Minnesota Physician, August 2019 by Minnesota Physician Publishing

MINNESOTA

AUGUST 2019

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIII, No. 05

The Gender Health Program Partnering with youth and families BY ANGELA KADE GOEPFERD, MD, FAAP

Reference-Based Pricing Insuring cost transparency and a private medical marketplace BY DAVE RACER, MLITT, AND GREG DATTILO, CEBS

n April 28, “…the Washington State legislature passed a bill to create standardized [public] health plans…The hallmark of these new plans, and the foundation of their claim to the title ‘public,’ is they are required to cap provider reimbursements at Medicare-based levels [emphasis added] (Health Affairs, May 1, 2019).” The new Washington State standardized plans are non-government, private health plans. They will base reimbursements on a Medicare-plus formula capped at 160% above the Medicare-allowable amount. Under this new law, physician payments must be at least 135% above Medicare, most likely to ensure that residents have access to nearby doctors.

Reference-Based Pricing to page 104

hile nearly 3% of Minnesota high school students identify as gender diverse, many of them do not know where to turn when it comes to finding culturally sensitive, gender-affirming care. Also, despite recent advances in health care, transgender and gender-diverse youth continue to face significant health disparities, including higher rates of harassment, discrimination, homelessness, and suicidality. This growing population of children and adolescents is also known to be medically underserved, as patients and families often don’t know where to go or how to access care, or have to wait months or drive several hours to get questions answered and access medical services. As part of Children’s Minnesota’s commitment to provide equitable and inclusive care to all The Gender Health Program to page 124

AUGUST 2019 MINNESOTA PHYSICIAN

ND 52 SESSION

AUGUST 2019

Volume XXXIII, Number 5

COVER FEATURES Reference-Based Pricing

Insuring cost transparency and a private medical marketplace

The Gender Health Program Partnering with youth and families By Angela Kade Goepferd, MD, FAAP

By Dave Racer, MLitt, and Greg Dattilo, CEBS

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Helping older adults reach their recovery goals Ellie Skelton, MA Touchstone Mental Health

MEDICINE AND THE LAW 14 Physician employment rights A new legal landscape

ONCOLOGY 18 An underutilized, superior screening tool Low-dose CT scans for lung cancer By Nancy Torrison and Manish R. Patel, DO

ONCOLOGY 20 Multidisciplinary tumor conferences A surgeon’s perspective By Kamrun Jenabzadeh, MD, FACS

CLINICAL AND NON-CLINICAL CARE TEAMS Improving interoperability

Thursday, November 14, 2019, 1–4 p.m. The Gallery, Hilton Minneapolis | 1001 Marquette Avenue South BACKGROUND AND FOCUS:

By Lawrence P. Schaefer, JD

MINNESOTA HEALTH CARE ROUNDTABLE

As health care costs constantly rise, containment strategies involve care teams. Many individuals are now part of every physician-patient encounter. Some are hands-on with the patient, some the patient never sees. New entities become part of care teams, offering services from chronic care management, to behavioral health screening, to care coordination, to coding, charting and much more. With goals of lowering costs, increasing reimbursement, and improving outcomes, clinics can customize teams to individual patient needs. Keeping up with this rapidly evolving landscape can exceed the capacity of many medical groups.

Social Disparities in Health Care 22

OBJECTIVES:

ONCOLOGY 16 Skin cancer A gateway to earlier interventions By Rebecca J. Morris, Phd, and Heuijoon Park, PhD

Correcting the curve

We will examine the diversity of care teams and how they interact. We will explore benefits that could result from improved coordination of these care teams. We will identify the barriers to this improved communication, such as incompatible EHRs and data privacy issues, and ways around them. We will provide examples of successful integration of clinical and non-clinical care teams and a road map for adopting and scaling these models for all elements of our health care delivery system.

PANELISTS INCLUDE:

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Vivi-Ann Fischer, DC, Chief Clinical Officer, Fulcrum Health Mike Starnes, mstarnes@mppub.com

EDITOR___________________________________________________ Richard Ericson, rericson@mppub.com

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ART DIRECTOR_______________________________________________Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email mpp@mppub.com; phone 612.728.8600; fax 612.728.8601. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

PURCHASE YOUR TICKETS AT MPPUB.COM MINNESOTA PHYSICIAN AUGUST 2019

CAPSULES

New website serves people with hearing loss

New law requires check of exclusion list

People with hearing loss can learn more about assistive technology, communications access, and other issues at a new website (www.mn.gov/ deaf-hard-of-hearing) launched recently by the Minnesota Department of Human Services (DHS). The site is designed for people who are deaf, hard of hearing, deafblind, and late-deafened; people experiencing age-related hearing loss; and people who live, work, and provide services to people with hearing loss. It features captioned videos in American Sign Language, or ASL, and English. Funding comes from a special 2017 legislative appropriation. The site is organized around the most common issues faced by people with hearing loss, with information on assistive technology, communications access, living with hearing loss resources, and more.

Anyone submitting claims to Medical Assistance–including hospitals–is now required to check the Department of Human Services (DHS) exclusion list “on a monthly basis and document the date and time the exclusion list was checked and the name and title of the person who checked the exclusion list … even if the named individual or entity is not responsible for direct patient care or direct submission of a claim to Medical Assistance.” If the hospital discovers that an employee or contractor appears on the list, the hospital is to immediately terminate payments to that individual or entity. The hospital must also refund any payment related to either items or services rendered by an individual or entity on the exclusion list dating back to the later of the individual’s or entity’s first appearance

on the list or the first payment made to the individual or entity. Failure to comply with this provision may result in withholding or reduction of Medical Assistance payments, suspension or termination of Medical Assistance participation, and civil monetary penalties of up to $25,000 per individual or entity on the exclusion list. To view the exclusion lists, visit www.tinyurl.com/mp-exclusion and click on “MHCP Excluded Group Providers” and “MHCP Excluded Individual Providers.”

University of Minnesota launches Gamma Knife Icon technology University of Minnesota Health (M Health) is the first in the state to treat brain tumor patients with the latest generation advanced radiosurgery technology, the Gamma Knife Icon, which delivers high doses of

Joint sponsorship by Minnesota Medical Association and Nura Pain Clinics

Chronic Pain Conference Tools and strategies for managing the chronic pain patient.

Friday, November 8, 2019 CME Conference at the Westin Galleria Edina 4

AUGUST 2019 MINNESOTA PHYSICIAN

radiation to a tumor without exposing the surrounding normal brain to significant radiation. Radiosurgery works by focusing radiation beams from different angles to a small target. While each beam delivers a small radiation dose that is well-tolerated by the brain, the point where the beams converge receives a high dose—sufficient to eradicate tumor cells. “For this radiosurgery to work, precision of radiation delivery is essential. Being off by a few millimeters can mean the difference between destroying tumor cells and mutilating normal brain” said Clark Chen, MD, Lyle French Chair and Head of the Department of Neurosurgery at the University of Minnesota Medical School. “The Gamma Knife Icon is the sixth generation of Gamma Knife radiosurgery machine. It is capable of targeting treatment areas with accuracy to within 0.15 mm, or the width of two human hairs. This

Please join us at this one-day CME conference where a variety of specialists will share tools, strategies and expertise on managing pain patients. Individual presentations, followed by a panel discussion, will provide new perspectives on providing care in the midst of the opioid epidemic. Go to nuraclinics.com for agenda and speaker information. Designation of Credit Statement for Jointly Sponsored Activities: The Minnesota Medical Association designates this live activity for a maximum of six point seven five (6.75) AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CAPSULES

is the most accurate of the Gamma Knife machines to date.” In contrast to previous generations of Gamma Knife machines that require a metal headframe to be affixed to the patient’s skull, the Icon gives clinicians the choice of using an individualized face mask during radiation delivery. In this way, Icon will improve patient comfort and experience. Because of the new motion tracking technology, treatment can additionally be divided across multiple sessions, a capacity that previous generations of the Gamma Knife machines lack.

Minnesota providers to receive first-ever opioid prescribing reports More than 16,000 Minnesota health care providers serving Minnesotans on Medicaid and MinnesotaCare will receive reports in coming weeks comparing their opioid prescribing rates to those of their peers as part of a quality improvement effort led by the Department of Human Services (DHS) in collaboration with the medical community. The first-ever reports in Minnesota aim to create awareness among providers about their individual prescribing behavior—a message shared in a video by one doctor in Greater Minnesota (https://youtu.be/EZlh06WbdIw), who reframed the conversation about pain management and opioids with his patients after learning how his opioid prescribing rates compared to his peers. Minnesota law requires DHS to share the individualized, anonymous opioid prescribing reports annually and manage a quality improvement program for providers whose reports show they continue to prescribe outside of community standards. Health care providers who prescribed at least one opioid to a Medicaid or MinnesotaCare enrollee in 2018 will receive their report over the coming weeks. This includes physicians, dentists, physician assistants,

and nurse practitioners. The reports assess prescribing behavior based on seven key measures using claims data, excluding data on opioids used to treat opioid use disorder and those prescribed to individuals in inpatient settings, with cancer, or who receive hospice or palliative care services.

Ridgeview and PrairieCare Medical Group enter agreement Ridgeview Medical Center (Ridgeview)—an independent health care system of hospitals, clinics, and specialty services—and PrairieCare Medical Group (PCMG), one of the region’s largest providers of inpatient and outpatient psychiatric care are partnering to offer new integrated behavioral health services in Waconia. The first partnership of its kind in Minnesota will have PCMG clinicians providing psychiatric services directly within Ridgeview’s Waconia campus through a joint operating agreement overseen by both Ridgeview and PCMG leaders. According to Todd Archbold, Vice President of Business Development at PCMG, “This formal collaboration will break down barriers that can exist between specialties, and create new efficiencies to allow nearly 1,500 more individuals to receive much needed mental health care in the first year. We are integrating psychiatric services in the general medical care setting, and reducing fragmentation between specialties to improve outcomes for our shared patients.”

Tickets at 612.377.2224 • guthrietheater.org

Eddie Palmieri

AUG 31

Latin Jazz Giant

Pat Metheny Side-Eye

w/James Francies & Marcus Gilmore

SEP 8

John McEuen & The String Wizards Present: Will The Circle Be Unbroken

SEP 12

Jenny and the Mexicats New School Retro Swing

SEP 4-5

9:30PM

SEP 25

Brian Blade’s Life Cycles Honoring the Music of Bobby Hutcherson

Lucibela

SEPT 12 7PM

Cape Verdean Voice-of-Gold

SEP 19-20

Michael Feinstein

Ambassador of The Great American Songbook

Candy Dulfer

SEP 26-27

Dutch Sax Superstar

Hepatitis A outbreak declared by MDH The Minnesota Department of Health (MDH) has declared an outbreak of hepatitis A in multiple counties among people who use street drugs (injection or non-injection), are experiencing homelessness or unstable housing, or have been recently incarcerated.

SEP 11

SEP 28 Patty Peterson Presents Jazz Women All-Stars

Al Di Meola: Past, Present, Future

612.332.5299 dakotacooks.com

1010 Nicollet Mall Mpls MN

Music of Di Meola, Piazzolla & The Beatles

MINNESOTA PHYSICIAN AUGUST 2019

CAPSULES

The outbreak includes 23 cases in nine counties: Pine (5), Hennepin (3), Kanabec (3), Mille Lacs (3), St. Louis (3), Washington (3), Chisago (1), Dakota (1) and Kandiyohi (1). Thirteen cases have been hospitalized and all have been discharged. While initial cases were clustered in east-central Minnesota and had links to each other, more recent cases occurred in counties in other parts of the state. The infection source is not known for some cases, suggesting some community transmission among those in high-risk groups. In May 2019, Minnesota began seeing an increase in hepatitis A cases. These cases had similar risk factors to national outbreaks of hepatitis A that have been occurring since 2016. Nationally, there have been more than 23,600 cases in 29 states. MDH has been monitoring the national outbreaks and conducting enhanced surveillance of hepatitis A since mid-2018.

MAAA receives national Aging Innovations Award Metropolitan Area Agency on Aging received a 2019 Aging Innovations Award for the Juniper program from the National Association of Area Agencies on Aging (n4a) on July 29, in New Orleans. The award is the highest honor presented by n4a to member agencies, going to programs that develop and implement cutting-edge approaches to support older adults, people with disabilities, and their family caregivers. According to Dawn Simonson, executive director of Metropolitan Area Agency on Aging. “Juniper has delivered health promotion classes to more than 16,000 people in Minnesota through a broad, distributed network that is deeply rooted in local communities. It’s making a difference in people’s lives.” As part of the Juniper network, Minnesota AAAs have become hubs

for community health and wellness. Across the state, they partner with 133 provider organizations and 660 class leaders.

Law on pediatric care coordination takes effect Minnesota law regarding care coordination at discharge now includes additional provisions on how a hospital provides care coordination for children with complex medical needs. The new law applies to “discharges involving a child with a high-cost medical or chronic condition who needs post-hospital continuing aftercare, including but not limited to home health care services, post-hospital extended care services, or outpatient services for follow-up or ancillary care, or is at risk of recurrent hospitalization or emergency room services due to a medical or chronic condition.” The law states explicitly that the hospital must ensure that the

following conditions are met and arrangements made before discharging any patient described in the paragraph above: The patient’s primary care provider and either the health carrier or, if the patient is enrolled in Medical Assistance, the managed care organization are notified of the patient’s date of anticipated discharge and provided a description of the patient’s aftercare needs and a copy of the patient’s discharge plan, including any necessary medical information release forms. The appropriate arrangements for home health care or posthospital extended care services are made and the initial services as indicated on the discharge plan are scheduled. If the patient is eligible for care coordination services through a health plan or health certified medical home, the appropriate care coordinator has connected with the patient’s family.

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AUGUST 2019 MINNESOTA PHYSICIAN

MEDICUS

Robert Dahlin, DO, has joined St. Luke’s Neurosurgery Associates in Duluth. Dahlin received his medical degree at Touro University Nevada College of Osteopathic Medicine in Henderson, Nevada. He then completed his neurosurgery residency at Riverside University Health System in Riverside, California, and a Spine Fellowship at the University of California–Davis Medical Center in Sacramento. He has a special interest in minimally invasive spine techniques and cervical artificial disc replacement surgery, both as a means to decrease surgical pain, and to improve surgical recovery.

BENJAMIN BEILMAN

Pamela Jordi, MD, has joined the growing practice at Clinic Sofia, an ob-gyn clinic with offices in Edina and Maple Grove. Jordi attended medical school at Creighton University in Omaha, Nebraska, and completed her residency at the University of Nebraska Medical Center. During the third year of residency, Dr. Jordi had her son, gaining an even greater appreciation for a healthy pregnancy, the labor process, and parenthood. Expanding her education and perspective, Dr. Jordi spent a month at the Institute for Latin American Concern in the Dominican Republic, providing health care for women at local hospitals and free clinics. She has also volunteered at free clinics in Omaha and provided education and testing for inmates at the Douglas County Corrections Facility. Dr. Jordi was drawn to Clinic Sofia’s holistic approach to women’s health care.

OSMO VÄNSK Ä

Jennifer J. Garber, MA, has been appointed as UCare’s Associate Vice President of Behavioral Health Services. Garber will lead this newly invigorated department in attainment of UCare’s behavioral health strategic goals for all Medicare, Medicaid, and Individual and Family Plan members. She will drive the organization’s vision to be a leader in ensuring behavioral health equity—especially for members of UCare’s Special Needs Plans. Garber brings more than 29 years of behavioral clinical experience, including 17 years of management experience within health plan behavioral programs. Most recently she was Director of Clinical Operations and Community Initiatives and Government Programs at Optum Health Behavioral Health Solutions with oversight of the Medica Behavioral Health Care Advocacy Center. Garber joined UCare this year and reports to Julia Joseph-Di Caprio, MD. She works with a team of Medical Directors, including a psychiatrist, to better integrate medical, behavioral health, and substance use services for members. Garber also manages UCare’s expanded behavioral health case management and substance use disorder reform to improve treatment delivery. These efforts include peer recovery support, treatment coordination, and comprehensive assessments and withdrawal management. She is licensed as an independent clinical social worker.

Osmo Vänskä /// Music Director

T I CK E T S ON SA LE N OW Season Opening: Osmo Vänskä and André Watts Sep 19-21

Saint-Saëns Violin Concerto Sep 27-29

Star Wars Live in Concert: The Empire Strikes Back COMPLETE FILM WITH THE MINNESOTA ORCHESTRA

Oct 2-6

Harry Potter and the Goblet of Fire™ in Concert COMPLETE FILM WITH THE MINNESOTA ORCHESTRA

Oct 25-27

612-371-5656 / minnesotaorchestra.org PHOTOS Vänskä: Nate Ryan. HARRY POTTER characters, names and related indicia are © & ™ Warner Bros. Entertainment Inc. J.K. ROWLING`S WIZARDING WORLD™ J.K. Rowling and Warner Bros. Entertainment Inc. Publishing Rights © JKR. (s18) © 2018 & TM LUCASFILM LTD. ALL RIGHTS RESERVED © DISNEY. Additional photo credits available online.

MINNESOTA PHYSICIAN AUGUST 2019

INTERVIEW

Helping older adults reach their recovery goals Ellie Skelton, MA

hospital, and they are more likely to remain safe and in their own homes.

Touchstone Mental Health

What are some of the ways Touchstone is partnering with medical systems to improve health care outcomes?

Please tell us about the mission of Touchstone Mental Health and how it started.

How has this mission evolved over the years?

We have adapted and grown to meet the needs of our clients. We do this through fundraising, exploring new grants, and finding new community partners. Safe and stable housing and creating access to community-based services that can assist our clients are areas of special concentration for us. We also work in partnership with many housing providers to ensure tenants aren’t evicted due to untreated mental health symptoms. What can be done to address the problems posed by social determinants of health?

As we focus our efforts to address social determinants of health, people are more likely to have improved housing and mental health stability, thrive in their community, and improve overall well-being. Our program staff work closely with agencies that provide community resources, health care, job training, employment, and food

AUGUST 2019 MINNESOTA PHYSICIAN

“...”

People over the age 55 are the fastest growing homeless population in Minnesota.

“...”

The mission of Touchstone Mental Health is to inspire hope, healing, and well-being. Our organization was founded in 1982 by a group of social workers from the University of Minnesota to ensure that older adults with mental illness had opportunities to live in a community of their choice with supportive services available to meet their health and recovery goals. For the past 37 years, we have brought cutting-edge ideas and programming to Twin Cities residents who have been diagnosed with having a serious mental illness. Touchstone’s philosophy of compassion and empathy sees each client as a whole person. Staff members aspire to be a touchstone in the lives of the people they serve, providing a point of reference that orients clients to recovery and well-being. We encourage our clients to define their life goals and we help them build supports to achieve them. Independence, dignity, connection, and choice are core values.

security, in order to optimize whole person health. Most of the people who come to us for services have very low incomes and many receive disability payments. Most of our clients have incomes of less than $10,000 per year, leaving little money for basic items for everyday living. One of our greatest challenges is supporting people in the critical first weeks after moving into a new setting. People often come to us directly from a hospital, personal crisis, or an unsuccessful housing situation. They come to Touchstone to help get their lives back on track and be part of a community again. Because of the disruption in their lives, they have few—if any—personal items essential to independent living, such as a bed, linens, or even a change of undergarments. By supporting our clients during short-term emergencies, we help them avoid a downward spiral that results from inconsistent medical treatment, a lack of food, or an unsafe place to live. Our experience shows us that when people have their basic needs met, their symptoms of mental illness decrease, they spend less time in the

Our goal is that each Touchstone client has a primary care provider and an annual physical. We track this metric and encourage clients to adhere to their medical treatment plan. Our clients often have not had consistent medical or behavioral health care and benefit greatly from this. We partner with the University of Minnesota School of Nursing to host Doctor of Nursing Practice students and offer interprofessional education working with a population that often has complex medical needs. Other metrics and goals include reducing inappropriate emergency room visits and providing community mental health services that reduce the need for psychiatric hospitalizations. We are always looking for new ways to partner and collaborate. Please tell us about the Minnehaha Commons project.

Minnehaha Commons is a permanent supportive housing program opening late 2019 in the Longfellow neighborhood of Minneapolis. It will house individuals 55 and older who are low income and are homeless. People over the age 55 are the fastest growing homeless population in Minnesota, according to Wilder Research’s homeless report, and we are working to reduce this trend. This is a collaboration of three organizations: Alliance Housing is the builder; Haye Gibson is the property management company; and Touchstone Mental Health will be the onsite service provider. Touchstone will offer customized living services, targeted case management, and housing support services with 24-hour onsite staff for individual support, assistance, and community referrals. What can you share about your Behavioral Health Home services?

Behavioral Health Home (BHH) services help people with mental illness reach their

wellness goals by coordinating medical and mental health care. Our BHH staff will meet you in your home or in the community to develop a health action plan to meet your needs. Our staff provides comprehensive care management, health promotion and wellness, comprehensive transitional care, family support, and referral to community and social support services. Eligible people include those who have a diagnosed serious mental illness, have medical assistance or a prepaid medical assistance plan, and are not currently receiving Targeted Case Management or Assertive Community Treatment (ACT) services. Another innovative program you offer is Project Community Success. How does this project work?

Project Community Success is designed to provide transition and housing-sustaining services for 125 low-income adults with a serious mental illness in Hennepin and Anoka counties. Touchstone Mental Health has received commitment for the project from affordable housing providers. Program success is measured by the number of people obtaining and sustaining housing. The program provides

services for people who are at imminent risk of becoming homeless. Project staff work with the individuals to develop a housing support plan and crisis plan. Staff provide education on how to be a good tenant, explain the roles and expectations of tenants and landlords, and stress the importance of developing relationships with neighbors, landlords, and others in their buildings. Staff help resolve issues with neighbors or landlords to decrease risk of eviction. How do you approach the challenges of care team coordination?

Our care guides often accompany clients to various medical appointments, providing support for the client and opening the lines of communication for all parties. When clients are hospitalized, we call their clinic to inform them of the hospitalization and to discuss any client needs. Care guides often have interdisciplinary team meetings. Since these meetings often are happening in the person’s home or in the community with other members of their team, our care guides will document the meeting and fax a summary to the primary care physician to keep them in the loop.

What criteria does the county use to determine who is eligible to participate in the services you provide?

There is a maze of eligibility depending on the service provided, and this is one of the most challenging parts of accessing mental health care. Private and public payers have different benefit sets, and this can be confusing to someone trying to access services. Our referral webpage (www.touchstonemh. org/referrals/) provides guidance for individuals making referrals to Touchstone Mental Health. What would you like doctors to know about how your work could benefit their patients?

Helping individuals with mental illness obtain and keep housing, make appointments, follow their physician’s plan of care, and navigate benefits aids in improving overall health. Partnerships between physicians and community mental health providers like Touchstone Mental Health is a key to helping people reach their recovery goals. Ellie Skelton, MA, is CEO at Touchstone Mental Health and a current board member for the Mental Health Providers Association of Minnesota.

MANY FACES OF COMMUNITY HEALTH 14TH ANNUAL CONFERENCE

COMMUNITY CENTERED CARE AND THE PEOPLE WE SERVE October 31 - November 1, 2019 • Earle Brown Heritage Center, Brooklyn Center, MN

Join us as we examine new community care innovations and health care delivery models that promote health equity, prevent and manage chronic diseases, and ensure access for all. Many Faces of Community Health is a two-day conference on improving care and health equity in underserved populations and among those living in poverty. Over 400 people attended Many Faces in 2018: health care professionals, students, staff from FQHCs and other safety net programs, policymakers, and Minnesotans active in community and public health. Attendees come together to learn about the impact of health care reforms, ways to advance health equity, and how to apply best practices to the delivery of primary care to the disadvantaged. Many health care organizations and companies support Many Faces as sponsors and/or exhibitors, joining with public health and community-based agencies to promote our conference and deepen our impact on Minnesota’s health care safety net providers and patients.

We hope you will join us in 2019 for this popular and inspiring conference Category 1 Continuing Medical Education (CME) credits will be available. A general certificate of attendance will be provided for continuing education/contact hours. Physicians should only claim credit commensurate with the extent of their participation in the activity.

For a complete list of speakers and times, visit the conference web site:

manyfacesconference.org

For more information: contact Shelby Maidl / shelby.maidl@mnachc.org / 612-253-4715 ext 0 MINNESOTA PHYSICIAN AUGUST 2019

3Reference-Based Pricing from cover

Bartlett eventually devised a Reference-Based Pricing health plan that paid hospitals an average of 234% above Medicare. The new plan pays The concept of reimbursing at a percentage above Medicare—Medicarephysicians and other medical providers not employed by hospitals about Plus—is nothing new. Though insurance companies prefer to tell their 165% of Medicare. The new Reference-Based Pricing health plan has members they have negotiated discounts off physicians’ bills, in reality, their turned the $9 million deficit into a $112 million surplus in two years, reimbursements are a percentage above Medicare according to Bartlett. Since implementation of the rates, which may be adjusted upward or downward Montana plan, Bartlett has not yet seen overall by geographical area. What is different about the medical prices falling as she had hoped—she Washington State idea is that government is setting believes this is likely due to the short time the RBP the cap. plans have been in place. Reference-Based Pricing ...

Here at home

turned [Montana’s] $9 million deficit into a $112 million surplus in two years.

Minnesota Gov. Tim Walz and the House of Representatives are working toward a similar goal, titling it ONECare. ONECare is a state-operated Platinum-level health plan designed to compete with private health insurance, but it sets reimbursements at Medicare levels. While state legislation did not pass in 2019, it will reappear before the 2020 session with hopes of being implemented in 2020.

Is this a wake-up call to physicians? If governments are moving to mandate caps on payments, is there an alternative that can head it off, ensure adequate payments for medical care, and enhance the professional relationship between physicians and their patients? Is there a different payment system that allows patients to shop for medical care based on price, but also quality, and access? If patients come to understand that the price of care affects their own costs, by what means can physicians publish prices so that patients can understand them? Would simpler price transparency improve the physician’s practice experience? In a larger context, can medical price transparency deliver marketplace discipline to reduce the high cost of health care? If any of this is desirable, a different way to pay physicians is needed.

A new model Reference-Based Pricing (RBP) insurance policies provide an alternative payment system that is more affordable for patients. Adherents claim it will provide more competition in medical pricing while simplifying price transparency. Simply stated, RBP insurance pays physicians at a set rate above Medicare, specified in the health plan. The purest form of RBP plans do not tell physicians the maximum rate they may charge above Medicare— the plan simply sets the maximum it will pay for medical care. Existing RBP plans are administered by carriers and/or third-party administrators in some other states. Large, self-insured plans may also be able to use their leverage to implement RBPs. The State of Montana launched an RBP health plan in 2016 for the 31,000 lives it insures as part of its state employee benefits. Ordered by a 2015 law to reduce health care spending for government employees, Montana turned to the RBP concept. In two years, it has saved the state millions of dollars. Montana faced a projected $9 million deficit in its self-insured health plan. Marilyn Bartlett, the Special Projects Coordinator hired by Montana to find a solution to this problem, wanted to quit robbing state employees of pay raises as a way to close the gap. She set a new goal—to reduce the cost of health care.

AUGUST 2019 MINNESOTA PHYSICIAN

Colorado and North Carolina officials have contacted Bartlett as they begin hopefully moving toward RBP plans. Colorado is also considering an RBP plan. A major business coalition in Indiana has retained the Rand Foundation to gather the data to learn how much above Medicare they have been paying. This new push for transparency and necessity to reduce prices, Bartlett believes, will see more self-insured plans moving to RBP payment systems.

Is RBP better? Reference-Based Pricing is by no means a perfect payment model, if one exists. It is, however, superior to current payment models in many ways. Insurance companies market their products as if they offer discounts from the physician’s billed fees, making them appear to be an indispensable player acting on behalf of their Members. In reality, insurance company reimbursements are built from the bottom up, from Medicare’s allowable amount plus a percentage above that amount. There is no discount, there is a mark-up. The current payment system requires a complex matrix of tens of thousands of billing codes, incomprehensible to patients and understood by very few physicians. Patients entrust insurance companies to sort it out and negotiate for them—but this drives up insurance premiums to pay insurance company and clinics’ administrative expenses. Worse, it keeps health care pricing secret. In most locales, insurance plans reimburse at rates significantly above Medicare. According to Minnesota Community Measurement, based on 1.5 million claims valued at $8.6 billion in 2017, insurance company reimbursements across the state averaged 187% above the Medicare allowable rate. The emerging Reference-Based Pricing health insurance products take advantage of the current Medicare-plus methodology of determining physician payments. It formalizes it and makes it transparent.

Making the price totally transparent and relevant protects the private medical care system For a medical care marketplace to emerge, patients must know and be concerned about the price they pay. Today’s insurance plans make price disclosure nearly impossible and seem to purposefully keep the price of care secret. The less the patient knows about price, the less they will question the cost, and the more they are dependent on insurance companies. The insurance policies many patients own do not require them to know the price of care, unless the patient has a high deductible policy.

Since someone else pays the bill, the patient has no incentive to know what it is. The current complaints about escalating, unaffordable insurance premiums, however, are generating a call for change—and some suggest “Medicare for All.”

Reference-Based Pricing plans eliminate networks since the insured person can go to any physician who is willing to accept payment based on the rate allowed by the health plan. In its truest form, RBP plans also allow balanced billing but only with complete transparency and disclosure before services are rendered.

“Medicare for All,” Governor Walz’s proposed Minnesota ONECare plan, and potential expansion of MinnesotaCare, all rely on physician payments lower than or equal to Medicare. If ONECare someday becomes an option, premiums will plunge, but so will access to physicians, hospitals, and all manner of medical care. Would simpler price Medicare rates will not support the current medical transparency improve the infrastructure. Cutting reimbursements from 187% physician’s practice experience? to 100% of Medicare would put quality health care in jeopardy and likely motivate some physicians to find a new profession.

RBP discloses the percentage above Medicare that a physician accepts as full payment. This provides a direct mechanism that engages the patient in price considerations related to choosing physicians, hospitals, imaging centers, labs, and all medical products. RBP would incent patients to choose physicians based on price, quality, and access. Physicians, too, could learn what other physicians in their area are charging for the same services, but no one would sign onto an RBP network contract—there are no networks, thereby reducing physician overhead expense, and increasing time to practice medicine.

Can RBP be a better option than Medicare for All? Price secrecy and the current reimbursement systems have spawned a maze of administratively expensive “provider” networks. A network is created by the price that physicians accept above Medicare. Multiple networks offered under the same health insurance brand pay different amounts for the same services based on a different mark-up above Medicare. In all this, however, the price is kept secret from patients and although recent legislation will require more price transparency, it will remain incomprehensible and confusing to most patients.

Simplify reimbursement calculations in RBP plans The RBP plan’s percentage rate above Medicare is totally transparent to the physician and the patient. It stands in contrast to the secret pricing of today’s health plans.

Reference-Based Pricing to page 344

MEDICAL MALPRACTICE ATTORNEYS

Angela Nelson

Matthew Frantzen

Ryan Ellis

Marissa Linden

Jennifer Waterworth

Tracy Jacobs

MINNESOTA PHYSICIAN AUGUST 2019

3The Gender Health Program from cover

One key component for most families is appropriate mental health assessment and referrals as needed. Our program includes a social worker/ children, we have launched the Gender Health Program. This personalized care navigator who participates in the initial intake assessment for each and comprehensive pediatric multispecialty clinic provides transgender family to help determine what resources are needed. We can connect parents and gender-diverse children and their families with resources and support for their questions, with medical care and support from pediatric and can connect youth with individualized experts they can trust, including experts in support systems. Our goal is to optimize care and pediatric gender health, pediatric endocrinology, outcomes for each patient, especially for those on and pediatric gynecology. a journey that involves transition, and to support Parental rejection is a the mental and physical well-being of the whole About the program significant risk factor for … child and the whole family. Having a strong Each family that comes to the Gender Health transgender youth. support system and a good understanding of what program will start with a gender consultation to expect helps youth and families be resilient in with one of our physicians. During this initial the face of change and weather any unexpected consultation, children and their families twists along the path. meet with a gender health expert to discuss For youth and families who are developmentally developmental questions or concerns about ready for medical treatment, we offer a variety of gender-affirming treatment gender identity and to develop a personal care plan. Each child and family options as part of unique treatment plans to meet individual patient needs. comes to the program at a different place and with a different path, so this consultation helps to answer questions, discuss goals, and think about next steps. Often youth—especially teenagers—and their families come to this initial consultation with different questions and goals. Our team is committed to helping understand what each child, parent, and family needs before moving forward. We can often help youth and families understand each other and learn to speak a common language as they navigate future steps on their journey.

The onset of puberty, for example, can be difficult for many transgender and gender-diverse adolescents, which is why Children’s offers both pubertal and menstrual suppression. These reversible interventions, delivered via shot or as an implant, pause puberty and/or menstruation for patients as necessary. Patients may also meet with a pediatric gynecologist for a consultation to discuss options to preserve fertility prior to beginning pubertal suppression and/or gender-affirming treatment. For patients who are in middle to late adolescence, gender-affirming hormone treatment may be appropriate. This hormone treatment creates changes in the body to align with the patient’s gender identity. The decision to move forward with such treatment is made with one of our gender health experts, along with a readiness assessment by a mental health professional to optimize outcomes—and to gauge the support and obtain the consent of parents.

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AUGUST 2019 MINNESOTA PHYSICIAN

Gender-affirming surgeries are most often performed for patients who are over the age of 18 and are not done at Children’s Minnesota. While Children’s Gender Health Program does not perform these surgeries, we can refer patients to plastic surgeons in the community as needed.

Tips for primary care physicians Transgender and gender-diverse youth who come to the Children’s Gender Health Program for specialized and expert care continue to receive their primary care—including well-child exams, immunizations, and ill-child visits—through their primary care offices. Primary care clinicians often have questions about how to best provide supportive and affirming care to transgender patients and their families. In turn, transgender and genderdiverse patients and their families often find themselves needing to educate primary care physicians, schools, neighbors, and family members about how to appropriately care for gender-diverse children. The best approach with any patient and family, including transgender and gender-diverse children, is to treat them how they would like to be treated. Ask each child the name they would like to be called, and the pronoun they use, and be sure to use this name and pronoun at each visit. Educate staff about how to ask each patient what name they would like to be called and what pronoun they use, so that they can do the same; this is

especially important for those answering phones, checking in, and rooming patients. It’s also important to remember that we all make mistakes, even when we are trying to do our best. When mistakes happen, we should acknowledge them, apologize, and commit to continuing to get it right in the future. Often, mistakes in calling a patient the correct name or using the correct pronoun are made due to limitations and barriers of the electronic medical record (EMR). Primary care providers should find out the best way to optimize their EMR system to visibly display the preferred or declared name of each child, as well as the pronoun they use. Think of situations in your office where these elements may or may not be visible in the EMR system. What do you see in the EMR when you check a family in at the front desk? How about when you open a patient chart? When you send a patient to lab and/or radiology, which name and pronoun is visible in the EMR? Being misgendered when seeking medical care is a common fear of transgender and gender-diverse patients and their parents, and anything we can do to ensure a smooth and affirming patient care experience will allow children and families to relax and focus on the medical reason for their visit. When children disclose questions about their gender identity, or affirm a gender identity other than that which they were assigned at birth, the best initial response from clinicians and others is to “support without steering.” This allows kids to explore their questions and identities with the knowledge that they can change course as needed.

Summary Although positive steps have been taken in recent years, transgender and gender-diverse youth are still a medically underserved population, experiencing a variety of health disparities. The Children’s Gender Health Program offers transgender and gender-diverse children and their families a place to go for exclusively pediatric, comprehensive, compassionate medical care when they have questions about their gender. This program offers a wide variety of gender-affirming services, including gender consultations, mental health assessments, pubertal and menstrual suppression, fertility preservation consultations, and gender-affirming hormone treatment, all delivered by a multispecialty team that includes gender health experts, pediatric endocrinologists, pediatric gynecologists, and a social worker. With this program, Children’s continues to strive to be every family’s essential partner, and to ensure that transgender and gender-diverse children can grow up happy, healthy, safe, and strong. Angela Kade Goepferd, MD, FAAP, is the medical director of Children’s Minnesota’s Gender Health Program, the Director of Medical Education and Vice Chief of Staff for Children’s Minnesota, and a general pediatrician in the Children’s Minneapolis Primary Care clinic. She is an advocate for advancing equitable health care for all children.

Parents often struggle to know how to best support their kids on top of dealing with their own feelings of grief, anger, disappointment, or fear. Primary care clinicians can affirm to parents that asking questions is okay, and seeking supportive resources is encouraged. Parents often need just as much, if not more, room to ask questions and seek support as they learn more about their child’s identity. Parental rejection is a significant risk factor for poor physical and mental health outcomes for transgender youth, including a significantly increased risk of suicide, so clinicians should always encourage parents to consistently reassure their children that they love them, even when they are struggling to understand their expressed identities. Unconditional parental love is the single biggest protective factor to keep transgender and gender-diverse kids healthy and safe.

Information and referrals In addition to providing supportive primary care services, when primary care clinicians need a place to send families for more information and support, they can now refer them to the Children’s Gender Health Program (www.tinyurl.com/mp-gender-health). Referrals can be made by calling our Children’s Physician Access line at 612-343-2121, or by contacting the Gender Health Program directly at 612-813-7950 (phone) or 612813-7955 (fax). Through this program, Children’s Minnesota will now offer comprehensive, compassionate, personalized, and coordinated care to support transgender and gender-diverse children and their families, wherever their journeys may lead them. Families can rest assured that our clinic will support the unique health care needs of transgender and gender-diverse kids at any age. Wherever a child or family is on their journey, we are committed to following the lead of patients and families and help them find their way forward. The journey will look different for each child, but the outcome should always be the same: to help transgender and gender-diverse kids grow up healthy, happy, safe, and strong. MINNESOTA PHYSICIAN AUGUST 2019

MEDICINE AND THE LAW

Physician employment rights A new legal landscape BY LAWRENCE P. SCHAEFER, JD

mployment laws matter more than ever for physicians, as practitioners move from smaller, private clinics and into salaried positions at large hospitals or HMOs. In these salaried roles, they may assert their rights as employees, rather than as independent contractors, who have far fewer legal rights and remedies. When issues arise about a physician’s clinical competence or behavior, most often culminating in a process called “peer review,” physician employees have a broad array of enforceable rights.

discussion and perhaps a documented warning; required attendance at CME or related courses tailored to the concerns raised; a formal plan to measure future care or behavior to ensure no similar issues arise; formal “proctoring” arrangements (e.g., supervision by a more experienced physician); and/or limits to the scope of procedures the physician has privileges to conduct. Interviews and meetings are held in an effort to uncover all relevant facts and to resolve the matter informally through means short of serious adverse impact on privileges. In Minnesota, every step of peer review is governed by the Minnesota Peer Review Statute, which provides confidentiality and immunity from damages for “review organizations,” defined to generally include committees of hospitals, clinics, and HMOs that gather and review information related to the care and treatment of patients. Similar immunity protections apply under the federal Healthcare Quality Immunity Act (HCQIA).

Knowledge of the legal rights of Peer review refers to the policy/procedure employee physicians is critical. that applies when internal complaints are made concerning physician care or behavior. This is wholly distinct from public complaints made to the Board of Medical Practice. Internal complaint policy and procedures can apply to any medical professional who provides services at the organization, and to both employed and independent practice physicians Confidentiality and immunity protections under these statutes will only who have been granted privileges at the organization. apply if the organization strictly abides by certain prescribed procedural While no generally available statistics are available, it is likely that most steps. Importantly, at this point in a review (disclosure of a complaint and hospital practitioners will be subject to peer review at some point in their informal remediation), a physician may be allowed to resign without a career, and for some this could be a more frequent occurrence. report being sent to the state licensing board or the National Practitioner Complaints triggering peer review can involve multiple issues, including Data Bank (NPDB). Established under HCQIA, NPDB is the nationwide problematic behavior and attendance concerns, failure to complete repository for all “reportable” incidents concerning physicians, regardless paperwork, a careless approach to protecting patient privacy, and serious of which state these physicians are licensed to practice. The NPDB data is concerns about patient care and outcomes. These complaints can be formally public and readily accessible to anyone inquiring, ensuring that a physician raised by an individual or individuals, and can come from a supervisor, experiencing serious care or behavioral issues in one state couldn’t simply colleague, subordinate, patient, or family member. A complaint or concern move to a different state, secure licensing, and begin practicing with a can also stem from routine organizational audits detecting anomalous clean slate. or concerning patient outcomes or outcomes that could be considered a If the physician does not resign, an NPDB report may still be avoided deviation from an acceptable standard of care. if the resolution of the complaint is exoneration or some relatively mild Current and future employment, credentialing, and the ability to preserve correction action, such as those listed above, which does not involve a or secure professional privileges, may depend on a successful resolution of a suspension of privileges for 30 days or more. peer review complaint. Given these high stakes, knowledge of the legal rights A formal investigation. When the initial disclosure and remediation step of employee physicians is critical throughout any peer review. fails, a decision is made (usually by the designated committee over the affected How the peer review process generally works physician’s specialty) whether to elevate the issue(s) to “formal investigation.” Though many of the specifics of an internal institutional review depend on This escalation is significant, because it means a suspension or termination a given institution’s bylaws and/or policies, the peer review process generally may occur that would require reporting to the state licensing authority and, involves four standard steps: potentially, the NPDB. After a formal investigation commences, a physician cannot resign and terminate the investigative proceeding without an NPDB Disclosure and remediation. First, there is usually an initial report being made, and this report thereafter being publicly available. “informal” disclosure to the physician by someone in a supervisory capacity that a complaint has been made, followed by an attempt to remediate expeditiously and without serious consequences, if the complaint does not allege serious misconduct or a significant deviation from a generally acceptable standard of care. Remediation can range from

AUGUST 2019 MINNESOTA PHYSICIAN

If the investigation concludes that no “reportable” incident has occurred, the process generally concludes with some minor remediation obligations by the physician, and no further adverse consequences. The HCQIA defines a reportable incident as any action that “revokes

or suspends (or otherwise restricts) a physician’s license or censures, reprimands, or places on probation a physician, for reasons relating to the physician’s professional competence or professional conduct… .” 42 U.S.C. §11132(a)(1)(A) (emphasis added). A “reportable incident” determination. The third step commences when the internal investigation concludes with a recommendation that a reportable incident has in fact occurred. Such a conclusion is again generally reached by committee, and often accompanied by a recommendation that privileges be terminated and the employment relationship end immediately.

be represented by legal counsel in this appeal, and has the evidentiary “burden of proof ” to establish that the recommended action is an abuse of the considerable discretion afforded to the decision-making authority/ committee. Typically, this burden requires the physician and counsel to show either that the alleged complaint is not supported by persuasive evidence, or that the recommended adverse action is wholly out of proportion to the actual offense. Once this internal process is exhausted, and if the final recommendation is adopted by the appeal committee and/or Board of Directors, there is the possibility of further legal action to challenge the final decision, but the scope and likelihood of success of such action depends significantly on the evidence developed during the investigation and the nature of the employment relationship. In other words, if the physician is an employee rather than an independent contractor, there are generally far more potentially productive legal claims to assert.

The health care industry is rife with antitrust disputes.

This typically occurs when, for instance, the behavioral issues are so severe (e.g., sexual harassment, extremely abusive interactions, or chronic failure to complete appropriate documentation or respect patient privacy), or the clinical competence issues lead to a conclusion that the physician’s continued practice would pose an “imminent” risk to patient care and cannot be otherwise effectively remediated. The appeal. The last step is the appeal from an adverse recommendation. This recommendation usually involves suspension and/or termination of privileges, which usually allows termination of the underlying employment relationship. Appeal generally involves a hearing with at least a 30-day notice provided (usually before a panel of physicians, at least one of whom should be familiar with the practice area). The physician can generally

The employment rights available to physicians It is critical to understand the circumstances where legal protections can be trumped and/or significantly influenced by other legal rights arising in the

Physician employment rights to page 324

V Alzheimer’s 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

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

• Intractable Pain

• Obstructive sleep apnea

• Post-Traumatic Stress Disorder

• Alzheimer’s

• Autism

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 AUGUST 2019

ONCOLOGY

Skin cancer A gateway to earlier interventions BY REBECCA J. MORRIS, PHD, AND HEUIJOON PARK, PHD

significant number of skin cancers involve recruited cells from the bone marrow as well as from hair follicle stem cells, according to findings from 14 years of research by the authors and their collaborators around the country. The research used a bone marrow transplantation model to induce carcinogenesis with a hydrocarbon carcinogen and a plant compound as a tumor promoter in mice. The results show that some squamous skin tumors have a previously unrecognized systemic component, and that carcinogen-exposed bone marrow can develop both benign and malignant skin lesions upon tumor promotion. The research could provide a gateway to studying new therapeutic targets to earlier interventions to stop the development of skin cancer and to treat non-melanoma skin cancers.

One-third to one-half of all human cancers originate in the skin.

Background Non-melanoma skin cancers such as basal cell and squamous cell carcinomas occur more frequently in the human population than any other type of malignancy, and more than one million new cases are diagnosed in the United States annually. It is estimated that one-third to one-half of all human cancers originate in the skin; that skin cancers exceed all others combined; and that the lifetime risk for development of skin cancer in the U.S. population is one in five. Solar ultraviolet (UV) radiation is the major known cause of non-melanoma skin cancers and is directly relevant to the etiology of skin cancer, as demonstrated by both epidemiological evidence and the tight correlation between non-melanoma skin cancer development in humans and UV radiation-induced skin carcinogenesis in mouse experimental models. Skin cancers as seen in the clinic are actually the results of a long history of which only the later stages are easily observed. The progression from normal maintenance of the skin to neoplastic growth involves multiple genetic and epigenetic alterations, resulting in altered cellular phenotypes and gene expression patterns. Epithelial cells covering the epidermis, or lining spaces in the gastrointestinal and respiratory tracts, can be identified by expression of certain cytoplasmic filament proteins, called keratins, or of cell surface marker proteins such as epithelial cell adhesion molecules (EpCAM). These cells can be tracked as they move around the bodies of genetically engineered mice that express green fluorescent protein (GFP) under the control of regulatory elements that govern the expression of specific epithelial cell markers, such as certain types of cytokeratin. This enables functional studies in which we can use GFP to visualize, isolate, and then culture these cells to investigate the origins of epithelial stem cells.

AUGUST 2019 MINNESOTA PHYSICIAN

There are several reports of cells with epithelial markers in the blood and bone marrow (BM) of “normal, healthy human subjects”; however, the proliferative and differentiative capacities of these cells are as of this date unknown. These bone marrow-derived epithelial cells (BMDECs) are heterogeneous with regard to their repertoire of surface markers and cytokeratin expression. For the most part, they are considered “undesirable background” in the “liquid biopsy” that seeks to measure circulating metastatic cells in the blood and BM of cancer patients. Although their presence cannot be denied, their functional and phenotypic characteristics and other attributes are unknown. Several attributes of blood-borne epithelial cells have been associated with epithelial cancers: 1. We know that the incidence of circulating epithelial cells with characteristics of cancer cells increases with metastatic disease.

2. Houghton and colleagues demonstrated that some bone marrow-derived cells (BMDCs) are recruited to and contribute to development of gastric cancer in a Helicobacter pylori-mediated mouse gastric cancer model. 3. Pantel and associates showed that circulating epithelial cells increase in some benign proliferative diseases of the colon. Moreover, Tamai and colleagues have demonstrated that a subset of BMDCs is recruited to the epidermis in a mouse model of epidermolysis bullosa. Further, we have recently demonstrated that BMDCs contribute to both initiation and promotion of cutaneous neoplasms (Park, Morris, et al). Taken together, these observations lead to the conclusion that it is essential to determine the proliferative and differentiative properties of circulating epithelial cells and bone marrow-derived epithelial stem cells. Thus, BMDECs might serve as a reserve population of progenitor cells. Certainly, they are recruited to cutaneous papillomas and non-healing ulcers. Equally certainly, carcinogen-exposed BM can initiate benign and malignant cutaneous neoplasia upon skin tumor promotion. But, beyond carcinogenesis, do BMDECs play a role in chronic wound healing? Do they actually have properties of stem cells?

Research methodology We began to lay the groundwork for this research upon reading the paper by Houghton et al., who reported that BMDCs contributed to gastric cancer in a mouse H. pylori model. We demonstrated that bone marrow cells (BMCs) also contributed significantly to non-melanoma skin cancer in mice, and in addition, proliferated, produced epidermal keratins, and stratified as in epidermal terminal differentiation. Furthermore, we demonstrated that cells in carcinogen-exposed BM are capable of becoming tumor-initiating cells.

A critical unanswered question from this work is: what is the nature of the recruited cells? No defining functional studies addressing this hypothesis have been forthcoming. We used gender-mismatched bone marrow transplantation (male GFPpositive BMCs to female recipients) in the context of a mouse model for skin carcinogenesis to determine the recruitment of Y-chromosome+ and GFP+ bone marrow cells (BMCs) in skin tumors. We detected a significant number of clusters of BMDCs in over 40% of benign papillomas where they occupied 25% or more of the lesional area. The BMDCs clustered in the cutaneous epithelium, where they expressed skin keratins, proliferated, stratified, and contributed to lesions along with the progeny of hair follicle stem cells, but as separate populations. We also performed ex vivo co-culture experiments where we cultured adherent BMCs in the presence of filter-separated epidermal keratinocytes, and found that the presence of keratinocytes induced some of the BMCs to make epidermal keratins in the absence of cell contact or fusion. Furthermore, when naïve female mice receive0d bone marrow transplants from donors previously treated with a carcinogen, several benign papillomas and a squamous cell carcinoma were observed after exposure to a skin tumor-promoting agent (which by itself does not cause cancer).

Summary This research will have far-reaching consequences for the fields of hematology and epithelial biology. In the very near future, we will solve two important problems. First, we will detect and quantify BMDECs in untreated mice and healthy human subjects to determine their phenotypic characteristics. Second, we will determine whether the BMDECs have functional characteristics of epithelial stem/progenitors in ex vivo and in vivo models. These experiments have the potential to open up new avenues of research, and will provide a basis for the development of new disease models as well as a possible source of epithelial progenitors for regenerative medicine.

This activity has been approved for AMA PRA Category 1 Credit™ and Minnesota Board of Social Work credit. ACPE contact hours for pharmacists pending.

• Professional: $125 • Resident/Fellow/Student: $25

Our findings have significant implications for a better understanding of the etiology of epithelial cancers, as well as for the development of its diagnosis and treatment. The take-home message is that while some squamous skin tumors originate in the skin, some of these tumors may have a pronounced systemic component. For additional information on this research initiative—led by the authors, Timothy Cragin Wang from Columbia University Medical Center, and others at multiple institutions—visit www.tinyurl.com/mp-morris. Rebecca J. Morris, Phd, is an I.J. Holton Professor of Stem Cells and Cancer at The Hormel Institute/University of Minnesota, where she leads her laboratory.

To register or for more infomation, visit slhduluth.com/umnethics or call 218-249-5139

She has maintained an interest in keratinocyte stem cells and cancer from her graduate work at Syracuse University, and has been funded by grants from the ACS, NIAMS, DOD, and NCI.

PRESENTED BY: THE UNIVERSITY OF MINNESOTA MEDICAL SCHOOL, DULUTH CAMPUS IN COLLABORATION WITH OUR PARTNERS.

Heuijoon Park, PhD, is a postdoctoral fellow at the Fred Hutch Cancer Research Center and lead researcher for the study referenced in this article.

University of Minnesota Medical School, Duluth Campus, The College of St. Scholastica, St. Luke’s, Essentia Health, Wisconsin Indianhead Technical College, University of Minnesota College of Pharmacy - Duluth Campus University of Wisconsin Superior, and Lake Superior College

MINNESOTA PHYSICIAN AUGUST 2019

ONCOLOGY

An underutilized, superior screening tool Low-dose CT scans for lung cancer BY NANCY TORRISON AND MANISH R. PATEL, DO

ung cancer is the second most common cancer in men and women and the leading cause of cancer death in the United States. The American Cancer Society estimates there will be 228,150 new cases of lung cancer and 142,670 deaths in the United States in 2019. Nearly twice as many women die of lung cancer as breast cancer. Seventy percent of lung cancer cases are not diagnosed until stage 3 or stage 4. Early detection of all forms of cancer leads to improved survival rates. When breast cancer is detected early and is in the localized stage, the fiveyear relative survival rate is 99–100%. From 1989 to 2016, as mammograms became better utilized, breast cancer mortality decreased by 40% (preventing more than 340,000 deaths). In 2015, the National Institutes of Health reported that 71.6% of women had received a mammogram. Screening for colon cancer has also showed significantly improved outcomes. In the case of lung cancer, screening has been less successful.

Low-dose CT scans: effective, but underutilized The National Lung Screening Trial showed that in 2011, screening people with risk factors for lung cancer with a low-dose CT scan (vs.

Specialists in Musculoskeletal Pain Treatment

conventional chest X-ray) showed a 20% decrease in lung cancer deaths and a 6.7% decrease in all-cause mortality (deaths due to any factor, including lung cancer). This study showed a 1.1% lung cancer detection rate with a 24% “false-positive” rate (nodules > 4mm). Four percent of false positives were found to have cancer. Approximately 8 million people living in the United States are eligible for annual LDCT screening for lung cancer.

Guidelines and statistics In 2013 the U.S. Preventive Services Task Force recommended annual LDCT screening for lung cancer in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. Statistics from the Nelson Study, presented by the American College of Radiology at the 2018 IASLC World Conference on Lung Cancer, showed that annual lung cancer screening with LDCT in high-risk patients reduced lung cancer deaths by 26 percent in men and up to 61 percent in women (up to a 44% reduction overall if male and female cohorts were evenly split). Given that the American Cancer Society predicts 142,670 lung cancer deaths in the U.S. in 2019, widespread screening could save up to 62,000 American lives each year. The Nelson Study reinforces three important points about lung cancer screening policy: 1. Screening older current and former smokers each year should be done far more widely; 2. Medical providers must become familiar with lung cancer screening guidelines and prescribe these exams for appropriate high-risk patients; and

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AUGUST 2019 MINNESOTA PHYSICIAN

3. Low Medicare reimbursement must be increased to support widespread screening. (Soon after announcing their coverage of these exams, the Centers for Medicare & Medicaid Services cut Medicare reimbursement to as little as $60 per exam in the hospital outpatient setting. This is less than half the Medicare provider reimbursement for a mammogram.)

Low levels of LDCT screening Despite these reports and recommendations, a cross-sectional study presented before the 2018 annual meeting of the American Society of Clinical Oncology showed that less than 4% of those who are eligible for LDCT lung cancer screening have undergone the procedure. Among adults aged 55–80 years who were at risk for lung cancer due to smoking, just 5.9% had had an LDCT in the year prior to 2015. What is the root of this disparity? Unlike breast and colon cancer screening, a patient’s primary care physician must approve the patient for a lung cancer screening exam during a shared decision-making visit. Providers may not be aware of the effectiveness of LDCT and its referral guidelines, or may be concerned about costs and false positives. Patients may be concerned

about the potential for shame and blame that may be associated with their smoking, making them reluctant to be screened. Social risk factors may make it difficult for patients to seek treatment.

caused by unhealthy personal choices, lung cancer patients receive the unkind comments and blame for their disease. This may further explain the high level of anxiety and depression suffered by smokers.

Cost savings

Summing up

Regarding the cost-effectiveness of lung cancer screening, actuarial simulation models predict that over the next 15 years, 985,284 quality-adjusted life years (QALY)—a generic measure of disease burden, including both the quality and the quantity of life lived—could be saved with screening. With the addition of smoking cessation to that screening process, the cost utility ratio of quality-adjusted life years could be reduced from $28,240 to $16,198 per life year gained.

A disease that has claimed up to 160,000 lives annually in recent years calls for aggressive screening and drastic measures from all of us who hold some responsibility for the health of our communities and the well-being of our families. Low-dose CT screening is up and coming and the next “big” thing in medicine, one that could yield results similar to those achieved through screenings for breast and colon cancer.

Annual lung cancer screenings in a high-risk cohort of adults aged 50–64 is highly cost-effective at $28,240 per QALY gained, compared to both the currently accepted cost-effectiveness threshold of $109,000 per QALY gained, and the more conservative threshold of $50,000 per QALY gained. This is similar to cost-effectiveness of mammographic screening for breast cancer and compares favorably to colonoscopic screening for colon cancer.

The Minnesota Cancer Alliance identified the following goal in its Cancer Plan Minnesota 2025 Objective 4: “Increase low-dose CT scan screening among persons at high risk for lung cancer.” Please join us at the 2019 Midwest Lung Cancer Summit (www.tinyurl. com/mp-torrison). Nancy Torrison is executive director of A Breath of Hope Lung Foundation,

Patient input

a Minnesota 501(c)(3) nonprofit whose goal is to improve the five-year survival

There is no question that false positive cause stress, but compared to the alternative, patients are willing to endure a few weeks of stress. The process of lung cancer screening will continue to improve, and this will happen as more patients are screened. And it should be noted that psychological studies show that a patient’s worry about false positives is short-lived, with no lasting effects. Partly in response to this concern, most centers have instituted multidisciplinary evaluations of suspicious nodules to determine an optimal way to manage them and to better counsel patients. Certainly, there remains intensive research effort to improve LDCT screening by evaluating biomarkers to decrease the false positive and false negative results.

rate for lung cancer. Learn more at www.abreathofhope.org.

Non-smoking causes of lung cancer Approximately 50% of lung cancer patients are nonsmokers at the time of diagnosis. Up to 20% of lung cancer patients never smoked. Smoking is one cause of lung cancer, but radon, asbestos, family history, unclean air, and other chemicals are also cited as causes of lung cancer. Lung cancer patients, whether they smoked or not, report unkind comments and judgment after being diagnosed. This stigma can lead to feelings of hopelessness. Studies from the National Institute of Mental Health and other agencies have shown that lung cancer is associated with high levels of depression and anxiety. Depression, also known as major depressive disorder or clinical depression, is a serious mood disorder that affects how a person feels, thinks, and handles daily activities. Anxiety, which can show up as generalized anxiety disorder or panic disorder, is also a mood disorder that can affect daily activities. Although the projected outcome for lung cancer patients has improved as treatment evolves, lung cancer is still the leading cause of cancer deaths. This fact is a likely contributor to the increased incidence of depression and anxiety among lung cancer patients. It is estimated that one in four persons with lung cancer experiences periods of depression or other psychosocial problems during and after treatment. Other studies have shown rates of 43–47% of patients with lung cancer experiencing depression. While smoking causes heart disease and other cancers, a diagnosis of lung cancer—more than any other smoking-related disease—generates significant, unkind stigma for some patients. While many diseases are

Manish R. Patel, DO, is a practicing oncology physician at the Masonic Cancer Center and Professor of Medicine, Division of Hematology, Oncology, and Transplantation at the University of Minnesota.

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MINNESOTA PHYSICIAN AUGUST 2019

ONCOLOGY

Multidisciplinary tumor conferences A surgeon’s perspective BY KAMRUN JENABZADEH, MD, FACS

ancer is a complex diagnosis, with more treatment opportunities than ever before. Advancements are most apparent in three areas: oncology medication, including neoadjuvant therapies and bio-markers; radiological technology, such as 3D imaging and tomography; and surgical techniques, including robot-assisted and laser surgery. Surgical treatment may vary significantly, depending on the type of tumor and the decision about adjunct therapies.

Providing the best care in conjunction with the patient’s wishes requires collaborative thinking from a multidisciplinary team of physicians, advance practice providers, non-physician caregivers, and support systems representing the full scope of cancer care. This team is often called a multidisciplinary tumor conference.

Value of a multidisciplinary tumor conference

A high-functioning cancer care team needs to talk often, not only because of the rapid changes in technology, but also because of changes in a patient’s condition. Most often, Our goal is always to Because of these rapid developments, this occurs in the formal setting of a regularly empower our patients. surgeons are becoming further involved in a scheduled multidisciplinary tumor conference. patient’s care, both before and after surgery. Our At Specialists in General Surgery, all of our stage input can help determine whether a patient is a 3 and 4 patient cases are presented at such a surgical candidate at all, or if it is in the patient’s conference on a weekly basis. The Commission best interest to operate first versus providing on Cancer (CoC) requires such a conference for chemotherapy and/or radiation therapy first. all accredited cancer centers, and we are lucky to have 28 such accredited More and more, we find ourselves providing the counseling, screening, centers in Minnesota. prevention, resource management, and palliative care.

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According to the CoC, required cancer committee members must include at least one physician representing each of the diagnostic and treatment services. Other required physician members include diagnostic radiologists, pathologists, surgeons, medical oncologists, radiation oncologists, and cancer liaison physicians. A multidisciplinary tumor conference for an accredited facility also requires several non-physician members, such as cancer program administrators, oncology nurses, and palliative care professionals. These conferences help members of the care team conduct meaningful conversations with patients and their families. Our goal is always to empower our patients with information to help them understand the risks and options of their unique treatment plan in order to achieve their specific goals. For some, this may be to preserve life at whatever cost. For others, it might be to manage pain, avoid chemotherapy, or reduce life-threatening side effects. For those patients who have not set specific goals, we can help them gain clarity and direct them to resources such as advanced directives, living wills, and physician orders for lifesustaining treatment (POLST). As surgeons, our role is to ensure the team, the patients, and their families understand the “why” behind our recommended approach.

Reasons for surgery in cancer patients As surgeons, our discussion encompasses the many reasons to consider or not consider surgery in the treatment of cancer, explaining our objectives to:

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MINNESOTA PHYSICIAN

Reduce cancer risk. For some patients, surgery can be used to reduce their risk of developing cancer. Women with a strong family history of breast or ovarian cancer, for example, or those who carry the BRCA1 and BRCA2

breast and ovarian cancer genes, may choose prophylactic surgery to reduce their risk. Patients with a family history of colon cancer often choose to have more frequent colonoscopies to remove precancerous polyps before they develop into colorectal cancer. Locate a cancer. Once cancer has been suspected, surgery is important at several stages of a patient’s diagnosis and treatment. In some cases, surgery is necessary simply to locate the cancer and determine how far it has spread. Diagnose and stage. For most types of cancer, a biopsy is the primary diagnostic tool. We also frequently remove lymph nodes for testing. For some tumors, the method of biopsy can affect the staging of the tumor, which, in turn, affects the intensity of the treatment. Remove the cancer. When cancer is found in only one part of the body, our goal is to remove the entire cancer. When that’s not possible because removal would cause too much damage to nearby organs or tissues, we debulk it to remove as much as possible to minimize side effects. Reconstruct tissue. Some cancers can be more disfiguring than others, especially tumors around the head and neck. Melanomas found deep within the skin often require the removal of significant amounts of tissue and may require reconstructive surgery. Breast cancer patients who have had a mastectomy also may choose to have reconstructive surgery. Reconstructive surgery can be performed at the same time as the initial surgery or later.

including a shorter length of stay. Many patients go home the same day of the operation. The incisional scars are smaller and less visible. Studies also have shown that surgeries using a robotic procedure result in fewer complications and less pain medication. The 3D visualization of a robot provides surgeons a better view of the surgical site when compared to laparoscopic procedures. This is especially important for obese patients or those with scar tissue or tortuous blood vessels. Robotic instruments also have a greater range of motion, resulting in greater surgical precision and access. At Specialists in General Surgery, we have performed many oncologic operations using the robotic platform, including colon, liver, and even the Whipple procedure for pancreatic cancer. Multidisciplinary tumor conferences to page 304

When loved ones need to be close

Provide palliative care. Cancers that cannot be removed can grow and cause pain and loss of function unrelated to the cancer itself. Nerves can be compressed. Intestines can become blocked. Bleeding can occur. Palliative surgery is performed to help relieve some of these symptoms and improve a patient’s quality of life.

Surgical techniques for patients with cancer We also discuss the many different surgical techniques used to treat cancer today. More and more surgeries are taking place in doctor’s offices, clinics, and ambulatory surgery centers instead of hospitals, thanks to new surgical techniques that are less invasive. Our surgeons perform several different kinds of surgery on patients with malignancies, depending on the patient’s medical condition, the extent of the cancer, and the patient’s preference. Open surgery is usually the preferred option for large tumors, those that involve a large portion of the body, or those that involve complex surgeries. Pancreatic cancer, for example, is often treated with an open surgery procedure called a Whipple or pancreaticoduodenectomy. During this operation, we remove the head of the pancreas, as well as nearby bile ducts and lymph nodes, the gallbladder, and sometimes part of the stomach.

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Minimally invasive laparoscopic surgery, in which we insert a small camera along with the surgical instruments, involves only small incisions. This leads to faster recoveries, less blood loss, shorter hospital stays, and often less need for pain medication. Laparoscopic surgery is often used for cancers of the colon, liver, prostate, uterus, and kidney. Robot-assisted minimally invasive surgery has seen a significant growth in the past few years. Many robotic surgeries today are performed with the da Vinci Surgical System. Robotic surgery has many patient advantages,

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MINNESOTA HEALTH CARE ROUNDTABLE

ST 51 SESSION

Social Disparities in Health Care Correcting the curve In this Roundtable we will discuss social risk factors in health care and what can be done to address them. It clearly costs more to serve populations with social risk factors in the emergency room than to provide them easy access to regular wellness check-ups and preventive care. Our expert panel will look at how we can change this dysfunctional social dynamic, and will examine the beginnings of a concerted movement to address this issue. We will begin by discussing terms that sound very similar but can mean very different things to different people, even those working to solve the same problems. Let us look at definitions for terms such as social disparity

Minnesota Physician Publishing’s 51st Minnesota Health Care Roundtable focused on the topic of Social Disparities in Health Care: Correcting the Curve. Six panelists and our moderator, Minnesota Physician Publisher Mike Starnes, met on April 25th, 2019, to discuss this topic. Our next Roundtable, on Clinical and Non-Clinical Care Teams: Improving Interoperability, will convene on November 14, 2019.

in health care, social determinants of health, social risk factors, health care disparity, health care equity, health care inequity, and others.

DR. SCHIFF: First, I’d like to propose we use the term “social risk factors,”

because if you call it a social determinant, it means that it is a forever thing, while some risk factors are malleable. I think of these in terms of two different groups—risk factors that we can potentially impact, and risk factors that we quite honestly do not want to impact and wish to celebrate, such as diversity, disability status, LGBTQ status, and veteran status. The second group includes risk factors that can be impacted. We break those down into two sets. One is economic risk factors—homelessness, deep poverty, or food insecurity—then we have risk factors that have to do with family functioning, incarceration, Child Welfare involvement, and individuals with a serious and persistent mental illness or a substance use disorder. We try to create some sort of a holistic framework. DR. JOSEPH-DI CAPRIO: I like the definition of social determinants or social

factors to be the conditions in which we are born, we live, we work, we age, because that applies to everyone. There are some conditions, factors, or determinants that have the effect we want on health, and then there are others that are detrimental to health. MR. MOUA: Public health and medical science confirm that most of what

creates health occurs outside of health care. In many ways, you could see health care as a subset of health, and health as a subset of social determinants of health. That is not to minimize the importance of the downstream provision

AUGUST 2019 MINNESOTA PHYSICIAN

of medical treatment, but to see a distinction. When we say “health,” we are acknowledging all various social—and I would add, political—determinants of health as well. It is important to assess these as both risks and virtues so that we do not inadvertently stigmatize them. I use the word “political” very deliberately, and not in partisan terms. The World Health Organization recognizes that these social conditions did not arise out of nowhere. They were actually created by human decision-making, which is greatly influenced by power and privilege. MS. HARDEMAN: We need to intentionally choose the words we are using in

our work in this space. One of the ways to do that is making the distinction between disparities and inequity. A disparity is simply a difference. We see differences throughout our society, but when we talk about health inequities, what we really are talking about is a justice issue that must be intervened on, can be intervened on, and that has a direct connection to the power—and that is the political piece as well. MS. WILLSHIRE: I sit on many committees with the new buzzwords “equity committee,” “diversity committee,” etc., and they never want to include people with disabilities. They do not even think about it. It is just amazing to me that with 2020 just around the corner, people with disabilities are fighting just to get at the table. It should not be that way. People with disabilities come from all socioeconomic areas. You can be a person of color and race and still be a person with a disability. That is sometimes forgotten.

JULIA JOSEPH-DI CAPRIO, MD,

is senior vice president and chief medical officer for UCare, leading the medical director team, as well as the clinical services, pharmacy, and quality management departments. These departments oversee multiple areas, including credentialing; response to complaints, appeals, and grievances; pharmacy; behavioral health; care and disease management; and many more.

Jeff Schiff, MD, MBA, served as the Minnesota Medical Director at the Minnesota Department of Human Services until recently. His interests include the role of social and family risk factors on health outcomes, integrated delivery systems, and mechanisms to improve quality measurement. He is committed to interweaving input from diverse communities to decrease health disparities and address health equity directly at all levels.

Rachel R. Hardeman, PhD, MPH,

is an assistant professor in the Division of Health Policy & Management at the University of Minnesota’s School of Public Health. She is a health equity researcher who uses the frameworks of critical race theory and reproductive justice to inform her equity-centered work in health services research and population health. She seeks to improve outcomes for Black moms and babies.

Jonathan Watson, MPIA, is chief executive officer at the Minnesota Association of Community Health Centers. His background includes public policy analysis, managed care, and fiscal analysis. He previously served as a budget and policy analyst for the Wisconsin Department of Health & Family Services, where he conducted fiscal and policy analysis on Wisconsin’s Medicaid managed care expansion and the welfare reform project.

Vayong Moua, MPA, is director of health equity advocacy at Blue Cross and Blue Shield of Minnesota, where he is responsible for developing strategy and action for Blue Cross’ prevention and health equity advocacy initiatives to reduce tobacco use, obesity, and health inequities among all Minnesotans. He focuses on integrating health equity into policy advocacy approaches and structural solutions. He cofounded the Minnesota Complete Streets Coalition.

Joan Willshire, MPA,

A patient may present in a clinic and the doctor may not be able to understand that they have social risk factors. How can we address this? DR. JOSEPH-DI CAPRIO: Doctors may have anywhere from eight to 15

minutes for a patient visit. You cannot really understand much about someone in that period of time, but what you can do is start to develop a relationship with them and build some trust to truly understand what is going on with them. There are other ways you can look at the social factors that people experience by building tools into your system so that you do not have to remember what to ask. The system will trigger you or your care team to ask as you are trying to understand the patient in front of you. MS. HARDEMAN: We need to rethink how we train physicians and all

of our future doctors that go out into practice to understand social risk factors, to understand the role that racism and other determinants play in the lives of their patients. Medical students are not getting enough of that curriculum, and then they go out into practice and into residency and continue not to be able to fill those holes. Since the majority of medical students come from high socioeconomic backgrounds and are predominantly white, they may not have that lived experience and may not understand what is happening in the lives of their patients. Awareness should be part of training from day one.

is executive director at the Minnesota Council on Disability, which advises the Governor’s office, state Legislature, state agencies, and the public on disability-related issues. She previously served as both member and chair of the Council, as well as at Courage Kenny. She is active within the disability community and has served on several boards, including the Minneapolis Advisory Committee on People with Disabilities.

How can physicians better understand the problems faced by patients with social risk factors? DR. JOSEPH-DI CAPRIO: It begins with training to build awareness. We

cannot just assume people will understand the impact of these factors or the importance or the influence of these factors on the health of the folks they care for. There must be a way to assess for these factors and do something about them. MS. WILLSHIRE: Everybody understands physical access to some degree,

but one of our issues in the disability community is programmatic access. If you are offering a particular program, say on heart disease, diet, or nutrition, it is not just a matter of making your entrance accessible, but also making your website accessible—and then looking at how you administer the program. Moving forward, it is like peeling away at the onion. You have to look at all of those aspects when you talk about the wide range of people with disabilities. A lot of people want to pigeonhole people in one particular diagnosis—everybody with cerebral palsy category must be like this, for example—and that is when you get yourself in trouble. The programmatic piece is as important as physical access, and it is probably the one that is not looked at as much. It’s not just getting in the door, but what are you going to do when you get in the door? Can you access everything? MINNESOTA PHYSICIAN AUGUST 2019

MINNESOTA HEALTH CARE ROUNDTABLE

DR. JOSEPH-DI CAPRIO: At Hennepin Health, we asked patients before we

left the room, “Is there anything else I can do for you today?” Sometimes they would answer, “Well, I don’t have a place to live.” You might have had five patients waiting for you, but you went to find the social worker, and hoped the social worker would find resources to help this family. As a doctor, you did not feel you had the resources to help.

who is working at the direct care level, but as you move more to the leadership in large health care organizations, there becomes virtually no diversity. The percentage of CEOs leading health care organizations who are female or other than European American is infinitesimally small, and the team around them oftentimes is without diversity as well. This does not result in picking teams with different views and different perspectives.

MS. HARDEMAN: That is the perfect example of why we need to think about

MS. HARDEMAN: If patients access a system that was not welcoming, we try to

how to build a new system that better serves the needs of our communities, rather than trying to figure out ways to address these massive issues in eight minutes or have patients presenting to family medicine doctors with mental health concerns and mental health issues that cannot be addressed in that one single visit. Until we are able to start recreating a new system, we are going to continue to struggle with this.

examine the front desk staff and all the different ways that patients are treated. The likelihood of follow-up care goes down if patients have a poor experience. When you layer that onto the social factors and all of the other things that are going on, it exacerbates the situation.

MR. MOUA: It is important to recognize that the

MS. WILLSHIRE: Physical access is huge for people

Why do some populations feel alienated by our health care delivery system?

with disabilities. They do not want to have to figure out how to jump on that exam table, and if someone offers to help, they wonder whether that person has been properly trained, because you could end up in some bad situations if the training was not been done correctly. That’s just The percentage of CEOs leading from the physical standpoint. I have talked to health care organizations who are many individuals who are deaf and feel extremely female or other than European alienated in some instances, because they are not talked to directly, they are talking to the American is infinitesimally small. interpreter. People with cerebral palsy, MS, MD, — Julia Joseph-Di Caprio, MD or any physical illness should not all be put in a little capsule as if they were all the same. It is easy, during an eight-minute visit, to do just that, but we must try to refrain from it. How does recognizing social risk factors translate into better care? MR. WATSON: African Americans and American Indian populations have a eight minutes itself is an inequity. It prioritizes efficiency and effectiveness over equity and treats equity as an amenity. If the question is around strengthening the capacity of physicians to act on social determinants of health or health equity, it is important to develop that skill and muscle through direct experience. When I began my work at Blue Cross, it was to pass local smoke-free ordinances. Our key messengers were physicians. They came out to testify. When we were working on active transportation policies, we had cardiologists come out to testify. We need to start with recognition, but also ensure that recognition pulls physicians outside their four walls.

MR. MOUA: Make sure that we frame and internalize cultural competence—

not just for the individual, but for the entire organization. It is not good enough just to have your physician or other caregiver be culturally competent if they are under-resourced, if managers do not listen to them, or if they have no clout or influence within the organization. Cultural competence has to permeate the board of directors, the leadership team, all other levels of the organization. MR. WATSON: This also applies to the front desk staff, community health workers, and throughout the organization. At Minnesota Community Health Centers, we hire from the communities we are located in. A Somali clinic with a lot of Somali patients is going to have Somali individuals working there, because the one currency that any provider has is trust. Those first impressions when you walk in the door and are greeted by front desk staff, if positive, can demonstrate that implicit bias is not present in that clinic. They can set the tone for your entire organization, regardless of how well your provider went through cultural competency training. This has to permeate through the entire organization. I know it is tough, but for the communities we serve—with 70% from communities of color—we hire from the communities at all levels. DR. JOSEPH-DI CAPRIO: I love health care because it is so diverse in terms of

AUGUST 2019 MINNESOTA PHYSICIAN

very different experience, too. There is history that you just cannot ignore, and these communities do not forget. Another concern is culture as we are diversifying and more immigrants come to Minnesota. They have a much different understanding of their former health care system—which may have been bleak, depending on where they are coming from—and how primary care and health care work here in the United States. Workforce is another concern. If you are coming from a community of color, you are coming largely to a provider type that does not look like you, and it is human nature to not accept that willingly. MS. WILLSHIRE: From the disability perspective, it really is coming from

the angle of who we are and what we are capable of doing. There may be limitations, but we need to accept it. People with disabilities want to improve themselves, but also need to have the ability to accept where they are at. It is crucial, but sometimes it gets lost in the hurry or the path to find a cure or provide treatment. MR. MOUA: Patients coming from an immigrant/refugee community may be dealing with posttraumatic stress, or have a world view and religion that views health as spirituality. If their experience with the western medical system is purely about treating the body, they may feel that, “You are just helping my body but you are not helping my health.” Take into account the

belief system, whatever that is, of the patient and the community member, who truly believes that their health is rooted in spirituality, in their ancestor’s wellbeing, and not their physical aspects. What are some of the unique concerns that patients in Greater Minnesota face in relation to the issue of social risk factors? MS. HARDEMAN: My colleague, Dr. Katy Kozhimannil, who is at the School

of Public Health and the director of the Rural Health Research Center, has been a leader in examining rural health care disparities, including inequities by race and ethnicity that, in the rural setting, are often not talked about. There is structural inequity and structural racism that play out in rural spaces, and as a result rural African Americans have a lower life expectancy. Maternity care closures in rural areas impact family access to places of safe birth.

community where they could have solidarity and emotional support as well as social services and health care services. MS. WILLSHIRE: In the disability community, especially in the rural area,

transportation is a huge issue. Volunteer medical drivers are critical in rural communities, but we have lost around 25% of them in the last couple of years due to a snafu with the funding. Again, access is another issue within some clinics. The good news is that many of the older clinics are being renovated and new ones are being built. That certainly helps, especially in rural communities. What does implicit bias mean and how does it play into our health care delivery process? MS. HARDEMAN: Implicit racial bias refers to

unconscious or automatic biases, the automatic thoughts that pop into our heads about people. One of my mentors, Dr. Michelle van Ryn, was one of the first people to dig into how implicit racial bias in particular was playing out in the clinical MR. WATSON: In our five clinics in Greater encounter between predominantly white providers Minnesota, the things on the top of our minds and patients of color. When providers are in a time are the opioid/substance use disorder crisis, crunch, they may draw on these automatic biases access to behavioral health services, and the or these unconscious biases to make decisions lack of anonymity in a rural small town. Here and conclusions about who this person is. If we in the Twin Cities, we can kind of disappear if We need to rethink how we are not able to understand why we have implicit we choose to when we access care. I spoke about train physicians. biases, we are not going to be able to break that being welcoming at the front desk. They can cycle. We talk about training a lot. Many people do that in these small towns because everybody —Rachel R. Hardeman, PhD, MPH attending implicit bias training shift their biases knows everybody, but that sometimes is a barrier a little bit, but not much. I am a co-investigator for people, because, unfortunately, there is a on a longitudinal study of medical students who stigma with patients who report these conditions. we have been tracking since 2010. We administer Rural disparity plays out in a completely different an implicit bias association test to those students way due to the lack of anonymity. every time we survey them. We have about four data points right now of their DR. SCHIFF: Our rural Native American brethren suffer in some areas with implicit biases through medical school, and they are not getting better. Among lack of access, or with access that has implicit bias. If we can create nearby those who have had some health equity four-hour training along the line in their programs where there is less stigma, we can improve health outcomes. There curriculum, their implicit bias scores tend to stay the same. They are definitely are a lot of stories about patients who do not want to go in because they are not getting lower. And among those who do not have any training, they are afraid they are going to be judged, and then they do not go in, and their getting higher. We should not rely on training as a solution to the problems that health outcomes suffer. we see with respect to discrimination and racism in the health care system. MR. MOUA: The themes here are physical and social disconnection and social and physical proximity to resources, whether that is a grocery store, a provider’s office, or a transit line. It was stated earlier that rural is not synonymous with white, and that there is a tremendous intersection in Greater Minnesota with immigration status, language, and education. It is important to understand that “rural” is not just white Minnesotans. Oftentimes the communities experience magnified inequities from a relational and ethnic standpoint because they are far away from a culture

DR. SCHIFF: At all levels in the health care system, institutional racism and institutional bias affect how people put together products or expectations for work at the policy level, and then that trickles down into the expectations at the local level. We have to address this bias, not just in the exam room with the provider—not to say that is easy—but that is where we put everything at the tip of the spear. The reality is further back in the organizations. If we can figure out a way to have those conversations, we can create the opportunity for more equitable interactions downstream.