Minnesota Physician • April 2020 by Minnesota Physician Publishing

MINNESOTA

APRIL 2020

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIV, No. 01

Prior authorization We need a better law BY SHELDON BERKOWITZ, MD, FAAP

rior authorization reform is long overdue in Minnesota. It has been discussed by physicians and lawmakers for many years, but nothing has changed. In a 2017 national AMA survey on prior authorization, 51% of respondents said that their prior authorization burden had increased substantially over the previous five years. Two companion bills now before the state Legislature— House File 3398, sponsored by Rep. Kelly Morrison, MD, an OB/GYN, and Senate File SF3204, sponsored by Sen. Julie Rosen—could bring some much-needed improvement to the existing law. For clinicians who have determined a path of treatment—only to face delays or denials of insurance coverage—this new legislation could ease the path to providing better care. It could also empower patients in resolving disputes with insurance carriers over services that should have been included under their plans, but for which they received no approval or coverage.

A futile quest Why “performance” measurement is not working BY KIP SULLIVAN, JD

ver the last three decades, Minnesota’s health care policymakers have gotten into a bad habit: They recommend policies without asking whether there is sufficient evidence to implement the policy, and without spelling out how the policy is supposed to work. Measurement and “pay for performance” (P4P) schemes illustrate the problem. Multiple Minnesota commissions, legislators, agencies, and groups have endorsed the notion that it’s possible to measure the cost and quality of doctors, clinics, and hospitals accurately enough to produce results useful to regulators, patients, providers, and insurers.

A futile quest to page 104

Prior authorization to page 144

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NNESOTA’S MI

APRIL 2020

REQUEST FOR NOMINATION

Volume XXXIV, Number 1

COVER FEATURES

A futile quest

Prior authorization We need a better law

Why “performance” measurement is not working

L RS EA IN F L L T H U E N T I AA D E C A R E LE

Publication Date: November 2020

By Sheldon Berkowitz, MD, FAAP

By Kip Sullivan, JD

Nominate the 100 Most Influential Health Care Leaders

DEPARTMENTS ORTHOPAEDICS 26 Osteonecrosis of the femoral head

In our November 2020 edition, Minnesota Physician will profile 100 of

responsible for making Minnesota a global model for health care delivery.

Serving pharmacists and patients

Diagnosing and treating a rare condition

Sarah Derr, PharmD Minnesota Pharmacists Association

By Paul Hoogervorst, MD, and Edward Cheng, MD

EPIDEMIOLOGY 22 Life in a global pandemic

FINANCIAL PLANNING 28 Investment strategies

CAPSULES

MEDICUS

INTERVIEW

Helping patients cope

Assessing a volatile marketplace

By Todd Archbold, LSW, MBA

By Katherine Vessenes, JD, CFP

our state’s most influential health care leaders. In a format featuring photos, bios, and quotes, we will highlight the men and women most These individuals will represent every aspect of the industry: physicians, business executives, political leaders, policy analysts, etc. We invite you, our readers, to participate in this recognition process. If you know anyone within your organization you feel should be considered, please fill out the form below and mail it or submit online (www.mppub. com/top100.html) or via e-mail (comments@mppub.com) prior to September 25. We welcome your input and participation in making this list as comprehensive and meaningful as possible.

COMMUNITY CAREGIVERS 2020 Recognizing Minnesota’s Volunteer Physicians 16 By Richard Ericson

I would like to nominate the following individual(s): Nominee’s name (please include all advanced degrees):

Nominee’s title: Nominee’s affiliation:

Brief description of the nominee’s work and influence:

Nominator information (strictly confidential):

Name: Phone #:

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EDITOR___________________________________________________________Richard Ericson, rericson@mppub.com ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. 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.

Email: Send to: Minnesota Physician Publishing: Top 100 PO Box 6674, Minneapolis, MN 55406 Online form: www.mppub.com/top100.html Email: comments@mppub.com For more information, call 612.728.8600

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CAPSULES

Anticoagulation protocol benefits patients with traumatic brain injury Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. In the United States, approximately 2.8 million people sustain a TBI annually. A new study in the April issue of The Joint Commission Journal on Quality and Patient Safety details how a prophylactic anticoagulation protocol helped decrease venous thromboembolisms (VTEs) in patients with TBI. Patients with TBI have an increased risk of developing complications from VTEs, a condition in which a blood clot forms and travels to the lungs, due to prolonged immobilization and a systemic hypercoagulability state. Recent reports suggest that prophylactic anticoagulation— preventive anti-clotting medication—can be safely used in patients

with life-threatening TBI if the brain injury is stable. In the study, “Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury” (https://tinyurl. com/hcn-tbi), researchers at North Memorial Health Hospital, Robbinsdale, used a trauma registry to identify patients with TBI before and after implementation of a new prophylactic anticoagulation protocol that incorporates education, weekly audits, and real-time adherence feedback. A total of 681 patients with TBI were identified—368 pre-implementation (PRE) and 313 post-implementation (POST) of the VTE protocol. Findings showed: • 80.5% of POST patients received anticoagulation compared to 39.4% of PRE patients. • Time to initiation for anticoagulation averaged

59 hours for POST patients compared to 140 hours for PRE patients. • POST patients (2.2%) had fewer VTE events compared to PRE patients (5.2%). Researchers concluded that the hospital-wide prophylactic anticoagulation protocol improved process measures and outcomes. They also concluded that benchmarking can assist institutions in identifying potential clinically relevant areas for quality improvement in real time.

Insulin price relief bill clears state Legislature Minnesota’s Alec Smith Emergency Insulin Act—named for a man who died of ketoacidosis after rationing his insulin—is now law. The House of Representatives voted 112–22 in support of the bill, with a Senate tally of 67-0. Gov. Tim Walz signed the legislation on April 15.

Nicole Smith-Holt and James Holt, parents of Alec Smith, had advocated before lawmakers for a year and a half in support of insulin price relief. Legislators had long recognized the need for action, but disagreed on the best path forward. In summer 2019, Sen. Eric Pratt, R-Prior Lake, suggested using existing patient assistance programs run by insulin manufacturers to provide a supply to those who meet income requirements. In its final form, the new law will impose fines on companies who fail to participate. Those fines increase as non-participation continues—$200,000 per month for six months, increasing to $400,000 per month for the next six months. After a year of non-participation, fines go to $600,000 a month. The industry had opposed this provision, arguing that it is an unconstitutional taking of personal property under the 4th Amendment

MEDICAL MALPRACTICE ATTORNEYS

Angela Nelson

APRIL 2020 MINNESOTA PHYSICIAN

Ryan Ellis

Marissa Linden

Jennifer Waterworth

CAPSULES

to the U.S. Constitution. But authors of the law say it is preferable to the drug companies to large licensing fees, which were part of a bill that passed the House this year that could have totaled $38 million, with most paid by the big-three insulin providers: Lilly, Sanofi, and Novo-Nordisk. The new bill creates an emergency supply for 30 days for diabetics who need insulin now and can’t afford it. It also sets up a longer-term program for those under certain income limits and for those who don’t have insurance (or have insurance with large co-pays). Both have the companies providing the product, either by resupplying pharmacists or sending insulin directly to patients.

UCare to cover novel coronavirus-related hospital costs Coinsurance, copays, and deductibles for UCare members who receive in-network hospital services to treat COVID-19 will now be covered through May 31, 2020. UCare will continue to track the situation and determine whether to extend this coverage beyond May 31. UCare has been working closely with state leaders and public health authorities to keep its members, employees, and communities safe. Like many health care organizations, it has temporarily closed its doors, but encourages members and providers to call or communicate online with questions on plans and coverage. To learn more about UCare’s services and coverage during this pandemic, visit https://tinyurl.com/ hcn-ucare.

COVID-19 response grants provide short-term emergency funding In March, Minnesota lawmakers passed an emergency law authorizing $200 million be used to support eligible health care costs

related to planning for, preparing for, or responding to the outbreak of COVID-19. Fifty million dollars was set aside as short-term emergency funding to provide immediate emergency cash flow relief to health care organizations to cover their highest-priority needs in the first few weeks of the COVID-19 outbreak. The Minnesota Department of Health (MDH) received more than 1,600 grant applications requesting more than $300 million. The grant application process is now closed and MDH has awarded $50 million in emergency funding to some 350 provider organizations across the state. Grant amounts ranged from several hundred dollars to $5 million dollars. The grants were awarded to assisted living facilities, health care clinics, Federally Qualified Health Centers, hospitals, health systems, pharmacies, ambulance services, and tribal health providers. Nursing homes had previously been eligible to get most expenses covered by the Minnesota Department of Human Services (DHS). They will now be able to apply for the upcoming $150 million COVID-19 Health Care Response Grant for items DHS was not able to cover, such as capital improvements. After dispersing the Short-Term Emergency funding, the remaining $150 million COVID-19 Health Care Response Grant is intended to cover costs related to planning for, preparing for, or responding to the COVID-19 outbreak. These funds will be awarded through a Request for Proposal (RFP) process. Learn more at https://tinyurl.com/hcn-rfp.

Fulcrum Health to deliver chiropractic telehealth Fulcrum Health has teamed up with health plan clients to deliver chiropractic telehealth services for its members. This approach is designed to support chiropractors in

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their efforts to safely and effectively use technology to deliver virtual care to patients and reduce potential exposure to COVID-19, while helping them manage their overall health and well-being during mandated stay-at-home orders, shutdowns, and access restrictions. Chiropractic care is a hands-on business, but with social distancing and mandated shutdowns due to COVID-19, providers are experiencing a significant reduction in the number of patients seeking care, potentially exacerbating existing health problems. “While some [chiropractic patients] may be able to forego treatment until the risks of in-person visits have abated, others could end up in already overtaxed emergency rooms due to unmanageable pain if they are not able to receive care,” said Fulcrum CEO Patricia Dennis. “Our goal is to make it easy and safe for our network of chiropractic providers

to evaluate patients and provide direction for steps they can take to manage existing issues and support ongoing mental and physical health.” Fulcrum’s program will: • Consult with patients regarding their current condition and potential treatment needs; • Reduce the risk of COVID-19 exposure associated with in-person visits; • Educate and reassure patients who are experiencing severe pain and offer appropriate at-home care advice, including the use of hot or cold therapies and stretching; • Provide active care instructions for achieving personal health goals, such as demonstrating exercises that can be done at home

to manage low-back pain without narcotics; and • Offer home instruction on daily living activities, such as how to achieve an ergonomically safe remote work environment or to modify activities to reduce pain or injury.

Workers compensation expands for nurses Contraction of COVID-19 at work had previously been considered an “occupational disease” under Minnesota’s Workers’ Compensation program, with workers required to provide evidence that they had contracted the virus at work. Under a new Minnesota law, nurses and workers who are on the frontlines of this pandemic are now presumed to have contracted COVID-19 through their employment. Under the new legislation, employers will need to

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provide proof that nurses and other health care professionals did not contract COVID-19 through the course of their employment. The law applies to corrections officers and security counselors, licensed peace officers, firefighters, paramedics, EMTs, workers required to provide childcare to first responders, and health care workers under Executive Order 20-02 and Executive Order 20-19. A nurse must either test positive for COVID-19 or be diagnosed by a physician or APRN. Then, either the positive test or documentation of the diagnosis must be provided to the employer. The only cause for rebuttal is if the employer can show that employment was not a direct cause. The date of injury is the date on which a nurse was unable to work after receiving a positive test or by exhibiting symptoms that were later diagnosed as COVID-19, whichever came first.

MEDICUS

Timothy Kufahl, MD, has joined St. Luke’s Mount Royal Medical Clinic. Boardcertified in family medicine by the American Board of Family Medicine, Dr. Kufahl is a member of the American Academy of Family Physicians, the Minnesota Academy of Family Physicians, the Lake Superior Medical Society, and the Wilderness Medical Society. His procedures include dermatology and orthopedic injections, diet and nutrition, addiction medicine, and wilderness medicine. Stephen Richardson, MD, a cardiac anesthesiology fellow at the University of Minnesota Medical School, is among the interdisciplinary developers of the Coventor, a compact, low-cost ventilator recently authorized for production and use by the FDA under the agency’s Emergency Use Authorization for the COVID-19 outbreak. The Coventor’s specifications will be made open source so other manufacturers globally can begin their regulatory and production processes. Charles Bruen, MD, a critical care and emergency medicine physician and researcher at Regions Hospital, is leading a HealthPartners Institute study of a drug for severe COVID-19 pneumonia that may prevent lung inflammation in hospitalized patients with COVID-19, after receiving fast-track investigational approval from the FDA. The intravenous drug, formally called CM4620-IE, blocks the body’s production and release of molecules that cause inflammation, potentially reducing lung damage and the need for a ventilator. Historically, it has been proven safe and effective in patients with acute pancreatitis with below-normal levels of oxygen. William Lundberg, MD, has joined St. Luke’s Orthopedics & Sports Medicine. Board-certified in orthopedic surgery with a sports medicine sub-specialty by the American Board of Orthopaedic Surgery, Dr. Lundberg received his medical degree from the Medical College of Wisconsin in Milwaukee. He completed his orthopedic surgery residency at the University of Minnesota in Minneapolis.

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INTERVIEW

Serving pharmacists and patients Sarah Derr, PharmD Minnesota Pharmacists Association Please tell us about the history of the Minnesota Pharmacists Association (MPhA).

Prescriptive authority for non-diagnosable conditions is an issue for the MPhA. What can you tell us about this?

MPhA—formerly known as the Minnesota State Pharmaceutical Association (MSPhA)—was founded in 1883. Meeting in St. Paul that year, a group of 12 influential druggists made plans and preparations to organize a state pharmaceutical association. MSPhA later produced the other institutions of pharmacy in Minnesota: the state Board of Pharmacy, established in 1885, and the University of Minnesota’s College of Pharmacy (CoP), established in 1892. Over the last 137 years, MPhA has served all pharmacists, student pharmacists, and pharmacy technicians. MPhA continues to be the organization that represents all pharmacists in the state of Minnesota. (See DiGangi, Frank E., A Century of Service and Leadership. 2003.)

The other organization that is well known in Minnesota is the Minnesota Society of Health System Pharmacists (MSHP). This organization’s members are mostly comprised of pharmacists from health systems and in administrative positions within hospitals. Another smaller organization is the Minnesota College of Clinical Pharmacy (MCCP), which has members serving in clinical roles, such as those working in the clinic and those working in specialties such as renal failure, hematology, and oncology. The other major player in Minnesota pharmacy is the CoP, which not only graduates PharmD students, but also plays a large role in keeping alumni connected and serving in large leadership roles in the profession. About a decade ago, the Practice Act Task Force was created, now known as the Minnesota Pharmacy Alliance. This brings together MPhA, MSHP, MCCP, and the CoP to discuss how we can best serve Minnesota pharmacists. The Alliance works closely together, especially on legislative issues, to ensure that we are one voice. This group works on several issues throughout the year.

APRIL 2020 MINNESOTA PHYSICIAN

“...” are the most Pharmacists accessible health care professionals.

“...”

There are other associations of pharmacists in Minnesota. What can you tell us about them and how you all work together?

MPhA has been pursuing prescriptive authority during the 2020 legislative session. We are pursuing conditions that do not require a diagnosis, such as nicotine replacement for smoking cessation, emergency opioid antagonists such as naloxone, and self-administered hormonal contraceptives. We are pursuing these three areas because they all are medications that a patient can have dispensed at the pharmacy. Pharmacists are the most accessible health care professionals, and they see patients, on average, 25 times a year. When a patient is ready to quit smoking, it is best that they get the medication and counseling that they need at that point in time, before they change their mind.

Prior Authorization is an issue that impacts most physicians in many ways. How does it impact pharmacists and what are some potential solutions to these problems?

Prior Authorization can be a challenge for all health care professionals. Pharmacists are impacted when a patient brings a script to the pharmacy that requires a prior authorization that the prescriber was not aware of. In these cases, the pharmacist has to contact the clinic to get a prior authorization. This can cause a delay in the patient getting their medication. Additionally, plans change their formularies at least once a month, if not more often. This can cause the need for a new prior authorization mid-year, which then can lead to further delay in patients getting their medication. Potential solutions are to stop health plans from changing their formulary mid-year. In addition, once a patient has had a prior authorization for a medication, we could eliminate the need to renew prior authorization each year.

Medication administration by pharmacists is another important issue. Can you explain your work in this area?

Pharmacists are well trained to counsel and teach patients how to administer their medications. Many patients are not comfortable administering injectable medications on their own. Pharmacists are well equipped to administer these medications. In the 2019 legislative session, the Minnesota Pharmacy Alliance passed legislation to allow pharmacists to administer long-acting injectables for mental health and substance use disorders. In 2020, the Minnesota Pharmacy Alliance has efforts underway to expand this to all injectable medications so that patients have the access to the medications that they need. Additionally, pharmacists are the most accessible providers and are often closer to the patient’s home than to the clinic. Several states have recently passed legislation around PBM transparency. These bills are now being challenged on the Supreme Court level as ERISA violations. Please explain why the legislation was necessary and why it is being challenged.

In the 2019 legislative session, the Minnesota Pharmacy Alliance passed legislation to regulate the PBMs through the Commerce Department. This is extremely important, as the PBMs are not well

regulated and there is little transparency regarding where the dollars go. If the Supreme Court were to agree with the Pharmaceutical Care Management Association (PCMA), this would mean that all private plans would be exempt from the transparency bill that we passed in Minnesota. We will continue to monitor the Rutledge v. PCMA Supreme Court case. Pharmaceutical prices are a major health care issue. What plans do you have to address these issues?

One of our most important plans is to pass legislation that provides transparency for PBMs and begins to regulate PBMs. This year, Minnesota Attorney General Keith Ellison worked with a group to create the “Report of the Minnesota Attorney General’s Advisory Task Force on Lowering Pharmaceutical Drug Prices.” MPhA will continue to work with Minnesota stakeholders to see how we can continue to lower medication costs. What is your position on Minnesota’s new insulin legislation?

MPhA spent much of the 2019 session working with state legislators to ensure that the insulin legislation worked for both patients and

pharmacists. The bill that was passed works well for both patients and pharmacists, as it utilizes existing programs through the manufacturer programs.

care. Access to the EMR is helpful for pharmacists to evaluate the effectiveness of drug therapy, as labs can assist in making medication decisions.

Interoperability of patient data across health system lines is an area of increasing concern. How does this impact patients on a pharmacy level, and what are some potential solutions?

What have been the biggest issues your members have had to deal with related to the COVID-19 pandemic?

Pharmacists are well trained to monitor medication and provide suggestions to changes in patients’ medications. In order to do this at the highest capacity, pharmacists need access to lab results and other information that can help pharmacists make informed decisions. Even readonly access can be helpful, although two-way communication is ideal so that the pharmacist can share any suggestions they may have. How could health care delivery benefit from better communication between pharmacists and physicians?

Communication between pharmacists and prescribers is vital in order to provide the best patient care. By communicating with the prescriber, a pharmacist can provide the highest level of patient

The biggest challenges have been access to personal protective equipment, ensuring that the patient is getting the medication for a legitimate medical reason, and payment for services. PPE is a large issue, as initially pharmacists were not considered “necessary” health care professions. This has since changed, thankfully. Medication shortages, particularly with hydroxychloroquine, have been a concern as prescribers are writing scripts before a patient is sick. This has improved, but there continue to be shortages of albuterol inhalers. Pharmacists have long fought to be paid for their services, and this continues to be an issue. Pharmacists are also concerned that they will not be paid to perform COVID-19 testing or administer a vaccine once it is available. Sarah Derr, PharmD, is Executive Director of the Minnesota Pharmacists Association.

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MINNESOTA PHYSICIAN APRIL 2020

3A futile quest from cover

quality measures for Minnesota that would be used to punish and reward “health care providers” (Minnesota Statutes, Section 62U.02). The law offered a few guidelines (such as MDH should “seek to avoid increasing the administrative burden on health care providers”), but it offered no details on how MDH was supposed to create useful measures.

But these policymakers did so with no explanation of how system-wide measurement was supposed to be done accurately, and without any reference to research demonstrating that accurate system-wide measurement is financially or technically feasible. The Minnesota Health Care Policymakers at the federal level have exhibited Access Commission (in 1991) and the Minnesota the same attitude. Like the half-dozen commissions Health Care Commission (in 1993) were the first of that have advised the Minnesota Legislature over the several commissions to exhibit this “shoot-first, aimlast three decades, the Medicare Payment Advisory later” mentality. Both commissions recommended the Commission (MedPAC) has endorsed measurement A report card that measures establishment of massive data collection and reporting a micro-fraction of all and P4P schemes for Medicare on the basis of zero systems, and both articulated breathtaking expectations services delivered will empirical evidence and without working out the of the “report cards” these systems would produce. be grossly inaccurate. details. As the Minnesota Legislature followed the According to the latter commission, for example, the evidence-free recommendations of the Minnesota data collection and number crunching would facilitate commissions, so Congress has followed MedPAC’s “feedback of data that reflects the entire scope of the undocumented recommendations. MedPAC’s health care process, from the inputs or structural influence is most apparent in the Affordable Care characteristics of health care to the processes and Act of 2010 and the 2015 Medicare Access and outcomes of care.” (p. 134) Yet neither commission offered even the crudest CHIP Reauthorization Act, which enacted the nation’s largest P4P program details on how such a scheme would be executed nor what it would cost, and, not (the insanely complex Merit-based Incentive Payment System). surprisingly, neither commission offered evidence supporting their high hopes. The proliferation of reporting and P4P schemes has triggered “significant In 2008, two other commissions and the Minnesota Legislature rethinking of measurement activities at the federal government, by national exhibited the same casual attitude toward evidence and details. That year, measurement organizations and health care payers, and within state the Legislature, egged on by the commissions, passed a law requiring the governments,” as MDH put it in a February 2019 report to the Legislature. Minnesota Department of Health (MDH) to create a “standardized set” of (p. 8) Minnesota’s Legislature is among those doing some rethinking. It enacted a law in 2017 that requires MDH to develop a “framework” for evaluating MDH’s “performance” measurement program which was authorized by legislation enacted in 2008. Because feedback is useless if it is not accurate, MDH should make accuracy the single most important criterion in evaluating any proposed quality or cost measure. MDH should use this opportunity to explain to the Legislature why MDH’s measurement system and systems like it are grossly inaccurate.

Three impediments to accuracy

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The inaccuracy of “performance” measurement has three distinct causes: 1) It measures a tiny fraction of the thousands of services a clinic or hospital delivers (the “bundled product” problem); 2) it is usually very difficult to determine which patient “belongs” to which doctor or clinic (the “attribution” problem); and 3) for all but the simplest of medical services, it is impossible to adjust scores accurately to reflect factors outside physician or hospital control (the “risk-adjustment” problem). I will illustrate each problem with an example, then examine each in more detail. The “bundled product” problem is the easiest to understand. To illustrate this problem, consider this analogy. Imagine that you want to issue cost and quality report cards on Home Depot, Menard’s, and Lowe’s. For the sake of discussion, let’s say these stores sell ten thousand different items—appliances, tools, construction materials, paint, repair services, plants, etc. You decide your report card will issue grades on just five items—sod, circular saws, tile cleaner, varnish, and dry wall. You ignore the other 9,995 items and services. How useful is your report card? Like home supply stores, clinics and hospitals sell thousands of services. There are 8,000 services doctors bill for (that’s roughly the number in the Current Procedural Terminology manual, the document all doctors use

to find codes to put on their claim forms), and 68,000 diagnoses (that’s the number of diagnoses listed in the current iteration of the International Classification of Diseases maintained by the World Health Organization). MDH currently lists 29 measures on its website. To illustrate the “attribution problem,” consider again the “optimal diabetes” measure discussed in Part I (https://tinyurl.com/mp-sullivan-p1) of this two-part series—a measure that Minnesota Community Measurement (MNCM) and many other report-card manufacturers use. This measures the percent of a doctor’s or clinic’s diabetic patients who have their blood sugar and blood pressure under control, who take aspirin and statins, and who don’t smoke. Obviously, the first step in calculating these percentages is to determine which patients “belong” to which clinic. But how do you do that? If you don’t do it accurately, you will be rewarding or punishing doctors for patients they don’t see.

The bundled product problem: Treating to the test Even the most expansive measurement-and-reporting schemes measure only a tiny fraction of the thousands of medical services sold in modern societies. Consider furthermore that each service can be evaluated at least four ways— by process measures (did the diabetic patient’s A1c levels get measured?), outcome measures (is the diabetic’s A1c level under 8?), structural measures (does the hospital have a catheterization lab?), and patient satisfaction as measured by surveys. The possible number of “quality” measures is in the tens of thousands. Compare tens of thousands to, for example, the 30 or so enforced by MDH and its contractor, MNCM, over the last 15 years.

To illustrate the third obstacle to accuracy—inaccurate adjustment of scores to reflect the impact of factors outside physician or hospital control—imagine that you have chosen the blood pressure measure within the “optimal diabetes” measure to be one of a handful of quality measures in your report card. You know that blood pressure is determined by multiple factors doctors have no control over, including patient age, income, education, willingness to exercise, stress levels at home and work, insurance coverage for and the price of blood pressure medications, etc. How do you adjust the scores on your report card to make sure they measure only physician expertise and not all those other factors?

A common argument presented by proponents of reporting schemes is that scores on some of the handful of measured services increase over time. But measurement proponents never investigate whether improvement on those scores was financed by “treating to the test,” that is, by shifting resources away from patients whose care was not measured. Common sense and a small body of research indicates that’s in fact what happens: the use of a tiny fraction of services that MNCM and other P4P proponents measure has induced teaching to the test. If in fact improvement on a few scores is financed by a worsening of the quality of unmeasured services, overall quality (at both the system and provider level) may not have improved at all. And if patient preferences were bulldozed by providers under pressure to honor the priorities set by report card producers, overall quality may have gotten worse. In either event, a report card that measures a micro-fraction of

Now imagine how inaccurate your report card is going to be if you can’t solve even one of these problems, never mind all three.

A futile quest to page 124

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MINNESOTA PHYSICIAN APRIL 2020

3A futile quest from page 11

based on my blood pressure, my blood sugar levels, whether I resume smoking in 2020, etc., outcomes they were totally unable to influence all services delivered will be a grossly inaccurate reflection of the quality of during 2020. Health policy analysts and consultants measure the integrity the providers subjected to measurement. of these attribution algorithms (or the lack thereof) by measuring their “leakage rates”—the rate at which patients fail to seek care often enough The attribution problem: Measuring during the “performance year” to be assigned to the phantom patients same clinic the next year. Research on the leakage Unlike the bundled product problem, the attribution rates of “accountable care organizations” (groups of problem does not afflict all measurements. We clinics and hospitals) and “medical homes” (single know, for example, exactly which hospitals and clinics), for which the plurality-of-visits method is which surgeons performed bypass surgery on which used, equal an astonishing 30% to 40%. As you can Feedback is useless if patients. If we want to prepare a report card on imagine, the addition of all those phantom patients it is not accurate. heart surgeons or the hospitals where heart surgery to the denominator of measures like the “optimal is performed, we don’t have to make up arbitrary, diabetes” measures, and the subtraction of so many complex rules to assign patients accurately. But we real patients, substantially augments the noise-todo have to make up arbitrary and complex rules to signal ratio of such measures. attribute patients to doctors, clinics, and hospitalclinic chains when the report card measures services The risk-adjustment problem like those in the “optimal diabetes” bundle. The third major contributor of noise to “performance” The most widely used attribution rule is to assign patients (without their knowledge) to a clinic or hospital-clinic chain if, during a baseline (or “lookback”) period of one or two years, patients made a plurality of their visits to the clinic or chain. Thus, if I visit Clinic A three times in 2019, Clinic B once, and Clinic C once, the plurality-of-visits rule will “attribute” me to Clinic A for the “performance year” 2020. Even if I never set foot in Clinic A in 2020, the doctors in Clinic A will be rewarded or punished

measures is crude risk adjustment. Risk adjustment is done to adjust scores for factors providers and insurance companies have no control over. The most efficient way to convey the unacceptable inaccuracy of today’s risk adjusters is to review the inaccuracy of the nation’s most widely used, most studied, and probably most accurate risk adjuster—the one CMS developed A futile quest to page 134

V Alzheimer’s is now an approved condition V

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APRIL 2020 MINNESOTA PHYSICIAN

3A futile quest from page 12 in the early 2000s to adjust payments to Medicare Advantage plans. This method, known as the Hierarchical Condition Categories (HCC) model, can only predict 12% of the variation in spending among Medicare enrollees. To understand how bad that is, consider these statistics reported by MedPAC: the HCC overestimates spending on the healthiest 20% of beneficiaries by 62% and underestimates spending on the sickest 1% by 21%. MedPAC has made it clear they have no expectation that the HCC can be made substantially more accurate. As these statistics suggest, inaccurate risk adjustment punishes providers who treat an above-average proportion of the sick and the poor and rewards those who treat an above-average proportion of the healthy and higherincome. This worsening-of-disparities effect can be seen, for example, in the outcomes of the Hospital Readmissions Reduction Program (HRRP), a program foisted on the fee-for-service Medicare program by the Affordable Care Act. The HRRP punishes hospitals with 30-day readmission rates above the national average. CMS uses a risk adjustment method similar to the HCC to adjust readmission rates for factors outside hospital control, but the risk adjuster is so bad it routinely punishes hospitals with sicker patients. Research published in the last three years indicates the HRRP may be killing heart failure and pneumonia patients. MDH, MNCM, and other “performance measurers” use riskadjustment schemes that are even cruder than the HCC, and in some cases they use no risk adjustment at all. MDH uses payer mix —the percent of patients insured by Medicaid, Medicare, and private insurers—as its risk adjuster. Unlike CMS, which reports the accuracy rate of its adjuster for at least cost (as opposed to quality), MDH has never reported what percent of the variation its payer-mix method explains. In a 2017 report to the Legislature (https://tinyurl.com/mp-2017-mdh), MDH did concede that “risk adjustment can typically only explain a fraction of differences in quality between providers,” and they knew of no way to improve the accuracy of their crude payer-mix method. But, MDH concluded, that’s OK because the payer-mix method is “reasonable.” (p. 14)

Learning from failure In its 1993 report to the Legislature, the Minnesota Health Care Commission based its breathtaking expectations of “performance” measurement on this breathtaking assumption: “The commission assumes that the dimensions of health care quality can be defined and measured in a useful and equitable way.”(p 134) The commission endorsed this assumption without even acknowledging the sources of white noise discussed here—the bundled product, attribution, and risk adjustment problems—much less suggesting ways to overcome them. None of the subsequently appointed commissions questioned the 1993 commission’s fanciful assumption. Nor did the Legislature. It’s time Minnesota policymakers admit that that assumption was based solely on groupthink, that the assumption persists to this day because of groupthink, and the assumption must at long last be rejected. Rejecting that assumption does not mean rejecting measurement. The issue at hand is not whether measurement is useful, but whether inaccurate measurement is useful. Nor does it mean abandoning all efforts to improve the quality of medical services or the health of Minnesotans. It means abandoning the default diagnosis that all problems in our health care system are due to defects in our doctors and hospitals, entertaining the

possibility that those problems that might be within provider control are due to insufficient resources, and abandoning the comforting myth that it’s possible to adjust “performance” scores accurately to reflect factors outside provider control. Above all, it means accepting the obligation to ensure that measurements are accurate before they are unleashed on Minnesota’s doctors and hospitals. Kip Sullivan, JD, is a member of the Health Care for All Minnesota Advisory Board. He was a member of Gov. Perpich’s Health Plan Regulatory Reform Commission. His articles have appeared in the New England Journal of Medicine, Health Affairs, and other peer-reviewed journals.

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3Prior authorization from cover

that 30% of the time, the wait to get a response to a prior authorization request was at least three days. At our hospital, we have had occasions where inpatients needing to go home with durable medical equipment (DME), such A personal perspective as feeding pumps, have experienced delays in getting approvals. Rather than Recently, I had the opportunity to testify on behalf of this proposed wait for the prior authorization approval and delay legislation before the House Health and Human their child’s discharge, families end up having to Services Committee. Committee testimony is one pay for the pumps out of pocket and hope that, in way that potential changes are brought forth for the end, their insurance company will authorize the a bill. In addition, numerous stakeholders also equipment and reimburse them. Patients should have a chance to meet with the bill’s authors Most doctors view prior not have to wait for essential equipment or services. and recommend changes. For a bill like this, authorizations as an attack organizations such as the Minnesota Council of In addition, I am very aware of the roadblocks on their autonomy. Health Plans have had extensive input, resulting that the current prior authorization processes can in changes such as lengthening the period of time present to a clinician wanting to provide the best a utilization review organization (URO) would care for his or her patients. There is an unspoken have to respond to a prior authorization request message by insurance companies and pharmacy from what the bill’s authors initially proposed. benefits managers (PBMs—another type of The initial proposal was to have a 36-hour limit on responding for all URO), that clinicians are not able to decide which tests or medications a requests (down from the current law that allows 10 days for a standard patient needs and that these UROs are better able to decide this. A 2019 determination or 72 hours for expedited requests), but as the bill has Medical Economics article, “The impact of prior authorizations” (https:// progressed, that time has increased to four business days for standard and tinyurl.com/mp-prior-authorization), stated that “ Most doctors view prior 48 hours for expedited responses. authorizations as an attack on their autonomy, their years of training, and While I understand the desire of insurance carriers to lower and control health care costs and the role of prior authorization in addressing that goal, patients and their families often endure long waits to see if the prior authorization will be approved. That same 2017 AMA survey found

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their ability to care for their patients. Plus, there’s the time wasted and revenue lost due to haggling with payers over approval for drugs and tests.” At the Committee hearing, a representative of the Minnesota Council of Health Plans actually stated that health plans may know more than the clinician about what medications or tests are best for a patient. The Blue Cross Blue Shield of Minnesota website states the following about what their decisions are based on: “Blue Cross makes prior authorization decisions using the Blue Cross Medical Policy. This policy includes evidence-based guidelines from the World Health Organization. Registered doctors and nurses regularly review these guidelines.” (See https://tinyurl.com/ mp-prior-authorization2.)

Current practices Prior authorization affects patients and clinicians in obtaining approval for procedures, inpatient admissions, medications, and durable medical equipment. The process of obtaining this authorization is time consuming on the part of clinicians and their office staffs and often seems to be designed to delay or prevent approval in the best interests of the insurers, not the patient. The 2017 AMA Survey found that 14.6 hours per week were spent by physicians and staff completing prior authorization work. I recently heard from a nurse in one of our clinics that she had spent over 13 hours on the phone over the period of a month trying to get one medication approved for a patient. Clinics and hospitals across the state have staff dedicated solely to processing prior authorization requests and appeals. In my hospital, we estimate that we have about 30 full-time equivalents (FTEs) on the front end working on prior authorization and another 10 FTEs on the back end fixing prior authorization issues. The administrative costs of handling these prior authorization matters are enormous. We have all experienced problems with obtaining prior authorization approval for a medication or DME on a Friday afternoon for a patient awaiting discharge from the hospital, when the insurance company prior authorization department, or another URO such as a pharmacy benefits manager, tells you they are closed over the weekend. At the recent Committee hearing, one

APRIL 2020 MINNESOTA PHYSICIAN

also provides much needed transparency to the prior authorization process legislator asked the same representative of the Minnesota Council of Health by requiring health plans to list annually how many prior authorization Plans who testified that insurance plans may know better what medications requests they received and what the outcome of those requests was. Prior or procedures a patient may need than their clinician, why insurance plans authorization can play a role in helping reduce health care costs, but all too can function on a Monday–Friday, 8–5 schedule, if hospitals and doctors often it delays or compromises patient care while function 24/7? The Health Plans representative adding administrative costs and burden. We can did not have a good answer for this question. As do better, and this legislation is a great start. previously mentioned, the proposed legislation would shorten the time health plans or UROs are Get involved allowed to review a prior authorization request to Prior authorization affects all physicians and We have all experienced speed approvals (although, as mentioned above, health care providers. Reach out to your state problems with obtaining prior the current version does not go as far as would have representative or senator to share your thoughts on authorization approval. been liked). House File 3398 and Senate File SF3204. Search There are also cases where delays in prior for names and contact information at www.gis. authorization for outpatient medications can lead leg.mn/iMaps/districts/. to increased morbidity and possible emergency To check the status of either bill, visit www.leg. room visits and hospitalization. At our hospital, state.mn.us/leg/legis. This webpage also includes we have seen situations where prior authorization for outpatient IVIG a link to sign up for the Legislature’s “MyBills Personalized Bill Tracking” administration for patients with immune deficiencies or treatments for email service, which delivers alerts on specific bills. patients with hemophilia were delayed, resulting in complications for patients. Any potential savings the prior authorization process purports to Sheldon Berkowitz, MD, FAAP, is a general pediatrician as well as the provide are immediately lost when a patient finds themselves in an emergency department, the most expensive, least efficient place to receive care. Medical Director for Case Management, Utilization Management and Clinical

Other examples Another problem with current prior authorization processes is that often, URO personnel may be using algorithms that “help” them decide when to approve or deny a request. They may have little to no medical training to make these decisions. One example where the current law can create delays is in our Pediatric Cardiovascular Intensive Care Unit, where we have often received denials and delays in getting a medication called sildenafil approved for our patients. You may know this generic drug by its more common brand name, Viagra, and I wouldn’t be surprised if many of you may have the same response that some URO reviewers have, which is, “why would a pediatric patient need Viagra?” However, in pediatric cardiology or intensive care, this drug is commonly used to treat pulmonary arterial hypertension. The medication helps to reduce the pressure. Having a URO not understand this often delays treatment and discharges from the hospital. Current law requires that a licensed physician in Minnesota make the prior authorization determination. This new law would require that this physician also “have experience treating patients with the illness, injury, or disease for which the health care service has been requested.” Requiring a pediatric cardiologist, intensivist, or neonatologist to review the request would expedite the response and most likely lead to approval. Finally, in pediatrics, we have also seen situations where our young patients in the hospital are denied liquid preparations for a medication by a URO and instead told we must prescribe a tablet. While it is common sense to any of us with children or grandchildren that young children often can’t swallow pills, apparently that doesn’t fit into a URO algorithm, especially if the tablet form is less expensive. Having a knowledgeable physician make these decisions will help.

Summing up Rep. Morrison and Sen. Rosen’s bill to streamline and improve the prior authorization process is a significant step in the right direction. The bill

Documentation Improvement at Children’s Minnesota. He is also the PresidentElect of the Minnesota Chapter of the American Academy of Pediatrics. He has testified at the Minnesota Legislature several times in the last year.

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2020 COMMUNITY CAREGIVERS

Gregory Beilman, MD Recognizing Minnesota’s Volunteer Physicians By Richard Ericson

Each year, Minnesota Physician Publishing recognizes physicians and health care providers who have volunteered their medical services. Whether volunteering at home or overseas, these caregivers help people in need and come away with a revitalized sense of their work. Their compassion, commitment, and generous spirit reflect the deeply held values in Minnesota’s medical community.

University of Minnesota Physicians

reg Beilman, MD (at left above), has led four annual “surgical camps” at the Ruth Gaylord Hospital in Kampala, Uganda, where doctors spend one week providing free surgeries to lowincome patients. The Ruth Gaylord Hospital—in Maganjo district, Kampala, Uganda—was established eight years ago with funds from the Friends of East Africa Organization. During the surgical camps, the hospital provides sleeping quarters and meals, access to patients, and any additional care needed at no cost to the patient, facilities, and personnel. In the most recent trip (December 2019), Dr. Beilman and a team of fellow University of Minnesota medical professionals evaluated 85 patients for their surgical needs and performed much-needed surgery for 41 patients. In its “Global Surgery 2030” report, the Lancet Commission estimates that an additional 1.27 million surgeons, anesthesiologists, and obstetricians are needed by 2030 to provide safe and affordable surgical care across the world. Faculty at the University of Minnesota are working to increase the absolute size of the workforce and the skill of the existing workforce in Asia, Africa, and Central America.

An additional 1.27 million (international) surgeons, anesthesiologists, and obstetricians are needed by 2030 To further address this global challenge, Dr. Beilman is working to grow surgical capacity in Uganda with the creation of a sustainable, socially responsible collaboration between the University of Minnesota and Kampala, Uganda’s Makerere University. Advancing research activities, providing surgical expertise, creating a bidirectional short-term training program in surgery and anesthesia, and training residents from both institutions in global surgical research, are a few of the benefits of a sustained collaboration. Dr. Beilman is a general and critical care surgeon for University of Minnesota Physicians and a professor in the Department of Surgery at the University of Minnesota Medical School. Currently, Dr. Beilman is singularly focused on leading the COVID Command Central in his role as senior vice president and medical director of Acute Care Operations with M Health Fairview. He earned his medical degree and completed his residency at the University of Kansas, School of Medicine. A fellowship in surgical critical care led Dr. Beilman to the University of Minnesota Medical School, where he has remained as a faculty-physician, treating patients during some of their most vulnerable moments and training the next generation of medical providers.

APRIL 2020 MINNESOTA PHYSICIAN

Stephen Dunlop, MD, MPH, FACEP

Brent Nelson, MD

Hennepin Healthcare

PrairieCare

tephen Dunlop, MD, MPH, FACEP, a board-certified emergency medicine physician-scientist with formal training in public health, advanced ultrasound techniques, and tropical medicine, has partnered with colleagues in low- and middle-income countries (LMICs)— primarily in Tanzania and Kenya—for more than a decade. In Tanzania, he has been involved with the development of emergency care.

rent Nelson, MD, is an interventional psychiatrist and technologist who has volunteered his time to work with Stillpoint Engage and Doctors Without Borders in Johannesburg, South Africa. He is Chief Medical Information Officer (CMIO) at PrairieCare, and is an assistant affiliate professor at the University of Minnesota.

Dr. Dunlop now concentrates on epidemiologic analysis of burdens of disease; education of emergency medicine residents in Sub-Saharan Africa; advocacy aimed at U.S.-based funders; and administration of an emergency

Outside of his time practicing psychiatry, he provides training and education to humanitarian aid outreach workers around the world on topics that range from the neurobiology of stress to coping with trauma and building resiliency in the field. We know that most humanitarian aid workers are illprepared to cope with the stress and trauma that can happen either directly or vicariously through their work in many developing areas of the world. It is paramount that these workers find ways to cope with the challenges that many face in the field—including trauma, isolation, and anxiety. His style of teaching includes a balance of science, theology, experience, and storytelling. Dr. Nelson’s passion for teaching others, and his openness to new idea, allows him to quickly build rapport with his audience and allow for profound learning and lasting memories.

“It became clear that I could make a much greater impact through education and systems development.”

Most humanitarian aid workers are ill-prepared to cope with the stress and trauma (of their international work).

department that now has the first residency-trained emergency medicine physician in Northern Tanzania. Among his many other roles, he serves as codirector of emergency services at Arusha Lutheran Medical Centre in Arusha, Tanzania, which expects to see 70,000 patients in 2020.

As a technologist, Dr. Nelson is working with the non-profit Stillpoint Engage (Minneapolis) to develop a web-based application that allows humanitarian aid workers to access ongoing training materials to bolster resiliency. This app will also help them remain connected to their peers and supervisors while deployed in the field. This innovative application will help track levels of stress and overall functioning while workers are managing their daily duties. The long-term vision is to incorporate a degree of machinelearning or artificial intelligence that will help predict patterns and behaviors in humanitarian aid workers that put them at-risk for trauma or mental illnesses.

A founding member of the African Federation for Emergency Medicine, Dr. Dunlop initially sought to work in a resource-limited hospital serving the world’s most vulnerable patients. “It became clear that I could make a much greater impact through education and systems development,” he said. “However, there was a huge discrepancy between where funding streams were aimed, what conventional wisdom was on the biggest issues facing LMICs, and what the reality was on the ground within ‘emergency departments’ across Sub-Saharan Africa.”

He currently has active research collaborations in Tanzania, Kenya, and Uganda, including studies on the use of ultrasound for elevated intracranial pressure in cryptococcal meningitis, lung ultrasound for diagnosis of pediatric pneumonia, and acute coronary syndrome among urban Tanzanians. At Hennepin Healthcare, his interests include health issues faced within immigrant communities. “This experience provides me with a unique perspective on how to tackle our current and future global health challenges that our patients, both at home and abroad, face,” Dr. Dunlop said. “Global emergency medicine is a prime example of a multifaceted approach to health maintenance, and places me at the intersection where efforts in public health fall short, attempts at restoration of health begin, and the data for future public health intervention can be collected.”

The combination of the learning content that he delivers and the online application he is building will be the groundwork for true transformation and enhancement of the humanitarian aid community. Dr. Nelson is passionate about this work, and has worked selflessly with countless stakeholders and third-party experts to help bring this critical training and technology to the individuals who need it. He has made contributions in almost every aspect of this initiative and has proven himself invaluable as a psychiatrist, teacher, visionary, and application developer.

MINNESOTA PHYSICIAN APRIL 2020

2020 COMMUNITY CAREGIVERS Dr. Nelson volunteered to be one of the first to travel to Tanzania through EAMAF in 1989. During that first visit, he served as a board examiner, and since then, he has served on EAMAFâ&#x20AC;&#x2122;s board and traveled to Tanzania over 30 times to volunteer at KCMC in various capacities, helping to build the program into what it is today. One of his proudest accomplishments is helping to install the first mammography unit in East Africa. Once the diagnostic radiology infrastructure for the 18 million Tanzanians whose main referral hospital was KCMC was in place, treatment was the next challenge that Dr. Nelson addressed through his volunteer efforts.

Michael Nelson, MD University of Minnesota Medical School

ichael Nelson, MD, a professor in the Department of Radiology at the University of Minnesota Medical School and a radiologist in breast imaging, volunteers at the Kilimanjaro Christian Medical Center (KCMC) in Misho, Tanzania.

This service was inspired by former University of Minnesota Medical School faculty member, Helmut Diefenthal, MD, who recognized a need to expand and improve radiological services in Tanzania. Dr. Diefenthal founded the East Africa Medical Assistance Foundation (EAMAF) to accomplish that goal and serve the communities there. Dr. Nelson, a student of Dr. Diefenthal, shared his commitment to world health.

[The] cancer treatment center in Tanzania now sees 75 to 90 patients per day and provides chemotherapy. The Foundation for Cancer Care in Tanzania (FCCT) was formed to expand treatment options by working closely with EAMAF. FCCT raised money to build a cancer treatment center in Tanzania that now sees 75 to 90 patients per day and provides chemotherapy. This partnership, which included leadership from Dr. Nelson, contributed to a decline in mortality rates, such as the mortality rate of Burkittâ&#x20AC;&#x2122;s lymphoma, from 85% to less than 15%. In 2018, Dr. Nelson received the American College of Radiology (ACR) Foundation Global Humanitarian Award for his service at KCMC for the last 25 years. In the time that he has served, he has seen the average life expectancy rise by decades. Dr. Nelson continues to go to Tanzania; in 2019, his time was spent conducting breast and liver cancer workshops.

Hello Progress Advancing health and wellness in local communities is at the heart of our endeavors. 612.524.6000 hdrinc.com

APRIL 2020 MINNESOTA PHYSICIAN

no Native people who were taking care of patients. There were no Native doctors and very few Native nurses,” she said. Dr. Owen resolved to become a doctor. After completing her residency, she moved to her home town of Juneau, Alaska, as a family physician at the Southeast Alaska Regional Health Consortium.

“I love it because I get to help get Native students into medicine”

Mary Owen, MD University of Minnesota Medical School, Duluth campus

ary Owen, MD, assistant professor and executive director at the Center of American Indian and Minority Health (CAIMH) at the University of Minnesota Medical School, Duluth campus, administers multiple programs that support Native students. The school is second in the nation for graduating American Indian and Alaskan Native medical doctors, thanks in large part to recruitment efforts by Dr. Owen and her colleagues. After completing her undergraduate studies, Dr. Owen worked with the Alaska Alliance for the Mentally Ill and the Alaska Psychiatric Institute while receiving health care at the Alaska Native Medical Center. “There were

In her current capacity at the Duluth campus, Dr. Owen opens career paths for other new physicians. “I love it because I get to help get Native students into medicine,” she said. “I tell students, you can be a doctor in our communities or you could be a neurosurgeon who mentors Native students. But you have to give back. That should be required of all medical students.” That same commitment extends to the larger population as well. Dr. Owen teaches an American Indian Health seminar, open to all students, that addresses health disparities and the gap in health care between the “haves” and the “have nots.” “It isn’t just the Native communities,” she says. “Outside of our community, the same immense health disparities affect many groups. The health seminar covers the ways we can make change.” Outside the walls of the Duluth medical school, Dr. Owen continues her parents’ legacy of community advocacy and service in Juneau. In addition to encouraging medical students to volunteer and serve their communities, she has written proposals to support even more students—starting as early as grade school—to pursue careers in the health care field. She practices with the Fond du Lac Band of Lake Superior Chippewa.

MINNESOTA PHYSICIAN APRIL 2020

2020 COMMUNITY CAREGIVERS Children’s Clinic, which is based out of Nogales, Arizona. She describes this as “essentially an international cleft team, in that we base the care on what patients in the United States would get for cleft care.” Services include not only cleft lip and palate but also alveolar bone grafts, orthodontic work, and cleft rhinoplasty. Over three days each trip, Dr. Roby’s team typically screens about 120 children and performs around 60 surgeries. She then works closely with the local nursing staff to help care for the patients after surgery. “It feels like a continuity clinic just like I would have in the United States,” she says. Her team is comprised of four surgeons (three pediatric facial

“Each year we are greeted warmly like we’ve been friends forever.”

Brianne Barnett Roby, MD Children’s Minnesota

n October 2019, Dr. Roby traveled to Hermosillo, Mexico, with Children’s Surgery International (CSI), a Minnesota-based, nonprofit volunteer organization that provides free medical and surgical services to children in need around the world. Dr. Roby has been volunteering with CSI since 2016, and has served on its Board of Directors since 2017. In addition to her own trips to Hermosillo, Vietnam, and Liberia, she also helps recruit surgeons for similar missions to Ethiopia, Liberia, and Tanzania. She had planned to provide care in India this year before that trip was canceled due to COVID-19. In Hermosillo, a city of over 800,000 people in the state of Sonora, Dr. Roby and her team work alongside the local CIMA Hospital and St. Andrew’s

plastics/cleft surgeons and one oral surgeon), one lead anesthesiologist and four others on the anesthesia team (anesthesiologist or nurse anesthetist), 1–2 pediatricians, operating room nurses, recovery room nurses, and floor nurses. Each and every time she visits Hermosillo, Dr. Roby is touched by how warm, kind, and patient the children and their families are as they wait to be screened or have surgery, even after traveling hours or even days to get to CIMA hospital to be evaluated. Dr. Roby has a special place in her heart for Hermosillo because, she says, “many of the kids I have operated on I did their cleft lip at a few months of age and returned a year later to do the cleft palate surgery.” She also loves that the parents, St. Andrew’s Clinic, and volunteers at CIMA Hospital keep her posted on the recoveries of the patients and, “each year we are greeted warmly like we’ve been friends forever.”

THE COMFORTS OF HOME The newly expanded neonatal intensive care unit at Essentia Health in Fargo, ND provides a beautiful, home-like environment for the tiniest of patients and their families. Equipped with advanced medical technology and designed to provide a calming, nurturing atmosphere, this specialized design encourages positive family interaction and overnight stays.

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APRIL 2020 MINNESOTA PHYSICIAN

the care they need during this pandemic, and decided to use our mobile care team to provide in-home visits for high-risk patients in need, regardless of insurance coverage,” he said. “We’ll continue to do so until this crisis is past.” The in-home visits are available on a case-by-case basis. Nura’s mobile nurses provide a variety of in-home patient care, including medication management, refills of pain pumps, medical evaluations, and arranging telemedical consultations directly with physicians as necessary.

“We did not want cost to stand in the way of patients receiving the care they need.” The decision to offer the free service comes at a time when Nura has had to furlough over 50% of its staff while elective pain procedures are on hold. For Schultz, though, it’s a case of patients over profits. “We’re providing free homecare for selected patients who are high risk for COVID-19, and who we feel would be put in jeopardy by leaving their homes during the crisis,” he said. “We feel it’s the right thing to do regardless of payment.”

David Schultz, MD Nura Pain Clinics

ven before Gov. Tim Walz’s Shelter-at-Home directive was issued, Nura Pain Clinics recognized that some of its patients would require an elevated level of in-home care during the COVID-19 pandemic. Dr. Schultz (pictured first from left with care team members) is founder and medical director at Nura, whose multidisciplinary approach to chronic pain includes targeted spinal drug delivery via pain pumps for its most extreme cases—a treatment unavailable to patients who can’t travel to the clinic or who have limited financial resources. Dr. Schultz directed his mobile care team to waive charges for many of those patients. “We did not want cost to stand in the way of patients receiving

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The vast majority of Nura patients requiring in-home care are those with pain pumps. Normally these patients visit the clinic every few months to refill the devices. Without timely refills, these patients could go into withdrawal, end up in an ER, or take up an inpatient bed that hospitals are trying to reserve for COVID-19 patients. Switching patients off of their pump medication and onto high-dose oral opioids for short-term care during the pandemic would create other potential problems. The home visits may save lives of some high-risk patients. “If I had to go out into the public with my immune system, generally I [would] pick up every bug around,” said Nura pain pump patient Brenda Standmark.

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MINNESOTA PHYSICIAN APRIL 2020

EPIDEMIOLOGY

Life in a global pandemic Helping patients cope BY TODD ARCHBOLD, LSW, MBA

n Feb. 11, the World Health Organization (WHO) announced the name of COVID-19, the novel coronavirus that had spread terror throughout Asia and Europe, and by then had already claimed the lives of thousands. Efforts to slow the spread to the United States was a topic of alarm and uncertainty. We knew little about COVID-19, which seemed shrouded in mystery, so far untreatable, and highly discriminatory to the elderly and those with weakened immune systems. President Trump declared a national state of emergency on March 13 and the stock market immediately plummeted, school was cancelled, businesses closed indefinitely, and the summer Olympics postponed. While many of us have lived through times of natural disasters, wars, recessions, and other outbreaks, no other event in recent history has impacted our daily lives like COVID-19. This pandemic has created an unprecedented existential threat to our daily lives that has created mass anxiety, fueled by daily uncertainty amplified by the speed with which new information and epidemiological data is being reported. There are no vaccines or treatments, there is no herd immunity, and your immune system has never seen this virus before. In

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addition, testing capabilities are lacking, and even the accuracy of results has been scrutinized.

The state’s health care preparedness Minnesota’s health care infrastructure is well-established and wellrespected. Preventative and specialty services are accessible and robust, cooperation between payers and providers is high, and our hospitals are recognized among some of the best in the nation. The strong work ethic and patient-centered culture among our professionals is enviable, and has put the patient experience and outcomes on the forefront. By any standards, Minnesota’s hospitals and health care workforce are as well prepared as any to face these threats head-on. However, when the threat of novel coronavirus manifested as a community spread killer, our system that valued high quality and integrity was instantly shaken. In retrospect, seeing empty store shelves where toilet paper and soap had been displayed was the canary in the coal mine warning of unprecedented problems ahead. Doctors and nurses never imagined fighting infectious diseases while wondering if they would have enough gloves, masks, and gowns. The thought of needing a thousand extra ventilators stored in reserve was both unthinkable and certainly costprohibitive. Information from the federal government on our lack of reliable testing almost seemed farcical. Many health care providers are now anxious or even fearful of going to work with a lack of personal protective equipment (PPE) and necessary medical equipment to save lives. While the camaraderie among Minnesota’s health care leaders is extraordinary, the unprecedented level of coordination required to manage emergency supplies and beds had not been rehearsed. And finally, the most crippling blow to our hospitals, leading to an ultimate paradox, was the necessary executive order to postpone all elective surgeries and non-essential procedures. The intention was to preserve our valuable supply of personal protective equipment and avoid exposing otherwise healthy patients to possibly infected carriers. The devastating result was the hardest financial hit Minnesota health care has ever experienced. While operating normally on a meager 1.7% margin, eliminating elective care procedures immediately resulted in a downturn in health care revenue of nearly 50% across the state, or an average loss of 31 million dollars per day. Many outpatient practices, including primary care and specialty care, have closed and furloughed significant portions of their workforce. Doctors and nurses have had their hours decreased during a time that our communities may need them the most. Rural hospitals are being hit the hardest, reporting nearly a 70% decrease in overall revenues since the executive order. We are preparing for a surge in COVID-19 patients that will overwhelm our hospitals and require creativity and adaptability that this workforce has never seen on such a massive scale. Our deservedly proud health care system is now battling a mysterious invisible killer, fragmented between a hundred circumstantially underequipped hospitals and alternative care sites with half of their usual funding, and a workforce that is skeptical—but nonetheless, dedicated, selfless, and

be done using telehealth, this method of care delivery will help thousands impassioned. In Bill Gates’ 2015 TED Talk about pandemics, he clearly remain connected to their supportive services through this crisis. stated that our health care systems have the people, science, and technology to defeat pandemics. What we lack is the large-scale coordination, When patients experience a psychiatric crisis—such as panic attacks, interstate cooperation, and disaster rehearsals. Governors are unwittingly a suicide attempt, drug overdose, or others—most often they end up in bidding against one another for basic supplies a hospital or emergency room. It is going to be and support from the private sector, only to have critical that mental health services remain fully the federal government buying stockpiles from intact and more accessible than ever so patients underneath them. Minnesota has been recognized experiencing these crises can avoid hospital or as a national leader in “flattening the curve,” emergency room visits, especially during the citing our strong community bonds and social anticipated COVID-19 surge. COVID-19 dominates most [mental consciousness as notable factors, yet we are not health] treatment sessions. While some of the larger societal disruptions infallible and nonetheless are facing the mortal have an obvious impact on mental health, other effects of infection, economic devastation, societal effects can be more subtle but equally impactful. disruption, and degradation of our mental health. Sleep experts and psychiatrists carefully monitor To punctuate the seriousness of the situation, patients’ circadian rhythms—the physical, the Centers for Medicaid and Medicare Services mental, and behavioral changes that follow one’s (CMS) reacted swiftly in early March by waiving bits and pieces of some usual daily cycle or routine. When even minimally disrupted, it can have of our most formidable federal laws governing US health care, such as a drastic impact on the quality of our restorative sleep, health, and wellEMTALA, HIPAA, Stark Law, and more. So far, a total of more than being. As many of us have adapted our daily routines to accommodate 100 waivers have been issued to increase access to care and to break down such things as working from home, helping kids with distance learning, barriers during this crisis. These laws had carried steadfast enforcement and having groceries delivered, and cancelling weekly social events, our rhythms threat of serious penalties. Suddenly, the walls came down and the federal are unwittingly impacted. This can lead to poor sleep, headaches, dietary government made it clear—care for patients first, document later. changes, weakened immune system functioning, and simply irritability.

The impact on mental health Each day nearly 20% of individuals struggle with symptoms of a mental illness, which have only been amplified during this pandemic. According to a poll conducted by the American Psychiatric Association in late March, “more than one-third of Americans (36%) say coronavirus is having a serious impact on their mental health and most (59%) feel coronavirus is having a serious impact on their day-to-day lives. Most adults are concerned that the coronavirus will have a serious negative impact on their finances (57%) and almost half are worried about running out of food, medicine, and/or supplies. Two-thirds of Americans (68%) fear that the coronavirus will have a longlasting impact on the economy.” Mental health experts are keenly tuned in to the impact of trauma and vicarious trauma on families and societies.

Life in a global pandemic to page 244

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Mental health needs are on the rise. Paradoxically, so are the barriers to accessing and providing care. Most healthy individuals receive emotional support from their peer groups and social circles, which have now been intentionally distanced and, at best, moved online. Mental health clinicians across the state are reporting that the topic of COVID-19 dominates most treatment sessions. Many patients are fearful of leaving the house, or are cancelling sessions for fear of job loss or financial strains. PrairieCare Medical Group saw a decrease of nearly 50% in outpatient sessions within days of the state’s declaration of a state of national emergency. While PrairieCare previously had provided about 5% of visits using telehealth, that number is now closer to 80% of visits done by telehealth, including group therapies. The waivers issued by CMS have greatly relaxed the rules for providing care using telehealth, which has benefited hundreds of individuals. Services can now be provided across state lines, physicians are able to prescribe new medications via telehealth, and almost any televideo platform can be used regardless of encryption level (previously a costly barrier for mental health clinicians). While not all psychiatric services can

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3Life in a global pandemic from page 23 The compounding effect of these disruptions to our daily lives can manifest as noticeable stress, and over time, and without proper intervention or rationalization, will lead to mental illness. It is the secondary and tertiary impact of the pandemic, and the impact of our societal response that will be difficult to measure in the long term.

The real threat and the existential threat

response and preparation has created the barriers to the resources that we need to persevere. The rationale for distancing from others is understood, but the order is not a temporary novelty, but an extreme measure to reduce chances for physical infections. This distancing has helped to slow the spread, but at a cost to our social welfare and emotional well-being. We are hearing concerning stories about dysfunctional and fragmented family systems that are now forced to function together without support. The elderly are isolated from family and friends. Kids have lost their bearings on their normally comforting academic-socialdevelopmental supports and structure. The future of many businesses and careers are unknown and on hold, indefinitely. There are currently five times more individuals applying for unemployment insurance than at the peak of the great recession. If that is not enough to wear down even the most resilient and optimistic of us, there is talk of the anticipated resurgence of this virus again next fall. The adaptations we’ve made to our normal lives has required us to find new strategies to cope with our new temporary normal: avoiding one terror only to face others.

While [we] previously had provided about 5% of visits using telehealth, that number is now closer to 80%.

Our daily lives have been disrupted by numerous events in the last several weeks, each one in itself enough to rattle an average resilient adult. It started with the recognition of the actual threat of COVID-19 in the United States that led to the state of emergency. Our global economy immediately plummeted in what is sure to be an enduring bear market. Then our means of daily entertainment—concerts, sports, socialization, and cultural events—were cancelled. We started talking about “social distancing” (a misnomer for what really means “physical distancing”) and slowing the spread. Soon after, schools closed with a government mandate to move to “distance learning,” a new concept for students, parents, and even teachers. Lastly, the Stay Home Minnesota executive order was announced, a formal effort to minimize transmission of the virus. The development of this pandemic’s storyline has created a societal situation today which few individuals and families prepared for, and our

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At the time of this writing, most Minnesotans have been greatly impacted by the threat of COVID-19, but not yet by the virus itself. Current projections from leading doctors and scientists show that nearly half of our state’s population will be infected, reaching its peak sometime between May and July. A majority of those infected will have mild symptoms, or even none at all, while a small portion will become severely ill. Hospitals are working intensively to coordinate efforts to add over 1,000 beds, procure elusive PPE, and at least 800 more ventilators for this inevitable “surge.” The Minnesota Department of Health has run numerous models in an attempt to understand what to expect in the near future, and the confidence interval is alarmingly wide. It seems that with each new day, we discover problems with yesterdays’ information. As Dr. Tony Fauci stated on March 25th, “you don’t make the timeline, the virus makes the timeline.”

Life after a global pandemic Many individuals and even businesses are going through the stages of grief, realizing that their past understanding of the world has changed. We have left our comfort zones and now need to face our fears, start to learn, and eventually enter the growth zone where we can rediscover ourselves, our businesses, and our lives. Whether moving through the stages of grief, or from the comfort zone to the growth zone, each person’s journey is unique. Some simple things that we can focus on to safely cope with these changes are: 1. Pay attention to nutrition, sleep habits, and staying active. Oftentimes when we’re overwhelmed with stress, our healthy habits and routines quickly fall by the wayside. This will impact our circadian rhythm and have negative physiological effects before we even realize it.

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2. Stay positive and give others the benefit of the doubt. When we convey positivity, our bodies and environments respond accordingly. You will be able to let go of stress, and those around Life in a global pandemic to page 254

3Life in a global pandemic from page 24 you will reciprocate. Helping others will give you a sense of agency when things seem out of control. 3. Focus on the things that you can control. In moments of big uncertainty and overwhelm, stop wasting energy on things you can’t control. It is empowering to focus on things you can control, like organizing a bookshelf, baking, building furniture, or going on a run at your own pace. 4. Practice radical self-acceptance. Accept everything about yourself, your current situation, and your life without question, blame, or pushback. You cannot fail at this—there is no roadmap, no precedent for this, and we are all truly doing the best we can in an impossible situation. Our current focus on public health is altruistic and admirable, and our compassion will be our guiding light. We will eventually see the pandemic subside and more patients move to convalescent care. While treatment and vaccines are developed, there will be a long and enduring aftermath of continued medical and economic proportions. Our economy will recover, as it always has, and as individuals and as a society we will need to plan for healing. The executive orders that have created such disruption in efforts to slow the spread, will have their own fallout that will need to be addressed. Students who moved to distance learning will have missed important life events such as concerts, prom, athletic tryouts, state tournaments, and walking at commencement ceremonies. Patients

who had to cancel or postpone elective procedures like mammograms, colonoscopies, skin cancer exams, and cataract surgeries are growing increasingly anxious. The procedures have simply been delayed, and otherwise preventable diseases will require inevitable treatments and cause mortality. The trauma and impact on mental health will be long lasting, and require specialized focus, care, and understanding. While measurements of those directly impacted by COVID-19 will be carefully tracked and reported, there will be an additional tenfold impact to our world that will go unmeasured and unreported.

A lesson from the past In 1948, C.S. Lewis wrote an essay about the fear of living in the atomic age. He poignantly describes the threats that humankind has endured over time, such as plagues, wars, motor accidents, diseases, and more. He ends by sharing an uplifting (if not ironic) perspective that the “novelty of our situation” has never changed. The comparison of this historical writing to our current situation should neither downplay the seriousness of COVID-19, nor be applied directly to the present. Rather, it is a reminder that we should not succumb to panic or allow fear to dominate our minds or paralyze our hearts. It is more important than ever to live and laugh, and to enjoy our time with the ones that we love. Begin to understand or even accept that this pandemic will change our lives, and we will emerge stronger, more compassionate, and wiser. Todd Archbold, LSW, MBA, is a licensed social worker and the chief executive officer at PrairieCare.

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ORTHOPAEDICS

Osteonecrosis of the femoral head Diagnosing and treating a rare condition BY PAUL HOOGERVORST, MD, AND EDWARD CHENG, MD

steonecrosis (also known as avascular necrosis, aseptic necrosis, ischemic necrosis, and atraumatic/non-traumatic necrosis) is characterized as a bone infarct with dead osteocytes due to numerous possible etiologies. While the exact pathophysiology is unknown, etiologic risk factors most often are corticosteroids, ethanol, trauma, and diseases such as lupus erythematosus (SLE) and sickle cell disease. The final common pathway most likely involves a compromised blood supply to the osteocyte with loss of normal bone remodeling. This often occurs adjacent to a joint surface, resulting in subchondral fracture with bony collapse and cartilage delamination leading to disabling osteoarthritis. Although any bone can be affected, the most frequently affected sites are the femoral head, proximal humerus, distal femur, proximal tibia, ankle, elbow, lunate (Kienbock’s disease), navicular (Köhler’s disease or Mueller Weiss syndrome) and metatarsals (Freiberg’s disease).

Epidemiology Osteonecrosis of the femoral head (ONFH) has an incidence of 10,000 to 30,000 new cases annually in the US. It is estimated that 5%–12% of all total

hip arthroplasties (THA) are performed because of ONFH. Although most hip arthroplasties are performed for degenerative joint disease in older individuals, osteonecrosis often affects younger adults, which is especially problematic as joint replacements at this age are not durable enough to last a lifetime.

Pathophysiology Traumatic ONFH can be a sequela of childhood disorders such as slipped capital femoral epiphysis, or secondary to events such as hip dislocation or displaced femoral neck fractures. Disruption of the arterial vasculature supplying the femoral head causes ischemia. Non-traumatic ONFH, however, is not secondary to a mechanical injury but instead related to various biologic insults that are not completely understood. Proposed explanations include intraosseous adipocyte hypertrophy compressing marrow microcirculation (steroids, ethanol), direct cellular toxicity (chemotherapy, radiation therapy, smoking), and coagulopathic states (pregnancy, sickle cell crises, thrombophilia, and hypofibrinolysis). Studies have clearly shown presence of an elevated intraosseous pressure, perhaps due to marrow fat hypertrophy or inflammatory response. Of the known factors associated with ONFH, glucocorticoids and alcohol exposure are the most common. Although several studies have shown a dose-dependent relationship between glucocorticoid exposure and osteonecrosis, a threshold dose for developing osteonecrosis is unknown. However, the relative risk for developing osteonecrosis is 4.5 times greater for every 10 mg increase in oral steroids for renal transplant patients and 1.3 times greater for every 20 mg increase in the non-transplant population. There is some evidence to show that even a short oral course of steroids for less than one week (methylprednisolone dose >300 mg) subjects individuals to a tenfold higher risk for having osteonecrosis. It is important to discuss this side effect with patients when prescribing these types of medications. Other risk factors for ONFH are sickle cell disease, SLE, acute lymphoblastic leukemia, Caisson disease, Gaucher’s disease, and HIV. However, in some patients it is idiopathic as a clearly identifiable risk factor is absent.

Symptoms Treatment outcomes are better when performed in the early stage of disease, yet this is difficult as most patients are asymptomatic at this time. Therefore, it is imperative to maintain a high level of suspicion in high-risk groups. Treatment is directed at preventing femoral head subchondral fracture and collapse, thereby preserving the native joint. Once subchondral fracture occurs, disabling osteoarthritis almost always ensues. Pain, of varying intensity, is the most common presenting symptom in ONFH. It is experienced in the groin, thigh, or buttock and may be related to weight bearing or activity. Approximately two-thirds of patients endorse pain at rest and one-third acknowledge night pain. Findings during physical examination are largely nonspecific. In later stages of disease, once a subchondral fracture develops, a limp may be present and exam findings are similar to any patient with end-stage arthritis. These commonly are a limited, painful range of motion, particularly during internal rotation and abduction.

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Imaging

CD is two-fold. First, it is thought to reduce the intraosseous pressure in the femoral head, thereby providing analgesia. Second, by opening As history and physical examination are not diagnostic, imaging studies are up the osteonecrotic lesion, the healing response may stimulate local essential. Magnetic resonance imaging (MRI) is the best study to detect or vascularity, thereby facilitating osteoprogenitor cell ingrowth. Despite this rule out osteonecrosis. Plain radiographs (XR) may demonstrate sclerotic theoretical benefit, many patients will progress to and cystic areas within the femoral head with develop a subchondral fracture. Therefore, many subchondral fracture, but often are normal. biological and mechanical adjuncts to CD have Once a subchondral fracture occurs, a thin been proposed and investigated. These range lucency beneath the joint surface is evident and from vascularized and non-vascularized bone this heralds the onset of later stages of disease. allografts and autografts, growth factors with The exact pathophysiology This so-called “crescent sign” is best visualized on bone morphogenic protein (BMP), and stem is unknown. the lateral frog leg hip view as the bony infarct is cell grafting harvested from either bone marrow usually in the anterior and superior segment of the aspiration or other sites. To achieve immediate femoral head. A single anterior-posterior (AP) hip structural support, porous tantalum rods and view is insufficient. polymethylmethacrylate cement (PMMA) Detecting a subchondral fracture is important augmentation have been trialed with meager for assessing disease stage and determining success. CD with or without augmentation by treatment and best imaged using computed tomography (CT). In one of the aforementioned options (except the vascularized bone allograft) symptomatic patients with known ONFH, if XR’s do not show the is a relatively safe and simple procedure and does not negatively influence subchondral fracture, CT should be obtained. Once collapse ensues, i.e., the technical aspect of performing a future total hip arthroplasty. compaction of the necrotic bone, the femoral head loses its spherical contour Any lesion with subchondral collapse or arthritis. Once collapse of the and does not rotate freely in the acetabular socket, causing irreversible femoral head has occurred, the potential benefit from CD is minimal and osteoarthritic changes. ONFH is bilateral in approximately 70% of patients, attempts at restoration of the native joint surface have not been successful. so imaging of the contralateral side should be obtained. Besides detection, MR imaging provides additional information for staging and prognosis such as quantifying the extent of the osteonecrotic lesion and evaluating treatment efficacy.

Classifications There have been many classification systems for osteonecrosis, however, the most important prognostic variables predicting a poorer outcome are the presence of a subchondral fracture, a larger size (extent of disease), and the location of the necrotic bone in the weight bearing, lateral portion of the femoral head where the mechanical compressive forces are highest. The most widely used classification systems, such as the Association Research Circulation Osseous (ARCO) system, include these variables.

Osteonecrosis of the femoral head to page 344

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Treatment strategies There is no known treatment that is universally effective in either controlling or curing this disease. Larger lesions tend to have poorer prognosis and warrant treatment. Small osteonecrotic lesions. In symptomatic patients with small osteonecrotic lesions, the large majority will remain pain free for many years and intervention may be deferred. If patients with small lesions have pain, alternative pathologies should be considered. Non-operative management, such as pain control and adaptations in weightbearing, are ineffective. Larger osteonecrotic lesions without subchondral fracture. The goal of surgical treatment in the early stages of ONFH is the prevention of subchondral fracture and subsequent collapse. This is attempted by pursuing biological pathways that reconstitute the bone architecture in the lesion or by offering immediate structural support.

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The most commonly employed treatment for pre-collapse disease is core decompression (CD). The evidence for pain reduction is stronger than for preventing a subchondral fracture. The theoretical benefit of MINNESOTA PHYSICIAN APRIL 2020

FINANCIAL PLANNING

Investment strategies Assessing a volatile marketplace BY KATHERINE VESSENES, JD, CFP

Takeaways:

hysicians on the front line of the COVID-19 war are faced with unprecedented stress, both on the job and with their personal finances. Many are working long hours, constantly exposed to a deadly pathogen. Others are furloughed, or working from home while home-schooling their children, all on a reduced paycheck. Life for a physician has never been more stressful.

• The best market days are not only unpredictable, they are concentrated in a few days.

It is easy, during tough economic times, for doctors to let their emotions take over and make costly financial decisions. Here are some examples of common investment mistakes, and reasons doctors should avoid them.

Timing the market The stock market’s sizzle is seductive, but timing the market doesn’t work. An S&P/Lord Abbett study looked at investing $10,000 on Jan. 1, 1994, and holding it until Dec. 31, 2019. The doctor who held his investment for this entire period saw his initial investment grow to $112,840, but the doctor who missed the 20 best days of the market made only $35,000—69% less than the doctor who stayed the course.

• Missing the best days dramatically reduces your returns. • When you time the market, you have to be right twice: when to get out and when to get in.

Buying depressed companies Some doctors might be tempted to buy depressed companies that may benefit from government bailouts, but look at history. Under TARP, Citigroup and AIG both received multibillion dollar bailouts. Unfortunately, Uncle Sam’s largesse did not improve their financial future. We looked at both of these companies and compared them to an Exchange Traded Fund that mimicked the S&P 500, from the period of December 2004 through the end of 2019. A hypothetical $10,000 investment in Citigroup, AIG, and the S&P was up slightly before the 2008 crash, but by 2009, all three investments had fallen. Both Citigroup and AIG never fully recovered. By Jan. 1, 2020, that $10,000 Citigroup investment was worth only $2,148. AIG did much worse. By Jan. 1, 2020, $10,000 of AIG was worth a paltry $548. By contrast, a $10,000 investment in an S&P exchange traded fund grew to more than $36,000. This is not the time to pick an individual stock and trust that it will bounce back after bailouts. Takeaways: • A broad basket of investments reduces risk. • Stock picking is a lot more difficult than it looks.

Stop investing, sell out, and sit in cash Consider the example from 2012 of a physician couple who owned their own primary care practice. At the beginning of 2008, they had started a 401k for themselves and for their employees. Six months later, their investments were down and they had liquidated their accounts, lost 50%, and vowed never to invest again. Unfortunately, if they had stayed the course, and continued with their investments, they would have doubled their money. A trustworthy advisor could have given them better advice and help calm their fears.

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Imagine three hypothetical investors—Dr. Blue, Dr. Navy, and Dr. Green—who each have $100,000 invested in the U.S. stock market on Jan. 1, 2007. Their accounts all go up, and then are immediately devastated by the crash of 2008. Dr. Green freaks out, sells everything, and stays in cash for the rest of the period. By Jan. 1, 2020, she still has a loss of over 40%; she is down to $57,320. Unfortunately, her investment didn’t keep up with inflation, either. She not only lost hard dollars, but also purchasing power, a double whammy. Dr. Navy also freaks out, sells all of his investments, and sits in cash for a year. He then gets back in the market and participates in part of the

historic runup. By Jan. 1, 2020, he has almost doubled his money. He is up to $195,315. Dr. Blue ignores the dismal daily news reports and stays put. She holds on to her existing investments and avoids looking at the news every day. By Jan. 1, 2020, her $100,000 investment has tripled, and is now worth $299,780; $100,000 more than the doctor who sat in cash for a year. Takeaways: • Your losses are just on paper until you actually sell. • It pays to stay put.

mutual funds fluctuates. By spreading the purchases out, they have the chance of buying more shares in some months because the price is down. This reduces volatility and allows the investor to reduce the overall purchase cost. One simulation compared investing this lump sum of $120,000 to 12 monthly investments of $10,000, assuming that the starting and the ending price of our mutual fund was $50 per share. However, during the year, the price fluctuated each month between a low of $40/share to a high of $65/share.

The same folks who invented the roller coaster, also invented the stock market.

Discontinuing DCA Investments

Let’s say you want to invest $120,000—the proceeds of a property sale, for example—in one lump sum. You may have concerns about the market and don’t want to invest it all at the “high” point. Consider taking $10,000 and investing it monthly over a year instead. There are many advantages to this approach. It takes the “guess work” out of timing the market and reduces the tension of trying to pick the perfect stock at the perfect time and then selling at the perfect time. In any year, the price of

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Most doctor/investors understand that the time you want to maintain your investment strategy, or even increase your investments, is during a down market, when your investments are “on sale.” A bad strategy would be to stop your investments during market down turns, because you miss the chance to buy a lot more shares when the prices are depressed. Does this technique “always” work? As long as you are a long-term investor in a properly diversified portfolio, this should be a good strategy for you, because we know that the market, over time, is always up. Investment strategies to page 304

Telephone Equipment Distribution (TED) Program

Dollar Cost Averaging (DCA) is an investment strategy that entails taking a fixed amount and investing systematically, usually on a monthly basis. We use very low-cost mutual funds that don’t have any sales charges.

At the end of the year, the lump sum was worth exactly the same, because the share price was the same, but Dr. Dollar Cost Average had a much better return. In my hypothetical: $181,157 v. $120,000.

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3Investment strategiesy from page 29 Because you can never predict the market, consider the DCA approach, which reduces volatility and anxiety.

There are some situations under which this approach may not work: • One would be if you are stock picking. The reason is a stock, unlike a mutual fund, can go to zero, meaning you could lose your entire investment. In that case, it doesn’t matter if you invest in a lump sum or use a DCA technique, you can still lose all your money.

Takeaways: • Keep investing on a monthly basis. Put any spare cash into the market. • If you have been trying to time the market, use DCA instead to even out the ups and the downs of your investments, potentially increase returns, and reduce your trauma.

It’s tempting to buy

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We market Systems are likely to be Digital way downCopier/Network for the rest of the year, Printer/Scanner and that will impact their One other consideration: if you We believe the market is going straightPrinter/Scanner market Digital Copier/Network Printer/Scanner Systems WeWe market Digital Copier/Network Systems We market market Digital We Digital market Copier/Network Copier/Network Digital Copier/Network Printer/Scanner Printer/Scanner Printer/Scanner Systems Systems Systems Throughout Upper Midwest, across America. over North time. up, as it did during most of 2019, then the you should invest your entireand salaries & Wide-Format Printers to savvy business owners && Wide-Format Printers toto savvy business aser ave ommunications & Wide-Format Printers to savvy business owners & Wide-Format Wide-Format Printers Printers to savvy to Printers savvy business business savvy owners business ownersowners owners lump sum at the beginning of& theWide-Format period because your investments will be 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main Investment strategies to North page 32America. 4 Throughout theNorth Upper Midwest, and across priced the cheapest. Throughout Throughout the Upper Midwest, and across America. Providers of Midwest, Business Communication Solutions – America. www.laserwave.net Throughout thethe Upper Midwest, and across North America. Throughout Throughout the Upper Upper Midwest, the Midwest, Upper and and across across North and North across America. North America.

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APRIL 2020 MINNESOTA PHYSICIAN

YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.

Family Medicine & Emergency Medicine Physicians • • • • •

For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com

Helping physicians communicate with physicians for over 30 years. MINNESOTA

AUGUST 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: •

Exploring new potential BY MICK HANNAFIN

ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

•

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

•

Share new diagnostic and therapeutic advances Develop and enhance referral networks Recruit a new physician associate

Advertise! IN MINNESOTA PHYSICIAN www.mppub.com

SICIAN

(612) 728-8600

Great Opportunities

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

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

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 2020

3Investment strategies from page 30 After the 2008 crash, real estate values took a long time to recover. If history repeats itself, that $1.5 million dream house is likely to be worth only $900,000 in a few months. The swim spa may cost $150,000 now, but if your contractor is desperate for work, he might charge only $85,000 at the end of the summer.

the daily investment news. Negative market news, as opposed to positive market news, earns the media more eyeballs and more advertising dollars. Think of this as entertainment, not advice. Takeaways: • Any changes today in your investments are likely to be meaningless over the long run. • Taking the long view in your investment reduces worries, something we could all use during difficult times.

Takeaways: • Even doctors can have pay cuts.

Conclusion

• Don’t be in a hurry. There can be great deals in a down market.

Not thinking like a long-term investor Now is the time to be thinking like a long-term investor. Even the 65-yearold doctor needs to be thinking long-term. We run our retirement plans to at least age 95. So, at 65, you will need your investments to last 30 more years. Any blips in the market today will only have the most minor impact on your finances 20 or 30 years from today. Think about your house. Some days the value of your home is up 5%, and other days it might be down 10%. But at no time are you likely to say to yourself: “My home is up 5%, I should sell now.” You are likely to be in your home for many more years and the value today is immaterial to what it will be when you decide to sell. You can take this long-term view with your home because, unlike the daily stock reports, you are not constantly bombarded with information about its value. Take the same approach with all of your finances, and don’t get caught up in

One pundit said recently, “The same folks who invented the roller coaster, also invented the stock market.” The people who stand up on the roller coaster, or get off before the ride ends, are the ones who get hurt. You have enough stress in your life during good times. Today when you are short on PPE, home-schooling your kids, and exposed to a deadly virus on a daily basis, stay calm and avoid making these mistakes about your finances. In a few years, you will be glad you did. Katherine Vessenes, JD, CFP, is the founder and CEO of Minnesota-based MD Financial Advisors, who serve over 500 doctors from Hawaii to Cape Cod. An award-winning Financial Advisor, Attorney, Certified Financial Planner, author, and speaker, she is passionate about bringing ethical investment advice to physicians. She can be reached at Katherine@mdfinancialadvisors.com.

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist

Ely VA Clinic

Hibbing VA Clinic

• Tele-ICU (Las Vegas, NV)

Current opportunities include:

• Nephrologist

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

APRIL 2020 MINNESOTA PHYSICIAN

•

www.minneapolis.va.gov

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

SHARE YOUR INSPIRATION. POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic)

On the U.S. Army health care team, you will enjoy the satisfaction of providing quality care to Soldiers and their families, in a setting with innovative technologies, robust resources and a dedicated, supportive team.

• 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

Learn more at healthcare.goarmy.com/nz72

Carris Health

is the perfect match

Carris Health is a multi-specialty health network located in west central and southwest Minnesota and 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: • • • • • •

Anesthesiology Dermatology ENT Family Medicine Gastroenterology General Surgery

• • • • • •

Hospitalist Internal Medicine Nephrology Neurology OB/GYN Oncology

• • • •

Orthopedic Surgery Psychiatry Psychology Pulmonary/ Critical Care • Rheumatology • Urology

Loan repayment assistance available.

FOR MORE INFORMATION: Dr. Leah Schammel, Carris Health Physician

Shana Zahrbock, Physician Recruitment Shana.Zahrbock@carrishealth.com (320) 231-6353 | carrishealth.com

MINNESOTA PHYSICIAN APRIL 2020

3Osteonecrosis of the femoral head from page 27 As such, treatment strategies universally are centered upon either prosthetic replacement of the joint or repositioning a healthier portion of the femoral head into the weight-bearing zone through osteotomies. As the functional result of hip arthroplasty is superior to any osteotomy procedure, most surgeons advise hip arthroplasty, in all but the youngest patients, once irreversible arthritis develops.

Summary and advice Osteonecrosis of the femoral head is a relatively rare condition that must be considered when a patient presents with pain in the hip or groin region and negative plain radiographs. A focused history on the presence of known risk factors, such as past corticosteroid use, alcohol abuse, or other high-risk conditions should raise the suspicion of possible osteonecrosis. MRI, in addition to radiographs, is necessary to rule out this disease. Furthermore, early diagnosis is imperative as it is associated with a better outcome. Paul Hoogervorst, MD, and Edward Cheng, MD, are orthopedic surgeons affiliated with the M Health Fairview University of Minnesota Medical Center. Dr. Cheng (Mairs Family Professor) is the current president of the Association Research Circulation Osseous (ARCO), a worldwide organization devoted to research in the field of bone circulation and its disorders, in particular of osteonecrosis.

Imaging studies of the same patient with right hip pain and no symptoms on the left. Top left: an AP view of the pelvis depicting no abnormalities. Top right: a frog leg view of the right hip depicting a possible antero-superior subchondral fracture with loss of sphericity of the femoral head. Bottom left is a CT image confirming the presence of subchondral fracture and femoral head collapse. Bottom right shows osteonecrosis (white arrows) which is often present on the contralateral side, even with negative radiographs.

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 2020 MINNESOTA PHYSICIAN

PAT I E N T C A R E QUALITY OUTCOMES

FOCUS ON WHAT MATTERS MOST WITH COVERYS. Quality outcomes for better patient care are more easily achieved when distractions are reduced. At Coverys, we illuminate unforeseen risks so you can focus on patient satisfaction and reduce exposure to malpractice claims. As a premier provider of medical liability insurance, Coverys’ data insights and risk recommendations will help you provide optimal healthcare outcomes that you can see clearly. Very clearly. Visit Coverys.com for more information or call 800.225.6168.

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MINNESOTA PHYSICIAN APRIL 2020

Sofia Lyford-Pike, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

mphysicians.org

Minnesota Physician • April 2020

Articles inside

INTERVIEW

ORTHOPAEDICS Osteonecrosis of the femoral head

EPIDEMIOLOGY Life in a global pandemic