Minnesota Physician April 2018 by Minnesota Physician Publishing

MINNESOTA

APRIL 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 01

FDA regulation of stem cells A look at changing guidelines BY AMY FOWLER, ESQUIRE, RAC

Ambulatory surgery centers Expanding choices for patients BY TOM POUL, JD, AND RACHEL STUCKEY

very day, more than 1,500 Minnesotans choose to have their outpatient surgery performed in an ambulatory surgery center (ASC) instead of in a traditional hospital. Undergoing anesthesia during surgery once meant you had to stay in the hospital for several nights. Today, surgical advancements and high deductible health insurance plans are influencing patients to choose outpatient surgical centers. “For appropriate patients, outpatient surgery has been shown to be safe and effective, achieving similar outcomes while allowing patients to spend less,” said Darci Nagorski, St. Cloud Surgical Center CEO. Ambulatory surgery centers to page 104

tem cell products and therapies are starting to reach mainstream medicine in the United States. Cellular therapies have been part of the practice of medicine for many years, but now there are more companies and clinics manufacturing and using stem cell products for human therapeutic use than ever before. The practice of medicine is not regulated by the U.S. Food and Drug Administration. However, certain stem cell products and practices are indeed under FDA’s jurisdiction. The term “stem cells” is a simplified term that can apply to a variety of cells with regenerative properties, such as MSCs (mesenchymal stem cells). Clinical uses of stem cells today include transplantation for tissue repair, gene transfer, and many other innovative uses. Stem cells are often used in conjunction with collagen scaffolds or other tissues for a variety of therapeutic benefits. The term “stem cells” is easy for the press to use when reporting to the masses, and it is probably the FDA regulation of stem cells to page 124

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New Location. Eﬃcient Space. Medical Neighborhood. Optimal Care. We focus exclusively on healthcare real estate and have a number of space options that may be right for you. We help your practice design space that works for you and your patients. Our healthcare team has proven results and will guide you through the process of getting the right space for your practice. Leased By:

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APRIL 2018 MINNESOTA PHYSICIAN

Owned By:

REQUEST FOR NOMINATION APRIL 2018

Publication Date: June 2018

Volume XXXI1, Number 1

NOMINATION CLOSING May 4, 2018

COVER FEATURES Ambulatory surgery centers Expanding choices for patients

FDA regulation of stem cells A look at changing guidelines

By Tom Poul, JD, and Rachel Stuckey

By Amy Fowler, Esquire, RAC

Seeking Exceptionally Designed Health Facilities in Minnesota

DEPARTMENTS

Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed

CAPSULES

MEDICUS

INTERVIEW

Promoting health for older adults

Sara A. Lindquist, MD Juniper

PAIN MEDICINE Understanding how to best treat pain

Less Reliance on opioids By Bret C. Haake, MD, MBA

PRIMARY CARE 24 Improving one practice at a time Small changes produce big results By Lara Lunde, MD, and Julia Murphy, MSc

RADIOLOGY Diagnosing Alzheimer’s

health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2018 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,

Advances in PET scanning solutions By Michael H. Rosenbloom, MD, FAAN

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, 2018. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota, or Iowa). Color photographs are required at 300 dpi resolution (no more than eight) with a caption for each. If you would like to nominate a

PREVENTION 16 Chronic disease management

facility, please fill out the form below and, a brief project description (150– 250 words) or fill out the form on our website by Friday, May 4, 2018.

Focusing on preventive services By Joanna Chua, MPH, and Rachel Pugliano, RHIT

Online form: www.mppub.com/architecture-and-design-honor-roll.html

Health Care Architecture & Design Honor Roll Nomination Form

PROFESSIONAL UPDATE: SURGERY

Facility name Type of facility

Cardiac catheterization in a conjoined twin A groundbreaking surgery By Gurumurthy Hiremath, MD, FACC

Location Ownership organization Owner address, phone

SPECIAL FOCUS: PHARMACY Improving patient diabetes outcomes 20

Architect/interior design firm

A pharmacist-driven solution

Architect address, phone

By Jeremy Faulks, PharmD The role of the pharmacist in mental health care 22

Engineer

A team approach

Contractor

By Randall Seifert, PharmD

Completion date Square feet

www.MPPUB.COM PUBLISHER

______________________________________________________________

Total cost Mike Starnes, mstarnes@mppub.com

Brief description

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.

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 APRIL 2018

CAPSULES

Hospital Errors Increasing in Minnesota Rates of adverse events at Minnesota hospitals, ambulatory surgical centers, and community behavioral health hospitals continue to rise, according to a new report from the Minnesota Department of Health (MDH). The number of adverse events reported to MDH rose to 341 in the reporting period between October 2016 and October 2017, up from 336 the previous year. There were 308 adverse events reported in 2014. The state’s Adverse Health Events reporting system tracks 29 serious events, including wrong-site surgery, severe pressure ulcers, falls, and serious medication errors. Falls and pressure ulcers were the most common types of events, accounting for 59 percent of adverse events during this reporting period. The four types of events that make up the surgical/invasive procedure category accounted for 24 percent of reports, with 83 events.

Of the 341 reports submitted during this period, 30 percent resulted in serious injury (103 events) and 4 percent led to the death of the patients (12 events). The most common causes of serious patient injury or death have been falls, medication errors, and product/device malfunction since the reporting system was implemented 14 years ago, and that pattern remains. Five of the deaths were associated with falls; two were associated with a product/device air embolism; two with the death of a neonate; one with suicide/attempted suicide; one with maternal death; and one with a medication error. “The recent rise in adverse events is concerning,” said Jan Malcolm, Minnesota commissioner of health. “Minnesota can and must do better to protect vulnerable patients. We will continue to work with our partners to improve patient safety and the quality of care.” Despite the overall rise in adverse events, there were improvements in some categories. The number of

pressure ulcers declined to 120, from 129 the previous year. These have been the most commonly reported adverse health event since the system was implemented. In addition, there were no instances of physical assault on a staff member or patient reported for the first time in six years. When a reportable adverse event occurs, facilities are required to conduct a root cause analysis to determine the factors and circumstances that led to the event. These may include miscommunication, lack of compliance with or lack of clarity in policies and procedures, and problems with the underlying organizational structure. Corrective action is then focused on a specifically identified root cause to prevent similar problems in the future. The most commonly cited root cause category for adverse events was related to rules, policies, and procedures, as it has been in previous years. Communication issues accounted for 20 percent of root causes. In 18 percent of cases during this reporting period, facilities were unable to

identify a specific root cause. The highest number of events with no identified root cause was falls. “Behind each of these events is a patient and family,” said Rahul Koranne, MD, chief medical officer of the Minnesota Hospital Association. “Minnesota’s nation-leading adverse events reporting system provides a strong framework for learning and continuous quality improvement— and our hospitals, health systems, and care teams use what they learn to continually improve patient safety.”

Hennepin Healthcare Opens Clinic and Specialty Center Hennepin Healthcare Clinic & Specialty Clinic opened on March 26 across from HCMC’s emergency department in downtown Minneapolis. The $225 million, six-story clinic and specialty center adds 377,000 square feet of clinical space to the hospital’s five-block Minneapolis campus. It houses more than 25 of

Providing (and Protecting) High Quality, Cost-Effective Patient Care The Minnesota Ambulatory Surgery Center Association (MNASCA) is a statewide, non-profit trade association OUR MISSION MNASCA is dedicated to promoting quality, value-driven outpatient surgical care. We are committed to ensuring that surgery centers continue to thrive as a distinct model for the delivery of safe, affordable and advanced surgical services to Minnesota’s health care consumers. OUR MEMBERS Our 42 certified member ASCs provide a full range of surgical services. MNASCA supports members through advocacy, outreach, communication, and supporting legislation that lowers the cost of care and increases the quality of health care outcomes. OUR MEMBERSHIP MNASCA offers a variety of membership levels, including individual/nurse membership, associate membership (for our non-ASC supporters), and full facility membership.

Join us for our Annual Conference (venue pending) Thursday, October 11 & Friday, October 12, 2018 Additional details will be posted at www.mnasca.org 4

APRIL 2018 MINNESOTA PHYSICIAN

For questions about MNASCA, our annual conference, or memberships, please contact Rachel Stuckey at rstuckey@messerlikramer.com.

CAPSULES

the hospital’s primary and specialty care clinics, including allergy, internal medicine, cardiology, endocrinology, oncology, pediatrics, and pulmonary, as well as same-day surgery, imaging, rehabilitation, and other services that were previously spread across the hospital’s five-block campus. The clinics have been consolidated under one roof in order to improve patient experience and make it easier for providers to collaborate. The facility also includes 363 exam and procedure rooms, which increases the clinics’ current capacity by 15 percent, and an outpatient surgery center on the top floor with 11 pre-op rooms and seven operating rooms. It has underground parking for patients and staff as well as a skyway that connects the new building to the rest of the campus. More than 110,000 people access Hennepin Healthcare clinics for health care services each year. In 2017, this represented a total of 630,000 clinic visits. The health care system estimates 530,000 clinic visits will be scheduled before the end of December at the new building alone. The space also includes room to grow in the future. Hennepin Healthcare has the option of adding three stories on top of a bump out in the back of the building that would add about 45,000 square feet.

Charter on Physician Well-Being Addresses Burnout Mayo Clinic and other leading medical centers have published a Charter on Physician Well-Being as an intended model for medical organizations to minimize and manage physician burnout as well as promote physician well-being. More than half of U.S. physicians say they experience burnout in their work. The new charter is aimed at organizations, medical leaders, and policymakers across the U.S. The charter, published in full in JAMA, has been endorsed or supported by many major medical organizations, including the American Medical Association and the Association of American Medical Colleges.

“This is a first step on a national level to lay out guiding principles and commitments that we consider essential for physician wellbeing throughout a career, beginning with the earliest training,” said Colin West, MD, PhD, a physicianresearcher at Mayo Clinic and senior author of the charter. The charter calls for adequate support systems for physicians dealing with stress, overwork, and mental health issues, and promotes development of institutional and organizational changes ranging from reengineering work schedules and personnel policies to providing wellness and counseling programs for physicians. “Physicians should not be alone in managing burnout. It is a responsibility shared between individuals and the organizations in which they practice,” said West. “Leaders must be engaged and responsive to these problems by creating a supportive culture that minimizes stigma and promotes a positive workplace.” According to Mayo Clinic, research shows that when burnout goes unchecked organizations and careers suffer. However, they note that patients can suffer the most due to treatment errors and reduced physician availability.

Glencoe Hospital Completes Renovation Glencoe Regional Health Services has completed a $5 million renovation on its Glencoe campus hospital that began in September 2016. The project included a renovation of the entire first floor that was completed in two phases. The first phase was completed in summer 2017, when the new entrance and several interior spaces opened back up to the public. The hospital’s podiatry, orthopedics, pulmonology, hematology, oncology, and urology exam rooms are now all located in the outpatient clinic closer to operating rooms and imaging technology for more efficient care. Urgent Care also has moved into new exam rooms near the hospital entrance. The final results also include a new hospital registration and checkin desk; a new specialty care suite;

TH 50 SESSION

CONSOLIDATION IN HEALTH CARE

Examining cost and quality issues

Thursday, November 1, 2018, 1-4 pm The Gallery, Downtown Minneapolis Hilton and Towers 1101 Marquette Avenue South

BACKGROUND AND FOCUS: Consolidation in health care threatens the viability of the system and is escalating at an alarming pace. Patients are left with fewer choices, both in terms of which doctor to see and in terms of treatment options, including medications, from the doctor they do see. Costs are often increased and quality often decreases when systems become too large. Demands to comply with increasing regulations leave many medical practices in a bind. How can they maintain independence without the infrastructure of a large system?

OBJECTIVES: We will examine the root causes of health care consolidation. We will illustrate what has worked and what has not. We will explore cases where FTC regulations are pushed to the limits and the threat to patients this poses. We will look at the larger continuum of care and how public health issues are impacted by consolidation. We will discuss state legislative initiatives that need to be in place and what must be done to keep patient well-being at the center of health care delivery. Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub.com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX Card #  Check enclosed  Bill me

Exp. Date  Credit card (Visa, Mastercard, American Express or Discover)

Signature Email

Please mail, call in, or fax your registration! • mppub.com MINNESOTA PHYSICIAN APRIL 2018

CAPSULES

a larger surgery waiting area; additional and larger pre-operative care and post-surgical recovery bays; a reconfigured nurses’ station in the surgery department; direct access between the emergency room and medical laboratory for staff to order tests and see results faster; a large, dedicated decontamination room for patients who have been exposed to chemicals or other hazardous materials; and an in-house MRI suite with a new scanner (previously, patients had to use the hospital’s mobile MRI unit outside the building). It also includes larger, more comfortable facilities on the hospital’s new third floor for patients undergoing infusion therapy.

Prescribing Trends for High-Risk Anticholinergic Medications Stay Stable Researchers at the University of Minnesota conducted an analysis to better understand prescribing trends of high-risk anticholinergic

medications in the U.S. They found that while the prescribing prevalence has remained stable over time, it varied by physician specialty and drug class. Anticholinergic medications can lead to risks of developing serious adverse events such as cognitive impairment, falls, dementia, and even mortality in older adults. They block the neurotransmitter acetylcholine, which is part of the nervous system and plays a role in involuntary muscle contractions. They are often prescribed for urinary, respiratory, and gastrointestinal disorders, or to treat depression. “High-risk anticholinergic prescribing should be avoided because there are safer alternative medications for older adults,” said Greg Rhee, PhD, MSW, adjunct assistant professor in the College of Pharmacy and lead author of the study. The repeated cross-sectional analysis of the 2006-2015 National Ambulatory Medical Care Survey showed that physicians’ prescribing behavior

remained stable over time, with these drugs being prescribed in about 6 percent of physician visits over a 10-year period. The researchers investigated whether these prescribing patterns vary by physician specialty and anticholinergic class among older adults in their office-based care, and estimated demographic factors independently associated with these high-risk anticholinergic medication prescriptions. The rate of prescriptions at physician visits suggested to the researchers that prescribing patterns vary by specialty. Specifically, psychiatrists and urologists had higher rates of prescribing the medications. They also found that by medication class, antidepressants were the most prevalent among anticholinergic drugs prescribed to older adults; women were more likely to receive prescriptions for the drugs; patients from the South were more likely to receive them; and patients who were prescribed six or more medications had a greater likelihood of being prescribed anticholinergic medications.

“Older adults are vulnerable to these medications due in part to physiological changes as they age,” said Rhee. “In general, older adults have a higher likelihood of developing adverse drug events from taking multiple medications.” They note that the study has limitations, including that it does not represent emergency department or hospital visits, so the results may not show the full impact of anticholinergic drugs. Rhee recommends increasing awareness of potential adverse effects and encouraging providers to prescribe medications with fewer risks. Full results of the study are published in the Journal of the American Geriatrics Society.

Creating a Healthier Minnesota Juniper is helping rural and urban communities across Minnesota create a culture of health. Our evidence-based programs give your patients the tools they need to take manage their health in a way that works. Juniper programs offer group training to prevent escalation of disease, reduce hospital admissions, lower health care costs, and improve independence. Programs concentrate on: n

Preventing Falls

Preventing and Managing Diabetes

Managing Chronic Conditions and Pain

To locate a Juniper program, or to start one through your clinic or in your community, please call us toll free at 1-855-215-2174 or email info@yourjuniper.org. To find our more about the Juniper program please visit: www.yourjuniper.org Innovations for Aging, LLC, a nonprofit subsidiary of Metropolitan Area Agency on Aging, is the managing partner for Juniper, providing management information systems, coordination, member services and support to our partner organizations.

APRIL 2018 MINNESOTA PHYSICIAN

Robert Levy, MD, family physician and assistant professor at the University of Minnesota Medical School, has been selected as the Family Medicine Educator of the Year by MAFP. Levy has been teaching family medicine students, medical students, and medical fellows since 2011. He is also board-certified in addiction medicine and completed a fellowship in addiction medicine and chronic pain at Hazelden, and leads substance abuse recovery services at the University of Minnesota Physicians Broadway Family Medicine Clinic. Levy earned his medical degree at State University of New York at Stony Brook. Jonathan Buchholz, MD, has joined the care team at Mayo Clinic Health System in St. James to offer newly available obstetrics and gynecology services. Buchholz will see patients in St. James every other Tuesday, where he will provide women’s health services including preventive health screenings, menstrual concerns, pelvic exams, and prenatal care. His professional interests include family planning, contraception, infertility, and pregnancy with preexisting hypertension or diabetes. Buchholz earned his medical degree at Sanford School of Medicine in Sioux Falls, South Dakota, and more recently completed his residency in obstetrics and gynecology at Louisiana State University Health Sciences Center in Shreveport, Louisiana.

Erin Keefe

Andrew Litton

Augustin Hadelich

Minnesota Chorale

Daniel Müller-Schott

Diane Kennedy, MD, rural family doctor at Sanford Luverne Clinic, has been named the Family Physician of the Year by the Minnesota Academy of Family Physicians (MAFP). The award is given to physicians who personify the highest ideals of family medicine— compassionate, comprehensive patient care and involvement in the community. Kennedy has served the community of Luverne for 25 years. Her patients and colleagues describe her as an advocate, a listener, and a servant leader who goes above and beyond to remove barriers that may be impacting her patients’ ability to receive care. In addition to her clinical responsibilities, she serves as a mentor and educator to medical students through the University of Minnesota Rural Physician Associate Program and Rural Medical Scholars Program. She is also a physician lead for rural family medicine with Sanford Health and sees patients at the local nursing home, Veterans Home, and Hospice Cottage. Kennedy earned her medical degree at the University of Minnesota.

Susie Park

Osmo Vänskä

Andrew Baker, MD, chief medical examiner for Hennepin County, has been recognized by The American Academy of Forensic Sciences (AAFS) for his contributions to the forensic pathology profession with two awards at its meeting in February—the Milton Helpern Award, which recognizes people who have demonstrated lifetime achievement and dedication to the mission of forensic pathology, focusing on leadership, service, and teaching; and the Kenneth S. Field Award of Appreciation, which recognizes those who have made a difference in the daily work of a department or AAFS staff member. During his 20 years with the AAFS, he has held several leadership positions. He currently serves as its pathology/biology section director, a member of the executive committee, and chair of the Forensic Sciences Foundation, which is the educational, scientific, and research arm of AAFS. Baker earned his medical degree at the University of Iowa College of Medicine.

Sharon Bezaly

MEDICUS

American Voices

Copland, Bernstein and Barber May 3–5

Osmo Vänskä, conductor / Sharon Bezaly, flute / Susie Park, violin

Britten and Schumann May 10–11

Michael Francis, conductor / Daniel Müller-Schott, cello

Andrew Litton and the Minnesota Chorale

Bernstein and Walton Jun 1–2 Andrew Litton, conductor / Christopher Maltman, baritone / Minnesota Chorale

Chamber Music

Mendelssohn and Dvořák

Jun 3

Minnesota Orchestra Musicians

Beethoven and Berlioz

Jun 8–9

Jun Märkl, conductor / Augustin Hadelich, violin

612-371-5656 / Orchestra Hall minnesotaorchestra.org PHOTOS Anders Krison (Bezaly). Additional credits available online.

Media partner:

MINNESOTA PHYSICIAN APRIL 2018

INTERVIEW

Promoting health for older adults Sara A. Lindquist, MD Juniper Tell us about the Area Agencies on Aging.

Minnesota’s seven Area Agencies on Aging (AAAs) include nonprofits, regional commissions, and one tribal organization sharing a common vision that communities should support aging with dignity and independence, and that older adults are valuable contributors to society. They help communities offer a comprehensive continuum of support services for older adults and their family caregivers. Nationally, AAAs are part of the aging network created by the federal Older Americans Act (OAA), which authorizes programs administered by AAAs in partnership with the states, including, but not limited to, in-home services for frail elders; programs that serve native American, low-income, and minority elders; nutrition services; and programs aimed at promoting health and preventing disease.

Participants learn to recognize and acknowledge how chronic conditions affect themselves and loved ones, and to communicate needs with family members and medical providers. They learn to manage symptoms and to address barriers to medication compliance, physical activity, diet, and self-care. Most care and management of chronic illness happens outside of a clinical setting. Juniper strives to empower

What other kinds of programs do you offer?

How did Juniper get started?

Please explain your Chronic Disease SelfManagement Education (CDSME) programs.

Initially developed at Stanford University, these EBHP programs are now licensed through the SelfManagement Resource Center. CDSME programs meet once weekly for six weeks and are lay led, frequently by volunteers who must complete a 4-day training program. Program offerings include: Living Well with Chronic Conditions (offered in English and Spanish), Living Well with Diabetes (English and Spanish), and Living Well with Chronic Pain.

APRIL 2018 MINNESOTA PHYSICIAN

“...” Juniper’s programs empower older patients to take more control of their health. “...”

Juniper was developed by Minnesota’s AAAs to help change the culture toward self-managed health and well-being. A network of community organizations delivers evidence-based health promotion (EBHP) programs that assist people to manage chronic health conditions, prevent falls, and foster well-being. Under a recent grant, the Metropolitan Area Agency on Aging (MAAA) partnered with the other AAAs to expand class offerings with the long-term goal of achieving the scale necessary to attain significant, positive impact on the health of older adults. We draw our name from the Juniper plant, a long-living, hardy evergreen with an interconnected root structure, considered by many cultures as a symbol of longevity and strength.

strategies promoting education may improve outcomes and lower costs. Health care systems can refer patients with one or more chronic conditions, or those at risk of falls, to Juniper’s established community programs. Health care systems can also partner with us to provide space for classes offered by community-based organizations.

people to think about their chronic conditions as something they can positively manage. How do CDSME programs partner with health care systems?

These programs improve many aspects of health, including fatigue, pain, self-reported health and self-efficacy, communication with providers, and frequency of ER visits and hospitalizations, with persistence of these improvements at a 2-year follow-up. The diabetes self-management program has shown improvements in A1C, depression, medication adherence, and hypoglycemic symptoms. Native-language programs enhance community support and understanding. Health expenditures are higher for those with below basic or basic health literacy. Public health

In addition to CDSME programs, Juniper offers four different fall prevention programs: 1) A Matter of Balance, in which participants learn strategies to overcome the fear of falling, thereby reframing falls as risks which are controllable; 2) Tai Ji Quan: Moving for Better Balance (Tai Chi), an exercisebased program to improve strength, balance, and mobility, which has been shown to decrease fall rates and the risk of multiple falls; 3) Stepping On, which provides information on identifying fall hazards, solving problems, forming movement strategies, and instituting lifestyle changes; and 4) Stay Active and Independent for Life (SAIL), which combines aerobic conditioning and strength training, along with health tips. Additional EBHP programs: 1) Arthritis Foundation Exercise Program (AFEP), also known as People with Arthritis Can Exercise (PACE), for adults with rheumatoid or osteoarthritis; and 2) Diabetes Prevention Program, for adults with obesity and a high risk for diabetes. How can patients become involved?

Patients can find a class at yourjuniper.org or may call us toll-free at 1-855-215-2174. Patients can be referred by a healthcare provider or family member or can self-refer and register independently. Consent should be obtained prior to referral, after which potential participants are emailed or called by a scheduler from their nearest AAA. The Indian Area Agency on Aging follows up with Native elders residing in reservation communities. Tell us about your new website.

Yourjuniper.org is a secure, user-friendly web portal and management information system designed as a “one-stop shop” for participants, providers, and community stakeholders. The system supports a single point of contracting for program delivery in local and statewide communities.

How many participate in Juniper programs, and what growth rate do you project?

Our growth has greatly surpassed initial expectations. In 2015, we offered 284 classes. By 2017, that grew 95 percent, to 555 classes. Since 2015, over 6,500 participants have completed EBHP programs. Estimates for Juniper-affiliated programs in 2018 include 579 classes and an additional 5,211 completers statewide. How can AAAs help health care organizations and payer systems meet quality goals and lower health care costs?

Health systems are under increasing pressure to show outcomes related to chronic disease and hospital readmissions. We believe that the Juniper approach can help improve outcomes related to these goals. A recent study in Health Affairs suggested that in counties where AAAs have broad informal partnerships with health systems, there were lower risk-stratified hospital readmission rates. Some estimates suggest that anywhere from 40 to 90 percent of poor health is attributable to social, economic, and behavioral factors. Social service providers such as AAAs can help health care organizations address these needs, improving the health of older individuals and containing costs. Community-based social service providers can bridge the gap between medical care

providers and patients by focusing on access to these social and behavioral needs. EBHP programs can also help payer systems meet Medicare Star Rating measures, such as improving and maintaining physical and mental health, reducing the risk of falls, and obtaining needed care.

primary care discussions. Patients are 18 times more likely to participate in these programs when recommended by physicians, according to the CDC. To learn more or to become involved in an advisory capacity for your clinic or health system, contact me at slindquist@yourjuniper.org.

What should physicians know about Juniper?

How does your prior work at an outpatient primary care clinic benefit your work with Juniper?

Chronic illness and falls are among the largest drivers of morbidity, mortality, and costs among older adults. Modifiable risk behaviors cause much of the illness and early death related to chronic diseases and conditions. Falls don’t have to be an inevitable part of aging. Juniper’s programs empower older patients to take more control of their health. In a 2011 Robert Wood Johnson Foundation Survey of over 1,000 primary care physicians, 85 percent believed that unmet social needs led to worse health and that those needs were as important to address as medical conditions, but only 20 percent felt confident that they could adequately address their patients’ social needs. A public health approach focusing on both individualand community-based strategies may reduce both the prevalence and cost of chronic disease. EBHP programs are not intended to be in lieu of standard medical care. Rather, they complement

I know the challenges of working with adult patients of all ages on medication compliance, health awareness, and healthy behaviors. I understand the difficulty in fitting health counseling into a visit already full of the patient’s own concerns and the priorities of competing clinical objectives. I see the value these programs can add in helping patients improve their health and in helping providers improve outcomes. My prior experience demonstrates the importance of educating patients on the basics of self-care, and I bring that fundamental belief and passion to my work with Juniper. Sara A. Lindquist, MD, is director of health care integration at Juniper. She is board-certified in both internal medicine and geriatrics.

Hello Progress Advancing health and wellness in local communities is at the heart of our endeavors.

612.524.6000 hdrinc.com

MINNESOTA PHYSICIAN APRIL 2018 9

3Ambulatory surgery centers from cover Minnesota is home to 61 Medicare-certified ambulatory surgery centers, many of which are members of the Minnesota Ambulatory Surgery Center Association (MNASCA), a statewide, nonprofit trade association committed to promoting high-quality, value-driven surgical services. According to its president, MNASCA works to ensure that surgery centers continue to thrive as a distinct model of care for Minnesota’s health care consumers. “It is well documented that ASCs are a highquality, low-cost option for outpatient surgery. The ability to avoid a long day or days at the hospital not only can impact the patient experience but also the family and friends assisting in the care process. When you combine that experience along with lower patient copays it creates a significant value to all involved,” said Rob Simmons, MNASCA president and COO at Twin Cities Orthopedics.

surgical care, including diagnostic and preventive procedures. ASCs have transformed the outpatient experience by providing a more convenient alternative to hospital-based outpatient procedures.

On average, patients who have their outpatient surgery at an ASC save 40–50 percent on the cost of their procedure, resulting in lower out-of-pocket costs. According to a recent University of California–Berkeley study, ASCs save Medicare $2.3 billion each year on the 120 most common procedures that they perform for Medicare patients. According to the same study, these savings could exceed $57.6 billion over the next 10 years. ASCs [focus] on providing same-day surgical care, In addition to a cost benefit, ASCs’ focused and including diagnostic and trained staff works closely with surgeons to ensure preventive procedures. an excellent patient experience. With hospital-grade operating rooms and dedicated teams committed to clinical quality, ambulatory surgery centers consistently experience lower rates of surgical site infections than hospitals.

Including Minnesota, 43 states currently have ASC associations that are working to increase quality, lower costs, and provide superior patient satisfaction. Many ASCs also belong to the Ambulatory Surgery Center Association (ASCA), a national organization.

Benefits of ambulatory surgical centers ASCs are modern health care facilities focused on providing same-day

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Efficient operating room management, easy “in-and-out” access for patients, and coordinated postoperative care make ASCs a more efficient and convenient option for patients. In fact, research shows that procedures performed at outpatient surgical centers typically take 31.8 fewer minutes than those performed at hospitals. In addition, ASC patients return home as early as the same day of surgery and receive personalized care to ensure that their discharge goals are met. Ambulatory surgery centers support a variety of specialties, including ear, nose, and throat; orthopedic, including joint replacement; dental/oral; spine; eye care; gynecology; podiatry; gastroenterology; and general surgery. “Because ASCs provide a more intimate setting related to size and design, it really motivates the staff to engage with each patient and ensure they have a positive experience. Our members take great pride in working in these efficient and high-quality environments knowing they are truly playing a part in lowering the overall cost of healthcare,” explained Simmons. In addition to benefits for patients, there are many advantages physicians experience when they choose to perform outpatient procedures at an ASC. For example, when surgeons are invested in the surgery center, they have the ability to control their environment and treat patients with the best care possible while creating an additional revenue stream. With enhanced efficiency in mind, physicians are also able to try new and innovative ways to maximize surgical time and minimize downtime for the physicians and staff. For procedures that do not require inpatient care, ASCs provide a safe, effective alternative.

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APRIL 2018 MINNESOTA PHYSICIAN

Communication, advocacy, and education MNASCA is comprised of a variety of membership levels, including individual memberships, associate memberships (for non-ASC supporters), and full facility memberships. MNASCA surgery center members vary in both shape and size. They include both physician-owned and hospitalowned centers as well as partnerships, and they also range from single specialty to multi-specialty facilities. All members share a common interest in promoting quality, value-driven outpatient surgical care. Members of MNASCA provide a variety of services, from gastroenterology and orthopedics to pain management and plastic surgery. Common procedures include knee arthroscopy, cataract removal, carpal tunnel release, colonoscopy, pain management injections, ACL reconstruction, hernia repair, implant removal, and shoulder arthroscopy.

In addition to providing its members with up-to-date information on legislative, safety, and procedural issues that may affect their centers, MNASCA also promotes the ASC industry through advocacy and education. MNASCA advocates on behalf of the ASC industry at the Legislature and with key state agencies. Each year, the association hosts a “Day on the Hill.” This is an opportunity for MNASCA members to visit the Capitol and meet with legislators to discuss issues of importance to their facilities as well as to the association. Meetings are scheduled with both local legislators and health care leaders. Each year, MNASCA identifies and analyzes critical issues affecting ASCs and acts on behalf of members to enhance and protect the ASC’s ability to provide high quality, cost-effective patient care. Priorities for the 2017–2018 legislative session currently include: • Workers Compensation payment reform for ASCs. • Support phasing out the Provider Tax by 2019. • Oppose any market restrictions on ASCs, such as certificates of need or moratoriums. • Support legislative changes to address contracting issues and transparency with payers. • Monitor scope of practice changes for nurses, chiropractors, and athletic trainers. • Participate on behalf of ASCs in the Minnesota Department of Health (MDH)’s X-ray rule modifications process, particularly around CT, MRI, and use of fluoroscopy.

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The association also helps their member facilities organize legislative tours and fundraisers at their centers. These events are great opportunities to introduce legislators to their facilities, provide information about the practice, and discuss issues of importance to physicians and staff. It is also an opportunity to provide legislators with more information about the association’s work at the Capitol and within the health care community. Funds raised help support the association’s political action committee (PAC). “Being a member in MNASCA allows ASC leaders to stay informed of key legislative issues which can impact operational and growth strategies. MNASCA has provided us that voice to ensure laws are scrutinized so that we can be proactive in addressing any downstream impact to the delivery of care to our patients,” said Simmons. MNASCA holds an annual conference intended to connect leaders in the ASC industry with key stakeholders and partners in the health care community. This conference provides members with continuing education, enabling them to stay current on key topics and issues affecting ASCs. MNASCA’s 2018 Annual Conference will be held October 11–12 in Bloomington. “The MNASCA conference brings together the right mix of people from the ASC industry to discuss the latest on regulatory hot topics and changes,” said Kari Scholz, RN, BSN, Quality Improvement Team Leader, St. Cloud Surgical Center. “The high quality of the speakers and seniority of other attendees are essential for gathering information and discussing issues we are faced with each day.” Ambulatory surgery centers to page 384

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MINNESOTA PHYSICIAN APRIL 2018

3FDA regulation of stem cells from cover term patients are using in their online searches for cutting-edge treatments. It is also an easy term to use in this article when referring to cells capable of developing into a variety of different types of cells. The FDA puts stem cells under an umbrella term of “regenerative medicine.” Regenerative medicine is a current area of focus for emerging regulations in emerging technologies.

Policies and enforcement

to U.S. Stem Cell Clinic of Sunrise, Florida, and StemImmune, Inc., in San Diego, California (FDA News Release, 8/28/17). U.S. Stem Cell reportedly injected stem cells extracted from fat into eyes, blinding one patient and permanently damaging the eyes of two other patients. StemImmune was developing a cell-based immunotherapy for cancer using live virus vaccine for smallpox in a way that concerned FDA. (New York Times, 8/28/17, “F.D.A. Cracks Down on ‘Unscrupulous’ Stem Cell Clinics.”) There can be a fine line between stem cells that are exempt from FDA regulation, those that are regulated as HCT/Ps, and those that require premarket review. “HCT/P” is the abbreviation for Human Cells, Tissues, and Cellular and TissueBased Products. HCT/Ps are defined in 21 CFR 1271.3(d) as articles containing or consisting of human cells or tissues that are intended for implantation, transplantation, infusion, or transfer into a human recipient. They must meet very specific criteria.

Creativity and innovation in medicine need to encouraged, not stifled.

Physicians and companies working with stem cells need to know whether the centrifugation of cells or the shipment of cells to another facility change their legal duties. FDA’s new comprehensive policy framework and enforcement actions are shaping the market and the landscape of stem cell products and therapies. FDA Commissioner Scott Gottlieb, MD, has been vocal, announcing that “as the FDA takes new steps to advance an efficient, modern approach to the regulation of cellbased regenerative medicine,” the Agency “will be stepping up enforcement action.” (FDA Statement, Gottlieb, 10/24/17) Enforcement actions are trumpeted by the Agency, as these press releases are picked up and reported quickly by the media. FDA’s January 4, 2018, press release announced a warning letter posted to American CryoStem Corporation of New Jersey for marketing Atcell, an adipose-derived stem cell product, without FDA approval and for a failure to follow good manufacturing practice requirements. FDA has also issued warning letters

The “Same Surgical Procedure Exception” In November 2017, FDA updated its guidance entitled “Same Surgical Procedure Exception under 21 CFR 1271.15(b): Questions and Answers Regarding the Scope of the Exception.” It is aimed at tissue establishments and health care professionals. It clearly states that some cells and procedures are not regulated, and that the Agency will “not assert any regulatory control over cells or tissues that are removed from a patient and transplanted back into that patient during a single procedure.” However, if the cells are expanded, or if the cells are shipped to another establishment, FDA considers the cells to be “manufactured,” and not under the Same Surgical Procedure Exception. This guidance document gives examples of procedures that are clearly within the exception, and these include autologous skin grafting and coronary bypass surgery using autologous vein or artery grafting. As always, there is a significant amount of “gray area” that comes with novel procedures. If the use of cells or tissues is not within the Same Surgical Procedure Exception, it may be considered to be an HCT/P, but the requirements are very strict. The cells or tissues must be “minimally manipulated” and be for “homologous use,” plus meet two other specific criteria.

Interpreting the terms FDA issued a November 2017 guidance document entitled “Regulatory Considerations for Human Cells, Tissues, and Cellular and Tissue-Based Products: Minimal Manipulation and Homologous Use” that helps interpret these terms. The guidance gives examples of processing procedures that are more than minimal manipulation and uses that are not homologous. The guidance also outlines areas where FDA will exercise enforcement discretion for products that normally would require approval before being evaluated in human clinical trials or going to market. For cells, minimal manipulation is “processing that does not alter the relevant biological characteristics.” Homologous use means the “repair, reconstruction, replacement, or supplementation of a recipient’s cells or tissues with an HCT/P that performs the same basic function or functions in the recipient as in the donor. In FDA’s example, hematopoietic stem/progenitor cells have the relevant biological characteristics for repopulating bone marrow by self-renewal, and also differentiating along lymphoid and myeloid cell lines. A process to obtain a higher concentration of cells through selection procedures would fall within the definition of minimal manipulation, because the cells

APRIL 2018 MINNESOTA PHYSICIAN

are simply concentrated. The cells are not changed in their mechanism of repopulating bone marrow. Culturing these same cells would not be minimal manipulation, because this process changes the cells’ biological characteristics for self-renewal and multipotency. Homologous use relates to the basic function the cells perform, which are typically metabolic or biochemical functions. The function of a hematopoietic stem cell could be the formation and replenishment of the lymphohematopoietic system. Where cells are transplanted from a donor’s peripheral blood to the recipient for the purpose of reconstituting the hematopoietic system, it is considered homologous use. If cells are taken from cord blood to repair damaged brain tissue, it would not be homologous use, because repair of brain tissue is a different cell function from their function in donor cord blood. Because FDA’s changing regulations on stem cells are affecting many companies and health care providers that are already providing beneficial treatments, the Agency is allowing 36 months from the publication of the guidance document for entities to get into compliance, unless there are significant safety concerns. This special period of time will extend to late 2020. Many entities that are not in compliance now will need to ensure that they are in line with the regulations by that time.

Moving forward Compliance of HCT/Ps with FDA regulation is fairly simple and straightforward. If the HCT/P criteria are not met, the product may slip into the definition of a medical device, drug, or biologic. Products within these definitions may need to comply with challenging premarket approval regulations and strict manufacturing requirements.

Because stem cells are being used in so many creative ways that require novel processing, many innovators will need to carefully analyze the FDA regulations for their unique situations and document their decisions. The framework and examples of FDA guidance will not provide a clear decision pathway in every situation. There will be many types of products that go far beyond the imaginations of the regulators, and the FDA guidance will need to be applied in a thoughtful manner, while keeping an eye on the Agency’s enforcement actions. In addition to the guidance, case law and warning letters will help clarify where the legal boundaries lie for lawfully producing, shipping, and selling stem cells for particular intended uses. Stem cell practices today span a wide range of safety and efficacy. Creativity and innovation in medicine need to be encouraged, not stifled. At the same time, safety is a concern. Situations like the U.S. Stem Cell disaster harm the entire field, including those therapies that have substantial benefit with little risk. Overall, awareness of FDA regulation needs to be raised for everyone working with stem cells. Amy Fowler, Esquire, RAC, is the founder of Pathmaker FDA Law. She has 26 years of experience in commercializing medical devices, pharmaceuticals, and combination products. Regenerative medicine law is a special focus for the firm. Amy received her chemistry degree from the University of Minnesota and her Juris Doctor from Mitchell-Hamline School of Law. Amy is an instructor for the Medical Device Regulation graduate program at St. Cloud State University and also serves as chair of the Minnesota State Bar Association’s Food, Drug, and Device Law Section.

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MINNESOTA PHYSICIAN APRIL 2018

PAIN MEDICINE

Understanding how to best treat pain Less Reliance on opioids BY BRET C. HAAKE, MD, MBA

s a neurologist, I have seen patients with various pain symptoms throughout my 28 years in practice. I have long been concerned about the way the health care system treats people with pain, and with its overreliance on opioid pain medications. Recently, it has been encouraging to see the medical community starting to curb the liberal use of opioids. Despite the increased awareness that prescription opioids have led to an opioid epidemic—and the fact that some providers have changed their prescribing practices—the medical community is still moving too slowly to stop the overprescribing of opioids. I believe that this is due to a misunderstanding of the risk of opioid tolerance, addiction, and hypersensitization, and to a lack of understanding on how to best treat pain. We should recognize that pain is normal and present in most individuals each day. It is mostly tolerable and is largely self-limited. In fact, many have noted that the persistence of pain after an injury has less to do with the severity of the injury, and more to do with other factors in the patient’s life. In general, with reassurance, positive expectations, and time, pain improves

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and mostly goes away. When pain does persist, it is better correlated with negative life events, and may also be perpetuated by negative thinking, persistent guarding, lack of exercise, and increasing hypersensitization by the pain medications that patients take.

Opioid use and hypersensitization Opioids, in fact, increase pain over time. Opioids definitely relieve pain with a single dose, but even after a single dose there is a period of opioid-induced hyperalgesia, and after prolonged use, the hyperalgesia can worsen and last longer. This hyperalgesia/hypersensitization occurs at the same time tolerance builds, causing the opioids to be less and less effective. Eventually, patients can develop a diffuse hypersensitization syndrome. This typically manifests in people on opioids having more pain over time, and it can eventually be noted in areas of the body not affected by the initial injury. It also explains why the patient’s pain persists, unlike that of most individuals, whose pain largely goes away with time. In short, physicians are giving more opioids to patients under the assumption that they are helping pain, while over the long run, they are increasing the patient’s pain. Most patients on opioids state that they must have the opioid pain medications just to get through their day, and that the pain would be unbearable without them. They also typically report that their pain is worse now than it was in the past. Most of them do not understand that, if they came off the opioid and let time pass, their pain would actually improve as the hypersensitization went away. The main difficulty with just stopping the opioid is twofold. Some individuals will exhibit addictive behaviors that hamper their ability to discontinue the drug. Others may be committed to the opioid removal, but suffer heightened pain during and after the opioid taper, for as long as 6–8 weeks. As patients start to adapt to the withdrawal of exogenous opioids, their bodies will start to re-regulate their neurons and start to depend again on their own neuronal systems to modulate pain. This leads to worse pain during the taper and hyperalgesia for the first several weeks off of the opioids. During this time, the patient will need significant support, both medically and behaviorally, until they start to see the improvement. Also, some individuals may have had significant issues that augmented pain even before the opioid was started. Issues such as trauma, anxiety, depression, somatization, lack of exercise, expectations, and fear will need to be addressed. All of these factors reinforce the idea that opioids should be avoided in the first place.

The risk of addiction It would be easier if there was no need for opioids in medicine, but since opioids are arguably the best medication for acute, severe pain, many believe that it would be inhumane to not use them. Ideally, one would use opioids for comfort at the end of life and in major tissue injury, including a bridge around the time of surgery, and for a handful of other very painful

APRIL 2018 MINNESOTA PHYSICIAN

diseases. I believe that if physicians uniformly understood the risk of using opioids (addiction, death, and opioid-induced hyperalgesia), opioids would be severely limited in their use. When needed for severe tissue injury (e.g., burn, frostbite, or major trauma), there would be a clear need to wean the opioids quickly during the recovery period.

therapy with a slow wean over time, while also increasing physical activity, addressing behavioral health issues, and promoting wellness and function.

Alternative pain treatments

So how does one treat pain more effectively in the first place? The treatment begins with a thorough history and How great is the risk for habituation? When examination, both to identify the pain generator the CDC looked at over 1,000,000 opioid-naïve and to build trust with the patient. Outside of patients that received an opioid prescription, major tissue injury and a handful of very painful nearly 7.5 percent of them were taking opioids disorders, the patient should be reassured that every day one year later. When patients received Opioids, in fact, increase pain is common and a normal body response. It a second prescription, nearly 15 percent were on pain over time. should be reinforced that pain is self-limited and opioids one year later. Thus, there is a very high improves with positive expectations, appropriate risk of opioid habituation when patients are activity, time, and avoiding medications that given opioids, and the risk goes up steeply when make pain worse over time. In general, providing additional prescriptions are given. reassurance and reinforcing that it is okay to be active goes a long way in helping patients heal. Some have argued that habituation and When people know that they will get better with time and that it is okay addiction are very different things. I think that the difference between to exercise, medication often can be avoided or can take a back seat in the two is on a spectrum, and that most have seen the blurring of this these discussions. distinction when patients are asked to stop their opioids. At that time, With opioid-naïve patients, it is often surprising to see how happy they addictive behavior is often seen, and at other times, one will witness an are to move forward with reassurance that they are normal and will be okay escalation of pain when the opioids are weaned, since the hypersensitization with time. When patients are resistant and push for opioids, more often than far outlasts any other withdrawal symptoms. In most of these cases, the not they have already been exposed to opioid pain medications and are either patient struggles coming off the medication, but if the goal is to improve pain, the opioid must be weaned. If the patient resists, the best treatment mimics the treatment for addiction. This would include medication-assisted

Understanding how to best treat pain to page 324

V PTSD is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year • Intractable Pain • Post-Traumatic Stress Disorder

• Severe and persistent muscle spasms, including those characteristic of MS

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS

(651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

MINNESOTA PHYSICIAN APRIL 2018

PREVENTION

Chronic disease management Focusing on preventive services BY JOANNA CHUA, MPH, AND RACHEL PUGLIANO, RHIT

the CDC reports that obesity rates grew from 10 percent in 1990 to 25 percent or higher in 2010 in most states.

reating chronic disease is one of the biggest challenges facing health care delivery today. According to the Centers for Disease Control and Prevention (CDC), one in two adults have one or more chronic diseases. In 2014, seven of the top 10 causes of death were due to chronic diseases, and 86 percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic conditions (the CDC includes mental health conditions in this figure). Due to the unsustainable increasing cost of care, the fee-for-service or volume-based model is shifting to a value-based system, where providers are encouraged to deliver care at lower cost while still providing high-quality care. By shifting the focus to value, providers can better prepare for an aging patient population with multiple chronic conditions.

To prevent chronic diseases from escalating further, Medicare has approved new services, such as the Welcome to Medicare visit, the annual wellness visit (AWV), chronic care management (CCM), transitional care management (TCM), and advanced care planning (ACP). It’s important for providers to know which services are available to patients, to understand the documentation requirements, and to bill correctly to ensure reimbursement.

U.S. health care spending is more than twice the average of other developed countries, according to the Organisation for Economic Cooperation and Development (OECD), which promotes policies to improve economic and social well-being. Obesity contributes to this disparity: the OECD cites studies showing U.S. obesity rates at double those of other countries, while

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Lake Region Healthcare is a nonprofit system with a 108-bed hospital, multi-specialty clinic, and cancer center serving rural west central Minnesota. In 2017, it served over 44,000 patients, 28 percent of whom were 65 and older. Prevalence of chronic conditions increases with age, leading to higher utilization of health care services. Understanding this challenge, Lake Region Healthcare joined the Medicare Shared Savings Program to help transform their delivery system.

Medicare wellness visits The Welcome to Medicare visit is not a routine check-up, but an introductory visit to the Medicare Part B program that must take place within the first 12 months of Medicare enrollment. It includes a physical exam, but the main emphasis is to develop a plan of care, as well as preventive and screening services to proactively manage the patient’s care. The AWV follow-up visits—approved once each 12-month period— allow providers to update and personalize prevention plans. It is not a yearly physical, but an opportunity to assist patients in taking responsibility for their own care and managing their chronic illnesses and health care needs. Patients often don’t understand or know what to expect from an AWV, so educating them is a key piece to success.

Managing chronic illnesses mnpsychconsult.com

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Chronic care management and complex chronic care management (Complex CCM) services were approved for Medicare reimbursement within the last few years. CMS sees CCM as an important part of managing a patient’s chronic illnesses for better health and care. It’s important to understand the requirements that must be met to bill for each of these services. CCM is a non-face-to-face service that includes communication with the patient and other clinicians for care coordination and medication management. It offers patient access to a health care provider 24 hours a day. Documentation requirements include: • Twenty minutes of clinical staff time directed by a qualified health care professional monthly to manage chronic illnesses. • A patient must have two or more chronic conditions expected to last at least 12 months or until death. • A comprehensive care plan must be established. Complex CCM differs from CCM in that additional consideration is taken for patients that have more complex chronic conditions:

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• A patient must have two or more chronic conditions expected to last at least 12 months or until death. • The chronic conditions place the patient at significant risk of death or acute exacerbation/decompensation. • Establishment or substantial revision to the comprehensive care plan. • Requires moderate to high medical decision-making. • Sixty minutes of clinical staff time directed by a qualified health care professional, which can be provided per calendar month.

smoking and tobacco use cessation counseling, diabetes outpatient selfmanagement training, medical nutrition therapy, and annual face-to-face interventional behavior therapy for cardiovascular disease.

Understanding the services and documentation requirements is one piece of the puzzle, but CMS’ shift to value-based payment models also poses other challenges, including the need to educate staff, providers, and patients. Keep in mind, though, that changing to this model involves a learning curve, requiring staff training, potential U.S. health care spending is EHR upgrades, and data analytics.

more than twice the average of other developed countries.

CCM and Complex CCM do share some common sets of service elements, such as: • Practitioner eligibility includes physicians, certified midwives, clinical nurse specialists, nurse practitioners, and physician assistants who are all qualified health care professionals. • The CCM service is to be performed under the overall direction of the provider, although their physical presence is not required. • An initiating visit (AWV or other face-to-face visit) is required for new patients or a patient not seen in the last 12 months. • The patient must consent prior to CCM services being furnished.

Investing in prevention

To help transition gradually into a value-based payment model, Lake Region Healthcare in 2016 joined a Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO). The MSSP is a transitional payment program that requires forming an ACO for which providers are accountable for the cost and quality of care of a defined Medicare population. It is also part of the ACO Investment Model, under which Medicare prepays shared savings. If the ACO is successful in containing cost while providing quality care, Medicare recovers the upfront payment from the shared savings. If the ACO is not successful in containing cost, there is no penalty and it does not have to repay Medicare, provided it remains in the program for three years.

• Recording of the CCM services must be documented in a certified EHR.

Chronic disease management to page 304

The chronic care management service is designed to support active management of the patient’s care plan on a regular basis. In addition, care is coordinated across multiple health care resources and active communication is expected to occur between the patient, providers, and other clinicians.

Preventing readmission Transitional care management services are designed to prevent health complications and the rehospitalization of chronically ill patients. The provider and clinicians coordinate, manage, and support the patient’s transition into the community following an inpatient stay. This ensures that there are no gaps in patient care. This service must take place within 30 days of discharge. The goal is to reduce the potential for readmission into an acute care facility or further acute care episodes. Providing these services also creates an opportunity to assess patients who may benefit from CCM services.

Planning care options While not directly related to chronic disease management, advanced care planning services are often provided to patients already receiving CCM or Complex CCM services. These voluntary discussions between provider and patient are designed to explain care options should the patient be unable to speak for themselves regarding their care. These services include explanation of advanced directives and the completion of forms.

Improving health outcomes Many other preventive care services improve care delivery and quality of care. These services include depression screening, alcohol misuse screening,

Telephone Equipment Distribution (TED) Program

• The patient must be able to access the provider or other qualified health care professional 24/7 to address urgent needs.

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 ted.program@state.mn.us mn.gov/dhs/ted-program Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services MINNESOTA PHYSICIAN APRIL 2018

PROFESSIONAL UPDATE: SURGERY

Cardiac catheterization in a conjoined twin A groundbreaking surgery BY GURUMURTHY HIREMATH, MD, FACC

with severe cyanotic congenital heart disease with tricuspid atresia, atrial septal defect, d-transposition of the great vessels, and ventricular septal defect.

t’s fair to say that a pediatrician can go through his or her entire career without ever taking care of a conjoined twin. As of 2017, I find myself part of an elite group. I have not only taken care of them, but also led a procedure that has never before been done in conjoined twins before separation.

Just one in 200,000 births result in conjoined twins, and many do not survive pregnancy. Survival after successful separation for a conjoined twin with fused hearts is even more rare, with a reported survival of 10 percent if fused at the atrial level and 0 percent if fused at the ventricular level. The conjoined twins we treated were joined at the thorax and abdomen (thoraco-omphalopagus type), with fusion at the atrial level. One had severe congenital heart disease and underwent successful heart catheterization, followed by surgical separation.

Special delivery The twin set was born via C-section at 33 weeks and six days. Fetal imaging, which included echocardiography, showed a shared liver, a shared pericardial sac, and a connection between the right atria of both twins. Twin A was found to have an otherwise anatomically normal heart, while Twin B was diagnosed

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The complex congenital heart disease in Twin B, with absence of a major heart valve and lack of a functional right ventricle, made their physiology even more complex, and meant that Twin B would need several heart surgeries after a successful separation. A plan for separation surgery was scheduled around three to four months of age. That would allow for somatic growth and maturation of their organ systems. The girls’ parents, family, and the treating team were prepared for a long road ahead, but they did not anticipate what came next.

An unexpected turn Twin B had no tricuspid valve, so for her to be stable there needed to be a patent atrial septal defect, a communication between the two upper chambers of the heart so that blue blood returning from the body had a place to go. A few weeks prior to the separation, the atrial communication became smaller and restrictive. This resulted in low cardiac output in Twin B, and her urine output fell. But before we could step in to help, we realized we didn’t need to. To our surprise, Twin A had taken over for Twin B, since both livers were connected. Instead of going across the restrictive communication, blue blood from Twin B went across the liver vasculature to Twin A, and a separate connection at the celiac artery level ensured that there was arterial flow from Twin A to Twin B; Twin A was functionally providing cross circulation for Twin B. This kept Twin B stable, but only as long as they were connected. As soon as they were separated, Twin B would suffer from low cardiac output unless the communication was opened up. The cardiac catheterization laboratory was called for help.

Uncharted territory Opening up the atrial septum in an infant in the cardiac catheterization laboratory is not uncommon, but doing the same in a conjoined twin prior to separation is unheard of and has never been reported, until now.

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calling PAL

This case was challenging, to say the least. I would have to manage two babies with cross circulation, which meant any medication administered to one child would reach the other; if you sedate or paralyze one twin, the other is paralyzed instantaneously. We needed to be well prepared, which required a lot of planning. The list of questions before us seemed endless: How will we position the babies so that we can access the groin for the procedure? How does the room need to be set? How many team members do we need? How do we accommodate two sets of everything in the room—two anesthesia machines and two ventilators? How do we provide surgical backup? And all along we knew that if we didn’t answer these questions with complete accuracy, and if things did not go as planned, this could be a procedure with 200 percent mortality. We found some answers through advanced technology within our very walls. Three-dimensional models developed at the University of Minnesota’s Earl E. Bakken Medical Devices Center that were created from the CT scans of the twins helped in planning proper positioning in the catheterization laboratory. The team met in the laboratory many times, planning for just about every possible scenario and conducting mock drills that encompassed operating room equipment and space and resource management.

APRIL 2018 MINNESOTA PHYSICIAN

Cardiac catheterization

It takes a village

The twin pair went to the catheterization laboratory a few weeks before separation. Two dedicated workspaces, equipped with an anesthesia ventilator, monitor, equipment cart, infusion set-up, etc., were prepared. Team members and workspaces were color coded: red for Twin A, blue for Twin B. Anesthesia was induced simultaneously via inhalation induction, and both twins were intubated successfully. After muscle relaxation, Twin B could be rotated and positioned by raising Twin A with blankets. Twin B was then more horizontal, and This case was the groin was accessible for venous access.

The twins underwent successful surgical separation a few days later by a team of more than 40 people. Twin B was immediately wheeled to the cardiac operating room to undergo a band placement across her pulmonary artery to decrease the amount of blood to her lungs. Both twins are now recovering and waiting for their chest and abdominal walls to heal. Twin B will need two more cardiac surgeries in stages and several cardiac catheterizations to palliate her single ventricle physiology.

challenging, to say the least.

Cardiac catheterization was then performed under echocardiographic and fluoroscopic guidance. Access was obtained in the index twin through the right femoral vein. The atrial septum was crossed using an angled glide catheter, and dynamic balloon atrial septostomy was performed using 9.5 and 10.5 mm B. Braun atrial septostomy balloons, followed by static balloon dilation with a 20 mm Tyshak II balloon. This resulted in a large atrial level communication, and the change in cardiac physiology in Twin B was immediate. There was an increase in the systemic blood pressure in Twin B and a decrease in the flow reversal in the aorta (indicative of more antegrade flow from her own heart rather than retrograde supply from Twin A). The successful atrial septostomy improved the chances of successful surgical separation in Twin B. There were no complications. This also served as a trial run for the more complex surgical separation that was to come in a few days.

Our case illustrates the importance of complete understanding of patient physiology and careful preseparation planning. Analysis of vascular connections and possible cross-circulation provided valuable information about hemodynamic behavior before, during, and after the separation procedure. The knowledge of the restrictive atrial communication and balloon atrial septostomy prior to the separation procedure prevented a potentially catastrophic cardiovascular collapse in Twin B after separation. 3D modeling and careful multidisciplinary planning was critical to the successful heart catheterization procedure. Gurumurthy Hiremath, MD, FACC, is director of pediatric cardiac

catheterization at the University of Minnesota Masonic Children’s Hospital. Listed twice as a “Top Doctor” by Mpls.St.Paul Magazine, he is interested in complex cardiac interventions in children and adults with congenital heart disease.

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SPECIAL FOCUS: PHARMACY

Improving patient diabetes outcomes A pharmacist-driven solution BY JEREMY FAULKS, PHARMD

iabetes is one of the largest and fastest growing health concerns in the U.S., affecting 30 million patients with diabetes, alongside an estimated 86 million Americans with prediabetes, according to the American Diabetes Association. This amounts to direct and indirect costs totaling over $322 billion annually. The typical patient with diabetes spends $7,900 more on health care annually than a comparable patient who does not have diabetes. By enabling patients to better manage their condition, we can more efficiently utilize these health care dollars and reduce overall health care costs. When you extrapolate those savings across the 30 million patients with diabetes today, in addition to those who have pre-diabetes, that’s a huge opportunity for us to effect change.

Barriers to care

One of the barriers to effective diabetes management is a lack of access to care. Many patients don’t have access, or don’t have frequent enough access, to a health care professional. In rural communities, there is likely no access to an endocrinologist or even a certified diabetic educator,

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leaving primary care physicians and nurses to manage these patients. With the continuing shortage of primary care, patients may only see their provider every six to 12 months, decreasing the effectiveness of any interventions and reducing opportunities for follow-up. Those who are newly diagnosed with diabetes or pre-diabetes are at greatest risk, as they need continuous education and reinforcement to ensure that they fully understand how to manage their condition. Hearing that you have been diagnosed with a chronic condition like diabetes can be hard to accept, and patients will have many questions. Empowering patients to better manage their condition prevents complications, helps them live healthier lives, and bends the health care cost curve.

Pharmacists to the rescue The local community pharmacy and pharmacist has long been a staple of rural communities. There are over 64,000 pharmacies across the nation, many of which are located in small towns, and may even be the town gathering point. Over the years, pharmacists have positioned themselves as one of the most trusted, and also most accessible, health care professionals. Patients frequently walk straight up to the counter and ask their pharmacist for advice on everything from simple OTC consultations to complex disease therapy management. As pharmacists continue to focus on therapy management, the pharmacy profession has undergone a shift, with less emphasis on filling prescriptions and more on clinical services and medication therapy management. Pharmacists are receiving in-depth training in both pharmacotherapy and the pathophysiology behind the various disease states. Many pharmacy schools offer rotations specific to geriatric care, cardiovascular conditions, oncology, and diabetes management. Pharmacists receive extensive training in motivational interviewing and other patient engagement techniques. Continuing education and disease-specific certification programs also combine to refocus and raise the expertise of pharmacists across the nation. These combined factors have positioned the pharmacist to have an impact on diabetes care and management. As we’ve looked for opportunities to play a larger role in health care, diabetes support rose to the top, and we’ve implemented a diabetes support program to deliver better patient outcomes while also lowering health care costs. Pharmacists who are given time to exercise their clinical skills can practice at the top of their license and participate in health care as the front-line care providers they should be.

Creating a diabetes support program In our diabetes support program, we empower our patients by simplifying their process and using focused coaching to drive engagement. We start with a comprehensive medication review to ensure they are taking the right medications. As part of this review, the pharmacist reviews the D5 (diabetes) treatment goals that were developed by MN Community Measurement. These five goals include: 1. Control blood pressure (is the patient currently taking an ACE or ARB?) 2. Lower bad cholesterol (is the patient taking a statin?)

appointment. This information is then loaded into our patient management platform to track and manage ongoing follow-up. Our patient care team reaches out 10 days prior to the patient’s upcoming medication fill due date to review any therapy changes, provider visit outcomes, missed doses, and side effects. The average patient with diabetes takes five additional medications, so in addition to diabetes drugs, we synchronize their full medication profile to one pickup date. Once we confirm that the patient medication list is correct, One of the barriers to effective we fill the patient’s medication pack and send it to diabetes management is a the local pharmacy for pickup on the agreed-upon lack of access to care. date. We manage any prior authorization or script renewals upstream, so there are no delays in getting the medications to each patient. Simplifying this process has resulted in adherence scores of over 95 percent, and patients averaging 354 days on therapy each year.

3. Maintain blood sugar (when/what was the last HbA1C check?) 4. Be tobacco-free 5. Take aspirin as recommended As pharmacists review these measures, they create recommendations and work together with the patient’s provider to address any concerns. We have collaborative practice agreements in place with several health systems that allow us to modify doses, or add or remove therapies as identified by our review. This collaboration enables us to leverage each other’s expertise, and we maximize both our time investment and the patient’s care. By addressing these five goals, we can reduce the risk for complications such as heart attack, stroke, and problems with the kidneys, eyes, and nervous system.

In addition to the drug regimen and measure review, the pharmacist performs initial counseling, gathers lab values including A1c and lipid panels, and works with the patient to set three goals of treatment, which may include lifestyle, diet, or exercise. By understanding the patient’s goals, and what they are willing to do to achieve them, we can customize our coaching for each patient. Once we have captured and documented the enrollment information, the patient is provided with additional educational materials for self-review, and receives a reminder of their next month’s

When the patient arrives in the pharmacy for pickup, our system notifies the pharmacist that the patient is enrolled in the diabetes program. The pharmacist meets with the patient to review progress on their goals, discuss any medication questions, and provide additional education and feedback. Findings are shared with the patient’s health care team, ensuring key providers are kept in the loop. This results in 24 touchpoints annually Improving patient diabetes outcomes to page 364

MINNESOTA PHYSICIAN APRIL 2018

SPECIAL FOCUS: PHARMACY

The role of the pharmacist in mental health care A team approach BY RANDALL SEIFERT, PHARMD

n innovative program in rural Minnesota to include a pharmacist as a member of a team of professionals treating clients with severe, persistent mental illness and primary health concerns has demonstrated the value of collaboration between physician and pharmacist. These patients often don’t respond to traditional outpatient therapy. Other approaches, such as assertive community treatment (ACT), can provide the best care by helping patients outside of the hospital or rehabilitation center with comprehensive, community-based care delivered by a single team 24 hours a day, seven days a week. Dr. Robert Jones, the medical director and sole psychiatrist at Northern Pines Mental Health Clinic (NPMHC), and Sharon Ng, a doctor of pharmacy, worked in collaboration with each other and also with the ACT program in Brainerd for one year. This program proved to be a learning experience for all involved and a success for those patients with severe mental illness and other health concerns.

A new idea Many of us in pharmacy practice and education have long had a vision that a doctor of pharmacy, as a full and consistent member of a team of

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medical providers in a mental health care setting, can help improve health outcomes. The issues stemming from severely ill mental health clients being undertreated for primary health concerns are well known. As early as 2006, C.W. Colton and R.W. Manderscheid, in an article in the journal Preventing Chronic Disease, documented that on average, people with serious mental illness lose approximately 25 years of potential life compared to the general U.S. population. Long concerned with this problem, a group of Minnesota medical professionals cooperated to introduce a pilot program in 2016 that would place a doctor of pharmacy as a member of the ACT Team serving the Brainerd area: Glenn Anderson, then the executive director at Northern Pines Mental Health Center; Amy Pittenger, PharmD, PhD, associate professor in the Department of Pharmaceutical Care and Health Systems at the University of Minnesota College of Pharmacy; Robert Jones; and Laura Schwartzwald, RPh, co-owner of GuidePoint Pharmacy, a community pharmacy with several locations in Minnesota, including Brainerd. Schwartzwald agreed to fund the one-year placement of a doctor of pharmacy who would be centered at NPMHC and who could work with the ACT Team in Brainerd. The year that followed is historic, and Ng’s and Jones’ experience is significant and a model for the future. Ng’s involvement as a team member at NPMHC has already led to improved client care through coordination of physical and mental health medication use and time-offset for Jones’ busy schedule. Having a pharmacist on the team has built more efficiency into the practice model at the mental health center, allowing Jones to see a greater numbers of clients. This collaboration has been of great value to clients because it was built on shared respect and expertise, which led to better care.

The doctor’s view To say that Dr. Jones is “busy” is an understatement. In addition to seeing patients at NPMHC, Jones’ responsibilities also include recruiting and retaining qualified professionals whose clients cover a wide swath of rural Minnesota. Jones is quick to credit those who initiated the program that brought Ng to NPMHC and the Brainerd ACT Team in 2016. He also acknowledges that he had no ideas at first as to how his team might benefit from Ng’s presence, but he asked himself two questions at the outset: 1) What can I learn from Dr. Ng? and 2) What can we do to make her experience here worthwhile? A year later, Jones now believes that having a doctor of pharmacy truly enhances his team and changed and shaped the practice for the better. Jones quickly formed a productive partnership with Ng that resulted in a productive exchange of ideas. Ng introduced Jones and the whole ACT team to the idea of using medication therapy management (MTM), which has been key to the success of this collaboration.

The pharmacist’s role Ng knew from the outset that establishing a relationship with other professionals would be her first task. Jones and members of the ACT

team were initially unsure and a bit wary as to the role that Ng would play in treating mental health patients. But Ng challenged herself to prove through her work the value of pharmaceutical knowledge in helping the ACT Team’s clients. Ultimately, she gained everyone’s trust through her knowledge of how medications work, especially how psychotropic drugs work alongside other drugs taken for primary health concerns.

under psychiatric and medical conditions. There was a disproportionately high occurrence of “Needs Additional Drug Therapy” in medical conditions and “Adverse Drug Reactions” in psychiatric conditions. These data underscore the value of continued medication management for clients with severe, persistent mental health challenges as well as primary health concerns.

In addition to her work in MTM, Ng Assertive community treatment At the beginning, Ng asked to be included contributed to the team’s work during the study [provides] comprehensive, on calls that members of the ACT Team made year in other ways: community-based care on clients in their homes. Then she asked for • She discussed lifestyle changes with delivered by a single team. permission to review the results of medication clients of the ACT Team and shared level test results. As yet unpublished data from information about the role of nutrition in Ng’s examination of 30 clients’ charts (for those the management of mental health (as well as clients who met inclusionary and exclusionary physical health) issues. parameters) revealed a total of 110 drug therapy problems (DTPs), with • She was instrumental in resolving an issue with an ACT Team a mean DTP per patient of four (see Pharmaceutical Care Practice, by client taking oxcarbazepine (Trileptal). Ng examined the results Cipolle, Strand, & Morley). The categories of drug therapy problems of levels drawn to determine correct dosage, but discovered that included unnecessary drug therapy, doses that were too low or too high, the testing had been done not on the drug being taken, but on adverse drug reactions, ineffective drug therapy, the need for additional carbamazepine (Tegretol), a close relative of the former, but one drug therapy, and noncompliance. having a different molecular assay. A correction was made. Dr. Ng documented all the categories of drug therapy problems that • She very carefully navigated discussions with clients in order to she discovered while performing comprehensive medication management not overwhelm them with information, but rather to focus on the (CMM) during client sessions. The highest occurring DTPs were “Needs importance of adherence, to inform on side effects, and to explain Additional Drug Therapy” (49 percent) and “Adverse Drug Reactions” (20 percent). In a secondary outcome measure, the DTPs were further classified The role of the pharmacist in mental health care to page 344

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PRIMARY CARE

Improving one practice at a time Small changes produce big results BY LARA LUNDE, MD, AND JULIA MURPHY, MSC

t just five years old, Liam never knows when his reactive airway disease will flare, causing him to cough and wheeze. His mom, Erica, used to bring him to urgent care for immediate treatment, but thanks to changes at Essentia Health–Moorhead Clinic, she now relies on her primary care practice to manage his condition. “It was like an act of Congress—I called today and was able to see you today,” she said during one visit. In addition to scheduling same-day appointments for patients like Liam, the care team can now quickly reference his clinical records, rather than taking down a new patient history every time he comes in. Such seemingly small changes are adding up to a better experience and higher quality care—not just for Erica and Liam, but also for all of the practice’s patients and caregivers throughout the Fargo-Moorhead metropolitan area. Applied nationally, this model could enhance care, reduce costs, and help all providers perform at the top of their practice.

The urgency of better primary care In 2017, Americans made an estimated 461.8 million visits to a primary

care provider, reflecting the fact that, for most people, primary care is the gateway to accessing health care. As a result, transforming primary care delivery is essential to improve the entire health care system. The opportunity for improvement is substantial. Americans spent $3.4 trillion on health care in 2017, accounting for almost 18 percent of Gross Domestic Product. Despite this level of spending, outcomes in the United States are often no better than in other advanced economies, including in important measures of health and well-being such as life expectancy and childhood mortality. Clay County’s premature death rate is 12 percent higher than the rest of Minnesota, partially due to a high prevalence of opioid abuse and babies born with opioid withdrawal symptoms. Those statistics are only exacerbated by gaps in care. The county’s primary care access rate is one physician per 3,400 people, compared to an average of one per 1,100 for the rest of the state. And with 60 to 80 new families moving into the county every month, primary care resources will only be stretched further. Better care and outcomes are needed—and primary care holds great promise for transformational change if solutions can be identified, replicated, and scaled.

Transforming one practice “from good to great”

Helping Beautiful Things Emerge From Hard Places

Recently, Essentia Health–Moorhead partnered with the Peterson Center on Healthcare—a non-profit organization dedicated to improving health care quality and lowering costs nationally—as part of an effort to promote high-performance primary care. The Center, working with Essentia Health–Moorhead and two other practices nationwide, sought to replicate the insights of landmark 2014 research from Stanford University’s Clinical Excellence Research Center. The study, which explored what makes high-performance primary care practices stand out, uncovered ways in which the practices improved clinical and functional outcomes for patients, and brought “joy in practice” back to the lives of physicians, all at a lower total cost. The Center then used the research results to develop specific, actionable steps for practices, and provided hands-on implementation support to all three practices. Ultimately, the Center hopes to assist practices nationwide in their individual journeys to advance “from good to great.” Fostering an environment for primary care practices to deliver the best possible patient care in a financially sustainable way can set the foundation for a high-performing health care system nationwide.

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Before beginning any transformation efforts at Essentia Health– Moorhead, the entire practice team was engaged to find out what mattered to them. An experienced practice facilitator from the Institute for Clinical Systems Improvement conducted interviews, revealing a collective vision that centered around deeper relationships with patients and with one another. The practice then created a practice improvement team, led by a physician-administrator dyad, which included representation from every role in the practice.

In short order, the teams learned how to collect, analyze, and apply data to implement changes needed to make a difference in their specific context. For example, the team quantified the amount of patient time physicians and licensed practical nurses (LPNs) were losing due to administrative tasks.

achieving high-value workflows, such as same-day access to care, closing care gaps, and partnering with patients in decision-making about care provided at the practice. Over time, the practice saw bright spots emerging in quality indicators, patient experience scores, and productivity.

Results: higher quality care, more productivity, and a culture of improvement

Practice leaders used the staffing data to request, and obtain, a full-time practice manager from Essentia Health’s regional leaders. After the practice manager started, the clinical team was immediately freed up to spend more time caring for patients—underscoring how important it is to work closely with system leadership throughout the transformation process.

Ultimately, the Essentia Health–Moorhead practice saw real improvements in care quality, The clinical team was immediately even as the number of patients grew and the freed up to spend more time challenges of treating people with complex needs caring for patients. remained. Over time, the practice doubled its quality ratings around depression remission while maintaining high rates of medication The system also gave the practice the green light adherence for people with diabetes. Even as the to test a new dedicated “pairing” of a physician and practice instituted new staff meetings and set an LPN. The practice started a new daily huddle aside time for team engagement, the productivity rate for physicians has with these pairs to improve coordination before patients arrived in the remained constant, and physician assistant productivity has increased by morning. These changes helped physicians prepare better for patient visits 5 percent. and helped nurses become more involved in their care, especially with regard The hard work of implementing these strategies also translated into to educating patients. Ultimately, this pairing structure became the core of leadership skills, increased operational capabilities, and the creation bigger care teams intended to benefit all staff. of a culture truly focused on continuous improvement. Ultimately, With data in hand and improved collaboration between the front office sustainability requires consistent engagement with system leadership, and clinical teams, the practice began conducting “Plan-Do-Study-Act” exercises to test and discover new ways of working together. For example, Improving one practice at a time to page 294 the practice implemented a tracking board that allowed the team to see at a glance which providers were in the clinic on any given day. This visual cue, combined with expanded team huddles between physicians, nurses, and front desk staff, allowed the team to more effectively manage patient requests for care. Meanwhile, the lab and radiology technicians began using standard supply ordering processes, and figured out a new way to monitor and manage expired orders.

From barriers to bright spots There were challenges along the way that led to a deeper understanding of what’s needed to improve health care performance. For example, implementing the physician-LPN pairs was complicated by the fact that Essentia Health applies a flex model for LPNs, shifting them to different practices to compensate for an overall shortage in this critical role. Regional executives who had not been actively involved in setting up the project were understandably reluctant to agree to a different staffing model. It wasn’t until the practice leadership established adequate structures and processes for ongoing review with the executive sponsor and regional leadership that the staffing requirement was achieved. Beyond structural challenges, the team also faced cultural difficulties to implementing the pairing. For example, one of the physicians was initially reluctant to hand off orders for labs and other screens to an LPN. The practice improvement team listened to his concerns and negotiated a one-day test for which data was collected on the LPN’s accuracy. The data showed the LPN was not only proficient, but also able to meet the standard of care for patients more effectively under this model. Some initial trust was built and, over time, LPNs have come to do more of this work for their physicians. Together, all of these small changes added up to increased capacity and new skills. In turn, these improvements helped move the needle on

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RADIOLOGY

Diagnosing Alzheimer’s Advances in PET scanning solutions BY MICHAEL H. ROSENBLOOM, MD, FAAN

n 1906, Alois Alzheimer, a young German psychiatrist and neuropathologist, presented the case of 53-year-old Auguste Deter, who was in progressive cognitive decline. Her autopsy revealed two pathological entities: extracellular proteinaceous clumps of amyloid plaques and intracellular clusters of tau protein known as neurofibrillary tangles.

Whereas this clinical description was a unique phenomenon in the early 20th century, the present-day health care community is facing an Alzheimer’s disease (AD) epidemic affecting 5.5 million individuals and costing $259 billion per year. AD is a common condition that confronts health care providers in both primary care and the medical specialties. In addition, most individuals with this disease have a parent, grandparent, brother, or sister who has had some type of this dementia. Although AD has been recognized as a chronic disease for more than a century, the diagnosis is overlooked in more than half of patients. In addition, AD is inappropriately diagnosed in 20 percent of patients. A major challenge in early AD diagnosis is that no specific blood test or imaging biomarker is available. Furthermore, the typical work-up is extensive, often

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consisting of a comprehensive history with a cognitive review of systems, cognitive screening, neuropsychometric testing, brain imaging, and laboratory studies. Finally, confirmatory diagnosis of “definite” AD requires a postmortem neuropathological examination. As a result, AD is a diagnostic dilemma for all clinicians; in the best-case scenario, a physician can diagnose “probable” AD while the patient is alive but must wait until autopsy to confirm a definite diagnosis based on the presence of the pathognomonic amyloid plaques and neurofibrillary tangles.

The dawn of the ability to detect amyloid in vivo A potential solution to the AD diagnostic dilemma would be to create an agent that binds specifically to the cerebral amyloid plaques and neurofibrillary tangles to demonstrate their presence on neuroimaging. In 2001, William Klunk, MD, PhD, and Chet Mathis, PhD, at the University of Pittsburgh, developed Pittsburgh compound B (PiB), a radioactive, amyloid-specific ligand that could demonstrate cerebral amyloidosis on positron emission tomography (PET) in living patients. Investigations showed a direct correlation between the amyloid detected on PiB imaging and that present in postmortem brain samples. There was only one problem: the half-life of this compound was 20 minutes, and therefore impractical for clinics without immediate access to a cyclotron. The subsequent development of florbetapir (18F), a ligand with a half-life of nearly two hours, enabled more widespread use of amyloid imaging in community neurology clinics. This compound was followed by the development of two additional fluorine-based agents, florbetaben and flutemetamol. The ability to detect in vivo amyloid in a clinical setting was an exciting concept to most dementia specialists, representing a major initial step in resolving the diagnostic dilemma. An assured “game changer” for AD research, it offered tremendous opportunity for improving clinical care. However, in 2013, the Centers for Medicare & Medicaid Services (CMS) declared that “the evidence is insufficient to conclude that the use of positron emission tomography (PET) amyloid-beta (Ab) is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of ... Medicare beneficiaries with dementia or neurodegenerative disease.” Ultimately, the concern was that, at as much as $10,000 per image, amyloid imaging was an expensive test with an unproven impact on health care outcomes. Thus, dementia investigators faced the major task of showing that amyloid PET was like colonoscopy in that its effects on health care outcomes and expenditures justified its ostensibly prohibitive cost.

Identification of patients most likely to benefit from amyloid PET The Alzheimer’s Association and the Society of Nuclear Medicine and Molecular Imaging convened a working group to develop criteria to identify patients most likely to benefit from amyloid imaging. For

65.9 percent of patients with AD. When presented, the final results from instance, a patient with a textbook AD presentation would incur minimal benefit from amyloid imaging because the clinician could determine this study will undoubtedly determine whether amyloid imaging has a valid the diagnosis without a scan. At the same time, the working group role in routine clinical practice. deemed amyloid PET imaging inappropriate as a screening test for AD The applications of tau-PET imaging in patients at high risk for the disease. The group concluded that patients In addition to describing amyloid plaques, with progressive, unexplained mild cognitive Alzheimer identified neurofibrillary tangles, impairment (MCI) or dementia of uncertain intracellular proteinaceous clusters consisting cause due to atypical or mixed symptoms would of tau, a key protein that normally contributes benefit most from the test. A disease characterized to the neuronal cytoskeleton. Neuropathology by abstract complaints of These criteria were critical in informing research has determined that the neurofibrillary memory loss and confusion the inclusion/exclusion criteria for the 2016 tangle best correlates with the clinical symptoms is now being approached Imaging Dementia: Evidence for Amyloid of AD. Thus, most clinical investigators share the in terms of its biology. Scanning (IDEAS) study, which was developed same desire to detect this protein in vivo, just like as a response to the 2013 CMS conclusions. The cerebral amyloid plaque is detected with amyloid purpose of the study, which was sponsored by imaging. While tau-PET imaging has most the Alzheimer’s Association and the American recently emerged as a research tool, it has the same College of Radiology, was to determine whether clinical applications as amyloid imaging. A variety of tau ligands bind to amyloid imaging 1) affected medical decision-making and 2) reduced affected regions, with AV-1451 being the most commonly studied agent. health care expenditure. A total of 18,488 Medicare beneficiaries aged 65 As patients progress from the mild to more advanced stages of AD, and older who met appropriate use criteria were enrolled at roughly 200 tau-PET imaging demonstrates increasing signal on PET imaging, sites throughout the U.S. demonstrating a potential role in determining disease severity and the For the first time, non-academic, community-based clinics were able to presence of neurofibrillary tangles. In addition to amyloid imaging, taunot only perform this diagnostic test but also have it covered by Medicare. PET could complement the former diagnostic test, providing evidence for Preliminary results from the first 3,979 subjects show that amyloid imaging affected medical decision-making in 67.8 percent of patients with MCI and Diagnosing Alzheimer’s to page 284

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3Diagnosing Alzheimer’s from page 27

In addition, this technology offers tremendous opportunities in terms of tracking disease progression and measuring the efficacy of an investigational drug. Perhaps the dementia clinic of the future will offer a series of PET scans to identify the appropriate biomarkers for AD diagnosis, ending the days of overlooking an AD diagnosis or misdiagnosing AD. Hopefully, this technology will bring us closer to a goal shared by the Alzheimer’s Association and the rest of the medical community—a world without AD.

both amyloid plaques and neurofibrillary tangles in living patients. The ability to demonstrate both AD pathological signatures in living patients is a provocative concept. Unfortunately, some experts have raised concerns about the specificity of the tau-binding ligands based on several recent imaging studies. At this time, tau-PET imaging is a developing research tool but may one day be subjected to the same rigorous study AD is a diagnostic dilemma in the clinical setting in a similar way to that for all clinicians. Michael H. Rosenbloom, MD, FAAN, is a of amyloid imaging in the IDEAS Study. The behavioral neurologist who serves as the clinical HealthPartners Center for Memory and Aging director of the HealthPartners Center for Memory is participating in research related to the role of and Aging as well as the chair of the HealthPartners intranasal insulin for mild cognitive impairment, Department of Neurology. Dr. Rosenbloom’s past Alzheimer’s disease, and Down syndrome. As and current research has included amyloid and it relates to Alzheimer’s, the center is studying FDG-PET imaging in atypical dementia. His current research role focuses on whether this spray is able to slow the progression of the disease.

the design and conduct of clinical trials investigating intranasal therapeutics

Conclusion The use of PET ligands for amyloid and tau in clinical practice may solve the century-old diagnostic dilemma of AD. While the exact nature of their application remains undetermined, PET ligands have advanced the field to a significant milestone in which a disease characterized by abstract complaints of memory loss and confusion is now being approached in terms of its biology.

in neurodegenerative disease. During the Imaging in Dementia Evidence for Amyloid Scanning (IDEAS) Trial, he was the principal investigator at the HealthPartners site.

Haydn’s Morning Symphony with Jonathan Cohen SPCO Artistic Partner and masterful Baroque interpreter Jonathan Cohen tracks the evolution of music from the Baroque style to the Classical. Friday, May 18, 11:00am Friday, May 18, 8:00pm Saturday, May 19, 8:00pm Ordway Concert Hall, Saint Paul Sunday, May 20, 3:00pm St. Andrew’s Lutheran Church, Mahtomedi Avison: Concerto grosso No. 5 in D Minor (after Scarlatti) Zelenka: Sinfonia in A Minor C.P.E. Bach: Sinfonia in E Minor, Wq. 178 Haydn: Symphony No. 6, Morning Jonathan Cohen, director and harpsichord

28 APRIL 2018

MINNESOTA PHYSICIAN

3Improving one practice at a time from page 25

Lara Lunde, MD, is the Medical Director at Essentia Health–Ada and Chair of the Family Medicine Department in Fargo–Moorhead. In these roles, she

communication among the care team, and diligently applying data and feedback to continue learning. Moving forward, Essentia Health– Moorhead wants to implement more components of high-performance care to help patients reach their goals and reduce costs, including advanced care planning and more opportunities for shared decision making.

provides oversight and leadership to the medical staff. Previously, Dr. Lunde was a physician at the Essentia Health-Moorhead clinic. She brings more than 14 years of her expertise to the community. She is certified in family medicine by the American Board of Family Medicine.

All of these small changes

Essentia Health–Moorhead is just one practice, added up to increased but it is encouraging that some of the changes we capacity and new skills. implemented are now being replicated by other practices at Essentia Health. By sharing what we have done here, perhaps the next team 160 can First more Street SE, Suite 5, New Brighton, MN 651-383-1083-Main Providers of Business Communication Solutions – www.laserwave.net easily improve the care they deliver.

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3Chronic disease management from page 17 While in the MSSP, all existing reimbursements stay the same. Since this is Lake Region Healthcare’s first venture into an alternative payment model, it decided to enroll in the MSSP over other ACO programs because it is the option with the least financial risk. As the organization started its ACO journey, it realized that in order to be successful, it needed to invest more in prevention and chronic disease management. Preventing illness and intervening early to limit complications can reduce the cost of care and improve quality of life, the two key goals of an ACO. Annual wellness visits and a CCM program were implemented to address gaps in care and to improve patient outcomes while receiving additional revenue through these reimbursable services. To incorporate AWVs into the clinic with the least interruption to the typical workflow, Lake Region Healthcare hired a nurse who was responsible for performing the AWVs using the dual visit model. In this model, the AWV is scheduled the same day as a regular Evaluation and Management (E&M) visit, allowing patients and benefits providers to address specific complaints arising from the AWV or to manage existing medical conditions without having to worry about time or billing issues. After some initial hiccups, this service has been well received by providers and patients. In addition to the AWV, Lake Region Healthcare also focused on increasing patient enrollment into the CCM program. To accomplish this, the care coordinator was proactive in educating providers about the program and clarifying that the care coordinator’s role was meant to complement

and not replace the care that the providers give their patients. By educating providers, the care coordinator was able to get them to buy in. As a result, the program grew significantly in two years and patient care improved. Although there are costs associated in instituting both AWVs and CCM, any upfront cost was outweighed by the benefits, such as improved patient satisfaction, improved quality of care, and reduced overall costs. Although the shift from volume- to value-based care presents many challenges, it also introduces unprecedented opportunities to reexamine and maximize the efficiency of the health care delivery system. Developing an infrastructure grounded in prevention and wellness, and billing accurately and appropriately, are key components to financial success in this new model of care. Joanna Chua, MPH, is the community health initiatives project coordinator for Lake Region Healthcare. She is responsible for coordinating, planning, implementing, and evaluating the health system’s various programs and grants, such as their Medicaid and Medicare ACOs.

Rachel Pugliano, RHIT, is a senior manager of coding services at Eide Bailly and consults with hospitals, health systems, and provider practices. She has more than 20 years of experience in health care coding, coding compliance, and documentation improvement and education services.

Three patients. Who is at risk for diabetes?

When there are no signs or symptoms, you may not know until it’s too late. Act now. Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk. • Refer your at-risk patients to a proven lifestyle change program and help cut their risk of developing type 2 diabetes in half.

1 in 3 adults are at risk!

• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications. Find groups in Minnesota at www.health.mn.gov/diabetes/programs

Minnesota Department of Health DIABETES PROGRAM

APRIL 2018 MINNESOTA PHYSICIAN

Patients with regenerative medicine questions?

Regenerative medicine focuses on the body’s natural ability to repair, replace, and regenerate damaged or aging tissues. At MINNESOTA REGENERATIVE MEDICINE (MRM), a specialty clinic of HOGUE CLINICS, autologous bio-cellular agents such as platelet-rich plasma (PRP), fat aspirate concentrate (FAC), and bone marrow aspirate concentrate (BMAC) are used to treat degenerative conditions. To ensure proper placement, ultrasound or fluoroscopy guidance is used when clinically indicated during regenerative medicine treatments.

Regenerative medicine treatment categories at MRM include: • Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine) • Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING • Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT

8 Hogue Clinics locations in Minnesota www.mregm.com • (763) 447-2500 or Toll Free (866) 219-4699 MINNESOTA PHYSICIAN APRIL 2018

3Understanding how to best treat pain from page 15 already addicted or are on the road to addiction. In either case, it is best to avoid the opioid prescription.

may overdose when they reintroduce opioids with less tolerance, perhaps with less understanding of the next opioid dose that they take.

Conclusion

In summary, I feel that we need to greatly curb the use of opioids for pain. Opioids should only be used for major tissue injury, for a handful of medical illnesses that are known to cause severe pain, as a bridge during major surgery, for significant pain at the end of life, and for opioid addiction treatment. When used outside of the end We need to greatly curb of life, they should be used for only a limited period. the use of opioids for pain. A second prescription should only be given when absolutely necessary. For patients with pain, one should use positive language to instill confidence that they will be okay. Opioids should be avoided. Patients who are already habituated to opioids should be weaned safely. If they are unable to wean, they should be under the care of an addiction specialist. In all cases, behavioral health support will likely be needed. Patients that are already habituated to opioids and resist coming off the medication, even with a promise that their pain will improve over time, are Bret C. Haake, MD, MBA, is vice president of medical affairs and chief best treated for addiction instead of pain. Specifically, opioid maintenance medical officer at Regions Hospital. He is also a neurologist. As a neurologist, therapy may be needed, with a goal of slowly weaning the opioids over time and Dr. Haake has studied how the brain works when it is healthy and when it is teaching self-care and relaxation, while also increasing activity and emphasizing function. In addition, we should address behavioral health issues that typically affected by mental illness, injury, or disease. emerge over time. One danger of simply stopping the opioids without addiction help is that the patient may turn to other sources of opioids that are less safe, or During the acute phase of injury, certain supportive modalities may be helpful. Medications are sometimes needed for severe injuries, but in the long run, the best treatment is to help patients learn to help themselves. This usually involves positive language with an emphasis on wellness, encouraging activity, and helping them to understand that medications are not the answer for their problems. When patients are particularly fearful, anxious, or somatic in their presentation, they may need extra help from an interdisciplinary team to learn how to be mindful, relax, exercise, and address various psychosocial issues.

Food Matters for Health Professionals Saturday,

June 16 1 – 6:45 pm and

Sunday,

June 17 9 am – 6:45 pm

Nourishing M I N N E S O TA

Are you prepared to answer questions in your practice such as: What are whole grains? What are the differences between vegan, vegetarian, and paleo diets? How do carbohydrates and fats affect weight gain/loss? What is the role of the gut microbiome in health and disease? This workshop is a blend of discussion and hands-on cooking (including full meals each day). Accredited for 9.0 AMA PRA Category 1 credits for physicians, this course is suitable for all health professionals who want to incorporate food-based nutrition in clinical practice and self-care. Topics include diabetes and metabolic syndrome; inflammation and the gut; and eating styles such as vegetarian, vegan, and paleo. Learn more and register at

z.umn.edu/FoodCE

APRIL 2018 MINNESOTA PHYSICIAN

RightMed® pharmacogenomic test CO-DEVELOPED AND EXCLUSIVELY LICENSED WITH

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MINNESOTA PHYSICIAN APRIL 2018

3The role of the pharmacist in mental health care from page 23

These benefits should not be overlooked as physicians continue to seek the outcomes that a collaborative team can provide.

how medications taken for mental health issues intersect with those taken for primary health issues.

According to the Minnesota Department of Human Services (DHS), eligible ACT Team providers at this time include a psychiatrist; a team lead, who must be a mental health professional; Optimizing the role of the pharmacist a registered nurse for medication management; Placing a doctor of pharmacy in a collaborative ACT mental health practitioners, including a substance Team in rural Minnesota proved so successful that abuse specialist; and a vocational specialist. There is Ng has now been retained by NPMHC to develop It’s critically important to integrate at this time no provision for a pharmacist as provider algorithms for coordinated, collaborative care of behavioral health care and on ACT Teams nationwide, save a 2014 action by clients in a pilot study of the service delivery model primary care. the Missouri Department of Mental Health that for Certified Community Behavioral Health Clinics (CCBHC). Robert Jones, who was the medical granted one psychiatric pharmacist provider and director for this pilot study, will rely on Ng for system prescriber status in that state. The success of this development based on her work over the past year. Minnesota program continues to demonstrate the enormous value that collaboration with a doctor of pharmacy can offer to Most medical providers agree that it’s critically important to integrate physicians and to entire teams of medical professionals. behavioral health care and primary care. To this end, placing a pharmacist on an ACT team in a rural area of Northern Minnesota was successful on several levels:

Randall Seifert, PharmD, is a professor in the Department of Pharmacy

• It demonstrated the value of medication therapy management provided by a pharmacist at NPMHC.

Practice and Pharmaceutical Services at the University of Minnesota Duluth

• It underscored the enormous value of collaboration and coordination of care.

Practice Innovation at the University of Minnesota College of Pharmacy. He has

• It highlighted the critical importance of professional relationship building in creating new models of care.

College of Pharmacy. He currently holds the Peters Endowed Chair in Pharmacy long advocated for the doctor of pharmacy to be a member of collaborative teams of medical practitioners in many settings, but particularly in the treatment of patients with severe, persistent mental illness.

Private health insurers have made

$65 billion in profits since 2010 Meanwhile, our patients face mounting deductibles and copays, skyrocketing drug costs, narrowing networks, and other barriers to needed care. And our medical profession is increasingly degraded by mindless paperwork and the games of a profit-hungry corporate bureaucracy. As doctors, we should be providing care to our patients, not haggling with insurers about the value of treatments that should have been covered in the first place.

Endorse The Physicians’ Proposal for Single Payer at pnhp.org/nhi 34

APRIL 2018 MINNESOTA PHYSICIAN

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

Sioux Falls VA HEALTH CARE SYSTEM

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.

The VAHCS is currently recruiting for the following positions:

POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available

Cardiologist

Orthopedic Surgeon

Psychologist

Endocrinologist

PACT/ Woman Health Director Pulmonologist

Emergency Medicine Physiatrist

Urologist (part-time)

Hospitalist

ENT (part-time)

Psychiatrist

apply online at www.USAJOBS.gov

Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

(605) 333-6852 ·

www.siouxfalls.va.gov

Urgent Care Physicians HEAL. TEACH. LEAD.

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE

with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Apply online at www.mankatoclinic.com MINNESOTA PHYSICIAN APRIL 2018

3Improving patient diabetes outcomes from page 21

collaboration with physicians. As we continue to become more integrated members of the health care team, seamless sharing of information will result in the most informed treatment decisions.

where we can provide focused education, coaching, and encouragement, and continually reinforce and track progress toward those goals. This enables Conclusion us to treat the patient holistically and manage more than just their diabetes medication. In addition to education, we utilize point-of-care testing to capture HbA1c values, lipid panels, and blood pressure. These results are an objective method to monitor The average patient progress, and allow us to communicate updates to with diabetes takes five the provider. Over the last six months, the program additional medications. has demonstrated an average HbA1c reduction of 0.8 percent for our patients.

Ensuring success One important point to note is that making a pharmacist-driven program successful depends on making it easy for patients to participate. The traditional pharmacy experience can be confusing and relies on the patient to manage the refilling of their medications. Using medication synchronization as the foundation for this program facilitated the delivery of these important services, and, as a result, the pharmacist-based interventions were delivered more consistently and effectively than with traditional dispensing models. This increased the impact that those services had and resulted in improved clinical outcomes across a wide range of endpoints. An additional area that we, as pharmacists, continue to focus on is improving communication and

Community pharmacists are among the most accessible health care providers, and are currently underutilized by the health care system. Pharmacists are uniquely positioned to deliver the Triple Aim, and this program demonstrates that community pharmacists can have a positive impact on the postdiagnostic management of patients with chronic diseases such as diabetes. Through a robust disease management program, combined with physician collaboration, we can reduce disease progression, improve quality of life, and deliver more efficient, cost-effective health care. In addition to diabetes management, Thrifty White offers a variety of medication management services across our 100 community pharmacy locations. Simply “ask your pharmacist” for more information on how we can work together to better support patients. Jeremy Faulks, PharmD, is director of Specialty Pharmacy at Thrifty White Pharmacy.

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

• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology

Loan repayment assistance available.

FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | Shana.Zahrbock@carrishealth.com | (320) 231-6353 | acmc.com We are pleased to introduce Carris Health, a new entity launched in January to deliver high quality health care to West Central and Southwest Minnesota. Carris Health is a partnership between ACMC Health, Rice Memorial Hospital and CentraCare Health. This partnership allows us to reach beyond our individual capabilities to combine the talent and skills of all three organizations. Visit www.carrishealth.com for more information.

APRIL 2018 MINNESOTA PHYSICIAN

Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice

Opportunities for full-time and part-time staff are available in the following positions: • Physician (Internal Medicine/Family Practice) • Physician (Hospice & Palliative Care)

• Physician (Pain Clinic/Outpatient Primary Care) • Psychiatrist (Mental Health)

• Physician (Pulmonologist) Part-Time 763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

THE STRENGTH TO HEAL and get

back to what I love about family medicine.

Do you remember why you became a family physician? When you practice in the Army or Army Reserve, you can focus on caring for our Soldiers and their Families. You’ll practice in an environment without concerns about your patients’ ability to pay or overhead expenses. Moreover, you’ll see your efforts making a difference. To learn more, visit healthcare.goarmy.com/kb60

• Physician (IM/FP) Montevideo MN

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

MINNESOTA PHYSICIAN APRIL 2018

The future

3Ambulatory surgery centers from page 11 Accomplishments Founded in 2006, MNASCA has enjoyed many achievements: • The association successfully opposed legislative attempts to implement market restrictions on ASCs, such as moratoriums and Certificate of Need. • MNASCA partnered with key health care stakeholders to pass legislation phasing out Minnesota’s Provider Tax by the end of 2019. • Led a successful effort to clarify the Supplemental Nursing Service Agencies statute to allow ASCs to hire temporary professionals, such as CRNA locum tenens. • The association worked to pass legislation addressing provider exclusions or narrow networks to allow provider recourse with insurers, such as ability to appeal. • MNASCA successfully negotiated language on a Surprise Billing provision that will allow appropriate reimbursement for ASCs in these unique situations.

ASCs will continue to play a vital role in the delivery of surgical care while technology and medical advancements will continue to expand the types of procedures performed in the ASC setting safely and cost effectively. As an organization, Simmons says MNASCA wants to continue to play a key role in quality, value-based care models. “We have several goals that will continue to shape our association’s future. We will continue to place a premium on getting exposure at both the state and federal level by educating our lawmakers on the quality and cost benefit ASCs provide,” Simmons said. “We also want to continue to support our members with education opportunities via our annual conferences as well as our benchmarking efforts to assist with best practice. In addition, we will be looking for additional networking opportunities for our members so that existing relationships can grow, new connections can be made and resources are available, all of which will all ultimately lead to better patient care.” Tom Poul, JD, serves as the legal legislative counsel for MNASCA, representing and advising the association on policy and political issues before the state legislature, executive branch, and state agencies. He is a shareholder at Messerli

• Successfully opposed physician “non-compete” legislation that would have negatively impacted ASCs and specialty practices.

| Kramer and a member of its Government Relations team.

• MNASCA supported ASCs in rulemaking processes with the MDH addressing ASC operating room regulations.

Rachel Stuckey serves as the executive director of MNASCA, and is a

• The association participates on behalf of ASCs with the MDH on major X-ray Rule modifications.

Rachel provides support to a variety of clients through issue research, legislative

legislative coordinator with Messerli | Kramer’s Government Relations division. committee monitoring, and association management.

Minneapolis VA Health Care System Opportunities are available in the following specialties:

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APRIL 2018 MINNESOTA PHYSICIAN

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www.minneapolis.va.gov

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