Minnesota Physician May 2013 by Minnesota Physician Publishing

Volume XXVll, No. 2

May 2013

The Independent Medical Business Newspaper

The power of partnership Forging a unique local response to local health needs By Charlie Mandile and George Wagner, MD

SPECIAL FOCUS: CROSS-SPECIALTY COLLABORATION Page 20

OBESITY to page 10

PAID

By Peter Dehnel, MD

HEALTHFINDERS to page 12

PRSRT STD U.S. POSTAGE

Strategies for motivating patients

he need to actively address obesity reduction— both in the clinic setting and through community initiatives—has reached the “burning platform” stage, to borrow a well-established concept from organizational change literature. “An organizational burning platform exists when maintaining the status quo becomes prohibitively expensive,” says Daryl R. Conner in the business management book “Managing at the Speed of Change.” He adds, “Major change is always costly, but when the present course of action is even more expensive, a burning-platform situation erupts.” The burning platform concept can be aptly applied to the issue of managing obesity. In terms of costs, the Centers for Disease Control and Prevention estimated that the medical care costs of obesity in the United States costs totaled about $147 billion in 2008; the costs for people who are obese were

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Reducing obesity

etween doctors and their patients lies an insurmountable gap for many people without health insurance. Despite historic health insurance reforms, institutional barriers and a complex system make entry difficult, even for the savviest health care consumers. Even more historic is the alarming burden of chronic disease affecting generations of families across our entire community. HealthFinders Collaborative (HFC) is a free community health center that has shown how to meet local needs for health access and chronic disease management in ways that don’t necessarily rely on new health system reforms. Through a commitment to collaboration, and the motivation to connect the needs of communities with organizations

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CONTENTS

MAY 2013 Volume XXVII, No. 2

FEATURES Reducing obesity Strategies for motivating patients

MINNESOTA HEALTH CARE ROUNDTABLE

By Peter Dehnel, MD

The power of partnership Forging a unique local response to local health needs

1 FORTIETH

By Charlie Mandile and George Wagner, MD

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

TRANSPLANTATION Bone marrow vs. peripheral blood

INFECTIOUS DISEASES Minnesota tickborne disease update

Bill McDonough

By Dennis Confer, MD

By Hannah G. Friedlander, MPH; Elizabeth K. Schiffman, MA; and David F. Neitzel, MS

MMIC

PRACTICE MANAGEMENT Claims processing 14 By Russel Campbell

WOMEN’S HEALTH Promoting healthy pregnancy

By Nicole Chaisson, MD, MPH, and Chrystian Pereira, PharmD

MEDICINE AND THE LAW Final rule on the “Sunshine Act” 16 By David M. Aafedt, JD, and Christianna L. Finnern, JD

SPECIAL FOCUS: CROSS-SPECIALTY COLLABORATION A new paradigm of The intersection of neurodepression care 20 logy and chiropractic 22 By Michael Trangle, MD, and Amy LaFrance, MPH

By Richard Golden, MD, and Vivi-Ann Fischer, DC

Oncology-plus

By Robert Delaune, MD

The Independent Medical Business Newspaper

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, resources and more. Advances in technology are extending life expectancies and require a redefinition of the term “endof-life.” It now entails a longer time frame than Addressing end-of-life issues one’s final weeks or hours and debate as Thursday, October 24, 2013 to when life is really 1:00 – 4:00 PM • Symphony Ballroom Downtown Mpls. Hilton and Towers over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Advanced care planning

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

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name

ASSOCIATE EDITOR Janet Cass jcass@mppub.com

Company

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Address

ART DIRECTOR Elaine Sarkela esarkela@mppub.com

City, State, Zip

OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com

Telephone/FAX

ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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MAY 2013 MINNESOTA PHYSICIAN

CAPSULES

Sanford, Fairview End Merger Talks Sanford Health and Fairview Health Services quickly ended merger talks in April after state lawmakers and regulators raised questions about the possible venture. On March 26, Attorney General Lori Swanson announced that Sioux Falls, S.D.based Sanford was in merger talks with Minneapolis-based Fairview. Swanson’s office immediately raised regulatory questions about the proposed merger. At the same time, it was revealed that the University of Minnesota was considering an acquisition of Fairview, which purchased the University’s medical center in 1997. At an April 7 hearing in St. Paul, Swanson called witnesses who questioned Sanford’s transparency and financial practices, and who pleaded with Swanson to make sure that Fairview, and the “jewel in the crown” facilities it owns at the University of Minnesota, would not be taken over by an out-of-

FOR LEASE

state company. State lawmakers also vowed to slow down or halt any merger, and on April 10, Sanford President and CEO Kelby Krabbenhoft pulled the plug on the merger discussions, saying his company has a policy of “only going where we are invited.” Discussions of a U of M acquisition of the health system have also ended, but questions remain about Fairview and the U of M’s future in a health care market where more consolidation seems likely. Fairview officials pledged they would continue efforts to improve the company’s relationship with the University.

MNsure Exchange Becomes Official One of the most controversial and anticipated pieces of health care legislation in the state’s history, a measure to create a health insurance exchange for Minnesota, was signed into law on March 20. But even with the landmark legislation passed,

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MINNESOTA PHYSICIAN MAY 2013

questions remain among industry leaders and policymakers on how an insurance exchange will work in this state. The exchange law could affect more than 1 million Minnesotans, providing coverage for 300,000 people who are currently uninsured. State agencies say the exchange, called MNsure, will save Minnesota families and businesses $1 billion in health care costs by 2016. With ACA tax credits, officials say, individual consumers could see an average 34 percent decrease in premiums for insurance purchased through the exchange. State agencies have been working to set up the groundwork for the exchange, and recently announced a MNsure web site, www.mn.gov/hix. The site is tailored for individuals and small employers, who will be the main customers of the new exchange. Consumers will be able to compare health insurance products, find out about subsidies and tax credits, and view data on quality. The state will also have a toll-free tele-

phone customer service line. “This is the most significant health care reform in the last 50 years,” says Rep. Joe Atkins (DFL–Inver Grove Heights), who authored the bill in the House. “Individuals, families, and small businesses will be able to get quality, affordable health coverage that saves them money and fits their budget. This is real, positive progress for the people of Minnesota.” Opponents of the bill cited a range of objections, from not enough consumer choice in the final product to the financial burden of the exchange on the state’s budget. Dave Renner, director of state and federal legislation for the Minnesota Medical Association, says his group is supportive, but cautious, about the new exchange. “There’s a lot of work to be done before this is up and running,” he says. “It did get caught up in some partisanship but in the long run, we still believe this is going to make it easier for individuals and employers to shop, compare, and purchase coverage.”

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MDH Data Shows “Alarming” Increase In Cases of Diabetes Approximately 80,000 adults in Minnesota may have diabetes and not know it, officials with Minnesota Department of Health (MDH) said recently. MDH officials released data on diabetes in the state as part of the national Diabetes Alert Day on March 26. Officials noted that the percentage of adults in Minnesota with diabetes nearly doubled between 1994 and 2010 and that these numbers underrepresent the true number of people living with the condition. About 290,000 adults in Minnesota, or 7.3 percent of the state’s adults, have been diagnosed with diabetes, but officials say national data suggest that another 80,000 Minnesotans may have the disease and not be aware of it. “Given the alarming increase of diabetes, we are encouraging Minnesotans to use this day to think about whether they or someone they love might have diabetes or prediabetes and not even know about it,” says Minnesota Health Commissioner Ed Ehlinger, MD. “Diabetes is a very treatable disease and it is important that everyone with diabetes take steps to get their blood sugar under control and lead a healthier life.”

North Memorial, MultiCare Associates Open Urgency Center North Memorial, along with MultiCare Associates, recently announced plans to open an emergency room at Blaine Medical Center. Officials say the North Memorial Urgency Center will be similar to a regular hospital emergency room, and will be staffed by physicians from North Memorial’s Level I Trauma Center. A stand-alone emergency room at a medical office building is new to Blaine, but the idea has been cropping up in the Twin Cities metro area, most recently with the Abbott Northwestern–WestHealth

Emergency Department in Plymouth, which opened in January. The North Memorial facility will be able to care for the same kinds of illnesses and injuries ERs see, officials say. Patients that need hospitalization can be transferred to North Memorial Medical Center in Robbinsdale. “The Urgency Center will allow us to treat almost every kind of emergency except those requiring a transport in by ambulance, such as cases of severe trauma,” says Amy Kolar, MD, medical director of North Memorial’s Emergency Department. “For many things that people traditionally go to the emergency room for—such as joint dislocation, broken bones, abdominal or chest pain, etc.— they can go to the Urgency Center instead.”

Spending Up, Profits Down for Health Insurance Plans Health spending was up and profits were down for health plans in Minnesota in 2012, according to a yearly report from the Minnesota Council of Health Plans (MCHP). Health plans spent $19 billion on health care services, an increase of 7 percent over 2011. Overall, health plans had an operating margin of 1 percent last year. The MCHP annual report looks at data from private health insurance plans as a whole rather than on an individualized basis. Health plan results can vary from year to year and company to company. For example, Blue Cross and Blue Shield of Minnesota released a separate statement saying the Eaganbased insurer had a negative operating margin of .06 percent for 2012, while Bloomingtonbased HealthPartners reported a margin of 4.4 percent for the same time period. MCHP officials note that spending for health care services rose $1.3 billion among all plans in 2012, compared with 2011. Health spending trends have been flat in recent years, possibly because of restrained spending by consumers in a poor ecoCAPSULES to page 6

David M. Aafedt (612) 604-6447 daafedt@winthrop.com

Christianna L. Finnern (612) 604-6435 cfinnern@winthrop.com

We Care AboutYour Legal Health. With our finger on the pulse of today’s constantly changing health-care industry, we focus on helping our health-care clients protect their interests, overcome their challenges, and meet their business goals. No legal issue, emergent, urgent or otherwise, is too small or large for our expert care. We are here to help.

MAY 2013

MINNESOTA PHYSICIAN

CAPSULES Capsules from page 5 nomic climate. The increase in spending on 2012 care resulted in the lowest operating margins for health plans since 2008, MCHP data shows. Income from state programs in 2012 was $4.1 billion for health plans in Minnesota, resulting in a 1.4 percent operating margin. MCHP officials say the average operating margin for state health programs over the past 10 years is 1.8 percent. Healthy margins on public programs have led to intense scrutiny of government plans such as Medical Assistance, which are administered by the state’s private health insurance companies. A recent audit said that the state overpaid insurance companies by $207 million over a nineyear period ending in 2011.

Majority of Physician Spouses Happy, Mayo Survey Shows A survey by Rochester’s Mayo Clinic found that a strong majority of spouses or partners of

physicians say they are happy in their relationships. The national survey of 900 spouses and partners of physicians found that 85 percent of those surveyed said that they were satisfied in their relationship and 80 percent said they would choose a physician spouse or partner again if given the choice. Officials say the findings are similar to other surveys of married adults in the U.S. overall. Questions about stress and physician burnout have been raised in recent years, and some have suggested that physicians’ family lives may suffer as a result of career choices. But the survey shows little evidence to suggest physicians have lowerquality relationships or are more likely to become divorced, says Tait Shanafelt, MD, primary author of the study and a Mayo Clinic hematologist and oncologist. “The findings challenge a number of stereotypes about physician relationships,” says Shanafelt. “While every relationship has challenges, our

research shows that on the whole, doctors’ spouses and partners are extremely happy in their relationships.”

Three State Groups Receive Grants from “Choosing Wisely” Three Minnesota health organizations have received grants from the Philadelphia-based ABIM Foundation aimed at reducing unnecessary tests and procedures. The Institute for Clinical Systems Improvement (ICSI), the Minnesota Health Action Group, and the Minnesota Medical Association (MMA) were recently given grants as part of the “Choosing Wisely” campaign. ICSI, a health quality organization, and the Minnesota Health Action Group, an association of health care purchasers, are both based in Bloomington. The MMA is based in St. Paul. Officials say the Choosing Wisely campaign seeks to encourage physicians and patients to think and talk about

medical tests and procedures that may be unnecessary or may even cause harm. Choosing Wisely draws on the expertise of medical specialty societies in identifying unnecessary or overused procedures. In an effort to expand the campaign, 21 groups around the country have received grants funded by the Robert Wood Johnson Foundation. Sanne Magnan, MD, PhD, president and CEO of ICSI, says the Minnesota groups can work together to reduce unnecessary procedures and thereby hold down health care costs. “We are uniquely positioned to reach physicians and patients in Minnesota, educate them on the specialty societies’ recommendations, and engage them in the Choosing Wisely campaign to help ensure patients get appropriate care,” she says.

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MINNESOTA PHYSICIAN

MAY 2013

MEDICUS Gaurav Guliani, MD, has joined the Neurology Department at Hennepin County Medical Center (HCMC). Guliani attended medical school at the University of Illinois in Chicago, and completed a residency in neurology at the University of Minnesota and a fellowship in neuromuscular medicine and electromyography at Washington University in St. Louis. He is an assistant professor and clinical scholar at the University of Gaurav Guliani, MD Minnesota Department of Neurology. Paul Nystrom, MD, has joined the Department of Emergency Medicine at HCMC. Nystrom went to medical school at the University of Iowa and completed his emergency medicine residency at HCMC. Nystrom has a special interest in tactical EMS and is an EMS Fellow in the Department of Emergency Medicine. John Manion, MD, has received the 2013 Paul Nystrom, MD Trustee of the Year Award from Aging Services of Minnesota. Since 1994, Manion has served on the board of directors at Saint Therese, a nonprofit that provides senior care services and housing in the Twin Cities metro area. He established a palliative care unit at Saint Therese, the first of its kind in the Upper Midwest. Essentia Health has announced several physician hires. Randall Millikan, MD, has joined Essentia Health Cancer Center in Duluth. He previously was a physician-scientist and associate professor at M.D. Anderson Cancer Center at the University of Texas in Houston. He earned his medical degree from the University of Miami and served a residency in internal medicine and a fellowship in medical oncology at the Mayo Graduate School of Medicine in Rochester. Jean Hoyer, MD, has returned to Essentia Health–St. Mary’sSuperior Clinic, where she practiced from 1993 to 2007. Hoyer earned her medical degree from the University of Wisconsin School of Medicine and Public Health in Madison. She served a residency in family medicine at the Sioux Falls (S.D.) Family Practice Center. Jaidev Bhoopal, MD, joined Essentia Health–St. Mary’s Medical Center in Duluth as a hospitalist. He earned his medical degree from Sri Ramachandra Medical College in Chennai, India, and served a residency in internal medicine at St. Joseph’s Regional Medical Center in Paterson, N.J. Rheumatologist Frank Vasey, MD, has joined Essentia Health St. Joseph’s–Brainerd Clinic. Most recently, Vasey served as chief of the Rheumatology Division at Wayne State University School of Medicine in Detroit. His 36-year career in academic and research posts includes chief of rheumatology at the University of South Florida College of Medicine in Tampa, Fla., as well as work at nearby James A. Haley Veterans Administration Hospital. Emily Anderson, MD, has joined Lake Superior Community Health Center, Duluth, as medical director. A board-certified family physician, Anderson attended medical school at the University of Minnesota, Minneapolis, and completed her residency through the Duluth Family Medicine Residency Program. Glacial Ridge Health System, Glenwood, has recently added two physiBrett Adams, MD cians. Brett Adams, MD, has joined the Emergency Department, working with eEmergency and telestroke technology. He graduated from the University of Minnesota Medical School, Minneapolis, and has practiced Erin Dahlke, MD family medicine in Tanzania and New Zealand. Erin Dahlke, MD, graduated from the University of Minnesota Medical School, Minneapolis, and completed her residency training with the Sioux Falls (S.D.) Family Medicine Residency Program.

New Specialty Care Center

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MAY 2013

MINNESOTA PHYSICIAN

INTERVIEW

Pursuing a “just culture” ■ Tell us a little about MMIC and how you work

Second, we can use that data to support analytics and foster an open and transparent culture. We help physicians serve patients in more effective, Right now, we have been looking at claims data, and that is too late in the process. Once something efficient, and safe ways. Data is critical to support happens it gets reported to us, and that makes up these new ways. Physicians are scientists by trainthe bulk of our data. What we really want is to ing, and they need to see there is evidence to suphave physicians, hospitals, and other clinics report port shifts in clinical practice and thinking. We to us when there are near misses, medical misadhave the data to help support that. ventures, or system issues, so that we can develop In addition, some institutions have adopted a culture within these organizations where that a “just culture,” which essentially means that it is kind of reporting is encouraged, so that it is not a very open culture, that reporting problems is punitive. We then can help them to identify the encouraged and normal. If there is a problem in things they can do to mitigate and improve those the aviation industry, employees are not only outcomes going forward. encouraged but required to report it, and they disFinally, we’ll have the ability to access an seminate the findings throughout the industry. inventory of proven safety innovations and soluThat doesn’t happen as much in health care. tions. Harvard and CRICO have been doing this for If there is a medical incident or mistake, people are more than 20 years; they have identified a variety reluctant to come forward because of the concern of things that have driven safety innovations and about liability. What MMIC is trying to do is to have improved clinical outcomes. change that mindset, so that when people come This will allow us to partner with our physiforward, we support them and use the incident to cians in ways that we never could help enhance patient safety. before. We are moving from being We have 30 years an insurance company they count ■ What can you tell us about on when they have a problem to the impact of professional of professional being a partner every day in their liability insurance on the cost liability data. clinical practice, helping them to of health care? enhance patient safety and to The cost of liability insurance in increase their reimbursement from third-party Minnesota is the second lowest in the country. Our sources. average cost of liability insurance for Minnesota with physicians.

Bill McDonough MMIC Bill McDonough, MBA, RPLU, is CEO of MMIC, a Minneapolis-based professional liability insurance company. MMIC bills itself as the largest policyholderowned medical liability insurance company in the Midwest, and offers a range of insurance and consulting services. The company has recently expanded, acquiring the Utah Medical Insurance Association and partnering with Boston-based CRICO. McDonough joined MMIC as CEO in 2008 and has more than three decades of experience in the insurance industry. Prior to his arrival at MMIC, he served as COO of Medical Mutual of Maine and president and CEO of Princeton Insurance.

physicians is around $5,500 annually. We have worked really closely with the plaintiff bar and the defense bar to mitigate those costs over a long period of time. A lot of physicians pay more for their auto insurance than they do for their professional liability insurance. I don’t think it’s a major driver of costs. ■ Could you talk about your recent efforts to use

data to improve patient safety? We have 30 years of professional liability data: underwriting data, claim data, patient safety-type data. That warehouse of data can be used in different ways. If hospitals or physician groups want to import their data and have us do data analytics on it, we have that capability. Recently, we entered into a relationship with CRICO, the insurance company to the Harvard medical systems. There are 15,000 physicians in that database and about two dozen large teaching hospitals. It is affiliated with a lot of other large teaching hospitals: Stanford University, University of Pennsylvania—a variety of large health systems, primarily in the East. First, we will combine our data and use it to identify variances in clinical practice. We will help our physicians and our clinics to identify best practices and, where there are variations in clinical practice, we’ll show physicians the data to help them to have better outcomes.

MINNESOTA PHYSICIAN MAY 2013

■ What challenges and opportunities does

health care reform present for professional liability insurance? Personally, I have significant concerns. We have the best health care system in the world and it certainly can be improved—but it seems to me the incentives in our systems are not aligned properly and I don’t see that changing. For example, Minnesota’s health care quality ranks among the best in the country, yet Medicare reimbursement is among the lowest. It doesn’t appear to me to be as much about health care reform as about health insurance reform. The big concern is that, at a time when the system is already stressed and individuals within the system are stressed, we intend to add millions of people into that system. This could lead to more medical errors and problems, not fewer. I think there is some value in health care reform, but this is actually insurance reform, in my view. ■ Some states have enacted jury award limits on

claims, others are considering them, and some have removed them. What can you tell us about how this impacts your industry? If reforms are reasonable and have strong bipartisan support, they can be very effective. In California, for example, when they enacted the Medical Injury Compensation Reform Act (MICRA), it was a very broad approach and not just caps on eco-

nomic damages. They have been effective. Professional liability rates in California have been relatively low for decades and there is a very competitive market there. Patients must be compensated fairly for their injuries when the standard of care isn’t met; plaintiff attorneys also need to be compensated fairly. A recent example of a political solution, rather than a long-term solution, happened in Missouri, where a package of reforms was passed and then overturned in a relatively short time. That creates chaos in the market. That said, a reasonable cap on noneconomic damages—essentially pain and suffering—is helpful for everybody. It provides stability and prevents shock-type jury awards. ■ What is the impact when large health

systems self-insure and provide professional liability insurance directly? In a market like we have had over the last five years, it probably makes sense for those systems. My concern is that often, this is a short-term economic decision, and I wonder if this is really the best use of capital for health care systems. Systems have the capital, but they don’t have the necessary spread of risk, nor the expertise in claim handling required for difficult cases. I don’t believe they understand the risk they are assuming.

2013 CME Activities

I understand that coming from an insurance company CEO this might sound like sour grapes, but it is important to look at the numbers. The last six years, the entire industry has been profitable, but in the first 30 years there were only two years where companies like MMIC were profitable. So, if you think that the last six years represent what is going to happen going forward—then you double down your bet and take on more risk. If it were me, I certainly wouldn’t bet that it is going to continue. ■ What made the change from 30 years of

not being profitable to six years of being profitable? If we could answer that question, we could predict what is going to happen. It is a combination of things. There has been a lot of press about tort reform that has enhanced people’s understanding of the issue. Efforts around patient safety within these organizations and within companies like ours have probably played some role. No one knows what drove this change. The likelihood of it continuing is not that great, given reforms in health care and the many patients coming into an already stretched system. There are likely to be more problems going forward than we have seen in the last six years.

■ What developments are coming to the

professional liability insurance industry? You might think I have a dour outlook—I don’t. There are many things coming to the forefront that can help. Everybody wants to reduce patient injuries and to create a safer environment for patients. The more that we can work together and do that, the better it will be going forward. I also see medical technology playing a significant role going forward. We have seen tremendous improvement in surgery and medical imaging. Surgeons can, in some cases, have a person out of the hospital in one day, compared to 10 or 15 years ago, when there was more chance of infection, longer hospital stays, blood loss, and other issues. There will be continued improvement in electronic health records that will help physicians make better medical decisions. We will get to a point where we make decisions based on evidence-based medicine. Technology is really helping in rural medicine. We have rural customers already that have the ability to have a patient on a monitor, with a physician in an emergency room hundreds of miles away managing their care, and with a chance of a much better outcome.

For a full activity listing, go to www.cmecourses.umn.edu

(All courses in the Twin Cities unless noted)

MAY - OCTOBER Topics & Advances in Pediatrics in cooperation with MN-AAP May 30-31, 2013 Midwest Cardiovascular Forum: Controversies in CVD June 1-2, 2013 Bariatric Education Days (9th Annual) June 5-6, 2013 Workshops in Clinical Hypnosis June 6-8, 2013 Update in GI Surgery (77th Annual) June 7-8, 2013 Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners September 5-6, 2013

Care Across the Continuum: A Trauma & Critical Care Conference September 27, 2013

Donald Gleason Conference on Prostate & Urologic Cancers November 1, 2013

NPHTI/Pediatric Clinical Hypnosis October 3-5, 2013

Internal Medicine Review & Update November 13-15, 2013

Twin Cities Sports Medicine October 4-5, 2013

Emerging Infections in Clinical Practice & Public Health: New Developments November 22, 2013

Maintenance of Certiﬁcation in Anesthesiology (MOCA) Training October 5, 2013 Psychiatry Review October 7-8, 2013 Got Your Shots? 2013 Immunization Conference October 10-11, 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

Transplant Immunosuppression 2013 October 16-19, 2013 Practical Dermatology October 25-26, 2013 Pediatric Trauma Summit November 1-2, 2013 Ofﬁce of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: cme@umn.edu

Promoting a lifetime of outstanding professional practice MAY 2013

MINNESOTA PHYSICIAN

Patient intervention scenarios Obesity from cover $1,429 higher than for those of normal weight (www.cdc.gov/ obesity/data/adult.html). And increasingly, in physician practices, we are seeing that the rising incidence of obesity threatens to overwhelm efforts by clinicians or clinic systems to achieve what the Institute for Healthcare Improvement calls the Triple Aim of improving patients’ experience of care, improving the health of populations, and reducing the per capita cost of health care. Indeed, evidence shows that obesity is increasingly leading to the opposite effects. To that end, it is time that physicians in Minnesota get much more serious about reducing the present and future harm due to adult obesity. Why? Two essential reasons: • The health care challenges that our patients will face as they

Consider obesity in the context of the following scenarios for some perspective on the clinical challenges in improving patient outcomes: • Arnie is a 28-year-old weight lifter who is looking to compete in an upcoming bodybuilding contest. He wants you to prescribe some topical testosterone gel to enhance his chances of winning this year’s contest. He does disclose that in addition to the requested testosterone gel, he is also using some “locker room–purchased” anabolic steroids as well as growth hormone. You have an extended and candid conversation with him outlining the risks and dangers of his current choices to increase muscle mass. • Irena is a 23-year-old graduate student who is requesting to have her oral contraceptives refilled. She does admit to smoking— “because it helps me control my weight”—and she reports a family history of “some sort of a clotting problem.” You have a significant discussion with her about the risk factors involved with her current situation, and she agrees to try a smoking cessation program and a different form of birth control. • Jitesh is a 32-year-old midlevel executive who comes in for evaluation of headaches. His blood pressure is measured at 160/110. He reports having at least three to four “quad shot” espressos each day, and this is often supplemented with two to three cans of an energy drink. He has a family history of hypertension, and his father died at age 46 from a massive heart attack. His condition prompts you to take the time to discuss ways of reducing the risk of following in his father’s footsteps. • Christina is a 42-year-old who comes in for evaluation of back pain. This started when she slipped on the ice and landed on her left buttock two weeks ago. She has no neurologic findings and has an area of resolving bruising on her left buttock. You also notice that her BMI is calculated at 38.7 and that her blood pressure is 158/98. You recommend some ibuprofen, prescribe a muscle relaxant, suggest twice daily local heat, and recommend a physical therapy evaluation for back pain. As she is leaving, you mention that “we should really start working on your weight issue,” to which she agrees as she hobbles out of the exam room.

approach the age of Medicare eligibility is significantly greater if they are obese, with a body mass index (BMI) of 30 or higher. • As the population ages, there likely will not be nearly enough health care resources to optimally manage all of the complications related to obesity—from cardiovascular disease, to type 2 diabetes, to cancer, to joint problems, and more. Thus, the essential questions for physicians are: How can we mitigate the impact of obesity on individual patients? How can we best prepare for the expected tidal wave of obesity that threatens to engulf our population? This article focuses on strategies and opportunities for physicians to be involved in reducing obesity on both the individual and the broader community levels.

Creating an opportunity for improvement How people get to the point of having a BMI of 30 or higher is obviously multifactorial, and it

MINNESOTA PHYSICIAN MAY 2013

is likely to have occurred over an extended period of time. Reversing that trend will be similar in terms of influences and timeframe. That said, there are some specific and important opportunities that clinics and clinicians can employ as catalysts in their patients’ transformations. The first is creating a clinic culture of acceptance for the person and anticipated improvement in his or her health. Obesity is a major, independent health-risk factor and will lead to significant morbidity and premature mortality. An explicit attitude of concern, support, and helpfulness by all clinic staff is critical. Having materials and resources readily available in the waiting room is also essential. Providing links on the clinic’s website to reliable online sources of information and a library of recommended apps for smartphones will aid many people. Discussing obesity with your patients can be an awkward and uncomfortable experience at first, but you will become much more adept over time. The accompanying sidebar presents scenarios that illustrate the breadth of clinical challenges involved in addressing obesity with patients. Two constructive approaches that can resonate with your patients are discussed below. Motivational interviewing. Motivational interviewing is a method of finding out patients’ priorities and then, based on those identified priorities, helping them target stepwise improvements in their health status. Short of pharmacologic intervention or surgery, physicians can help patients improve their BMI and its associated comorbidities by focusing on three main topics: • Weight reduction: Is there a specific weight goal or clothing size that they wish to achieve, and how can that goal be achieved through incremental, weekly efforts?

• Increased activity: Thirty minutes a day of moderate physical activity can be literally life-saving. Is your patient willing to start by walking 10 to 15 minutes, three times a week? • Dietary improvements: The New England Journal of Medicine reported in its February 2013 issue that for people at high cardiovascular risk, a Mediterranean diet supplemented with extra virgin olive oil or nuts reduced the incidence of major cardiovascular events. Is your patient willing to consider small, stepwise changes in his or her diet and cooking patterns? Other, more global motivational priorities can include being there for a daughter’s or son’s wedding; being an active grandparent; having a healthier retirement; or not wanting to follow the family tradition of a major cardiovascular event by age 55. These priorities all can be tailored to the motivational interviewing process. The 5-2-1-0 improvement plan. Up to this point, this plan has been applied primarily in pediatric settings, but it can be easily adapted for adults. The numbers stand for: 5: Five (or more) servings of fruits or vegetables per day 2: No more than two hours of screen time per day 1: At least one hour of moderate (or vigorous) physical activity per day 0: No sugar-sweetened beverages. For adults, alcoholbased drinks could be included in this category. Based on these four main categories, physicians can use the motivational interviewing process to help patients choose one or more goals that they wish to work on. For example, is the patient willing to cut back on his screen time from four hours per day to three? Is she willing to consider adding a fruit or vegetable serving to each meal? Can the patient reduce his pop consumption from five cans per day to three, or even two, and drink water instead?

To that end, it is time that physicians in Minnesota get much more serious about reducing the present and future harm due to adult obesity. Whatever choices patients begin with, modifying and adding to them as they see improvement is the key. Celebrating successes, however small, is a key motivator for many people. The ability of physicians and clinic staff to monitor and record progress will be key to providing reinforcement for patient. Tracking actual outcomes of the intervention measures will also be important for clinicians.

Other clinic interventions There are numerous other, office-based interventions, although they likely will require more resource expenditure. For example, creating a specific weight loss program may require a fair investment of time and may not get reimbursed by insurance plans; self-pay would be an option, or the clinic could refer patients to existing, proven weight loss programs. Additional staff resources for intervention strategies include: • Having a dietitian as part of the clinic team, to provide nutrition education • Having a physical therapist on-site, to foster increased physical activity • Providing psychological resources on-site, or at least as an easy referral source, for patients who may want additional counseling support

Beyond the clinic walls Because obesity takes time to develop and has many triggers, physicians have a unique ability to partner with others in the community to help stem the obesity tide. Physician involvement in community health and wellness initiatives can boost patients’ efforts in seeking out and tapping community-based resources to combat their obesity. Interfacing with schools and community education programs can contribute to patients’ success. Bloomington, Edina,

Richfield, Northfield, New Ulm, and Moorhead are among the Minnesota communities that have launched initiatives to improve the health and health care of their residents, and a number of Minnesota city councils are currently considering healthy community initiatives. Physician support will be influential in those council discussions.

Embrace clinical challenges Creating a new paradigm of obesity reduction will require significant change within most health care settings. One important change is that physicians and clinics will need to embrace the clinical challenge of patient obesity, just as they approach the clinical challenge of any other significant medical condition. They can no longer consid-

er intervention for obesity as “optional,” just as it is not optional for treating diabetes or heart disease. Every day, in essentially every clinic setting, physicians see patients experiencing the harm of obesity. The opportunities for improvement that we physicians can prompt are real and can be successful in mitigating this current and future harm in our patients. Equipped with a renewed attitude, and a few basic tools, today’s physicians can help launch our patients— and their communities—on a new trajectory of health. Peter Dehnel, MD, is a medical director for utilization management at Blue Cross and Blue Shield of Minnesota, immediate past president of the Twin Cities Medical Society, and a practicing physician.

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MAY 2013

MINNESOTA PHYSICIAN

HealthFinders from cover that can help meet those needs, HFC has established itself as a critical access point to marginalized families in southeast Minnesota. Ten years after taking insurance off the table, HFC is forging ahead in a new space, mobilizing neighborhoods, and connecting institutions to create a local response to local health needs. With a population of over 60,000, Rice County is both diverse and rich in resources. Northfield, Faribault, and surrounding communities in south central Minnesota are home to family farmers, agricultural processing plants, food and transport industries, and manufacturing hubs fed by a vibrant I-35 corridor and two liberalarts colleges. The local workforce supporting these local economies is a mix of intergenerational farmers, owners of small businesses, academics, metro commuters, and growing populations of Latino immigrants and Somali refugees. HFC is a free community health center that provides

quality health care, advocacy, and wellness education to those in our community who have limited health care alternatives. HFC leverages community voice and local resources to provide an access point to health and wellness for the uninsured and underinsured. Our primary care services and medication assistance programs address immediate and ongoing medical needs; an extensive patient advocacy program actively connects patients with longterm resources; and a thriving array of wellness programs breaks down the walls of the clinic to put patients in charge of their health. History of the collaborative

HFC is a collaborative built from the ground up—a strategy as fundamental to our business strategy as it is a part of our vision and model of care. In the summer of 2002, a group of leaders from St. Dominic parish in Northfield began meeting after mass to identify ways to address a growing need for access to health care and pre-

scription medications. Parishioners and church leaders approached the community at-large, convening medical professionals, local health administrators, public health and business leaders, social service providers, faith-based organizations, and civic groups to come together to fill this gap. At the time, the collaborative was unique in how it transcended cultural groups and geographic boundaries to address a pressing local health care need. HFC found its first home in the basement of Little Prairie United Methodist Church, located on a rural highway equidistant from Faribault and Northfield. Volunteers from across the county went to work remodeling the physical space and acquiring lab and equipment donations. Agreements were developed with all local clinics and hospitals for in-kind diagnostic and laboratory services. All area pharmacies similarly came on board to establish a prescription drug program. In early 2005, HFC opened its doors to patients, staffed by one full-time employee and the dedicated services of volunteer physicians, nurses, social workers, interpreters, and receptionists who came after work, out of retirement, and as a part of their schooling to support the effort. HFC bloomed into a corps of volunteers who brought the free clinic and its allied programs into being, establishing collaborations and partnerships fundamental to its current existence. Today: beyond the clinic walls

Since then, HFC has grown into a staff of 10 supporting more than 75 dedicated volunteers and dozens of student interns. In our first eight years of operation, HFC has seen over 5,000 patients and filled thousands more prescriptions. Patients are seen at locations in Dundas, Northfield, and a newly opened space on Central Avenue in Faribault. Nearly all patients are within 200 percent of the federal poverty line. Across all services, approximately 60 percent of HFC patients are Latino immigrants, 25 percent are Caucasian, and 15 percent are MINNESOTA PHYSICIAN MAY 2013

Somali refugees. The clinic sees patients of all ages, children through adults, and uses volunteers not only to provide care but also to motivate their peers to health. Imagine how motivating it might be to sit knee-toknee with your neighbor who is giving her time and expertise for you to be healthy. Reflecting the growing epidemic in the overall population, HFC patients experience a disproportionate burden of chronic diseases such as diabetes, hypertension, overweight and obesity, and teen pregnancy. To meet these evolving needs, HFC has expanded its services to our communities. Our comprehensive diabetes management program reaches more than 90 families that receive supplies and medication, along with monthly group education. The program uses culture, dance, food, and curriculum to support and engage families in the management of their own disease. Our Pura Vida Healthy Lifestyles Program grew out of neighborhood walking groups facilitated by HFC in target neighborhoods. The groups started walking to the local YMCA—and a partnership was born. The program uses fitness instructors, coaches, and students from the YMCA and local colleges to teach exercise and nutrition through Zumba, yoga, and everything in between. Groups also meet at the Faribault Community Center, and a women’s group is held in partnership with the Somali Community Service. The disparity in teen pregnancies among local Latinas, combined with the HFC’s position as a community-based organization representing Latino families, brought a comprehensive teen pregnancy prevention program to HFC. Collectively called MESA (Mejoando la Salud de los Adolescentes/Improving Adolescent Health), this program was recently recognized and expanded by an Eliminating Health Disparities grant from the Minnesota Department of Health Office of Minority and Multicultural Health. MESA not only sup-

ports teens in making healthy decisions; but also, through the Teen Outreach Program, puts youth in charge of communityservice learning projects, improving educational and health outcomes. Other programs focus on environmental determinants of teen pregnancy, such as family meals, school policy, and parent engagement, and are coordinated through a Latino family leadership council. Connecting communities

The immigrant health paradox observes how immigrants and refugees, whatever their country of origin, come to the United States in superior health compared to the average American. But over time, these immigrants and refugees not only assimilate to have the same health as the average American, but in many areas (such as diabetes and obesity), experience health disparities and worse health than native-born Americans. This phenomenon not only implicates the environmental and other social determinants of health in the U.S. but also poses the question: What is it about these immigrant groups that made them initially healthier than us, often coming from situations of poverty? The answer: community connections and cultural health knowledge. Effective health access and chronic disease care recognize the important contribution of families, social networks, and communities to individual health. Therefore, HFC engages these groups as equal partners with biomedicine and mobilizes community voice through leadership and engagement opportunities. Connecting institutions to community need creates a broad movement for health. Institutional support

HFCâ&#x20AC;&#x2122;s safety net services would not be possible without the support of the formal health care system. Two independent community hospitals have a long history of supporting HFC. In anticipation of opening a custom-built space in downtown Faribault, District One Hospital (DOH) in Faribault and HFC came together to deepen our partnership and develop an

innovative plan to serve the needs of the entire community. The first year of this plan (2012) enabled HFC to research and develop a comprehensive Wellness Plan that integrates HFC wellness with clinical programming, coordinating services around patient-centered care. The results combined Wagnerâ&#x20AC;&#x2122;s Chronic Care Model, the Health Belief Model developed in the 1970s and â&#x20AC;&#x2122;80s, and Minnesotaâ&#x20AC;&#x2122;s health care home standards. The HFC Wellness Plan aims not only to improve quality of care at HFC, but also to increase connections between HFC and the formal health care system. At the same time, DOH leveraged support from Mayo and Allina health systems. These organizational connections not only support care coordination and wellness services at HFC, but also have connected hard-to-reach populations to the hospital, and set the stage for regular and coordinated information exchange. For example, HFC has brought community voice to hospital initiatives around Somali birthing practices, mental health, an upcoming community assessment, and its Diversity Advisory Committee. This year, HFCâ&#x20AC;&#x2122;s first nurse practitioner will join the clinic, and clinic hours will begin in downtown Faribault. HFC is continuing to implement an electronic medical records system (with servers housed in the Northfield Hospital data center), as well as a comprehensive evaluation model to monitor process and health outcome needs and successes in the communities we represent. Community leadership

As much as HFC looks to the health system, we break past the walls of the clinic to develop sustained partnerships with patientsâ&#x20AC;&#x2122; families and their communities. Health and wellness happens at home and is supported by families, cultures, and neighborhoods. HFC has entered this space with a growing patient engagement and community leadership initiative. Rather than starting by placing patients on the board of

directors, HFC is going to its programs to cultivate patient engagement and community leadership through on-theground community organizing, community wellness meetings, and coalition-building. We are identifying leaders within patient communities and HFC programs to organize Family Health Councils. This strategy places communities in control of identifying health needs and solutions, partnering to meet these needs, and creating an organized voice in the community. These councils will eventually bring their voice to serve on the HFC board of directors, as well as contribute to community-wide discussions about health and diversity. Evolving needs, evolving organization

As local needs have evolved, so has HFC. We are not just positioned, but embedded in the communities that have the power to change the alarming trajectory of chronic disease and conditions associated with lack of health access. It is only

because of our collaborative nature, and our lasting partnerships with a broad base of committed stakeholders, that we can do this. Together, we are forging a unique and powerful local response to local health needsâ&#x20AC;&#x201D;because it is not medical providers who will prevent teen pregnancy or manage diabetes, but the teens and patients themselves. With visionary institutional support, HFC is using the manageable size of our rural communities to build an organized and effective voice for community health, both inside and outside of the clinic. HFC is not only helping to connect patients with resources, but also using the power and partnership of both to develop a model of care for everyone. Charlie Mandile is executive director of HealthFinders Collaborative; he is completing a master of public health degree in community health promotion at the University of Minnesota. George Wagner, MD, a family practice physician in Faribault, is medical director of HealthFinders Collaborative.

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MINNESOTA PHYSICIAN

PRACTICE

ealth care providers submit more than 12 billion claims for processing annually to commercial payers and government payers (Council for Affordable Quality Healthcare 2012). About 2 percent of those claims are rejected. While 2 percent of the entire claim volume may not seem like a large number, these claims may be the high-dollar claims, and your billing staff may be spending a higher percentage of their time resolving them. My claims processing business continually analyzes the problems with claims that are submitted. Unfortunately, one thing we’ve found is that regardless of the types of claims submitted and whether they are billed to commercial payers or government payers, many providers’ billing staffs aren’t getting the job done. Of course, every provider knows that errors often occur at the insurer’s end of the claims process, rather than at the provider’s office. Since those types of errors are beyond the direct control of the provider,

MANAGEMENT

Claims processing Office-based strategies for reducing rejected claims By Russel Campbell this article focuses on the rejected claims that never get past the payers’ front-end edits and fail to enter the adjudication systems. The discussion below covers three main reasons why health care claims are rejected, and the steps providers and their office staff can take to reduce errors in billing procedures. Reason #1: Patient ineligibility

The No. 1 reason claims are rejected is that the insurer deems that the billed services were provided to patients who are not eligible or cannot be identified as being eligible to receive services. Our company’s most recent analysis identified almost 37 percent of the rejected claims as having an eligibility issue. The reasons for these rejections run the gamut, from

MINNESOTA PHYSICIAN MAY 2013

the patient having no coverage at all, to having no coverage for the stated date of service, to a mismatch of data identifying the patient or subscriber. The bottom line is that the payer has deemed that the claim submitted is not going to be processed or paid. Today, because the eligibility response transaction contains more data than in the past, payers are closely scrutinizing the demographic data submitted on the claim. Though many providers contract for eligibility verification services, problems still will arise unless all of the data received in the eligibility response from the payer has been loaded into the provider’s billing system and used when submitting the claim to the insurance payer. To give a common example, not only the member/subscriber insurance ID, but also the patient’s address and name, need to match the ID in the payer’s system, or the claim may be rejected. In November 2012, some Medicare claim processors started to reject claims because the Medicare subscriber’s last name did not exactly match the CMS demographic record on file—even though the Medicare ID for the patient was correct. Common mismatch rejections are associated with hyphenated last names (e.g., Mary SmithJones) or with double last names that are not hyphenated (e.g., Mary Smith Jones). Your office can reduce these kinds of rejected claims by making sure that the patient data entered by the billing staff exactly matches the payer’s information for the patient. Be sure your billing staff compares the demographic data that is returned from the payer against the information that is stored in your billing system. If the member/subscriber ID does not match, payers will reject that

claim during their initial processing, and rightfully so. Our company uses systems to analyze the subscriber/member ID numbers that fail. These tools can identify which data entry staff have problems, such as transposing numbers, that may cause front-end rejections. The most successful way to ensure that a claim passes the payer’s front-end edit is to use the data that the payer provides. Reason #2: Claim coding

The second largest category of front-end claim rejections relates to the coding on the claim. In our analyses, just over 30 percent of all errors are related to coding. A few of the challenges for providers’ offices are discussed below. Procedure coding and diagnosis coding. Currently, errors in procedure and diagnosis coding account for only a small portion of claims that are rejected for coding errors. However, the number of diagnosis rejections likely will increase dramatically with the transition to ICD-10 coding, effective Oct. 1, 2014. The change in the coding methodology will be similar to the recent HIPAA claim format change from 837 version 4010 to the current version 5010. The mandated Jan. 1, 2012, implementation date for that transition stretched from November 2011 to March 2012. Our company upcoded claims and remittance files from 4010 to 5010 and downcoded claim and remittance files from 5010 to 4010; in fact, we are still upcoding claims for some provider groups. The transition from ICD-9 to ICD-10 will follow the same sort of variable timeline. Again, some payers will not enforce the deadline by which to accept ICD-10 only; others will accept both ICD-9 and ICD-10 beyond the deadline. Additionally, certain payers (e.g., the entire property and casualty industry, i.e., workers’ comp and auto/medical) will be exempt from the mandate to use ICD-10, though they may decide to do so. This means that providers’ offices will have to be ready to deal with multiple claims pay-

ment scenarios: Some payers will require ICD-10 on all claims on the ICD-10 cutover date of Oct. 1, 2014; others will allow both ICD-9 and ICD-10. Some payers will not be ready to make the transition; others will not have to participate in the transition at all. In the case of the ICD-9 vs. ICD-10, there is no upcode, there is no downcode, and there is no “crosswalk” between the two methodologies. In the Federal Register, CMS has advised strongly against any attempt to develop a crosswalk between the ICD-9 and ICD-10 coding system. NDC numbers. A larger percentage of the errors in the coding category are related to the National Drug Code (NDC) numbers. These errors include missing data, missing segments, and incorrect NDC numbers. Procedure descriptions. Another new feature of the HIPAA version 5010 claim formats is the addition of procedure descriptions beyond the claim notes that existed in the version 4010. Any procedure

The No. 1 reason claims are rejected is that the insurer deems that the billed services were provided to patients who are not eligible or cannot be identified as being eligible to receive services. code (CPT or HCPCS) that is identified as “unspecified” or “miscellaneous” should be submitted with a description in the electronic claim. The link www.dmepdac.com/crosswalk/ 2013.html will be useful in sorting out these new requirements. To minimize delays in payment, monitor the claim processing guidelines published by the payer and supply additional information during the initial claim submission. P&C (property & casualty) claims. Workers’ compensation claims are especially problematic to the staff that submit the usual medical claims. Because the topic is so complex, this article touches on just a few issues related to workers’ comp claims. The main problem with

these claims occurs when the patient, instead of the employer of the patient, is listed as the subscriber on a P&C claim. This is especially tricky because the patient is listed as the subscriber when a claim is submitted to a payer such as Medicare or BCBS. For P&C claims, the data related to the patient is submitted in the “patient” section of the form; it is never submitted in the “subscriber” section. Workers’ comp claims always require claim attachments and a P&C file number. The P&C file number essentially equates to the member insurance ID number on standard claim forms—but it is entered in a different place in the P&C claim. The attachments have to be identified within the submitted claim, and the attachment

must be submitted within a few days after the claim file is accepted by the payer. For the claim to be processed successfully, the best approach is to submit the claim and the claim note attachments at the same time. Billing staff should also be aware of a couple of other potential claims snags: • Many P&C claims require patients’ social security numbers, though they are often unnecessary, or not allowed, on Medicare and commercial payer claims. • For services provided in Minnesota, providers must submit P&C claims electronically to comply with Minnesota statute 62J, which states that such transactions “must be transmitted electronically among providers, payers, and clearinghouses using a single, uniform, standard data content and format.” Reason #3: Errors in provider information

The third largest category of CLAIMS to page 38

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MAY 2013

MINNESOTA PHYSICIAN

MEDICINE

ust in time for spring: Sunshine. On Feb. 1, 2013, the Centers for Medicare & Medicaid (CMS) issued the final rule on the “Sunshine Act.” The Sunshine Act requires drug and device companies to report transfers of value to physicians and teaching hospitals. CMS issued its proposed regulations in December 2011. The final rule includes 35 pages of regulations, preceded by 251 pages of explanations, showing CMS’s thoughtful analysis of the nearly 400 comments it received during the comment period. The final rule revises and clarifies a number of provisions. We first wrote about the Sunshine Act’s implications for Minnesota physicians in the November 2012 issue of Minnesota Physician (“Sunshine and scrutiny: managing compliance with ACA’s Sunshine provisions from a provider perspective”). Here, we provide Minnesota physicians with updated guidance based on CMS’s final rule. This article outlines the definitions, timeline, exclusions, rules on meals, and reporting cate-

AND

THE

LAW

Final rule on the “Sunshine Act” Be ready to comply By David M. Aafedt, JD, and Christianna L. Finnern, JD

gories set out in the final rule; and explains how the final rule affects Minnesota’s existing partial gift ban and reporting requirements.

are not AMs. Or an AM is (2) an entity under common ownership with an entity in part (1), which assists in making or selling a covered product.

The final rule establishes a new timeline for the Sunshine reporting requirements. The start date for data collection is Aug. 1, 2013. Definitions

The final rule clarifies certain definitions: An “applicable manufacturer” (AM) is (1) an entity operating in the U.S. that is engaged in making or selling a covered product. Distributors that do not hold title to the covered product

An “applicable group purchasing organization” (AGPO) is an entity operating in the U.S. that arranges for the purchase of a covered product. “Physician” is defined as provided in the Social Security Act, which includes licensed doctors of medicine and osteopathy, dentists, podiatrists, optometrists, and chiropractors. It excludes physicians who are employees of an AM and excludes residents. “Teaching hospitals” are defined as those that receive CMS funding for graduate medical education; CMS says it will publish, annually, the list of teaching hospitals. Timeline

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MINNESOTA PHYSICIAN MAY 2013

The final rule establishes a new timeline for the Sunshine reporting requirements. The start date for data collection is Aug. 1, 2013. Applicable manufacturers and applicable group purchasing organizations must track transfers of value to physicians or teaching hospitals. They must also track ownership or investment interests held by physicians or their immediate family members. The data collected from Aug. 1–Dec. 31, 2013, must be submitted to the CMS’s Open Payments website by March 31, 2014. Physicians will be able to register with Open Payments in 2014 to review the reported data

before it is made public so that they can dispute and correct any mistakes. This data will be made publicly available on Sept. 30, 2014. Exclusions from reporting

The final rule sets out clear exclusions from reporting. Key exclusions include transfers of value less than $10, except where the annual total would exceed $100. Small incidental items under $10 (e.g., pens) given away at large conferences do not count toward the annual total. Other exclusions are: • Transfers of value because of existing personal relationships (e.g., where an AM employee gives a gift to her physician spouse) • Educational materials that directly benefit patients (such as anatomical models, but not medical textbooks) • Discounts and rebates • In-kind items for providing charity care • Product samples (including vouchers intended to defray patient costs) • The loan of a medical device for a short-term trial period, not to exceed 90 days In the final rule, CMS carefully explains what fits and does not fit within each of these exclusions. For example, physicians accepting items for charity care should be sure that the patients receiving this care truly cannot pay for it. If it would not be a hardship for a patient to pay for this medical care, then donated items are considered transfers of value to the treating physician. Rules on meals

The final rule also explains how meals must be reported. Often, an AM’s sales representatives provide meals for an entire practice. If a physician partakes in the meal, it is considered a transfer of value and must be reported; however, the initial regulations were unclear on how the cost of the meal would be allocated. According to the final rule, the total cost of the meal is to be divided by the total number of

Resources and additional information

Reporting categories

The final rule also specifies exactly what must be reported. The AMs will be reporting the physician’s full name, specialty, business address, National Provider Identifier (NPI) number, and the state professional license number. The reports must include the amount, form, date, and nature of the payment, and the name of the related covered product. If there is not a related covered product, AMs can report a related non-covered product or “none.” Payments can be eligible for delayed publication if made pursuant to research on new drugs or devices in order to keep this research confidential while it first gets under way. If the payment was made to an entity other than the physician at the request of that physician, the name of this entity must be reported. Lastly, payments to physician owners or investors must be reported. When AMs report the costs related to a physician’s attendance at a medical conference, the AM cannot bundle these costs. This means that a physician who travels to a medical conference can incur many different transfers of value—and each will be specified in the publicly available reports. There will be separate lines for travel, meals, honoraria, and speaking fees if applicable. Though these transfers of value may be entirely appropriate, physicians should be aware that each of these costs will be reported as a separate payment and the appli-

• CMS’s final rule on the Sunshine Act: www.federalregister.gov/ articles/2013/02/08/2013-02572/medicare-medicaid-childrenshealth-insurance-programs-transparency-reports-and-reporting-of • Physician Payment Sunshine Act Final Rule: Definitions, Policy and Medicine, Feb. 5, 2013: www.policymed.com/2013/02/physicianpayment-sunshine-act-final-rule-definitions.html • Physician Payment Sunshine Act Final Rule: Quick Reference Guide, Policy and Medicine, Feb. 13, 2013: www.policymed.com/2013/ 02/physician-payment-sunshine-act-final-rule-quick-referenceguide.html • Minnesota Statute §151.461 (“Gifts to Practioners Prohibited”): www.revisor.mn.gov/statutes/?id=151.461 • Minnesota Statute §151.47 (“Wholesale Drug Distributor Licensing Requirement”): www.revisor.mn.gov/statutes/?id=151.47 • CMS’s National Physician Payment Transparency Program: Open Payments: www.cms.gov/Regulations-and-Guidance/Legislation/ National-Physician-Payment-Transparency-Program/index.html cable drug or device’s name will be attached to each. This means that if a physician flies business class, stays in a five-star hotel, eats at a Michelin-starred restaurant, and is paid a high honorarium while attending a meeting about a particular stent, and then begins to use this particular stent, the physician should be aware that this invites scrutiny under the federal Anti-Kickback Statute (AKS). It remains illegal under AKS to pay physicians in order to influence their choice of a drug or device (42 U.S.C. §1320a-7b, “Criminal penalties for acts involving federal health care programs”). Prosecutors could easily interpret an $800 flight, $500 hotel, $300 meal, and $1,500 honorarium as influencing a surgeon’s decision to use a new stent. Effect on state partial gift ban and reporting requirements

Many Minnesota physicians already are familiar with some of the requirements of the Sunshine Act because of Minnesota’s partial gift ban and reporting laws (Minn. Stat. §151.461 and §151.47, subd. 1(f) (2012)). Minnesota bans gifts worth more than $50 annually to physicians (this applies to drug—not device—manufacturers and distributors) and requires these companies to report payments, honoraria, reimbursement, or other compensation to physicians totaling more than $100. However, in light of the CMS’s final rule, the Minnesota Board of Pharmacy has announced that it will amend its disclosure requirements.

In a Jan. 8, 2013, letter, Board of Pharmacy Executive Director Cody Wiberg, noted that the “vast majority of data that is reported under Minnesota law is information covered by the Sunshine Act”; and, thus, the Board of Pharmacy has determined that it will “not require wholesalers and manufacturers to report any data for calendar year 2012” (letter available at www .medispend.com/documents/ MN-RepealofReporting.pdf).

Telephone Equipment Distribution (TED) Program

individuals who partake in the meal (including physicians and non-covered individuals such as nurses or staff). This number is the reportable transfer of value, but only for the physicians who actually partake in the meal. If a practice has three physicians and 10 nurses and the meal costs $240, but only two physicians partake, the value is $240 divided by 12, or $20 per person. The AM must report transfers of value of $20 each for those two physicians. This rule allows physicians to avoid a reportable transfer of value by choosing not to partake in a meal supplied by an AM.

Additionally, the Board of Pharmacy will ask the Minnesota State Legislature to repeal the state’s reporting requirements in 2013. The board will not be asking for a change to Minnesota’s partial gift ban. This means that Minnesota physicians must check only the federal Open Payments website (see sidebar) to review reported transfers of value. Using Open Payments, Minnesota officials will be able to keep track of transfers of value from drug companies that would be disallowed under the partial gift ban. Physicians should be careful not to allow AMs to exceed the $50 annual limit on gifts—and this includes meals. For physicians who interact only with drug companies, Sunshine is a new paradigm. All Minnesota physicians should evaluate what payments they are comfortable receiving as this data becomes public in a little over a year. David M. Aafedt, JD, and Christianna L. Finnern, JD, are attorney shareholders at Winthrop & Weinstine, PA, Minneapolis.

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hat is now called hematopoietic cell transplantation (HCT) used to be called bone marrow transplantation because the only available graft source was marrow extracted from a donor’s pelvis. Today, when performing HCT with an unrelated donor (URD HCT), a transplant physician may choose among three graft sources that he or she believes will be best for a patient undergoing HCT: bone marrow cells, peripheral blood stem cells (PBSCs), or umbilical cord blood cells. Each stem cell source has its advantages and disadvantages, and the ultimate selection involves several clinical factors, including patient age, disease, and disease stage. In the past decade, transplant physicians have shown a preference for PBSCs over marrow because early studies showed that PBSC collections contained more blood progenitor cells than did bone marrow harvests. In addition, PBSC grafts resulted in faster engraftment, thus restoring immune function faster and reducing the

Bone marrow vs. peripheral blood Which is better for allogeneic transplant? By Dennis Confer, MD

concurrent risk of opportunistic infections. Donors also seemed to prefer PBSC donation, which involves an apheresis procedure rather than the anesthesia and needles involved in a marrow harvest. However, this shift toward PBSC transplantation in the last 10 years has occurred without solid clinical evidence that PBSCs were an overall better stem cell choice for URD HCT. Now, solid clinical evidence on this issue is available, through a landmark study coordinated by the National Marrow Donor Program and the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) and published in the Oct. 18, 2012, issue of the New England

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Journal of Medicine. This study, led by Claudio Anasetti, MD, of the Moffitt Cancer Center in Tampa, Fla., has demonstrated that bone marrow transplantation has a significant advantage over PBSC in one important regard. Although the study found no significant difference in two-year overall survival between the two graft sources, marrow recipients experienced significantly lower incidence of chronic graftversus-host disease (GVHD). Chronic GVHD can be a debilitating side effect of URD HCT, and occurs when donated stem cells recognize the recipient’s body as foreign and mount an immunological attack against it. This result has the potential to change clinical practice in the HCT field, namely, by shifting the general clinical preference toward bone marrow grafts and away from PBSC grafts for the majority of patients. Although it is too soon to determine whether such a shift is occurring, there are several reasons, explained in the “Discussion” section, to believe that it will eventually occur. Study methodology

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This large-scale, phase 3 study examined outcomes of 551 adults transplanted using unrelated donors at 48 transplant centers affiliated with the BMT CTN in the United States and Canada. Both donors and transplant recipients were randomized to donate/receive either bone marrow or PBSC grafts. More than 90 percent of the patients received a transplant from the assigned, randomized graft source. Patients were adults younger than 66 years of age, and the primary end point of the study was two-year overall survival. Secondary end points included post-transplant inci-

dences of engraftment failure, neutrophil and platelet engraftment, acute and chronic GVHD, infections, and relapse. The trial was conducted between March 2004 and September 2009, and had a median follow-up of 36 months. The marrow and PBSC groups were well balanced in age, sex, Karnofsky scores, diagnosis, disease risk, cytomegalovirus (CMV) serostatus, and race. Patients were eligible to be enrolled in this intention-to-treat study if they were scheduled to undergo transplantation for acute myeloid or lymphoblastic leukemia, myelodysplasia, chronic myeloid or myelomonocytic leukemia, or myelofibrosis. Together, these diseases represent approximately 75 percent of unrelated-donor transplantations in North America during the study period. Acute myeloid leukemia was the most common indication in patients, accounting for 47 percent of the transplants performed. Bone marrow cells were harvested using established collection protocols from the posterior iliac crests of a donor’s pelvis. Peripheral blood stem cells were collected via apheresis following five or six days of daily injections of filgrastim (10 µg per kilogram of body weight), which induces bone marrow stem cells to migrate from the marrow into the peripheral blood. A second apheresis procedure was performed on day six only if the day five collection contained insufficient CD34+ cells. A majority (78 percent) of the pre-transplant conditioning regimens were myeloablative and utilized cyclophosphamide with or without total body irradiation. Twenty-two percent of the conditioning regimens contained fludarabine and were considered reduced-intensity regimens. Study results

As shown in Table 1, patients in the marrow and PBSC cohorts had comparable overall survival at two years post-transplant. The incidence of chronic GVHD was significantly higher in patients receiving PBSC grafts compared to those receiving marrow grafts. Incidence of graft failure was significantly higher in mar-

row recipients compared to PBSC recipients. There were no significant differences between the two patient groups on relapse, non-relapse mortality, and incidence of acute GVHD (GVHD appearing in the first 100 days post-transplant). Engraftment of neutrophils (>500/mm3) and platelets (>20,000/mm3) was significantly faster in PBSC recipients compared to marrow recipients. Median time to neutrophil engraftment was five days shorter (p<0.001), and median time to platelet engraftment was seven days shorter (p<0.001), in PBSC recipients. Relapse was the most common cause of death in the marrow and PBSC patient cohorts: 50 percent and 48 percent, respectively (p>0.05). Deaths due to chronic GVHD were significantly higher in the PBSC group than in the marrow group: 21 percent vs. 10 percent (p=0.002). Deaths due to graft failure were significantly higher in the bone marrow group than in the PBSC group: 8 percent vs. 0 percent, respectively (p=0.002). Discussion

These results have several important clinical implications, all of which give patients, donors, and physicians more concrete evidence to consider when deciding on the course of an unrelated donor allogeneic transplant. Because this study showed no distinct survival benefit for either stem cell source, a decision on using either a marrow or PBSC graft should be based on specific clinical aspects of individual cases. For example, because engraftment is significantly faster when using PBSC grafts, patients who have been heavily pre-treated and have systemic infections might benefit from PBSC transplantation. Similarly, PBSCs might also be the best graft source for patients at high risk of experiencing graft failure, such as those undergoing reducedintensity conditioning without prior exposure to intensive chemotherapy. However, bone marrow may be the best graft choice for patients who do not have a high risk of graft failure, such as those who are immuno-

TABLE 1. Two-year outcomes of unrelated donor transplants by graft source. Outcomes at two years

PBSC

Marrow

p-value

Overall survival

51%

46%

0.29

Chronic GVHD

53%

41%

0.01

Extensive chronic GVHD

48%

32%

<0.001

0.002

Graft failure

Key points • There are three graft sources for patients undergoing allogeneic hematopoietic cell transplantation (HCT): bone marrow cells, peripheral blood stem cells (PBSCs), or umbilical cord blood cells. • In the last 10 years, transplant physicians have preferred PBSCs to marrow, despite a lack of solid clinical evidence that PBSCs were an overall better stem cell choice for unrelated donor HCT patients. • A recent study demonstrated that bone marrow recipients experienced a significantly lower incidence of chronic graft-versus-host disease (GVHD) than PBSC recipients. • The study also showed that the incidence of graft failure was significantly higher in marrow recipients compared with PBSC recipients. • Because the study showed no distinct survival benefit for either stem cell source, a decision on using either a marrow or PBSC graft should be based on specific clinical aspects of individual cases. suppressed from prior chemotherapy. But clearly the most important finding of this study is that PBSC grafts significantly increase the risk of chronic GVHD. The authors conclude that PBSCs should therefore not be the default choice for most unrelated donor transplants, and should only be considered in patients for whom the benefits of a PBSC graft outweigh the increased risk of developing chronic GVHD. It’s hard to predict how and when this main result will affect clinical practice in the field of HCT, but anecdotal reports from the field give a strong hint. These study results garnered widespread attention among transplant physicians both after the NEJM report was published, and, prior to that, when the study was presented as an abstract in a plenary session at the American Society of Hematology Annual Meeting in December 2011. Transplant physicians—and many of their patients considering allogeneic HCT—are therefore aware of the higher risk of chronic GVHD after unrelated donor PBSC transplantation. Considering how debilitating chronic GVHD can be, it’s likely that transplant patients and their physicians will now both be motivated to select marrow grafts over PBSC grafts whenever possible. However, there are also fac-

tors at work that might prevent a shift toward a preference for marrow over PBSC grafts. As previously mentioned, most donors prefer the apheresis procedure required in a PBSC collection over the anesthesia and needles involved in a marrow harvest. Transplant physicians make their requests for either

marrow or PBSC grafts from donors, but it is the donors themselves who decide what donation procedure they are willing to undergo. It is therefore easy to imagine that transplant physicians may make many more requests for marrow than will be accommodated. A second factor that may prevent a shift toward more marrow transplants was highlighted in an editorial by Frederick Appelbaum, MD, that accompanied the NEJM report. Dr. Appelbaum, a transplant physician from the Fred Hutchinson Cancer Research Center, wrote: “While this study should change practice, it will be interesting to see if it really does. The benefits of peripheral blood are seen early, under the watchful eyes of the transplantation physician, whereas the deleterious effects occur late, often after the patient has left the transplantation center.” Dennis Confer, MD, is the chief medical officer of the National Marrow Donor Program, and was senior author of the NEJM article reporting these study results.

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With health reforms aimed at improving quality and cost-effec-

Collaborative approach aids patients, physicians

tiveness in care, we are seeing increased collaboration across

By Michael Trangle, MD, and Amy LaFrance, MPH

medical specialties. The special focus this month looks at three different types of cross-specialty collaboration taking place in Minnesota: between behavioral health and primary care providers; between neurologists and chiropractors; and among a wide variety managing complex oncology cases.

epression can hide in plain sight. Consider a patient who came for care because his wife pushed him to tackle his irritability, sleep problems, and stress. He wasn’t subjectively even feeling sad. Generally he was not in touch with his feelings unless he was angry. He felt hopeless, pessimistic, and irritable and angry. Depression made him feel so stuck that nothing in his life was going well. The man began using antidepressants and improved somewhat, but he was still quite anxious. Using a second medication and talk therapy helped to change his outlook and habits.

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As he got better he was fretting less, and he could consciously leave work earlier and focus on his family interactions more. He started to get more exercise, which helped his anxiety and sleep. That patient understood the impact of his depression more as he recovered. He wasn’t even aware of it before treatment, yet it was significantly affecting his marriage, his enjoyment of being a father, and his career. He says his life is much better today. This patient’s experience is not unusual. A partnership for fighting depression

Depression is very common. It often grows imperceptibly and can ruin people’s lives in ways that are so subtle and undramatic that it is almost like a silent disease. One barrier to treatment is the unhealthy and inaccurate idea that people should just “buck up” and use their willpower to get over it. It’s wrong. Depression is not a sign of weakness or moral failure. These attitudes must shift so more people get adequate treatment and get into remission. A proactive team of providers and engaged patients makes a powerful partnership to fight depression. By far the best outcomes are obtained when using a collaborative care model. In this model, depressed patients are put in a registry, and their symptom intensity is periodically measured using a quantitative tool, typically a PHQ-9 (Patient Health Questionnaire–9). A care manager routinely educates the patient, follows the patient closely to identify and overcome problems and obstacles, and engages the patient in behavioral activation and self-management.

Under the collaborative care model, a psychiatrist spends some time advising the care manager and primary care physician, and outcomes are measured. Another example of collaborative care in action is a patient who spoke with her primary care provider a few months after finalizing a divorce. The patient’s complaint was insomnia; in fact the patient was anxious and depressed. The primary care provider prescribed a sleep medication and referred the patient to the care manager for review. The PHQ-9 scores confirmed the patient had depression. The case manager explained to the patient that she had symptoms of depression: She was moderately anxious, socially isolating herself, not feeling productive at work, and drinking one to two drinks each evening to fall asleep. The provider started the patient on a low-dose antidepressant. The care manager worked with her to reduce her drinking, first from two drinks a night to one, then from one drink a night to a watered-down half-drink a night. The patient started walking for exercise, and added the social support of walking with a friend. She decreased her caffeine intake. Initially the care manager had weekly contact with the patient for a few months. Over time the patient stopped drinking completely, maintained her low intake of caffeine, and achieved remission from her depression. A new doctor-patient paradigm

In the past, the doctor-patient relationship was sometimes viewed more like a mechanic-car relationship—the attitude was that the patient could just passively wait for the doctor to perform the tune-up. Now that more clinics are implementing best practices for depression care and using the PHQ-9, it is easy for patients and providers to jointly monitor symptom severity and improvement. That changes the whole paradigm. The patient is more likely to be an equal, active partner.

Collaborative care models in Minnesota Efforts to enhance collaborative care models are under way throughout the state and nation, and the scope is getting broader. “The depression projects like DIAMOND were a proof of concept that you could do behavioral health in a systematic way in a primary care clinic and get good results. Now people are broadening that in recognition that behavioral health overall should be integrated into primary care,” says C.J. Peek, PhD, associate professor in the University of Minnesota Medical School’s Department of Family Medicine and Community Health. A few efforts to support or expand collaborative care models in Minnesota are described below. • Dr. Trangle helped to develop “Help and Healing: Resources for depression care and recovery” (www.mnhealthscores.org/ ?p=depression_resources) with MN Community Measurement and the Minnesota Health Action Group to share useful materials with providers and patients. The Help and Healing toolkit can put useful, patient-centered materials and tools in patients’ hands. Trangle recommends that both

There’s evidence to show that patients who are more engaged and active in their own treatment tend to have better outcomes. Engaged patients are more likely to reach remission from their depression and also to stay in remission.

patients and providers access the resources to determine what may be most useful for an individual patient. • The Institute for Clinical Systems (ICSI) has a program that unites a physician, care manager, and consulting psychiatrist to provide better care to patients with depression in the primary care clinic. Called DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction), the model has expanded to address patients with risky substance use, as well as those with both mental health and chronic physical conditions. It is available at more than 60 primary care clinics. Details are available at www.icsi.org/health_ initiatives/diamond_for_depression/. • Integrating behavioral health overall into primary care is very important. The Agency for Healthcare Research and Quality (AHRQ) devotes a full website to detailing how to accomplish this integration and providing supportive resources (http://integrationacademy.ahrq. gov/). The initiative is directed in part by the National Integration Academy Council, which

Improved treatment/outcomes

Addressing depression can also have additional benefits, especially for patients with complex conditions. Patients with diabetes, recent heart attacks and strokes, cancer, chronic pain, and substance abuse and dependence all have higher rates of depression and significantly

includes three Minnesotans: C.J. Peek, PhD; Macaran Baird, MD, MS, professor and head of the University of Minnesota Medical School’s Department of Family Medicine and Community Health; and Roger Kathol, MD, president of Cartesian Solutions, Inc. and board-certified in internal medicine, psychiatry, and medical management. • Mayo Family Clinic Northeast in Rochester has integrated behavioral health into its primary care services, beginning in 2008 when the clinic began participating in the DIAMOND program. The integrated team includes primary care providers; two full-time licensed clinical social workers; a clinical psychologist who is on-site one day a week; and two post-doctorate psychology fellows who work with patients under the supervision of the clinical psychologist. Over the past three years, the clinic has shown both consistent improvement and high performance in its ability to address depression care. (source: MN Community Measurement 2012 Health Care Quality Report, p. 114)

worse outcomes if the depression is not treated. Community standard is that most medical or specialty clinics treating these conditions do not routinely screen for depression. A few do, and most should. People with depression deserve for this to be recognized and treated as much as any other disease.

As a physician, your outcomes will be deservedly better if you recognize and treat depression too. Michael Trangle, MD, is a psychiatrist and associate medical director for Behavioral Health at HealthPartners. Amy LaFrance, MPH, is manager of strategic partnerships at MN Community Measurement.

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lthough treatment collaboration between chiropractors and neurologists began informally about 30 years ago, the pace of collaboration is accelerating with the current focus on health care cost and quality. This type of interdisciplinary collaboration makes sense, as neurologists often treat chronic and incurable conditions that can benefit from both a medical and chiropractic care model. With recent changes in the health care model, and research data demonstrating the benefits of chiropractic care, interdisciplinary collaboration is increasingly important as it expands into multiple allopathic disciplines, including orthopedics, spinal surgery, rheumatology, and internal medicine for musculoskeletal conditions. In addition to the cost and quality issues, another driver of increased use of chiropractors for treatment and diagnoses of neurological disorders is the availability of providers. Under current health care reforms, patients may find it more diffi-

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The intersection of neurology and chiropractic Collaborative care on the rise By Richard Golden, MD, and Vivi-Ann Fischer, DC

cult to schedule time with medical specialists, and may look to other types of providers, including chiropractors, as the first line of care and diagnosis. Health payers like this type of collaboration because of the

municating and sharing skill sets for treating certain conditions. Collaborative care examples

Collaboration between neurologists and chiropractors can ben-

Payers understand the value of doctors communicating and sharing skill sets for treating certain conditions. potential for improved efficiency, lower costs, and better patient outcomes. Payers understand the value of doctors com-

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efit patients suffering from a variety of common neurological conditions, including headaches, vertigo, and symptoms relating to brain-stem trauma such as that sustained from an automobile collision or sports injury. Other neurological conditions such as sciatica, carpal tunnel syndrome, and weakness of the arms or legs also benefit from this collaboration. Chiropractors are trained to recognize neurological conditions that need medical management and to make appropriate referrals to specialists based on these assessments. Patients with headaches. Unfortunately, migraine headaches are a common occurrence. The World Health Organization reports that half to three-quarters of adults 18â&#x20AC;&#x201C;65 years of age have had headaches in the past yearâ&#x20AC;&#x201D;and among those individuals, more than 10 percent have reported migraines. Treatment of these severe headaches is one example of collaboration between neurologists and chiropractors that may provide synergistic benefit to the patient. Recognizing the type of headache a person is experiencing can determine whether chiropractic or medical interven-

tion should be the first course of treatment. Recent research has shown that when receptors in neck muscles are overstimulated, changes in the part of the brain stem that generates migraines can occur. Sometimes, spinal manipulation reducing muscle tension and restoring joint function can relieve migraine symptoms. The same can be true for most types of muscle tension headaches. Chiropractic manipulation to treat migraines also may be particularly attractive to patients who do not like taking medication. Some types of migraines respond best to medicine. In Dr. Fischerâ&#x20AC;&#x2122;s experience, about 10 percent to 20 percent of headaches are best treated with a combined medical and chiropractic intervention. In such cases, collaborative care may provide a much more efficient approach to headache care. Patients with dizziness or vertigo. Vertigo episodes occur in 20 percent to 30 percent of the adult population. Vertigo can be caused by a number of inner-ear conditions. In some cases, such as those involving tumors, surgery is required. Others result from muscle spasms in the neck, which can be treated by a chiropractor. If a vertigo diagnosis is made and the dizziness likely is explained by neck spasm, a referral to a chiropractor might be indicated. The referral should include the diagnosis and a recommendation that the chiropractor confirm the diagnosis and treat accordingly. It is always important and appropriate to receive periodic progress reports and for the neurologist to follow the patient at regular intervals. Patients with closed head trauma. Head trauma is another health condition that is treatable via care coordination between neurologists and chiropractors. The American Association of Neurological Surgeons reports that 1.7 million cases of traumatic brain injury (TBI) occur in the U.S. every year, and that 50 percent to 70 percent of TBI accidents are caused by motor vehicle crashes.

When a person experiences trauma to the brain stem, such as harm incurred in an auto accident or a severe sports injury, the body reacts by trying to freeze the muscles. A chiropractor begins with a less invasive approach, working to improve joint mobility and function, followed by exercises that rebuild muscle. Neurologists need to step in for pain management, second opinions, or for evaluation of more severe disease. Ideally, if the chiropractor believes a second opinion or pain management medication would be useful in an injury case, a referral would be made to a neurologist, providing details regarding the injury, diagnostic imaging, and treatment that has occurred to date, and requesting a neurological evaluation. The consulting neurologist would then proceed with a complete neurological workup, including further diagnostic imaging if appropriate, and provide findings and recommendations to the referring chiropractor.

arm symptoms. In either carpal tunnel syndrome or neck impingement, if the patient does not improve or the condition is severe, referral of the patient to a neurologist would be indicated.

Collaborative care between neurologists and chiropractors allows the providers to help each other, and patients end up with the best combination of care. Patients with radicular symptoms such as sciatica or carpel tunnel syndrome. Sciatica can be caused by a muscle spasm, joint impingement, or nerve impingement. These conditions can be treated by a chiropractor through manipulation, active care exercises, and adjunct physiotherapy such as acupuncture, ultrasound, or muscle stimulation. A severe nerve impingement would call for collaboration with a neurologist. Orthopedic and neurologic exam findings such as a loss of reflex, or imaging findings (MRI or CAT scan) demonstrating a severely compressed nerve, would be a reason for a referral to a neurologist or neural surgeon. Jobs requiring heavy computer use or work based on

repetitive motion can contribute to carpal tunnel syndrome. Unless the symptoms are severe, chiropractic care is often a good starting place. Chiropractic care mobilizes the wrist and arm joints, loosens the muscles, and provides the patient with exercises to recondition the arm and wrist. In some cases, the symptoms associated with carpal tunnel syndrome, such as hand or arm numbness, originate from a nerve impingement in the neck, and the condition is not, in fact, carpal tunnel syndrome. The exam findings will provide this differential diagnosis, and if the cause is determined to be a neck condition, chiropractic care would then focus on relieving the neck impingement to improve the

Collaboration can benefit patients, curb costs

Collaborative care between neurologists and chiropractors allows the providers to help each other, and patients end up with the best combination of care for the lowest possible cost. The authors have collaborated on patient care for years. Our hope is that more neurologists and chiropractors establish relationships of trust and collaboration to benefit patients and achieve the goal of more cost-effective care. Richard Golden, MD, is a neurologist at Noran Neurological Clinic, Minneapolis. Vivi-Ann Fischer, DC, is chief clinical officer for Chiropractic Care of Minnesota, Inc., in Shoreview.

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ultidisciplinary care teams have become the norm in health care, especially in the subspecialty of medical oncology. This transition is a result of more patients presenting with multiple comorbidities. These patients more routinely require cross-specialty collaboration to effectively manage their complex cases. Oncologists recognize that proactively partnering with other specialists can improve patient outcomes. Multidisciplinary teams facilitate communication among health care professionals, helping to minimize costs and expedite time from diagnosis to treatment initiation.

Tumor conferences

Minnesota Oncology’s Maplewood Cancer Center currently hosts two different tumor conferences that are based upon multidisciplinary care-team models. One conference focuses on colorectal cancer patients; the other reviews head and neck cancer cases. The conferences are held one or two times a month and include specialists

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C R O S S - S P E C I A LT Y

Oncology-plus Care conferences reflect a holistic approach to meeting patients’ needs By Robert Delaune, MD

from the various disciplines these patient populations often encounter throughout their cancer journey. Conference participants include medical oncologists, radiation oncologists, ENT and colorectal specialists, radiologists, pathologists, pharmacists, dieticians, genetic counselors, speech pathologists, and care coordinators. This holistic approach helps ensure that all of the patient’s needs are met. The multidisciplinary tumor conferences provide a consistent opportunity for specialists to collaborate on developing treatment plans. Physicians present cases that include new cancer diagnoses, patients with disease progression, or tumors that are unresponsive to treatment. The

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C O L L A B O R AT I O N

MINNESOTA PHYSICIAN MAY 2013

group then reviews the cases and discusses treatment options. This cross-collaboration is invaluable. It allows all the specialists to use their expertise and offer their own perspectives, and it helps prevent treatment options from being overlooked. For example, a medical oncologist may not be aware of surgical and radiation options while, conversely, a surgeon may not be aware of all the potential chemotherapy regimens and radiation treatments. In essence, the plans are individually orchestrated to give each patient the best possible outcome. To truly function as a multidisciplinary care team, it is imperative that representatives from all of the disciplines— including support services such dieticians, genetic counselors, speech pathologists, and care coordinators—be involved in treatment. The absence of a specialty creates a weak link in developing a comprehensive care plan. For example, genetic counselors are present at the colorectal tumor conference to highlight genetic changes that could be attributed to a patient’s diagnosis or to discuss the need for familial testing. Without participation from genetics, family members with the same genetic mutations may go undetected and miss the opportunity to receive prophylactic care. Similarly, registered dieticians are critical members of the head and neck care team. They become connected with patients early in the treatment process to ensure proper nutritional planning occurs, including facilitating the placement of feeding tubes and determining appropriate nutritional supplements. This comprehensive approach to treatment planning is far superior to having health care providers treating independently.

Benefits for patients, physicians

The cross-specialty tumor conferences benefit both patients and physicians. A team model promotes numerous efficiencies in care. For example, the radiologist can determine the best scan for a particular area of the body to be looked at and save time spent getting multiple different exams/tests. Also, questions come up around staging and treatment options that can be discussed with the participants so that all the information is present to make decisions. If a patient is not eligible for surgery, that step or evaluation can be eliminated and the patient can move onto other specialties. Most importantly, it facilitates care coordination and expedites care delivery. This is an enormous benefit in the oncology world, where hearing the word “cancer” fills patients with anxiety and fear. Collaboration minimizes time between diagnosis and initiating treatment, whether it involves surgery, radiation therapy, chemotherapy, or nutrition therapy. A work-up plan is determined upfront and by the multidisciplinary team, eliminating time delays associated with having patients consult with individual specialists and determining a plan along the way. This is comforting to patients and creates the sense that their health is a priority to those treating them. The tumor conferences yield benefits in testing, communication, and education as well. Collaboration helps ensure appropriate testing is completed. It reduces the likelihood of ordering incorrect or duplicate diagnostic testing, offering cost savings to patients and insurance companies. This is particularly important in today’s world of accountable care organizations, underinsured populations, health savings plans, and reimbursement cuts. Nobody wants to go through unnecessary scans or duplicated procedures. Participation by radiologists at these conferences ensures that tests are ordered accurately and helps expedite patient work-up in a timely manner.

The regular tumor conferences also minimize communication barriers among the specialists. It is not uncommon for health care providers to use different patient charting systems that require providers to personally communicate status changes. This can be time-consuming and create delays in care. The care conferences reduce the need for physicians to reach out to other specialists individually to gain their perspective. In addition, the conferences help keep team members current, since all stakeholders are present at the same time to update the entire team on the patient’s status and care plan. Multidisciplinary conferences also serve as a forum for ongoing education, providing health care professionals with access to emerging trends, different treatment approaches and strategies. Participants often discuss data on new and emerging surgical techniques; new information on specific types of tumors (for example, molecular profiles that may help individu-

The multidisciplinary tumor conferences provide a consistent opportunity for specialists to collaborate on developing treatment plans. alize care for a particular patient’s tumor); and new drug therapies specifically targeting certain patient populations. Continuing education credits are available to participants of the multidisciplinary care conferences at the Maplewood Cancer Center, giving health care professionals additional impetus to attend. Challenges and goals

In addition to the benefits of multidisciplinary care teams, there are some challenges. Among them is the availability of the specialists. As noted above, there are many players involved in these teams. Each person has a complex schedule with clinic and/or surgical obligations. It can be an arduous

task to organize calendars and find a convenient time for everyone—but without representation from all disciplines, the team cannot attain a comprehensive care model. In addition, these types of care conferences are not reimbursable services by third-party payers. According to the Centers for Medicare & Medicaid Services, the patient needs to be present in order for a physician to report time spent in a team conference. This is unfortunate, since these conferences add value to the patient’s experience of care and require physician expertise and time. With the graying of the population in the United States, the need for cancer care services will continue to rise in the years

ahead. At the same time, new national health care mandates will increase Medicare regulations and decrease reimbursement in many cases. These factors create a “perfect storm” that will require health care professionals and organizations to employ every method at their disposal to collaboratively streamline health care protocols and increase efficiencies. Our goal must continue to be to provide the best, most effective and cost-efficient treatment plans possible for our patients. At Minnesota Oncology, we sum it up this way: “Our mission is to combine the strength of hope with the power of science, one patient at a time.” Robert Delaune, MD, is board-certified in medical oncology, hematology, and internal medicine. He practices at Minnesota Oncology’s Maplewood Cancer Center.

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MINNESOTA PHYSICIAN

INFECTIOUS

espite a high level of awareness of Lyme disease among Minnesota residents and medical providers, persistent misperceptions about diagnosis and treatment remain. Five additional tickborne diseases (TBDs), with varying levels of public and provider awareness, are also endemic to Minnesota. Medical providers throughout the state should be aware of TBD clinical presentations, recommended laboratory assays, treatment guidelines, and should feel comfortable speaking with their patients about how to minimize risk. Epidemiology of tickborne diseases in Minnesota

Lyme disease (LD) (Borrelia burgdorferi); babesiosis (Babesia spp.); human anaplasmosis (HA) (Anaplasma phagocytophilum), a form of human ehrlichiosis (HE) (Ehrlichia muris-like agent); and Powassan disease (POW virus) are considered endemic to Minnesota and Wisconsin, where they are associated with bites from Ixodes scapularis (blacklegged tick or â&#x20AC;&#x153;deer tickâ&#x20AC;?).

DISEASES

Minnesota tickborne disease update Providers can help patients minimize risk By Hannah G. Friedlander, MPH; Elizabeth K. Schiffman, MA; and David F. Neitzel, MS Although more common in southern states, Rocky Mountain spotted fever (RMSF) (Rickettsia rickettsii) is known to occur in the Upper Midwest. Unlike Minnesotaâ&#x20AC;&#x2122;s other TBDs, the primary tick vector of RMSF is Dermacentor variabilis (American dog tick or â&#x20AC;&#x153;wood tickâ&#x20AC;?). When considering a TBD diagnosis, physicians should determine patient exposure to tick habitats, as tick bites often go unnoticed. I. scapularis ticks are most abundant in hardwood forests or brushy areas and are active during most warm months of the year. Disease risk from I. scapularis is highest from mid-May through mid-July, coinciding with the primary feeding period of the tickâ&#x20AC;&#x2122;s

nymphal stage. Lower disease risk occurs during spring and fall months when adult I. scapularis feed. RMSF risk is highest during spring and early summer in wooded and grassy habitats where D. variabilis ticks are active. In recent years, I. scapularis has emerged in formerly nonendemic regions of the state, particularly to the north and west of historically endemic east-central Minnesota. The Minnesota Department of Health (MDH) has confirmed I. scapularis presence as far north as the Canadian border and in many western Minnesota counties with suitable wooded habitat. Figure 1 shows the tickborne risk in Minnesotaâ&#x20AC;&#x2122;s counties.

Diagnosis and management

Lyme disease Lyme disease is caused by infection with the bacteria Borrelia burgdorferi. The incubation period for LD is 3â&#x20AC;&#x201C;30 days, though disseminated infections may not be recognized or diagnosed until weeks or months later. The pathognomonic erythema migrans (EM) rash is present in the majority of early localized cases of LD. The rash expands in size over time, although it may lack the central clearing or the characteristic â&#x20AC;&#x153;bulls-eyeâ&#x20AC;? appearance. Disseminated B. burgdorferi infections may involve dermatologic, rheumatologic, cardiac, peripheral nervous system, or central nervous system manifestations. The recommended diagnostic testing procedure for LD is by two-tiered serologyâ&#x20AC;&#x201D;an ELISA or IFA followed by Western blot (if ELISA is positive or equivocal). However, if a patient has a single EM and symptoms began in the last 2â&#x20AC;&#x201C;4 weeks, antibody testing is not recommended due to low sensitivity at this stage of infection. If

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FIGURE 1. Minnesota tickborne disease risk* a patient has been symptomatic for >1 month or did not develop an EM, clinical diagnosis should be supported with evidence of IgG antibodies by Western blot. An IgG-positive result is expected in patients with symptoms lasting longer than one month. Long-term or repeated antibiotic courses for the treatment of “chronic” LD are not necessary, safe, or recommended. Persistence of viable B. burgdorferi after proper antibiotic treatment (2–4 weeks duration) is not supported by scientific literature. Continued symptoms following treatment may result from lingering inflammatory processes, an unrecognized tickborne co-infection, or an unrelated process. Babesiosis Babesiosis is a potentially fatal, malaria-like disease resulting from infection with intra-erythrocytic parasites of the genus Babesia. Unlike LD, where infection is seen in all age groups, babesiosis is most commonly observed in elderly or immunocompromised patients, who may

*Based on average incidence (cases/100,000 population) of Lyme disease and human anaplasmosis cases in Minnesota, 2007-2011

Tickborne disease (TBD) risk is confined to forested areas throughout the state

Minnesota Department of Health — Infectious Disease Epidemiology, Prevention and Control Division April 2013

present with fever, chills, sweats, myalgias, arthralgias, anemia, and/or thrombocytopenia up to eight weeks after an exposure. Severe complications, including hemolysis, respiratory distress, and organ failure, have been known to occur in infected individuals. If babesiosis is suspected, confirmatory testing by PCR or through a combination of peripheral blood smears and serology is recommended, as blood smears alone fail to capture all cases, especially in instances of low parasitemia. Serologic testing is less reliable in early infection, and determining whether positive serologic results indicate a past exposure or a current infection on an acute specimen can be difficult. A fourfold increase in antibody titer between acute and convalescent specimens may be suggestive of current infection. Transfusions are a known source of babesiosis transmission, and transfusion-associated illness should be considered in patients who develop fever and TICKBORNE to page 32

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MAY 2013

MINNESOTA PHYSICIAN

WOMEN’S

ccording to the most recent data, there were 4.1 million live births in the United States in 2009. While pregnancy rates have declined in nearly all age groups, the proportion of women over 35 years of age continues to increase. This shift in pregnancy rates toward older women has led to an increase in the proportion of pregnant women with chronic diseases. Furthermore, increasing rates of obesity at younger ages in the U.S., together with associated comorbidities such as diabetes and chronic hypertension, have contributed to higher-risk pregnancies. Consideration of drug therapy in pregnant women is a common medical decision. Though several existing resources can help determine the safest medications to be used during pregnancy, these references are mainly designed to help with decision-making at the initiation of therapy after a pregnancy has been diagnosed. At this point, the provider can weigh the risks/benefits of alternative options and choose a

Promoting healthy pregnancy Chronic medical conditions and the pregnant patient By Nicole Chaisson, MD, MPH, and Chrystian Pereira, PharmD

medication associated with the lowest risk. Providers face a different, and somewhat harder, decisionmaking process when a patient is already on medication(s) and then becomes pregnant. Here, the provider must also weigh the risks/benefits of the patient’s history with the medication(s) and control of symptoms in combination with the potential harm/benefit of changing to a different medication. Preconception care: A missed opportunity?

Improving women’s health before conception and recognizing the effects of chronic conditions and treatment for those

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MINNESOTA PHYSICIAN MAY 2013

No .7

2007

conditions on a pregnancy before conception can result in improved reproductive health outcomes. Yet, preconception care is often a missed opportunity. Though approximately 50 percent of pregnancies in the U.S. are unplanned, studies indicate that more than 80 percent of women of reproductive age visit a health care provider during the year prior to their pregnancy. There is opportunity for primary care providers to engage women in proactive discussions about future reproductive health plans, either to assist with decisions about contraception or to prepare for a healthy pregnancy in the near future. The 2011 National Women’s Health Survey Data of women 18-44 years old noted that 9.2 percent had asthma, 30.2 percent were hypertensive, 11.4 percent had diabetes, and 62.1 percent were overweight or obese; all of these rates have increased over the past decade. A reproductive health plan can reflect a woman’s intentions regarding future pregnancies in the context of personal health, values, and life goals. For women with chronic medical conditions, it can also help direct treatment and inform expectations of the impact of a pregnancy on the condition(s). Good and consistent preconception counseling includes reviewing chronic health conditions, chronic medications, and use of over-the-counter or herbal meds, and how these factors may affect future pregnancies. Clearly, if a patient is considering a pregnancy in the near future, avoiding medications with known harm in pregnancy is ideal unless the potential maternal benefits outweigh the fetal risks. Alternatively, discussing delaying conception

with use of effective contraception may be warranted if maternal conditions are more severe and treatment is riskier with a concurrent pregnancy. Many medical conditions may be affected by a concurrent pregnancy or may increase the risk of adverse pregnancy outcomes for women and/or their infants. Decision-making is complicated by the pharmacotherapy used for these conditions and the limited data regarding use of chronic medications during pregnancy. This article reviews some common chronic conditions encountered during pregnancy. Asthma

Asthma can adversely affect both maternal quality of life and perinatal outcomes. Pregnant women with asthma are at significantly increased risk of several adverse perinatal outcomes, including preterm labor, preeclampsia, low birth weight, neonatal hypoxia, and stillbirth, particularly if the woman’s asthma is uncontrolled. A women’s asthma may stay the same, worsen, or even improve during pregnancy; however, patients with more severe asthma to start with are the most likely to worsen during pregnancy. Management of asthma during pregnancy is generally the same as management prior to pregnancy. Updating the patient’s Asthma Action Plan at the beginning of the pregnancy can help reinforce the idea that “staying in control” is safest for the outcome of the pregnancy. Fortunately, while several changes in the respiratory system occur in pregnancy, there is no change in FEV1 or PEF; therefore, these measures can be used to monitor response to therapy during pregnancy. Patients also can be prepared to notice possible exacerbations in the third trimester and to understand that it is safe to treat these exacerbations if they occur. Generally, the medications most commonly used to treat asthma are quite safe during pregnancy. Studies indicate that the risk of uncontrolled asthma on perinatal outcomes is much greater than the theoretical risks of asthma medications. Inhaled

corticosteroids and short-acting beta agonists have proven safety and efficacy. Long-acting beta agonists such as salmeterol and formoterol have not been well studied in pregnancy and are known to have associated risks of worsening exacerbations when used as monotherapy outside of pregnancy; therefore, it is recommended that these be avoided during pregnancy. Maternal use of oral corticosteroids has some associations with low birth weight and preeclampsia; however, they are generally considered safe for asthma exacerbations and for management of severe asthma in order to prevent maternal death. Diabetes

Gestational diabetes, both preexisting and pregnancy related, occurs in approximately 7 percent of all pregnancies in the U.S.; these rates have steadily increased, as has the rate of diabetes affecting all women of reproductive age. The perinatal effects of poorly controlled diabetes on the fetus are well known and include neonatal hypoglycemia, respiratory distress syndrome, hyperbilirubinemia, congenital malformations, and stillbirth. Maternal effects include preeclampsia, birth trauma, and hypertension. Preconception care for diabetes is critical, as perinatal outcomes are best when glycemic control is achieved before conception. Studies have linked an increased rate of congenital malformations and spontaneous abortion to poor pregestational glycemic control. Therefore, contraceptive status and reproductive intent should be reviewed with all diabetic women of reproductive age at their routine diabetes visits. Pregnancy outcomes are clearly related to how well controlled the patient’s diabetes was before pregnancy. But even patients with well-controlled diabetes need to step up their glucose monitoring during pregnancy and visit their provider more frequently to determine whether their medications need adjustment. Pregnancy is characterized by increased insulin resistance and reduced sensitiv-

A reproductive health plan can help direct treatment and inform expectations of the impact of a pregnancy on the condition(s). ity to insulin, largely due to the effect of placental hormones on the system. As insulin resistance increases throughout the pregnancy, the body’s requirements for exogenous insulin can change over time, with the greatest insulin requirements occurring in the third trimester. The gold standard for pharmacotherapy in pregnancy is initiation of or conversion to a combination of NPH and regular insulin. Insulin, due to its molecular size, does not cross the placental barrier; therefore, it helps control maternal glucose but does not affect the fetal system. Newer insulin formulations such as Glargine have not been approved for use in pregnancy, but share the same characteristics as older formulations and are not known to pass the placental barrier. More recently, oral hypoglycemics have received attention as a treatment option. Glyburide does not pass the placental barrier and has been recognized as safe during pregnancy. Metformin does pass the placental barrier, but studies during pregnancy have generally demonstrated no significant adverse events with its use; nevertheless, it has not been widely recognized as adequate monotherapy during pregnancy. Depression

In the U.S., it is estimated that more than half a million pregnancies annually involve women with psychiatric illnesses. It is also estimated that one-third of pregnant women are exposed to psychotropic medications at some point in their pregnancy and more than 70 percent of pregnant women report symptoms of depression during pregnancy. Clinical management of depression must be individualized to account for the risk of the medications on the fetus and newborn and the potential effect of untreated maternal illness on the pregnancy; and to review

any available alternative therapies. Untreated depression may result in poor utilization of prenatal services and poor selfcare during pregnancy and can affect maternal-newborn bonding after delivery. Maternal depression during pregnancy has been linked to intrauterine growth restriction (IUGR), low birth weight, and postnatal morbidities. While psychotherapy should be considered a mainstay for treatment of depression during pregnancy, some women will need to remain on or restart antidepressant medications in order to remain mentally healthy. Some early studies found increased risks of birth defects specifically associated with tricyclic antidepressants (TCAs); however, more recent studies indicate that these may be considered safe, though not neces-

sarily first-line treatment for depression. The selective serotonin reuptake inhibitors (SSRIs) have been linked to neonatal hypoglycemia and respiratory problems; however, the majority of that evidence was associated with the use of paroxetine (Paxil) in particular. SSRIs generally are considered safe, and the benefits of treatment normally outweigh the small known risk of use during pregnancy. All psychotropic medications used to treat depression cross the placenta and may enter human breast milk even in small amounts; however, changing meds throughout the pregnancy may increase the exposure to the fetus and should be avoided if possible. For women already taking a medication, it is preferable to increase the dose of one medication rather than switch to a different medication or start a second one. Hypertension

Chronic hypertension affects approximately 3 percent of pregPREGNANCY to page 30

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MINNESOTA PHYSICIAN

Pregnancy from page 29 nant women. Pregnancies complicated by chronic hypertension may be associated with superimposed preeclampsia or eclampsia, cardiovascular compromise, worsening renal dysfunction, or stroke. Risks to the fetus include preterm birth, IUGR, and fetal demise. Poor control of blood pressure prior to pregnancy is highly correlated with poor perinatal outcomes. Preconception counseling should focus on dietary changes and weight loss and should include discussion of the effects of hypertension, any associated end-organ damage, and hypertensive medications on a pregnancy. For women who are early in pregnancy or considering a pregnancy soon, there is insufficient evidence to recommend tight control of blood pressure (<140/90) vs. less tight control (<160/100) in order to maintain adequate perfusion of the placenta during pregnancy. For women whose blood pressure has been tightly controlled prior to pregnancy, the more lenient

Incorporating care and input from psychotherapy, nutrition, and Pharm D, in addition to medical care, can promote a healthy pregnancy environment for patients. goal of 160/100 during pregnancy may affect the dosing of current medications or allow discontinuation or withdrawal of some medications during pregnancy. The ACE inhibitor class of antihypertensive medications has become increasingly popular as a first-line treatment for chronic hypertension, especially when women have other comorbid conditions such as diabetes. However, these medications are strongly linked to several congenital defects and fetal death, and they should be discontinued in the event of pregnancy and should be discouraged if a woman is considering getting pregnant in the near future. Methyldopa has long been considered the safest medication during pregnancy, but labetalol and nifedipine have been used

frequently for both inpatient and outpatient control. While diuretic therapy generally has been avoided in order to avoid volume depletion, data indicate that women taking HCTZ prior to pregnancy did not have any adverse effects from taking the medication during pregnancy as well. However, Furosemide should be avoided because of associations with birth defects. Migraine headache

Migraine headaches generally occur less frequently during pregnancy, and breastfeeding may continue that decreased rate of migraine exacerbation. About 80 percent of pregnant women with migraine will notice a decrease in the frequency of their headaches. This pattern is so predictable that an increase in the frequency of migraines

should potentially prompt an investigation of other conditions such as preeclampsia or other, rarer conditions. Women who are already on prophylaxis with the betablocker propranolol or riboflavin may continue these medications, as they are considered safe during pregnancy. However, initiating or continuing the use of other chronic daily prophylaxis (e.g., topamax) should be avoided, as they are likely unnecessary during pregnancy. Intermittent treatment with biofeedback or other behavioral techniques may be useful. If intermittent pharmacological treatment is preferred, there are several options for abortive treatments. Opioids are safe and effective, though short-acting forms are preferable (e.g., Tylenol with codeine or hydrocodone). Oral serotonin receptor agonists (triptans) are very effective for acute treatment of migraine, and accumulated data in the pregnancy registry suggests they are safe during pregPREGNANCY to page 36

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MINNESOTA PHYSICIAN MAY 2013

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Additional information

Tickborne from page 27 anemia after receiving cellular blood products. Suspected transfusion-associated cases should be reported promptly to associated blood banks and MDH. Human anaplasmosis and human ehrlichiosis Although infections of human anaplasmosis and several forms of human ehrlichiosis share similar clinical presentations, taxonomic changes in disease classification have led to frequent misuse of the two terms. Endemic to Minnesota, HA is transmitted by I. scapularis and leads to the infection of granulocytes by the bacteria Anaplasma phagocytophilum. In contrast, Ehrlichia chaffeensis, endemic to southern states and not typically observed in Minnesota, is transmitted by Amblyomma americanum (Lone Star tick) and results in infection of monocytes. The newly identified Ehrlichia muris-like agent is transmitted by I. scapularis and causes a clinical syndrome similar to that seen in cases of HA and other human ehrlichioses.

â&#x20AC;˘ For information on the clinical assessment, treatment, and prevention of Lyme disease, anaplasmosis, and babesiosis, refer to the IDSAâ&#x20AC;&#x2122;s clinical practice guidelines at: www.idsociety.org/Lyme/ â&#x20AC;˘ For information about ehrlichiosis and RMSF: www.cdc.gov/ ticks/diseases/index.html â&#x20AC;˘ For more information about tick-transmitted diseases in Minnesota: www.health.state.mn.us/divs/idepc/dtopics/tickborne/index.html With an incubation period of 3â&#x20AC;&#x201C;21 days, most HA and HE patients will present with an acute onset of high fever, chills, headache, myalgias, leukopenia, thrombocytopenia, and/or elevated aminotransminases. Symptomatic infections are more frequently observed in adults than in children. Due to serologic cross-reactivity, assays for both Anaplasma and Ehrlichia should be ordered when infection with either agent is suspected. Though less frequently used, PCR has greater sensitivity and specificity than available antibody tests and identifies the species of Anaplasma or Ehrlichia present. Peripheral blood smears for Anaplasma may also be performed, but sensitivity is low. Regardless of testing modality, patients with symptoms consistent with HA or HE

should be treated empirically while results are pending. As with babesiosis, transfusion-associated cases of anaplasmosis have been documented in Minnesota and should be considered in patients who develop a fever and thrombocytopenia post-transfusion. Powassan disease Powassan virus, a tickborne flavivirus transmitted by I. scapularis and related to West Nile virus, can cause severe neuroinvasive disease and death. Twenty-one cases, including one fatality, were identified in Minnesota residents in the years 2008â&#x20AC;&#x201C;2012. Although most identified POW cases to date nationwide have had encephalitis or meningitis, POW virus can also cause an acute febrile illness without neurologic involvement, and many infections are likely

subclinical. The incubation period is 3â&#x20AC;&#x201C;21 days. No antivirals are approved for treatment of POW virus; clinical management usually involves supportive care and rehabilitation for patients with neurologic involvement. Serum or CSF specimens from patients with central nervous system disease can be submitted to the MDH Public Health Laboratory for arboviral disease testing, including POW virus. No commercial laboratories currently offer serologic testing for POW virus. Rocky Mountain spotted fever Rocky Mountain spotted fever results from infection with Rickettsia rickettsii and is the most widespread rickettsial disease in the United States. Though rare in Minnesota, 2â&#x20AC;&#x201C;11 cases have recently been reported each year, many with likely in-state exposure; the first confirmed RMSF fatality in the state was documented in 2009. Signs and symptoms commonly present 2â&#x20AC;&#x201C;14 days after exposure and include fever, headache, maculopapular or petechial TICKBORNE to page 34

Fairview Health Services Opportunities to fit your life

Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. 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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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, youâ&#x20AC;&#x2122;ll continue to practice in your community and serve when needed. Youâ&#x20AC;&#x2122;ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. Youâ&#x20AC;&#x2122;ll make a difference. 7R OHDUQ PRUH FDOO RU YLVLW ZZZ KHDOWKFDUH JRDUP\ FRP T ÂŠ 2010. Paid for by the United States Army. All rights reserved.

fairview.org/physicians 55: &&0 "" &NQMPZFS

MINNESOTA PHYSICIAN MAY 2013

Practice Well. Live Well.

Family Med/ER Physicians

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.

Small Town, Big Impact!

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 • Internal Medicine

• Orthopedic Surgeon • Pediatrics • Psychiatrist • Psychiatric NP or 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

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. Apply online at healthpartners.jobs or email your CV and cover letter to sandy.j.lachman@ healthpartners.com. EO Employer

Lake Region Healthcare is an Equal Opportunity Employer. EOE

www.lrhc.org

healthpartners.com

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 Optometry

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

Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000. Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org AA/EOE - Not subject to H1B Caps

www.averamarshall.org

MAY 2013

MINNESOTA PHYSICIAN

Tickborne from page 32 rash, myalgias, nausea and vomiting, and/or thrombocytopenia. In 80 percent of cases, a rash appears 2–5 days after fever onset; however, the rash may be atypical in appearance or absent altogether. As a result, patients presenting with a combination of fever, thrombocytopenia, and exposure to tick vectors should prompt consideration of RMSF and empiric treatment of suspected cases. Diagnostic tests for RMSF include PCR or immunohistochemistry on skin biopsies from rashes. Because R. rickettsii does not widely circulate in the blood, except in the most severe stage of infection, PCR testing on whole blood is not usually recommended. Serologic testing by IFA can be used but may be negative within 7–10 days of symptom onset. In certain cases, MDH will work with providers to arrange for additional testing, including culture, through CDC. Prevention

MDH recommends personal protective measures, including

During physicals and other health care visits, medical providers should discuss TBD risk and prevention with patients who live, work, or spend time in endemic areas. tick repellents, for anyone who spends time in tick habitats anywhere in the state. While tick checks are an important component of prevention, even the most careful checks might miss ticks, and the duration of tick attachment to transmit the agents of some TBDs is short enough (e.g., 15 minutes or less for POW virus; 12 hours for HA, HE, and babesiosis vs. 1–2 days for LD) that late-day tick checks might take place after transmission has occurred. Repellents containing DEET (up to 30 percent), which is sprayed on clothing or skin, or permethrin, which is pre-applied to clothing and lasts through multiple wearings and washings, are recommended. During physicals and other health care visits, medical providers should discuss TBD

risk and prevention with patients who live, work, or spend time in endemic areas. Patients should be counseled that although I. scapularis is responsible for most transmission of TBDs in Minnesota, risk of RMSF infection from D. variabilis also exists. TBD risk is highest from May through midJuly, although disease transmission is possible during any warm month. Providers should inform patients of non-LD TBD risk; any acute febrile illness occurring within one month of exposure to tick habitat, even without known tick bites, may be suggestive of a TBD. Certain aspects of LD diagnosis and treatment may be confusing to some patients, particularly in regard to the resolution of symptoms and/or persistence of antibodies post-

Sioux Falls VA Health Care System Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Chief of Primary & Specialty Medicine Psychiatrist Hospitalist Podiatrist Cardiologist

Neurologist Endocrinology Emergency Medicine Primary Care (Internal Medicine or Family Practice)

Sioux Falls VA HCS (605) 333-6858 www.siouxfalls.va.gov Applicants can apply online at www.USAJOBS.gov

MINNESOTA PHYSICIAN MAY 2013

treatment; misinformation about “chronic” LD or co-infections has been widely disseminated. When treating TBDs, providers should take the opportunity to discuss antibody testing, diagnostic challenges (e.g., whether treatment is empiric or supported by laboratory evidence), and balancing risks and benefits of antibiotic therapy with patients. All TBDs are reportable in Minnesota. Reports to MDH should include demographic, clinical, and laboratory information. Providers are also encouraged to contact MDH for diagnostic assistance with suspected cases of POW or RMSF. Additional information about tickborne diseases is available at the websites listed in the sidebar on page 32. Hannah G. Friedlander, MPH; Elizabeth K. Schiffman, MA; and David F. Neitzel, MS, work in the Minnesota Department of Health Division of Infectious Disease Epidemiology, Prevention and Control.

Here to care At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 11 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, ﬂexible schedules and competitive beneﬁts in an environment where passionate people thrive and excel. Make a difference. Join our award-winning team. Madalyn Dosch, Physician Recruitment Services Toll-free: 1-800-248-4921 Fax: 612-262-4163 Madalyn.Dosch@allina.com allinahealth.org/careers EOE/AA 10127 0213 ©2013 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM

Emergency Room Physicians Looking for leisure work hours?

The perfect match of career and lifestyle.

• Set your own hours • No contract • No obligations

Attention Physicians • Immediate openings • Casual weekend or evening shift coverage

• Choose from 12 or 24 hour shifts • Competitive rates • Paid malpractice

Great Emergency Department in Southern Minnesota

Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • Geriatrician/Outpatient Internal Medicine • Hospitalist • Infectious Disease

• Internal Medicine • Med/Peds Hospitalist • OB/GYN • Oncology • Orthopedic Surgery • Psychiatry

• Psychology • Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

For additional information, please contact:

763-682-5906 • 1-800-876-7171 F-763-684-0243 michelle@whitesellmedstaff.com

Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366

Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

www.acmc.com

Emergency Medicine 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.

Opportunities available in the following specialties: Dermatology Southeast Clinic

Family Medicine Cannon Falls Clinic and Pine Island Clinic

Hospitalist Rochester Hospital

Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:

Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:

Internal Medicine Southeast Clinic

recruiting@epamidwest.com or visit our website at

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: dcardille@olmmed.org

www.epamidwest.com

Phone: 507.529.6748 Fax: 507.529.6622 EOE

Your Emergency Practice Partner

www.olmstedmedicalcenter.org MAY 2013

MINNESOTA PHYSICIAN

Pregnancy from page 30 nancy. Sumatriptan in particular has the most evidence supporting safety. Several antiemetics have noted safety: For example, ondansetron carries a pregnancy category B rating; and prochloroperazine, while rated Category C, has received safer ratings in TERIS, a computerized database designed to assess teratogenic effects of medications and provide guidance to medical providers. Other options during pregnancy include daily supplementation with vitamin B6 and/or the intermittent use of doxylamine or hydroxyzine. Other medical conditions

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age. When untreated, both hyperthyroidism and hypothyroidism have been linked to pregnancy complications. For hyperthyroidism, propylthiouracil is the preferred treatment during pregnancy. For hypothyroidism, levothyroxine doses may need to be adjusted

during the pregnancy, as many women will require nearly a 50 percent increase in the dosage over the course of the gestation. It is recommended that the TSH be checked every trimester in order to assess whether adjustments are needed. Hyperlipidemia is a cardiovascular risk in patients with diabetes and those with other known disease. Treatment for this condition should be approached with some caution in reproductive-age women. Statins carry a pregnancy category X and are contraindicated in pregnancy. Although teratogenicity is most likely to occur in later stages of pregnancy, it is best to discontinue statins medications as soon as possible. The issue may be addressed in preconception planning by considering alternative drug therapy such as niacin, or by focusing on lifestyle changes if the woman is actively trying to become pregnant. Benefit from statin therapy should be considered a longterm gain, and interruption of this therapy due to pregnancy may be a minor loss compared

to the overall gain. Women with seizure disorders are at risk for complications during pregnancy if their seizures are not well controlled. However, many seizure medications have been linked to congenital defects. It is recommended that these patients be on the fewest medications and at the lowest dose possible to provide seizure control prior to conceiving. Close consultation with the patient’s neurologist may be warranted to achieve this goal. Keys to improved reproductive health

Increasing preconception health overall can result in improved reproductive health outcomes. For physicians who treat women of reproductive age: • Consider developing a reproductive health plan for all women of reproductive age with chronic medical conditions and incorporate reproductive health discussions into routine visits. • Be aware of common medications that are contraindicated

in pregnancy not only when a woman is pregnant, but also for women who may become pregnant during the course of their therapy. • Weigh the risks of no treatment vs. treatment when assessing a pregnant woman with acute illness or exacerbation of chronic illness. • Embrace a team-based approach to the care of pregnant women with chronic conditions. Incorporating care and input from psychotherapy, nutrition, and Pharm D, in addition to medical care, can promote a healthy pregnancy environment for patients. Nicole Chaisson, MD, MPH, is a family medicine physician with UM Physicians at Smiley’s Clinic and an assistant professor in the Department of Family and Community Health at the University of Minnesota Medical School. Chrystian Pereira, PharmD, is a clinical pharmacist at Smiley’s Clinic, and is an assistant professor in the University of Minnesota College of Pharmacy.

Trinity Health One of the region’s premier healthcare providers.

Currently Seeking BC/BE s Ambulatory Internal Medicine s General Surgery

s Psychiatry s Urology

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

MINNESOTA PHYSICIAN MAY 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

St. Cloud VA Health Care System Opportunity Announcement

Opportunities for full-time and part-time staff are available in the following positions: x

Associate Director, Primary & Specialty Medicine (IM)

Dermatologist

ENT

Geriatrician/Hospice/Palliative Care

Internal Medicine/Family Practice

Medical Director, Extended Care & Rehab (Geriatrics)

Orthopedic Surgeon

Pain Specialist

Psychiatrist

Urgent Care Physician (IM/FP/ER)

Applicants must be BE/BC.

Since 1924, the St. Cloud VA Health Care System has delivered excellence in health care and compassionate service to central Minnesota Veterans in an inviting and welcoming environment close to home. We serve over 38,000 Veterans per year at the medical center in St. Cloud, and at three Community Based Outpatient Clinics located in Alexandria, Brainerd, and Montevideo.

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit www.USAJobs.gov or contact Nola Mattson STC.HR@VA.GOV Human Resources 4801 Veterans Drive St. Cloud, MN 56303 (320) 255-6301 EEO Employer

Our Community Located sixty-five miles northwest of the twin cities of Minneapolis and St. Paul, the City of St. Cloud and adjoining communities have a population of more than 100,000 people. The area is one of the fastest growing areas in Minnesota, and serves as the regional center for education and medicine. Enjoy a superb quality of life here窶馬early 100 area parks; sparkling lakes; the Mississippi River; friendly, safe cities and neighborhoods; hundreds of restaurants and shops; a vibrant and thriving medical community; a wide variety of recreational, cultural and educational opportunities; a refreshing four-season climate; a reasonable cost of living; and a robust regional economy!

MAY 2013

MINNESOTA PHYSICIAN

Claims from page 15 front-end claim rejections is completely avoidable. This group of errors relates to the provider information submitted on the claim. Incorrect, missing, or redundant information accounts for nearly 23 percent of claims rejections. Our staff sees claims with missing billing office employer identification numbers (EIN), missing billing NPI (National Provider Identifier) numbers, and incomplete address information. This is the information about your office, submitted by your office; your billing staff needs to get it right. That said, there are some pitfalls related to addresses entered on claims forms. • One of the most significant changes in the HIPAA ANSI X12 837 format (version 5010) is the ZIP+4 requirement— meaning that a nine-digit ZIP code is required for both the billing office information and the outside service address. On the claim form, “outside service address” refers to a location where providers perform services that are not ren-

dered at the same location as their billing office location. • ZIP+4 is not required in the optional “pay-to” address and is not a requirement for the patient or subscriber address. • Importantly, if the billing office supplies address information that is redundant, that is a reason for the payer to reject the claim. So if the outside service address is the same as the billing office address, or if the optional payto address is the same as the billing office address, you may not submit that information— or the claim can be rejected. Though some payers have chosen not to enforce the redundant address restriction, they are in the minority and, in the end, complicate the issue by not adhering to the claim standard. Other issues affecting billing procedures

Over the past 10 years, improvements in technology and standardized transactions have changed the way we do business in health care. Yet, though com-

puters are faster and data transmission is faster, we have not managed to solve the basic problem of getting doctors paid for the services they provide. In part, this is because the billing systems used by providers have not kept up with the times. Work with your claim submission partner to make sure your computers and software applications are up to the task of meeting complex and changing industry standards for claims submission and processing. On the staffing and services side, choose a claim-submission partner with a proven track record that will work with you and your staff on the issues discussed above; and make training of data entry and billing staff a priority. Having the right staff in your office and supporting your billing procedures will go a long way toward easing the inherent challenges of submitting claims. Benefits for staff, patients, and the bottom line

Roughly 90 percent of the health care claims that are rejected are within the control of you and your staff.

To minimize errors on your end: • Ensure that your office data is correct and compliant. • Verify the patient’s eligibility and update your system’s data so it reflects the payer’s demographic data for the patient. • Use correct diagnosis and procedure coding. • Staff your claims processing department with accurate and efficient workers, and train them well. • Choose a skilled, experienced claims submission partner. Accomplishing these objectives will yield multiple benefits. Your dedicated claim processing staff will have time to focus on the real claim issues. Your patients will be happier because they will receive fewer statements from your office and fewer “explanation of benefits” forms from their payer(s). And you will see your revenue increase—and your accounts receivable decrease. Russel Campbell is president and CEO of ClaimLynx, Inc., based in Plymouth, Minn.

continuing education Fundamental Critical Care Support Simulation Facilitator Course Trauma Education: The Next Generation* * Formerly Emergency Medicine and Trauma Update: Beyond the Golden Hour Managing Life Limiting Illness and End of Life Care (two-day event) Primary Care Update: Pathways to Knowledge

August 20-22, 2013 September 5, 2013 October 1 and October 3, 2013 October 10-11, 2013

Fundamental Critical Care Support

October 24-25, 2013

Simulation Facilitator Course

November 6-8, 2013

Pediatric Fundamental Critical Care Support

November 14-15, 2013

35th Annual Cardiovascular Conference: Current Concepts and Advancements in Cardiovascular Disease

December 12-13, 2013

Education and research to improve the health of our community

July 18-19, 2013

MINNESOTA PHYSICIAN MAY 2013

HealthPartnersInstitute.org

It’s time to see beneath the surface. September 8–10, 2013 http://www.mayo.edu/transform/

Relax. Discover solutions that put you at ease.

At MMIC, we believe patients get the best care when their doctors feel calm and conďŹ dent. So we put our energy into creating risk solutions designed to eliminate worry. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. Itâ&#x20AC;&#x2122;s our own quiet way of revolutionizing health care. To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.