MINNESOTA
FEBRUARY 2019
PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 11
Evidence synthesis Improving outcomes, avoiding waste BY TIMOTHY WILT, MD, MPH; WEI (DENISE) DUAN-PORTER, MD, PHD; AND NANCY GREER, PHD
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he amount of information available to make health care decisions is enormous and changing rapidly. Clinicians, health systems, policy makers, researchers, and patients often find it difficult to identify the “right information” about the effects of health care interventions. These medical information “end-users” increasingly rely on systematic reviews and corresponding clinical guidelines to provide trusted health care information.
Change management Improving outcomes in health care
Evidence synthesis to page 144
BY CLAIRE S. NEELY, MD, FAAP; AND SARAH HORST, MA
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For more than 20 years, clinicians and researchers at the Minneapolis VA Evidence-based Synthesis Program (ESP) and other evidence synthesis teams at the VA and the University of Minnesota have conducted and disseminated systematic reviews of health care interventions for high priority clinical topics. In this article, we describe our Minneapolis VA ESP processes and products, highlight examples of recent and ongoing
“People are entitled to joy in work.”—W. Edwards Deming
n health care, where change management is often viewed with dread rather than enthusiasm, this might seem like a surprising way to begin. Change management is most often defined as the process, tools, and techniques required to achieve a certain business outcome. This includes supporting people to make changes. Yet for many reasons, change management in health care—perhaps in the areas of new clinical guidelines, evidence-based practices to integrate behavioral health and collaborative care, implementation of Triple Aim objectives, or staffing structures—often fails to Change management to page 104
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FEBRUARY 2019
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Volume XXXII, Number 11
COVER FEATURES Change management
Evidence synthesis
By Claire S. Neely, MD, FAAP; and Sarah Horst, MA
By Timothy Wilt, MD, MPH; Wei (Denise) Duan-Porter, MD, PhD; and Nancy Greer, PhD
Improving outcomes in health care
Improving outcomes, avoiding waste
DEPARTMENTS CAPSULES
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MEDICUS
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INTERVIEW
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Shaping our health and well-being John R. Finnegan Jr., PhD University of Minnesota School of Public Health
PAIN MANAGEMENT 18 Dialing down opioid use
BEHAVIORAL HEALTH 26 Adolescent medicine Meeting unique needs
Correcting the curve
By Andrea Westby, MD; Michelle D. Sherman, PhD, LP, ABPP; and James Smith, MD, MPH
Thursday, April 25, 2019, 1–4 p.m.
MEDICINE AND THE LAW 30 “Stark” legislation and regulation
BACKGROUND AND FOCUS:
Updating the updates
Alternative treatments
By Antonio “Tony” Fricano, JD
By David Schultz, MD
CARDIOVASCULAR DISEASE 32 The “Million Hearts” initiative
BEHAVIORAL HEALTH 20 Play therapy
SOCIAL DISPARITIES IN HEALTH CARE
Helping medically complex pediatric patients
Addressing heart attacks and strokes
By Monica Oberg, MSW, LICSW
By Stanton Shanedling, PhD, MPH
PROFESSIONAL UPDATE: CARDIOLOGY Acute aortic dissection 24 Timely recognition and multidisciplinary care By Jasmine Curry, BS; Matt Pavlovec, RN, BSN; and Kevin M. Harris, MD
The Gallery, Hilton Minneapolis | 1101 Marquette Avenue South
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.
OBJECTIVES: 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. PANELISTS INCLUDE: Julia Joseph-Di Caprio, MD, Chief Medical Officer, UCare Rachel R. Hardeman PhD, MPH, Assistant Professor, Division of Health Policy and Management, University of Minnesota School of Public Health
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EDITOR___________________________________________________ Richard Ericson, rericson@mppub.com 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.
Vayong Moua, MPA, Director of Health Equity Advocacy, Blue Cross and Blue Shield of Minnesota Jeff Schiff, MD, MBA, Medical Director, Minnesota Health Care Programs Department of Human Services Jonathan Watson, MPIA, CEO Minnesota Association of Community Health Centers Joan Willshire, Executive Director, Minnesota Council on Disability SPONSORED BY:
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UMN First In U.S. to Offer New Targeted Therapy for Recurrent Brain Tumors University of Minnesota (M Health) has become the first health system in the U.S. to begin offering GammaTile Therapy, a new approach to treating recurrent brain tumors. GammaTile is an FDA-cleared, surgically targeted radiation therapy that is designed to delay tumor growth for patients with brain tumors. The first patient was treated by University of Minnesota physician Clark Chen, MD, PhD, head of the department of neurosurgery at the Medical School. Aggressive brain tumors tend to be resistant to current treatments and almost always recur, with outcomes for patients with brain tumors improving little over the past 30 years. GammaTile works differently—it consists of a bioresorbable, conformable 3D-collagen tile embedded with a cesium radiation source. It is placed
at the time of surgery so it immediately begins to target residual tumor cells with radiation while limiting the impact on healthy brain tissue. The treatment offers some advantages over other treatments for patients undergoing surgery for recurrent brain tumors. It doesn’t require any additional trips to the hospital or clinic, unlike current treatments— for example, a course of External Beam Radiation Therapy (EBRT) requires daily treatments for up to six weeks. Additionally, many patients may not be candidates for EBRT at the time of tumor recurrence because the risk of additional EBRT outweighs potential benefits. And those who may be candidates for EBRT typically have to wait four weeks or more for surgical wound healing before beginning treatment, allowing residual, microscopic tumors to grow during the waiting period. Chen has conducted research that supports the efficacy of radiation
treatment immediately after resection. His study, published in the Journal of Neuro-Oncology, showed that patients with glioblastoma, the most common form of primary brain cancer in adults, who received immediate postoperative radiation exhibited improved survival relative to those who did not.
Study Shows Most Health Systems Plan to Expand Virtual Care Services Virtual care software company Zipnosis has released a new report analyzing how health systems are deploying and using virtual care. Results of the 2018 On-Demand Virtual Care Benchmark Survey indicate that there will be a major increase in virtual care use by health systems over the next year, primarily driven by the enhanced efficiency that virtual care offers to providers. According to Zipnosis, studies have yet to examine how health systems are
deploying virtual care, and this study attempts to fill in that gap. The indepth analysis offers insights into the state of virtual care and looks at everything from adoption to common and future uses. A recent JAMA study showed that although telemedicine has grown steadily over the past few years, the majority of patients are still opting for in-person visits with their provider. However, the results of Zipnosis’ report show that 96.4 percent of health systems are planning to expand their virtual care services in the next year, with only 3.5 percent stating that they have no firm plans to do so. Among the systems with plans to expand, the most commonly selected options were adding modes of care and expanding use cases and specialties for patient-initiated visits. The report showed several other key trends. Behavioral health topped the list of areas that respondents would like to see virtual care address (nearly
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
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• Severe and persistent muscle spasms, including those characteristic of MS
• Intractable Pain
• Obstructive sleep apnea
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See our website for a detailed first year report. mn.gov/medicalcannabis
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FEBRUARY 2019 MINNESOTA PHYSICIAN
CAPSULES
40 percent), followed by chronic disease detection and management (16 percent). Nearly two-thirds of respondents looking to expand their platforms reported wanting to add real-time chat, video, and asynchronous capabilities to their modes of care. The majority of respondents (nearly 43 percent) reported the average work time for virtual visits is between one and five minutes, compared to the median visit length of nearly 16 minutes for in-person visits, according to National Institutes of Health data. Most respondents reported using virtual care to treat simple and more common conditions, with more than 50 percent reporting that they use their virtual care solutions to treat upper respiratory infections, urinary tract infections, cough, and pinkeye. In addition, nearly 42 percent of respondents said their virtual care solution did not integrate with their EMR. While only 21 percent indicated that as a challenge, EMR integration is an area that can help vastly improve the patient experience and should be a key focus moving forward, according to Zipnosis.
Physician Burnout Shows Some Improvement Research from Mayo Clinic and collaborators has shown that physician burnout appears to be improving, along with indicators for physician well-being, although physicians are still at high risk for burnout. Researchers from Mayo Clinic, the American Medical Association, and Stanford University collaborated in the national survey of physicians across more than 20 specialties to assess any changes since the previous study that was conducted in 2014, and the original survey that was conducted in 2011. Burnout varies by specialty, but overall, reported levels of burnout and satisfaction with work-life integration improved between 2014 and 2017. However, those numbers only fell to 2011 levels. The researchers say individual
and organizational efforts have improved the situation, but more work needs to be done. More than 30,000 physicians were invited to participate in the electronic survey. Of those, about 17 percent (5,197) responded, and a second attempt to reach those who did not respond gained another 248 participants. Questions mirrored those on previous surveys. The researchers say the reason for the change may be that physicians adapted to the new work environments over the three-year period. In addition, much progress may be attributed to interventional programs to stem burnout in hospitals and other health care facilities. However, they also note that the indicators may have improved because many distressed physicians have left the profession.
Intervention at Incarceration Could Help Prevent Opioid-Related Deaths A collaborative study from Hennepin Healthcare and Hennepin County has shown that a large proportion of opioid deaths in Hennepin County in 2015 and 2016 occurred after a jail stay. The researchers, who analyzed death and jail records for the study, say this finding confirms county officials’ suspicions. The results showed that 71 out of 252 opioid deaths in Hennepin County occurred within one year of release from custody. Nearly 25 percent of those occurred within two weeks of release, and more than half were within 90 days. Among those who died from an overdose after a jail stay, 81 percent were incarcerated for at least 24 hours. The researchers say the findings point to the need for a shift in how officials in corrections and health and human services offer recovery services. “Most people with an opioid use disorder will spend time in the criminal justice system,” said Tyler Winkelman, MD, MSc, a physician and researcher at Hennepin Healthcare.
REQUEST FOR NOMINATION Publication Date: June 2019 NOMINATION CLOSING May 3, 2019
Seeking Exceptionally Designed Health Facilities in Minnesota Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2019 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any construction designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible. In order to qualify for the nomination, the facility must have been designed, built, or renovated by January 1, 2019. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota, or Iowa). Fill out the form below and provide a brief project description (150–250 words), or fill out the form on our website by Friday, May 3, 2019. Color photographs are required at 300 dpi resolution (no more than eight) with a caption for each; send photos to amarlow@mppub.com. Online form: www.mppub.com/honor-roll.html
Health Care Architecture & Design Honor Roll Nomination Form Facility name Type of facility Location Ownership organization Owner address, phone Architect/interior design firm Architect address, phone Engineer Contractor Completion date Square feet Total cost Brief description
Send to: Minnesota Physician Publishing Honor Roll 2812 East 26th Street, Minneapolis, MN 55406 Fax: 612.728.8601 Email: comments@mppub.com For more information, call 612.728.8600
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MINNESOTA PHYSICIAN FEBRUARY 2019
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CAPSULES
“This report shows that correctional facilities can and should play a critical role in the public health response to the opioid epidemic. Expanding treatment options for this population could substantially lower opioid deaths in Hennepin County.” Currently, Hennepin County social workers connect people with behavioral and chemical health resources for follow-up after being released from jail. However, this new information shows that diagnosing opioid use disorder and beginning medical treatment while in custody could have positive outcomes for people and reduce the number of deaths and the traumatic and expensive overdose-hospitalization-jail cycle that usually precedes them. Other agencies’ work has shown that this intervention is effective. In Rhode Island, they implemented treatment for opioid use disorders at every jail and prison in the state— one year later, overdose deaths
following release from jail decreased by 60 percent and overdose deaths statewide decreased by 12 percent. Hennepin County is in the process of applying for grant funds available through recent federal legislation, which will be used in combination with county funding, to strengthen current practices. These consist of including substance use disorder screening in jail health intake; creating a system to help people start treatment, or support those who are already using medications like naltrexone, buprenorphine, or methadone to control their disorder; and strengthening connections to community treatment providers. Other findings from the study time period show that 755 Minnesotans died from causes related to opioids (a 26 percent increase from 2011–2012). Hennepin County residents accounted for 33 percent of those deaths; African American and Native American people
were disproportionately represented among those that died from opioid-related causes; and residents of suburban Hennepin County accounted for nearly half the deaths.
Health Care Spending Growth Slowed in 2016 Health care spending for Minnesota residents reached $47.1 billion in 2016 and grew at one of the lowest rates in the past decade, according to a report from the Minnesota Department of Health (MDH). However, the report, Minnesota Health Care Spending: 2015 and 2016 Estimates and Ten-Year Projections, also warns that continued growth could double overall spending on health care in the next 10 years. According to MDH, the slower spending growth in 2016 was driven by reductions in public program spending for beneficiaries of Minnesota Health Care Programs. The reduction resulted from changes in
how the Minnesota Department of Human Services negotiated payments to health plans. They note that had public program spending continued its 2015 trend, overall spending would have increased more than 5 percent in 2016, by an additional $1.6 billion. Private health insurance spending increased 6.1 percent and Medicare spending increased 4.9 percent in 2016. The long-term projections suggest health care spending over the next decade will double, reaching $94.2 billion, meaning Minnesota is on track to spend $1 out of every $6 generated by the state’s economy on health care. The report also found that hospital spending remained the largest spending category with inpatient spending comprising 18 percent and outpatient hospital spending accounting for 14.8 percent of total health care spending in 2016.
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MEDICUS
Donn Dexter, MD, neurologist with Mayo Clinic Health System in Eau Claire, has received the inaugural Donn Dexter Physician Excellence Award from University of Wisconsin Organ and Tissue Donation for his comprehensive leadership and clinical work to support organ donation. The program decided earlier this year to create a new physician award to recognize high standards in donation support—while the team was creating the award criteria, Dexter’s work was cited as examples of the gold standard, leading to the decision to name the award in his honor. Dexter earned his medical degree at Mayo Clinic College of Medicine.
Nancy Guttormson, MD, a surgeon with Fairview Health Services, has received the 2018 First a Physician Award from the Twin Cities Medical Society. The award is given annually to a member who selflessly gives of their time and energy to improve the health of their patients, has made a positive impact on organized medicine and the medical community’s ability to practice quality medicine, and/ or has been instrumental in improving the lives of others in the community. Guttormson’s colleagues at Fairview Ridges Hospital recognize her as a highly skilled head and neck endocrine surgeon and breast surgeon, as well as a respected leader and teacher. She is credited with pioneering the thyroid cancer program and helped establish the Breast Center at Fairview Ridges Hospital, as well as a multidisciplinary tumor board. She earned her medical degree at the University of Minnesota.
Timothy Zavadil
Illych Rivas
Macaran Baird, MD, MS, Professor Emeritus and retired department head in the University of Minnesota department of family medicine and community health, has received the 2018 Shotwell Award from the Twin Cities Medical Society Foundation, for making significant contributions in the field of health care. Baird began his career practicing in the rural community of Wabasha for five years. He launched his academic career in 1985 by serving as an assistant professor at the University of Oklahoma, followed by an appointment as professor and chair of the State University of New York Medical School, Syracuse, department of family medicine. He returned to Minnesota in 1996 to serve as associate medical director for HealthPartners, then moved to Mayo Clinic where he served as medical director of Mayo’s health insurance program and professor of family medicine. He then returned to his alma mater, the University of Minnesota, as professor and head, department of family medicine and community health within the Medical School, where he served from 2002 through his retirement in December 2017. In November 2017, he was called on to serve as the interim chief executive officer of University of Minnesota Physicians. During the 12-month assignment, he was a key leader who helped create new institutional partnerships and strengthened key relationships within and beyond the university group practice. He is now retired.
Sarah Hicks & Sam Bergman
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MINNESOTA PHYSICIAN FEBRUARY 2019
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INTERVIEW
Shaping our health and well-being John R. Finnegan Jr., PhD University of Minnesota School of Public Health What do you want people to think when they hear the term “public health”?
difficult if you’re poor; it’s harder if you’re poor and a person of color; and even harder if you’re poor, a person of color, and an immigrant.”
Public health is about the forces and factors that combine to shape the health and well-being of population groups. Core to public health is disease prevention and health promotion, and the partnerships it takes to make these efforts effective. Just a few examples of the variety of public health work from our school: We’ve developed apps for just-in-time interventions to stop HIV transmission; we help keep farm children safe from injuries; and we design and run some of the largest clinical trials in the world in infectious and communicable diseases. Public health has a full dance card!
What are the biggest challenges facing the field of public health?
Let me single out three: aging populations, climate change, and the need for further federal investment in U.S. public health. Today, 8.5 percent of people in the world are 65 and older; by 2050, that will likely reach 17 percent. This means a greater burden of chronic disease, rising health and long-term care costs, strains on health infrastructures, and an even more urgent need for prevention and health promotion at younger ages.
What are some of the common misperceptions people have about the field?
And second, some think public health efforts lead to “a nanny state,” though most public health professionals, including our school’s graduates (master’s and doctorates), work in the private sector. Regardless of that fact, public health relies on education, technology, and community partners to disseminate what it learns through evidence-based research that explores what is hurting or helping our collective health. What can you tell us about gun violence as a public health issue?
Some 100 people die every single day from guns in the U.S., and suicide accounts for 63 percent of those deaths. What’s more, a 2018 study in Health Affairs found that U.S. children ages 15–19 were 82 times more likely to die from gun homicides than those in our peer nations. We look at the problem through multiple interventions. I know that some people are deeply afraid that preventing gun violence means taking away people’s guns, but
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FEBRUARY 2018 MINNESOTA PHYSICIAN
“...”health’s focus on Public the population contrasts with medicine’s focus on the individual. that’s not a public health approach. For us, it’s about realistic, achievable ways to reduce the carnage.
As for federal funding, we’re not spending enough as a nation on prevention and health promotion. Some 90 percent of our nation’s health dollars go to health care, a system which many studies have shown is the most expensive and least efficient on the planet. We need a rebalancing!
How can public health initiatives address social disparities in health care?
What could the media do to heighten awareness of public health issues?
“...”
First, a lot of people think of public health in medical terms, such as treating patients. There is a strong complementary connection between medicine and public health, to be sure, but the focus and the tools are different. Public health’s focus on the population contrasts with medicine’s focus on the individual, for example.
Climate change exacerbates a host of public health concerns, such as the emergence and reemergence of infectious diseases, respiratory illness, water pollution, and excessive heat affecting aging adults and other vulnerable populations.
One approach we take is to shine a light on health care disparities, then follow up whenever possible with solutions that often lie in public policy and system changes. Two examples: Associate professor Katy Kozhimannil, PhD, found that birth doulas improve birth outcomes for low-income women, among whom women of color and American Indians are overrepresented. Her research had direct impact on the 2013 passage of Minnesota’s “Doula Bill” that permitted Medicaid coverage of services provided by a certified doula. SPH’s Upper Midwest Agricultural Safety and Health Center is addressing the well-being of immigrant farm workers. Co-director professor Jeff Bender, DVM, says, “Accessing health care is
The media can play a positive role to further public health, especially through advertising and television programming. The recent Merck ad (www. tinyurl.com/mp-merck) for HPV vaccine is extremely effective. On the other hand, with the explosion of social media there is potential for negative impact. Witness the anti-vaccine movement that promotes the falsehood that childhood vaccines cause autism. I also believe that scientists and journalists need to communicate research better to the public. Recently you were awarded one of 11 research grants nationally to improve the interface between public health research and physicians in clinical practice. What can you tell us about this project?
The grant supports a collaboration among SPH,
Mayo Clinic, and Hennepin Healthcare. With a $4 million, five-year award, we’ll train researchers in a game-changing approach to health care and health care research called learning health systems (LHS). In LHS, researchers embed in a health care system, bringing continuous and real-time learning into the relationship between researchers and clinicians to improve the quality of patient care. Fairview Health Services, Minneapolis VA Health Care System, Children’s Minnesota, Ebenezer, Essentia Health, and HealthPartners will partner with the program (Minnesota Learning Health System Mentored Career Development Program) to train the scholars, offering diverse patient populations and dynamic learning laboratories. What concerns do over-consolidation in health care pose to public health?
Like it or not, consolidation is the rule today and the question is whether or not it will reduce costs and keep quality high. Many experts believe that this trend is actually raising health care costs, shifting costs to consumers, but not improving patient care. We know that the consolidation of certain services leaves many in rural areas with reduced
access to health care. A recent study from our school (www.tinyurl.com/mp-SPH-study) found that rural U.S. counties that lost hospital-based obstetric services and were not adjacent to urban areas had significant increases in out-of-hospital births, births in a hospital without an obstetric unit, and preterm births in the first year. What can you tell us about the role of public health in shaping health care legislation?
Public health research provides data and evidence for health care legislation and helps guide policy decisions. Health policy and management are major parts of many schools of public health, like ours, and our research shapes the design of public programs, such as Medicare and Medicaid. For public health to be truly effective, though, we need legislators to pay more attention to research. We also need to make our findings easier to understand and apply. Our school did a study with the University of Minnesota Medical School and found that only 41 percent of all formal legislative discussions on childhood obesityrelated bills in Minnesota from 2007–2011 cited some form of research-based evidence.
What can physicians do to become more involved with a public health agenda?
Physicians are our best partners when it comes to protecting people from disease and fostering good health and well-being. We have physician-researchers on our faculty as well as physician-students who seek an MPH or PhD. Often they discover public health after they have spent many hours treating people with chronic diseases that could have been prevented. Those of us in public health and primary care have an important opportunity to form strong partnerships with communities to promote disease prevention and a culture of health. A good example of this is the Practical Playbook (www.tinyurl.com/mp-playbook). John R. Finnegan Jr., PhD, has been dean and professor at the University of Minnesota School of Public Health since 2005. With a doctorate in journalism and training in mass communication, he developed public health campaigns and a research and education program in health communication. He serves on several health-related local, national, and international boards.
MINNESOTA PHYSICIAN FEBRUARY 2018
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3Change management from cover
with so much external change, that resistance to internal change management programs continues and may even be growing within physician ranks.
provide this necessary support to health care workers before, during, and after any system change or process improvement.
Change management or rigid mandate?
When physicians and other health leaders resist change, it can be challenging for administrators and change agents to introduce and implement new systems and process improvements. When faced with resistance, management can easily fall into the trap of issuing rigid mandates disguised as quality improvements. This often leaves organizational change agents feeling like a modern-day Sisyphus, Embracing change is not optional, dragging unwilling participants up the hill toward the it’s a requirement to survival. desired outcome, only to repeat the same effort the next day, and the day after.
When it comes to quality improvement and the transformation required to thrive in a value-based care environment, the idea of facing one more process improvement can seem overwhelming. In fact, when there’s a choice between making a change and maintaining the status quo, most people choose the latter. So how can physicians and other health leaders not only implement change but achieve strong engagement around change (or even “joy”), particularly when many health care workers are feeling burned out and disillusioned? There isn’t an easy answer. Too often, what organizations call “change management” are actually top-down management mandates, instead of what should be an inspirational, creative practice.
The practice of medicine has faced unbelievable amounts of change over the past decade. Much of that change has been externally driven, from federally mandated electronic health records, to the introduction of the ACA and the implementation of Medicare star ratings. Further disruption has resulted from medical information being widely available on the internet. This has armed health care consumers with knowledge, but at times has created challenges when the information was of poor quality. It’s not surprising, faced
Obviously, there’s a problem with change management in health care. At quality improvement workshops led by the Institute for Clinical Systems Improvement (ICSI), we’re asked the same question over and over again: “How do we get people to participate in improvement?” The answer is not rigid mandates, which create defiance rather than engagement. The answer lies in creating an atmosphere that embraces collaboration and the co-creation of solutions. Simply put, the answer is a return to teamwork. Physicians can and must be the leaders in transforming how health care approaches and manages change and quality improvements. They must embrace the idea that the responsibility for any improvement resides with everyone, not just the quality improvement (QI) staff or a designated change agent. Most health care organizations already have a good understanding of Lean and Six Sigma principles. It’s the engagement skills that have been left behind. To truly engage people within health care, change has to be a collaborative process. Physicians should play a strong role in moving to what often constitutes a brand new mindset around change management
Developing the “how” through small tests of change
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Redefining change management can benefit from taking a fresh look at the Model for Improvement (MFI) developed by quality experts Gerald J. Langley and Kevin M. Nolan, authors of “The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.” Although most health care leaders “know” the MFI, the actual implementation of the MFI and its associated tools may not always be carried forward in its true spirit of trial and learning. In our experience, most organizations are taking on activities that are too big for the MFI’s Plan-Do-Study-Act (PDSA) cycles. Using smaller PDSAs can further change more effectively. By involving the team in specific, smaller cycles, PDSAs can also serve as a vehicle for re-introducing a more collaborative approach. Evidence has shown that testing hypotheses on a small scale actually speeds up improvement. The cycles iterate more quickly, and knowledge is acquired more rapidly. It’s clear that nearly everyone understands “what” needs to be done. It’s usually the “how” that isn’t planned well. The “what” is often the mandate, such as a strategic goal, or compliance to certain required metrics. Redefining the “how” can help achieve stronger engagement, by using a team approach and building a solution that reaches the desired outcome.
Steps to engaging the team in quality improvement Most health leaders and other change agents feel they’ve tried just about
everything, and many are frustrated by their inability to motivate teams to improve. What usually hasn’t been tried, however, is asking the team to participate in creating the “how.” It may seem like a leap of faith to believe that the team will co-create strong solutions, but in most cases, that’s exactly what happens. While there is some variation depending on the size of the team and the situation being addressed, most successful engagement follows these four steps: 1. First, clearly define the non-negotiable “what.” In other words, be clear about the goal that must be achieved. Explain that the status quo is not an option and that their participation is a necessary and vital part of developing process improvements. Physicians should consider using data and patient stories that help support the staff’s understanding of the goal.
and then co-create possible solutions based on ideas generated from the team. Solutions may not be clear at first, but there needs to be a sense of freedom and safety to explore any avenue. Physicians are trained to be analytical and find problems, but this is a time to hold back on analyzing potential outcomes. This allows many possible solutions to be considered before choosing what to try.
Too often, what organizations call “change management” are actually top-down management mandates.
2. Next, encourage ownership of the “how.” Gather ideas from the team in a group setting on ways to accomplish the goal, and/ or to reach the desired outcome. Ask them to hold each other accountable for contributing ideas. Physicians can support the QI facilitator in this idea-gathering phase by encouraging all members of the team to share ideas. An outside facilitator can be helpful when doing this exercise with a new team. 3. Now, focus on embracing every idea. Create a safe environment where all suggestions have a place on the table to be considered by the team. The goal is to gain a better understanding of the problem together,
4. Finally, experiment with small PDSA cycles. As the team examines the results of each test cycle, they need to be willing to use what works, keep testing those which seem promising, and abandon ones that simply didn’t work. It’s important for new processes to represent real improvements, not merely changes. This is the phase where a physician’s strong analytical skills can and should be used.
A major premise of improvement experts Langley and Nolan’s guide is that change isn’t achieved through the implementation of a single solution. It’s the impact of several changes that have the most effect on the whole system. Understanding this, and adopting an iterative, team-based approach, can accelerate quality improvements. Team members feel a sense of ownership around the improvements, which in turn results in more engagement in the future. Change management to page 124
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3Change management from page 11 Infusing change management with collaboration Change management may be difficult to tackle within many health care organizations where physicians and staff are overworked, overwhelmed, or even burned out. An unusual but effective tool that has proven useful involves applying the rules of improvisational arts to quality improvement. In ICSI’s “Prime the Pump” workshop series, physicians and health care staff are invited to re-engage with change management through the collaborative framework of improv. Anyone who has watched the popular show “Whose Line Is It Anyway,” listened to jazz, or seen a performance by Stevie Ray or Brave New Workshop is familiar with improv. Watching successful improv is to see a group of people creating a safe, supportive environment where exceptional teamwork is employed to address a challenge together. Practicing the principles of improv can help drive collaboration within everyday work scenarios. Improv principles map beautifully to the process of change management, which requires an open, learning-based environment. Improv has a performance style with many layers of complexity, but these few key components of improv can be used to effectively create a collaborative environment for change management and conducting small tests of change: • Always say “Yes, and…” rather than “No” or “But” to any idea. This honors and validates others’ contributions, creating a supportive environment for new ideas to develop and thrive.
• Choose to always move forward. Embracing change is not optional, it’s a requirement to survival. Phrases like “If not this, then what?” help people consider new options when they are stuck. • Make your partners look good. Encourage participants to see themselves as interconnected and dependent on each other for success. • Genuinely listen and support others by discontinuing habits of negating, ignoring, or refusing ideas. Physicians who have participated in ICSI’s workshop Prime the Pump: Activate the Team, Accelerate Improvement often report back that they’ve learned new ways to collaborate with their staff and lead teams to co-create stronger, more positive change. Participants feel much safer making suggestions, and the atmosphere of teamwork that improv brings presents change management in a supportive, positive, and, often, joyful light.
Conclusion Change management in health care needs a makeover. Physicians can support this by using the four steps to engagement. Clarifying the “what,” team ownership of the “how,” and embracing ideas and testing them together builds a collaborative process for an iterative model of change. Adopting improv tools is one way to help create a team-based mindset and empower teams to change the system in a profound and meaningful way. Claire S. Neely, MD, FAAP, is chief medical officer at the Institute for Clinical Systems Improvement (ICSI).
Sarah Horst, MA, is a project manager/health care consultant at ICSI.
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Fast-acting relief from complex pain cases Fast-track scheduling of advanced pain procedures. Dealing with complex, chronic pain cases can tax your resources and your patience. Led by nationally-renowned pain specialist David Schultz MD, Nura Clinics offers quick access to the Midwest’s most advanced interventional procedures. With referrals typically scheduled within one week, Nura is the answer to complex chronic pain cases. Call our Provider Answer Line at 763.325.9696 for an immediate consult from a dedicated pain specialist and expedited appointment scheduling.
Why Nura Dr. Schultz is a pioneer in interventional pain management. His Nura Clinics are nationally recognized centers of excellence for the most complex pain procedures. These include implantable systems like neurostimulation devices and pain pumps for precision-targeted drug delivery, along with stem cell and regenerative therapies. Nura is also one of the leading sources of performance-based research data for these approaches. Put your patients in some of the best hands in the Midwest. Call today for fast access to the most advanced interventional therapies for chronic pain.
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3Evidence synthesis from cover reviews, and discuss future challenges and opportunities, with suggestions to assist readers in utilizing findings to improve health care quality.
Evidence synthesis at the Minneapolis VA Health Care System
medical organizations, including the American College of Physicians, the American Urological Association, and the National Kidney Foundation. We also support reviews initiated by clinicians, health care systems, and researchers to improve care quality or serve as foundations for research grant applications.
Evidence synthesis and methods work is often conducted in collaboration with other The Minneapolis VA ESP is comprised of evidence reviewers, including Philipp Dahm, a multidisciplinary group of clinicians and MD, MHSc, coordinating editor of Cochrane researchers with expertise in health care practice, Patient data … can lead to Urology (Urology Section). Dr. Dahm and policy, and research. The ESP receives funding meaningful improvements in Shahnaz Sultan, MD, MHSc (Gastroenterology from the VA Quality Enhancement Research patients’ experiences and health. Section) are international leaders in evidence Initiative and is under the direction of Timothy review methodology. As members of the Grading Wilt, MD, MPH, general internist and health of Recommendations Assessment, Development services researcher and professor of medicine at and Evaluation (GRADE) Network, they provide the University of Minnesota. The ESP is one of national training and mentorship in systematic four nationally funded VA programs and part of reviews and evidence-based health care. We also partner with the University the Minneapolis VA Center for Care Delivery and Outcomes Research, a VA of Minnesota School of Public Health as the Agency for Healthcare Research national Health Services Research and Development Center of Innovation. and Quality (AHRQ)-funded Minnesota Evidence-based Practice Center Our evidence teams prepare rigorous, readable, and relevant syntheses of (EPC), co-directed by Dr. Wilt and Mary Butler, PhD, MBA, associate published scientific literature and make their findings available to clinicians, professor of the School of Public Health. managers, and policymakers to improve the health of Veterans and others. Nancy Greer, PhD, is the ESP program manager, and Wei (Denise) DuanPorter, MD, PhD, is associate director. In addition to VA reports, our evidence team conducts reviews funded by and designed to inform clinical practice guidelines for multiple
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Background on evidence synthesis programs ESPs produce and disseminate systematic reviews of existing evidence to: identify effective services to improve patient outcomes; avoid ineffective, wasteful, and potentially harmful care; support development of evidencebased policies, practice guidelines, and performance measures; and set the direction for future research to address knowledge gaps. ESPs help VA fulfill its vision of functioning as a “learning healthcare system” to improve Veterans’ health and health care. ESP teams are comprised of a core group of individuals with expertise in systematic review methodology complemented by project-specific content experts. ESP members provide disclosures and are not permitted to have significant scientific or financial conflicts of interest. Topics are nominated by clinical and policy stakeholders, who help refine key questions to ensure they are clinically useful while remaining manageable in scope. Questions are developed to address clinical benefits, harms, and costs, as well as implementation barriers and facilitators using a PICOTS framework (Patient, Intervention, Comparator, Outcomes, Timing, and Setting). ESP reports begin with executive summaries highlighting key findings. Full reports include detailed methodological information, results, and discussion of research gaps and policy implications. Reports undergo peer review with a focus on highlighting findings useful for clinicians and policy makers. Technical reports are available online throughout the VA and in the public domain, and summaries are often published in medical journals and presented in national VA Cyberseminars. “Management e-Briefs” are prepared to provide succinct nontechnical information to VA management and policy leaders, enhancing implementation. Project timelines range from several months to one year.
Evidence reports and their impact on health care practice and policy Four examples highlighting the range of topics and health care impacts:
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FEBRUARY 2019 MINNESOTA PHYSICIAN
support. The report, led by Dr. Greer in collaboration with Jennifer Bolduc, The utility of screening pelvic examinations. While more than 60 PharmD, focused on pharmacist-led care for patients with diabetes, hypertension, million pelvic examinations are conducted each year, often as part of a and lipid disorders, comparing outcomes with those of patients who did not general wellness exam, the utility of the pelvic exam is not known. The participate in pharmacist-led care (defined in the report as “usual care”). VA Office of Health Promotion and Disease Prevention and the Women’s Health Network requested a review evaluating Data from 63 studies indicated that pharmacistthe diagnostic accuracy, clinical benefits, and led care, when compared with usual care, was potential harms of the pelvic examination in associated with comparable numbers of visits to asymptomatic, nonpregnant women. Led by primary care offices, urgent care, or emergency Hanna Bloomfield, MD, MPH, results from departments; hospitalizations; and medication Rigorous reports that do not 52 studies found no data supporting the use of adherence. Pharmacist-led care increased the number align with clinical and policy pelvic examination in asymptomatic, averageor dose of medications received and improved needs are not useful. risk women. Low-quality data suggested that glycemic, blood pressure, and lipid goal attainment. pelvic examinations may cause pain, discomfort, Mortality and clinical events were similar. Evidence fear, anxiety, or embarrassment in about 30 on patient satisfaction was mixed. Further research percent of women. Report findings led to VA is needed to determine whether pharmacist-led care clinical guidance statements. The American improves clinical outcomes. The results support College of Physicians subsequently developed health systems expanding the role of pharmacist-led care, especially if targeted clinical guidelines recommending against performing screening pelvic intermediate goals have demonstrated beneficial outcomes. examinations in asymptomatic, nonpregnant women. Chronic musculoskeletal pain scales. Chronic musculoskeletal pain is Evaluating pharmacist-led care. Pharmacists have expanded their a major source of disability and morbidity. Management remains challenging involvement in patient care, including independent prescribing privileges. This and pain experts have called for more strategic pain therapy research. A VA may increase access, improve outcomes, and lower costs. The VA National State of the Art Conference on chronic musculoskeletal pain management and Clinical Pharmacy Research Group and Pharmacy Benefits Management the VA Pain Measurement Outcomes Workgroup requested a review describing program requested an evaluation of the effectiveness and harms of pharmacistexisting research on key psychometric properties of self-report measures of pain led chronic disease management, which may include medication monitoring, medication therapy review, prescribing authority, and/or disease self-care and Evidence synthesis to page 164
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3Evidence synthesis from page 15
required because they can lead to biased and contradictory findings not easily discerned. This can result in distrust in “evidence-based” health care, in part because evidence reports require numerous decisions to efficiently summarize original research. These decisions should be transparent and defendable. (See sidebar for questions to ask when critically appraising systematic reviews.)
severity and functional impairment. To address their needs in the rapid time frame required, we conducted a “rapid review and evidence map.” We developed this approach to illuminate the research gaps and data synthesis challenges. Led by Elizabeth Goldsmith, MD, PhD, we found that five measures had the most evidence, though there was substantial variation in estimating psychometric properties, defining chronic musculoskeletal pain, [Physicians] often find it difficult and reporting patient demographics. Further to identify the “right information” research is needed to validate patient-reported pain about the effects of health care outcome measures in populations with chronic interventions. musculoskeletal pain. Preventing long-term nursing home placement. Nursing-home placement has high financial and social costs. Identifying modifiable determinants of, and interventions to reduce, long-term nursing home placement can improve patient- and caregiver-centered outcomes and reduce health care costs. An ongoing review, led by Wei (Denise) Duan-Porter, MD, PhD, is intended to enhance national VA program policies and practices to optimize the ability of Veterans to remain in their own homes if desired.
Challenges and opportunities Evidence synthesis teams must overcome future challenges. These include incorporating advances in systematic review methodology and enhancing results communication. Reducing the overabundance of systematic reviews that are scientifically flawed or conducted by groups with strong conflicts is
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However, rigorous reports that do not align with clinical and policy needs are not useful. Future evidence synthesis team roles include assisting partners to identify steps required for reliable evidence reports, as well as where and if additional value lies in conducting a report. Evidence reports must increasingly be responsive to rapid advances in medicine and end-users’ timelines. Tradeoffs between “scientific thoroughness” and timeliness are required, though large consequences exist with flawed shortcuts because evidence reports inform practice implementation and performance measurement development. “Socializing” evidence reports and carefully engaging in “informed speculation” is challenging, but allows evidence reports to serve as a trustworthy “bridge” between rigorous, refined research settings and unique day-to-day patient care experiences. As the amount of knowledge and needs of stakeholders expands, “living guidelines” with continuous evidence updates or searches for signals of important new information will be required so that review findings remain up-to-date. Despite these challenges, numerous opportunities exist. Clinicians will increasingly need accessible, reliable evidence to address questions relevant
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to their patients. Health care systems will seek guidance on local policy and purchasing decisions; e.g., should they design and put into place new multicomponent pathways for post-operative care and, if they do, what implementation barriers and facilitators exist; are the benefits of selected technologies worth the upfront and downstream harms and costs; what are the comparative trade-offs when selecting among different medications for inclusion on a pharmacy formulary; can “smart” electronic reminder systems be established to enhance personalized care quality based on reliable evidence of benefits and harms and, if so, how will they be used to derive and monitor pay-for-performance? Researchers and funders will want to know what evidence gaps exist and the types of research needed to close clinically important gaps.
Wei (Denise) Duan-Porter, MD, PhD, is a general internist at the Minneapolis
Rigorous, readable, relevant (and timely) systematic reviews and their accompanying practice guidelines will increasingly be valuable resources to help fill these needs. The Minneapolis VA ESP and other Minnesota evidence synthesis groups welcome opportunities to assist stakeholders define, discover, and deliver high value health care.
led evidence reports across a wide range of health care topics.
Timothy Wilt, MD, MPH, is a general internist and health services researcher at the Minneapolis VA Center for Care Delivery and Outcomes Research and professor of medicine at the University of Minnesota. He is the director of the
VA Health Care System, health services researcher at the Minneapolis VA Center for Care Delivery and Outcomes Research, and assistant professor of medicine at the University of Minnesota. She is the associate director of the Minneapolis VA Evidence-based Synthesis Program. Her research has focused on improving patient-centered outcomes and quality of care for medically complex older adults.
Nancy Greer, PhD, is a health science specialist at the Minneapolis VA Center for Care Delivery and Outcomes Research. She is the program manager for the Minneapolis VA Evidence-based Synthesis Program (ESP) and project manager for ESP and other evidence review projects, overseeing a team of project coordinators and research assistants. She has conducted and
STATISTICAL ANALYSIS
Minneapolis VA Evidence-based Synthesis Program and co-director of the Minnesota AHRQ-Evidence-based Practice Center. Dr. Wilt’s clinical and research interests are in health promotion and disease prevention, detection, and treatment, with an emphasis on enhancing high value care and reducing low value care.
Questions to ask when critically appraising systematic reviews
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• Do the key questions address the clinical situation relevant to my patients and practice? • Was the literature search comprehensive and up-to-date? • Are clinical benefits and harms, including costs and burden, adequately considered? • Are results presented in absolute as well as relative terms? • Are important patient and condition subgroups evaluated (e.g. age, sex, race, condition severity, and comorbidities)? • Is there an assessment of individual study quality and overall results’ certainty? • Are the conclusions justified by the results?
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PAIN MANAGEMENT
Dialing down opioid use Alternative treatments BY DAVID SCHULTZ, MD
T
As a result, from 2000 to 2010, the rate of opioid prescribing, the number of opioids distributed, and the average prescription size all increased markedly as deaths from opioid overdoses ramped up in parallel.
How did we get here?
Patients with chronic pain present with a broad continuum of different problems, ranging from nociceptive (biological) pain caused by severe inflammatory conditions like rheumatoid arthritis, to neuropathic pain caused by damage to the nervous system, to pain behaviors driven primarily by psychological mechanisms and personality disorders. Sorting out the causes for chronic pain and developing an effective treatment plan are challenging tasks for physician pain specialists. Regardless of the cause for pain, it has become increasingly apparent that prescribing opioids to treat chronic pain may lead to addiction in susceptible patients and overdose death in some of these patients. And most experts agree that the liberal opioid prescribing practices of the past have contributed to our current national opioid crisis.
he opioid crisis currently gripping the U.S. presents significant challenges for the treatment of chronic pain. For much of the 2000s, opioids were liberally prescribed to treat pain, but in recent years, it has become clear that prescription opioids may lead to abuse, addiction, and overdose death in a certain population of chronic pain patients. The risks associated with opioid treatment have forced patients dealing with chronic pain—and physicians attempting to treat that pain—to look for alternative treatment options. Fortunately, a variety of alternative, non-addictive pain treatments are available and will be discussed in this article.
In the 1990s, the under-treatment of acute and chronic pain in the U.S. became recognized as a major public health problem. In response, Congress ushered in the “Decade of Pain Control” in 2000 at the same time that health care regulators designated pain to be the “Fifth Vital Sign” and prominent physicians advocated for more liberal opioid prescribing. This trend toward more aggressive pain management was bolstered by the pharmaceutical companies as they developed and marketed powerful new opioid formulations.
By 2012, the U.S. was in the midst of a full-blown opioid crisis that persists today. According to the recently published Surgeon General’s Spotlight on Opioids, opioid overdoses killed more than 48,000 Americans in 2017, and deaths from opioids in the U.S. have surpassed deaths from motor vehicle accidents and shootings combined in every year since 2013. Although illicit fentanyl is now a major contributor to the current crisis, prescription opioids administered for pain have been implicated in causing the addictions that have led to many opioid overdose deaths.
Options beyond opioids: multidisciplinary intervention Fortunately, the science and technology of pain management has advanced over the past two decades to the point where there are now alternatives to opioid management for chronic pain that may provide better pain relief with less risk. Physicians in the new medical specialty of interventional pain management (CMS designation 09) have pioneered the use of minimally invasive, image-guided procedures to identify and treat the physical generators of pain and utilize high tech, fully implantable pain control systems for extreme pain that proves unresponsive to more conservative measures. Multidisciplinary, interventional approaches coordinate these pain-relieving procedures with physical therapy and behavioral health treatments to effectively treat chronic pain in a holistic fashion with less reliance on opioids. Nura is a multidisciplinary, interventional pain clinic in the Minneapolis/St. Paul area. When a patient is referred with complex chronic pain, we start with a comprehensive, pain-focused evaluation to create a tailored treatment plan that best fits the patient’s needs. We begin by optimizing medication management using non-addicting medications such as NSAIDs, acetaminophen, anti-depressants, and nerve-stabilizing drugs like gabapentin.
New drugs in development There is intense international research within academic institutions and large pharmaceutical companies aimed at developing highly selective
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stimulation is often tried first because it is an epidural system that is not in drugs to block specific pain pathways with minimal side effects. Nura direct contact with the spinal cord and does not involve medications. Pain participates in research studies on some of these investigational treatments, pumps are somewhat higher risk because they utilize an intrathecal catheter giving selected patients access to new and novel therapies. The monoclonal that deposits medication directly onto the spinal cord to provide targeted antibody tanezumab is one such drug that belongs to an investigational drug delivery (TDD). group of pain medications targeting nerve growth factor, a protein involved in the growth of nerve TDD eliminates addiction potential cells. In 2012, U.S. regulators banned monoclonal Although TDD is considered only as a last resort, antibodies to treat chronic pain because of a concern it is perhaps the most powerful and effective that medicines targeting nerve growth factor treatment available for refractory, intractable pain There are now alternatives could worsen osteoarthritis in a small percentage from cancer, multi-level spinal degeneration, and to opioid management of patients. That ban has recently been lifted and other severe conditions. TDD is a reversible, nonfor chronic pain. tanezumab, along with other highly targeted oral destructive method for controlling severe chronic and parenteral drugs, are currently being evaluated pain that moves patients from the “fix it” path of to treat lower back and cancer pain, as well as other more surgeries and more medical interventions types of chronic pain in the U.S. to the “quality of life” path of reduced pain In the future, medications may treat pain and improved function. Pump medications are so effectively that other methods of pain relief will become largely ”targeted” to the spinal cord, rather than the brain, and block pain at the unnecessary. At present, however, medications alone are often not sufficient spinal cord level, thus keeping the brain free from drug effects. to manage complex chronic pain, and medication side effects are sometimes A typical pump infusion consists of an opioid (fentanyl, morphine, and/ as bad as the pain these medicines are treating. In comparison to opioids, or hydromorphone) mixed with a local anesthetic (bupivacaine). These approximately 100,000 U.S. patients are hospitalized, and 16,500 patients drug admixtures are continuously infused at low dose into the spinal fluid at die each year from NSAID-related complications, whereas acetaminophen the spinal level of maximal pain, blocking pain receptors within the spinal toxicity is responsible for 56,000 emergency department visits, 2,600 cord and avoiding brain drug effects such as mental clouding, somnolence, hospitalizations, and 500 deaths each year. The take-home message is that medication management of chronic pain has limited efficacy and is Dialing down opioid use to page 234 associated with significant morbidity and mortality.
Integrating non-drug treatments If medications are not adequately controlling pain or are causing untenable side effects, interventional techniques can be utilized for those patients with identifiable structural abnormalities contributing to pain. The goal of the interventional pain specialist is to identify the physical generators of pain and to precisely target and treat them to the greatest extent possible using image-guided, minimally invasive procedures. At Nura, we coordinate interventional procedures with physical therapy and behavioral health treatments as necessary for a comprehensive, multi-point approach. For those who fail to respond to therapeutic procedures, physical therapy, and behavioral health treatments, we consider implantable pain control options. We believe in moving from simple to more complex treatments as necessary to reach our goals of reducing pain and improving function. For those patients who respond to non-addictive medications, physical therapy, chiropractic adjustment, and/or complementary medical treatments such as acupuncture, we encourage the patient to continue these low-risk therapies. For pain that does not respond to conservative, non-invasive treatments, we first consider diagnostic and therapeutic procedures such as targeted spinal steroids and radiofrequency nerve ablations. When these minimally invasive procedures fail, we consider implantable pain control systems as last-resort alternatives to long-term oral or skin patch opioids. Implantable pain control options include spinal cord stimulators that generate electrical signals to block pain transmission in the spinal cord and pain pumps that block pain receptors within the spinal cord using small doses of targeted medications delivered by an intrathecal catheter. Both options involve a trial of the therapy and, if successful, a minimally invasive outpatient surgery to implant the permanent delivery system. Spinal cord
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BEHAVIORAL HEALTH
Play therapy Helping medically complex pediatric patients BY MONICA OBERG, MSW, LICSW
An underrepresented segment of care
ix-year-old Hannah has required around-the-clock care for spina bifida and other complex medical conditions her entire life. A trach tube, feeding tube, and wheelchair are indicators of her numerous days and nights spent in a hospital or clinic awaiting another test or surgery—experiences that have impacted how she manages her emotions and interprets the world around her today.
At Pediatric Home Service (PHS), we often see medically complex patients and the caregivers who support them focusing the majority of their attention on physical health care needs while overlooking emotional health— understandable, given the physical hurdles and challenges these individuals consistently face. But when mental health counseling is included in the conversation, another piece of the puzzle helps us to assemble a more holistic care plan—one that could also provide tips for physicians and other health care providers.
S
While Hannah’s entire childhood has been surrounded by medical professionals dedicated to improving her physical health, there wasn’t a care plan in place to focus on her mental health and how she can learn to effectively communicate feelings or cope with challenges. In addition to Hannah living through her own traumatic experiences, her parents have felt the emotional, physical, and financial impact of being primary caregivers, coordinators, appointment schedulers, and more. Her 8-year-old sister Sophie has also been affected by the care Hannah requires as she internalizes feelings about the attention, time, and difficult procedures she’s seen her sister endure.
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With many methods of counseling available, the age and cognitive level of a client can be an effective indicator of which approach will work best. Three types in particular—play therapy, individual therapy, and sibling support programs—have been efficient in meeting the needs of clients as young as age 2 through adulthood. They may have a diverse range of interactions with physicians and health care interventions, depending on their medical history or personal experience. Clients who benefit from receiving therapy may be personally or closely connected to someone facing a chronic or life-threatening disease like cancer or muscular dystrophy. Multiple factors can impact their mental health: dealing with the long-term effects of repeated surgeries, therapies, and procedures; processing an unexpected life event like a divorce or death of a family member; or any number of other experiences. By helping individuals, regardless of age, address their fears surrounding medical procedures or confusion about a personal experience, they can begin to build tools that will enable them to more effectively understand and express their feelings in the future.
Expressing emotion through play
mnpsychconsult.com
It’s natural and healthy for play to bring out emotions from a child’s past experiences, and this is no different for children like Hannah who have endured extensive medical care in their short lives. At just 6 years old, she may not completely understand the feelings she is experiencing or how to express them—but that doesn’t make them less important.
calling PAL
In our play therapy sessions, children ages 2 to 10 use toys as their tools and play as their words. This therapeutic method is based on metaphors and, while it may look unstructured to an untrained eye, counselors are educated in observing and recognizing behaviors that indicate points of tension and insight on stress or emotional trauma. Throughout a series of sessions, the client and facilitator will organically work through what is presented in child-led play—not with the goal of solving all their issues, but to provide them new tools to help cope with future situations in a healthy way. Play rooms may look like a random assortment of toys, but fall into categories specifically designed to help children process emotions. Categories may include: • Realistic toys—a real stethoscope, Band-Aids, and medical kits. • Nurturing toys—play food, a kitchen set, baby dolls, and bottles.
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• Aggressive toys—plastic swords, chain saws and guns, aggressive animals like lions and tigers, and an angry puppet.
peers who don’t have a medically complex sibling in the home, or a sibling undergoing treatment for chronic illness or repeated medical procedures.
• Expressive toys—a sand table, art and craft supplies, and musical instruments. • Pretend and fantasy toys—dress-up clothes and masks.
In a PHS support program created specifically for siblings, children ages 6 to 11 meet in a group setting where they have a space to process thoughts, work through feelings, and express themselves amongst other individuals who have encountered similar experiences. While the conversation may not always be around their brother’s or sister’s medical needs, just having the knowledge that they’re in a safe environment of peers brings a Parents carry their own risk of secondary trauma. sense of comfort and belonging as they interact and find a community.
Mental health professionals conduct these play therapy sessions, but primary care physicians are in a position to watch for signs of trauma or stress in their pediatric patients and encourage parents to consider a treatment like play therapy, just as they would recommend a care plan for any physical ailment. For parents of a play therapy client like Hannah, mental health counseling is an opportunity to prepare for success as their child learns to manage emotions in a healthy way, while also navigating the challenges that may arise with their physical health.
Remembering to focus on self-care While Hannah and Sophie are top priorities for their parents, primary caregivers like mothers, fathers, and other close relatives would be remiss to overlook the importance of focusing on their own mental health needs. Through individual therapy, one-on-one conversation facilitates an opportunity for adolescents and adults to work through challenging experiences.
“Our older daughter requires a lot of our attention because of her medical treatments and appointments,” said one mom whose daughter participated in a sibling support program. “Our younger daughter notices it and we talk to her, but recognizing she is not the only one who has a sister with some medical issues was very eye-opening for her. Now, she is a lot more comfortable talking about feelings, and knows there are other kids out there dealing with these same feelings she has.”
Utilizing different formats As clients get older or their circumstances change, it is sometimes appropriate or necessary to shift into another type of therapy. In one circumstance, the Play therapy to page 224
Parents carry their own risk of secondary trauma as they maintain a routine of complex cares, endure their child undergoing invasive procedures, and work to maintain a normal family dynamic that doesn’t always have to focus on the medical aspect of their life. Hannah’s parents have encountered a wide array of circumstances since having their second daughter. Through individual therapy, they have been able to process the feelings of grief, trauma, anger, and anxiety left behind as a result—empowering them to improve their own emotional health. Clients who are 11 or older—and therefore not good candidates for play therapy—would still benefit immensely from counseling and an opportunity to have conversations surrounding their emotions. As Hannah gets older, she may use individual therapy as a way to process new challenges she encounters, such as social issues at school or loss of people she has met along her medical journey. While older patients may have a better understanding of the procedures and care they’re receiving, this is still not without an abundance of emotion. Individual therapy provides an outlet for this processing to take place in a more age-appropriate setting. Through this simple act of self-care, adolescents and adults can work on making sense of the experiences that have led them to where they are, and create a plan moving forward—a resource that all individuals can benefit from. Physicians and other health care professionals can stress this point during their patient visits, encouraging patients to take care of their physical and behavioral health needs.
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3Play therapy from page 21 sister of a child with medical complexities started in a 12-week sibling support program and then moved into play therapy—allowing her one-on-one interaction that continues to address her emotions. “We used mental health services to help our 5-year-old cope with the implications of having a medically complex child in our home,” said another mom. “We wanted to make sure our daughter had an outlet and a way to express those feelings and emotions regarding her sister’s medical needs later in her life and give her the tools to deal with those, not only now but into the future as well.”
type of therapy that better suits their needs. It’s important to remember that there are numerous styles available beyond these three types that will best suit different needs, ranging from diagnosis-specific groups, family psychotherapy, medical support groups, or a number of other theory-based types of therapy. It is worth investing the time to find the right option for each person, and to remember that those needs may change over time.
Medical care generates a great deal of emotion for everyone.
Data supports approach In post-session surveys distributed following the completion of a sibling support program, 67 percent of parents who had a child enrolled said that their child is more comfortable talking about his or her emotions since attending the group. Seventy percent reported that their child realized that kids share similar experiences if they have siblings with medical support needs, thanks to the support group.
Medical care generates a great deal of emotion for everyone involved in a patient’s journey, and taking time to address these feelings and concerns leads to better mental health for the individuals involved while providing lifelong tools for children, adolescents, and adults.
While these examples target the medically complex children we serve and their families, all patients—at all ages—benefit by focusing on both physical and mental health. Watch for signs of trauma or stress factors, and encourage your patients to seek help. Monica Oberg, MSW, LICSW, is a clinical social worker at Pediatric Home Service, where she provides individual therapy, play therapy, and sibling
An abundance of options to fit needs
support programming for children, adolescents, and adults. She received her
Clients may shift from play therapy to individual therapy or from the sibling support program to play therapy or individual therapy, or find another
Bachelors of Science degree in social work from Bemidji State University and her Master’s degree in social work from Augsburg College.
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3Dialing down opioid use from page 19 and confusion. Intrathecal opioids are not absorbed to any great extent into the bloodstream and therefore exert far weaker systemic effects compared to drugs administered by any other route. Although physical dependence may develop with pump opioids and withdrawal may occur if the pump infusion is abruptly stopped, there is no addiction potential with pump opioids because there is no euphoria and no “high” feeling. Furthermore, for those pump patients with severe physical pain and active addiction, the physician controls the drugs within the pump and they cannot be abused and/or diverted by the patient.
place of breakthrough oral pain pills. We recently polled our pump patients and found that the vast majority of them felt the pump was a very helpful intervention that had changed their lives for the better.
Conclusion Reducing pain down to tolerable levels with medications, injections, and/ or implantable pain control systems is an important first step in pain management, but improving physical functioning through ongoing physical therapy and managing anxiety and depression with behavioral techniques are equally important for long-term recovery. Although there is no single best treatment for most complex chronic pain, combining interventions, physical therapy, and psychology-based treatments in a coordinated fashion offers pain patients the best chance to lead a more productive life free from opioids.
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23
PROFESSIONAL UPDATE: CARDIOLOGY
Acute aortic dissection Timely recognition and multidisciplinary care BY JASMINE CURRY, BS; MATT PAVLOVEC, RN, BSN; AND KEVIN M. HARRIS, MD
A
n acute aortic dissection (AD) occurs when there is a tear in the intima, the inner layer of the aorta, allowing blood to travel through a separate channel (false lumen), often leading to complications which may include cardiac tamponade, aortic regurgitation, ischemia of the branch vessels, and, ultimately, aortic rupture. The patient’s symptoms depend on the path of the dissection and which organs are malperfused. Most commonly, patients with AD have symptoms of chest or back pain that may mirror the much more prevalent acute coronary syndromes, and are frequently mistreated as such. If the ascending aorta (Type A) is involved, this condition represents an acute surgical emergency, with a mortality that is historically 1 percent per hour until surgery can be performed. The Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital (ANW) has developed an AD Program with a goal of increasing recognition and more rapidly instituting treatment.
Clues to recognition A focus of the American Heart Association guidelines for aortic disease is timely recognition of AD. On average, in the International Registry of Acute
Aortic Dissection (IRAD), the median time for presentation to diagnosis of AD is 4.3 hours, with an additional 4.3 hours until surgical intervention. Given that delays may be even longer when patients are transferring from outlying hospitals, there is a need for a streamlined process to rapidly diagnose and transfer these critically ill patients. Unfortunately, delays in recognition do occur. In some cases the diagnosis is not established until autopsy, which illustrates how critical early recognition is. Early recognition is best made by the clinician integrating high-risk historical features (known aortic aneurysm, aortic valve disease, family history of aortic disease, prior cardiac surgery), symptoms (severe, sudden chest/back pain), and exam findings (blood pressure discrepancy, pulse deficit, diastolic murmur suggestive of aortic regurgitation, or neurologic finding). The vast majority of patients with AD will have one of these clinical findings. Most ADs occur in males with a mean age of 62 years, though it can occur in patients across a wide age spectrum. Younger patients that have connective tissue disease may be afflicted, and although rare, females during or after pregnancy can be at risk. Overall incidence is approximately three per 100,000 people annually. Although more common in males, females typically present with AD at an older age, and often have more severe in-hospital complications and mortality. Significant delays in recognition can occur in patients with atypical presentations, such as those without pain, in females, and among those presenting to non-tertiary hospitals. Clinical suspicion is confirmed via diagnostic testing, most commonly computed tomography (CT) imaging— though transesophageal echocardiography (TEE) or magnetic resonance imaging (MRI) could also be used.
Initial treatment Once an AD is recognized, the principles of medical therapy include control of the patient’s blood pressure with beta blockade principally, but also with pain medications. At the time of transfer, the focus of the team is blood pressure and heart rate control preferentially with beta blockers. The goal of care during this early phase is to prevent the dissection from extending or rupturing by both lowering the pressure and by lowering the number of pulses being generated. This last point, limiting pulse generation, is one of the keys to using beta blockers over other anti-hypertensives. If the patient presents to a non-tertiary hospital, it is imperative the patient move quickly to a facility with expertise in surgical treatment. If the ascending aorta is involved, (Type A AD), and the patient is a surgical candidate, then urgent surgery should occur. The corrective surgery includes graft replacement of the ascending aorta (often including the under surface of arch). With a Type B AD (where the tear starts in the descending aorta), consultation with a vascular surgeon is needed, and if high-risk features are present, such as ischemia of the mesenteric or peripheral vessels, then an urgent surgical procedure (often stent grafting) should take place.
Needs for improvement Since AD is significantly less common than acute coronary syndromes, the
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FEBRUARY 2018 MINNESOTA PHYSICIAN
clues suggesting the diagnosis are less evident and, without a point-of-care information on cardiovascular protocols, as well as a checklist on Aortic laboratory assay, the diagnosis is often delayed or missed. Death in AD Dissection (AoD) Protocol. This latter checklist is also available at www. is most frequently due to aortic rupture, and thus lifesaving surgery must tinyurl.com/mp-AD-Protocol). be initiated before this occurs. The AD Program was created based on While the patient is en route, a page goes out to assemble the surgical team, the same principles of the Level 1 Heart Attack and to notify the emergency department (ED) and program for ST elevation myocardial infarction, accepting units of impending arrival of an AD. With which emphasizes standardized and protocolized outside transfers, all surgical emergencies go through care in concert with a regional referral network the ED, where the patient meets the emergency resulting in rapid transport directly to the cath lab physician, cardiologist, and cardiovascular and/ for emergent percutaneous coronary intervention. or vascular surgeon. This allows time for massive Aortic dissection represents a
Components of the AD Program
high-risk surgical emergency.
The multidisciplinary AD Program goals included standardizing diagnostic testing/ imaging, decreasing the time to diagnosis and surgical treatment, early and aggressive blood pressure control, rapid access to blood products, and standardizing intraoperative imaging and surgical techniques. Once the diagnosis of AD is confirmed, a call through a dedicated emergency phone number is used to arrange transfer to the AD team, including cardiothoracic and/or vascular surgeons, cardiologist, and emergency physician. Image transfer is also a priority. Throughout this phase in the AD protocol, order sets (which specify blood pressure goals, including recommended doses of beta blockers) are utilized by the transferring team to standardize care between providers and hospitals within the same system. This process focuses the team on clinical priorities and ensures critical steps are addressed during the final preparation for surgery. (For current AAD protocols, install the MHI/ANW CV Resources App, which includes
transfusion orders to be placed, the operating room (OR) to be prepped, and the opportunity for repeat imaging if needed. The OR staff, led by the anesthesiologist, moves the patient from the ED to the OR and rapidly prepares the patient for surgery. The use of TEE for intraoperative imaging is universal and helps confirm the anatomy of proximal aorta and additional cardiovascular findings. These TEE findings aid in surgical decision-making regarding concomitant need for aortic valve surgery. Over the past five years, vascular surgery has been actively involved in all Type A AD. Selected patients with high-risk features, including branch vessel ischemia or descending aorta progression, are managed with a hybrid approach where a concomitant stent graft is placed at the time of ascending/arch repair. Following surgery, Acute aortic dissection to page 294
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25
BEHAVIORAL HEALTH
Adolescent medicine Meeting unique needs BY ANDREA WESTBY, MD; MICHELLE D. SHERMAN, PHD, LP, ABPP; AND JAMES SMITH, MD, MPH
A
dolescence. For many parents, educators, and health care providers, this word elicits some combination of terror, uncertainty, and excitement. Adolescence (defined by the World Health Organization as ages 10–19) is a time of tremendous change across physical, social, relational, and spiritual domains, as youth transition from dependence on caregivers to greater autonomy and independence. Young people strive to form their own identities and to separate from their families, while simultaneously becoming more connected to peer groups. The health care needs and experiences of teenagers are distinct from those of young children and early adults. Physicians and other health care professionals need to provide culturally appropriate and trauma-informed care and consider numerous complex issues such as confidentiality when supporting these young people. Choices adolescents make can have lasting effects on long-term health. For example, contracting HIV, experiencing a traumatic injury that leads to paralysis, poorly controlling chronic health conditions such as
diabetes, unintended pregnancies, or substance abuse can lead to future disease burden. It is essential that providers empower adolescents to take responsibility for their behaviors and for health-related decisions. Four specific domains of health that involve unique challenges for adolescence include substance use, depression and elevated risk for suicide, sexuality, and transitions of care from pediatric to adult-based primary care and specialty services. All of these domains of health, but particularly substance use and depression, are impacted by social determinants of health, as well as interpersonal, household, and community dynamics.
The developing brain Prior to addressing these four domains, it is important to note how the adolescent brain is extremely plastic and malleable, able to learn and change very quickly. The limbic system (the reward center of the brain) matures well before the prefrontal cortex (the area responsible for planning, higher level decision-making, and executive function, which does not fully develop until the mid-20s). This mismatch in brain development sets up adolescents to be prone to risk-taking behaviors and impulsivity without considering all the potential consequences. If those risk-taking behaviors impair brain development, such as in the case of substance use, they can have significant long-term effects, particularly because the brain is so plastic at this stage. Historically, risk-taking, experimentation, and exploration were considered pathologic in adolescents. However, our improved understanding of brain development has changed this thinking. These behaviors are now considered a normal part of development, and the challenge (for all who work with teenagers) is to help mitigate the potentially negative effects of risky behaviors through appropriate health behavior counseling and adult support. Understanding the etiology of some of adolescents’ risk-taking behaviors can help providers have more patience and engage in respectful, non-judgmental discussions with youth.
Substance use Adolescent brain development and long-term health are closely linked to substance use. The plasticity of the adolescent brain, learning quickly and adapting to changes, makes it particularly susceptible to substance use disorder. According to 2014 data from the Substance Abuse and Mental Health Services Administration (SAMHSA), 74 percent of adults aged 18–30 who were admitted to long-term substance use treatment started using substances before the age of 17, and of the patients who were receiving treatment for multiple substances, more than 70 percent had started using before the age of 11. Electronic cigarette use rates are rising; in the 2017 Minnesota Student Survey, 19 percent of high school students reported e-cigarette use, compared to 10 percent who reported conventional cigarette use. The Minnesota Department of Health has named e-cigarettes an emerging public health threat. The potential legalization of cannabis products also has significant implications for the well-being and brain development of adolescents.
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FEBRUARY 2018 MINNESOTA PHYSICIAN
was having sex with males and was pregnant. In general, explaining For primary care physicians and health care professionals in all to teenagers your medical rationale for assessing their sexual behavior, fields, screening, intervention, and prevention are imperative to decrease reassuring them about confidentiality and its limits, asking open-ended the burden of substance use disorders. Incorporating a SBIRT screening questions, using inclusive and person-centered language, and emphasizing (Adolescent Screening, Brief Intervention, and Referral for Treatment; see that your goal is to help them make good choices www.tinyurl.com/mp-sbirt and www.tinyurl. can be useful strategies when discussing this com/mp-sbirt-toolkit), or the CRAFFT screener domain of health. (Car, Relax, Alone, Forget, Family or Friends, Trouble; see www.tinyurl.com/mp-crafft) into Autonomy your clinical practice can be useful to increase As adolescents begin to desire and gain more detection of these problems. The adolescent brain is extremely autonomy, it is important to foster independence
Mental health
plastic and malleable.
Often intertwined with issues of substance abuse are mental health concerns. According to the Centers for Disease Control and Prevention (CDC), suicide is the second leading cause of death among youth ages 10–24, surpassed only by accidents. Further, many more teens attempt suicide than actually complete it. In the national 2017 Youth Risk Behaviors Survey, about 17 percent of teens (22 percent of females and 12 percent of males) had seriously considered attempting suicide and 7 percent (9 percent of females and 5 percent of males) reported that they had made at least one suicide attempt in the preceding year. Underlying these concerning statistics are numerous factors, including but not limited to mental illness, bullying, social isolation, substance abuse, family violence, LGBTQ status, loss, impulsivity, and hopelessness. Thus, it is important for health care professionals to screen adolescents for depression and suicidality, have processes in place for when there is imminent danger, and collaborate closely with mental health professionals to co-manage teens in significant distress.
Sexuality Another aspect of health that is particularly notable in the adolescent period is sexuality. The teenage years are a time of normal exploration regarding one’s sexual attraction, fantasies, identity, and behaviors. However, rates of sexually transmitted infections are reaching record highs. The CDC says that almost half of all new cases of chlamydia in 2017 were in females 15 to 24 years old. Furthermore, rates of depression, substance abuse, and suicide are considerably elevated among LGBTQ youth, with recent data showing over half of female-to-male transgender youth have attempted suicide (Toomey et al., Transgender Adolescent Suicide Behavior, in Pediatrics; see www.tinyurl.com/mp-toomey.) Thus, issues surrounding sexuality are important and highly relevant for physicians to address with youth. However, physicians often do not discuss sexuality at all, and such discussions, when they do occur, can be brief and awkward. Providers may feel unsure about what terms to use, worry about offending the teen and damaging the therapeutic relationship, and have insufficient time to discuss sensitive issues. Similarly, teens may feel embarrassed, worry about potential disclosure of their personal information, worry about the provider’s judgment, and not understand medical terminology. For example, during a prenatal visit, a 17-year-old girl who was 24 weeks pregnant described her experience at her school’s Sexual Health Fair. She had listed “gay-curious,” and was subsequently told she was at low risk for STIs or pregnancy. The screener missed the fact that she
in interactions with medical providers. Adolescents should be encouraged to be the main focus of the visit and answer most of the provider’s questions—transitioning away from prior visits in which parents or caregivers did most of the talking. Teenagers should be interviewed and examined separately from their parent or caregiver to give them the opportunity to engage with medical providers confidentially, and to empower them to take control of their health and medical interactions. In Minnesota, minors can seek care without parental consent for a select number of conditions, including pregnancy testing and care, sexually transmitted infections, and alcohol or drug abuse. Providers should assure teens that what they share will be kept confidential, except in the case of Adolescent medicine to page 284
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3Adolescent medicine from page 27 suspected abuse or intent to harm themselves or others. However, if a parent’s insurance is to be billed for any testing, parents may find out indirectly what was discussed. Generally, providers should encourage teens to talk openly with their parents, but empower them with the knowledge that they have the right to privacy should they choose not to do so.
Additional training in adolescent medicine The specialty of adolescent medicine is relatively new. The Society of Adolescent Health and Medicine was founded in 1968, and is celebrating its 50th anniversary this year.
Physicians who have completed residencies in family medicine, pediatrics, internal medicine, or combined internal medicine/pediatrics and who seek additional training in working with adolescents may consider speciality fellowships, It is essential that providers most of which are three years. Fellowships provide Transitioning into adult care empower adolescents to take additional experience as well as access to cuttingAdditionally, adolescents with special health responsibility for their behaviors. edge research and training in best practices in needs or chronic disease need to begin to working with adolescents. Multiple professional transition from a pediatric-focused health care societies also have continuing education and approach to an adult approach. For children conferences about adolescent health, including living with chronic diseases, the pediatric the Society for Adolescent Health and Medicine, specialist clinic serves as their medical home; the American Academy of Pediatrics, the American Academy of Family often these pediatric patients do not have a regular primary care provider. Physicians, the American College of Physicians, and the International However, in adult health care, primary care providers (PCPs) are the first Association for Adolescent Health. contact point for acute and chronic needs; PCPs consult with specialists as indicated and assist with coordination of care. This change in health care models can be challenging for adolescents and their families. It is important to help teens begin to take responsibility for their health, independent of their parents or caregivers. Accessible providers and clearly defined role expectations for each provider involved in care can minimize confusion and frustration.
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The Society of Adolescent Health and Medicine has an excellent repository of learning modules and links to materials to improve skills and knowledge about working with adolescents, including modules about sexual and reproductive health, transitioning to adult care models, and substance use and abuse. See www.tinyurl.com/mp-curriculum.
Conclusion It is important for health care professionals, parents/caregivers, and teens themselves to be aware of the unique developmental and social needs of adolescents, and to seek appropriate care. Interdisciplinary, holistic approaches to health, partnerships with community resources, and diverse well-trained providers who are nonjudgmental and easily accessible are key tenets of effective care for adolescents. Andrea Westby, MD, is an assistant professor in the University of Minnesota Medical School’s Department of Family Medicine and Community Health and core clinical faculty at the North Memorial Family Medicine Residency Program in North Minneapolis.
Michelle D. Sherman, PhD, LP, ABPP, is a board-certified couple and family psychologist and a professor in the Department of Family Medicine and Community Health at the University of Minnesota–Twin Cities. She is the director of behavioral health at the North Memorial Family Medicine Residency Program.
James Smith, MD, MPH, is a first-year family medicine resident at the Quality Transcription, Inc. 8960 Springbrook Drive, Suite 110 Coon Rapids, MN 55433 Telephone 763-785-1115 Toll Free 800-785-1387 Fax 763-785-1179 e-mail info@qualitytranscription.com Website www.qualitytranscription.com
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FEBRUARY 2018 MINNESOTA PHYSICIAN
University of Minnesota’s Family Medicine Residency program. He earned an MPH at the University of Minnesota. He has a particular clinical interest in adolescent health.
3Acute aortic dissection from page 25
Jasmine Curry, BS, is a physiology graduate from the University of Arizona, and worked at the Minneapolis Heart Institute Foundation summer intern
hospitalized patients are cared for by a multidisciplinary team including the surgical teams, intensive care, and cardiology.
program on aortic dissection research in 2018. She is now enrolled in the Wy’east Post-Baccalaureate Program at Oregon Health and Science University, where she will attend medical school.
Follow-up An additional key component of the AD Program is systematic surveillance, including standardized imaging and clinical follow-up. Clinic visits emphasize blood pressure management with guideline-directed pharmacotherapy; work and lifestyle advice, including tobacco cessation; genetic screening in specific cases; and coordinated familial screening. AD is a lifelong disease that requires regular follow-ups to decrease adverse outcomes. Patients are at continued risk of progressive aortic expansion, new dissection, and aortic rupture years after the initial event (see Figure 1).
Matt Pavlovec, RN, BSN, is the clinical coordinator for the CV Emergencies Program at
Patients with AD present with acute chest or back pain.
Patients undergo CT or MRI imaging prior to discharge, along with an echocardiogram, and tomographic imaging should be repeated at three, six, and 12 months, and then annually thereafter as suggested by American Heart Association’s aortic guidelines. Patients who are compliant with follow-up clinic visits and imaging have improved outcomes.
Minneapolis Heart Institute/Abbott Northwestern Hospital, which includes the Level 1 STEMI, ECPR, and Aortic Dissection Programs. He brings over 20 years of combined nursing and paramedic experience in cardiovascular, critical care, and emergency medicine.
Kevin M. Harris, MD, is a clinical cardiologist, echocardiographer, site director of cardiology training, and the aortic dissection program at the Minneapolis Heart Institute/Abbott Northwestern Hospital. He is a member of International Registry of Acute Aortic Dissection.
Successes Data shows that both time to diagnoses and treatment of AD has improved with the implementation of the AD Program. Since the initiation of the protocol, the median time from outside hospital presentation to diagnosis decreased by 43 percent, and time to OR by 30 percent. For patients transferred from outlying hospitals, the overall time from arrival decreased by over six hours, a rather significant time in a condition that has a 1 percent/hour mortality. The 30-day mortality rate for surgical Type A’s has decreased and is at 14 percent for the last three years, while 30-day Type B mortality has decreased to 14 percent overall. Additional improvements include almost all eligible patients receiving beta blockers at time of arrival and discharge, and intraoperative TEE is now used in all surgical cases.
Conclusion Aortic dissection represents a high-risk surgical emergency that requires immediate recognition and streamlined management. Patients with AD present with acute chest or back pain, and clues to recognition may include high-risk historical features (aortic valve or connective tissue disease, family history of aortic disease, prior cardiac surgery) or physical exam features including perfusion deficit, diastolic murmur, or hypotension. The AD Program was the first of its kind to systematically treat these high-risk patients with a multidisciplinary care team in conjunction with regional partners. This approach has led to earlier recognition, decreased time to treatment, and guideline-directed blood pressure and heart rate management. Additionally, MHI surgeons have adopted a hybrid approach to Type A AD patients, allowing cardiothoracic and vascular surgeons to work simultaneously, address high-risk potential complications, and reduce the potential need for future surgeries. Following initial treatment of AD, patients remain at lifelong risk for complications and benefit from ongoing surveillance and guideline-driven management of risk factors to ensure longevity.
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MINNESOTA PHYSICIAN FEBRUARY 2018
29
MEDICINE AND THE LAW
“Stark” legislation and regulation Updating the updates BY ANTONIO “TONY” FRICANO, JD
A “brief” history of Stark
n June 20, 2018, the Centers for Medicare & Medicaid Services (CMS) announced that there will be what CMS called a “Regulatory Sprint” to revamp the Physician SelfReferral Law (commonly referred to as the “Stark Law,” named for its original sponsor, California Congressman Pete Stark). CMS is seeking recommendations and input from the public on how to address any undue impact and burden of the Stark Law on care coordination and delivery of value-based care. Under the current administration, CMS leadership has made it clear that one of its top priorities is to scale back regulations where the government is overstepping its grounds and unduly burdening providers—in some cases leading to significant potential liability for providers.
It is beyond the scope of this article to discuss every exception, definition, or test applicable to a Stark Law analysis of what may be considered an improper physician self-referral, but a brief summary will illustrate its history.
O
This article will illustrate how the Stark Law has developed over time; discuss the application of Stark under the current regulations, as well as some of the practical challenges encountered by providers today; and speculate on some of the courses CMS may take on this issue.
Family Medicine & Emergency Medicine Physicians • • • • •
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Initial purpose. The Stark Law is a set of federal laws that prohibit physician self-referral to an entity with which the physician (or an immediate family member) has a financial relationship. At the time of enactment, Congress reasoned that a bright-line rule would help physicians self-regulate and avoid fraud and abuse issues. Despite this initial intent, the law has been expanded and modified over the years through various pieces of legislation, resulting in a complex and convoluted framework of laws that involve very few bright lines. Further complicating the issue is that there is no “intent” requirement for the Stark Law (e.g., no demonstration that the provider had knowledge of wrongdoing). Even unknowing providers with no malicious intentions could be in violation of the Stark Law and subject to massive monetary fines for technical violations. Stark I. The first iteration of the Stark Law (Stark I), which passed as part of the Omnibus Budget Reconciliation Act of 1990, prohibited a physician from referring a Medicare patient to an entity for clinical laboratory services if the physician or the physician’s immediate family member had a financial relationship with the entity. The statute provided for several exceptions to the prohibition, with some applying to ownership arrangements and some applying to compensation arrangements (or both). Stark II, Phase 1. Shortly after passing Stark I, Congress agreed that the limitation of Stark to clinical laboratory services was too narrow. This led to the passage of “Stark II,” as part of the Omnibus Budget Reconciliation Act of 1993, which expanded Stark to cover Designated Health Services (DHS) and expanded coverage to Medicaid programs. The 10 categories of DHS included in the rule are: 1) clinical laboratory services, 2) physical therapy, occupational therapy, and speech-language pathology services, 3) radiology and certain other imaging services, 4) radiation therapy services and supplies, 5) durable medical equipment and supplies, 6) parenteral and enteral nutrients, equipment, and supplies, 7) prosthetics, orthotics, and prosthetic devices and supplies, 8) home health services, 9) outpatient prescription drugs, and 10) inpatient and outpatient hospital services. There were also several definitions that were added and revised in this iteration of the law. Stark II, Phase 2. On March 26, 2004, CMS published Phase 2 of Stark II (Phase 2), intending to define prohibitions narrowly and the exceptions broadly. Some important provisions of Phase 2 are: 1) the creation of the holdover exception for lease arrangements, 2) the allowance for termination of agreements prior to one year (provided no new agreements may be entered into within that year), 3) the exclusive use of space or equipment by lessee requirement for leases, 4) clarification on the regulations related to productivity bonuses for physicians, and 5) clarification that the “set in advance” requirement for compensation arrangements allows payment based on percentages of collections.
Stark II, Phase 3. On September 5, 2007, CMS published the Phase 3 Final Rule on Stark (Phase 3). In this iteration of the rule, CMS: 1) indicated that fair market value can be determined using any commercially reasonable methodology that is appropriate under the circumstances, 2) extended the holdover exception from leases to personal service arrangements, and 3) indicated that physicians “stand in the shoes” of their group practices, thus requiring a direct exception to the Stark Law in situations where an indirect compensation arrangement exception would have previously sufficed. Stark modifications under the Hospital Inpatient Prospective Payment System (IPPS). There were significant changes to the Stark Law affecting its application to hospitals that were part of the 2009 IPPS Final Rule. First, the “stand in the shoes” requirement of Phase 3 was eliminated for physicians that were not owners in the group practice. Second, CMS revisited the percentage-based compensation discussion from Phase 2 and restricted the use of percentage-based compensation in the fair market value, indirect compensation, and office and equipment lease exceptions under the Stark Law. Third, CMS prohibited per-click lease arrangements (unit-based compensation in arrangements for the rental of office space or equipment). Fourth, CMS added a grace period under certain circumstances for obtaining signatures in order to meet an exception’s technical requirements. Finally, CMS provided guidance for calculating the period of disallowance for Stark Law penalties. Stark Waivers under the MSSP (Medicare Shared Savings Program), ACO (Accountable Care Organizations) Program, and BPCI (Bundled Payments for Care Improvement) Program. Section 1115A(d)(1) of the Social Security Act authorizes the Secretary of Health and Human Services to waive certain fraud and abuse laws (including the Stark Law) for certain service delivery models developed by the Center for Medicare and Medicaid Innovation (CMMI). The extent of the waivers and conditions vary, but currently there are waivers for 11 different programs (see www.tinyurl.com/mp-waivers). 2016 Medicare Physician Fee Schedule Final Rule (“2016 Final Rule”). The 2016 Final Rule included multiple provisions impacting Stark. In a significant turn of events, CMS indicated that the Stark Law writing exception can be met through a collection of documents, noting examples of documents that together could form the basis for a contract. Even though this added new options for providers seeking to fit prior arrangements into an exception, the issue has been litigated and courts have held that the documents must contain clear indication of agreement. Additionally, CMS expanded the grace period for signatures to 90 days (inadvertent or not). CMS also clarified that as long as a contract lasts one year, it doesn’t matter that the term in contract isn’t for one year. CMS provided detailed guidance on timeshare leases and CMS also indicated that holdover leases could continue indefinitely, as long as certain conditions are met.
Analysis under the current regulatory framework The Stark Law prohibits a physician from making referrals for DHS to any entity with which the physician has a financial relationship, unless the arrangement qualifies for an exception. If a provider is ever in a position to receive referrals of DHS, it is important that there be a process put into place to ensure Stark compliance. Below is a very high-level framework for such a process: First, to determine whether Stark applies, we need to ask: 1. Does the arrangement involve a “physician”? 2. Does the “physician” or an “immediately family member” of the physician have a “financial relationship” with the “entity furnishing DHS”? 3. Is there a “referral” of “DHS”? “Stark” legislation and regulation to page 384
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Penalties for non-compliance. Some of the penalties for violating the Stark Law include: 1) denial of payments and/or refund of payments received, 2) fines of up to $15,000 for each service provided, 3) three times the amount of the improper payment received from Medicare, 4) exclusion from participation in health care programs, and 5) civil penalties of up to $100,000 for each circumvention scheme. In addition, under the False Claims Act, providers face exposure for private causes of action for Stark Law violations, providing significant monetary incentives for employees or competitors to prosecute violations.
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31
CARDIOVASCULAR DISEASE
The “Million Hearts” initiative Addressing heart attacks and strokes Goals
BY STANTON SHANEDLING, PHD, MPH
P
reventing one million heart attacks and strokes over five years is a powerful call to action— one that was taken on in 2012 by the U.S. Department of Health and Human Services, and co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) under the Million Hearts initiative. While Minnesota is known as a heart-healthy state, heart disease and stroke are still among our leading causes of death. That’s why the Minnesota Department of Health (MDH) is a partner in the Million Hearts initiative, to further the state’s efforts to promote healthy lifestyles and behaviors, create healthy environments and communities, and increase access to early and affordable detection and treatment. Minnesota is working alongside 120 official Million Hearts partners, 20 federal agencies, the remaining 49 states, and the District of Columbia. More than 12,000 individuals and organizations have pledged their support to reduce heart attacks and strokes, and more than 50 public and private organizations have made specific, actionable commitments to fight cardiovascular disease.
The initiative scales up proven clinical and community strategies, bringing together existing efforts and adding new programs to improve health across communities—and, ultimately, to help Americans live longer, healthier, more productive lives. For the first five years, the initiative had two primary goals: • Keeping people healthy through healthier habits and environments by ensuring fewer people are smoking, cutting back on sodium in processed and commercially prepared food, and eliminating transfat in the food supply. • Optimizing care by encouraging health systems and professionals to focus on the “ABCS”: Aspirin use when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation.
ABCS: by the letters Our focus on ABCS is turning the curve on the impact of cardiovascular disease here in Minnesota. In 2014, CDC and Million Hearts recognized two of the project’s health practices—St. Luke’s P.S. Rudie Medical Clinic and Essentia Health, Duluth—that achieved blood pressure control for at least 70 percent of their adult patients with hypertension. MDH also partnered with Healthy Northland, a regional public health collaborative, to implement a Million Hearts project to enhance the ability of clinics to identify and manage patients with hypertension using a team-based approach focusing on three main evidence-based strategies from the Guide to Community Preventive Services: • Measuring blood pressure accurately. • Adopting a hypertension treatment protocol with clinical decision supports. • Implementing a home blood pressure monitoring program.
Helping physicians communicate with physicians for over 30 years. MINNESOTA
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PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 05
CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD
U
niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.
Physician/employer direct contracting
CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144
Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: •
Exploring new potential BY MICK HANNAFIN
W
ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.
•
Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124
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Share new diagnostic and therapeutic advances Develop and enhance referral networks Recruit a new physician associate
Advertise! IN MINNESOTA PHYSICIAN www.mppub.com
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FEBRUARY 2018 MINNESOTA PHYSICIAN
(612) 728-8600
To ensure that Minnesota clinics are better able to identify and manage patients with undiagnosed hypertension, MDH encourages implementation of NQF 18: Controlling High Blood Pressure. We provide support to clinics and their staff in developing a process to pull data that can guide treatment. Those data points can help clinics to bolster their services based on the ABCS: Aspirin use. The rates of Minnesotans following an aspirin regimen for optimal diabetes/vascular care are high, according to 2016 dates of service data collected by MN Community Measurement: 99.4 percent of Minnesota patients ages 18–75 with diabetes (both type 1 and type 2) and comorbid ischemic vascular disease (IVD) take a daily aspirin, unless contraindicated, as do 93.4 percent of patients ages 18–75 with vascular disease. Those local numbers compare favorably with national statistics. The CDC’s 2013 Behavioral Risk Factor Surveillance System (BRFSS) reports
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
•
www.minneapolis.va.gov
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
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MINNESOTA PHYSICIAN FEBRUARY 2019
33
the percentages of men ages 45–79 and women ages 55–79 who reported that they took aspirin daily or every other day: • 26.6 percent overall rate for men and women
Smoking. The CDC’s 2016 BRFSS and the 2014 Minnesota Adult Tobacco Survey (MATS) show that the state’s smoking rate is slightly lower than the national average:
• 27.0 percent rate for men • 26.2 percent rate for women Blood pressure. 2015 dates of service HEDIS (Healthcare Effectiveness Data and Information Set) data—calculated from a sample of Managed Care patients and published in MN Community Measurement’s 2016 Health Care Quality Report—show that 76 percent of Minnesota patients ages 18–85 with a diagnosis of hypertension or high blood pressure had adequately controlled blood pressure based on the following criteria:
of Minnesota patients ages 18–75 with vascular disease are on a statin medication, unless allowed contraindications or exceptions are present.
• 15.2 percent adult (18+) smoking rate (BRFSS)
The state’s smoking rate is slightly lower than the national average.
• Patients ages 18–59 whose blood pressure was lower than 140/90 mmHg. • Patients ages 60–85 with a diagnosis of diabetes whose blood pressure was lower than 140/90 mmHg. • Patients ages 60–85 without a diagnosis of diabetes whose blood pressure was lower than 150/90 mmHg. Cholesterol management. 2016 dates of service data on statin use collected by MN Community Measurement show that 90.1 percent
• 14.4 percent adult (18+) smoking rate (MATS) While Minnesotans and their physicians are already following many of the ABCS—and maintaining our reputation as a heart-healthy state—Million Hearts strives to improve outcomes through education and advocacy.
The national impact According to the Million Hearts Meaningful Progress 2012–2016 report, during the first two years of the initiative, about 115,000 cardiovascular events were prevented. That number is relative to the expected number of events if 2011 rates had remained stable. Although final numbers will not be available until 2019, CDC estimates that up to half a million events may have been prevented from 2012 through 2016. These outcomes were fueled by these achievements by Million Hearts and health care advocates: Seven million fewer people smoked cigarettes in 2015 than in 2011. Quitting smoking immediately reduced their risk for a heart attack or stroke. Guidance was drafted and issued in June 2016 for the food industry to voluntarily reduce sodium in processed and commercially prepared food. The intention of this step is to help Americans gradually reduce their sodium intake to the recommended level of less than 2,300 mg per day, which will improve their blood pressure. Although daily sodium intake has not dropped significantly in the past five years, widespread implementation of healthy food purchasing policies and voluntary industry adoption of recommendations for lower sodium food choices are expected to help all Americans eat healthier in the years ahead.
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.
Million Hearts mobilized health care systems to deliver high value care for people at risk of cardiovascular diseases by focusing on the ABCS in clinical quality measures.
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.
A focus on the ABCS has generated slow but steady improvement in aspirin use, blood pressure control, and statin use among people who are eligible, based on current guidelines.
We’re just over an hour south of the Mall of America and MSP International Airport.
Electronic health records have helped to identify more than half a million people who may have hypertension.
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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Partially hydrogenated oils will be removed from the food supply in 2018. This action is expected to prevent thousands of fatal heart attacks every year.
FEBRUARY 2018 MINNESOTA PHYSICIAN
Million Hearts 2022 priorities The work to prevent heart attacks and strokes is far from complete. Million Hearts is continuing and expanding its priorities to meet the aim The “Million Hearts” initiative to page 364
St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria
Family Medicine Northfield Hospital & Clinics is seeking a Family Medicine Physician (no OB) to join our growing practice in our Lakeville Clinic, conveniently located just off Hwy 35. Joining our independent healthcare organization allows you to advocate for patient choice while providing the best care for the individual. We use a team approach to provide seamless, integrated care with easy access to a variety of services and specialties. Learn more at www.northfieldhospital.org/careers or submit your resume to recruiting@northfieldhospital.org. For more information contact our Recruiter, Erin, at 507-646-8170.
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 • 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
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35
3The “Million Hearts” initiative from page 34 of preventing one million heart attacks and strokes by 2022. These actions will align with the development of Healthy People 2030: Objectives for the Nation. Million Hearts 2022 will continue focusing on the goals to keep people healthy and to optimize care. The initiative is placing new emphasis on efforts to increase physical activity and focusing specifically on highly affected populations. These populations were selected based on data showing a significant cardiovascular health disparity, evidence of effective interventions, and partners ready to act. These include African Americans 35 to 64 years of age, people who have had a heart attack or stroke, and people who have a mental illness or a substance use disorder.
Together we can help ensure a well-informed Minnesota population that recognizes the signs and symptoms of heart attack and stroke. At the same time, we can promote proven practices that prevent heart attacks and strokes from happening in the first place, while also managing risks and using interventions that prevent people from having another event.
While Minnesota is known as a heart-healthy state, health is not shared equally across all populations. MDH is committed to health equity for all Minnesotans, where all communities are Clinicians and health care systems have an integral role to play. thriving and all people have what they need to be healthy. For those who are at higher risk of cardiovascular disease because of economic, racial, or other societal factors, we need to continue identifying strategies that effectively reach these individuals, reduce disparities, and increase opportunities for health.
The role of providers Clinicians and health care systems have an integral role to play in meeting the goals of Million Hearts, including: • A commitment to system-wide excellence in the ABCS. • A focus on team-based care and using technology to effectively measure, report on, and improve ABCS outcomes.
Stanton Shanedling, PhD, MPH, is the supervisor of the Cardiovascular Health Unit at the Minnesota Department of Health. In this role he advances the MDH agenda to improve cardiovascular health and reduce the burden of heart disease and stroke across Minnesota.
• Partnerships between the medical and public health arenas.
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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FEBRUARY 2018 MINNESOTA PHYSICIAN
PRACTICE WHERE BEAUTY SURROUNDS YOU
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:
Family Practice Physician
• 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
Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.
• 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
WORK-LIFE BALANCE: • Competitive salary • Significant starting & residency bonuses • 4-day work weeks • 51 annual paid days off
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
Sioux Falls VA
Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190
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
★ Compensation & Pension
★ Women’s Health (PACT)
★ Neurologist
★ Emergency Medicine (part-time)
★ Oncologist
★ ENT (part-time)
★ Psychiatrist
★ Gastroenterologist (part-time)
★ Pulmonologist
★ Urologist (part-time)
★ PACT
apply online at www.USAJOBS.gov
(605) 333-6852 ·
www.siouxfalls.va.gov
MINNESOTA PHYSICIAN FEBRUARY 2019
37
3“Stark” legislation and regulation from page 31 Each of the words in quotations has a specific whether it applies for Stark purposes. Second, if the Stark Law does apply, the next question is whether the arrangement fits squarely into an exception. There are numerous exceptions to the Stark Law, and a Stark analysis will focus on the tests specific to the particular exception that might be applicable to the arrangement. Some commonly relied upon exceptions are for: 1) bona fide employment, 2) personal services, 3) leases, 4) medical staff incidental benefits, and 5) non-monetary compensation.
under the Stark Law and the referral requirement is in writing and subject to: 1) patient choice, 2) third-party payer determination of provider, and definition or test as to 3) the physician’s judgment regarding the patient’s best medical interests. See 42 C.F.R. § 411.354(d)(4). Further, the required referrals must relate to the physician’s services that are covered in the arrangement, and the referral requirement must be “reasonably necessary to effectuate the legitimate business purposes” of the arrangement. If the arrangement is structured appropriately, it can be The depth and breadth of Stark-compliant—but, like everything else with these regulations ... are a Stark, there is a lot to consider. far cry from the “bright lines”
that Congress intended.
Third, if the arrangement satisfies the technical requirements of an exception, will it stand up to scrutiny of: 1) fair market value, 2) commercial reasonableness, and 3) no relation to volume or value of referrals. Usually when we see large verdicts or settlements, it is not because of a technical violation, but rather because the arrangement has an issue in this area. In one instance (United States ex rel. Drakeford v. Tuomey Healthcare Sys., Inc.), parties eventually settled for more than $72 million after a $237 million judgment. In the case of health care institutions that require their employed physicians to refer to onsite facilities, the referral requirement will not be a Stark violation if the physicians meet the bona fide employee exception
A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year
POSITIONS AVAILABLE:
OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic)
The depth and breadth of these regulations can be difficult for even the most experienced lawyers to navigate and are a far cry from the “bright lines” that Congress intended for providers to use to selfregulate when the law was initially enacted.
How can we fix it? One option that has been considered is to follow the model used for the MSSP program and other CMMI programs and extend waivers for fraud and abuse laws to participation in commercial programs involving providers taking financial risk or participating in clinical integration networks. The aforementioned waivers were extended in the MSSP and CMMI programs because those programs discourage overutilization. Extending these waivers to commercial arrangements that also discourage overutilization would further CMS’ goals of reducing regulatory burdens on providers and incentivizing the movement toward value-based care. There need to be some guidelines as to which commercial arrangements should qualify for the waivers. Fortunately, there is already a body of law that analyzes this issue. The Federal Trade Commission (FTC) and the Department of Justice issued guidance back in 1996, evaluating clinical integration and financial integration amongst providers as part of the analysis of whether such arrangements violate the Sherman Antitrust Act of 1890 (see www.tinyurl.com/mp-antitrust). The same criteria used by the FTC in determining whether an arrangement is allowable under antitrust law would apply in determining whether the arrangement is appropriate for receiving a waiver of the fraud and abuse laws. As many commercial arrangements involving financial integration and clinical integration already require analysis to ensure compliance with antitrust law, requiring the same analysis for determination of whether the arrangement should qualify for fraud and abuse waivers would have a minimal burden on providers. Antonio “Tony” Fricano, JD, is special counsel at Gray Plant Mooty
• 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
and specializes in health care regulatory law. He was previously associate
Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com
Health and Human Services’ Office of Inspector General. He was a member
general counsel and the MSSP ACO compliance officer for the largest health system in Illinois, based out of Chicago. Mr. Fricano has reviewed and advised on hundreds of potential Stark violations and has experience working through the disclosure process with CMS and the U.S. Department of of the Loyola Law Journal and a Fellow in the Institute for Consumer Law and Antitrust Studies.
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FEBRUARY 2019 MINNESOTA PHYSICIAN
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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.
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MHealth.org/heartcare
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