MINNESOTA
JANUARY 2019
PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 10
Social engineering Is your practice prepared? BY GINNY ADAMS, RN, BSN, MPH, CPHRM
T
he human element is a key factor in cyber and computer network operations, and it is the most unpredictable factor in cybersecurity. Patient records contain a wealth of personal information, and many hackers have learned to trick unsuspecting health care employees into helping them plan and execute their data breaches through “social engineering,” defined in information security terms as the art of using influence or manipulation to trick targets into giving up confidential information or access to an organization. Cybercriminals will often use social engineering tactics as a first step in gaining access to privileged information because it is generally easier to exploit human weaknesses than to breach network or software vulnerabilities.
Blockchain technology The future of medical innovation
According to the 2016 Healthcare Industry Cybersecurity Report (Information Security Media Group), health care ranks 15th out of 18 industries in social engineering. This is a clear reflection of the vulnerability of health care organizations to Social engineering to page 144
BY DAVID R. BROWN, MD, FACE; JOEY WILSON, MS; CHARLIE HU, MSC; AND DOUGLAS CORLEY, BSC
D
igital finance is a rapidly evolving, disruptive technology incorporating elements effective for large-scale transactions in a globally integrated economy. The health care arena is particularly conducive to the concepts of “cryptocurrencies” such as bitcoin and the underlying technology of blockchain as an economic, integrative, and data management technology. Within clinical medicine, blockchain applications could address innovative—yet highly expensive—new therapies, unleashing potential advantages and creative economic opportunities. Large-scale financing of biomedical companies, drug development, genomic technologies, and molecular-based precision Blockchain technology to page 104
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New Location. Efficient Space. Medical Neighborhood. Optimal Care. We focus exclusively on healthcare real estate and have a number of space options that may be right for you. We help your practice design space that works for you and your patients. Our healthcare team has proven results and will guide you through the process of getting the right space for your practice. Leased By:
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JANUARY 2019 MINNESOTA PHYSICIAN
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JANUARY 2019
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Volume XXXII, Number 10
COVER FEATURES Blockchain technology
Social engineering
By David R. Brown, MD, FACE; Joey Wilson, MS; Charlie Hu, MSc; and Douglas Corley, BSc
By Ginny Adams, RN, BSN, MPH, CPHRM
The future of medical innovation
Is your practice prepared?
DEPARTMENTS CAPSULES
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MEDICUS
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INTERVIEW
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A trusted voice to create positive change Rose Roach Minnesota Nurses Association (MNA)
HEALTH CARE POLICY 16 The 2019 Minnesota legislative preview
PHYSICIAN-PATIENT COMMUNICATION 18 Surviving a stroke
SOCIAL DISPARITIES IN HEALTH CARE Correcting the curve
Lessons learned from being a patient By Michelle D. Sherman, PhD, LP, ABPP; and LuAnn Kibira, APRN, NP
Thursday, April 25, 2019, 1–4 p.m.
MEDICINE AND THE LAW 30 Physician employment agreements
BACKGROUND AND FOCUS:
Understanding assignment provisions
The Gallery, Hilton Minneapolis | 1101 Marquette Avenue South
Examining cost and quality issues
Astonishing advances in medical science are coming more quickly than they can be incorporated into best practice. Unfortunately, another area of rapid advance involves social disparities. Social and economic factors can account for the greatest single element of being healthy. Whether we call it health equity, health inequity, social disparity, health disparity, or any related term, matters of race, age, disability, sexual orientation, geography, and economics create barriers to care with measurable negative downstream consequences. The number of people who are suffering and dying needlessly is growing and in five years projects as a major epidemic.
PROFESSIONAL UPDATE:
OBJECTIVES:
Heartburn 32
To solve any problem we must first understand the question, and we will start by defining the terms. We will examine the reasons certain populations are alienated and discouraged by our health care delivery system. We will share some of the extensive work that has been done to address these issues and discuss why it is not being implemented. We will discuss the role that every health care industry sector plays in creating these disparities and ways they can work together to correct them.
By Antonio “Tony” Fricano, JD
Deadlock is not an option By Tom Hanson, JD, and John Reich
MINNESOTA HEALTH CARE ROUNDTABLE Consolidation in Health care 20
Individualizing diagnosis and treatment By Kourtney Kemp, MD, FACS
PANELISTS INCLUDE: Julia Joseph-Di Caprio, MD, Chief Medical Officer, UCare
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Jonathan Watson, MPIA, CEO Minnesota Association of Community Health Centers SPONSORED BY:
ASSOCIATE EDITOR_________________________ Amanda Marlow, amarlow@mppub.com ART DIRECTOR_______________________________________________Scotty Town, stown@mppub.com ACCOUNT EXECUTIVE_______________________________ Shawn Boyd, sboyd@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; email mpp@mppub.com; phone 612.728.8600; fax 612.728.8601. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.
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Mayo’s Alden And Kiester Locations To Close January 25 Mayo Clinic Health System has made the decision to close its clinics in Alden and Kiester in Southeast Minnesota effective Friday, January 25. The health system said in a press release that they reached the conclusion that they were not able to staff the two clinics at a level that will provide proper clinical care. “This decision was not made lightly as we understand how and where people receive health care is a very important issue,” said Jay Mitchell, MD, chair of outpatient practice for Mayo Clinic Health System’s Southeast Minnesota region. “We listened to community concerns and pursued several options. With patient data showing that more than half of the patients using the Alden and Kiester clinics come from other communities, as well as less than 10
patients being seen on any given day at either clinic, we believe patients’ health care needs will be better served in other nearby clinic locations in Lake Mills, New Richland, Wells, and Albert Lea.” The move follows Mayo Clinic’s announcement in October that due to staffing challenges, it would reduce services at the two clinics to one day a week from November through the end of 2018, after which there would not be a prescribing provider on site in either clinic. Community meetings were held with city and community leaders in both locations to discuss the challenges of rural health care and gain insight as to what level of care is needed. Mayo Clinic says the decision continues to reflect ongoing issues affecting rural health care, including recruitment of providers. The two clinics used the one day a week they were open in January to provide education to local
patients and community members on how to access care in other ways.
Report Shows Financial Health of Minnesota Hospitals and Health Systems The Minnesota Hospital Association (MHA) has released its third annual report examining the financial health of Minnesota’s hospitals and health systems. It analyzes publicly available data from fiscal year 2017 (the most recent available) that hospitals and health systems are required to submit to the Minnesota Department of Health annually. According to MHA, a hospital’s operating margin is the most recognizable bottom-line measure of whether it can continue to meet patient and community needs. Overall, hospitals’ operating margins improved in 2017. The trend of overall median hospital operating margin in
Minnesota has remained steady in the state at just over 2 percent since 2013, but the statewide operating median operating margin moved to 2.3 percent in 2017. Fifty-six of the state’s hospitals and health systems in the report generated positive margins in 2017, but MHA noted that 26 hospitals (31 percent of hospitals and health systems in Minnesota) experienced negative operating margins. That number is down from the previous year—29 showed negative operating margins in 2016. MHA notes that historically, Minnesota’s urban hospitals have had higher margins than those in rural areas. However, that gap is narrowing. The median operating margin for urban hospitals was 2.8 percent, down from 3 percent in 2016. For rural hospitals, the median operating margin was 2.1 percent, up from 2 percent in 2016. The full report is available on the MHA website.
V Autism and Obstructive sleep apnea are now approved conditions V
HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS
• Inflammatory bowel disease, including Crohn’s disease
• Seizures, including those characteristic of Epilepsy
• Terminal illness, with a probable life expectancy of less than one year
• Severe and persistent muscle spasms, including those characteristic of MS
• Intractable Pain
• Obstructive sleep apnea
• Autism
• Post-Traumatic Stress Disorder
Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.
OFFICE OF MEDICAL CANNABIS (651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us
Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.
See our website for a detailed first year report. mn.gov/medicalcannabis
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JANUARY 2019 MINNESOTA PHYSICIAN
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Gillette Foundation Receives Grant to Expand Spine Program The Fred C. and Katherine B. Andersen Foundation has awarded the Gillette Foundation a five-year grant to expand Gillette Children’s Specialty Healthcare’s spine program. It is the largest grant Gillette Foundation has ever received. The funds will be used to grow the spine program from a regional center of clinical care to a national pediatric spine institute focused on high-quality clinical care, research, and education. Currently, Gillette has the only spine program in the state skilled at treating all types of spinal curvature including scoliosis and kyphosis. They treat 3,500 patients each year who have scoliosis and provide 80 percent of spine surgeries for children in Minnesota age 14 and younger.
UMN Names Cambridge Medical Center as MMCORC Affiliate Site Cambridge Medical Center (CMC) has received a two-year grant from the University of Minnesota to increase the availability of clinical trials in Minnesota communities. The center is now an affiliate site for the Metro-Minnesota Community Oncology Research Consortium (MMCORC), which works with hospitals and clinics across the metro area so local physicians have access to the newest advances in cancer research and links community cancer specialists, primary care physicians, and other health care professionals to NCI-approved research studies. “The CMC oncology team has offered clinical trials since 2014 when CMC became accredited by the Commission on Cancer Center, which requires that a certain percentage of patients diagnosed with cancer at CMC are placed on a clinical trial,” said Gary Shaw, president of
Cambridge Medical Center. “Becoming an affiliate site for MMCORC will help our team connect even more patients with opportunities to participate in clinical trials.” Arvind Vemula, MD, an oncologist and hematologist at CMC, will be the senior research investigator on the project. He has an extensive research background and previously served as the director of clinical trials and research at North Iowa Mercy Cancer Center. According to CMC officials, they have a high population of patients who have financial challenges and many need assistance to pay for treatment. They hope that working with the MMCORC through this grant will provide more treatment options to patients that likely wouldn’t have been able to consider advanced care outside of their community.
Sanford Health Joins Civica Rx Sanford Health has joined 11 other health systems as new founding members of Civica Rx, a not-forprofit generic drug company that will address shortages and high prices of lifesaving medications. It was established in September by seven health systems and three philanthropies, including Mayo Clinic. Together, the 12 founding health systems represent about 300 hospitals across the U.S. When combined with hospitals represented by the initial governing members, about 800 hospitals have joined the venture so far. “Drug shortages have become a national crisis where patient treatments and surgeries are canceled, delayed, or suboptimal,” said Martin VanTrieste, CEO of Civica Rx. “We thank these organizations for joining us to make essential generic medicines accessible and affordable in hospitals across the country.” Civica Rx is working toward becoming an FDA-approved manufacturer, and will either directly
COMMUNITY C AREGIVERS REQUEST FOR NOMINATION Publication Date: April 2019
Recognizing Minnesota physician volunteers Minnesota Physician Publishing announces our annual Community Caregivers feature. We are seeking nominations of Minnesota physicians who have volunteered medical services in communities in Minnesota, in the U.S., or abroad. The nominees selected for recognition will be featured in the April 2019 edition of Minnesota Physician, the region’s most widely read medical publication. To qualify, nominees should be physicians practicing in Minnesota who have performed medical services, either locally or abroad, during 2018. Both teams and individual physicians may be nominated; if the nomination is for a team, please designate one or two physicians who could fill out a questionnaire if selected for the feature. To nominate a physician or team of physicians, please fill out the nomination form at www.mppub.com/community-care-givers.html or mail the form below by February 22, 2019.
I would like to nominate the following physician(s): Name and location of physician’s practice: Physician’s contact info (email and phone): What country/state/city did the volunteer service take place?
Brief description of the physician’s medical volunteer service:
Nomination submitted by: Phone #: Email: Send to: Minnesota Physician Publishing: Community Caregivers 2812 East 26th Street, Minneapolis, MN 55406 Online form: www.mppub.com/community-care-givers.html Fax: 612.728.8601 Email: rericson@mppub.com For more information, call 612.728.8600
www.mppub.com
MINNESOTA PHYSICIAN JANUARY 2019
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CAPSULES
manufacture generic drugs or subcontract manufacturing to reputable partners. It has identified 14 hospital-administered generic drugs that are the initial focus of its efforts, and expects to have its first products on the market as early as mid-2019.
Telemedicine Visits Rose and Evolved Different Uses for Metro And Non-Metro Patients According to results of a study from the Minnesota Department of Health and the University of Minnesota School of Public Health, Minnesota had a nearly seven-fold increase in telemedicine visits between 2010 and 2015, from 11,113 to 86,238. The researchers analyzed data from the Minnesota All Payer Claims Database to determine patterns of telemedicine use. They did
not look into the effectiveness of telemedicine, but discovered a rapid increase in its use. Though less than 1 percent of patients use telemedicine, the researchers found that it has evolved to serve somewhat different uses for metro area and Greater Minnesota patients and for those with private or public insurance. Non-metro patients in Greater Minnesota more commonly used telemedicine for real-time visits initiated by providers and included specialty consultations. In metropolitan areas, including the Twin Cities, Rochester, St. Cloud, and Duluth areas, the majority of telemedicine services were online evaluation visits for primary care provided by nurse practitioners to patients with commercial insurance. A greater number of telemedicine users lived in metro areas, however the rate for telemedicine use was higher in non-metro areas for people with Medicare and Medicaid.
“This research shows that telemedicine may be emerging as an option to overcome some of the geographical barriers of accessing specialty care in Greater Minnesota, particularly in the area of mental health,” said Jan Malcolm, Minnesota commissioner of health. “We need more research to ensure quality is being maintained, but this study highlights the importance of seeking innovative ways to provide access to health care in Greater Minnesota, including thinking broadly about funding investments in the health care workforce, as well as technology such as telemedicine equipment and broadband access.” According to the researchers, the data also indicate that Minnesota’s telemedicine market during that period was shaped in part by differences in telemedicine coverage by insurance plans rather than
the differing clinical needs of patients—for example, there was very low direct-to-consumer use among Medicaid patients. During the study period, commercial plans increasingly covered patient-initiated online medical evaluations, while Medicare and Medicaid primarily covered the real-time consultations with clinicians. At the end of the study period in 2015, the Minnesota Telemedicine Act was passed that required private insurers and Minnesota Health Care Programs to provide the same coverage for telemedicine as in-person visits and removed requirements for a previous in-person visit. The researchers are continuing to analyze telemedicine data and are studying the impact of telemedicine visits on follow-up costs, utilization, and quality of care.
SMART COLON CHOICE CARE ISFOR AN COLON EXPERIENCE THE SMARTEST CARE. THEY’LL REMEMBER. BUT THEN, YOUNEVER PROBABLY KNEW THAT. M N G A S T R O S M A R T FA C T:
OUR POLYP DETECTION RATE IS 200% OF THE NATIONAL QUALITY BENCHMARKS. 95% of cancers in the colon begin as adenomatous polyps. We find more polyps, provide an unrivaled clinical experience and expertise, and offer kind, respectful patient care. Don’t your patients deserve the best quality when it comes to colon care? Refer your patients to MN Gastroenterology today by using our secure online Referral Site at https://referrals.mngastro.com or by calling 612-870-5400.
THE SMARTEST CHOICE IN COLON CARE.
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JANUARY 2019 MINNESOTA PHYSICIAN
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MEDICUS
Osmo Vänskä /// Music Director
Robert M. Jacobson, MD, professor of pediatrics in the Mayo Clinic College of Medicine and pediatrician in the Mayo Clinic Department of Pediatric and Adolescent Medicine, has received Minnesota’s 2018 HPV Vaccine is Cancer Prevention Champion Award, which is led jointly by the CDC, the Association of American Cancer Institutes, and the American Cancer Society. According to the Minnesota Department of Health, uptake of the vaccine, which is recommended for adolescents at age 11-12, has lagged far behind the other recommended vaccines for the age group—only about 19.5 percent of 13to 15- year-olds have completed the recommended HPV vaccine series in Minnesota. However, among Jacobson’s patients ages 13-15 seen in the last 24 months, 71.2 percent have completed the HPV vaccine series. Since the vaccine was introduced in 2006, Jacobson has worked to help improve rates by giving trainings and presentations to colleagues on how to strongly recommend the vaccine and have conversations with vaccine-hesitant parents; leading Mayo Clinic’s efforts to train pediatric residents in addressing vaccine hesitancy using a simulation training so they can practice conversations with parents; and serving on workgroups and advisory committees to advance best vaccination practices. Jacobson earned his medical degree at the University of Chicago.
Julian Bliss
Karen Gomyo
David Beckmann, MD, has been hired as District One Hospital’s first dedicated hospitalist, where his primary professional focus is the general medical care of hospitalized patients. Beckmann is an experienced physician with decades of clinical practice. He began at the Faribault Clinic after his residency in 1987 and has practiced internal medicine in Faribault in the clinic and hospital for 31 years. He earned his medical degree at Mayo Medical School.
Roma Duncan
Jane Glover
Ali Salavati, MD, MPH, a resident in the University of Minnesota Medical School’s department of radiology, has received a 2018 RSNA Trainee Research Prize from the Radiological Society of North America (RSNA). Salavati received the award for his research titled, “Detection Rate of 18F-FACBE (Fluciclovine) PET/CT Scan as a Function of Prostatic Specific Antigen (PSA) Level: Initial Experience of 76 Patients with Biochemically Recurrent Prostate Cancer.” Each subcommittee of the program committee may award three prizes each year—one prize for the best paper or scientific poster submitted by a resident or physics trainee, one prize for the best paper or poster submitted by a fellow, and one prize for the best paper or poster submitted by a medical student. The Trainee Research Prize consists of $1,000 and a certificate indicating the name of the trainee and the title of the paper or poster.
Bizet, Mozart and Vivaldi Thu Jan 31 11am / Fri Feb 1 8pm SYMPHONY IN 60
Bizet, Ravel and Vivaldi Sat Feb 2 6:15pm & 8pm
Two 60-minute concerts to choose from!
Beethoven and Strauss
Thu Feb 7 11am / Fri Feb 8 & Sat Feb 9 8pm INSIDE THE CLASSICS
Stravinsky’s Petrushka Sat Feb 16 8pm
Julian Bliss Septet: Gershwin and Tin Pan Alley Sun Feb 17 2pm
Mozart’s Double Piano Concerto Fri Feb 22 & Sat Feb 23 8pm
612-371-5656 / minnesotaorchestra.org Orchestra Hall / #mnorch PHOTOS Duncan: Travis Anderson Photo. Other photo credits available online.
MINNESOTA PHYSICIAN JANUARY 2019
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INTERVIEW
A trusted voice to create positive change Rose Roach Minnesota Nurses Association (MNA) MNA has successfully grown and adapted to the needs of its members as health care delivery evolves. What are some examples?
Health care technology is one such change, but MNA nurses have legally binding contracts with language that provides a voice for nurses to ensure that technology does not impact patient care. One example would be the use of acuity tools to help determine patient staffing needs and basic charting through systems such as Epic. Nurses believe, however—in their professional, “hands-on” judgment related to patient care—that more time spent at the computer rather than at the bedside puts both patients and the nursing profession at risk.
a specific number of patients to care for during their shift. As science and technology continue to make advancements, people live longer. Inevitably, people in our hospitals are much sicker than they ever used to be. Patients have surgery and are
Nurses are also very focused on protecting patients, hospital staff, and themselves from the violence that has become a daily occurrence at hospitals. Nurses are constantly pushing hospitals to increase security, implement de-escalation training for employees while tracking violent occurrences, and involve RNs in the discussion of solutions to prevent workplace violence.
Another recent attempt by hospitals to save money is through the implementation of “Lean” management initiatives. Nurses have used their collective voices to ensure that such initiatives do not come at the expense of patients.
Right-to-work laws and the lobby around them pose serious problems. What can you tell us about this?
You advocate for single-payer health care. What can you share with us about this?
We are penny-wise and pound-foolish in this country when it comes to health care. We blame the diabetic for struggling to take their insulin when the price of insulin has risen 3,000 percent, but we never hold the pharmaceutical companies accountable for the deaths they cause due to diabetic ketoacidosis. It costs $15,000 per day for an intubated diabetic in the ICU because he or she couldn’t afford the $700 per month insulin. None of us should die sooner than we’re supposed to simply because we couldn’t afford the care we need when we need it.
“...” We are penny-wise and pound-foolish in this country when it comes to health care. “...”
Every one of us needs, or will need, health care. Instituting barriers to care through narrow networks, high deductibles, and co-pays is immoral, inhumane, and financially irresponsible. Health care is not a consumable good. It’s a public good. We don’t notice that chemotherapy is on sale and then try to get cancer to take advantage of the discounted price.
issue is to achieve proper staffing levels based on their judgment of the acuity needs of their patient. Nothing concerns nurses more than when they have so many patients requiring attention that they are forced to “prioritize” based on severity of medical need at a given moment.
discharged on the same day. Nurses are expected to keep working faster, regardless of what the patient needs. Nurses have a legal, ethical, and moral obligation to not accept more patients than they can reasonably care for at one time. Patients are in the hospital because they need nursing care; otherwise, they would be outpatient.
MNA believes in the workers’ right to organize a union and collectively bargain a contract. We oppose any efforts to silence employees’ collective voices in their workplace, including the anti-union effort to make Minnesota a “right-to-work” state. We work alongside our brothers and sisters in the AFL-CIO unions to make sure that any attempts to make Minnesota a right-to-work state are defeated. With the ongoing consolidation of health care and an increasing number of physicians becoming employees, what benefits might be gained if physicians unionized?
They would gain power. The only way to deal with the industry’s push to take the patient’s needs out of the center of the health care system is for providers to come together in solidarity to fight for their respective professions and patients. Physicians, like nurses, are experiencing severe burnout as corporations dictate care overriding physicians’ professional assessments. Physicians would once again have a say in the treatment of their patients and in their profession.
Staffing ratios are a key priority for the MNA. Please tell us about these issues.
In addition to being a professional association, the MNA is also a labor union. What are some of your labor issues?
What are some of the legislative issues that the MNA will focus on this coming session?
Nurses have to care for too many patients at one time. Nurses on every patient unit are assigned
Nurses uniquely use the collective bargaining process for patient advocacy. Their number one
MNA is in the process of putting together its legislative agenda for the 2019 session.
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JANUARY 2019 MINNESOTA PHYSICIAN
Issues that may come up at the Capitol in 2019 include: ensuring there is a funding source for MinnesotaCare, to replace the provider tax that is slated to sunset on Jan. 1, 2020; expanding MinnesotaCare so that more people can buy into it; strengthening workplace violence prevention laws; addressing gun violence prevention initiatives; and dealing with the rising cost of prescription drugs. The roles of advanced practice providers and care teams continue to expand. From a nursing perspective, how could interactions with physicians be improved?
Mutual respect is the key word, even though physician organizations’ oppositions to expansion of scope of practice for advanced practice registered nurses (APRNs) remains a significant obstacle. In addition, we believe that: Collaboration and team approaches are the only ways that physicians and APRNs can provide safe, quality care to patients and the community. APRNs should be allowed to practice to the full extent of their education. The profession should understand that APRNs are not taking over physician jobs, but
are filling the gaps in the health care needs and shortages of primary care providers. The Institute of Medicine states that it is imperative that all health professionals practice to the full extent of their education and training to optimize the efficiency and quality of services for patients. The term “independent practice” for APRNs has become a charged term for some physician groups, which view it as implying solo or competitive practice. MNA operates a booth at the Minnesota State Fair. What stories can you share?
The fair gives nurses a chance to talk directly to patients about health care issues. We’re building a community of patients who want to help us tackle these issues together. At one recent fair, a man wearing a National Rifle Association patch wanted to talk to a nurse about health care and the rising costs and declining care. He ended up signing our petition and joining our mailing list of single-payer advocates. That kind of story tells us that we’re all hurting from the state of health care, and that nurses are a trusted voice to create positive change.
What new ways can nurses and physicians partner together?
Nurses should be instrumental in the development of collaborative teams. Having the right people on a collaborative team for process improvement in patient care is critical to a successful improvement effort. Nurses should have a strong voice on health care teams that seek to build a better process of communication. Open communication between leadership and nurses, and mutual support of the health care team, are certainly in the best interest of patient care. Nurses would advocate for a team environment that increases open, nonjudgmental communications, and would participate in a health care-driven team approach designed to improve patient care. Rose Roach is the executive director of the Minnesota Nurses Association. She has also served on Gov. Mark Dayton’s Task Force on Health Care Financing and the City of St. Paul’s Earned Safe and Sick Time Task Force. She attended Metro State University in St. Paul and Inver Hills Community College in Inver Grove Heights.
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3Blockchain technology from cover medicine will be greatly enhanced and accelerated by the opportunities and advantages of blockchain technologies and Initial Coin Offerings (ICOs) of cryptocurrencies.
A blockchain primer This revolutionary technology is currently disrupting whole industries, offering unparalleled levels of both hope and hype. Simply referring to blockchain can skyrocket valuations of a company; Long Island Iced Tea, now Long Blockchain Corp., increased 500 percent in one day. The largely unregulated and dynamic blockchain industry currently holds a market valuation of around $250 billion. (U.S. individuals or businesses that use virtual currencies to pay for goods or services, sell or exchange them, or hold them as an investment may incur tax liability.)
to record not just financial transactions, but literally everything of value,” according to Don and Alex Tapscott, authors of “Blockchain Revolution.” It provides an unalterable, distributed ledger system that may be used for the tracking of any sort of “transaction” across systems. Users—individuals, governments, companies, or a combination of actors—can see the past and present conditions of whatever they are tracking without the need for “independent” verification by an intermediary. Further, this information is independently verified by an additional layer of processes.
Blockchain approaches are highly applicable to the current realities and needs of precision medicine.
But blockchain is about much more than the financial world. Blockchain may seem abstract, but it is tangible and easily applied to solve numerous problems. The point of blockchain is simplified, efficient, and secure data storage. At a micro level, a blockchain is simply a series of “blocks” linked together, thus forming a “chain.” A block is generally a data container that holds a record of recent “transactions” and a reference to the block before it. These blocks of information are then validated, linked to the other blocks, and put on the public ledger—the “blockchain.” From a macro lens, it is “an incorruptible digital ledger of economic transactions that can be programmed
When combined with artificial intelligence (AI) and Internet of Things (IoT) devices, blockchain provides a thorough and effective analytic system that is unparalleled in comparison to other current technologies. Each element works together to integrate systems, collect and analyze information, and make decisions. Blockchain technology is decentralized, trustless/peer-to-peer, immutable, and transparent.
The core of the distribution ledger technology, which underpins blockchain in the broadest context, is that it induces trust between parties, in the absence of a central core such as government. This is accomplished by ensuring that information cannot be unilaterally altered nor manipulated. Once smart contracts are added to the equation, which are already being given recognition by the courts, these trustless systems offer unparalleled capacity for parties to engage with each other with minimal interaction or prior connection.
Cryptocurrencies People frequently conflate and/or confuse blockchain and cryptocurrencies. Bitcoin, perhaps the most commonly known cryptocurrency, utilizes blockchain technology and can be thought of as a blockchain application. Consider blockchain as the base technology, and cryptocurrency as the tokenized, monetized entity that is used to pay for and power the infrastructure of the overall network, incentivize users to employ a specific network, and play a role in transaction validation based upon governance structure. The creator of bitcoin, an anonymous user known only as Satoshi Nakamoto, announced the release of an “electronic cash system that uses a peer-to-peer network to prevent double spending” in late 2008. With this, Satoshi created a digital currency. Unlike the U.S. dollar, bitcoin does not depend on a central authority for governance. It relies instead on mathematics and cryptography to encode and thus enforce its rules, creating a trustless system that is recorded on a decentralized blockchain ledger. People also frequently mistake bitcoin with Ethereum, a separate dominating cryptocurrency that serves very different functions. Bitcoin can be thought of as a stable commodity like gold, a store of value. Ethereum currency—Ether—is a commodity like oil or gas, a usable fuel that powers processes. When you buy Ether, you are in theory buying computational power on its platform to run programs and complete processes, such as smart contracts, as well as decentralized applications (dApps).
Blockchain “contracts” Ether is the “what” or the currency that enables you to get things done, and smart contracts are the “how” or the means by which things get done. Smart contracts enable the direct and almost instantaneous payment for services upon their completion. Contracts may be written with terms
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services upon their completion. Contracts may be written with terms that are met and validated in real time, until the fulfillment takes place and the pre-decided transaction completed. Using the Ethereum platform, programmers can create their own dApps and projects that run on their own currency. Thus, you can view the Ethereum platform like the internet, and dApps as websites that run within the framework. dApps frequently utilize their own tokens, further increasing simplicity and integration as well as token-specificity, accounting for execution of specific commands within smart contracts. These commands are defined by the Ethereum-20 token governance protocol, which applies to specific dApps and their functionality. Tokens, whether on the bitcoin platform or created independently, are sometimes also referred to as “altcoins.” In fact, all non-bitcoin cryptocurrencies are generally classified as an alternative coin or an “altcoin.” Altcoins have varying purposes. Altcoins range from “joke coins” like Dogecoin to coins with real world applications, such as Ripple, a coin designed for money settlement and remittance payment. Tokens also allow blockchain companies to finance in a completely new way. ICOs have taken the space by storm—jointly bringing in over $6.8 billion in 2017. They are known as the cryptocurrency variant of crowdfunding, and they operate in a similar manner. ICOs allow blockchain companies to raise money efficiently and effectively for projects (usually in bitcoin or Ethereum, which offer liquidity) from investors who get tokens from the platform in exchange. These tokens are not equivalent to equity, but still offer potential for strong short- and long-term return on investment. On the other hand, these investments are highly speculative and carry a higher risk profile. Because of the regulatory inaction as of yet (which may soon change), as well as regulatory uncertainty (as ICOs span national borders), there are few laws to protect consumers from bad ICOs. In fact, current regulation leaves room for ICOs to get around barriers to entry by labeling themselves as “crowdsales” or “donations,” even if this designation does not reflect reality. There have been recent talks about labeling various cryptocurrencies as securities and requiring ICOs to register with the U.S. Securities and Exchange Commission (SEC). This has been put on hold, however, and, even if done, not all ICOs (as defined by functionality) would be categorized as an investment in a security. In every case, investors must conduct thorough due diligence and tread carefully. Many use-cases for blockchain projects exist; however, some of the most promising use-cases on the horizon are in the field of medicine and health care.
Precision medicine and why it should be on the blockchain Blockchain opportunities in the clinical setting focus on rapidly advancing yet expensive diagnostics and precise therapeutics not currently integrated into third-party private or public reimbursement programs. Health insurance has not prepared for the economic implications of advanced stem cell (iPSC) therapies, CAR-T cell applications, and the introduction of molecular medicine developments involving gene editing technologies such as CRISPR and TALENs. In many cases, costs are several hundred thousand dollars per treatment and exceed available patient resources. Genomic diagnostics and multiomic-based precision medicine involving potentially thousands of biomarkers (genomic, proteomic, metabolomic, epigenomic, and microbiomic) also may not be covered by traditional financial reimbursement schema.
The advent of genome editing treatments for degenerative neurologic diseases (Huntington’s, Parkinson’s), various forms of dementia, single-gene Mendelian disorders, and individualized molecular and cellular cancer therapies will further challenge current financial mechanisms for health care reimbursement. Current approaches to health care costs impact the introduction and development of innovative clinical advances—and blockchain could help. New concepts of cost sharing, peer-to-peer economics, and blockchain approaches are highly applicable to the current realities and needs of precision medicine. Many of these technologies are emerging from the private sector, which needs innovative financial investment, increased data security, and verification tools. These will also generate new applications of blockchain to address the issues of cost containment, and allow the intrinsic value of their data to underwrite cost reductions for their products. One potential example would be long-term, multi-patient clinical research studies involving complex, multifactor studies of newborn infants, followed over many years to identify and characterize the determinants and financial challenges of adult-onset disorders. Clinical implementation of these advanced procedures will, by necessity, require a global effort incorporating private and public sector advancements in ways that previous medical endeavors have not. Blockchain is particularly applicable to this aspect of development, incorporating financial realities with the required data security and verification elements. Blockchain technology to page 124
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3Blockchain technology from page 11
are integrated so that whenever users make the decision to sell their data, payment is instant, as is the transfer of data to the end-user, creating a win-win for researchers and individuals alike. The lowered sequencing costs and benefits will incentivize more people to sequence their genome, thereby cyclically growing the data marketplace. Comprehensive datasets are created anonymously through smart surveying tools and AI.
One particularly interesting example that addresses many aforementioned concerns comes in Nebula Genomics, which is in the realm of genomic sequencing. Companies like 23andMe and Ancestry. com offer well-marketed, popularized genetic data services for individuals; however, they are encountering worrisome problems, more specifically related to sequencing costs, data protection, data acquisition, and the memory cost of genomic “big Each year, 800,000 people die data.” With these challenges in mind, Nebula worldwide due to complications Genomics is innovating and enabling the enhanced from taking counterfeit drugs. commercialization of genomic sequencing. How? It all involves their nebula token economy. Through token incentives and pay schemes, individuals will have their genomic data subsidized by buyers in the research or pharmaceutical industries, lowering the cost of sequencing. In fact, after some time, individuals should actually be able to make money from their data through this licensing process. The data is safe because of memory-efficient encryption, which minimizes the data footprint while keeping it secure, accessible, and available; further, the system will keep sellers anonymous while making buyers completely transparent. Individuals have complete control over who can use their data and how they can use it, so they have peace of mind. Blockchain smart contracts
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Blockchain could be used in many instances across the clinical care cycle to solve issues ranging from data access to data security to product verification/reliability and more. One of the most intuitive (and thus most common and wide-ranging) health care applications relates to digitizing and sharing of health records. Currently, patients’ health records are fragmented across the health care system; further, even if effectively shared, data hygiene is a consistent problem due to frequent changes to patient identifiers (e.g. name, address, insurance policy). If comprehensive, quickly accessible health records were available, effective health care provision for everyone, from doctors to insurance companies, would increase exponentially. Blockchain solutions aim to create a Master Patient Index (MPI) that could safely and securely enable the sharing of health information in a streamlined system, even enabling patients to set “permissions settings” for their data. You could let a designee have access to your entire file, while ensuring your ophthalmologist wouldn’t be able to access your sexual health history. An MPI that includes one’s genomic data provides many possibilities for patients. One example is the option to sell one’s genomic data (or demographic, fitness, nutrition, or innumerable other kinds of personal data) for scientific research or other purposes. This could help solve the massive patient recruitment and retention problem impacting clinical trials: over 50 percent of trials are delayed, 30 percent of successfully recruited patients drop off, and 85 percent fail to retain enough patients to continue. Further, for trials that do complete, 80 percent are delayed by at least one month. At an estimated cost anywhere from $600,000 to $8 million per day for trials, the waste of time and money is substantial. Genomic data, quickly available, could help identify patients who not only qualify for clinical trials, but would benefit from participation. Genomic information could also enable machine learning applications that use these diverse, wide-ranging data sets to show the positive or negative health impacts of specific behaviors, genomic traits, biomarkers, or other personal identifiers. This, in turn, would allow doctors and patients to attempt to alter behaviors for positive health outcomes or to monitor certain aspects of their health that appear to be at risk. One example of this is related to precision medicine, an emerging field that combines robust and comprehensive data sets of multiple natures over a patient’s life-cycle to determine likely health risks and outcomes. However, the personal sale of genomic data raises some ethical concerns—and requires further verification within service providers’ dAPPs to ensure that people do not provide untrue information to attempt to make their own data more valuable. The use of blockchain to minimize and eliminate fraud is also promising. Each year, 800,000 people die worldwide due to complications from taking counterfeit drugs. The pharmaceutical industry suffers an
fake drugs. Blockchain has already been widely used across the supply chain to verify everything from designer handbags to luxury alcohol brands, so its use in verifying manufacturing materials, date, and location is certainly possible. The Chronicled Smart Supply Chain Platform has teamed up with The LinkLab to work on the MediLedger Project. This project was designed to comply with the U.S. Drug Supply Chain Security Act and GS1 Standards, while also being interoperable for the most efficient and effective practical application in the pharmaceutical industry. It aims to improve the track-and-trace capabilities for prescription medicines, from raw materials sourced and used to temperature during drug transport to countless other aspects across the supply chain. Supply chain components that were once unlinkable can now be connected. The open network allows full privacy and protection of business intelligence, while still allowing for the necessary levels of verification and reporting across the supply chain. For the end user, it allows identity provisioning, app-based verification, and counterfeit product fraud reporting integrated with law enforcement. Also related to fraud is billing and claims for health insurance. Smart contracts could be instated that automatically link satisfactory completion of a procedure with billing to create a seamless transaction for clinics and patients. Further, blockchain could be used to double-verify patients’ treatments in clinics to ensure insurance claims are both real and accurate. Blockchain-based double verification would help insurance companies verify claims and ensure that patients and care providers are on the same page before bills come back in the mail. SimplyVital Health is a company that is already doing this. They are seeking to increase the level of security and transparency throughout the entire clinical cycle of care. More specifically, SimplyVital Health is challenging the status quo of the reimbursement and billing process. ConnectingCare centralizes different medical organizations onto a single platform. Here, records are shared across the network for shared patients, enabling better communication and more synergistic collaboration for treatment. Further, embedded algorithms utilizing AI analyze financial and clinical data to provide actionable suggestions for treatment to optimize cost and patient outcomes in real time.
decentralized markets, and a critical need for transformation of capital services. In addition, rapid accumulation of digital content, data storage limitations, data verification and security issues, developments in AI applications for clinical medicine, and rapidly evolving legal and ethical issues regarding emerging biotechnologies all make blockchain-based technologies exciting opportunities to address challenging issues effectively and concurrently. David R. Brown, MD, FACE, is senior vice president of biomedical innovation at DHB Global.
Joey Wilson, MS Tsinghua University (global affairs), is a DPhil candidate at Cambridge University (Oncology).
Charlie Hu, MSc Neyrode Business Universiteit (financial management), is Chinese blockchain advisor and cofounder of the DAOONE Blockchain Community.
Douglas Corley, BSc Creighton University (biological sciences), is CEO of DHB Global.
The idea is that providers both can and must work together to minimize cost and duration of care for the patient. For example, in the modern context, orthopedic surgeons and physical therapists are relatively disconnected, resulting in wasted money and time for both patients and the entire health care system. The ConnectingCare system aims to prevent that by tying reimbursement to variables like patient outcomes and cost, as well as interoperability and coordination between providers, monitored by an audit trail. Thus, the system drives providers to collaborate in the patient’s best interest and focus on results and patient follow-up. Further, by examining the patients’ treatment and results, the system can suggest beneficial paths of treatments for the same individual and other individuals thereafter. Interestingly, another SimplyVital Health product, the HealthNexus data validation and governance protocol, which utilizes Ethereum’s system to safely share health data, is the first health care blockchain protocol to be HIPPA-compliant.
Summing up Health care finance and innovation implementation are facing an economic paralysis as a consequence of factors such as accelerating technological advancement, population growth, governmental and regulatory changes, MINNESOTA PHYSICIAN JANUARY 2019
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3Social engineering from cover
demands to know why. Acting rushed and annoyed, he demands immediate access to the system.
this type of breach. That same report said that data breaches occurred in 85 percent of large health care organizations’ systems in 2014. Social engineering depends on human inclinations toward trust, curiosity, and empathy. One of the reasons that social engineers love health care employees is their natural tendency to be trusting and their desire to be helpful. The complexity of most health care organization structures, networks, and systems is also an advantage to social engineers.
Phishing and spear-phishing Embracing change is not optional, it’s a requirement to survival.
One form of social engineering that allows cybercriminals to physically gain entrance is called tailgating. Here are some common scenarios: 1. A social engineer flashes a fake ID at the front desk. He says he is there to fix an internet problem and the IT department sent him down. He is led to the router and is able to install malware onto the entire health care network. 2. A social engineer shows up at the employee entrance with an armful of pizza boxes. A helpful employee holds the door open for him and he has gained access to non-public areas. 3. A social engineer calls in posing as an assistant to a high profile physician. His boss is having problems accessing the system and he
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JANUARY 2019 MINNESOTA PHYSICIAN
More commonly, cybercriminals act remotely, using electronic social engineering techniques. Common examples include phishing and spearphishing, business email compromise, and ransomware.
Phishing attacks use email or fake websites to trick employees into clicking on a link and/or entering personal information, allowing access to a network or system to collect billing and health information or deposit malware.
Phishing emails and websites are often designed to look as if they have come from a legitimate source. In November 2016, the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) notified health care-covered entities of a phishing scam that used fake government letterhead and a fake email address to direct individuals to a fake URL. The fake email address and fake URL each had only a very subtle difference (a single added hyphen) from the official addresses, a typical approach in phishing scams. Spear-phishing is a specific method of phishing that targets specific individuals or groups within an organization. Emails, social media, and other platforms can be used to persuade users to divulge personal information or perform actions that lead to network compromise, data loss, and/or financial loss. While phishing often involves random individuals, spear-phishing is aimed at specific targets and involves prior research. According to the Internet Crime Report published by the FBI’s Internet Crime Complaint Center (IC3), phishing and related tactics were the third highest cybercrime experienced across the nation in 2017.
Business email compromise Business email compromise (BEC) is a sophisticated crime that typically targets employees who have access to company finances. The cybercriminals trick these individuals into making a wire transfer to accounts thought to belong to trusted partners, but are actually controlled by the criminals. BEC, also known as CEO spoofing, often starts by the criminals gaining access to a company’s network through a spear-phishing attack and the use of malware. This allows the criminals to study the organization’s vendors and billing systems, as well as the CEO’s style of communication and perhaps even his or her travel schedule, without detection. When the time is right, a spear-phishing request is made to a specific individual, such as a bookkeeper, accountant, controller, or CFO, requesting an immediate wire transfer, often to a trusted vendor. If paid, this money is often hard to recover due to laundering techniques and accounts that drain the funds into other accounts that are difficult to trace.
Ransomware Ransomware is a type of malware in which attackers lock the data on a victim’s computer, typically by encryption, and payment is demanded before the ransomed data are decrypted and access returned to the victim. In 2017, the FBI’s IC3 received 1,783 ransomware complaints with adjusted losses of over $2.3 million.
Unlike other types of attacks, the victim is usually notified that an exploit has occurred and is given instructions for how to recover from the attack. Payment is often demanded in a virtual currency, such as bitcoin, so that the cybercriminal’s identity isn’t known. Of course there’s no guarantee that the criminals will release the files or that the files have not been breached or disrupted in some way. There is usually a delay between the insertion of the ransom software and the execution of the attack. This delay is intended to enhance the spread of the ransomware throughout the system, especially into backup files. This decreases the likelihood that the data can be recovered without paying the ransom.
Lines of defense So how do you prevent social engineers from having a negative impact on your organization? One certainty is that as technical security factors become more stringent, social engineering techniques will respond in kind. The weakest link in the security chain is the human who accepts a person or scenario at face value. Although some technical barriers can be put in place, employee training is the most important defense an organization has to protect against social engineering crimes. Consider the following tips to reduce your risk: Email attacks To reduce the risk of a phishing attack, keep malware and spam filters up to date. To reduce the risk of falling victim to BEC, implement a formal structure and process for releasing information and making payments. Employees
should be trained to be very suspicious of an email directive to wire money, mail a check, or release personal information. Consider the following actions recommended by the FBI’s IC3 (2016): • Verify changes in vendor payment location and confirm requests for transfer of funds. • Consider financial security procedures that include a two-step verification process for wire transfer payments. Double-check with a human. Call to verify and use the corporate telephone book rather than calling the numbers listed in the email. • Do not use the “Reply” option to respond to any business emails. Instead, use the “Forward” option and either type in the correct email address or select it from the address book to ensure the intended recipient’s correct email is used. Social media security Develop and implement a policy on employee use of social media, including personal page posts and references to the organization. Train your staff members on locking down their personal social media pages, and inform them of the risk to their personal property and well-being when too much personal information is shared. Ransomware To reduce and/or mitigate the risks of ransomware: • Develop a response plan, which may require outside experts. Social engineering to page 384
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HEALTH CARE POLICY
The 2019 Minnesota legislative preview Deadlock is not an option BY TOM HANSON, JD, AND JOHN REICH
N
ow that all of the votes have been counted following the contentious mid-term elections, it is time to look ahead to the 2019 Minnesota legislative session and the key health care issues that will arise. With the 2018 legislative session ending in deadlock between Gov. Mark Dayton (DFL) and the Republican-controlled House and Senate, many issues were left unresolved when legislators adjourned in May 2018. Deadlock in 2019 is not an option because a new biennial budget is due by July 1, 2019.
New players at the Capitol The 2018 general election significantly changed the major players at the state Capitol. With the retirement of Gov. Dayton, Rep. Tim Walz (DFL) defeated Hennepin County Commissioner Jeff Johnson (R) by a 53–42 percent margin. Walz campaigned on a platform featuring a single payer health care system and promising a strong public health care option for any Minnesotan who wants it. He also pledged to reduce barriers to mental health care and to make additional investments in medical research.
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Minnesotans gave control of the Minnesota House of Representatives to the DFL after Republicans had controlled the chamber for the last four years. DFLers picked up a total of 18 seats, primarily by winning by large margins in the suburbs of Minneapolis and St. Paul. With a majority of 75–59 percent, Rep. Melissa Hortman (DFL-Brooklyn Park) will become the new House Speaker when the Legislature reconvenes. While the entire state Senate is not up for election until 2020, there was one Senate seat on the November 6th ballot. The seat became vacant when Sen. Michelle Fischbach (R) became lieutenant governor. Republican state Rep. Jeff Howe and DFL Stearns County Commissioner Joe Perske ran for the seat, which Howe won by a 57–43 percent margin. With this victory, Senate Majority Leader Paul Gazelka (R-Nisswa) and the Senate Republicans retained control of the Senate with a 34–33 majority.
Key issues With the governor and the House in DFL control and the Senate in Republican control, Minnesota will have split control of state government. Agreement across party lines will be necessary to resolve key issues. The biggest responsibility of Gov. Walz, the House, and the Senate will be adoption of a 2020-2021 biennial budget. This need to adopt a biennial budget generally drives resolution of policy issues because key policy language is included in budget proposals. Following are key issues that will likely be addressed in the 2019 legislative session: Health and Human Services spending. In the current 2018-2019 biennium, Minnesota will spend $13.6 billion for health care costs and human services programming. This number is expected to grow by almost 9 percent to $15.4 billion in 2020-2021. A big cost driver in this spending is the funding for the Medical Assistance (MA) program, which reimburses providers under both a fee-for-service system and a managed care system. Decision-makers will consider numerous proposals for rate increases from provider groups. Success or failure of these proposals will depend on their cost and how broad-based their support is within the Legislature. Provider tax sunset. As part of the 2011 budget agreement, Gov. Dayton agreed to sunset the provider tax—a 2 percent tax on health care services— on December 31, 2019. The provider tax is the main source of funding for the Health Care Access Fund, which was originally established to fund the MinnesotaCare program. Over the years, the Health Care Access Fund has been used for other programs, such as student loan forgiveness programs and Medicaid coverage. If the provider tax were to sunset, it’s estimated that there would be a sizable deficit in the Health and Human Services budget by the 2022-2023 biennium, which would force the Legislature either to make cuts in health care spending, reinstate the provider tax, or find other sources of funding to pay for health care programs, such as an assessment on health plans or the general fund. Reinsurance. With the advent of the Affordable Care Act, individual market insurance rates have increased dramatically since 2014. During
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the 2018 legislative session, the Legislature and the governor passed two measures to help decrease the cost of premiums. First, they spent $325 million on a 25 percent rebate to consumers in the individual market for the 2018 plan year. This was a temporary fix to provide immediate relief in the near term. In an effort to combat further increases, the Legislature passed the Premium Security Plan, which was a state-funded reinsurance plan to offset the high loss claims incurred by the health insurers. The program was put in place for two years at a cost of $542 million. While it came at a great cost, it had the intended effect of reducing health insurance premiums by more than 20 percent in some cases. The Legislature will have to decide whether to reauthorize such a program for the 2019 plan year, as the insurers will begin filing their products early next year and will need to understand the parameter of any reinsurance program for actuarial and pricing purposes. Opioid stewardship fee. As overdoses and deaths from opioids continue to make headlines, a number of stakeholders involved with substance abuse issues have coalesced around a proposal to require the manufacturers and distributors of opioids to pay a stewardship fee that would raise approximately $20 million. The funds would be used for child protection issues that have arisen as a result of the opioid epidemic, as well as for treatment and prevention. The pharmaceutical companies have vigorously opposed the legislation and will continue to do so. Gov. Walz and the new DFL House leadership have indicated support for the measure. It stands a good chance of becoming law in 2019, having passed the Republican Senate 60–6 in the 2018 legislative session. Opioid prescribing. During the 2018 session, legislation to limit opioids as part of a prescription was adopted in the omnibus bill that was vetoed by Gov. Dayton. The medical community successfully included language that allowed for physician discretion in prescribing opioids. Prescribing limits will certainly be hotly debated again in 2019. Minnesota Health Records Act reform. A broad coalition of health care providers and business groups are expected to introduce comprehensive reform to the Minnesota Health Records Act. This coalition will likely seek to conform Minnesota law to HIPAA for purposes of authorizing the release of health records for treatment, payment, or health care operations. Proponents of the reform will argue that the efficiencies that providers would realize by conforming to HIPAA would benefit the health care system. Privacy advocates and certain legislators concerned with patient privacy opposed similar legislation in 2018 and the reform did not pass.
Learn more There are multiple ways to keep abreast of happenings at the state Capitol. Here is a list of services available to the public: House Public Information Services provides several ways to receive nonpartisan news about the Legislature. Sign up for electronic notification at www.house.leg.state.mn.us/hinfo/subscribesw.asp. Key Senate publications can be found at www.senate.mn/publications/ index.php. To learn more about individual House or Senate bills, or to track bills that may be introduced during the 2019 session, visit www.leg.state.mn.us/leg/legis.
Tom Hanson, JD, an attorney with Winthrop & Weinstine, represents clients before the Legislature and regulatory bodies. Prior to joining the firm, he worked for the Republican caucus in the Minnesota House of Representatives for eight years and served for eight years in Gov. Pawlenty’s administration, including four years as the Commissioner of Minnesota Management and Budget.
John Reich, director of government relations at Winthrop & Weinstine, has extensive experience in lobbying and strategy management. Prior to joining the firm, he worked for the DFL caucus in the Minnesota House of Representatives for five years and served for four years in Gov. Dayton’s administration.
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PHYSICIAN-PATIENT COMMUNICATION
Surviving a stroke Lessons learned from being a patient BY MICHELLE D. SHERMAN, PHD, LP, ABPP; AND LUANN KIBIRA, APRN, NP
“You’ve had a stroke.”
E
ach of us heard these words from an emergency room physician earlier this year, coincidentally about a month apart. Shocking? Life-changing? Perspective-offering? Reminding us of the importance of gratitude? Yes. We are friends and coworkers (a clinical psychologist and a nurse practitioner, respectively) in a family medicine residency clinic. We’ve each had over 20 years of experience caring for patients with a wide array of physical and mental health problems, but getting a serious diagnosis and being admitted to the hospital were uncharted territories. The experience was humbling, frightening, confusing, and overwhelming. Fortunately, we both have no residual damage from our strokes and are extremely grateful for great prognoses, excellent health care teams, and supportive families, friends, and coworkers. As we both spend much of our professional careers teaching resident physicians and trainees from other allied health disciplines, we often reflect upon teaching opportunities. Having a stroke, spending time in the hospital,
and having mandatory time off work for recovery involved unique experiences and time for reflection. In attempting to make meaning of the journey, we have contemplated our experience as patients, including what was especially helpful and what was difficult in interacting with the health care team. We want to use our experiences to shape our teaching—and, hopefully, invite others to consider our lessons learned from the other side of the hospital bed.
What to tell patients Reflecting on our experiences as patients in the emergency room and hospital floor, we humbly offer the following recommendations for health care professionals: Be aware of how much information I can digest, especially shortly after a major medical event. One of us was visited bedside by a specialist three hours after the stroke. He stood at the end of the bed at 6 a.m. and gave a one-hour, highly detailed neurological overview of strokes and treatment options. Although I wanted information, I simply couldn’t assimilate this level of detail; hearing all this information and trying to absorb it was stressful. A simple, short explanation right away, followed by more details later, would have been more helpful.
Experts at integrating food prescriptions into care for patients with type 2 diabetes and other illnesses Research shows that food prescriptions, like those filled by FOODRx, can lower HbA1c scores and the total costs of caring for patients with type 2 diabetes. FOODRx brings healthy food directly into health care settings, removing common barriers to nutrition and creating a cost effective, simplified prescription for wellness. “We need to take off our blinders and start learning new ways to address the real-life circumstances that make our patients sick. FOODRx creates the partnerships we need to do this work. We’ve got some real ‘Ah-ha’ moments ahead of us.“ —Dr. Diana Cutts, Hennepin Healthcare To learn more, contact us at 651.282.0887 or at foodrx@2harvest.org
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JANUARY 2019 MINNESOTA PHYSICIAN
Sit down. Balance computer work with meaningful patient interaction. Although sitting down next to the patient is possibly a common-sense suggestion, we learned it is not a consistent practice by the providers in both our emergency departments and patient rooms. We both had a few physicians sit down in chairs by our beds, which allowed for more comfortable communication. However, many providers stood quite a ways away at the end of the bed, seeming to tower over us. We understand that documentation in the computer (oftentimes on standing platforms) is necessary, but some providers asked questions and documented information while looking primarily at the computer. Instead, start the interaction by sitting down at our level, and make eye contact whenever possible. Please use simple language and avoid acronyms. Even as seasoned health care professionals, we felt overwhelmed after our strokes. We were unsure of the cause of our strokes, and we asked ourselves what we might have done (or not done) that led to this medical event. We worried if the immediate post-stroke symptoms (e.g., headaches, dizziness) would go away. We wondered when we could return to work. We were afraid of having another stroke, and wondered what we could do to prevent a recurrence. While dealing with these questions and trying to cope with the shock of the diagnosis, we struggled to process new information. Providers’ use of technical terms, jargon, and acronyms made comprehension more difficult. Instead, offer concise explanations, repeat them, use layperson language, and elicit questions from the patient. Please be consistent in the terminology of medications. It’s confusing when health care team members alternate between generic (lisinopril) and brand (Prinivil) names ... and sometimes use drug class names (e.g., “ACE,” for “angiotensin-converting-enzyme inhibitor”) or even abbreviations (do you want your “dil”—for diltiazem). Drawings or written information are helpful, but check on patients’ preferences. In the hospital, we were each given detailed booklets on strokes that included key terms, risk factors, and treatment options. However, immediately after a major medical event, even opening such a book can feel overwhelming and daunting. We never thought that a book called “Life after stroke” would be relevant for us. We appreciated physicians who walked through key parts of the book and drew some basic pictures for us. Too much detailed information and too many visuals can be frightening, so please consider balance. One of us will never forget the pictures of the white spots in her brain, real proof of the damage done by the stroke. It would be helpful to ask patients if they want to see the picture rather than just showing them. It would also be very helpful if patients could have a small notebook in which to write down their questions and the doctors’ responses.
Avoid terms of endearment. Although we definitely appreciate kindness and compassion, we are still your patients and ask that you maintain professional boundaries. Although we know you’re trying to be kind when you refer to us as “honey,” “sweetie,” or “dear,” we are none of those things to you; such terms can feel patronizing. Instead, ask us what we like to be called and then address us by our preferred name. Being in the hospital can be boring, and we spend a lot of time waiting for doctors. We know you’re very busy and have many patients on your service. However, any indication of when you’ll be available or stopping by is very helpful (e.g., “I tend to round in the morning”). Surviving a stroke to page 364
When loved ones need to be close
THE SAINT PAUL HOTEL has a long-standing special pricing policy for guests with loved ones that require hospital stays. If you have patients from either out of state of suburbs that require hospitalization at any of the outstanding St. Paul area hospitals, please let them know that family members and loved ones are welcome to our discounted health care stay pricing.
Seeing you consult with your colleagues is comforting, but observing conflict among health care team members is distressing. Patients appreciate when team members work together to define treatment options and understand there may be differences of opinion. However, watching you disagree in front of us and seeing you badmouth your colleagues is upsetting. Please address disagreements outside of the patient’s room. Words of encouragement are extremely helpful. As patients, we have not been through the routine “stroke protocol” and don’t know what to expect. Receiving reassurance and hope for recovery can feel very good. One us has had a good friend (who was incidentally also a physician) visit her on the first day after her stroke. His words —“you’ll only get better from here” (referring to the sequelae of this stroke)—were incredibly comforting and bolstered her spirits immensely.
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MINNESOTA HEALTH CARE ROUNDTABLE
TH 50 SESSION
Consolidation in Health care Examining cost and quality issues Consolidation in health care is a necessary part of the evaluation of the industry. Just as with any microeconomic sector, there will be mergers, acquisitions, new partnerships, etc. Just as there is good cholesterol and bad cholesterol, there is good consolidation and bad consolidation. Let us start by explaining what we mean by health care consolidation. What should we think when we hear this term? MS. QUAM: Collaboration is our future. Collaboration is a good idea, and
maybe we should look at consolidation as a model of collaboration. There are combinations of every sort going on and more coming all the time. Physicians are consolidating in many ways. They are staying independent but then they are having a management company. They are becoming employees. They are changing who they consolidate with and maybe it is not just with family physicians, it is family physicians and another practice. DR. JENSEN: You can try to define consolidation, but it is helpful to look at the motivation. Sometimes the motivation is survival. Sometimes it is greed. Sometimes it is power. We consolidate at many levels. Within a small office, you consolidate your efforts with your staff, and you do that for the good of the patient. One size does not fit all. In the world of consolidation, the patient frequently gets squeezed out in terms of what they want for medical care, and often the provider does as well. DR. DOWD: Consolidation can mean almost anything. A physician network
might be just a loose affiliation of physicians, until it comes time to talk to the insurance company, and then some people begin to describe it as a pricing cartel. On the other end of the continuum, you have organizations or provider entities that are actually in a hierarchy of ownership of services. What are some of the most important ways that health care is different from other industries? DR. KETOVER: Everybody who goes into health care sees it as a higher calling.
Even if you do not provide direct patient care, your work does make a difference to individuals, not just to systems. Consolidation is all about scale, bringing groups together so that you have more influence. That influence can be used economically to generate more revenue or to decrease expenses, but it should be used to create opportunities for what the collective group can do that individuals could not do: what types of services they can provide, what types of subspecialty areas, what types of additional customer service they can deliver. Much of the discussion about consolidation is about who is making
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Minnesota Physician Publishing’s 50th Minnesota Health Care Roundtable focused on the topic of Consolidation in Health Care: Examining cost and quality issues. Eight panelists and our moderator, Minnesota Physician Publisher Mike Starnes, met on Nov. 1, 2018, to discuss this topic. The next roundtable, on Apr. 25, 2019, will address Social Disparities in Health Care: Correcting the curve.
more money out of consolidation, instead of the benefit of consolidation to the community and to patients at large. DR. FIRKINS SMITH: There are probably not many industries where the
government has such an incredible role in how we purchase a specific thing. When you go to Target or Best Buy, you do not look at a television set and wonder how much it will cost or how it will run. And you don’t have the government pay for it. Essentially, that is what happens with a lot of our health care. Patients do not always understand exactly what they are buying, what is going to happen on the tail end, and how it will be paid for. DR. BARTHELL: In intensive care or emergent care, we are dealing with life and
death situations. People do not think about shopping around ahead of time, unlike primary care, where someone may ask a friend, “Do you have a referral for a good doctor?” I always tell families in the newborn intensive care unit that no one ever plans to have a baby in the NICU. It always catches people by surprise, and they are locked into the most convenient place to go. DR. DOWD: Cindy gave us a nice list of the features that distinguish health care from other products: market failures, poor information, restricted entry, and distorted prices. There are two views you can take on that. One is to say that, yes, that is right and there is nothing we can do about it. Markets cannot work and so we need to bring in the government to run the health care system. The other point of view is to say that, yes, it is true, but we could fix a lot of those problems if we had the will to do so.
JANE BARTHELL, MD, MSED,
is a neonatologist with more than 10 years of experience at Minnesota Neonatal Physicians, PA. Board-certified in neonatal and perinatal medicine by the American Board of Pediatrics, she received her MD from the University of Minnesota Medical School and completed a general pediatrics residency and neonatal fellowship at the University of Minnesota Medical Center.
SCOTT M. JENSEN, MD, is a senator (District 47) at the Minnesota Legislature, where he serves as vice chair of the Health and Human Services Finance and Policy Committee; a family physician at Catalyst Medical Clinic; and clinical associate professor at the University of Minnesota Medical School. He was named 2016 Minnesota Family Physician of the Year by the Minnesota Academy of Family Physicians.
BRYAN DOWD, PHD, is a professor in the Division of Health Policy and Management, School of Public Health, at the University of Minnesota. His research interests include markets for health insurance and health care services and econometric methods. His current research includes analysis of tiered clinic cost-sharing and evaluations of Next Generation and Vermont ACOs for CMS.
SCOTT R. KETOVER, MD, AGAF,
CINDY FIRKINS SMITH, MD, practices dermatology in Willmar. As clinical professor at the University of Minnesota and president of the Minnesota Medical Association, she advocated for collaboration across specialties, systems, and geographies. As president/CEO of ACMC Health, she led the independent system’s integration with Rice Memorial Hospital and CentraCare Health.
LIZ QUAM is the executive director of the CDI Quality Institute, a nonprofit entity affiliated with the Center for Diagnostic Imaging (CDI). After serving as an assistant state health commissioner during the Clinton era, she founded a nonprofit devoted to finding health care coverage solutions for entrepreneurs and small businesses. She continues to serve a leadership role in health policy discussions.
TIMOTHY HERNANDEZ, MD,
LEN KAISER is the chief administrative officer for Entira Family Clinics, an independent family medicine organization serving the East Metro. He is also executive director for Community Health Network, an Accountable Care Organization that is a partnership between HealthEast Care System, Entira Family Clinics, and independent specialty providers. Prior to joining Entira he worked at HealthEast Care System.
is a family physician who has spent his career at Entira Family Clinics in West St. Paul. He is an adjunct associate professor at the University of Minnesota as well as medical director at Entira Family Clinics. He has served and continues to serve on many boards and committees, including the MN Community Measurement Board.
is president and CEO at Minnesota Gastroenterology, where he holds a leadership role with the Board of Directors. He is also the founding president and CEO of the Digestive Health Physicians Association. A Diplomate of the National Board of Medical Examiners, he is board-certified in internal medicine and gastroenterology.
Publisher’s note: Timothy Hernandez, MD, left midway through the panel discussion to deliver a baby. Len Kaiser, also of Entira Family Clinics, replaced him.
DR. HERNANDEZ: When I started practicing, we were pretty much a cottage
DR. KETOVER: In our practice, consolidation occurred in 1997 when
industry. You hung your shingle and you opened your door. Now we see the effect of third-party payers, not just in the government realm, but also in the commercial world, with the development of narrow networks which you can get boxed out of, depending on how those contracts are arranged and what sorts of promises are made by different provider groups and systems. It puts a lot of pressure on those of us in independent practice.
three groups came together. Since that time we have grown organically, from 30 physicians to our current 80 gastroenterologists. Our motivation for consolidating and growing our practice is that there are many subsubspecialties in gastroenterology to which a group of four, five, six, or 10 cannot devote the appropriate resources, because they are under-reimbursed. We have, throughout our history, been able to make choices to have some of our partners invest a significant amount of time providing clinical services, performing activities that are under-reimbursed for the amount of cognitive effort and skill that they put into them, but we as a collective partnership can subsidize those kinds of activities for the benefit of the population we serve.
Can anyone cite examples of things that have worked really well because of consolidation? DR. FIRKINS SMITH: In rural Minnesota, we have a number of very small
clinics and very highly stressed critical access hospitals. These health care providers or institutions are struggling on a day-to-day basis just to survive and to serve people. If they cease to exist, we will have a whole slew of rural Minnesotans who will not get health care or will not get health care close to home. We are endeavoring to work together or collaborate with the small health care facilities, critical access hospitals, individual or independent physician-owned clinics, and figure out the best collaborative model to sustain them and keep care close to home. The goal is, whenever possible, to keep the right care at the right place at the right time for the right sustainable cost. That is a prime example of the way consolidation needs to work.
DR. JENSEN: When Medicare and Medical Assistance came about in 1965,
many physicians were in their own independent clinics. At that time, you might have a chart for this patient and I might have a chart for this patient and, if we consolidated, we would have just one chart. We could collate the information and be less likely to duplicate tests. The motivation was truly noneconomic. After 1965, we had some pent-up demand that gave the whole system a jolt. Some people call those the golden years, because there were lots of services being provided, lots of business, and the payment was there. Then in the 1970s we saw runaway inflation in price and utilization, and we said that we cannot keep doing this. We tried the HMOs and other things. I went into medicine in 1970 and saw first-hand the catastrophic results of what a MINNESOTA PHYSICIAN JANUARY 2019
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capitated system could do to the motivation to take care of a patient. All of a sudden you were told that if you provide less care, you get more dollars. Can we look at a couple of ways that consolidation has created negative results? MS. QUAM: There are good studies that show that costs have gone up. As the
costs go up, it makes our whole system solution more difficult. DR. HERNANDEZ: In the past, referrals were based
on relationships. That is not always the best way or the most data-driven way to make referrals, but it had some value in terms of being able to engender trust. Now, as you get into various contractual arrangements, you are forced to use certain subspecialists and hospitals. Our group has always prided itself on trying to be low cost and high value. The larger consolidated groups form narrow networks with payers that we are boxed out of unless we agree to become closer, which usually means, at minimum, professional service arrangements or just plain acquisition. There are a number of threats to those of us in independent practice now. Consolidation has brought decision-making up to such a high level that it is out of our hands and there is not a lot that we can do about it. DR. KETOVER: As the hospital systems have
relationship. It is very important that we maintain it and make sure that, when we collaborate and/or integrate, those relationships are at the core of everything we do. DR. DOWD: The Robert Wood Johnson Foundation studied 11 hospital mergers, and found that prices went up in eight of them. Prices did not go down in the other three, they just did not go up. We have to remember that when you have concentration of supply in any industry, the prices do not just go up for the consolidating industries. When the industry itself becomes more consolidated, the prices go up for everybody, so this would be true for hospital mergers. It would be true of hospitals buying physician practices. Every time a hospital buys another practice, it is not enough money to warrant the attention of the FTC or the Justice Department, but if you have enough hospitals buying enough practices, then you end up with a very consolidated hospital industry and a very consolidated physician industry. MS. QUAM: I would like to talk about trust. As
Someone who can make a choice is going to be more engaged than someone who is told what to do.
a health system gets larger, patients feel more locked in. They cannot go someplace else, because the physician inside the health system says, “If you go to this therapist or this imaging provider, your records will not be a part of your medical record here in our system.� That might lead to duplicate tests or other duplicate care, and it also causes an erosion of trust. The patient goes home and Aunt Polly says the very best medical specialist is so-and-so, but the patient cannot get to that specialist. How do we allow patients to have second opinions?
grown in size and influence, they have become — Jane Barthell, MD, MSEd more concerned with controlling leakage than with quality and patient outcomes. It has become important for those systems to keep that patient, service, and revenue within the system instead of looking around the community and asking, where is the best-qualified place Whether knowingly or unknowingly, federal reforms have contributed for my particular patient to get care? significantly to health care consolidation. Can anyone talk about how DR. BARTHELL: In vertical consolidation, when physicians are reporting to
administrators, it potentially can interfere with their loyalty to the patient. Independent providers can more easily focus their attention on the best quality care for their patients than they could if things were being dictated by people outside of that relationship. From a provider and patient level, are there problems that lead to a dehumanization of medical care? DR. JENSEN: We order tests that patients cannot afford. We do not bother
to check in with them, and by the time we are done ordering tests we have often damaged them physically or damaged them emotionally. That dehumanization of the relationship between patient and physician does not do our patients any good. DR. FIRKINS SMITH: Our physicians are really struggling, and unhappy physicians take bad care of patients and the relationship is dehumanized. One of the disruptors right now in medicine is a lot of virtual care, e-medicine. It is hard to have a humanistic relationship when you are doing so on your iPhone. Virtual medicine will probably be really good for select people under select circumstances at select times, but it can potentially dehumanize that
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that has played out? DR. KETOVER: One word is overhead. Hardly six months goes by where there is not another federal regulation requiring another form, another thing that has to be checked off in the electronic medical record, or another task that has to be performed in order to see the patient. The cumulative effect of all of this is that most providers spend more time in front of the electronic medical record than they do in front of the patient. The government has contributed to this by creating policies that layer one on top of the other. That creates a tremendous administrative expense for any organization, whether you are for profit, not-for-profit, consolidated or not. It takes a lot of time and support to get through all of those requirements and to do them correctly. DR. HERNANDEZ: I think about ACOs and their requirements. To win or lose
in an ACO, you have to consolidate or at least collaborate at a high level. The positive thing for those of us that are independent, single-specialty groups is that it has forced more structured conversations. Years and years ago, during those capitation days, we tried to do some very loose arrangements. We spoke with specialists about trying to manage populations from a cost standpoint, but the incentives were not built-in, the payment was not built-in, and it was pretty much all based on relationships. As great as that may be, it did not go
very far. You can argue about whether the ACO structure and form has been a good or a bad thing, but it has forced those consolidations. It forces primary to work with specialty, hospitalist to work with ambulatory, and everyone to play in the same sandbox. DR. JENSEN: If you are going to refer your patient for an MRI under your
own roof, it is going to increase your gross revenues, potentially decreasing your overhead and increasing the number of dollars that are going to come to your wallet. At some level, that is fee splitting. We have said that is okay in ACOs. We have said that monopolization and some of these consolidation moves are okay. We never used to say that. To me, the ACO is sort of a retooled HMO product that did not work very well a long time ago, but we are right back at it. Are there elements of health care delivery such as health insurance, PBMs, hospital and clinic systems, or pharmaceutical manufacturers that need to be kept apart as separate entities? DR. FIRKINS SMITH: Doesn’t it depend on their
they contract with providers, but we should be able to discover how much a knee replacement costs in St. Paul versus Owatonna. DR. BARTHELL: We also need transparency with outcomes. Anyone ought to
be able to look online and figure out which NICU has the best survival rate for infants born at certain gestational ages. People go to U.S. News and World Report and say, “Okay, this hospital is listed here, so this must be the best care,” but that is not really telling the picture that matters to families and that affects everyday life. The outcome measures for neonatology in the U.S. News and World Report rankings are blistering central line-associated infections, accidental extubations, babies who got the wrong breast milk, and babies who go home on breast milk. Those are important, but there is nothing about chronic lung disease of infancy, necrotizing enterocolitis, or retinopathy of prematurity. These are real diseases that affect long-term neurodevelopment of children. Someone who walks into a hospital and delivers a 26-weeker is going to have no insight on that and really can go nowhere online to find the best institution to take care of their baby at gestation.
motivation? I do not know that you can make a DR. HERNANDEZ: When MN Community blanket statement. If all of the organizations are Measurement develops their quality metrics In 2021, the average health insurgoing to consolidate for the purpose of cutting and cost metrics, they bring a wide variety ance premium will cross 50 percent out other entities or increasing their profit, of stakeholders to a neutral table: consumers of average household wage income. whatever their motives are, that is obviously or patients, employers, providers, payers, the bad. For instance, the Mayo Clinic is trying to Department of Health and Human Services, and —Bryan Dowd, PhD create a pharmaceutical company, and that is a the Minnesota Department of Health. We do not consolidation. But their motivation is not to necessarily come up with perfect solutions, but corner the market on pharmaceuticals. Their we do come up with proposals that at least have consolidation is to reduce costs. Isn’t that a good some consensus. That may be a model for trying idea? If the motivation is to provide the right care and to reduce cost and to drive some of these accountabilities, or at least to help us determine how to increase quality, I would be interested in hearing about that consolidation. measure the success or failure of consolidation efforts. What accountability should the big systems have? Who should they be accountable to? DR. KETOVER: They should be accountable to everyone: patients, stakeholders,
people who work for them, and the community at large. Our charge master, what we charge for our services, has been on our website for more than five years. I cannot find another institution in the United States that does that. That would be one place to start. You would at least have a chance of understanding what different institutions charge for the same service. The challenge is that the payer for the product is rarely the patient. They do pay out-of-pocket, but mostly it is third-party payment, either an employer or the government. Those institutions do not really care about transparency. The big insurance companies do not want transparency because that gets into how
DR. DOWD: A lot of our discussion has been about being accountable to
consumers. If you are not accountable to your consumers, your consumers might go someplace else to get their care. But there is a substantial number of very influential politicians and other people in the country who have not bought into that model at all. The model they have bought into views health care as a public utility that is run by the government. DR. JENSEN: MN Community Measurement says that to do a good job of treating depression, you have to get a PHQ-9 above such and such a number at time zero. At three to six months you have to do another PHQ-9. If the number isn’t better or the patient does not follow up, you get a black mark. We spend so much time trying to tabulate this data. We spent $14,000 last year to try to come up with the correct data so we could submit on whether
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or not we had done MN Community Measurement depression things. You are telling me that that is how we should hold accountability? I would think that maybe we could let the patient trust and decide, “Gee, Jensen, when I come to your clinic I always feel worse than I did before and I want to commit suicide.” Maybe they will find someone else. With this idea of having government take over one more layer, we are more and more distancing the patient. One of the issues when you are dealing with contracts that send the patient to preferred providers and narrow networks with restrictive formularies is that they might counteract good clinical practice. What do you do as a provider when you are looking down the barrel at that? DR. HERNANDEZ: We could spend two or
the health system’s top executives are being paid and on health outcomes. It is both measurement and then it is transparency on that measurement. Who can be an advocate for the interests of patients and physicians in an increasingly consolidated health care delivery system? DR. FIRKINS SMITH: Patients and physicians. That is the answer. When
it comes to these health systems, it is imperative that you have physician leadership or strong clinician leadership throughout the entire organization. There is data that suggests that physician-led organizations have higher quality and better outcomes, and I am all for having patient advocacy in there as well. We need to have a patient voice throughout the entire organization. MS. QUAM: A year or so ago there was a small
bill in Jefferson City, Missouri, that stated that three days talking about formularies and prior an order to deny a prior authorization request approvals. The contractual obligations and the required a health care physician licensed in the hoops that we have to run through and the state of Missouri. That is all it said. We had one systems that we have to build to work through lobbyist for all of the physician organizations, them and around them are so significant that and there were 18 health plan lobbyists in the sometimes you wonder, wouldn’t it be nice to room. It is not dissimilar here in Minnesota, have just one master and just one way of doing where there might not be that many bodies Physician-led organizations have it? That gets us down a whole trail of single payer sitting in the health committee meetings, that I do not necessarily advocate, but there higher quality and better outcomes. but there is this army of law firms behind the are some huge bureaucratic barriers that would insurance lobbyists. It becomes overwhelming, —Cindy Firkins Smith, MD be broken down. When I prescribe Suboxone even when you are doing your best and you or buprenorphine, it is not unusual to have know you are on high ground with whatever the the insurance company say, “Nope, we are not issue is for patients or physicians, because we are going to pay for that.” So we try like crazy to distorted in how advocacy happens under our find out which pill they will pay for and which current system. pharmacies they will be able to get it at. In the meantime patients suffer. DR. JENSEN: During the last two weeks of the 2017 session, there was one health system that wanted extra hospital beds. Throughout the entire How do we differentiate between good and bad consolidation? legislative session, we had never had any level of intensity like that. Twenty DR. BARTHELL: That gets back to motivation. You cannot argue that to 25 people descended, spent the whole day there. They were pulling us off consolidating in a rural area, where there is risk to some provider’s survival, the senate floor to talk to us over and over again about why they had to have is a bad thing. When you look in bigger areas where there is more choice and these hospital beds. Tony Lourey, a Democrat from Moose Lake, said we you see bigger institutions taking over more market power, then you start to should get an opinion from the Department of Health. The opinion from question whether consolidation is the right thing. the Department of Health said we could not justify it. Still the tug-of-war went on. It was in the 11th hour and in the end a compromise was hammered DR. JENSEN: If consolidation is occurring in an effort to create more out. What the systems, payers, and pharmaceuticals can unleash in terms of openness, that would be a good thing. If consolidation is occurring to cause lobbying power is intimidating. more opacity, that would be a bad thing. It does not take a rocket scientist to see when it is being done with the primary motivation being power, control, and increased revenues. We used to have the FTC ferreting out monopolies, and we had CMS concerned about self-referring and fee-splitting, but those have been sort of waived. In a lot of ways, it is the legislatures that have failed the system. We are the ones who maybe bought it hook, line, and sinker. Now we have narrow networks, patients displaced from the decision-making process, and patients who do not have a clue whether their first day in the hospital is going to cost $10,000 or $1,000. We need to start taking steps to stop this.
DR. FIRKINS SMITH: I agree with that, but if we walk away and say, “Oh,
MS. QUAM: We need measurement and transparency. There is no other way to
DR. DOWD: One study shows that in 2021, the average health insurance
identify motivations. We need measurement and transparency on how much
premium will cross 50 percent of average household wage income. In
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they’ve got all the money, they’ve got all the power, they’ve got all the people, we can’t do anything,” that is a useless attitude. I refuse to accept it. It took me 11 years to get tanning booth legislation passed in this state. Eleven years. It is up to us to be pit bulls when it comes to getting this stuff done. If the problem is the lobbyists and money, then change the law. Why do they get to have 100 lobbyists in the Capitol pulling on everybody’s ears? Why do they get to donate $100 million to the people who are running for office in order to have that kind of influence? Let’s change it.
2033, it will cross the entire household wage income. That just cannot happen. The optimism is that we won’t let it happen. The somewhat cynical viewpoint is that every household that the health care industry prices out of the health care market is another point on the demand curve for really disruptive innovation, and there are hungry people in the tech world who are working on disruptive innovation in health care. They are not thinking about innovative payment reform. They are thinking about innovative bypasses to the U.S. health care system. Part of the problem here is that there is a trust that health care organizations are altruistic in looking out for the best interest of consumers, but this may not always be the case. How do we address that? MR. KAISER: There has to be a way to measure
and create accountability for what is being said or what they are trying to do. When I think about the consolidations that happen within the market, I think about the statements that are made about the benefits that consolidation will create for the community. I never see any followup on how those benefits are actually achieved or how they have demonstrated the value of the consolidation. Having more follow-up after the consolidations and holding accountability around whether they follow up on the promises that they make when they get together and form these larger systems would be important.
Bigger and larger health systems have clearly not produced lower consumer costs or higher quality care. What needs to happen for this to be made clear and to effect change? DR. JENSEN: Over the last 50 years, we have taken the patient out of the equation, and I think many patients feel inadequate to being their own best champion. Somehow we have got to get patients to understand that they can say “no” to that angiogram. Almost 30 percent of our expenditures are related to low-value services that do not need to be done in order for us to optimize patient care. If you look at the data from the top 15 first-world countries, we perform more MRIs, CT scans, and coronary artery bypass grafts than anyone else. Price has certainly escalated, but utilization has inflated with some of these bigbuck procedures that are easy to do, and they play on the fears of the people. DR. KETOVER: It starts with the goals. All health
care organizations say “patients first.” But how many times do they ask how the decisions they make will affect the delivery and outcome of patient care? One big thing that is missing in this whole debate is the patient’s responsibility in their health. The best thing that I can do for There are a number of threats to those a patient is to say, “I’m going to reach in my of us in independent practice now. toolbox and recommend these three tools for you. —Timothy Hernandez, MD But I cannot make you use them. You have to be motivated and believe that this is going to help you.” There has to be an environment in which a MS. QUAM: You could start with the hospitals. physician can say to a patient, “I understand your Look at their charter, their nonprofit charter, anxiety and concern about your symptoms, but I and make sure that they are meeting it back to do not think you need the MRI today. Let’s wait measurement and transparency, especially as it relates to Medicaid. two weeks and see what happens.” Our system has evolved to the point where providers who do that are under-reimbursed relative to providers who just U.S. antitrust laws prevent collusive practices that restrain trade, check the box for the MRI. restrict mergers, lessen competition, and prohibit the creation of a monopoly and the abuse of monopoly power. These seem to be being run roughshod over. Who is going to enforce those? DR. DOWD: Most health economists would say they believe the Justice
Department has been asleep at the switch for the last 20 years. I think that is a little too harsh. The federal government has a limited budget, and so does the Justice Department. When they are going after Microsoft, that is a big deal. The health care industry is a big deal too, but they have got to make choices. I am not a lawyer, and so I am not able to say if there is some technical legal impediment to enforcement of the antitrust laws, but I sure hope someone could explain that to me, because otherwise I have got to conclude that the judges are just approaching gullible from the other side.
DR. FIRKINS SMITH: People often do not understand what real quality is.
I may have a patient who just had a knee replacement come in for skin disease. They rate the quality of their knee replacement on the appearance of their scar: “The surgeon did a really good job, look at that scar.” It is great to have a good scar, but the real quality is how does your knee work, how can you get around, are you having a good quality of life, is it functioning, is it going to get infected, is it going to work for five years, those kinds of things. I just read an article that said people do not actually search out health care for quality. They are far more likely to search based on a relationship or a recommendation, either by their physician or their next-door neighbor.
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MINNESOTA HEALTH CARE ROUNDTABLE
If some of this needs to be addressed through legislation, what kind of data do we need to bring to the legislatures to make them aware of these issues?
Is there some irony in the fact that laws that were made to prevent physicians from colluding with each other have allowed payers to do just that?
MR. KAISER: There is a challenge with trying to get good data and
DR. KETOVER: In the process of renegotiating one of our contracts with a
agreement on what is good data. From a cost standpoint, we as an organization are constantly trying to find information about the highvalue partners that we should be working with. Who provides low cost and high quality? We get contradicting data from pretty much everybody, so it would be nice to have consistency.
commercial payer, they asked us to justify our request. They said, “Why don’t you share with us what you are being reimbursed by other payers?” I thought to myself, “You already have access to a lot of that information.” The insurers have each other’s information, but we do not. In another state, a provider group went on Craigslist and advertised that they would pay for the EOBs from patients for various procedures so that they could see how things were getting paid for by different payers. As a provider organization it is rare to have extensive knowledge of reimbursement differences in your market, so your only leverage in dealing with insurance companies is either to accept the contract or be out-of-network.
DR. JENSEN: We have a lot of services ordered because some studies indicate that one out of every four dollars spent in health care is based on some form of defensive medicine intended to avoid litigation. I do not think this will be solved by trying to get legislators to understand the data, because they will be influenced by the biggest category of lobbyists in the 11th hour. We need to have people like this audience who are well-spoken and understand the system to keep hammering. You need to hold your legislators accountable. You are the stakeholders. DR. DOWD: Walt McClure once said that the
best way to improve measurements systems is to implement measurement systems. If you do that, you will immediately hear what all the problems are with them. But with MN Community Measurement and the all-payer claims database, we are further ahead than any other state in the country. If we cannot do something on the consumer path of health care reform, nobody else can do it.
You need to hold your legislators accountable. You are the stakeholders.
Antitrust laws use the word “cartel” to describe an entity that controls manufacturer supply and access to a market sector and limits or removes competition. Over time we have steadily enacted policies that effectively, if not intentionally, exempt health care delivery from these public protections. What needs to happen for this to change? MS. QUAM: There was an article in the Wall Street Journal about “secret
deals” involving an agreement for the insurer not to steer away from a health plan because the health plan took a 1 percent inpatient rate reduction. The insurer might be promoting something to the self-insured clients, but actually there is a “secret deal” between a health system and the insurer. Those kinds of arrangements need to be transparent, too. It is not just the pricing for each individual patient. If this is the nonprofit sector, and most hospitals are, then is there something we should be doing even with those contracts where there are certain specific things that they have to reveal? DR. DOWD: The good news from the industrial organizations literature is that the same greed that forms the cartel also gives the efficient members an incentive to break the cartel. We just have to give them a reason, make it worth their while, and pay them to break the cartel.
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DR. FIRKINS SMITH: That is a significant problem for those of us in rural areas. When patients are out-of-network in urban areas, they can go down the street. When we are out-of-network, where do they go? They either pay huge increases for their care, or they drive to the Twin Cities.
MS. QUAM: Sometimes it is called out-ofnetwork, sometimes called “surprise billing,” which is causing even more problems. We have a really decent bill in Minnesota, but at the federal level, Senator Cassidy is offering a bill that the insurers are trying to hijack so that if you are outof-network, you are only paid a percentage of Medicare. In California, I believe it is 120 percent of Medicare.
—Scott M. Jensen, MD
Increasing health care consolidation is contributing directly to a serious public health issue, specifically the rising number of individuals with health care disparities. Let’s talk about this a little bit and ways that this can be addressed. DR. FIRKINS SMITH: I would need to know why we think that consolidation is
increasing health care disparities. One of the reasons that we consolidated in rural Minnesota is that our population is well over 50 percent Medicare and Medicaid, and a lot of our population is very poor, under-represented, and has a lot of social disparities. Our concern was that if we did not come together as a larger organization and create some scale and address these problems, we were going to have to abandon those patients, and we were unwilling to do that. For us, consolidation was an answer to address and deal with social disparities. You are completely right. There is good consolidation and bad consolidation. Liz, you cited an example of this being a chain reaction: when one organization owns the insurance and can price the product out of reach of a certain number of individuals, it has downstream effects. How does that work? MS. QUAM: Trust is a really big thing, especially for some populations, and
if you already do not trust the health care system, going into a big white
sterile hospital setting is not a good thing. You just stay away. Studies show that across the country. We want multiple options for access, especially for vulnerable populations of all different kinds. If we only have one big hospital door every 50 miles, we contribute to that disparity. DR. JENSEN: Social disparities do occur in the consolidation movement when
people to live in the community. Providing good health care does nothing for the people in our community if we bankrupt them in the process, and I would say the same for the employers in the community. Part of the disruption in rural health care will be working directly with the payers. By that I mean the employers, because nongovernmental payers are primarily employers.
facility fees are all of a sudden a new part of the plan. Patients do not see it coming, and people who suffer the adverse consequences of social disparities often do not have the skill set to negotiate or push back. I had a patient who brought in an EOB and his bill was $70,000. By the time the insurance company had adjudicated it, the $70,000 list price had been brought down to $12,000, and the patient had to pay $40. He said, “Doc, how can a bill be $70,000 and be brought down to $12,000?” I said, “I think it happens with some frequency.” But if there is anybody who does not get that advantage, it is a person without insurance and with no advocate, nobody negotiating on their behalf, and they are stuck with a $70,000 bill. They go to the hospital and they plead, beg, borrow, get on their knees, and they finally get a reduction from $70,000 to $65,000. This is the way social disparity affects us so profoundly. Most providers spend more time in In the first half, we mentioned the tiered front of the electronic medical record system. Let’s talk about that a little bit. than they do in front of the patient. DR. DOWD: Minnesota state employees choose a
Also in the rural setting, there are not a lot of other choices that the community has to go for care. DR. FIRKINS SMITH: Certainly people can drive,
and other organizations might come in. There is not a lot of profit in doing that because the vast majority of our patients, well more than 50 percent, are government paid, low reimbursed. One of my concerns is that when disruptors hit our market they are going to go after people that have money, and we now use people that can pay for health insurance and employers that can pay for health insurance to cost-share those that cannot. So when they start siphoning off the ones that have the better reimbursement, how are we going to be able to cost-share those costs for the people that have very low reimbursement? DR. KETOVER: There are maybe a handful of
—Scott R. Ketover, MD, AGAF
primary care clinic placed by the state into one of four cost-sharing tiers. The primary care clinics then serve as gatekeepers and direct your referrals to hospitals and to specialists. That system gives both the providers and the consumers an incentive to choose efficient providers. If you just stick the consumer in a high-deductible health plan, they cut back on the care they should get. If you just give them information but no incentive to act on it, then nothing happens. One study that just came out in the American Journal of Health Economics involved Safeway. They gave consumers information about quality of care. Nothing happened. Then they tacked on reference pricing, and they started getting 29 percent savings on their total health insurance cost with no difference in quality. You have got to give both the consumers and the providers an incentive to be more efficient. To address the issues in the rural setting, would it be possible for the clinics to negotiate directly with employers? DR. FIRKINS SMITH: We would like to do a lot with employers. They are
the lifeblood of our community. People and employers are what allow
organizations in the country that could survive on 100 percent Medicare rates. That is a fallacy when we talk about Medicare for all. There are many institutions here in the Twin Cities that would disappear if all they were paid was Medicare rates. We need to address that. It is the commercial insurance reimbursement that subsidizes the insufficient payments from Medicare and Medicaid.
DR. JENSEN: Consider the concept of direct primary care, especially if you had a core package of catastrophic coverage that linked in direct primary care. You really do not have the clinic and physicians being exposed to loss. At the worst, they would be out time, but they are generally going to be inclined to be very efficient. They will do whatever they can to get that patient plugged into an ideal setting. The direct primary care model has some bugs in it, but I think it is a good idea, and it could be good for outstate Minnesota. DR. FIRKINS SMITH: One of the problems with direct primary care is that it has
generally been offered for people that can afford that extra monthly payment. A lot of our patients just do not have it. We need to find a way to implement that kind of model for the people that do not have that additional money.
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MINNESOTA HEALTH CARE ROUNDTABLE
What are the most important things we need to do to stop consolidation in health care that does not benefit patients and ensure consolidation practices that do benefit patients? MR. KAISER: To ensure appropriate consolidation, we need to identify the value when consolidation is occurring. If there is consolidation that is ongoing, what does it do? We are almost to a point now where consolidation is not a value add, it is more a response to current systems failing. How do we create and support the established existing systems that we have today to make sure that groups that are not part of large systems, who want to remain independent and viable, have those resources and support in order to stay viable in the long term?
going to have to change in order to ensure health care delivery with the best value, the best outcomes, and the lowest cost in the future. When people want to consolidate, check the motives, check the intent, and then ask them how they are going to address, in an innovative way, the change that needs to happen to deliver care and ensure future health care outcomes. And then I would hold people to the fire. I really like the idea of transparency. We are dreadfully lacking transparency in medicine. DR. DOWD: In the past I would have said to
enforce the antitrust laws, but I think it may be too late for that. What I would say now is that we have to redesign the system so we reward efficiency instead of penalizing it. MS. QUAM: I do not think we can get where
DR. BARTHELL: To keep consolidation where
it is most helpful, we should acknowledge that studies in psychology, sociology, and economics show that people’s best engagement and best performance happens when there is self-direction. Autonomy, mastery, and sense of purpose are what drive human behavior. Choice is also part of what engages patients. Someone who can make a choice is going to be more engaged than someone who is told exactly what to do. It is the same with providers. When providers can direct what they think is the best care for their patients, they are going to be more invested.
As a health system gets larger, patients feel more locked in. They cannot go someplace else.
DR. KETOVER: We have to bring the patient back
into this, and be an active part of the transition to value-based care. When assessing the value of future consolidation, we need to understand the motivation driving the potential consolidation. What is the goal of the consolidation? Is it reactionary to a market where you need to have scale to survive? Is it proactive in a market where you want to have scale so you can control the market? I do not know that we can legislate good intent, nor can we go back and have penalties if the good intent does not produce a community benefit, but it certainly should be more of the discussion. When organizations, especially large organizations, are talking about consolidation, they ought to at least be challenged by having the community ask, “How will this benefit us? We know how it will decrease your expenses and maybe increase revenue, but how will the community benefit from this consolidation? DR. FIRKINS SMITH: We need to look to the future as well. A lot of
consolidation has been done as a reaction to the changing health care environment, and a lot of people have bemoaned it, wishing for things to stay the same. The problem is that things cannot stay the same. We are
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—Liz Quam
we need to go without intraoperability as it relates to patients going through the health care mega system. I think there is a disruptor coming. If you take a look at Apple Health, see where that might go, you do not have to worry about HIPAA. It is the patient who is clicking on “send this record” wherever the patient wants it to go. That is an open API, and that is coming. Medtronic has a product called Bind that shows pricing, hopefully quality too, again on your phone through an API. They are talking about it in Washington. Everybody knows what a mess Washington is, but if you pay attention to that, I think it will give you hope because it may allow the patient to begin directing his or her care again. DR. JENSEN: Determining whether consolidation
is good or bad is a dicey proposition. If we can demonstrate that consolidation is truly for patient ease, patient quality, and patient understanding and there is no adverse price impact on this—that it is not being done to add facility fees on to things—then I think it is justifiable. I do not think we can give up on enforcing patient protection laws. We have government agencies already in existence that have the ability to discern whether or not this a monopoly, fee splitting, or self-referral. In the early 2000s, Mike Hatch took aim at Allina and Medica and said, “Break it up.” Do we have any systems in place around here today that mirror what he broke up in the early 2000s? I do not think anybody in this room would have too much difficulty coming up with a few examples. If we are going to selectively enforce the laws and make special exemptions, we are just going to have more and more problems.
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MEDICINE AND THE LAW
Physician employment agreements Understanding assignment provisions BY ANTONIO “TONY” FRICANO, JD
A
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Changes to PTO/sick days/benefits.
s legislators debate the politics of the single-payer system (or a version of that), the free market continues down the path of consolidation, oblivious to the political discussion. Health systems and payers are purchasing physician practices, and larger health systems are purchasing smaller health systems.
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Increased responsibility and time commitments.
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Higher levels of bureaucracy and oversight.
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Uncertainty around discretionary bonuses.
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Uncertainty around noncompete requirements.
If you are a physician with an equity stake in the group that is being acquired, you are in a pretty good spot. You will likely be compensated for the sale of that equity consistent with a fair market value analysis, and you will likely receive an employment contract as the new owner attempts to establish continuity for the clinic operations.
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Loss of ability to obtain an equity interest.
But what if you are an employed physician? What if you are a contracted physician? You will not be choosing the acquiring organization and you will not be receiving a payout upon the sale. The acquiring organization will have new policies and procedures, which may not be consistent with those you signed up for. Below are a few of the common issues physicians face when their employer is acquired by a new organization:
Types of acquisitions Acquisitions are generally accomplished through either asset sales or equity sales. An asset sale involves the sale of specific assets and operations from one legal entity to another legal entity (e.g., Party A sells its widget factory to Party B). An equity sale involves the purchase of ownership interest in one entity by another entity (e.g., Party B purchases 100 percent of the voting stock in Party A). This distinction can be important because the type of transaction at issue may affect your rights as described below.
Prior to transaction: review assignment and change of control provisions Most employment agreements include an assignment provision, which specifies conditions under which contract provisions may be assigned to the acquiring entity. This provision will indicate whether an assignment is allowed and whether consent is required. The distinction between an equity sale and an asset sale is important in this situation, as an asset sale will require the practice to assign your contract to the acquirer, and an equity sale will usually not require an assignment.
with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:
Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com
Apply online at www.mankatoclinic.com
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JANUARY 2019 MINNESOTA PHYSICIAN
If the sale is an equity sale, then the change of control provision would usually be the relevant provision (as opposed to assignment). If there is a change of control provision defining certain rights, such as consent, payment, or termination, the other party will usually have to provide notice of any change that involves a change in ownership of greater than 50 percent, and sometimes the consent of the other party will be required. Change of control provisions are uncommon in physician employment agreements. If your employment agreement requires you to consent to a change in control or assignment, then you will have some options. If you refuse to consent to the assignment or change in control, you will usually have the option to terminate the contract if the sale proceeds without your consent. Depending on how critical your individual practice is to the overall sale, this may place you in a position to negotiate a retention bonus from your current employer or a better deal from your future employer (subject to the Stark Law governing physician self-referral and fair market value requirements).
Responding to unwelcome change After the transaction is complete, you will get your first glimpse into the operations of the new administration. Assuming that your employment contract was not amended as part of the transaction (which should require your consent), your rights as a physician shouldn’t change from what they were previously. However, even though your rights have not changed, a lot of changes
will be implemented. The question of whether you need to accept these changes depends on the language of your employment agreement. If your agreement specifies a certain number of days off or a specific bonus structure, then the new employer will need to adhere to those requirements. However, if those issues are not specifically addressed, then it will be difficult to require that the new employer treat situations in a particular way. That is why it is important to be specific when discussing rights and obligations. If an employer promises you something, they shouldn’t object to including it in the agreement (see detailed discussion below). The same logic applies with respect to after-hours work, time limits during patient consults, etc. If your prior employer had authority to enforce certain requirements or to establish new requirements during the course of the agreement, then the new employer will have that same level of authority.
The noncompete Another common issue and question is whether a noncompete provision in the employee’s agreement can be assigned as part of an asset sale. Minnesota generally holds that agreements with noncompete provisions are assignable if the agreement allows for assignment. However, if you find that the noncompete provision becomes more onerous as a result of the sale, then you may have a good argument that the scope should be reduced. In order for a restrictive covenant to be enforceable, it must protect a legitimate business interest of the employer and be reasonable in scope, duration, and geographic region. In some jurisdictions, courts will completely invalidate unreasonable noncompete provisions, but Minnesota courts are not required to rule in an “all or nothing” fashion and can effectively rewrite the provisions so that they are equitable. An example that often comes up as it relates to sales or acquisitions is that an employer restricts the employee’s ability to work within a certain radius of an employer-owned clinic. If there is a sale that increases the number of clinics, that would effectively increase the geographic scope of the restrictive covenant in such a way that it would be inequitable to uphold the restrictive covenant.
that includes the detailed rights and obligations of both parties is really the best way to ensure a successful employment relationship. If the rights and obligations between employer and physician are clear, then the changes implemented by a new operator should not affect those rights. Being clear and specific is a good practice for any contract, though, and admittedly sometimes it is easier said than done as specificity needs to be balanced against the need for a contract that is flexible enough to be operationalized. At a minimum, the primary obligations of the physician should be spelled out and the physician should have a chance to review any employer policies that they will be bound to.
Disclaimer Notwithstanding the benefits of strategic negotiation, the end result from negotiations has a lot to do with each party’s leverage. Larger employers have leverage and will insist on standardization given their need for efficiency and scale. However, smaller practices lack this type of leverage and will often negotiate to obtain the right candidate. In either scenario, it is always in a physician’s interest to have their contract reviewed by an experienced attorney. Most health law attorneys can review and comment on an employment agreement pretty efficiently. An ounce of prevention is worth a pound of cure. Antonio “Tony” Fricano, JD, is a health care attorney at Gray Plant Mooty. He has extensive experience advising physicians, health systems, and other health care organizations on physician employment and services agreements.
Negotiation of a consent requirement for assignment During the negotiation process, lawyers spend a large chunk of their time negotiating noncompete, indemnification, and termination provisions. In my experience, there usually isn’t a lot of negotiation on the assignment or change of control language. Most physicians aren’t thinking about their employer getting acquired when they start their employment, and this usually isn’t high on the employer’s list either. A typical assignment provision will not allow either party to assign the agreement without the consent of the other, except if there is an asset sale of the employer, in which case the agreement can be assigned without the physician’s consent. In the employment agreement context, an employer will never agree to a clause allowing an individual physician to assign the agreement. With that being the case, if a physician were to argue that any assignment rights should be equal, the likely compromise would be that any assignment requires the other party to consent (without exceptions). The assignment right is certainly more important for the employer than the physician, but with the tendency to “meet in the middle” during the negotiation process, some employers may agree to allow a mutual consent requirement for assignments. With a mutual consent requirement for assignments, the physician can opt to terminate an employment agreement upon the sale of the group practice.
Bigger picture solution While obtaining a mutual consent requirement might give a physician some leverage during an asset sale, drafting a specific employment agreement
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PROFESSIONAL UPDATE
Heartburn Individualizing diagnosis and treatment BY KOURTNEY KEMP, MD, FACS
P
atients with heartburn often begin a lengthy journey of diagnosis and treatment before their conditions are accurately identified and their symptoms resolved. A new, comprehensive, personalized approach to diagnosing and managing patients with heartburn is necessary, taking into account the unique needs and issues of each patient.
The incidence of conditions causing heartburn symptoms, including acid reflux and gastroesophageal reflux disease (GERD), is growing, according to the American Society for Gastrointestinal Endoscopy (ASGE). Up to 40 percent of the U.S. population experiences GERD, a chronic digestive disorder in which stomach acid flows back into the esophagus, causing heartburn and irritation in the lining of the esophagus. Today, proton pump inhibitors (PPIs) are among the top selling drugs in the U.S. While they often are the first line of treatment for patients with acid reflux, about 30 percent of GERD patients do not respond to standard dose PPI medications. In addition, long-term use of PPIs can sometimes mask the symptoms of heartburn. PPIs may make the patient feel better, but they might not be treating the cause of the discomfort. If
left untreated, heartburn can result in more serious esophageal disorders, such as dysphagia, chronic reflux damage, adult-onset asthma, Barrett’s esophagus, and esophageal cancer. Through our Heartburn Center, we specialize in caring for patients with esophageal and digestive disorders that frequently present as heartburn. In addition to GERD, these can include: • Achalasia, a degeneration of the nerves in the esophagus, causing the esophagus to fail to move food and liquids into the stomach and tighten the sphincter between the esophagus and stomach. • Barrett’s esophagus, a condition in which the lining of the esophagus is replaced with tissue similar to the stomach lining, often as the result of long-standing GERD and sometimes leading to esophageal cancer. • Esophageal cancer, which can occur in any part of the esophagus and spread to lymph nodes, windpipe, large blood vessels in the chest, and nearby organs. • Hiatal hernia, a weakness in the diaphragm that causes the abdominal contents to move upward into the chest cavity.
Diagnosis options Because the symptoms of GERD are so diverse, diagnosis can be difficult. Reflux testing is a reimbursed procedure that enables providers to definitively diagnose esophageal disorders and determine the best course of treatment for their patients. Here are the most common diagnosis options available today. Esophagram. An esophagram is often the first choice of physicians when seeing patients with an initial concern of heartburn. It provides X-ray imaging of the esophagus and upper stomach, including the anatomy and motility of the esophagus. We use it to evaluate swallowing problems, as well as reflux. Allergic reactions to the barium patients drink are uncommon.
with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:
Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com
Apply online at www.mankatoclinic.com
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JANUARY 2019 MINNESOTA PHYSICIAN
Endoscopy or esophagogastroduodenoscopy (EGD). An endoscopy or EGD enables providers to visualize the esophagus, stomach, and duodenum, spotting conditions such as ulcers, erosions, and Barrett’s esophagus. EGDs are performed in our procedure centers and involve only a slight risk of sore throat, bleeding, or perforation of the upper GI tract. While this is a good diagnostic tool, the ASGE reports that up to 70 percent of patients who do not respond to optimized PPI therapy have a negative EGD. High resolution impedance manometry (HRIM). HRIM measures pressures and fluid movement in the esophagus, helping to diagnose esophageal motility disorders. Performed in the office, the procedure involves placing a small, flexible catheter into the esophagus through the nose. Patients are asked to swallow small amounts of salt water 10 to 12 times during the test. Some patients have difficulty with gagging, but with relaxation most patients can complete the procedure.
24-hour esophageal impedance pH test. This test evaluates the extent of Surgical options gastric reflux that flows into the esophagus during 24 hours. Sensors on a Surgery is often the best option for patients with severe esophageal disease catheter measure the level of acidity at various levels in the esophagus, as who have failed to respond to short-term medication use. Today, we have well as the reflux of stomach contents up into the esophagus. The catheter a wide range of surgical options available to us: is connected to a pocket-sized recording device Nissen or partial fundoplication. This procedure worn by the patient. It is the most accurate test wraps the top of the stomach around the lower to document gastroesophageal reflux and is esophagus to reinforce the lower esophageal generally our preferred test because it measures sphincter, creating a new sphincter between the acidity at different levels, as well as non-acid esophagus and stomach. reflux events. Up to 40 percent of the U.S. Hiatal hernia repair. Most hiatal hernias population experiences GERD. Bravo capsule esophageal pH test. The Bravo require surgery to pull the stomach down, reduce capsule test measures and records the level of pH the opening in the diaphragm, and reconstruct the in the esophagus over 48 to 96 hours, enabling esophageal sphincter. providers to document relationships between LINX. The LINX procedure is a relatively new symptoms and acid reflux events. The device way to treat heartburn with implanted magnetic consists of a capsule about the size of a vitamin beads that tighten the esophageal sphincter. pill that attaches to the esophagus via a catheter and transmits information Designed for patients diagnosed with GERD through abnormal pH testing, wirelessly to a pocket-sized receiver that the patient carries. The Bravo the device is about the size of a quarter and is implanted around the outside usually is placed during an endoscopy procedure while a patient is under of the lower esophageal sphincter through a minimally invasive laparoscopic sedation. The capsule dislodges itself in about three to seven days and passes procedure. Despite the fact that the beads are magnetic, patients with a out with the stool. In rare cases, patients can experience chest pain, the LINX device can continue to have MRIs. capsule may not fall off spontaneously, or food may become lodged on the capsule. Patients should not undergo an MRI if they suspect the capsule is still in the body.
Bariatric weight loss surgery. Nissen or LINX procedures may be ineffective and too high risk for patients who are severely overweight. In
Lifestyle and medication treatment options
Heartburn to page 344
Each patient is unique and deserves a personalized treatment approach. In some cases, lifestyle changes can make significant improvements to a patient’s heartburn symptoms. Maintaining a healthy weight, learning what foods aggravate the heartburn, and avoiding large meals, especially late at night, sometimes can solve the problem. Avoiding carbonated and caffeinated beverages also can be helpful, as can avoiding clothes that fit tightly around the waist. We also remind patients that smoking and drinking alcohol can both decrease the esophageal sphincter’s ability to close properly, thus increasing reflux and heartburn. Some patients also find that elevating the head of their bed or placing a wedge between the mattress and box spring makes a difference in their ability to be symptom free at night. If lifestyle changes are not helpful, we often turn to short-term use of medications. There are three classes of medications prescribed for heartburn: 1. Antacids, such as Tums, neutralize the stomach acid for quick relief. 2. H-2 receptor antagonists, such as Zantac, work to reduce stomach acid, but most people will develop a tolerance to these medications, making them ineffective over time. 3. Proton pump inhibitors, including Prevacid, Nexium, and Dexilant, may provide longer-term relief, but are not without possible side effects, such as osteoporosis, bone fracture, hypomagnesaemia, and pneumonia. In some cases, medications other than those specifically aimed at treating heartburn may be useful, including muscle relaxants, steroids, antianxiety medications, and pro-motility agents.
SHARE YOUR INSPIRATION.
On the U.S. Army health care team, you will enjoy the satisfaction of providing quality care to Soldiers and their families, in a setting with innovative technologies, robust resources and a dedicated, supportive team.
Learn more at healthcare.goarmy.com/nz72
©2018. Paid for by the United States Army. All rights reserved.
MINNESOTA PHYSICIAN JANUARY 2019
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3Heartburn from page 33
body will regenerate new tissue in the esophagus. This is often followed by surgery to treat the underlying cause of Barrett’s esophagus to prevent recurrence of irregular cells.
these cases, we often recommend bariatric weight loss surgery, such as Rouxen-Y gastric bypass and gastric sleeve (gastrectomy) surgeries. Roux-en-Y Many esophageal surgeries can be performed robotically. We have the is the most common gastric bypass procedure. largest number of robotic-trained surgeons in Surgeons divide the stomach to create a small the Upper Midwest and have found that treating pouch to which a portion of the small intestine esophageal diseases with minimally invasive is attached, causing food to bypass a large section robotic surgery results in improved outcomes of the stomach and intestine. With a gastrectomy, with less pain and faster recovery time. a portion of the stomach is actually removed, Treating patients with heartburn Summing up creating a narrower stomach called a sleeve. Both can be complex. Treating patients with heartburn can be complex, make long-term changes to the digestive system but today physicians have a number of outstanding by limiting the amount of food a patient can eat diagnostic and treatment options to help their or reducing the absorption of nutrients. Like other patients reach a successful—and personalized— major surgeries, bariatric surgery carries a number outcome much sooner and more safely than ever. of serious risks and should only be considered when less extensive options have failed. Minimally invasive esophagectomy. During this surgical procedure, surgeons remove part of the esophagus and reconstruct it using a piece of another organ, usually the stomach. It typically is reserved for esophageal cancer, but also may be used for Barrett’s esophagus if aggressive precancerous cells are found.
Kourtney Kemp, MD, FACS, is board-certified in general surgery and leads the Specialists in General Surgery Heartburn Center.
Radiofrequency ablation. This minimally invasive procedure uses electrical energy and heat to remove irregular cells as part of a treatment for Barrett’s esophagus. Once the diseased tissue is removed, a patient’s
Carris Health is the perfect match “I found the perfect match with Carris Health.” Dr. Cindy Smith, Co-CEO & President of Carris Health
Carris Health is a multi-specialty health network located in west central and southwest Minnesota. Carris Health 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: • Dermatology • ENT • Family Medicine • Gastroenterology • Geriatrician • Hospitalist
• Internal Medicine • Nephrology • Neurology • OB/GYN • Oncology • Orthopedic Surgery
• Psychiatry • Pulmonary/ Critical Care • Rheumatology • Urology
Loan repayment assistance available.
FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | Shana.Zahrbock@carrishealth.com | (320) 231-6353 | acmc.com
Carris Health is an innovative health care system committed to reinventing rural health care in West Central and Southwest Minnesota. Carris Health was formed in January 2018 and is part of CentraCare Health. Visit www.carrishealth.com for more information.
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JANUARY 2019 MINNESOTA PHYSICIAN
Family Medicine & Emergency Medicine Physicians • • • • •
Great Opportunities
Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice
St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria
Opportunities for full-time and part-time staff are available in the following positions:
• Physician (Care In the Community/ Integrative Whole Health) • Physician (Hospice & Palliative Care)
• Physician Psychiatrist (Mental Health)
• Physician (Hematology/Oncology) Part-Time • Physician (Pulmonologist) Part-Time
• Physician (Orthopedic Surgeon) Part-Time 763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
• Physician (IM/FP) St. Cloud MN • Physician (IM/FP) Brainerd MN
• Physician (IM/FP) Montevideo MN
• Associate Chief of Staff/ Education (Office of the Director)
YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.
• Associate Chief of Staff Primary & Specialty Ambulatory Medicine US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.
For more information:
Visit www.USAJobs.gov or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303
(320) 255-6301
For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com
©2013 Paid for by the U.S. Air Force. All rights reserved.
MINNESOTA PHYSICIAN JANUARY 2019
35
A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year
Urgent Care Physicians HEAL. TEACH. LEAD.
At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician
POSITIONS AVAILABLE:
OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available
• Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE
Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com
Join the Best. Join Entira Family Clinics. Entira Family Clinics is an award-winning, physician owned and operated group of primary care, after hours care, and express care clinics serving the East Metro for over 50 years. If you want the opportunity to influence how your practice is run, then look no further. Where Generations Thrive®: Our community-based clinics offer high-quality care specializing in family medicine and serve families at all stages of life.
Join our team today!
For more information, contact: Len Kaiser: 651-772-1572 or lkaiser@entirafamilyclinics.com
| entirafamilyclinics.com |
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MINNESOTA PHYSICIAN JANUARY 2019
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3Surviving a stroke from page 19
be admitted to the hospital tonight—I’ve got charts to close and patients to see!” Even though we have degrees behind our names and also work in health care, we want, need, and deserve the same empathy, explanations, reassurance, and time from you as your other patients.
Being in a hospital gown in a hospital bed is a powerless, vulnerable, and confining experience. We couldn’t eat when or what we wanted (dietary restrictions on the hospital menu), we couldn’t Closing thoughts shower when we wanted (public shower down the We are grateful for the many caring nurses, doctors, hall), we couldn’t use the restroom when we wanted physical and occupational therapists, and food to (need to monitor input/output), and we couldn’t service and housekeeping staff who took care of leave the room (risk of flu exposure). Being in a us. We will take the lessons we’ve learned from our hospital bed can make you feel like a caged animal Observing conflict among health experiences in the hospital into the care we provide at times. Therefore, when there are decisions we care team members is distressing. our patients every day. As shocking as our diagnoses can be involved in, we appreciate being part of the and subsequent hospitalizations were, they have discussion. Similarly, we appreciate your engaging made us more empathic providers and helped us our family members in our care when possible. relate better to our patients. We were both fortunate to have supportive family members and friends with us for most of our hospital Michelle D. Sherman, PhD, LP, ABPP, is a stays. When you help our support network (e.g., professor in the Department of Family Medicine and Community Health at answering their questions, getting them a blanket), you help us as patients. Please treat us as patients, not as providers or colleagues. When you’re taking care of health care professionals, please remember that we are now your patient. When sitting in a hospital bed, we’re not functioning as a provider. We are accustomed to being in control and making the treatment recommendations; we are frightened by the diagnosis (or diagnostic uncertainty) and scared to be in the vulnerable role of patient. After all, “we” aren’t supposed to get sick! We both remember thinking, “I cannot
Sioux Falls VA
the University of Minnesota. A licensed clinical psychologist, she directs the
behavioral health program at the University of Minnesota’s North Memorial Family Medicine Residency Program.
LuAnn Kibira, APRN, NP, is a nurse practitioner at Broadway Family Medicine, a University of Minnesota Physicians clinic in North Minneapolis. Her medical interest is women’s health.
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 positions: ★ Cardiologist
★ Psychologist
★ Endocrinologist
★ Pulmonologist
★ Hospitalist
★ Women Health Director
★ Neurologist
★ Emergency Medicine (part-time)
★ Oncologist
★ ENT (part-time)
★ PACT
★ Gastroenterologist (part-time)
★ Physiatrist
★ Urologist (part-time)
★ Psychiatrist
★ Vascular Surgery (Invasive) (part-time or full time)
apply online at www.USAJOBS.gov 36
JANUARY 2019 MINNESOTA PHYSICIAN
(605) 333-6852 ·
www.siouxfalls.va.gov
3Social engineering from page 15
unsolicited messages through a different means, such as a phone call or face-to-face conversation.
• Physically back up files outside of the network each day. Make a copy on electronic media or an encrypted external hard drive. Maintain the files in a secured location, preferably off-site or on a firewall-protected network or “cloud,” and periodically test them.
• Refrain from opening links or attachments in emails from unknown sources.
• If you experience a ransomware attack, notify all system users and shut down the systems as soon as possible to contain the spread. Notify the local FBI office and/or file a complaint with IC3 (www. IC3.gov). Notify your insurance carrier to determine coverage. Recovery will almost always require the help of outside experts.
• Do not use unknown or potentially compromised thumb drives that might contain malware.
• Involve your manager if you have any doubts or concerns.
Education Provide all employees with ongoing education to combat these threats. Consider the following: • Provide explanations and examples of the social engineering tactics currently being used by cybercriminals, particularly in the health care sector. • Exercise vigilance regarding emails, unsolicited phone calls, or inperson interactions that attempt to get them to reveal personal or sensitive information, or that require going to an unfamiliar website or installing an unfamiliar program. Do not be afraid to question and/or challenge strangers or unusual requests, and always verify the identity of the requestor rather than taking people at their word.
• Require ID badges to be worn; inconsistent enforcement allows a social engineer to merely say they forgot their ID badge.
Summing up Cybercriminals are becoming increasingly sophisticated, and health care is a prime target. Assess the security of your computer systems and enhance them as needed. Train your employees on an ongoing basis. Develop and practice contingency plans for these attacks. Given the scope and impact of the threats posed by modern cybercriminals, consider retaining outside security support as needed. Ginny Adams, RN, BSN, MPH, CPHRM, is a senior risk consultant for Coverys, a medical professional liability insurance company. She has a background in critical care nursing, nursing administration, performance improvement, regulatory compliance, and risk management.
• Be wary of unsolicited postal mail and unexpected emails, especially if they are requesting an urgent action. Always verify
Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.
Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist
Ely VA Clinic
Hibbing VA Clinic
• Tele-ICU (Las Vegas, NV)
Current opportunities include:
Current opportunities include:
• Nephrologist
Internal Medicine/Family Practice
Internal Medicine/Family Practice
US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.
Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage
For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417
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JANUARY 2019 MINNESOTA PHYSICIAN
•
www.minneapolis.va.gov
STAY FOCUSED AMONG THE DISTRACTIONS.
Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E A N A LY T I C S R I S K M A N A G E M E N T E D U C A T I O N
Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company® MINNESOTA PHYSICIAN JANUARY 2019
39
is for cardiology. University of Minnesota Health Heart Care As leaders in heart care interventions for over 60 years, we make innovative care our mission. We’ve transformed lives with major breakthroughs in valve replacements, transplants, cardiac resuscitation and other pioneering techniques to treat heart disease. With multiple centers and clinic locations throughout the region, we’re just a heartbeat away. We see patients six days a week. Learn more about our expert, innovative care.
Visit
MHealth.org/heartcare
University of Minnesota Health is a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ©2018 University of Minnesota Physicians and University of Minnesota Medical Center