Research Institute, www.genome.gov National Society for Genetic Counselors, www.nsgc.org Surgeon General’s Family Health History Initiative, www.hhs.gov/familyhistory/ and clinical decision support related to genetic medicine. Thus far in our discussions with primary care physicians throughout the eMERGE network, we have learned that: • Generally, they do not feel prepared to practice genomicbased medicine. • They are cautious and want assurance that genetic information is ready for clinical use. • They are concerned about privacy issues and the potential for genetic discrimination. The Pharmacogenetics Research Network, also funded by NIH, has developed a Clinical Pharmacogenetics Implementation Consortium (CPIC) to address some of the barriers to implementing pharmacogenetics tests into clinical practice. As of February 2013, the CPIC had published guidelines for seven gene/drug pairs (www.pharmgkb.org/page /cpicGeneDrugPairs): TPMT/thiopurines, CYP2C19/clopidogrel, CYP2CP and VKORC1/warfarin, CYP2D6/codeine, HLA-B/abacavir, SLCO1B1/simvastatin, and HLA-B/abacavir. Physicians also regularly mention “alert fatigue” as a barrier to the integration of decision-support tools into EMRs to support genomic medicine. Although there is a lack of empirical evidence concerning how common alert fatigue is and how it affects clinical decisions, this factor needs to be considered when developing and implementing any new clinical decision-support tools. In general, patients want us to move genetic discoveries into clinical practice as quickly as possible, yet they are also con-
cerned about the potential for genetic discrimination. Few people are aware of the federal Genetic Information Nondiscrimination Act (GINA) that was passed in 2008. Although not yet tested in courts of law, GINA should prevent genetic discrimination that physicians and patients fear, at least in terms of employment and health insurance. Life, disability, and longterm care insurance are not covered by GINA. The other group that is vital to the realization of personalized medicine is third-party payers. Although the FDA has labeling for genetic testing for a number of medications, very few have
become a standard of care, in part because more research on cost effectiveness is needed. Our research in eMERGE has shown that to be successful, we need to engage everyone who will be affected by genomic medicine— providers, patients, payers, and researchers. For us to truly realize the promise of personalized medicine, the following issues still need to be resolved: • Electronic health record availability • Data sharing • Data storage and data security • Clinical decision support tools • Community engagement We’re not ready for prime time yet with genomic medicine—but we know what we need to get there. Researchers in the eMERGE network and elsewhere are working with health care organizations to make it happen. Catherine A. McCarty, PhD, MPH, is a genetic epidemiologist and a principal research scientist at Essentia Institute of Rural Health, Duluth.
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MARCH 2013
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s I write this, my grandson is recovering from heart surgery. He is doing well, and I am grateful for that. I am also impressed that his entire team of providers gathers twice a day for rounds and welcomes family to be in the room during their discussions. Listening in on these meetings over the past three days, something struck me. In orchestrating the medications and technology supporting him, this team is grappling with an enormous mystery that their experience and the many monitors and laboratory tests they use cannot make sharp and clear at the beginning. Infused, inhaled, and ingested, the medications prescribed for my grandson enter a complex world unique to him. The results are at least directionally predictable, but the way each of the medications reacts with his unique physiology and with each other means the doctors, nurses, pharmacists, and other team members are seeing a story unfold that they have never precisely seen before.
GENETICS/GENOMICS
Insurers and genetics Key issues to consider as knowledge grows By Patrick Courneya, MD
The team members are very skilled and confident in their ability to respond to the surprises that this little-humansized world will show them; I am confident in them as well. Even so, I know we all would
information flowing from genomics research. Promise and disappointment
I marvel at that possibility of caring for patients with a better understanding of their genetics.
I marvel at that possibility of caring for patients with a better understanding of their genetics. feel much better if we could shrink the mystery and make the result of each care decision more predictable. This, many in the field of genomics hope, is one promise of the explosion of
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Even so, I can’t help but think of the times during the course of my 25 years as a family physician when we have let the seductive hope of innovation or new approaches using old tools pull us far out ahead of sound evidence. In far too many cases, it has led to generally accepted practice that produced unexpected harm at unanticipated expense with promised results undelivered. The disappointing outcomes of prostate cancer screening and the public health crisis we face because of cavalier use of opioids for chronic noncancer pain are two examples. Another is the infuriating and expensive stubbornness of the problem of chronic back pain in the face of a wide array of nonsurgical and surgical approaches that have not lived up to their promise. Just as importantly, the rapid and reliable dissemination and application of care changes that we know work is still remarkably difficult. Many other factors complicate the transfer of genomics research results into clinical practice. The genome is stunningly complex. Human genes contain the code for roughly 20,000 proteins, but these genes account for only 2 percent of the DNA in the genome. Until recently, researchers believed much of the remaining 98 per-
cent was “junk,” the residue of billions of years of evolution carried along as excess baggage. However, in research results released in 2012 from the international Encode Project, it has become clear that 80 percent or more of that so-called “junk” DNA actually performs important biochemical/regulatory functions that dictate much of the expression of those key protein-coding genes. Yet even when we already know a good deal, it can take a long time for that knowledge to grow to the point where it makes a significant difference. For example, according to Ronald Ma, MD, of the Chinese University of Hong Kong, 70 percent to 80 percent of the risk of developing diabetes is heritable, but the 60 or so diabetes-related genetic markers identified so far account for only about 10 percent of that heritability. Finally, the Association for Molecular Pathology vs. Myriad Genetics case, taken up by the U.S. Supreme Court this session, will determine whether the process of taking a gene out of the human genome for study is patentable in the U.S. The decision will have profound implication for the commercialization of the human genome research effort. Regardless of the outcome of that case, it is unlikely that progress in bringing genomic science to the front lines of care will come to a halt. Weighing the evidence to make wise decisions
So what does all this have to do with the key issues facing insurers as we consider paying for genetic testing? Seduced by innovation, driven to reduce the harm caused by illness, and drawn by hope of new answers, we make judgments every day about paying for tests and technologies using evidence that is often incomplete in a dynamic and complex environment like the one for genomics research. We make those judgments mindful of past examples of disappointing results, but eager to be sure beneficial tests and treatments are available to those members who need them. We also know these decisions, in the
context of limited resources, will have an impact on the affordability and availability of care. To make those decisions wisely, we need to know as much as we can. When making the decision to cover medically necessary new services, tests, or other technologies, insurers look for convincing evidence to answer a variety of questions that fall into three categories: • How does the technology or test improve on effectiveness and safety of current treatment? • Whom specifically is it proven to help? • How much will it change direct and indirect costs for care? These questions are important to researchers and those who develop treatments and tests because they will need to respond to them when they seek payment. If not well prepared, those seeking coverage can be surprised and disappointed. Some believe that getting through the FDA approval process is sufficient. For devices
In the case of breast cancer treatment, insurers now collaborate with providers to assure more reliable use of genetic testing. and tests in particular, however, the approval process does not go nearly far enough to answer the questions above; and so, in many cases, FDA approval puts a device or test only a short way down the road to coverage. The use of genetic testing to guide treatment decisions is not new, and there are gratifying examples where it is making a big difference. Breast cancer, leukemia, cystic fibrosis, anticoagulant management, and sickle cell disease are a few of the examples where genetic tests have reduced uncertainty, improved precision, guided decisions, and improved outcomes. In the case of breast cancer treatment, insurers now collaborate with providers to assure more reliable use of genetic testing. In this example, it can improve outcomes for patients, as well as help them avoid was-
ted time, needless suffering, and unnecessary expense. It is a great story and hints at the potential of genomics science to revolutionize many aspects of care. Seeking meaningful innovations in care
Since the first draft of the human genome was released in 2000, it has been the subject of intense research in the U.S. and across the globe. Our understanding of the genome has developed rapidly at the same time that the cost of sequencing genes has dropped dramatically. As in the case of “junk” DNA, the more we learn, the more we realize what we do not know. While it is moving more slowly than we would like, we have already seen the benefit of expanding application of that knowledge to improve health
and care. Even so, it is frustrating but important to realize that many of the things we learn will not have impact and will not lead to payment. Knowing how insurers approach decisions about coverage will help innovators prepare to make their case, will make those decisions better from the outset, and will assure that meaningful innovations find their way to the care of patients as quickly as the evidence shows their value. For my grandson, the idea of a fast, reliable, low-cost way of checking a genetic profile and predicting more accurately how he would respond to the medications his care team uses as he recovers from heart surgery would be a remarkable and valuable use of technology. It would be a clear example of improved quality, better experience, and lower costs. Genomics research that can deliver this kind of result is something we should and would be eager to pay for on behalf of our members. Patrick Courneya, MD, is medical director, health plan, at HealthPartners.
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mong the promises of the genomic era is the potential to test patients for undetected or future maladies based on their genetic composition. However, progress in profiling disease susceptibility has been limited to date, with genome-disease associations of mostly modest strength demonstrated thus far, precluding routine clinical deployment. In an effort to make progress in this domain, in 2007 the National Human Genome Research Institute (NHGRI) formed a network of academic medical centers known as eMERGE—electronic Medical Records and Genomics network. (See also the article on p. 20.) Many observers have written on the dramatic progress in genomic technology, greatly accelerating the time to generate genetic information and the volume of such information that can be ascertained from people or experimental organisms. With the availability of “high-throughput” genomic techniques, the rate-limiting factor for uncovering new genotype-phenotype
FOCUS:
From bench to bedside The eMERGE project and the integration of genomic data into practice By Christopher G. Chute, MD, DrPH, and Iftikhar J. Kullo, MD
associations became the clinical characterization of patient conditions, outcomes, disease propensity, or treatment risk. The obvious research goal was to develop algorithms for highvolume characterization of medically relevant phenotypes from electronic medical records (EMRs) to correspond with high-throughput genomic methods. This would rebalance our ability to conduct translational genomic research. The eMERGE Consortium was formed in part to validate the hypothesis that highthroughput clinical phenotyping of patient data from EMRs was 1) possible; 2) scalable; and,
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most importantly, 3) portable across multiple academic medical centers. During the first four-year funding period of the NHGRI funded eMERGE Consortium, the members (which included Mayo Clinic, Vanderbilt University, Marshfield Clinic, Northwestern University, and University of Washington– Group Health Puget Sound) convincingly demonstrated their ability to create computer algorithms that would reliably and accurately identify patient cohorts and disease types from EMRs. Furthermore, this consortium was able to demonstrate that algorithms generated in one medical facility could be executed at another with similar accuracy and precision. This remarkable achievement has ushered in an active area of research now known as highthroughput clinical phenotyping. We expect to see large-scale application of these methods and techniques in clinical and translational research going forward. Accelerating the clinical dimension of genomics
Meanwhile, NHGRI recognized that conducting more and better genomic association research, while valuable, does not always translate directly into improved patient care. To accelerate that dimension, the second four-year period of the eMERGE network, which began in 2011, emphasizes storing the results of genomic evaluations in EHRs in such a way that they might materially improve patient care. Genomic data and pharmacogenetics. The most promising domain of genomic data affecting clinical care directly in 2013 remains pharmacogenomics, where genotyping or
sequencing data can inform clinicians of whether or not specific drugs should be used at all for a specific patient, or whether the patient should receive a higher or lower dose than is used for most patients. This is because many patients have genomic variants that influence the degradation or activation of pharmacological agents, either accelerating this metabolism or, alternatively, having slow or virtually no enzymatic activity. This realization of personalized medicine—drug therapy tailored to a patient’s genomic makeup—has direct implications for drug effects, dosing, and previously unrealized contraindications for specific patients. Thus, for centers applying for the second round of eMERGE funding, NHGRI required a commitment from clinical organizations to integrate genomic results into their electronic medical records, and in such a way that automated clinical decision support infrastructures could take advantage of that data and help care providers, patients, and families understand the risks and benefits of different drugs for specific patients. Additionally, a supplemental eMERGE grant was offered, in partnership with Pharmacogenomics Research Network (PGRN) of the National Institute of General Medical Sciences, to members of the consortium to pilot integration of pharmacogenomic decision support into their practice. So far, virtually all of the eMERGE Consortium members (which now include Mount Sinai Medical Center, Children’s Hospital of Philadelphia, Boston Children’s Hospital, Cincinnati Children’s Hospital, and Geisinger Clinic, in addition to the original members) have initiated efforts to integrate genomic data into their electronic records in a way that can sustain electronic access and inferencing. Leveraging its existing clinical decision-support engines, including its GE systems in Rochester and its Cerner systems throughout the Mayo Clinic Health System in the Upper Midwest, and the Mayo campuses in Arizona and Florida, Mayo Clinic is focusing
its efforts on three drugs: clopidogrel, warfarin, and statins. The 1,000 patients in Mayo’s cohort were specially consented for CLIA-approved blood draws, the use of the PGRN “very important pharmacogene” (VIP) chip, and the integration of these results into clinical decision-support roles for patients who are likely to be prescribed these medications. Coronary heart disease risk. In addition to the pharmacogenomics pilot project, Mayo’s second-round eMERGE application included a separate experiment, where clinical risk factors for coronary heart disease (CHD) are combined with a panel of CHD genomic risk markers. While the strength of association of any single genomic marker with CHD has so far been modest, a panel of such markers may contribute importantly to the shared decisions made by patients and providers about lifestyle changes and the initiation and intensity of drug treatment. For this project, Mayo is consenting a small cohort of
The most promising domain of genomic data affecting clinical care directly in 2013 remains pharmacogenomics. patients who will be randomized to receive specialized genomic evaluation for CHD risk, and a group that will receive routine care. The question is whether additional genomic information will influence adoption of preventive measures such as weight control, smoking cessation, or more aggressive management of hypertension and hyperlipidemia. Challenges ahead
An interesting challenge encountered by the genomics community, including the eMERGE network, is how to name the myriad genomic findings uncovered in sequencing studies in a comparable and consistent way. Historically, the genomic community has applied many nomenclatures and naming schemes to genomic findings, which complicates their consistent application in clinical envi-
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ronments. It is obvious that a common, international naming scheme for genomic variants must be fostered if the health care system is to have any hope of consistently leveraging genomic findings in decisionsupport algorithms beyond a handful of academic medical centers. The spectrum of genomic associations will grow as more genomic testing is done, more clinical phenotyping can be algorithmically captured, and more patients consent to genomic association research. No clinician can reasonably master the various emerging genomic associations, their clinical impact, or their treatment implications—the volume of information is overwhelming. However, intelligent integration of such results with clinical decision-support systems offers a way forward. Related to that
vision is the recognition that not every clinical center should or could research, craft, and validate the hundreds or thousands of clinical decision-support rules that may be needed to implement genomic medicine. A national repository of genomic decision-support rules, curated by agencies such as the National Institutes of Health, will likely evolve to support this challenge. The opportunities for genomic data to profoundly change the nature of clinical practice are increasing daily. However, the practical issues for effectively harnessing this information remain a research activity. The eMERGE consortium is making impressive progress, and the translation of its findings to the larger health care community is imminent. Christopher G. Chute, MD, DrPH, is professor and section head of medical informatics in the Department of Health Sciences Research, Mayo Clinic, Rochester. Iftikhar J. Kullo, MD, is a professor in the Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester.
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
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he Human Genome Project has brought advances that are dramatically changing genetic testing. As a result, knowledge in the field of genetics is rapidly changing and bringing many clinical answers, as well as challenges. The key challenge before us is how to integrate genetic knowledge into our current medical system while minimizing harm to patients and their families. Because the field of genetics is complex and evolving, this is a daunting task. We need to find optimal ways to deliver highquality genetic services, leveraging the skills of trained genetic professionals while increasing genetic and genomic education and competencies for other medical providers. Education/training, licensure, billing
Geneticists and genetic counselors form the backbone of our current genetic workforce, which also includes a small number of individuals who have specialized genetic training in other professions, such as
FOCUS:
Genetic counseling An evolving role as knowledge advances By Barbara Kunz, MS, CGC genetic nurses. Geneticists are MD-, DO-, or PhD-trained and are boarded in medical genetics through the American Board of Medical Genetics. Clinical geneticists often staff general and specialty genetics clinics; their skills are important for accurately diagnosing and managing genetic diseases. Many geneticists are also involved in the development and oversight of genetic testing laboratories and research. Genetic counselors are health professionals who are trained through accredited graduate-level programs. According to the American Board of Genetic Counseling (ABGC), nationally there are 31 accredited programs, including the graduate program through the University of Minnesota. Genetic counselors are educated and
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GENETICS/GENOMICS
MINNESOTA PHYSICIAN MARCH 2013
No .7
2007
trained in the principles of human genetics; areas of science that relate to medical genetics; a broad range of inherited diseases; and the diagnostic process, including testing. Training also encompasses the development of competencies in communication and counseling skills. Graduates of these programs are eligible for national certification through the ABGC, which requires continuing education for ongoing certification. Nationwide, there is a trend toward state licensure for genetic counselors. According to the National Society of Genetic Counselors, in 16 states genetic counselors are either already licensed health care providers or soon will be, due to passage of state licensure bills. Minnesota’s legislature has not yet moved to license genetic counselors. Most insurers now provide coverage for genetic counseling services and appropriate testing. Many insurers in Minnesota allow genetic counselors to directly bill for their services. Some payers have also begun to require that pre- and post-test counseling be provided by trained genetics professionals in order to pay for the genetic testing. Genetic counselors are not yet independent billing providers under Medicare, but Medicare has guidelines for coverage of many genetic tests and will pay for genetic counseling provided by physicians. These and other recent changes in billing by many payers have increased patient access to genetic counselors and have improved the efficiency of genetic counselors in clinics. However, the patchwork of coverage is still a challenge for many clinics. Continued billing improvements and more efficient delivery models are needed to further leverage the skills of genetic counselors. For example, there are a few telephone-based counseling providers, but these services are available through only a
limited number of insurers that contract for this care. Solutions for better delivery of care should include ways to provide telephone or web-based services since there is a shortage of genetic services in nonurban areas of Minnesota. The evolution of genetic counseling roles
The pool of genetic counselors in Minnesota has expanded from five genetic counselors in the mid-1980s to about 90 today. This growth has been accompanied by increasing diversity in roles and job settings, as new opportunities have emerged. Initially, most genetic counselors worked at large academic health institutions or were hired by hospitals to provide pregnancyrelated counseling. According to the National Society of Genetic Counselors’ professional status surveys, 60 percent of genetic counselors listed a university medical center as their primary work setting in 1980, compared to 36 percent in 2012. In 2002, 59 percent of genetic counselors listed their specialty as prenatal genetics, compared to 29 percent in 2012. The most recent job growth in genetics counseling has occurred in cancer genetics and laboratory-based positions. In 1994, 10 percent of genetic counselors worked in cancer genetics; by 2012, this level had reached 25 percent. Mayo Clinic and Laboratories illustrates the growth of lab-based jobs: There were no genetic counselors in Rochester in the mid-1980s, whereas now there are about 20. Genetic counselors have a skill set that is well suited to the laboratory setting. They have the technical and scientific knowledge to understand the complexity of testing, and they also have the communication skills to work with local and national clients. This expertise is critical to ensure that correct testing is ordered and that the testing results are interpreted properly. The Minnesota Department of Health employs lab-based genetic counselors through the state’s Newborn Screening Program. The genetic counselors work with physicians around the
state when screening shows that a newborn may have a genetic condition that should be assessed without delay. These services are critical, since quick, accurate identification of newborns with these conditions is needed to prevent medical complications and save lives. Many genetic counselors work in other specialized areas and clinics, often as members of multidisciplinary teams. Some clinics deal with conditions that are diagnosed in childhood, such as cystic fibrosis, spina bifida, Down syndrome, and phenylketonuria (PKU). Others focus on medical specialties or diseases that have specialists in common, such as hematology, cardiology, metabolic disease, hearing loss, and neuromuscular diseases. Genetic counselors in Minnesota also are employed at a fetal diagnosis and treatment center; a bone-marrow donor program; and a program for biobanking, personalized medicine, and genomics. Emerging specialties for genetic counselors include cardiovascular genetics, psychiatric genetics, preimplantation genetic diagnosis, and pharmacogenetics. These new areas are emerging as the clinical applications of genomic advances take place, and there is a new need for skilled genetic providers. The genetic counseling process
The majority of genetic counselors provide direct patient care. They typically see patients on referral from physicians or through self-referral. Depending on the setting, a genetic counselor usually sends a summary back to the referring physician so that he or she can coordinate care. Because genetic counselors work in diverse settings, genetic counseling visits vary with the context of the visit. For example, a visit with a family that has a child with the new diagnosis of cystic fibrosis includes different elements than a visit with a family to assess whether a pattern of cancer is likely to be hereditary. Similarly, the number of visits to a genetic counselor will vary depending on the setting and testing results, type and severity of the genetic condition, and
whether short-term or ongoing support is needed. At the initial visit, the genetic counselor collects a personal medical history and a detailed three- to four-generation family history. This process focuses on the information needed for the specific assessment or visit. For example, a cardiac genetic counselor will focus on collecting different information than a prenatal genetic counselor. Based on this information, the genetic counselor will use his or her knowledge to provide an assessment and personalized counseling. One of the most important aspects of genetic counseling is the interaction with patients, so that they can learn needed information about the medical situation, weigh options, and make informed decisions. When appropriate, genetic counselors discuss testing options and the benefits and limitations of current testing. Counselors coordinate testing, make sure the correct test is ordered, and provide post-test counseling, which includes interpretation of positive, negative, and ambiguous results, in the context of a specific medical and family history. For individuals or families that are found to have a hereditary condition, a genetic counselor can be a resource to them for years. Genetic counselors can guide patients to different resources and provide support as different emotional and medical needs arise. Genetic counselors are uniquely trained to address issues such as the implications of a diagnosis for other family members and how to convey genetic information to relatives. Emerging challenges and opportunities
This past year has ushered in a new era of clinical genetic tests, including targeted multigene panels and clinical exome sequencing. These are powerful clinical tools with amazing potential to uncover causes of human diseases, but they also pose new challenges. For example, currently there are few guidelines about who should be offered many of these tests. The growing number and
availability of tests also makes it easier for mistakes to occur in ordering the proper test. Because there are now more genes included in one test, and because many of the genes have not been included in previous tests, the interpretation of results is more complex. For many genes, there is not yet enough genetic knowledge to be able to fully interpret results. There also will be more results that find uncertain variants in genes. These are ambiguous results that should not be treated as true mutations, because many of these genetic variants are not linked with disease risk. Medical providers need to be very cautious about interpreting results, especially genetic variants. In addition, we need to continue to build systems of care that can accurately handle genomic information. For example, the electronic medical record (EMR) should include more options for providers to accurately list genetic diagnoses and test results in data fields. We have seen uncertain results listed as true mutations in the
EMR because that was the only field choice. This is a serious concern, as patients and their physicians may make surgical, screening, and treatment decisions based on this erroneous information. Continued efforts in educating health providers about genetics and genomics are also needed, because the number of trained genetics professionals is relatively small. All providers— from primary care physicians to subspecialists—will need a solid base of genetics to supplement their clinical practice, particularly as genetic advances increasingly affect clinical care. Over the next decade, genomic medicine will transform medical care. With its strong health care system and medical educational institutions, Minnesota is well positioned to apply these advances in ways that will benefit our patients. Barbara Kunz, MS, CGC, is a cancer genetic counselor through Humphrey Cancer Center and the past chair of the Minnesota Genetic Counselors Association. She also serves on the Minnesota Cancer Alliance steering committee.
THE STRENGTH TO HEAL
and stand by those who stand up for me. Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference. 7R OHDUQ PRUH FDOO RU YLVLW ZZZ KHDOWKFDUH JRDUP\ FRP T Š 2010. Paid for by the United States Army. All rights reserved.
MARCH 2013
MINNESOTA PHYSICIAN
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PROFESSIONAL
S
exually transmitted diseases (STDs) continue to be a significant public health problem in Minnesota and the U.S., with the epidemic of chlamydia of particular concern. Chlamydia is the most frequently reported infectious disease in Minnesota and the U.S., yet the general public and many health professionals are largely unaware of the extent of the problem. From an all-time low of 115 cases per 100,000 in 1996, the incidence of chlamydia in Minnesota more than doubled to 319 per 100,000 in 2011, when nearly 17,000 (16,898) cases of chlamydia were reported to the Minnesota Department of Health (MDH). Adolescents and young adults 15–25 years of age accounted for 69 percent of the reported cases, although they account for only 14 percent of the population. Seventy-five percent of the reported cases occurred in females, and people of color were also disproportionately affected. Chlamydia cases were evenly distributed among Minneapolis/St. Paul (32 per-
U P D AT E :
EPIDEMIOLOGY
Chlamydia More than a medical problem By Candy Hadsall, RN
cent), the remaining sevencounty metropolitan area (35 percent), and Greater Minnesota (29 percent). Background
Because 75 percent to 85 percent of females and 50 percent of males with chlamydia are asymptomatic, most people with chlamydia are unaware of their
treated simultaneously, and every additional chlamydial infection increases the likelihood of complications. Preventing complications that result from untreated chlamydia remains the primary medical reason for improving chlamydia screening and treatment rates. Although death attributed to untreated chlamy-
Screening rates for chlamydia remain substantially lower than rates of screening for other critical women’s health services. infection. As a result, they do not seek testing and treatment, thereby increasing the chance of developing serious sequelae. Females are frequently reinfected if their partners are not
dia is very rare, consequences can be serious and have lifelong impact. Twenty percent to 50 percent of young women with untreated chlamydia are diagnosed with pelvic inflammatory disease. Fifteen percent to 20 percent of those women develop infertility, 9 percent experience ectopic pregnancies, and 18 percent develop chronic pelvic pain. Chlamydia can contribute to premature deliveries, and babies born to infected mothers can get chlamydial infections in their eyes and lungs, leading to conjunctivitis and pneumonia. These longterm physical consequences can contribute to multiple gynecologic and emotional issues across a woman’s lifespan. In men, untreated chlamydia can cause scarring in the reproductive organs, leading to sterility, although this is rare. Both women and men with chlamydia are up to five times more likely to become infected with HIV, if exposed. Minnesota takes action to address chlamydia
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MINNESOTA PHYSICIAN MARCH 2013
Past public health efforts to combat chlamydia have used a disease intervention model aimed at identifying people who are infected and treating them and their partners to prevent
further spread to additional partners. In March 2010, with funding from the National Chlamydia Coalition, MDH convened the Minnesota Chlamydia Partnership (MCP), a group of individuals and organizations interested in collectively exploring additional ways to address chlamydia. MCP sponsored the state’s first summit on chlamydia in August 2010. More than 275 people attended, learning about the epidemic and its effects on individuals and communities, and discussing ideas for reducing the rates across the state. Participants came from nonprofit organizations, local public health departments, public health clinics, private health clinics/providers, educational institutions, and health plans. Of note, high school- and college-aged students accounted for 16 percent of the total audience. Following the summit, workgroups developed ideas for a statewide action plan on chlamydia. In April 2011, MDH released the Minnesota Chlamydia Strategy: www.health.state .mn.us/mcp The plan discusses strategies that community groups can implement in their local efforts to address the chlamydia epidemic, and identifies five action areas, including raising community awareness and working with providers to increase screening and treatment. In September 2012, the MCP published its recommendations as “A Special Report: Chlamydia Prevention”: www .mnchlamydiapartnership.org The report is designed to help individuals and organizations tailor chlamydia prevention strategies to their particular communities. The MCP is now working with a group of health plans collaborating to improve chlamydia screening rates for women enrolled in the state’s public health programs, through ongoing quality improvement activities targeted to the clinics and providers serving these communities (see sidebar on p. 29). Screening
Physicians can make a difference in reducing and improving screening for chlamydia. Centers
Chlamydia Screening Provider Toolkit As part of a collaborative performance improvement project (PIP), Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, and UCare, with support from Stratis Health, have developed the Chlamydia Screening Provider Toolkit to help clinics and providers across the state improve their clinic processes and awareness of this growing public health challenge. The toolkit is available at www.stratishealth.org/pip/chlamydia.html The collaborative’s goal is to increase the rate of chlamydia screening in sexually active women 16–24 years of age who are enrolled in the state’s Prepaid Medical Assistance (PMAP) and MinnesotaCare (MNCare) public health programs. The collaborative’s work supports organizations already working on this issue, including the Minnesota Chlamydia Partnership. Each health plan partner will encourage clinics in using the toolkit to improve their chlamydia screening rates. Providers will be offered training on medical issues related to the disease, such as symptoms, prevalence, treatment options, and short- and longterm effects. The collaborative will partner with local public health, high schools, and health services at colleges, universities, vocational, and technical schools, and will share the toolkit and other resources at health fairs and conferences. The toolkit provides background on the significance and distribution of chlamydia in Minnesota, as well as educational and resource materials for patients, parents, and providers. For example, provider materials include information on tests for chlamydia screening, sexual history-taking, STD treatment guidelines, repeat testing after positive, for Disease Prevention and Control (CDC) guidelines for screening and treatment of chlamydia are available at www.cdc.gov/std/treatment/2010/ chlamydial-infections.htm Screening rates for chlamydia remain substantially lower than rates of screening for other critical women’s health services. According to national HEDIS data for 2007, only 40 percent of sexually active women 16–24 years of age were screened for chlamydia, compared to 73.9 percent of young women who had a Pap test. In Minnesota, data collected by MN Community Measurement in 2011 showed that rates of screening by providers in all types of settings had improved in recent years, yet still fell below 50 percent in many clinics. To reduce the transmission of chlamydia, it is important that physicians screen all women who fit the criteria, as well as their sexual partners, whenever possible and appropriate. The CDC recommends screening all sexually active
and expedited partner therapy (treating sex partners of persons with chlamydia in the absence of medical evaluation or prevention counseling). Of particular interest to providers, the toolkit includes sample office policies, protocols, and procedures, as well as strategies for using social media to reach youth and young adults and strategies for sharing best practices. Profiles of four Minnesota clinics, each with unique characteristics, demonstrate how they have implemented system-wide changes to increase screening rates. They each show rates and confidence intervals performing above the 2011 medical group average on the chlamydia Screening in Women Ages 16–24 quality measure, as measured by MN Community Measurement. To improve screening rates, clinics have taken the following steps: • Identified an internal “champion” to lead chlamydia screening improvement efforts • Put policies and procedures in place for chlamydia screening • Identified chlamydia screening as a priority in the clinic • Included, in the workflow, chlamydia screening setup for all patients 16–24 years of age • Implemented aids in the electronic medical record to identify patients needing chlamydia screening • Implemented a policy to provide expedited partner therapy • Offered chlamydia or STD patient education materials to all sexually active females 16–24 years of age
females under 25 years and women over 25 years who report risk factors for sexually transmitted diseases. Test of cure is not recommended by CDC because retesting less than 30 days following treatment can result in false positive results and unnecessary re-treatment. Adolescents and young adults seldom come into a clinic unless they are sick, making routine screening difficult. Therefore, screening should be offered to sexually active teens and youth whenever they come into the clinic (sports physicals are an excellent time). In addition to explaining to these patients that all adolescents and young adults in the clinic are offered this test, providers can talk with them about the importance of taking care of their overall sexual health. When parents are present, this is an excellent opportunity to educate them about chlamydia and the importance of screening, and to support their efforts to provide accurate health information to their adolescent children.
The availability of very sensitive lab testing using nucleic acid amplification techniques has made screening easier. Acceptable specimens include urine from both males and females, cervical swabs, and patient-collected vaginal swabs. The CDC stresses the importance of rescreening patients who have tested positive three to four months following the completion of treatment or whenever they return to the clinic in the next year. Rescreening is not a test-of-cure but rather a new screening test to detect a possible new infection. Reinfection rates of 15 percent to 30 percent are commonly reported, and are suspected to be the result of sexual partners not being treated and patients becoming reinfected after resuming sexual activity with their previous partners. Treatment
The CDC recommends treating uncomplicated cases of chlamydia in patients who test positive, and their sexual partners, with azythromicin (1 gm orally, in CHLAMYDIA to page 30
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
www.lrhc.org MARCH 2013
MINNESOTA PHYSICIAN
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Chlamydia from page 29 one dose) or doxycycline (100 mg orally, twice daily for seven days). These medications are highly effective and almost no resistance to them has been documented. The single-dose regimen is easy for patients to take; it is highly recommended for patients for whom compliance is a concern, and the cost is comparable to the seven-day regimen. Ironically, the ease of treatment may lead patients to believe that having chlamydia is not that serious and that, if they get it more than once, they can simply take a pill and it will go away again. Physicians can play a crucial role in educating patients, especially females, about the importance of yearly screening if they are under age 25 and sexually active; the complications associated with untreated chlamydial infections; the asymptomatic nature of chlamydia; and the importance of treating partners of people who test positive.
Preventing complications that result from untreated chlamydia remains the primary medical reason for improving chlamydia screening and treatment rates. Treating partners
One key to lowering rates of chlamydia is to ensure that all sexual partners are treated whenever possible. Expedited partner therapy (EPT) is the practice of treating sex partners of people diagnosed with chlamydia (and/or gonorrhea) without an intervening clinical exam of the partner. In 2008, the Minnesota legislature amended a pharmacy statute to make it possible for any prescribing provider to employ EPT (www.health.state.mn.us/ept/). EPT is employed when the chlamydia patient believes that his or her partner(s) will not agree to come into the clinic to receive treatment, and the patient is willing to deliver the medication or prescription to the partner(s). The first option for partners always is to come
into the clinic for evaluation and treatment; EPT is to be used only for people who refuse to come into a clinic and otherwise would not receive treatment. Payment for partner treatment remains problematic. Insurers do not cover the cost, the clinic may not be able to supply medications for partners at no cost, and a partner may not be able to afford to fill the prescription. In addition, electronic medical records may hinder physicians from prescribing medications for anyone who is not a patient in the clinic. Nonetheless, EPT is a powerful tool. The Minnesota Medical Association supports the use of EPT to treat sexual partners in accordance with CDC guidelines. Physicians or clinics interested in implementing EPT can contact MDH for assistance and more information.
For more information
Physicians are an important part of addressing the chlamydia epidemic in our state. Health professionals interested in becoming involved in the Minnesota Chlamydia Partnership and clinics interested in consultation on ways to increase screening and treatment rates can contact the author at the Minnesota Department of Health, (651) 201-4015, or at candy.hadsall@state.mn.us. April is National STD Awareness month, and MDH will release new STD statistics that month. Information about upcoming events and information related to STDs is available at www.cdcnpin.org/stdaware ness/AwarenessMonth.aspx Candy Hadsall, RN, is the STD nurse specialist and coordinator of the Minnesota Infertility Prevention Project at the Minnesota Department of Health, STD and HIV Section. She is a co-convener of the Minnesota Chlamydia Partnership and the author of the Minnesota Chlamydia Strategy.
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MINNESOTA PHYSICIAN MARCH 2013
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ONCOLOGY
I
t is a fascinating time to be engaged in the practice and science of oncology. I began my career 23 years ago when open surgical techniques, chemotherapy, and radiation were the mainstays of therapy. During the past two decades, I have witnessed the advent of improved symptom control, the use of targeted agents, and the development of focused radiation techniques. Finally, new surgical techniques are available that have significantly reduced surgical morbidity and hospital stays. In addition, there is a new awareness that these mainstays of therapy certainly do not work optimally without the engagement of the patient and the patient’s community of friends and caregivers. Increasingly, the care structure is focused around a positive environment of care and psychosocial support that barely existed two decades ago. All of these factors have contributed to improved outcomes and quality of life for the cancer patient.
Toward “nontoxic” cancer therapies Future dreams and present realities By Christopher Moertel, MD
Targeted agents
The era of personalized or targeted cancer therapy began in the late 1990s when native Minnesotan Brian Druker, MD, led the first clinical trials studying a novel tyrosine kinase inhibitor called imatinib
Increasingly, the care structure is focused around a positive environment of care and psychosocial support. (Gleevec) for the treatment of chronic myelogenous leukemia. Gleevec turned out to be relatively nontoxic and replaced the relatively broad and nonspecific chemotherapy approach that
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www.altru.org 32
had been employed previously. Before the Gleevec era, most patients would progress to accelerated phase or blast crisis if not transplanted in time, and many older patients did not qualify for transplant. The drug also has been employed with great suc-
MINNESOTA PHYSICIAN MARCH 2013
cess for the treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL) and gastrointestinal stromal tumor (GIST). In the past decade, many other drugs have been designed along the same principles, including vemurafenib (Zelboraf), a drug specifically designed to inhibit the BRAF V600E mutant chemical pathway that is involved in many patients with malignant melanoma. We have also just begun using this drug effectively for the treatment of some brain tumors containing this mutation. Finally, the discovery of basal-cell nevus syndrome (Gorlin syndrome) by the late Robert Gorlin, MD, at the University of Minnesota, led to the discovery of the sonic hedgehog (SHH) pathway and, ultimately, the pathway-specific inhibitor vismodegib (Erivedge). This drug is now used effectively for the treatment of basal cell carcinoma and other SHH–associated cancers. Immunotherapy
The current era has also seen the development of nontoxic cancer prevention through immunotherapy. The first cancer prevention vaccine was the hepatitis B vaccine, the first recombinant version of which was
made available in the late 1980s. Studies in vaccinated populations in Taiwan showed a marked reduction in childhood hepatocellular carcinoma soon after the vaccine was made widely available there. This was followed by the vaccine against human papilloma virus (HPV). HPV is associated with cancers of the cervix, vulva, penis, anus, and throat. The development of Gardasil vaccine provides the potential to prevent, annually, about 4,000 cervical cancer deaths and 7,000 (chiefly oropharyngeal) cancers in men. The modern era of effective and less toxic immunotherapy for treatment of established cancer probably began with the use of bacillus Calmette Guerin (BCG) to prevent progression of bladder cancer. Indeed, Herr et al. (JCO, 1995) showed that patients followed for a long period of time after BCG had a lower incidence of bladder resection and improved diseasefree survival. More recently, sipuleucel-T (Provenge) became the first FDA-approved cancer vaccine. It is specifically designed for advanced-stage prostate cancer and, like BCG, is designed to be immunostimulatory. Recent clinical trials studying the treatment of childhood neuroblastoma have shown that patients with advanced-stage cancer treated with an antibody directed toward neuroblastomaspecific antigens in addition to autologous bone marrow transplant and retinoic acid have an improved survival. Malignant brain tumors are an important field of immunotherapy study, given their resistance to current treatment strategies. Immunotherapy approaches have included specific vaccine against an over-expressed tumor-specific antigen, EGFRvIII, a protein found in approximately 50 percent to 60 percent of glioblastoma tumors; autologous tumor vaccine (Liau and colleagues); and, from the University of Minnesota, an allogeneic brain tumor vaccine that is currently in clinical trials there and at the University of Pittsburgh. CANCER to page 34
Urgent Care
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
Psychiatry
Ophthalmology
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.
Optometry
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
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
healthpartners.com
www.averamarshall.org
Sanford Health is the largest not for profit rural integrated health care system with over 1200 primary and specialty care physicians in over 140 clinic locations. The following communities are looking for BE/BC Family Medicine Physicians: Aberdeen, SD: • Large newer clinic attached to brand new 48-bed hospital • Current call 1:7 • OB is optional • Numerous onsite hospital services • Specialty physicians include Anesthesiologists, General Surgeons, and Interventional Cardiologists • Population over 25,000 • SD has no state income tax Windom, MN: • Current call is 1:7 for admits only and shared with community physicians • OB is a must
• Population over 4,300 • MN Medical school loan repayment available • J1 physicians may apply Worthington, MN: • Medical staff of primary care and some specialists • Current call 1:4 • Population over 10,000, service area 35,000 • City is 200 miles Southwest of Minneapolis/St. Paul • MN Medical school loan repayment available
Excellent benefits package including Paid Malpractice and Tail Coverage Competitive compensation and generous incentive
Dedicated to the work of health and healing
For more information, contact: Mary Jo Burkman, Physician Placement Associate Sanford Health (605)328-6996 or (866)-312-3907 Mary.Jo.Burkman@sanfordhealth.org Visit: www.practice.sanfordhealth.org MARCH 2013
MINNESOTA PHYSICIAN
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Gilda’s Club Twin Cities Cancer from page 32 Imaging
The more general use of MRI and limited-dose computed tomography has been of significant benefit to cancer patients. MRI imaging has allowed imaging, especially of the extremities and brain, without exposure to ionizing radiation. Computed tomography (CT) has been revolutionized by the invention of spiral CT or cone beam CT, leading to a marked diminution of X-ray exposure and increasingly detailed images. MRI “quick� studies are now used at our center to evaluate children with limited images, obviating the need for sedation or exposure to X-ray. MRI development has been mind-boggling: 1.5 Tesla magnets are now almost universally replaced by 3 Tesla magnets, and much bigger magnets are currently under development at the University of Minnesota Center for Magnetic Resonance Research (CMRR). Intraoperative MRI is now the standard of care for institutions doing brain tumor surgery, as are surgical guidance systems
Gilda’s Club Twin Cities (GCTC), an affiliate of the Cancer Support Community, is scheduled to open a facility in the Twin Cities in 2013. It’s a place where men, women, teens, and children living with cancer, along with their families and friends, can join with others to receive social, emotional, and psychological support. GCTC expects as many as 17,000 annual visits based on the experience of Gilda’s Clubs located nationwide in similar metropolitan communities. Named for comedienne Gilda Radner, who died of cancer in 1989, the organization’s program includes support groups, education, healthy lifestyle programs, social opportunities, and information and referral services. All services are facilitated by licensed professionals and are free. GCTC provides information about a wide range of cancer-related topics through its Frankly Speaking library of CDs and printed material, some of which is available in Spanish. All library information is free and is shipped free of charge. GCTC also sponsors free Sunday evening Kundalini yoga and meditation classes, currently held at the Penny George Institute for Health and Healing at Abbott Northwestern Hospital, Minneapolis. For more information: (612) 227–2147 www.gildasclubtwincities.org/get-help/ such as the Medtronic StealthStation neuronavigation system. The combination of these technologies has led to improved diagnosis, better surgical planning, and improved surgical outcomes. Radiation therapy
I remember well walking with my father through the Curie
Pavilion at the Mayo Clinic in the 1960s. The radiation therapy rooms contained huge machines that used radioactive cobalt as a source and employed opposing beams to achieve the dose of radiation needed for a particular cancer and site of disease. Since then, we have seen the advent of intensity-modulated
Fairview Health Services
radiation therapy (IMRT), computed tomography IMRT (tomotherapy), gamma knife, and, most recently, proton beam radiotherapy. Proton beam deserves some attention, since those who own the facilities spend a great deal of time touting its low toxicity and disease outcome benefits. Proton beam therapy is based on the physics of the proton particle as described by the Bragg Peak, for which William Bragg won the Nobel Prize in 1915. Proton beams are created by a cyclotron or synchroton. Consequently the footprint for delivery is that of a building, not a suite. The new Mayo Clinic facility, for instance, was constructed at a cost of $185,000,000 according to the Rochester Post Bulletin. Of course, this cost implies necessary economics to recoup investment and maintain the facility. The cost of proton beam will, therefore, exceed the cost of other radiation delivery methods and will necessitate long-distance travel and stay for many people. CANCER to page 36
Opportunities available in the following specialties:
Opportunities to fit your life
Adult Psychiatry Southeast Clinic
Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Shape your practice to fit your life as a part of our nationally recognized, patient-centered, evidence-based care team. Whether your focus is work-life balance or participating in clinical quality initiatives, we have an opportunity that is right for you: t Dermatology t &NFSHFODZ .FEJDJOF t 'BNJMZ .FEJDJOF t (FOFSBM 4VSHFSZ t (FSJBUSJD .FEJDJOF t )PTQJUBMJTU t *OUFSOBM .FEJDJOF
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7JTJU fairview.org/physicians UP FYQMPSF PVS DVSSFOU PQQPSUVOJUJFT UIFO BQQMZ POMJOF DBMM PS F NBJM recruit1@fairview.org.
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fairview.org/physicians 55: &&0 "" &NQMPZFS
34
MINNESOTA PHYSICIAN MARCH 2013
Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
Dermatology Southeast Clinic
Family Medicine Byron Clinic, Cannon Falls Clinic, and Pine Island Clinic
Hospitalist Rochester Hospital
Internal Medicine Southeast Clinic
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: dcardille@olmmed.org Phone: 507.529.6748 Fax: 507.529.6622
www.olmstedmedicalcenter.org
EOE
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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. Orthopaedic Associates of Duluth is a group of nine orthopaedic surgeons that provide comprehensive orthopaedic services ranging from specialty specific exams and diagnosis to state-of-the-art inoffice MRI and imaging and surgery at their physician-owned surgery center.
Email CV to jwaller@slhduluth.com or call 800-461-8843 (Sue) or 218-625-2731 (June)
Along with...
Wapiti Medical Group and Connect Healthcare are looking for quality physicians to provide ER & Hospitalist coverage in our partner facilities in MN
Be a part of the Leading Provider of outsourced Physician coverage • Full and Part time work available • Physician Owned, Physician Run • Life work Balance
• Competitive Pay • Paid Malpractice coverage • Boarded IM & FP welcome
“Connecting Quality Healthcare to Rural America” Contact Brad McDonald, MD CEO 888-733-4428 or email: brad@erstaff.com www.erstaff.com
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 • Compensation & Pension Examiner • Emergency Medicine • Admitting physician, ED (off tour shifts) • Gastroenterology • Imaging o Resident Coordinator o Interventional Radiology o Neuro Radiologist
• Internal Medicine or Family Practice • Interventional Cardiologist • Hematology/Oncology • Hospitalist • Outpatient Clinics: Internal Medicine or Family Practice o Maplewood, MN o Ramsey, MN o Chippewa Falls, WI o Rice Lake, WI • Medical Director, Rochester Outpatient Clinic
• Psychiatry: Inpatient • Psychiatry: Outpatient Clinics o Superior, WI o Ramsey, MN o Rice/Hayward, WI–V-tel and on-site o Maplewood, MN –V-tel and on-site • Radiation Oncology • Rheumatology
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 MARCH 2013
MINNESOTA PHYSICIAN
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Cancer from page 34 Now the rub: A recent analysis of patients with prostate cancer, the major population that supports proton beam facilities, presents significant concern regarding this new technology. Yu and colleagues from the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) center at Yale University studied a database of Medicare beneficiaries (27,647 men). Two percent of the population received proton beam therapy. They were younger, healthier, and from more affluent areas compared with the group that received IMRT. Median Medicare reimbursement was $32,428 for proton beam and $18,575 for IMRT. At 12 months, there was no difference in genitourinary toxicity or gastrointestinal toxicity; and to date, there are no clear survival outcome differences. Indeed, clear outcome differences have not been published for any patient group to date. Supportive care
Ultimately, it is supportive care that improves patient experience
The IOM report lists 10 specific recommendations, ranging from standard of care to support from payers. and treatment-related toxicity. There is no doubt that nursing care is more sophisticated compared with the beginning of my career. Antiemetics such as ondansetron (Zofran) changed the patient experience overnight. Filgastrim (Neupogen or Neulasta) has lessened the threat of opportunistic infection. Dietary support and appetite stimulants like megestrol acetate (Megace) have improved patients’ nutritional status. Complementary therapies such as aromatherapy, acupressure, massage, and acupuncture are employed on a regular basis. Similarly, medical facilities are focusing more on creating a positive patient experience through improvements in the environment of care and customer service. In addition, family support through residential facilities like Hope Lodge and Ronald McDonald House are
growing in number and relieve a lot of family stress. Many communities are blessed with nonresidential cancer support facilities such as Gilda’s Clubs and its national affiliate, the Cancer Support Community. I believe that we as a community should examine these goals and help local care providers understand how they and their patients would benefit from a Cancer Support Community facility (see sidebar). Twentyfour other states have such facilities, but as yet Minnesota, though touted as a health care leader, does not. In its 2007 report, “Cancer Care for the Whole Patient,” the Institute of Medicine (IOM) stated that “… it is not possible to deliver good-quality cancer care without using existing approaches, tools and resources to address patients’ psychosocial needs. All patients with cancer
and their families should expect and receive cancer care that ensures the provision of appropriate psychosocial health services.” [www.iom.edu/Reports/ 2007/Cancer-Care-for-the-WholePatient-Meeting-PsychosocialHealth-Needs.aspx] The IOM report lists 10 specific recommendations, ranging from standard of care to support from payers. As a provider and a family member who has gone through the cancer experience with relatives more than once, I would encourage my fellow health care consumers and providers to review these recommendations and to ask their care centers how they are working to meet these goals. I truly believe that how a center focuses on these objectives reflects the care a cancer patient will ultimately receive. Christopher Moertel, MD, is medical director of the Hematology Oncology Clinic, clinic director of the Brain Tumor Program, and a professor of pediatrics at the University of Minnesota, Minneapolis.
Trinity Health One of the region’s premier healthcare providers.
Currently Seeking BC/BE s Ambulatory Internal Medicine s Emergency Medicine s General Surgery
s Psychiatry s Urology Contact us for a complete list of openings.
Based in Minot, the trade center for Northern and Western North Dakota, Trinity Health offers the opportunity to work within a dramatically growing community that offers more than just a high quality of life. Comprised of a network of nearly 200 physicians in hospitals, clinics and nursing homes, Trinity Health hosts a Level II Trauma Center, Critical Care Helicopter Ambulance, Rehab Center, Open Heart and Lung Program, Joint Replacement Center and Cancer Care Center.
For immediate confidential consideration, or to learn more, please contact
Physicians are offered a generous guaranteed base salary. Benefits also include a health and dental plan, life and disability insurance, 401(k), 401(a), paid vacation, continuing medical education allowance and relocation assistance.
www.trinityhealth.org
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MINNESOTA PHYSICIAN MARCH 2013
Shar Grigsby Health Center - East 20 Burdick Expressway Minot ND 58702 Ph: (800) 598-1205, Ext 7860 Pager #0318 Email: shar.grigsby@trinityhealth.org
Family Med/ER Physicians
Sioux Falls VA Health Care System
Small Town, Big Impact!
Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.
We’re recruiting Family Med physicians with Emergency Room experience for our full-time practice in the western Wisconsin community of Amery. Utilizing a team of five dedicated FM/ER physicians, Amery Regional Medical Center’s ER has an annual volume of 6,000 and provides backup to ARMC’s 12,000 visits/year Urgent Care unit. Our FM/ER physicians work 32 hours per week in a block schedule of 12-hour (weekday) and 24-hour (weekend) shifts. BC/BE Family Med physicians with ER experience and an interest in pursuing alternative EM board certification are preferred; ABEMcertified EM physicians are also welcome to apply. You must have or be eligible for WI medical licensure. Nestled near the WI/MN border, Amery offers abundant outdoor recreation, affordable housing and excellent schools — all just 60 minutes east of Minneapolis/St. Paul, MN. As part of the HealthPartners Medical Group,our Amery FM/ER physicians receive a competitive comp and benefits package, paid malpractice coverage and the security of being part of a successful multi-specialty medical group.
Sioux Falls VA HCS, SD Urologist Psychiatrist Hospitalist Family Practice
Cardiologist Internal Medicine Neurologist Endocrinology
Sioux Falls VA HCS (605) 333-6858 www.siouxfalls.va.gov
Apply online at healthpartners.jobs or email your CV and cover letter to sandy.j.lachman@ healthpartners.com. EO Employer
Applicants can apply online at www.USAJOBS.gov
healthpartners.com
Heart of Minnesota Lakes Country Practice Opportunities
Look for the friendly doctor in a MN based physician staffing service ...
Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff
Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us
P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
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 • 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 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
MARCH 2013
MINNESOTA PHYSICIAN
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Tax relief from page 13 hospitals and extends the Medicare-dependent hospital program for rural hospitals until Oct. 1, 2013. Ambulance add-on payments. ATRA extends the add-on payment for ground ambulance payments through Dec. 31, 2013, and the air ambulance add-on until June 30, 2013. ATRA also requires an HHS study of ambulance service costs. Medicare managed care. ATRA extends through 2013 the authority of Medicare Advantage (MA) plans for special-needs individuals to restrict enrollment to certain populations and the authority for Medicare reasonable cost contracts to operate in areas served by at least two MA coordinated care plans. IPPS documentation and coding adjustment. As noted in the “doc fix” discussion above, ATRA requires the HHS Secretary to continue to reduce Medicare IPPS payments to hospitals to correct for changes in the coding or classification of discharges associated with
implementation of the MS-DRG system in 2008 that do not reflect real changes in patient case-mix. Revisions to the ESRD bundled payment system. ATRA requires the HHS Secretary to reduce the Medicare end-stage renal disease (ESRD) bundled payment amount for services furnished on or after Jan. 1, 2014, to account for reductions in utilization of certain ESRD drugs and biologicals. ATRA also delays inclusion of “oral only” ESRD drugs in the ESRD bundled payment until Jan. 1, 2016. Payment for multiple therapy services. Effective April 1, 2013, ATRA increases (from 25 percent to 50 percent) the multiple-procedure payment reduction that is applied to certain Part B outpatient therapy services furnished on the same day. Payment for stereotactic radiosurgery. ATRA establishes a special payment rule for stereotactic radiosurgery furnished under the Medicare hospital outpatient PPS by certain hospitals.
Equipment utilization rate for advanced imaging services. ATRA includes an adjustment in the utilization factor used to establish Medicare payments for advanced imaging services provided in physician offices and independent diagnostic testing facilities from 75 percent in 2013 to 90 percent beginning in 2014. Pricing for retail diabetic supplies. ATRA requires CMS to set the Medicare payment basis and amounts for retail diabetic supplies, including test strips, through a competitive bidding process to begin during 2013. Medicare payment adjustment for non-emergency ambulance transport for ESRD beneficiaries. Beginning Oct. 1, 2013, ATRA provides for a 10 percent reduction in the fee schedule amount for nonemergency basic life support services involving transport of an individual with ESRD for renal dialysis services furnished by a provider of services or a renal dialysis facility. Elimination of funding for the Medicare Improvement
Fund. ATRA eliminates funding for the Medicare Improvement Fund, which was established by the Medicare Improvements for Patients and Providers Act of 2008 to finance improvements to the Medicare fee-for-service program. Rebasing of state DSH allotments. ATRA provides special rules for calculating state disproportionate share hospital (DSH) allotments for 2021 and 2022. No permanent solutions
Though the passage of ATRA steered the nation away from the fiscal cliff, the health care provisions discussed in this article should be viewed as temporary patches rather than longterm strategies for implementing the ACA. Stay tuned for intense wrangling in Congress over how—and whether—to fund the next steps in health care reform. Timothy Johnson, JD, and Greg Larson, JD, are principals at Gray Plant Mooty, specializing in health care law.
health professional education Women’s Health and OB/GYN Update
April 11-12, 2013
Managing Life Limiting Illness and End of Life Care (two day event) Simulation Facilitator Course
May 8-10, August 20-22 or November 6-8, 2013
Pediatric Fundamental Critical Care Support Fundamental Critical Care Support (two events) Emergency Medicine and Trauma Update: Beyond the Golden Hour Managing Life Limiting Illness and End of Life Care (two day event) Primary Care Update 35th Annual Cardiovascular Conference: Current Concepts and Advancements in Cardiovascular Disease
Education and research to improve the health of our community
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MINNESOTA PHYSICIAN MARCH 2013
May 7 and May 9, 2013
May 16-17, 2013 July 18-19 or October 24-25, 2013 September 5, 2013 October 1 and October 3, 2013 October 10-11, 2013 December 12-13, 2013
HealthPartnersInstitute.org
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
It’s time to see beneath the surface. September 8–10, 2013 http://www.mayo.edu/transform/