MINNESOTA
MAY 2018
PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 02
Is bigger better? Do’s and don’ts of consolidation BY JAMES A. RICE, PHD, FACHE
F
or the past 20 years, across the U.S. and Minnesota, there has been a continuing escalation in the consolidation of physician practices, hospitals, and health insurers. The numbers of licensed facilities are expected to continue to decline from consolidations and closures (for an overview of current statistics here in Minnesota, see the Minnesota Department of Health’s 2017 directory of all licensed facilities at https://tinyurl.com/mdh-2017-dir). Bigger has been assumed to be better. But are we reaching a point of diminishing returns? How can we ensure that this accumulation of economic and technological resources yields optimal value to the people who live and work in Minnesota? How can local physicians work with their local board and administrative colleagues to secure the benefits of larger scale short of a complete merger?
Mast cell mastery Our new clinical challenge
This article explores the case and the cautions for future consolidation, as well as actions key players can take to help ensure that each consolidation delivers on its promise of value.
Consolidation to page 144
BY GREGORY A. PLOTNIKOFF, MD, MTS, FACP, AND KATHLEEN HOPKINS, DO
M
ast cells have been best known for their role in IgE-mediated allergic reactions. Many physicians have generally considered them less important than eosinophils and about as clinically interesting as basophils. But no longer. New insights require the attention of all physicians. Mast cells are multifunctional immune cells active in multiple non-allergy disease states (Table 1). Primary care and subspecialty physicians need to understand, recognize, and treat mast cells. Mast cells are understood as sentinels and first responders with the capacity to secrete pre-formed and/or de novo-synthesized mediators. These include proteases and Mast cell mastery to page 104
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MAY 2018 MINNESOTA PHYSICIAN
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CONSOLIDATION IN HEALTH CARE
Volume XXXI1, Number 2
COVER FEATURES Mast cell mastery Our new clinical challenge
Consolidation Earning value for money?
By Gregory A. Plotnikoff, MD, MTS, FACP, and Kathleen Hopkins, DO
By James A. Rice, PhD, FACHE
Examining cost and quality issues
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
8
Ensuring care in an evolving market
Lawrence (Larry) Lee, MD, FACP, MBA UCare
RESEARCH Cancer clinical trials
16
New U of M network to expand Minnesota access By Douglas Yee, MD
BEHAVIORAL HEALTH 22 Gender-specific substance use disorder care
Thursday, November 1, 2018, 1-4 pm The Gallery, Downtown Minneapolis Hilton and Towers 1101 Marquette Avenue South
Why it matters By Karina Forrest-Perkins, MHR, LADC
PHARMACY 24 Minnesota Prescription Monitoring Program
BACKGROUND AND FOCUS:
Controlled substance insight alerts By Katrina Howard, PharmD
Consolidation in health care threatens the viability of the system
BEHAVIORAL HEALTH 26 Understanding the opioid epidemic in Minnesota
er choices, both in terms of which doctor to see and in terms of
Increases in deaths and disparities By Kate S. Erickson, MSW
and is escalating at an alarming pace. Patients are left with fewtreatment options, including medications, from the doctor they do see. Costs are often increased and quality often decreases when systems become too large. Demands to comply with increasing regulations leave many medical practices in a bind. How can they maintain independence without the infrastructure of a large system?
SPECIAL FOCUS: CARE TEAMS Network growth spurs team integration 18 Ensuring effective, efficient care
OBJECTIVES:
By Jennifer Welsh, MD, and Karen Mulder, RN
We will examine the root causes of health care consolidation. We
Certified community behavioral health clinics 20
will illustrate what has worked and what has not. We will explore
Benefits to patients, physicians, and communities
cases where FTC regulations are pushed to the limits and the
By Pahoua Yang, MSSW, PhD, LP, LICSW, and Claire Wilson
threat to patients this poses. We will look at the larger continuum of care and how public health issues are impacted by consolidation. We will discuss state legislative initiatives that need to be in place and what must be done to keep patient well-being at the center of health care delivery.
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CAPSULES
New State Opioid Prescribing Guidelines Released Gov. Mark Dayton has released new state guidelines to reduce the risk of opioid addiction in Minnesota by helping doctors and health care providers decide when to prescribe opioids, how much to prescribe, and how to monitor their use. The guidelines were developed by the Opioid Prescribing Work Group, which consisted of health care providers, pharmacists, consumer and law enforcement representatives, and state agency staff. They were previously released in draft form in December 2017. The guidelines address opioid prescribing for immediate pain relief, as well as short- and long-term uses, and there is especially strong guidance for several weeks following an injury or surgery, which is a critical time to prevent long-term opioid use. The full guidelines are available through the Minnesota Department of Human Services website.
Minnesota officials are encouraging all providers in the state to adopt the new guidelines. Providers whose prescribing is found to be excessive, and who participate in Medical Assistance and MinnesotaCare programs, will be required to participate in a quality improvement program to help them meet the new prescribing standards. Dayton also announced $700,000 in new opioid prevention grants that will fund local teams in eight Greater Minnesota communities to address opioid abuse. The recipients each received $75,000 or $100,000 grants—Alexandria Clinic, a Service of Douglas County Hospital; Carris Health Redwood Falls Clinic; Chippewa County Montevideo Hospital; Fairview Mesaba Clinics–Hibbing, Nashwauk, and Mountain Iron; FirstLight Health System–Mora, Pine City, and Hinckley; Lake Region Healthcare, Fergus Falls; Mille Lacs Band of Ojibwe; and Riverwood Healthcare Center–Aitkin, Garrison, and McGregor. The funds will support controlled substance
care teams consisting of pharmacists, physicians, social workers, nurse care coordinators, mental health professionals, and others to implement tested strategies to reduce opioid abuse.
Negative Online Physician Reviews Differ From Patient Surveys Research from Mayo Clinic has shown that physicians who receive negative reviews online do not receive similar responses in rigorous patient satisfaction surveys. And compared with colleagues who do not receive negative online reviews, they score lower on factors that go beyond patient interactions and some that are beyond their immediate control. “Our study highlights the disconnection between industryvetted patient satisfaction scores and online review comments,” said Sandhya Pruthi, MD, an internal medicine physician at Mayo Clinic and senior author of the study. “Patients need to be aware of these
distinctions as they make decisions about their health. Physicians also need to be aware, as they manage their online reputations.” One in six physicians have been rated online. This is the first study to compare data of physicians who had negative online reviews and those who did not. In a pilot between September and December 2014, researchers used Google searches and alerts to track negative online reviews of physicians at Mayo Clinic’s Rochester campus. Of 2,148 physicians, 113 received negative online reviews. The physicians represented 28 departments and divisions. The researchers then compared these physicians’ scores in a formal patient satisfaction survey with the scores of other Mayo Clinic physicians in similar fields who had no negative online reviews. They found no statistical differences in the overall scores, or in the scores for patient communication and interaction. The results also showed that the group with negative reviews scored
Providing (and Protecting) High Quality, Cost-Effective Patient Care The Minnesota Ambulatory Surgery Center Association (MNASCA) is a statewide, non-profit trade association OUR MISSION MNASCA is dedicated to promoting quality, value-driven outpatient surgical care. We are committed to ensuring that surgery centers continue to thrive as a distinct model for the delivery of safe, affordable and advanced surgical services to Minnesota’s health care consumers. OUR MEMBERS Our 42 certified member ASCs provide a full range of surgical services. MNASCA supports members through advocacy, outreach, communication, and supporting legislation that lowers the cost of care and increases the quality of health care outcomes. OUR MEMBERSHIP MNASCA offers a variety of membership levels, including individual/nurse membership, associate membership (for our non-ASC supporters), and full facility membership.
Join us for our Annual Conference (venue pending) Thursday, October 11 & Friday, October 12, 2018 Additional details will be posted at www.mnasca.org 4
MAY 2018 MINNESOTA PHYSICIAN
For questions about MNASCA, our annual conference, or memberships, please contact Rachel Stuckey at rstuckey@messerlikramer.com.
CAPSULES
much lower on factors beyond patient interaction, including variables such as interaction with front desk staff, nursing, physical environment, appointment access, waiting time, problem resolution, billing, and parking. The data did not indicate the specific instances or patient experiences that led to the negative reviews. The researchers note the study’s limitations, including that physician groups were small, the time period to collect data was limited, they only used one search engine, and the online reviews reflected single experiences of patients. Full results of the study were published in Mayo Clinic Proceedings.
Redwood Area Hospital to Join Carris Health Redwood Area Hospital and the city of Redwood Falls have taken the initial steps toward joining the new regional health system, Carris Health, a subsidiary of CentraCare Health. The hospital and city have spent the past four months considering a potential partnership with Carris Health, a health care delivery model that was formed by Rice Memorial Hospital, ACMC, and CentraCare Health in January. The work was led by a steering committee with representatives from the hospital, hospital commission, local physicians, city council, Carris Health, and CentraCare Health. The city council voted April 17 to create a letter of intent to move forward with the merger. The final agreements will be outlined for approval in June, with an anticipated closing date of Dec. 31. The letter of intent outlines a transfer of ownership to Carris Health with the health system committing to invest $60 million over the next 10 years, including a new health campus that will bring the hospital and Redwood Falls clinic to one location. The hospital and clinic also plan to transition to the same electronic medical record system to better coordinate care. Planning for the new health campus will continue into the second half of 2018. It also outlines strong financial stability for taxpayers with a payment
SINCE 1894 tradition of caring in lieu of taxes for an additional 10 enrichingLIFE SINCE 1894 years and opportunity for additional buildingCOMMUNITY feel atHOME payments based on hospital perforThe mance. Carris Health will make lease STRENGTHEN enrichingLIFE Transitional payments for the current hospital building over the next two years that HEART ENGAGE buildingCOMMUNITY SINCE 1894buildingCOMMUNI will offset costs for disposition of the tradition of CARING HEART building upon completion of the new atHOME health campus. enrichingLIFE feelatCenter
CARE
“In a highly volatile healthcare industry, risk and instability of healthcare finance will no longer fall on taxpayers, and the community can feel confident about the future availability of high quality healthcare through the significant financial investment CentraCare and Carris Health will make in our community,” said Keith Muetzel, Redwood Falls city administrator. “The Redwood Falls City Council has also considered the importance of local governance and feels confident that a high degree of local control over the hospital operations still exists through this transition.”
buildingCOMMUNITY
HOME SINCE 1894
buildingCOMMUNIT
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STRENGTHEN enrichingLIFE refreshfeel atHOME
U of M Launching Cancer Clinical Trials Network
Physical • Occupational • Speech • Aquatic Therapy
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Patients throughout the state will soon have better access to new cancer treatments through clinical trials with a new state-funded partnership led by the University of Minnesota. The University is launching the Minnesota Clinical Cancer Trials Network (MNCCTN) as part of the Minnesota Discovery, Research, and InnoVation Economy (MnDRIVE) partnership with the State of Minnesota. The goal of the partnership is to improve prevention, treatment, and survivorship through greater access to cancer clinical trials. These trials will originate from Minnesota’s two National Cancer Institute-designated Comprehensive Cancer Centers—the Masonic Cancer Center and Mayo Clinic Cancer Center, along with The Hormel Institute in Austin. It will include multiple locations across the state. The MNCCTN is a collaboration between the Masonic Cancer Center, Essentia Health Community Oncology Research Program; Fairview Health Services; The Hormel Institute; Mayo Clinic Cancer Center; Metro-Minnesota Community
SINCE 1894buildingCOMMU
tradition of CARING
HEART
Care For: SINCE 1894Specialized enrichingLIFE
Stroke Rehab • Orthopedics HEART caring Cardiac • Pulmonary Conditions buildingCOMMUNITY
HOME refresh enrichingLIFE buildingCOMMUNITY enrichingLIFE Neurological • Comorbid Conditions HEARTCare • Specialized IV Skill Set Wound
SINCE 1894 building COMMUNITY feel atHOME SINCE 1894 YOUR BRIDGE BETWEEN BETWEEN feel atHOME refresh engaging HOSPITAL & HOME buildingCOMMUNITY tradition of caringenrichingLIFE
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MINNESOTA PHYSICIAN MAY 2018
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CAPSULES
Oncology Research Consortium; and Sanford Community Oncology Program of the North Central Plains. There will be 18 new locations across the state that will participate in MNCCTN cancer clinical trials in the first year of the program. Additional sites across the state will be added in subsequent years. The first 18 locations are Aitkin, Albert Lea, Austin, Cambridge, Deer River, Detroit Lakes, Fosston, Grand Rapids, Hastings, Hibbing, Mankato, Monticello, Park Rapids, Princeton, Thief River Falls, Virginia, and Worthington. Hibbing will host two locations, one through Fairview and one through Essentia Health. “Early cancer screening and world-class care saved my life,” said Gov. Mark Dayton. “The $8 million in new MnDRIVE funding secured last session will help ensure greater access to new cancer treatments and enhanced care for patients across Minnesota.” Nearly half of all Minnesotans will be diagnosed with potentially
life-threatening cancer in their lifetime, and current access to clinical trials is difficult for many— 56 percent of residents live more than 30 miles from a hospital or clinic that offers access to these trials. The partnership will help increase access to clinical trials in Greater Minnesota, which will create more equitable access to care and could improve cancer outcomes statewide.
Law Enforcement, Health Care Communities Create Roadmap To Enhance Safety Minnesota’s law enforcement community and health care providers have created a statewide roadmap for improving collaboration and communication when caring for individuals who need health care while involved with law enforcement. The Health Care and Law Enforcement Coalition launched in August 2016 by the Minnesota Department of Health, Minnesota Hospital
Association, and Minnesota Sheriff ’s Association to improve communication and better protect patients, law enforcement, and health care staff. The coalition includes hospitals, health systems, police departments, county sheriff offices, hospital emergency medical services, and government agencies. “Protecting the health and safety of Minnesotans is a core component of the Department of Health’s mission,” said Jan Malcolm, Minnesota commissioner of health. “We applaud this coalition for its dedication and excellent work designing strategies for improved communication and enhanced patient and staff protections.” The coalition’s new road map incudes a collection of best practices and tools for health care and law enforcement stakeholders that includes sample policies, procedures, court orders, and other resources. It is designed to help law enforcement and care providers safely provide care. It clarifies roles and responsibilities in
situations such as when an incarcerated person is brought to a hospital by law enforcement for evaluation or treatment; when health care staff call law enforcement personnel for assistance; or other instances where the professions collaborate to care for patients in health care settings. The roadmap also provides guidance on how a hospital or health system and local law enforcement partners can meet regularly to develop working relationships, make security and communications plans, and prepare for potentially urgent or emergency situations. “Through this coalition, we have all developed a better understanding of and response to situations when health care and law enforcement come together,” said Rahul Koranne, MD, MBA, chief medical officer of the Minnesota Hospital Association.
Contact DMS Health: 800.437.4628 sales@dmshealth.com www.dmshealth.com
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MAY 2018 MINNESOTA PHYSICIAN
Osmo Vänskä
Augustin Hadelich
Daniel Müller-Schott
Carolyn Sampson
The New Standards
Pierre Noel, MD, has been named medical director of Mayo Clinic’s newly formed Center for Military Medicine. Noel is an internal medicine physician and a professor of medicine within Mayo Clinic College of Medicine and Science. He also serves as a primary consultant in protective medicine for the White House Medical Unit and a senior visiting fellow at the Brent Scowcroft Center for Strategy and Security. He has held leadership positions at the National Institutes of Health, including acting director of security and emergency response, and at the U.S. Department of Health and Human Services. In 2012, Noel developed a Special Operations Tactical Medicine Training Program at Mayo Clinic for military Special Mission Units, which specializes in combat trauma, prolonged field care, and critical care. The program has trained more than 600 physicians, physician assistants, medics, and troops, and is recognized in the Special Operations community as one of the best tactical emergency and critical care programs. Noel earned his medical degree at the University of Sherbrooke in the Province of Quebec in Canada.
Andrew Litton
Dawn Martin, MD, a pediatrician at Hennepin Healthcare, has been named a 2018 CDC Childhood Immunization Champion for her dedication to promoting childhood immunization in Minnesota. Martin has been with Hennepin Healthcare (formerly Hennepin County Medical Center) since 1994. During her career, she has worked locally and globally to care for patients with vaccine-preventable diseases. She played a pivotal role in Hennepin Healthcare’s response to the 2017 measles outbreak in Minnesota, working closely with clinic staff to guide response planning and contact hundreds of families with children in need of an MMR vaccine. Martin also serves as co-chair of Hennepin Healthcare’s vaccine committee. Outside of her work at Hennepin Healthcare, she serves as chair of the Minnesota Chapter of the Academy of Pediatrics Immunization Workgroup; a member of the Minnesota Department of Health’s Minnesota Immunization Practices Advisory Committee; and a board member for the Minnesota Childhood Immunization Coalition. She is also the assistant program director for primary care at the University of Minnesota Pediatric Residency Training Program. She earned her medical degree at the University of Wisconsin–Madison.
Minnesota Chorale
MEDICUS
Andrew Litton and the Minnesota Chorale
Bernstein and Walton Fri Jun 1 & Sat Jun 2 8pm Andrew Litton, conductor / Christopher Maltman, baritone / Minnesota Chorale
Chamber Music
Mendelssohn and Dvořák Sun Jun 3 2pm
Minnesota Orchestra Musicians
Beethoven and Berlioz Fri Jun 8 & Sat Jun 9 8pm
Rick Hilger, MD, SFHM, chief of staff and medical director at Regions Hospital, has received the Award of Clinical Excellence for Physicians from the Society of Hospital Medicine. Hilger has been a hospitalist with HealthPartners Regions Hospital for 16 years. During that time, he created one of the first hospital medicine resident pathways, which was a joint venture between HealthPartners and the University of Minnesota; was one of the first hospitalists asked to participate on a National Quality Forum committee; and has helped improve hospital reimbursements by more than $4 million by driving physician coding compliance to nearly 100 percent. More recently, Hilger worked on developing an internal University of Minnesota physician advisor program, the Hospital Medicine Pathway for Residents, which has improved Regions Hospital’s budget by $10 million. He earned his medical degree at Creighton University School of Medicine.
Jun Märkl, conductor / Augustin Hadelich, violin
Season Finale: Vänskä Conducts Mahler’s Fourth Thu Jun 14 11am / Fri Jun 15 & Jun 16 8pm Osmo Vänskä, conductor / Carolyn Sampson, soprano
SCORE! with The New Standards Fri Jun 29 8pm
Chan Poling, piano and vocals / John Munson, bass and vocals Steve Roehm, vibraphone Please note: The Minnesota Orchestra does not perform on this program.
612-371-5656 / Orchestra Hall minnesotaorchestra.org Photo credits available online.
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MINNESOTA PHYSICIAN MAY 2018
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INTERVIEW
Ensuring care in an evolving market Lawrence (Larry) Lee, MD, FACP, MBA UCare Please tell us about your work at UCare.
As chief medical officer, I am UCare’s senior executive responsible for clinical strategy and operations. Fundamentally, UCare packages health service benefits into “products” that allow our members to access care from our contracted providers. I oversee the departments and teams that ensure the quality and appropriateness of the care our members receive within their products. I also lead UCare’s functions that interact directly with our members to improve their health. Those functions include care coordination, complex case management, and population-oriented programs to identify members with health risks and guide them to appropriate care.
ultimately become part of standard of care. Benefit contracts and regulations for health insurance usually restrict coverage to medical services that are considered standard of care and not experimental. There is not a simple “bright line” criterion that specifies when a medical innovation transitions from experimental to standard of care. Health plans give a lot of weight to clinical practice guidelines
Procedural codes enable accurate and specific description of health care services for purposes of documentation, analysis, and payment. Just because a procedure has had a code assigned to it does not necessarily mean that the procedure should be considered standard of care or that it would be paid by a particular health plan. Furthermore, the codesetting process does not specify levels of payment. When a new code enters the system, it may be years before that code gains sufficient real-world usage to calibrate a Relative Value Unit (RVU) or other normative payment level.
Please tell us about your prior work with Blue Cross and Blue Shield of Minnesota, the VA, UnitedHealthcare, and HealthPartners, and how it applies to your work at UCare.
Advances in medical science occur faster than health care delivery systems can integrate them into best practice standards, and faster than payers can develop reimbursement codes. What can you tell us about this?
Two phenomena at play here. First is the adoption of medical innovations—procedures, devices, diagnostic tests, and pharmaceuticals— into medical practice, where that innovation might
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MAY 2018 MINNESOTA PHYSICIAN
Please tell us about your work to manage opioid-addicted patients and your partnership with HCMC’s emergency department.
“...” We are exploring partnerships to improve social determinants of health in the community.
“...”
Minnesota is a microcosm of the United States when it comes to health care delivery and financing. Minnesota-based health plans serve all market segments: employer-financed (including huge multi-state employers), fully insured commercial (group and individual), and public managed care programs (Medicare and Medicaid). Minnesota plans include network-based models, a payercombined-with-provider model, and a variety of collaboratives and joint ventures between payers and providers. As a health plan executive, I’ve had the privilege of working in these different models. As an internal medicine physician, I’ve also practiced in different provider organizational models. These experiences led me to appreciate the dynamism and innovative spirit of health care here in Minnesota. I try to bring that perspective and history to the myriad professional and business interactions that I conduct for UCare internally and externally.
Current Procedural Terminology (CPT) codes, which is the same as Level I HCPCS codes, is conducted by the CPT Editorial Panel and its advisory committees, which are a joint effort of the American Medical Association, national medical specialty societies, representatives from the health insurance industry, the American Hospital Association, and CMS.
from authoritative national sources, where there is extensive, formal vetting by recognized clinical experts. The Guidelines from the National Comprehensive Cancer Network (NCCN) is a great example of that—one that many health plans, including UCare, use as the primary information source in making necessity determinations for newer technologies in cancer care. The other phenomenon, separate but related, is the designation of a code that is specific to that medical service for purposes of documentation, analysis, and payment. The formal process for assigning new codes is elaborate and timeconsuming. The process for Healthcare Common Procedure Coding System (HCPCS) codes is conducted by the Centers for Medicare & Medicaid Services (CMS). The process for
UCare and its peer health plans have a role to play in addressing the opioid epidemic. We work with our pharmacy benefit management (PBM) partner to institute claims processing rules at the point of sale (i.e., the retail pharmacy) to prevent or at least reduce the likelihood of inappropriate prescribing. UCare has sought to do this in a thoughtful and clinically meaningful way, so that the rules are less likely to trigger false alarms and administrative hassles for prescribers and patients. UCare has launched a program to support members who are on Medication Assisted Treatment (MAT) by identifying and addressing risk factors that might interfere with the member’s ability to take the MAT drug as directed and adhere to the plan of care of the substance abuse treatment clinician. It’s important to eliminate barriers to MAT. Notably, UCare does not require prior authorization for Suboxone. UCare’s partnership with HCMC’s emergency department is one of our most recent and potentially groundbreaking initiatives to improve metro-area
access to MAT. We funded a grant to establish the capability to initiate MAT and intensive outpatient follow-up in the emergency department. That effort includes embedding addiction counselors in the ED and training HCMC’s emergency medicine physicians to gain federal certification to prescribe Suboxone. The HCMC program is patterned after one tested by Yale School of Medicine researchers, and will be evaluated with rigorously collected data and scientific analysis. Based on the lessons learned, UCare could foresee extending the effort outside the metro area. Please tell us about the Medicare Stars Program and the work you did there.
Medicare Stars is a rigorous and comprehensive quality measurement system administered by CMS and is integral to the Medicare Advantage (MA) program. The MA health plan is at risk for cost of care and quality under the Quality Bonus Payment (QBP) mechanism. UCare was the first Minnesotabased health plan to provide MA products on a large scale, and UCare has the most extensive experience of any Minnesota-based health plan in Stars with its risk-based QBP. The UCare for Seniors family of products has a Star rating of 4.5 out of 5 stars, which puts UCare in the top decile of MA plans nationwide.
Medicare Stars measures process of care, selected clinical outcomes, appropriate prescribing, accurate administration of covered benefits, member satisfaction, and long-term health status reported by the individual beneficiary. To maintain a high rating, a plan must improve year-over-year across most of its measures. UCare has several, company-wide specialized teams dedicated to our Stars program. Success in Stars requires a combination of focus, attention to detail, and longterm, persistent effort. The QBP is applied to the MA plan’s payment from CMS three years after members receive clinical services, so the time lag from quality improvement intervention to payment is three years. You recently became a board member at MN Community Measurement. What projects are you are working on there?
All of the health plans that are members of the Minnesota Council of Health Plans are represented on the board of MN Community Measurement. The health plans work collaboratively within the board and its stakeholders (especially from the provider organizations) to continuously improve the value and impact of community-wide measurement of health care services. We share
an objective of making measurement meaningful to its audiences, helpful for guiding constructive change in medical practice, timely and efficient in its production, and less costly and administratively burdensome upon providers. What else can you tell physicians about UCare?
As Minnesota health care and its financing continue to evolve, UCare is rising to the challenge with thoughtful, targeted innovation and a commitment to continually improve how we serve our members in tandem with our provider partners. We continue to address gaps in care and focus on empowering members to seek preventive care. UCare takes a holistic view of health care and the impact of social determinants on the overall health of our members. True to our mission, we are exploring partnerships to improve social determinants of health in the community. Lawrence (Larry) Lee, MD, FACP, MBA, is senior vice president and chief medical officer at UCare, a not-for-profit health plan in Minnesota. He is a board-certified general internist.
Creating a Healthier Minnesota Juniper is helping rural and urban communities across Minnesota create a culture of health. Our evidence-based programs give your patients the tools they need to take manage their health in a way that works. Juniper programs offer group training to prevent escalation of disease, reduce hospital admissions, lower health care costs, and improve independence. Programs concentrate on: n
Preventing Falls
n
Preventing and Managing Diabetes
n
Managing Chronic Conditions and Pain
To locate a Juniper program, or to start one through your clinic or in your community, please call us toll free at 1-855-215-2174 or email info@yourjuniper.org. To find our more about the Juniper program please visit: www.yourjuniper.org Innovations for Aging, LLC, a nonprofit subsidiary of Metropolitan Area Agency on Aging, is the managing partner for Juniper, providing management information systems, coordination, member services and support to our partner organizations.
MINNESOTA PHYSICIAN MAY 2018
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3Mast cell mastery from cover Common quality-of-life threatening conditions vasoactive mediators plus a broad spectrum of cytokines, chemokines, and growth factors with autocrine, paracrine, and systemic effects. They are widely distributed, including the skin, connective tissue, lining of the gastrointestinal tract, respiratory tract, cardiovascular system, reproductive system, and nervous system. Simplified, they are found at the interface of epithelial tissue and the external environment. They are extremely important in maintaining appropriate physiological and pathological functions, including the regulation of vasodilation, vascular homeostasis, innate and adaptive immune responses, angiogenesis, wound healing, bacterial and parasite elimination, as well as bone growth remodeling and remineralization. They are considered protective. But they are also active in detrimental, nonresolving, pro-inflammatory loops in chronic inflammation, cancer, and autoimmune disease. Mast cells, of course, have the high-affinity IgE receptor that is so important in allergic disease. But they also have many other receptors important in non-allergic disease. These include pathogen recognition receptors (PRRs), and receptors for inflammatory peptides, complement, IgG antibodies, cytokines, chemokines, and growth factors. This means that mast cells can react to many non-allergy types of stimuli. Multiple triggers exist and are delineated in Table 2. Mast cells are hematopoietic cells that uniquely differentiate in local tissue niches. This means that they are heterogenous in their content and activity. They can be both pro-inflammatory and anti-inflammatory depending upon
Migraine, endometriosis, functional dyspepsia, adverse food reactivity, irritable bowel syndrome, postural tachycardic syndrome (POTS), idiopathic dizziness, chronic fatigue syndrome, sleep disturbances, and obesity.
Chronic pain syndromes Fibromyalgia, chronic pelvic pain, interstitial cystitis, prostatitis, neuro-immune neuropathic pain, nerve compression pain (e.g. sciatica, carpal tunnel), and temporomandibular joint disorder (TMJ).
Neuro-inflammatory disease Traumatic brain injury, stroke, multiple sclerosis, and intracerebral hemorrhage.
Neurodegenerative disease Alzheimer’s disease and Parkinson’s disease.
Neuropsychiatric disorders Autism, attention-deficit disorder, depression, post-traumatic stress disorder (PTSD), and schizophrenia.
Fibrotic diseases Cardiac fibrosis, pulmonary arterial hypertension (PAH), idiopathic pulmonary fibrosis, and myelofibrosis.
Cancer and cancer metastases
Food Matters for Health Professionals Saturday,
June 16 1 – 6:45 pm and
Sunday,
June 17 9 am – 6:45 pm
Nourishing M I N N E S O TA
Are you prepared to answer questions in your practice such as: What are whole grains? What are the differences between vegan, vegetarian, and paleo diets? How do carbohydrates and fats affect weight gain/loss? What is the role of the gut microbiome in health and disease? This workshop is a blend of discussion and hands-on cooking (including full meals each day). Accredited for 9.0 AMA PRA Category 1 credits for physicians, this course is suitable for all health professionals who want to incorporate food-based nutrition in clinical practice and self-care. Topics include diabetes and metabolic syndrome; inflammation and the gut; and eating styles such as vegetarian, vegan, and paleo. Learn more and register at
z.umn.edu/FoodCE
Atherosclerosis and coronary artery inflammation Autoimmune diseases Crohn’s disease, Sjogren’s syndrome, rheumatoid arthritis, type 1 diabetes, and Guillain-Barre syndrome.
Table 1. Non-Allergy Mast Cell-Associated Medical Conditions
the microenvironment. They share a core signature of 128 genes relevant to production of their known mediators. Unlike neutrophils and basophils, mast cells are long-lived. They can proliferate despite being fully differentiated. They can recharge and replenish after stimulation. They have innate immune memory. Mast cell degranulation results in local and systemic effects including vasodilation, skin rashes, flushing, inflammation and swelling, contraction of smooth muscle, altered peristalsis, dyspepsia, nausea, vomiting, headache, palpitations, depressed mood, bone pain, increased mucus production, and anaphylaxis. For this reason, mast cell-related disease results in multiple, non-specific complaints affecting multiple organ systems.
Mast cell activation syndrome In 2018, the differential diagnosis for patients with complex, chronic,
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Environmental stressors Heat, cold, or rapid change in temperature; friction, vibration, or mechanical irritation to skin; pollution, pollen, or toxins; sunlight; or scents and fragrances.
Physical stressors Illness (viral, bacterial, fungal), surgery, exercise, fatigue, or venomous stings.
Emotional stressors Emotional, psychological, or spiritual stress.
Pharmaceutical stressors Many medications, including but not limited to amphotericin B, anesthetics, extromethorphan, opiates, vancomycin, and iodine-based contrast dye).
Dietary stressors Many foods, especially high histamine foods (leftovers, aged cheese, fermented foods, tomato, soy sauce, chocolate, and more).
multi-organ system debilitating disease now includes mast cell activation syndrome (MCAS). These patients are often quite impaired yet can have normal screening laboratory values. Their symptoms can look like allergy and atopic disease, but IgE testing can return as normal. They can have multiple chemical sensitivities, adverse food reactions/aversion, non-specific cognitive concerns, and recurrent anaphylactoid reactions. Their symptoms can wax and wane for no apparent reason. Their condition can be mistaken for a mental health issue such as anorexia, hypochondriasis, anxiety, depression, or conversion disorder. Their pleas for relief can escalate to the point of being misdiagnosed with a personality disorder. These patients are also at risk for multiple very expensive medical evaluations without therapeutic relief. Symptoms can include the common histamine reactions, such as flushing, itching, hives, diarrhea, and hypotension. Symptoms can also include brain fog, cramping, fatigue, weight loss, enlarged lymph nodes, easy bruising/bleeding, headaches, and body aches. In the worst case scenarios, people can experience angioedema and anaphylaxis. The latter are unmistakable; the former can be misperceived as vague and without a unifying diagnosis. Internationally accepted consensus statements guide use of the term mast cell activation syndrome. Three criteria exist: 1) the presence of mast cell activation symptoms, 2) the presence of the products of mast cell activation, and 3) symptoms that respond to mast cell-stabilizing agents
Table 2. Mast cell triggers
Mast cell mastery to page 124
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3Mast cell mastery from page 11
out of mind. Ideally, tissue biopsies in patients suspected of having a mast cell disorder should be tested for CD117 and CD25 by flow cytometry, and morphologic descriptions of the mast cells should also be provided. Finally, testing for the gain-of-function mutation in the transmembrane tyrosine kinase receptor c-KIT D816V should be considered.
or agents that modify mast cell mediator production, mediator release, or mediator effects. All three need to be fulfilled to meet the definition. However, numerous practical challenges exist in the measurement and documentation of the products of mast cell Patients with MCAS can be understood as activation. Ideally, serum tryptase, histamine, falling into one of three categories: 1) primary and chromogranin A would be measured in MCAS with c-KIT-mutated, clonal mast cells are emergency rooms when people present with present, 2) secondary MCAS where underlying suspected mast cell activation. For many reasons, inflammatory disease but no c-KIT-mutated Mast cell-related disease results in this is almost never done. And, ideally, 24-hour mast cells are found, and 3) idiopathic MCAS multiple, non-specific complaints refrigerated urine collections for prostaglandin where neither an IgE dependent allergy nor affecting multiple organ systems. D2, leukotriene E4, 2,3 dinor 11-beta c-KIT-mutated mast cells are detectable. To prostaglandin F2 alpha, and n-methylhistamine identify which category applies, a bone marrow would be done in outpatient settings. However, biopsy is required. the half-lives of these mast cell products are both short and temperature sensitive. Hence, Cautions and precautions these tests require exquisitely careful chain-ofMast cell activation symptoms can range from custody management from the clinic to the receiving hospital to Mayo, mild to life-threatening. The severity depends upon multiple contextual Quest Diagnostics, LabCorp, or ARUP Laboratories. Practically speaking, factors, including genetics, number of mast cells, triggerability of the from even hospital laboratories, such testing results in a high prevalence mast cells, the type of allergen, and the presence of co-morbidities. The of exceptionally low levels of prostaglandin D2, consistent with impaired potential presence of systemic mastocytosis must be considered. Multiple sample management. prescription medications can cause mast cell degranulation (a complete list can be found on the Mastocytosis Society website at https://tmsforacure. Regretfully, biopsied tissue from any organ is stained for analysis with org). Triggers can also include medication excipients such as coloring agents, agents that do not show mast cells. They are invisible: out of sight means etc. Triggerability means that special precautions need to be taken with all medical procedures, including radiology procedures with and without contrast or dyes. Pre-procedure prophylaxis is described here: https:// tmsforacure.org/documents/ER_Protocol.pdf.
Treatment The best treatment plans include supportive care, resilience training, and trigger avoidance. With these, medications and supplements can be critical for management. At this time, cure is not possible.
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M A P L E G R O V E • B L A I N E • P LY M O U T H • C R Y S T A L
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Prescription mast cell-stabilizers include cromolyn, ketotifen, and elmiron. The first two are available via specialized compounding pharmacies at lower cost (cromolyn) or capsules (ketotifen). Mast cellmediator blockade can include H1 blockers (fexofenadine, loratadine, diphenhydramine, cetirizine, hydroxyzine hydrochloride, low-dose Doxepin), and H2 blockers (nizatidine, famotidine, cimetidine, ranitidine). Proton pump inhibitors can be added. With elevated eiconosaids, use of montelukast can be helpful. In special circumstances, the tyrosine kinase inhibitor imatinib and the anti-IgE antibody omalizumab may be helpful. In 2017, the FDA approved Midostaurin, a multi-kinase inhibitor with activity against c-KIT, for treatment of aggressive mastocytosis. Non-prescription mast cell-stabilizers represent fundamental treatments. These include quercetin or the quercetin, rutin, luteolin combination sold as NeuroProtek. Additional stabilizers include buffered vitamin C, r-alpha-lipoic acid, vitamin E, and palmitoylethanolamide (PEA). The latter is of particular interest for its wide applicability to pain-related concerns. Low dose naltrexone (LDN) offers additional anti-inflammatory action as a TLR4 antagonist. The probiotic bacteria Lactobacillus rhamnosis and Bifodbacter species can reduce histamine loads.
In contrast, the probiotic bacteria Lactobacillus casei and Lactobacillus bulgaricus can produce histamine. Many patients benefit from a low histamine diet. Additionally, a shortterm low FODMAPs diet may help decrease the symptoms while they are undergoing further workup to remove the main trigger or triggers.
Conclusion Mast cell mastery represents a new competency for all physicians. Three important dimensions deserved to be highlighted. First, every physician knows of patients who, despite great effort and expense, and despite having a team of skilled clinicians representing multiple subspecialties, still do not have a unifying diagnosis or a satisfactory therapeutic response. Such patients can trigger symptoms of burnout in time-pressured contexts. Mast cell activation syndrome needs to be considered in all such patients.
go-to experts. Examples include patients without IgE-mediated disease and patients without myeloproliferative disease. In fact, in 2016, the World Health Organization removed mastocytosis from the category of myeloproliferative neoplasms due to the disease’s heterogenicity. The bottom line is that without any one subspecialty assuming leadership in mast cell related diseases, all of us need to step up and seek mastery in mast cell management. Gregory A. Plotnikoff, MD, MTS, FACP, is senior consultant and medical director at Minnesota
Mast cell mastery represents a new competency for all physicians.
Second, nearly every subspecialty addresses diseases where aberrant mast cell activation is a strong component of the pathophysiology. Mast cell activation management may represent an important adjunctive or even primary treatment of such diseases.
Personalized Medicine. A board-certified internist and pediatrician, he has received national and international honors for his work in cross-cultural and integrative medicine.
Kathleen Hopkins, DO, is a consultant in integrative and functional medicine at Minnesota Personalized Medicine. She is board-certified in family medicine and osteopathic manipulative therapy.
Third, mast cell activation diseases can fall into an orphan disease category with no primary or subspecialty group being identified as the
Your Link to Mental Health Resources
mnpsychconsult.com
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COLLABORATIVE SOLUTIONS. INSPIRED DESIGN. The LEO A DALY team brings a passion for designing spaces focused on the human experience. Elizabeth Schulze, AIA, LEED AP BD+C Healthcare Market Sector Leader EOSchulze@leoadaly.com • 612.752.8733 MINNESOTA PHYSICIAN MAY
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3Consolidation from cover History, objectives, and goals
consolidation; hardwiring the incentive compensation of physician and administrative leaders to achieve measurable goals of consolidation; and ensuring that the consolidation goals include metrics for health gain as well as health care that has a sharper focus on results for the citizens and patients who should be the principal beneficiaries of the consolidation.
Throughout the 1970s up through 1994, several of us were actively engaged in a series of consolidations that became Allina Health. Looking back, we can conclude that the driving force then, as now, was to assemble a critical New players and performance metrics mass of people, technology, money, and political The case for consolidation in the coming decade influence to accomplish five key objectives: 1) build should be argued now as a means to accomplish five Myth 1: Getting bigger economies of scale and shared services to reduce important goals that accrue substantial advantages is a guarantee that the the escalation of costs to the purchasers and end of consolidation: organization will be better. users of health care services; 2) develop teams of 1. Develop programs and a culture that clinicians that could improve the quality of clinical ensures superior patient experiences along the outcomes and the patient’s experience; 3) access continuum of care. capital under more favorable terms to keep pace with exploding calls by patients and physicians 2. Access capital under favorable terms to for the best and brightest technologies and care facilities; 4) leverage our support innovation in programs, processes, technologies, and contracting influence with health plans and insurance companies; and 5) facilities that not only restores health, but also protects and expand the pride of board members and executives to be a part of something promotes health gains. bolder, bigger, and more innovative than others around us. 3. Establish care management protocols and support systems and staff Today we need to initiate processes to assess and monitor results from that enable substantial influence over favorable payment terms with the first four objectives, and be less concerned with the fifth. This will public and commercial health plans. be more likely when physicians, policy makers, and patients ask for three 4. Enhance reputation to earn and attract substantial philanthropic essential requirements: expanding engagement and amplifying the voice of support of the organization’s mission. physicians and advanced practice providers in the planning and design of 5. Create scale that enables modern human resources management and talent development of staff, physicians, and advanced practice providers to sustain an optimal mix of services within the host community.
Achieving these goals and advantages, however, will not be easy within an operating environment characterized by these factors:
Helping Beautiful Things Emerge From Hard Places
Uncertainty over the ability of state and federal policy makers to reach agreement on the degree of discomfort that should be owned by providers, payers, patients, or the public. Unfortunately, confused political economics will probably demand more from the lifestyles of physicians than from the lifestyles of the public and patients. Policy makers do not have the patience or will to call for the public to reduce calories and increase fitness as a requirement for public insurance risk pooling and payments. Furthermore, larger scale health systems are ill-prepared to deal with social determinants of disease such as poverty, housing, and nutrition. The degree of integrated and results-driven care management between physicians, hospitals, and purchasers, which requires a reliance on data mined from as-yet weakly integrated medical and health records. The incentives and information needed to reward behavior change by the public to “walk-the-talk” of more exercise, less obesity, and more happiness (see this on happiness measures: https://tinyurl.com/nytimes-happiness).
The cautions for consolidation TWO CENTERS.
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Overcoming these obstacles requires physicians to avoid certain myths of consolidation that need to be acknowledged and avoided by physician leaders: Myth 1: Getting bigger is a guarantee that the organization will be better. Response: This myth is not always the case because local physicians and board Consolidation to page 324
Patients with regenerative medicine questions?
Regenerative medicine focuses on the body’s natural ability to repair, replace, and regenerate damaged or aging tissues. At MINNESOTA REGENERATIVE MEDICINE (MRM), a specialty clinic of HOGUE CLINICS, autologous bio-cellular agents such as platelet-rich plasma (PRP), fat aspirate concentrate (FAC), and bone marrow aspirate concentrate (BMAC) are used to treat degenerative conditions. To ensure proper placement, ultrasound or fluoroscopy guidance is used when clinically indicated during regenerative medicine treatments.
Regenerative medicine treatment categories at MRM include: • Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine) • Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING • Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT
8 Hogue Clinics locations in Minnesota www.mregm.com • (763) 447-2500 or Toll Free (866) 219-4699 MINNESOTA PHYSICIAN MAY 2018
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RESEARCH
Cancer clinical trials New U of M network to expand Minnesota access BY DOUGLAS YEE, MD
P
atients across Minnesota will soon have increased access to new cancer treatments, thanks to a state-funded partnership between the University of Minnesota and several of the state’s major health systems. The Minnesota Cancer Clinical Trials Network (MNCCTN), which received funding from the Minnesota Legislature in 2017, will bring access to cancer clinical trials closer to home for more Minnesotans.
Funding and participants The network will receive $4 million in annual state funding approved by the Minnesota Legislature last year via the MnDRIVE (Minnesota’s Discovery, Research, and InnoVation Economy) partnership between the state of Minnesota and the University of Minnesota. The MnDRIVE partnership aligns areas of research strength with the state’s key and emerging industries to address grand challenges. In 2013, the state of Minnesota authorized an $18 million recurring annual investment in four research areas: robotics, global food, environment,
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Sciatica Neuromuscular Disease Muscular Dystrophy Dizziness Numbness Stroke Multiple Sclerosis ALS And other neurological disorders
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and brain conditions. In 2017, as the opportunity for new projects funded under MnDRIVE came about, Brooks Jackson, dean of the Medical School at that time, suggested a statewide cancer clinical trials network, and the Masonic Cancer Center proposed such a network. Of the projects put forth, only the Minnesota Cancer Clinical Trials Network was selected by the Minnesota Legislature to move forward. This is an amazing opportunity for some of the largest health care organizations in Minnesota to cooperate to make Minnesota a healthier state. The Minnesota Cancer Clinical Trials Network is a collaboration between the Masonic Cancer Center, Essentia Health Community Oncology Research Program, Fairview Health Services, The Hormel Institute, Mayo Clinic Cancer Center, Metro-Minnesota Community Oncology Research Consortium, and Sanford Community Oncology Program of the North Central Plains.
A running start In the first year of the program, 18 new locations across the state of Minnesota are scheduled to participate in cancer clinical trials. The locations are: Aitkin, Albert Lea, Austin, Cambridge, Deer River, Detroit Lakes, Fosston, Grand Rapids, Hastings, Hibbing, Mankato, Monticello, Park Rapids,
Princeton, Thief River Falls, Virginia, and Worthington. Hibbing will host two locations—one through Fairview Health Services and the other through Essentia Health.
in the Twin Cities or Rochester, with just a few additional locations in Greater Minnesota. This means that many people living in large parts of Minnesota need to travel long distances to receive the potential opportunities these trials provide. By adding these 18 new locations around the state with access to a variety of trials, the Minnesota Cancer Clinical Trials Network aims to significantly ease the barriers to participation in cancer clinical trials.
There are plans to increase the number of locations in future years, making it much easier for physicians to find an appropriate trial for their patients as well as making it more convenient, with easier access, for patients to participate in trials close to home. Future locations have not yet been finalized, but we plan to add several This network enhances physicians’ clinics to enhance overall coverage of Minnesota.
ability to collaborate in bringing
This expanded access will reduce the travel burden for patients and decrease the time spent away from their family and their work—as well as costly travel and lodging expenses. This improved ability to participate in clinical trials could also decrease patient costs, as the partnerships with different health care groups will increase insurance coverage options.
The trials for the Minnesota Cancer Clinical the latest care to their patients. Trials Network will be developed at three Minnesota academic institutions: the Masonic Cancer Center, University of Minnesota; the Hormel Institute; Secondarily, expanding the reach of cancer and the Mayo Clinic Cancer Center. The Masonic trials in the state provides researchers a larger Cancer Center and Mayo Clinic Cancer Center are patient pool from which to draw, enhancing the opportunity to increase both National Cancer Institute-Designated Comprehensive Cancer Centers the number of successful trials. The inability to recruit enough patients to a and are the only two such centers in the state. trial is the main reason a clinical trial fails, as each trial needs to accrue an The focus for the network will be bringing Minnesotans access to appropriate number of required participants. Access to additional patients investigator-initiated trials and increasing access to national cooperative will help researchers move successful treatments through the clinical trials group trials though MNCCTN’s National Cancer Institute Community process more quickly, and should decrease the time in which new treatments Oncology Research Program partners. and cures are made available to the general public. This overall progression
Payoffs for patients
Currently, Minnesotans’ clinical trial access is limited to clinics and facilities
Cancer clinical trials to page 304
V PTSD is now an approved condition V
HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS
• Inflammatory bowel disease, including Crohn’s disease
• Seizures, including those characteristic of Epilepsy
• Terminal illness, with a probable life expectancy of less than one year • Intractable Pain • Post-Traumatic Stress Disorder
• Severe and persistent muscle spasms, including those characteristic of MS
Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.
OFFICE OF MEDICAL CANNABIS
(651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us
Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.
See our website for a detailed first year report. mn.gov/medicalcannabis
MINNESOTA PHYSICIAN MAY 2018
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SPECIAL FOCUS: CARE TEAMS
Network growth spurs team integration Ensuring effective, efficient care BY JENNIFER WELSH, MD, AND KAREN MULDER, RN
right time, while avoiding unnecessary duplication of services and preventing medical errors.” Basically, we need to own the care complexities for our patients.
airview’s provider network has grown and changed significantly over the last year. With the combination of Fairview and HealthEast systems in June, as well as the addition of several new independent practices, Fairview Health Network (FHN) welcomed 51 new clinics and 915 providers in 2017. Our network now includes more than 3,400 Fairview-employed, independent, and University of Minnesota Physicians providers in 318 clinics across the metro.
Reorganizing care coordination
F
This growth has challenged us to integrate our multiple care teams— those serving patients of legacy Fairview, HealthEast, and our independent primary care network practices. The added complexity has further challenged us to better leverage the players, data, and analysis for more efficient and effective care. Our patient and provider experience demonstrates that a care team offering multidimensional skills supports the most effective delivery of health care. The goal, as described by the Centers for Medicare and Medicaid Services, is “to ensure that patients, especially the chronically ill, get the right care at the
Patients in transition across multiple care settings—or those with chronic, complex medical, social, or financial situations—benefit greatly from the support of robust and integrated care team care. For example, at least one-third or more of patients in some of our network practices struggle with the cost of medical care. Challenges include fixed low income, high medical bills, or a high-deductible health plan. We remember a recent patient who faced the horrible dilemma of paying for rent or buying medications and food. Our care coordinators not only helped her search for a drug assistance program to pay part of her medication costs, they also helped her complete the program application, which can be daunting. Further, they found options for subsidized meals, provided food shelf information, and helped her search for lower cost housing. Care management has matured into a broad, system-wide approach supported by the Minnesota Department of Health’s Health Care Homes (HCH) program model. Care coordination, anchored by registered nurses and social workers embedded in primary care practices, forms the platform for a strong Accountable Care Organization. Recently, we aligned care management under one system director who partners with our system director for population health. Together, these leaders work to establish a standardized care management model across our primary care service line, regardless of which clinic a patient uses. We believe that successful care coordination leads to improved patient outcomes, increased patient and provider engagement, and reduced health care costs for a patient population.
Evolving roles for better care management As our system-wide care management approach evolves, so too have care team roles. For example, the new role of “lead” care coordinator functions as the care coordination quarterback, bringing together the resources and players to help us begin to own the complexity of care and simplify the patient experience. All care team members work together, embedded within primary care clinics. Examples include: • Registered nurse care coordinators: RNs use clinical assessment and a patient-centered plan of care to manage transitions as well as complex and chronic disease, to include resolving gaps in care. • Behavioral health specialists: Embedded in clinics that have received behavioral health care home certification from the Department of Human Services, behavioral health specialists provide in-person or phone-based patient counseling. They help physicians understand patients’ behavioral health needs. • Medication Therapy Management (MTM) pharmacists: Many health issues involve inappropriate medication use, including optimizing medication doses, cost, adherence, and drug interactions.
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The MTM pharmacist helps ensure appropriate use and effectiveness of medications to achieve clinic health goals and reduce costs.
management tool within the Epic electronic medical record system, to integrate data, analytics, and reporting.
• Social Workers: Stress about non-medical issues, such as arranging transportation or paying for care, can impact a patient’s health. Those recovering from major surgery may not have the support they need to enable them to recover at home. Social workers can connect patients and families to critical community resources. • Certified diabetes educators: These registered nurses and registered dieticians help those with diabetes manage medications and diet for optimal diabetes control.
Care coordinators use both single-condition as well as multiple predictive modeling risk scores to identify patients who need preventive care or who have management gaps for chronic illnesses. For example, recurrent emergency department visits, driven by coexisting mental health or substance abuse issues, may trigger care coordinator involvement. The data informs our standard, evidence-based work. Patients are more Components include 48-hour post-hospital followlikely to achieve goals up calls, 24-hour post-ED calls, and 7-day primary they helped to set. care provider visits following hospital or transitional care unit (TCU) discharge. By identifying patients at risk of complications and helping them connect to more appropriate care, we can reduce unnecessary ED visits, TCU stays, and re-hospitalizations.
• Health coaches: Because patients are more likely to achieve goals they helped to set, health coaches work with patients to determine what is important to them and to find strategies to accomplish health goals.
• Medical assistants: These team members function in a variety of roles, including as care navigators, care guides, and community health workers, as well as clinic staff.
Reducing inappropriate hospitalizations, TCU stays, ED visits, and costs
We’ve further developed “warm hand-off” communication across the care continuum. Care coordinators use summary templates to carry key details and identify potential gaps in care as the patient moves from hospital to TCU to home care, and then back to primary care. These handoffs help care coordinators address such considerations as post-hospital oxygen set up, referrals to MTM pharmacists, end-of-life-planning, and social work for psychosocial or financial concerns.
Care coordinators play a key role in evaluating and responding to integrated EHR data. We use Epic Healthy Planet, a population health and care
Three patients. Who is at risk for diabetes?
Network growth spurs team integration to page 384
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
MINNESOTA PHYSICIAN MAY 2018
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SPECIAL FOCUS: CARE TEAMS
Certified community behavioral health clinics Benefits to patients, physicians, and communities BY PAHOUA YANG, MSSW, PHD, LP, LICSW, AND CLAIRE WILSON
A
midst all the discourse about health care that has captured national attention, not enough has been said about one of the biggest shifts in behavioral health provision: the creation of Certified Community Behavioral Health Clinics (CCBHCs). CCBHCs represent a leap forward in patient-centered care, with benefits extending beyond patients to physicians, health care systems, and communities at large.
What Are CCBHCs? Essentially, CCBHCs represent a full-service community behavioral health model with a deep focus on accessibility, quality, and coordination to offer a successful whole-person approach. Per Substance Abuse and Mental Health Services Administration (SAMHSA) guidance:
Telephone Equipment Distribution (TED) Program
CCBHCs are designed to provide a comprehensive range of mental health and substance use disorder services, particularly to vulnerable individuals with the most complex needs. The service array is deliberate. CCBHCs provide the comprehensive array of services that are necessary to create access, stabilize people
Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.
1-800-657-3663 ted.program@state.mn.us mn.gov/dhs/ted-program Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services
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MAY 2018 MINNESOTA PHYSICIAN
in crisis, and provide the necessary treatment for those with the most serious, complex mental illnesses and addictions. CCBHCs also integrate additional services to ensure an approach to health care that emphasizes recovery, wellness, trauma-informed care, and physical-behavioral health integration. Minnesota, like many other states, is struggling to make behavioral health services readily and evenly available, resulting in serious gaps in the continuum of care for those who are particularly vulnerable. This means people may go without critical services or are forced to use services that are not appropriate for their need. Navigating mental health and substance use disorder treatment systems can be difficult. In the current systems, in order to get the set of robust services to support their recovery, a person with a mental illness and/or substance use disorder may be working with multiple agencies, providers, timelines, assessment and treatment processes, and rules and regulations. There are additional challenges in obtaining integrated mental health and substance use disorder treatment. CCBHCs improve the way Minnesotans access mental health and substance use disorder treatment by creating a model of community clinics that provide comprehensive, coordinated, and integrated care to children, adults, and families. People who use CCBHCs may receive mental health and substance use disorder services, health screening and monitoring, peer and family support, and connections with other providers and systems. This high level of care coordination and partnerships between providers, social services agencies, counties, and other key stakeholders increases the likelihood that care will be received before a person experiences a crisis, lessening the burden on emergency rooms, law enforcement, and families. In 2014, the U.S. Congress enacted the Excellence in Mental Health Act, which established an eight-state demonstration project to test CCBHCs. The 2015 Minnesota legislature provided funding to support planning. In December 2016, Minnesota was chosen to be one of eight states to pilot the CCBHC service delivery and payment model for a two-year period. The Minnesota Department of Human Services selected six clinics to participate in this federal Medicaid demonstration program. The demonstration sites represent a broad range of urban and rural services, from the northwest to the southeast corner of the state. The Amherst H. Wilder Foundation in Saint Paul is one such clinic. Along with piloting a new service delivery model, the federal Medicaid demonstration also gives Minnesota an opportunity to pilot a new way of paying for services under Medicaid. The CCBHC reimbursement model is based on the actual cost of providing services. This allows CCBHCs to address the behavioral health care workforce shortage by hiring additional staff to meet the demands of client need. At Wilder, in addition to the ability to hire more staff who reflect the diverse communities we serve, we have also been able to hire more multi-disciplinary staff that have not
traditionally been a part of our service continuum—such as peer specialists, care coordinators, and community health workers—to address service gaps and needs. As we expand how we are able to hire, we are hopeful this will result in better services and outcomes for clients and will allow us to create more career ladders within our organization.
Expected outcomes CCBHCs are an opportunity to provide more coordinated, cost effective, patient-centered care. CCBHCs are expected to result in: seamless transitions for people across the full spectrum of health services, patient and family satisfaction with program participation, and reduced rates of mortality, hospitalization, and incarceration.
Accessing a CCBHC
The CCBHC model offers a “no wrong door” approach. At Wilder, that means one phone number provides access to a full-service clinic and, from there, finding the correct service for each patient. It removes the patient guesswork of finding a provider who offers the services they need before they have a diagnosis and know what services would be appropriate for them. All of Wilder’s CCBHC patients receive an initial evaluation, and care CCBHCs improve the way coordinators connect them to appropriate Minnesotans access mental continuing services. health and substance
use disorder treatment.
By creating an enabling environment that addresses all five A’s of access—affordability, availability, accessibility, accommodation, and acceptability—CCBHCs aim to help more people access services and increase the level of participation that those users choose. We want people to be seen as soon as they are ready to receive care, and for as often and long as they need to be seen. By following their lead and offering true patient-centered care, we expect to see an increase in patient functioning, recovery, and stability. Beyond the benefits to patients, we expect the CCBHC model will increase our capacity to serve more people and improve collaboration and care coordination across providers—including physicians.
A key benefit of CCBHCs is universal patient eligibility. Anyone seeking services at a CCBHC has access to a full suite of services, regardless of age, insurance status, language, or any other qualifier.
Beyond the pilot The CCBHC pilot has a deep evaluation plan that utilizes national, state, and provider level metrics. Many of the measures are recognized Healthcare Effectiveness Data and Information Set (HEDIS) measures, which seek to align CCBHC metrics with existing value-based purchasing models. By examining accepted standards of service quality that are tied to outcomes, CCBHCs will be able to make the case for sustaining the model of care and, hopefully, expanding it nationwide. Ultimately, this will serve Certified community behavioral health clinics to page 314
MINNESOTA PHYSICIAN MAY 2018
21
BEHAVIORAL HEALTH
Gender-specific substance use disorder care Why it matters BY KARINA FORREST-PERKINS, MHR, LADC
U
nderstanding substance use disorders (SUD), what causes them, and what modalities to employ in order to catalyze healing is challenging to the most seasoned professional. The complexity that accompanies SUD often includes an adaptation in brain development as a result of stress accumulation over the lifecourse, incidences or patterns of trauma, and adverse social conditions that prevent positive influences from being the controlling factor in well-being. Due to the foundation of trauma, violence, and/or stress, it is often thought that women are more adversely affected than men; however, this is likely not the case. Since developmental trauma, violence, and/or stress impact family systems and the children within those systems, those factors necessarily impact both women and men. What is most unique among women is what is needed in order for these illnesses or injuries to heal. SUD in female populations hold complexities that are unique from male populations. Women experience various societal expectations related to body image, pregnancy and parenting, economics, emotional expression, historical
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subordination in power dynamics, and many other social characteristics unique from male counterparts. This then impacts the models of care and iterations of those models that work best with this population. Due to the close association between substance misuse and emotional/ physical trauma, the compounding conditions of mental health problems are often present. This is not only a complicating factor for the woman experiencing the co-occurring condition, but also presents challenges to providers who must navigate this complexity in a non-linear and concurrent manner. Substance abuse and mental health professionals with targeted education, acumen with this population, and years of experience in the field often find this co-occurring client presentation challenging. When individuals present in the primary care environment, where the education, skills, and experience regarding these issues are limited, and relational contacts are limited to eight- to 10- minute increments, it is not surprising that medical professionals struggle with lower outcomes mediating these conditions.
Physiological impact The majority of women who require residential treatment or medically supervised withdrawal management have experienced a high accumulation of stress during sensitive developmental periods (ages 0–28). This creates an adaptation in brain functioning that is in addition to the impact of substance misuse. This adaptation in response to developmental context causes the individual to have more sophisticated survival skills and less sophisticated executive functioning skills. This adversely impacts the individual’s ability to concentrate, co-design and complete treatment plans, be able to hold the challenges of their own sobriety/recovery and the responsibilities of parenting, maintain a high-performing presence in the workplace, and secure safe and stable housing for her family. Her thought processes may be more survival-oriented in nature, mistrustful of solutions offered by systems that have historically been punitive or discriminatory toward her, and overwhelmed by holding competing accountabilities without the ability to cope with this stress. Some providers, like Minnesota’s Wayside Recovery Center, have evolved over the years to accommodate the healing complexities associated with women and co-occurring disorders. Each decade since the 1950s has brought new science and best practices for women struggling with SUD. Wayside now incorporates cutting edge, family-centered care that offers high quality therapeutic interventions braided with longer term “in-community” care coordination and recovery-oriented supports. This includes a foci on the healing of relationships, the strengthening of the family unit, the ability to incorporate new coping mechanisms into patterns of behavior, and a distinctive focus on whole health for the life-course. Wayside and others understand the necessity of incorporating thoughtful partnerships with cross-sector systems (primary health, housing, workforce development, parenting support, and children’s mental health) in order to achieve successful outcomes for women in our state. The organization offers
a full continuum of care, with programs that include early intervention, intensive residential services, tele-psychiatry, supportive housing for women and families, and recovery care/relapse prevention.
Challenges with current systems of care
can appear to be messy and lengthy; however, what might appear messy and lengthy addresses the core issues of this problem in a way that has a long-term effect for the woman, her children, her family members, her community, and, ultimately, for Minnesota.
The Triple AIM Standards of care promoted by the Institute for Healthcare Improvement focus on the sweet spot of lowering the cost of care, increasing the satisfaction with care, and improving the population’s overall health. As with People become ill in the context any well-designed chronic disease management of relationships, and they strategy, SUD in the female population require heal in that same context. While these strategies may appear to reduce a significant investment on the front end with a cost, they do not. Scientists such as Robert Anda, more affordable investment over the life-course. MD, researcher and co-principal investigator of If the front end whole health investment is the Centers for Disease Control and Prevention’s compromised, we will continue to see increased Adverse Childhood Experiences Study (ACES), emergency room utilization, increased problems and Bruce Perry, MD, author of the Neurowith child abuse and neglect in the family and community context, increased Sequential Model of Therapeutics, suggest that the current neuroscience problems retaining safe and stable housing, and increased incidences of research does not support this trend. Building new neuropathways that criminal justice involvement. support new behaviors takes time, and this time is not achieved in a 30-day stay in one residential community-based program, nor would the science Children and families support that treating the woman in isolation from her children/family Often women avoid treatment because they have no safe adult in their would be successful. The consistent focus is that people become ill in the life (and/or no financial resources to secure one) in order to care for their context of relationships, and they heal in that same context. This is not children. Wayside is one of six Minnesota providers that encourage women something that happens quickly or efficiently. Unfortunately, as with most Gender-specific substance use disorder care to page 364 human behavior and learning, healing from trauma and substance misuse The challenges of this approach are multi-faceted. The trend in SUD treatment is to shorten lengths of stay, to reduce cost on the front end by limiting the intensity of care, and to avoid intervening in the parent-child relationship until an injury or illness on the part of the child/family emerges.
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PHARMACY
Minnesota Prescription Monitoring Program Controlled substance insight alerts BY KATRINA HOWARD, PHARMD
T
he sending of unsolicited reports or proactive alerts is considered to be a prescription drug monitoring program (PMP) best practice, according to prominent stakeholders in the fight against prescription drug abuse. Unsolicited reports may be sent by state prescription monitoring programs to prescribers, pharmacists, law enforcement, and/or health licensing boards regarding individuals with highrisk prescription behavior, prescribers with inappropriate prescribing trends, or pharmacies with concerning dispensing behaviors. With prescription monitoring programs being state governed and operated, each state’s respective laws not only govern if the state PMP can send unsolicited reports, but also to whom the notifications may be sent. According to the National Alliance for Model State Drug Laws (NAMSDL), as of June 30, 2017, 42 jurisdictions have the authority to send unsolicited reports to prescribers and 39 jurisdictions have the authority to send such notifications to dispensers.
Unsolicited reporting in Minnesota On August 1, 2014, the Governor signed into law the ability for Minnesota Prescription Monitoring Program (MN PMP) staff to assess
patients’ prescription behavior in the database and to alert prescribers and pharmacists when the established criteria are met, indicating potential high-risk behavior. The threshold utilized was established by the Minnesota Board of Pharmacy in consultation with the MN PMP’s Advisory Task Force. The criteria established signify multiple provider episodes and are in a format of multiple prescribers and dispensers supplying the patient with controlled substance prescriptions in a given period of time. The MN PMP has given the name “Controlled Substance Insight Alerts (CSIAs)” to such notifications.
Controlled Substance Insight Alerts (CSIAs) The MN PMP began sending CSIAs in January 2015. Each month a report is generated which contains the individuals that met or exceeded the threshold in the specified timeframe. Clinical judgment is applied to determine if the patient is truly exhibiting suspicious prescription activity or if the prescription information in the patient’s profile report makes sense for a legitimate medical reason. The patient profile reports where high-risk behavior is not identified are considered “false positives” and prescribers and pharmacists are not notified. Examples of false positives include when hospice or palliative care providers are identified or if all of the prescribers work at the same health care facility. Once the false positives are removed, notifications are sent to the prescribers and dispensers who provided care for the individuals where potential
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2015
2016
2017
Number of individuals for which CSIAs were sent to prescribers and/ or pharmacists
214
100
46
Number of individuals who met the threshold more than one time during the year
34
19
7
Number of CSIAs sent to prescribers (number of unique prescribers to receive a CSIA)
1661 (1351)
795 (689)
322 (305)
Number of CSIAs sent to pharmacies (number of unique pharmacies to receive a CSIA)
1245 (551)
506 (299)
172 (145)
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Table 1: Controlled Substance Insight Alerts, 2015–2017
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MAY 2018 MINNESOTA PHYSICIAN
high-risk behavior was identified. The goals of sending CSIAs are to reduce prescription drug abuse, misuse, and diversion; to decrease the number of individuals who meet the threshold and exhibit potential high-risk behavior; and to increase use of the PMP.
CSIA analysis Since January 2015, CSIAs have been sent in regards to 338 unique individuals. The number of individuals for which CSIAs were sent has declined annually, to date. Of note, the annual individual counts shown in Table 1 cannot be added together. An individual may have met the threshold in 2016 and then again in 2017. In this instance, they are counted in each year’s assessment, but only as “one” unique individual in the historical count of 338 individuals. Table 1 shows key findings for the past three years. Occasionally, individuals will meet the threshold more than one time. If the behavior appears to be high-risk, CSIAs will continue to be sent regarding the individual, even if they were previously sent. When individuals meet the threshold more than one time, it may be because they are receiving controlled substance prescriptions from new prescribers and pharmacies than previously identified. These can be the more egregious cases of potential high-risk behavior. Prescription trends are analyzed three months after CSIAs are sent to determine if potential high-risk behavior has declined or if there are signs that an intervention occurred. Table 2 highlights key findings for 2015 and 2016.
Year and number of individuals
2015 (214)
2016 (100)
Percent of individuals with a reduction in the number of prescriptions dispensed
95.8%
92%
Percent of individuals with a reduction in the total quantity of units dispensed
88.3%
79%
Percent of individuals with a reduction in the number of prescribers
96.3%
93%
Percent of individuals with a reduction in the number of pharmacies
97.7%
94%
Percent of individuals with one prescriber and one pharmacy**
21.5%
26%
Table 2: Prescription Trend Analysis Three Months after CSIAs were sent* *Trend analysis was performed by assessing prescription trends of a timeframe which occurred three months after CSIAs were provided to prescribers and/or pharmacists. These trends were then compared to the initial timeframe in which high-risk behavior was first noted. If a patient met
Prescriber and dispenser feedback regarding CSIAs The PMP administers an annual survey to prescribers and pharmacists. Part of the survey is specific to those who have received a CSIA. In 2017, 10.1 percent of prescribers responded to the PMP’s survey indicating they had received a CSIA at some point in time. Of those prescribers who received a CSIA and responded, 63.1 percent indicated they learned new information about their patient as a result of the CSIA. When asked what type of new information they had learned, 80 percent of responders indicated they learned about the number of prescribers visited, 74 percent indicated they learned of the volume of drug(s) prescribed over a short period of time, and 67 percent learned of the number of pharmacies their patient had visited. Minnesota Prescription Monitoring Program to page 344
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the threshold more than one time in a year, they are included in this analysis based on the initial occurrence in which CSIAs were sent only. **One prescriber and one pharmacy reported as prescribing and dispensing may be indicative of
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MINNESOTA PHYSICIAN MAY 2018
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BEHAVIORAL HEALTH
Understanding the opioid epidemic in Minnesota Increases in deaths and disparities BY KATE S. ERICKSON, MSW
The increase in opioid-involved overdose deaths parallels increases in overall drug overdose deaths, hospitalizations from alcohol, and suicide rates in Minnesota in recent years. These trends demonstrate that the opioid epidemic is not happening in isolation from other related harms.
All forms of opioids (prescription opioids and illicit opioids) have a risk for physical and psychological dependence, addiction, withdrawal, and overdose There are many pathways to developing a substance use disorder. Some people have been prescribed opioids for physical pain and become addicted
Find life worth living.
500 All opioid-involved deaths 395
400
300
Number of deaths
I
n recent years, Minnesota has seen an increase in deaths and hospitalizations involving drugs, alcohol, and suicide. In 2016, 395 Minnesotans died of an opioid-involved overdose. Of the 395 opioid-involved overdose deaths, 194 involved prescription opioids. While prescription opioids still account for the greatest number of opioid-involved deaths in Minnesota, there was also a 32 percent increase in heroin-involved deaths and an 83 percent increase in synthetic opioid-involved deaths from 2015 to 2016. Figure 1 shows the drug categories involved in these 395 deaths.
Opiod-involved deaths continue to increase in Minnesota, driven by heroin and other synthetic opiods (i.e. fentanyl, tramadol)
Other Opioids and Methadone 194
200
Heroin 150 100
Synthetic Opiods 99
0.0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16
year
Figure 1. Drug categories involved in 2016 opioid-related deaths in Minnesota.
to them, others use opioids and other drugs as a way to cope with mental health needs or trauma, and others use opioids recreationally. Regardless of the pathway to opioid use, prescription and illicit opioids have similar effects on the body. Opioids act on the µ-opioid receptor and are effective at alleviating or numbing pain, whether the suffering stems from a physical injury, mental illness, and/or trauma. Opioids activate reward pathways, alter the body’s chemistry, and cause the release of endorphins. These are explanations for why opioids have a high abuse potential. While opioids temporarily relieve pain or suffering, many patients are unaware of the risks, including dependence, addiction, withdrawal, and overdose. Opioids produce respiratory depression, making them a potentially fatal drug. Opioids do not address the root causes of pain or substance use.
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Symptoms of opioid use disorder are more regularly observed than they are diagnosed. The criteria listed in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for an Opioid Use Disorder requires a minimum of two to three factors for a mild substance use disorder, including, but not limited to: • Taking the opioid in larger amounts and for longer than intended. • Having cravings or a strong desire to use opioids. • Wanting to cut down or quit but not being able to.
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MAY 2018 MINNESOTA PHYSICIAN
• Spending a lot of time obtaining the opioid. Like most conditions, early identification of signs and symptoms of a substance use disorder provides an opportunity for early intervention. When providers are taking a look at their population, and those that have been prescribed opioids, the question becomes not only which patients
These stories highlight the social determinants of health that are at play in the opioid epidemic (e.g., employment, housing, environmental conditions, transportation, sexual exploitation, health care access). The Social inequities contribute to the risk of developing a substance opioid epidemic is not happening in isolation from other conditions and use disorder social problems. There are intersections between The realities of poverty, racism, classism, social the opioid epidemic and pain, substance use isolation, sexual exploitation, and other social disorders, mental health, suicide, infectious inequities may affect people’s vulnerability to disease, domestic violence, sex trafficking, labor and capacity for effectively dealing with drugtrafficking, criminal justice, sexual health, and related harms. How someone develops a substance There are many child protection. use disorder is as unique as the person’s life pathways to developing It is important to know why and how drug use circumstances (names and identifying information a substance use disorder. were changed to protect privacy): starts. The reasons are unique to each person and may change over time. Some examples include: Mark works in the trades. When he wanted are continuing opioid use despite harm, it also includes which patients are continuing opioid use without benefit.
to work longer hours and make more money, he would take opioids to get through the day. As he used opioids for a longer period of time, his pain sensitivity increased and his functioning decreased. His body started needing higher and higher doses to get the same effect. Shayla was trafficked. She was forced to have sex with strangers. Her trafficker started giving her opioids. When she had withdrawal symptoms, her trafficker would offer more opioids in exchange for sexual acts with himself and others. Shayla came to use opioids as a way of numbing the pain of her sexual exploitation. William had surgery on his back following a car crash. He was prescribed opioids while in the hospital and sent home with opioids. When he ran out, he got extras from friends and family. No one ever told him about the risks of opioid dependence or addiction. Six months following his surgery, he was still taking opioids and going to great lengths to obtain them.
• Drug use is what is known, it is routine, familiar, and/or a part of family life. • For pleasure, entertainment, or sense of wellbeing. • Other forms of treatment are not working. • It is cheaper than other forms of treatment. • Escape, coping, or numbing. • Distancing from emotions or feelings of unworthiness. • Softening the pain of another trouble. Understanding the opioid epidemic in Minnesota to page 284
Liz works at a hotel. She cleans rooms and does laundry. She is on her feet all day. Her shoes are threadbare and she sleeps on an air mattress on the floor at home. At a family gathering, her aunt saw Liz holding up her aching lower back. Her aunt gave her prescription opioids that she was no longer using. Liz was scared to talk to her doctor about her pain because she knew that getting medications from someone else was illegal.
Age-adjusted rate (per100,000 residents)
Drug overdose mortality rates by race, MN Residents, 2015 and 2016 2016 64.6
70.0
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stdavidscenter.org 952.548.8700 Figure 2. Disparities in opioid-related deaths in Minnesota, 2015–2016. MINNESOTA PHYSICIAN MAY 2018
27
3Understanding the opioid epidemic in Minnesota from page 27
using more than one drug intentionally. More recently, illicit substances are being laced with other substances, such as methamphetamine laced with heroin, or heroin laced with fentanyl and/or fentanyl analogs. Another way • To stay awake all night, or to squelch hunger or cold. that multiple drugs may appear on a death certificate is when a person is • Self-medicating for anxiety, depression, or trauma. prescribed one or more medications from a provider, and/or they are using • Opioids are prescribed by a health care some form of illicit drug. It is important to note provider. that if the toxicology report finds a prescription medication within normal limits, and the Minnesota’s overall drug mortality rate decedent had a prescription, the drug may not be masks racial disparities listed on a death certificate. In other words, when The opioid epidemic is not Minnesota has one of the lowest drug overdose a drug is listed on a death certificate as the cause happening in isolation from other mortality rates in the nation. While Minnesota of death, it is because that drug was involved in conditions and social problems. is low in overall mortality rates, these rates are the death of a person. A relevant application in masking significant racial disparities. The rate the current epidemic is the use of two different disparity between whites and African Americans, drugs in close succession, termed “speedballing.” and between whites and American Indians, is the The two drugs have an opposite effect (upper worst in the nation. In Minnesota in 2016, African and downer) on the body; this drug use route is Americans were more than two times more likely to extremely dangerous and leads to a very confused central nervous system. die of a drug overdose than whites. In Minnesota in 2016, American Indians The person often does not feel the full effect of either drug, which can were almost six times more likely to die of a drug overdose than whites. Not dysregulate the body even more. only have mortality rates grown worse from 2015–2016, the disparity has grown Polysubstance use is important to understand for multiple reasons: more disparate, as shown in figure 2. All programs, policies, and interventions must have a racial equity lens in order to not replicate these harms. • Naloxone, the medication that blocks the effects of opioids
Multiple substances are showing up on death certificates for drug overdose deaths
during an opioid overdose, only works on opioids (not on other substances involved).
More than one drug is sometimes found in the toxicology report when an autopsy is completed. This does not necessarily mean that the person was
• Drug use patterns change, and can become more risky or chaotic, over time.
Healthcare Planning and Design
• When someone is addicted to a substance, it takes more and more to get the same effect, so people may use multiple substances to attain the desired effect. • At the height of a drug addiction, substances are no longer taken to get high, they are taken to avoid withdrawal symptoms, so people may use whatever is available to prevent being “dope sick.” • The awareness of polysubstance use has implications for clinical decision-making, for example the need to consult with the entire care team, educating patients about overdose risk, and meeting patients where they’re at. In 2016, the proportion of overdose deaths that involved polysubstance use differed by race in Minnesota: • 62 percent of drug overdose deaths among whites involved more than one drug. • 66 percent of drug overdose deaths among African Americans involved more than one drug. • 70 percent of drug overdose deaths among American Indians involved more than one drug
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MAY 2018 MINNESOTA PHYSICIAN
The race rate disparity in drug overdose death, and the higher incidence of polysubstance use being involved in overdose death, point to the complexities, obstacles, and systemic nature of health inequities. There may be many reasons why African Americans and American Indians are using, and dying from, polysubstance use at higher rates. Practice-based evidence has shown some of the reasons may include: • Lack of access to medical care or health insurance.
• Lack of trust with health care providers.
treatment, universal mental and chemical health screening, promoting safe use, safe storage, and safe disposal).
• Failure of appropriate diagnosis. • Easier access to illicit drugs. • Premature or abrupt discontinuation of opioids. • Illicit drugs are currently addressing symptoms. • The normalizing of sharing prescription medications with loved ones. • Higher incidence of historical trauma. • Higher incidence of adverse childhood events.
• Primary prevention (e.g., improving opioid prescribing practices, querying the prescription monitoring program, preventing the demand for altering substances, early identification and intervention for trauma and mental health needs, addressing risk factors that create trauma, building on Symptoms of opioid use disorder protective factors).
are more regularly observed than they are diagnosed.
Kate S. Erickson, MSW, is the opioid overdose
• Less research or evidence about the efficacy of interventions.
prevention director for the Minnesota Department
• Stigma around pursuing mental and/or chemical health care.
of Health (MDH) Opioid Dashboard, a one-stop
Providers and health care systems can save lives, address the harms that have already happened, and prevent harms from happening in the first place Providers are in a position to have a positive impact on the opioid epidemic through: • Emergency response (e.g., naloxone, nonfatal overdose follow-up, discharge planning, infectious disease control).
of Health (MDH). Visit the Minnesota Department shop for opioid-related data and information: www. health.state.mn.us/opioiddashboard.
This publication was supported by the Data Driven Prevention Initiative Grant or Cooperative Agreement Number, NU17CE924861-02-01, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
• Treatment and intervention (e.g., buprenorphine or methadone
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MINNESOTA PHYSICIAN MAY 2018
29
3Cancer clinical trials from page 17
the risk of colon cancer. This is a low-risk prevention trial, ideal for sites that are new to cancer research in their practice.
of clinical research—and potential new treatments—benefits all cancer patients, whether or not they participate in a clinical trial.
As the network is built and refined, and as sites gain experience conducting cancer clinical trials, the Minnesota Cancer Clinical Trials Network plans to open therapeutic trials, including phase 2 or phase 3 drug trials. The goal is to start small and progress at an appropriate pace to ensure patient safety.
A third aim of the Minnesota Cancer Clinical Trials Network is to educate the public about clinical trials and inform them about the enhanced excellent care associated with participation in a cancer clinical trial. Education plays a key role in dispelling many of the myths associated with clinical trials. By educating patients and physicians, we can help create and support more informed decision-making about care options.
Payoffs for physicians
The short-term goal of the Minnesota Cancer Clinical Trials Network will be to recruit more geographically diverse patient populations, allowing more Minnesotans access to opportunity for enhanced care, all with the long-term goal to lower the rates of cancer incidence and mortality in Minnesota and beyond.
What does this mean for Minnesota physicians? Importantly, this network enhances physicians’ ability to collaborate in bringing the latest care to their patients. While enhancing care for individual patients, it is also facilitating cancer clinical trials and cancer research while moving potentially lifechanging therapies and cutting treatments faster to the bedside.
With the best and brightest Minnesotan minds at work and focused on making the Minnesota Cancer Clinical Trials Network a success, more breakthroughs are on the horizon for enhanced cancer care. Working together, we know we can make a difference.
Notably, this process will strengthen Minnesota’s health care systems by including new training and protocols provided to the trial sites. Ultimately, more equitable access to research and treatment should improve cancer outcomes throughout the state.
Douglas Yee, MD, is director of the Masonic Cancer Center, University of
The first study scheduled to launch throughout the network aims to evaluate the effects of a twice-daily dose of ginger on the patient’s gut microbiome. Ginger has known anti-inflammatory properties, and researchers want to know more about whether it has the potential to reduce
medical degree at the Pritzker School of Medicine, University of Chicago, did his
“The Hub helped me get back on Social Security so that I could pay my bills while I continue to work on my health.”
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MAY 2018 MINNESOTA PHYSICIAN
Minnesota, where he holds the John H. Kersey Chair in Cancer Research. He is also a professor of medicine and pharmacology. A board-certified medical oncologist, he sees patients at the MHealth Breast Center. Dr. Yee obtained his residency at the University of North Carolina, and completed his fellowship at the National Cancer Institute. He previously held faculty positions at Georgetown University and the University of Texas Health Science Center at San Antonio.
Resources, tools, solutions. With Disability Hub MN, you can put an essential resource directly in your patients’ hands. From explaining health coverage options to submitting medical benefit applications, Hub experts are uniquely positioned to support people with disabilities.
3Certified community behavioral health clinics from page 21 to increase the quantity and quality of available behavioral health services, reduce the burden on physician providers, and improve the overall network of care for patients. As care coordination improves, so do outcomes for patients and clinics.
Putting the patient first We see the benefits of the CCBHC model every day and we hear from patients the difference the “onestop-shop” has made in their lives. One example:
As of today, he has completed intensive treatment, reconnecting with his own voice and courage on the journey to recovery. He has remained sober and is stably housed. He and Wilder staff actively work together to achieve his other goals of obtaining employment and health insurance. His family is no longer afraid of him or for him, and continues to be supportive and confidently engaged in his care. There is hope and healing throughout the entire family.
Minnesota was chosen to be one of eight states to pilot the CCBHC service delivery and payment model.
This example reflects the reality that physical, mental, and social health are interconnected. By recognizing this, CCBHCs have the potential to A mother and father came to Wilder’s clinic demonstrate better results for patients, providers, seeking mental health support for their adult son health care systems, and communities in general. after a referral from the local police department. 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main We hope this is just the beginning of a movement to During the process to assess his needs, staff Providers of Business Communication Solutions – www.laserwave.net make mental health and substance use disorder care discovered that he was struggling with both mental more accessible and effective. health issues and substance abuse. In addition, 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main 160 FirstFirst Suite 5,MN New Brighton, MNMN 651-383-1083-Main there were many other basic needs, such as housing, employment, lack of 160First First Street SE, Suite 5,New New Brighton, MN 651-383-1083-Main 160 160 Street First Street SE, Suite 160 SE, Suite 5,Street Street 5, SE, Brighton, New SE, Brighton, Suite 5, 651-383-1083-Main New MN 651-383-1083-Main Brighton, 651-383-1083-Main Providers Communication – www.laserwave.net vice president of Community Pahoua Yang, MSSW,of Business PhD, LP, LICSW, isSolutions Providers of Business Communication Solutions – www.laserwave.net Providers ofBusiness Business Communication Solutions –www.laserwave.net www.laserwave.net Providers Providers of of Business Communication Providers Communication of Business Solutions Communication Solutions – – www.laserwave.net Solutions – www.laserwave.net health insurance, and overall general poor health. When he walked in the Mental Health and Wellness at the Amherst H. Wilder Foundation. HelloMakers Technology Decision Makers Hello Technology Decision Hello Technology Decision Makers Hello Hello Technology Technology Technology Decision Decision Makers Decision Makers Makers door, he became a Wilder client with aHello team of providers ready WeCCBHC market Digital Copier/Network Printer/Scanner Systems to support him. Claire Wilson is assistant commissioner at the Minnesota Department of & Wide-Format Printers to savvy business owners After identifying a treatment path with Wilder staff, he began attending Human Services. We market Digital Copier/Network Printer/Scanner Systems We market Digital Copier/Network Printer/Scanner Systems WeWe market Digital Copier/Network Printer/Scanner Systems We market market Digital We Digital market Copier/Network Copier/Network Digital Copier/Network Printer/Scanner Printer/Scanner Printer/Scanner Systems Systems Systems individual, group, and Throughout family therapy sessions. To support his recovery, he the Upper Midwest, and across North America. & Wide-Format Printers to savvy business owners also engaged in case management peer&support services. Within two ave Wide-Format Printers toto savvy business aser ommunications Wide-Format Printers to savvy business owners &&Wide-Format &and Wide-Format & Wide-Format Printers Printers to savvy to Printers savvy business business savvy owners business ownersowners owners weeks of admission, he was safely housed in a sober home. 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main
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160 First St., SE, New Brighton, MN 55112 FreePeripherals Space Optics – VoIP Systems – Data Networks - Multi-Function Peripherals Free SpaceSystems Optics – VoIP Systems – Data Networks - Multi-Function Free SpaceSpace Optics ––Networks VoIP – -Data Networks - Peripherals Multi-Function Peripherals Free Space Optics –VoIP VoIP Systems Data - Systems Multi-Function Peripherals Free Space Free Optics Space –Optics –Systems VoIP Free Systems – –Data Optics Data – VoIP Networks - Multi-Function – Data Peripherals Networks - Multi-Function Peripherals Free Space Optics – VoIP Systems –Networks Data Networks - Multi-Function Multi-Function Peripherals
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3Consolidation from page 14
Actions for physicians and community leaders
members may not be diligent enough about the process to carefully build strategies and commitments to apply the scope and scale of resources that result from the consolidation to meet the local needs for service enhancements and organizational vitality as a key employer and care provider.
Achieving positive results from future consolidations requires all of us within the health sector—physicians, administrators, and board members—to strive for initiatives that focus on patients’ needs first. Physicians can be the central players in this journey to earn value from scale, but also to retain the agility and local leadership for as long as possible.
Myth 2: Blending the cultures among the In the eyes of local community leaders and consolidating organizations will be easy and quick. patients, physicians remain trusted leaders for Response: The euphoria of getting the deal done Physicians make smart decisions positive health system change. This respected role, too often overlooks the difficulty of earning the when given good information however, can erode if physicians are not ready excitement and support of employees and physicians to step up and step forward to ensure that the in the smaller organization. Substantial time, positive attributes of consolidation are maximized, training, and sincere expressions of appreciation for and the negatives minimized. Three actions are heritage and local culture by the physician, board, and important for physicians to consider in their administrative leadership are essential. Investment critical leadership roles: funds for the celebration of the local culture and personality are needed to Be the patient’s champion. Physicians need to be encouraged unleash the full potential of the consolidated talent in all organizations. by community board members and administration to be vocal and Myth 3: Physician support will be very difficult to achieve for the effective champions for what is best not just for their patients, but for consolidation. Response: Physicians make smart decisions when given good the community. Physicians must ask for any process of joint planning information about the options and rationale for a particular path. When or alliance to clearly define how the consolidation will yield measurable physician leaders see that a consolidation will generate value for their benefits to all segments of the population. Ask for not just the measures of patients, the community, and their organization, their engagement will not value—such as improved access to specialty care, enhanced care quality, only be forthcoming, but of immense importance to the scope and nature and demonstrable savings in out-of-pocket costs to patients—but for clear of the collaboration. explanations of how those gains will be achieved, and in what timeframe. Ask how the patient’s perspective and participation can best be optimized in the process.
Sioux Falls VA HEALTH CARE SYSTEM
Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.
The VAHCS is currently recruiting for the following positions:
Cardiologist
Physiatrist
Urologist (part-time)
Endocrinologist
Psychiatrist
ENT (part-time)
Emergency Medicine
Psychologist
Orthopedic Surgeon
Pulmonologist
apply online at www.USAJOBS.gov
Forge strategic alliances. Physicians can work with your hospital managers and board leaders to define a structured process to invite proposals for support from larger health systems regarding how they would deliver value to your patients and hospital while minimizing the community’s sense of lost local pride or independence. The most common areas of support are: part-time specialists that provide services and procedures in your hospital; advice and counsel about practical ways to strengthen your local clinical care processes and the mapping of superior patient experiences; and economic strength from shared services or co-ventures in selected diagnostic or rehab service centers, especially in heart, cancer, and orthopedics. Explore options. Physicians can organize a relaxed evening dinner and invite physicians and board members from other communities that have experience with consolidations. The guests can provide insights into factors that served to frustrate or facilitate achieving the desired benefits and outcomes from the consolidation. They can also help define obstacles to avoid and initiatives to hardwire into your process to gain the advantages of larger scale while minimizing the disadvantages. Consolidations are not going away in the health sectors of all states, but their outcomes can be enhanced by applying the considerations in this article. James A. Rice, PhD, FACHE, is managing director for governance and leadership at Gallagher Integrated in Minneapolis.
(605) 333-6852 · 32
www.siouxfalls.va.gov
MAY 2018 MINNESOTA PHYSICIAN
For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com ©2013 Paid for by the U.S. Air Force. All rights reserved.
MINNESOTA PHYSICIAN MAY 2018
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3Minnesota Prescription Monitoring Program from page 25 Prescribers were asked to select all factors that applied regarding the CSIA they received. Of those who responded, some of the top answers were as follows: • Identified a patient that was misusing, abusing, or diverting controlled substance prescriptions (43 percent). • Performed a query in the MN PMP on the individual after receiving the CSIA (40.4 percent).
patients misusing controlled substances use various methods to obtain such medications and that prescribers and pharmacists may not be aware of all of their patient’s activities. It is the belief that well-informed practitioners can and will use their professional expertise to assist patients who may be misusing controlled substances. The PMP trusts that providing prescribers and pharmacists with this information will lead to optimum patient care.
More than 85 percent of prescribers felt the information provided by the CSIA was useful.
If you receive a CSIA it is recommended that you assess the patient’s controlled substance prescription history in the MN PMP database. Upon viewing the patient profile, it is suggested that you:
• Spoke to my patient about their PMP report (27.5 percent).
• Confirm that you wrote the prescriptions attributed to you.
• Discontinued prescribing controlled substance medication(s) for my patient but continued to provide care for him/her (25.5 percent).
• Consider contacting other prescribers on the report in an effort to coordinate care.
Overall, more than 85 percent of prescribers felt the information provided by the CSIA was useful.
What do I do if I receive a CSIA? Prescribers and pharmacists are not obligated to take action in response to receiving a CSIA. It is not the program’s intent to suggest how providers conduct their practice. The PMP staff recognize that some patients have special needs or conditions that justify large quantities of controlled substances. On the other hand, the PMP staff are also aware that oftentimes
• Discuss the report with your patient. If you are not currently registered with the MN PMP, you can register for an account by visiting http://pmp.pharmacy.state.mn.us/access-requestforms.html. Once access is requested you should have an account within 15 to 30 minutes.
How to learn more about CSIAs? More information regarding CSIAs can be found on the MN PMP’s website under Frequently Asked Questions (http://pmp.pharmacy.state.mn.us). Additional questions can be directed to the PMP office: minnesota.pmp@ state.mn.us.
Mandated registration Prescribers are reminded of the law change that went into effect July 1, 2017, requiring the registration and maintenance of a MN PMP account. Specifically, all Minnesota licensed prescribers who practice in this state, and who hold a valid Drug Enforcement Administration (DEA) prescriber registration to prescribe to humans, are required to register for and maintain an account with the MN PMP. The Health Licensing Boards are overseeing compliance with the mandate. Questions regarding required registration should be addressed to the respective health licensing board.
with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:
Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com
Apply online at www.mankatoclinic.com
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MAY 2018 MINNESOTA PHYSICIAN
As of December 2017, 10,293 medical doctors (MDs), doctors of osteopathy (DOs), and physician assistants (PAs) have an active MN PMP account, out of 26,653 possible account holders. An active account is defined as an account that has been logged into upon notification of initial approval and has been revalidated annually. The total possible number of account holders are the number of providers licensed by the Board of Medical Practice and eligible for a DEA registration. It is important to keep in mind that just because the prescriber is licensed by a Health Licensing Board, it is does not necessarily mean they have a DEA registration. Katrina Howard, PharmD, works as the pharmacist consultant for the MN PMP. Dr. Howard currently serves on the National Association of State Controlled Substances Authorities (NASCSA) PMP Committee.
A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year
THE STRENGTH TO HEAL and get
POSITIONS AVAILABLE:
back to what I love about family medicine.
OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic)
Do you remember why you became a family physician? When you practice in the Army or Army Reserve, you can focus on caring for our Soldiers and their Families. You’ll practice in an environment without concerns about your patients’ ability to pay or overhead expenses. Moreover, you’ll see your efforts making a difference.
• 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
To learn more, visit healthcare.goarmy.com/kb60
Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com ©2010. Paid for by the United States Army. All rights reserved.
Minneapolis VA Health Care System Opportunities are available in the following specialties: • Chief of Internal Medicine • Chief of Nephrology • Cardiologist • Internal Medicine/Family Practice • Neurologist/Epileptologist • Psychiatrist • Tele-ICU (Las Vegas, NV) • Outpatient Clinics: - Hibbing, MN - Ely, MN 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.
Minneapolis VA Health Care System (MVAHCS) is a teaching hospital providing a full range of patient care services with state-of-the-art technology, as well as education and research. Comprehensive health care is provided through primary care, tertiary care and longterm care in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics and extended care.
Possible Education Loan Repayment • Competitive Salary Excellent Benefits • Paid Malpractice Insurance
For more information on current opportunities, contact: Nicole Barthelemy: Nicole.Barthelemy@va.gov • 612-467-4304 or Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964
One Veterans Drive, Minneapolis, MN 55417
•
www.minneapolis.va.gov
MINNESOTA PHYSICIAN MAY 2018
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3Gender-specific substance use disorder care from page 23
SUD and co-occurring assessments in your facility and to care-coordinate transportation or referrals from that point.
to bring their children with them when they enter residential treatment. This allows for the child to receive mental health treatment and support, repair the parent-child bond, improve the family’s well-being comprehensively, and invest in familyfocused healing in order to stop the multigenerational transmission of risk.
Most Minnesota mental health and substance use disorder professionals are on the Fast-Tracker Referral System (http://www.fast-trackermn.org). This system enables you to find open bed space, locations, levels of care offered, and locations where assessments can be provided.
Tips for the medical community Know who is across the table from you when a woman accesses your health facility and has a substance misuse issue. Try to understand her whole health picture and what might be contributing to the problem. Research shows that having one healing relationship, even from your family physician, may help to counteract the impact of adverse childhood experiences.
Often women avoid treatment because they have no [options] to care for their children.
Build meaningful referral relationships with community-based resources who understand this population and the associated complexities, including the need to address both substance abuse and co-occurring behavioral health concerns concurrently. Initiate partnerships with these providers to enable co-location in your medical facility. This allows for the woman to experience a warm referral at the moment of contact, rather than waiting for a referral to take place on her own initiative at a later date. You may want to partner with resources that can provide
Moving forward Minnesota has been known for its bold leadership in the field of addiction medicine for many decades. Today we need that bold leadership again, in conjunction with collaborative health systems, to set the pace for change regarding what women and families need to heal from trauma, substance misuse, and a lifetime of suffering.
Karina Forrest-Perkins, MHR, LADC, is a national consultant on how the accumulation of stress contributes to substance misuse, best practices in co-occurring treatment, and the prevention of substance misuse. She is the CEO of Wayside Recovery Center and a technical consultant for the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for the Application of Prevention Technologies.
Carris Health is the perfect match “I found the perfect match with Carris Health.” Dr. Cindy Smith, Co-CEO & President of Carris Health
Carris Health is a multi-specialty health network located in west central and southwest Minnesota. Carris Health is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/ BC physicians in the following specialties: • Dermatology • ENT • Family Medicine • Gastroenterology • Geriatrician • Hospitalist
• Internal Medicine • Nephrology • Neurology • OB/GYN • Oncology • Orthopedic Surgery
• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urology
Loan repayment assistance available.
FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | Shana.Zahrbock@carrishealth.com | (320) 231-6353 | acmc.com We are pleased to introduce Carris Health, a new entity launched in January to deliver high quality health care to West Central and Southwest Minnesota. Carris Health is a partnership between ACMC Health, Rice Memorial Hospital and CentraCare Health. This partnership allows us to reach beyond our individual capabilities to combine the talent and skills of all three organizations. Visit www.carrishealth.com for more information.
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MAY 2018 MINNESOTA PHYSICIAN
Family Medicine & Emergency Medicine Physicians • • • • •
Great Opportunities
St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria
Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice
Opportunities for full-time and part-time staff are available in the following positions: • Physician (Internal Medicine/Family Practice) • Physician (Hospice & Palliative Care)
• Physician (Pain Clinic/Outpatient Primary Care) • Psychiatrist (Mental Health)
• Physician (Pulmonologist) Part-Time 763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
• Physician (IM/FP) Montevideo MN
Urgent Care Physicians HEAL. TEACH. LEAD.
At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE
US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.
For more information:
Visit www.USAJobs.gov or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303
(320) 255-6301
MINNESOTA PHYSICIAN MAY 2018
37
3Network growth spurs team integration from page 19 As a result, we have seen patients who underwent total joint replacements, for example, do better at home with appropriate support than they would in a nursing facility. Similarly, we have shown that hand-offs to MTM pharmacists have significantly lowered readmissions (Holly Budlong, et.al, Impact of Comprehensive Medication Management on Hospital Readmission Rates. Population Health Management 2018; 00: 1-6). Data and protocols are important, but we never lose sight of the patient’s story or forget the need for passion and good judgment. We look to all care team members to bring clinical thinking skills and a consistent desire to improve outcomes for patients.
Measurement illustrates gains We’re proud of our initial results. Fairview’s hospitals in Edina, Burnsville, Princeton, Wyoming, and Hibbing score in the top quartile nationally for low 30-day readmissions, compared to CMS national benchmark data. Further, Pioneer ACO (CMS) data show Fairview Health Network readmissions score better than the national rate, as do our patient acuity and cost, which measure in the 25th percentile. Network providers, both Fairview-employed and those with independent practices, recognize the benefit of care coordination. In a 2016 survey of network providers, 117 out of 158 (74 percent) of respondents agreed or strongly agreed that care coordination in their clinic assists patients in achieving care plan goals. In a related survey, 97 percent of network providers responding indicated that their use of MTM services improved outcomes toward patients’ clinical goals.
While we still have work to do to engage providers, we work to strengthen adoption by cultivating a culture of quality. This is the idea that everyone on the care team helps to identify and respond to patient needs to support best outcomes and efficiency.
Physicians can ensure successful hand-offs Care coordinators can support patients and the care team best when providers involve them. Yet, introducing the idea of a care coordinator may require finesse on the part of the physician. Patients who aren’t feeling well may become anxious at the thought of someone other than their physician participating in their care. Because most patients trust their primary care doctors, physicians can help to ensure a successful hand off to a care coordinator. When physicians recommend care coordination in person as a way to simplify care, help to lower costs, and improve outcomes, most patients agree to the process. We love working with care teams—especially when serving patients with multiple complex needs. Such needs may feel heavy for the primary care providers. Yet we have seen these wonderful care partners work their magic so providers can focus on what they do best. Patients enjoy better health outcomes this way, and that’s our first priority. Jennifer Welsh, MD, is a primary care physician who recently moved from Fairview Clinics–Fridley to Fairview Home Care and Hospice.
Karen Mulder, RN, is Fairview system director, care coordination.
Private health insurers have made
$65 billion in profits since 2010 Meanwhile, our patients face mounting deductibles and copays, skyrocketing drug costs, narrowing networks, and other barriers to needed care. And our medical profession is increasingly degraded by mindless paperwork and the games of a profit-hungry corporate bureaucracy. As doctors, we should be providing care to our patients, not haggling with insurers about the value of treatments that should have been covered in the first place.
Endorse The Physicians’ Proposal for Single Payer at pnhp.org/nhi 38
MAY 2018 MINNESOTA PHYSICIAN
STAY FOCUSED AMONG THE DISTRACTIONS.
Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E A N A LY T I C S R I S K M A N A G E M E N T E D U C A T I O N
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is for children. Innovative pediatric care University of Minnesota Health leads the way in children’s healthcare. Inspired by the need to explore and develop, we’re committed to bringing breakthrough treatment options to kids.
Refer your patients by calling 888-543-7766 to give them expert pediatric care that’s always at the forefront of research and technology.
University of Minnesota Health pediatric clinic locations: Burnsville • Maple Grove • Minneapolis • Woodbury Learn more at MHealth.org/childrens
The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. © 2018 University of Minnesota Physicians and University of Minnesota Medical Center.