Minnesota Physician, December 2019 by Minnesota Physician Publishing

MINNESOTA

DECEMBER 2019

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIII, No. 09

An inconvenient truth Transparency in pricing BY MERLIN BROWN, MD

s an independent primary care physician who has been in private practice in internal medicine for 20 years, I’ve observed a looming black fog slowly roll across the health care skyline. In the past, it seemingly hovered in the distance, going unnoticed by most, but it now consumes all visibility. That black fog prevents price transparency. Being in private practice—and providing personalized health care on a fee-for-service basis with no annual fee—gives me first-hand information on the business side of medicine, rather than merely relying on what the media reports say. The way health care is paid for is not only shocking, but it’s the only industry where both the individual and the provider are left completely in the dark about the cost of care.

Comprehensive medication management Expanding the primacy care interprofessional team BY KYLE WALBURG, PHARMD; SARA MASSEY, PHARMD; KYLEE FUNK, PHARMD, BCPS; RANDY SEIFERT, PHARMD; AND TODD SORENSEN, PHARMD

magine a typical day in your primary care clinic. You are two patients behind schedule. Two of your practice partners are out of the office, and you are covering their inbox. Refill requests are pouring in, and your new medical assistant is not quite up to speed. Your next patient is one of your most complicated; you have struggled to make progress through a list of many medications in your 20-minute visits. You inherited this patient from a recently retired provider and have not had a chance to dig through their medical Comprehensive medication management to page 104

Patients pay significant monthly premiums for health care coverage in hopes that they will be An inconvenient truth to page 124

DECEMBER 2019 MINNESOTA PHYSICIAN

ND 52 SESSION

DECEMBER 2019

Volume XXXIII, Number 9

COVER FEATURES Comprehensive medication management

An inconvenient truth Transparency in pricing

Expanding the primacy care interprofessional team

By Merlin Brown, MD

By Kyle Walburg, PharmD; Sara Massey, PharmD; Kylee Funk, PharmD, BCPS; Randy Seifert, PharmD; and Todd Sorensen, PharmD

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

SENIOR CARE 20 Age-friendly health systems Providing care that matters

CLINICAL AND NON-CLINICAL CARE TEAMS Improving interoperability Thursday, March 5, 2019, 1–4 p.m.

Serving behavioral health patients

By James T. Pacala, MD, MS

The Gallery, Hilton Minneapolis | 1001 Marquette Avenue South

Jennifer J. Garber, LICSW UCare

ADDICTION MEDICINE 22 The resurgence of methamphetamine

BACKGROUND AND FOCUS:

BEHAVIORAL HEALTH 14 Minnesota’s leading edge Creativity and collaboration By Todd Archbold, LSW, MBA

CARE TEAMS 16 Behavioral health consultants A valuable new member of the care team

A dual epidemic By Tyler Winkelman, MD, MSc; Julie Bauch, MS, RN, PHN; and Christine Hauschildt

HEALTH CARE POLICY 24 The 2020 Minnesota legislative preview Divided body faces a large surplus By Tom Hanson, JD, and John Reich

By Jeni Kolstad, MSW, LICSW

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.

OBJECTIVES:

SENIOR AND LONG-TERM CARE 18 Trends in older adult residence design

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.

Emphasizing quality of life By Gaius G. Nelson, MA

PANELISTS INCLUDE: Dori Cross, PhD, Division of Health Policy and Management University of Minnesota School of Public Health Vivi-Ann Fischer, DC, Chief Clinical Officer, Fulcrum Health

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Christopher “Kit” Crancer, Senior Director of State Legislative Policy, Center for Diagnostic Imaging 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.

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CAPSULES

HealthPartners to close retail pharmacies HealthPartners will close all of its Minnesota and western Wisconsin retail pharmacies in 2020. The move affects 30 retail pharmacies located within HealthPartners, Park Nicollet, Central Minnesota, and Stillwater Medical Group clinics. The organization’s mail-order pharmacy operations will also cease. Some 300 positions, including 100 pharmacists, will be eliminated as a result of the closures. HealthPartners’ specialty, infusion, and hospital pharmacies will continue to operate, along with health plan pharmacy management and medication therapy management services. Sarah Derr, PharmD, executive director of the Minnesota Pharmacists Association, said that the action reflects a national decline in the retail pharmacy industry that has included closures of many rural independent outlets. The National

Community Pharmacists Association predicts that up to 58% of pharmacies nationwide could close in the next two years. Despite this trend, she is hopeful that the pharmacy industry will be able to restructure the way it is reimbursed for services and open new outlets in coming years. The closures begin Jan. 20, 2020, and are expected to be completed by April 1, 2020.

Medical cannabis program to add qualifying conditions The Minnesota Department of Health (MDH) will add chronic pain and age-related macular degeneration as new qualifying conditions for the state’s medical cannabis program. Under state law, the new conditions will take effect in August 2020. MDH also approved two new delivery methods: water-soluble cannabinoid

multi-particulates (for example, granules, powders, and sprinkles), and orally dissolvable products such as lozenges, gums, mints, buccal tablets, and sublingual tablets. The program’s two medical cannabis manufacturers will double the number of patient cannabis treatment centers in accordance with legislation passed during the 2019 Minnesota legislative session. These new sites will mean greater access to cannabis treatment centers. As in years past, MDH used a formal petitioning process to solicit public input on potential qualifying conditions. Throughout June and July, Minnesotans submitted petitions to add qualifying conditions. Following this petition period, the process included public comments and a citizens’ review panel. MDH staff also prepared a set of documents summarizing the available research pertaining to the use of medical cannabis for each prospective condition.

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DECEMBER 2019 MINNESOTA PHYSICIAN

Improved outcomes for ventilated hospital patients Delta Dental of Minnesota Foundation has partnered with the Minnesota Hospital Association (MHA) to work with hospitals and health systems across Minnesota to improve oral health for patients on ventilators. With support from a $400,000 grant from the foundation, MHA created a best-practices toolkit for treating the oral health of ventilator patients and to pilot with local hospitals to improve overall health outcomes. Poor oral health has been linked to hospital-acquired pneumonia and to ventilator-associated pneumonia (VAP), the focus of this project. More than a quarter million people in the United States receive mechanical ventilation each year, making them vulnerable to serious health complications such as acute lung injury and respiratory distress syndrome, as well as increased risk of mortality related

CAPSULES

to pneumonia. VAP occurs in 8% to 28% of these patients, which leads to an additional $41,000 in health care costs, a 14-day increase in the length of hospitalization, and, for 9% to 13% of patients, mortality. The MHA-led project contributes to the goal of reaching a 20% reduction in ventilator-associated events as called for by the Centers for Medicare & Medicaid Services. Research shows that oral hygiene is an important intervention, in combination with other strategies, to prevent VAP. With Delta Dental support, MHA and oral health experts from across the state identified specific steps hospital care team members can take to help maintain oral health for ventilated patients. Successful steps include raising awareness of oral health for ventilated patients by identifying a designated coordinator or including oral health on a list of topics to review for each patient. Care team members brushed patients’ teeth or swabbed or rinsed patients’ mouths every two to four hours. Documenting each oral health intervention—brushing, swabbing or rinsing—in the patient’s chart was critical to maintaining oral health as a priority.

Grants to support people with dementia, caregivers Help is on the way for patients with Alzheimer’s disease and other forms of dementia—and those who care for them—under a package of $750,000 in grants appropriated by the Legislature and awarded by the Minnesota Board on Aging. Planned activities include memory screenings, collaborations with health care providers to improve referrals, and culturally responsive trainings. Several organizations are offering Dementia Friends training, designed to change the way community members think, act, and talk about dementia. “These funds support not only people with Alzheimer’s and other

forms of dementia but their family and friends, who play such a critical role in caregiving,” said Kari Benson, executive director of the Minnesota Board on Aging. “Alzheimer’s alone impacts some 91,000 Minnesotans over age 65, a number that continues to grow, and more than 254,000 people who provide care informally.”

Initiative Designed to Help Stop Abuse of Adults with Disabilities “Treat People Like People— Abuse Stops with Us,” a new campaign designed to raise awareness of abuse of adults with disabilities, was recently initiated by the Minnesota Office of Ombudsman for Mental Health and Developmental Disabilities (OMHDD) and the Governor’s Council on Developmental Disabilities (GCDD). The Department of Human Services (DHS) will also be joining as a partner and funder of the campaign. From 2012 through 2016, there was an increase of more than 2,000 maltreatment reports of vulnerable adults in the state, according to DHS. During this same period, reports of neglect increased 38% among people with disabilities, and abuse grew by 26 percent. In response to these trends, OMHDD and GCDD have developed a plan to raise awareness of abuse and mistreatment and to educate people with disabilities, their families and guardians, mandated reporters, and the general public on how to identify and report instances of abuse. An overarching goal of the initiative was to show that individuals living with disabilities are valuable, unique human beings deserving of respect and inclusion. People with disabilities shared, in their own voices, their experiences and stories. Videos, tools, and resources for direct care providers, vulnerable Minnesotans, their families, and the public are available online at https:// treatpeoplelikepeople.org.

DEC 31

The Bad Plus

DEC 25-28

New Year’s Eve with Davina and the Vagabonds Dinner show 6pm Cocktail show 10:30pm

Progressive Jazz Scientists

JAN 3

Joyann Parker Band

JAN 15

Masters of Hawaiian Music feat. George Kahumoku Jr., Led Kaapana & Kawika Kahiapo

Passion, Power & Soul

JAN 16

The Sweet Remains

Three Tantalizing Harmonizing Troubadours

JAN 17

Bruce Henry

The Music of Curtis Mayfield

JAN 18

Tina Schlieske Sings Sinatra to Simone

Afro-Cuban All Stars

An Evening of Torch and Swing

Voice of Traditional Cuban Music

FEB 7

Patty Peterson Presents Memories - The Music of Barbra Streisand 612.332.5299 dakotacooks.com

JAN 30

FEB 10-11

Manhattan Transfer

Chart-topping Vocal Jazz Legends

1010 Nicollet Mall Mpls MN MINNESOTA PHYSICIAN DECEMBER 2019

CAPSULES

Heart attack risk may be elevated in middle-aged adults with BPD Middle-aged adults who show symptoms of borderline personality disorder may be at greater risk for a heart attack, as they show more physical signs of worsening cardiovascular health than other adults, according to research published by the American Psychological Association. “Although borderline personality disorder is well studied for its relationship to psychological and social impairments, recent research has suggested it may also contribute to physical health risks,” said Whitney Ringwald, MSW, MS, of the University of Pittsburgh, lead author of the study. Borderline personality disorder is characterized by intense mood swings, impulsive behaviors, and extreme emotional reactions. This inability to manage emotions often makes it hard for patients to finish

school, keep a job, or maintain stable, healthy relationships. According to the National Institute of Mental Health, 1.4% of adults have BPD, but that number does not include those with less severe symptoms. Researchers looked at self-reported basic personality traits, as well as those reported by up to two of the participants’ friends or family members, and self-reported symptoms of depression. By combining several physical health measurements, including blood pressure, body mass index, and the levels of insulin, glucose, cholesterol, and other compounds in the blood after a 12-hour fast, the researchers established a relative cardiovascular risk score for each participant, along with a significant association between borderline personality traits and increased cardiovascular risk. The researchers said their findings have important implications for primary care doctors and mental

health professionals who treat patients with BPD.

Healing center for moms with depression, anxiety breaks ground Hennepin Healthcare recently started construction on its Redleaf Center for Family Healing for Twin Cities moms, babies, and families. About one in seven mothers experience depression and anxiety during and after pregnancy, according to Helen Kim, MD, medical director for the Mother-Baby Program and co-founder of the Redleaf Center. Without treatment, the impact on a mother’s mental health can be devastating—and sometimes fatal, affecting the entire family as well as future generations. The Redleaf Center will expand on the space and services of Hennepin Healthcare’s Mother-Baby Program, Minnesota’s first intensive

mental health program for pregnant and postpartum moms. It will support families through services that nurture the mind, body, and spirit— from comprehensive mental health and relationship support to onsite childcare, integrative medicine, a teaching kitchen, gathering space, and more. The groundbreaking ceremony drew leaders from health care, the community, and local government, including Hennepin County Commissioner Marion Greene (District 3). Families who have benefited from the Mother-Baby Program also attended the ceremony. The $30 million endeavor was initiated by a $10 million donation from the Lynne & Andrew Redleaf Foundation. The ceremony also recognized a new gift of $2.25 million from the Pohlad family. Construction is slated to be completed in November 2020.

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

DECEMBER 2019 MINNESOTA PHYSICIAN

MEDICUS

Nathan Chomilo, MD, will serve as medical director for the Department of Human Services’ health care programs, beginning in January. A pediatrician and internist, Dr. Chomilo is a founding member of Minnesota Doctors for Health Equity, a statewide coalition of physicians, and serves as medical director for Reach Out and Read.

Osmo Vänskä /// Music Director

JA N UA RY C O N C E R T S

Conor Ryan, MD, has joined the pediatric neurology team at Noran Neurological Clinic. Dr. Ryan’s clinical interests include general child neurology, pediatric neuromuscular medicine, electromyography (EMG), and developing medical devices. He is boardcertified by the American Board of Psychiatry and Neurology, and holds a special qualification in child neurology.

Jason Howard, DO, an anesthesiologist, has joined the Essentia Health–St. Joseph’s Medical Center in Brainerd. Dr. Howard earned a medical degree from A.T. Still University in Kirksville, Missouri, and completed a residency in anesthesiology at the University of Florida College of Medicine in Gainesville, Florida. He is board-certified by the American Board of Anesthesiology.

MusicMakers with Osmo Vänskä and the Minnesota Orchestra Fri Jan 10 8pm Osmo Vänskä, conductor Kevin Puts, Composer Institute director The culmination of the Orchestra’s 17th annual Composer Institute, this concert features the music of some of America’s most gifted young composers, plus a behindthe-scenes look at the craft of music-making. Ticket Price includes a pre-concert and intermission beverage.

Mahler and Ravel PAUL WATKINS

Maricela Schnur, MD, has joined St. Luke’s Interventional Pain Management program in Duluth. Dr. Schnur treats numerous areas of chronic pain utilizing medical management, interventional injections, and surgical options such as spinal cord stimulation and peripheral nerve stimulation. Her interests include myofascial pain, chronic low back pain, peripheral neuropathies, and joint pain.

SIMONE YOUNG

Andrew Haak, PhD, from Mayo Clinic in Minnesota, has been named to a new American Lung Association research team, part of the organization’s Airways Clinical Research Center (ACRC) Network and its Awards & Grants program. Dr. Haak was given the Catalyst Award for his research project, titled “Catecholamine Signaling Regulates Pulmonary Fibrosis.”

Fri Jan 17 8pm Sat Jan 18 8pm Simone Young, conductor Tara Erraught, mezzo Romantic, artful and expressive, this program features music by Mahler, Ravel and Debussy.

Beethoven, Bach and Britten Thu Jan 30 11am Fri Jan 31 8pm Paul Watkins, conductor and cello Strings take center stage as Paul Watkins joins us for a luminous cello concerto and more.

612-371-5656 / minnesotaorchestra.org Orchestra Hall PHOTOS Vänskä: Travis Anderson Photo; Young: Bertold Fabricius; Watkins: Paul Marc Mitchell. All artists, dates, prices and programs are subject to change.

MINNESOTA PHYSICIAN DECEMBER 2019

INTERVIEW

Serving behavioral health patients Jennifer J. Garber, LICSW UCare Your new position recognizes, from a payer’s perspective, the role of behavioral health in lowering the cost of care and improving outcomes. What can you tell us about this vision?

importance of behavioral health parity. A person should have access to behavioral health services in kind with the medical services and benefits that are available to them.

UCare recognized that we wanted to better support members with behavioral health challenges. We set up a team to work with members, families, providers, and other key constituents to assist with assessing members’ situations and their timely access to quality services. We established a toll-free number for members, families, and providers to get assistance, and built more robust case management support. People with medical concerns, particularly chronic medical conditions, may also have behavioral health challenges, and have been shown to have significantly higher overall claims costs. We are focused, not just on intervening with members with behavioral health concerns, but also active and chronic medical concerns as well, knowing this will support member’s overall health and quality of life, and positively impact claims costs.

Adverse Childhood Experiences (ACEs) are now widely recognized as a health care concern. What can you tell us about ACEs?

Here’s one example that UCare has supported. Hennepin Healthcare’s Emergency Department proposed a project to hire Licensed Alcohol and Drug Counselors (LADCs) to consult with ED staff and immediately engage with patients. Historically the focus of the ED was to medically stabilize the patient prior to sending them on their way. Having the LADC staff available allows them to stabilize the patient medically while also immediately addressing their substance use disorder. This may mean starting patients on a regimen for Medication Assisted Therapy in the ED and referring them to the onsite clinic for followup, or referring them for other treatment services. M Health Fairview is another example; they now place behavioral health professionals in the primary care setting. When the primary care provider identifies a behavioral health concern, they can immediately connect the patient with the behavioral health resource, who can assess the

DECEMBER 2019 MINNESOTA PHYSICIAN

“...” health equity Behavioral focuses on the importance of all people having access to services. “...”

How can integration of behavioral health teams with other elements of health care delivery improve patient outcomes?

“ACEs” include all types of abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18. These experiences have been linked to risky health behaviors, chronic health conditions, low life potential, and early death.

situation, and even see the patient for a limited number of sessions or make referrals to other behavioral health providers. What is behavioral health equity and why is it important?

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines behavioral health equity as “the right to access quality health care for all populations regardless of the individual’s race, ethnicity, gender, socioeconomic status, sexual orientation, geographical location and social conditions through prevention and treatment of mental health and substance use conditions and disorders. Behavioral health equity builds on a general definition of health equity and directs specific attention to mental health and substance use conditions and disorders.” Behavioral health equity focuses on the importance of all people having access to services that are going to contribute to their overall good health, regardless of any specific demographic qualifiers, and supports the overall sense of the

The Centers for Disease Control and Prevention (CDC), in conjunction with Kaiser Permanente, surveyed 17,000 people regarding their childhood experiences and current health status and behaviors. This study demonstrated that the total sum of the different categories of ACEs corresponds to negative health and wellbeing. Some populations are more vulnerable to experiencing ACEs because of the socio-economic conditions in which they live, work, and play. Outcomes associated with ACEs include mental health concerns (such as depression, anxiety, suicide, and PTSD); unintended pregnancy and complications; HIV and other STDs; cancer; diabetes; alcohol and drug abuse, unsafe sex; and reduced overall success in education, occupation, and income. Please tell us about your products for special needs populations.

These products are for adults between the ages of 18–64 with certified disabilities. There are two types of plans: those that combine Medicare and Medicaid benefits, and those that only have Medicaid benefits. By nature, these members have complicated health concerns (medical, developmental, behavioral), and likely will need extra support. The plans provide members with a care coordinator who helps ensure that the needed services are in place and are coordinated. These plans also have unique benefits, such as a health club membership.

What can you tell us about your new behavioral health hotline?

Our new behavioral health-dedicated line provides members, families, concerned persons, and providers a direct pathway to the behavioral health-specific team, who have had specialized training and experience with regards to behavioral health concerns, challenges, and resources. We expect that we will have the opportunity to help connect people with the best possible resources for their specific situation, both utilizing their health plan benefits and things that fall outside their benefit set; help them be educated about how and what to expect; help triage their specific situation; and expediently and appropriately get them connected with resources. We know there are times when members will call us in the midst of their personal crisis. We have no higher priority than taking that call at that point. Please comment on the emerging field of comprehensive medication management.

UCare covers comprehensive medication management services for all of our lines of business (Medicare, Medicaid, and Health Exchange). Additionally, UCare currently has a

formal medication management protocol in place for some products, and is looking for ways to expand this program in the future. This protocol is for patients who have a certain constellation of complex medical conditions, and/or are on multiple medications. The program includes an appointment with a pharmacist to do a comprehensive review of all medications at least annually, and outreach calls on a quarterly basis, if there are any newly identified concerns. If there are gaps identified in the treatment regimen, this may also result in an outreach call to the member and/or their physician. It is designed to support both the patient and their physician in the most effective combination of pharmaceuticals for our membersâ&#x20AC;&#x2122; optimal health. What can you tell us about your expanded behavioral health case management and how it improves treatment delivery?

UCare has historically offered case management services for members who have behavioral health challenges, as well as medical conditions. We are significantly increasing the availability of those resources to assist those with either short-term or long-term needs. This will

include providing these services to members who have behavioral health challenges only, but also for those who have both medical and behavioral health challenges. This is being rolled out product line by product line, and will include coordination and collaboration with other key providers and partners, working with the individual using a member-centric model focused on recovery and resiliency for the member. It is critical that the member be involved in this process, and that we support them in what actions/supports need to be put into place in order to accomplish their goals, and have overall quality of life and improved health. We are also exploring partnerships with provider agencies to provide â&#x20AC;&#x153;feet on the streetâ&#x20AC;? care management for specific situations. What should physicians know about recently enacted and proposed legislation around behavioral health?

It would be beneficial for physicians to know about three key legislative priorities: Serving behavioral health patients to page 104

MEDICAL MALPRACTICE ATTORNEYS

Angela Nelson

Ryan Ellis

Marissa Linden

Jennifer Waterworth

MINNESOTA PHYSICIAN DECEMBER 2019

3Comprehensive medication management from cover history, but you do know that none of their chronic conditions are at goal. Your coffee is cold. You have already missed two of your child’s hockey games, and after checking your watch, doubt you will make it home for dinner … again.

A recipe for burnout—and a strategy

residency training. Nearly 50% of graduates from the University of Minnesota College of Pharmacy now complete a residency and pursue a wide variety of career opportunities. While pharmacists have long been a core member of interprofessional teams in hospital settings, a similar role is now emerging more frequently in primary and specialty care clinics. In fact, more than 150 clinics in Minnesota currently have pharmacists integrated into the interprofessional care team.

Provider burnout is a well-documented issue within primary care. With shortened appointment Comprehensive medication management times, higher patient loads, and increased provider Most of these clinic-based pharmacists deliver a The value of physician-pharmacist responsibility due to shifts towards value-based service referred to as “comprehensive medication collaboration extends beyond care, the burden carried by primary care providers management (CMM).” In this practice model, just revenue. is heavy. In an environment where budgets are pharmacists evaluate patients on an appointment tight and expectations to quickly improve health basis, collect information regarding their outcomes are high, where might we look to medications and overall health, ensure that all of improve provider work-life balance and reduce a patient’s medication-related needs are addressed burnout? Recent research has demonstrated that using a defined assessment process, develop and adding a pharmacist to the primary care team can be one strategy. implement care plans, and follow up with patients to ensure that the goals As health care has evolved, so too has the profession of pharmacy. Pharmacists are doctorate-trained health professionals with a minimum of six years of education (most have a bachelor’s degree prior to completing a four-year Doctor of Pharmacy program) and optional postgraduate training. While the majority of pharmacists in retail or other outpatient settings enter the workforce immediately following completion of their degree, many pharmacists now complete one or two years of postgraduate

of therapy are achieved. These actions are done in collaboration with the patient’s primary care provider (PCP) and other team members. While there is some potential financial benefit to pharmacists practicing in the primary care setting, payment opportunities have not developed as quickly as the efforts to integrate pharmacists into medical practices. Reimbursement for services is often low and may not cover the expense organizations incur to employ a pharmacist in this setting. However, the value of physician-pharmacist collaboration extends beyond just revenue. Evidence suggests that physician-pharmacist collaborations have a net positive impact on each of the three elements of the Institute for Healthcare Improvement’s Triple Aim: to improve health care quality through optimizing patient satisfaction, promote the health of populations, and reduce the per-capita cost of patient care.

Adding an “aim”

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Two themes surfaced from interviews with PCPs. These primary care providers indicated that working alongside pharmacists offering CMM resulted in: 1. A new skill set within the team

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2. A collaborative partner in patient care that was unique compared to other teams

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As a result of this unique collaboration with a pharmacist, the PCPs described seven outcomes that impacted their work-life:

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As burnout has emerged as a significant issue in health care, the Triple Aim has been updated to the “Quadruple Aim” to encompass the importance of improving provider “work-life,” including clinical work, professional satisfaction, and burnout. This new focus creates an opportunity to consider the factors that lead to medical provider burnout. A recent study published in the Journal of the American Board of Family Medicine explored this issue with PCPs in Minnesota health systems that have adopted an integrated model with pharmacists, and has identified a positive correlation.

DECEMBER 2019 MINNESOTA PHYSICIAN

Physician Coaching Leadership Coaching Clinical Team Building

• Decreased workload • Satisfaction among patients receiving better care

• Reassurance • Decreased mental exhaustion • Enhanced professional learning • Increased provider access • Achievement of quality measures

Not only were the pharmacists able to resolve many medication-related problems for the patient, but the organization of the pharmacists’ assessment led to an easier discovery of any unresolved needs to be addressed by the primary provider.

Barriers

While these are positive and impactful A pharmacist can add complementary skills to outcomes, there are barriers to pharmacist and the primary care team in numerous ways. Having provider collaboration. Insurance coverage a pharmacotherapy expert easily accessible within might limit patient ability to see pharmacists A pharmacist can add a clinic can improve efficiency and enhance for CMM visits. Secondly, the strength of this complementary skills to professional learning. Pharmacists are well-versed collaborative partnership is based on a trusting the primary care team in evidence-based guidelines, and understand relationship. Without a trusting relationship in numerous ways. clinical nuances in medication selection, cost, between both pharmacist and provider, it may and insurance coverage. Questions related to be difficult to collaborate and improve patient medication coverage and selection can be relayed health and outcomes. It is important to note through the pharmacist, allowing the provider that clinic-based primary care pharmacists to finish documentation or move on to another are embedded within the primary care team, patient; this saves time for the provider during the allowing development of a strong working course of their day. Additionally, a patient with many medication questions relationship. These aren’t pharmacists working at dispensing pharmacies could be referred to the pharmacist for CMM services, leaving open an or insurance companies offering recommendations via fax machine; these appointment slot for patients with other medical needs, thereby improving are pharmacists working alongside providers, seeing the same patients, access to care. The pharmacist’s approach to patient care is unique, and and working within the same electronic health record. Finally, patient because of this, medication-related problems that could have been overlooked understanding of the role of a pharmacist in their primary care visits may be discovered and subsequently resolved by the pharmacist. Clinic-based primary care pharmacists are not practicing independently. As members of the health care team, trust is built between providers and pharmacists whereby the burden of care for the most complex patients can be shouldered together. In the study, PCPs viewed pharmacists as a collaborative partner. In most settings that have adopted this model, pharmacists operate under a collaborative practice agreement that establishes the parameters in which a pharmacist can start, stop, or adjust medications. These are often less prescriptive than a protocol and allow pharmacists to apply evidencebased guidelines and their knowledge of pharmacotherapy to help develop a treatment plan that achieves the desired outcomes of therapy. This partnership and collaboration led to PCPs feeling supported and reassured, even stating that they felt “less burned out.”

Other benefits In the study, providers also mentioned several areas where pharmacistprovided CMM improved their own work-life and reduced burnout. Pharmacists were noted to decrease workload for providers through sharing patient care and communication responsibilities. Pharmacists assisted with refill requests and inbox messages, leaving PCPs more accessible for other activities; PCPs believed this increased their own and their patients’ satisfaction. PCPs described an increased sense of satisfaction, perceiving that their patients were receiving more comprehensive, quality care. They felt this led to an increased sense of support when care was shared amongst the team, leading to increased confidence in their clinical decisions through consultations with a pharmacist, including reduced fear of malpractice suits.

Comprehensive medication management to page 324

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Importantly, providers felt a decreased sense of mental exhaustion when they collaborated with pharmacists. Complex patients often have many medication-related problems, and the providers believed the pharmacists’ assessment led to simplification and organization of the patient’s medications. MINNESOTA PHYSICIAN DECEMBER 2019

3An inconvenient truth from cover

measure of success is making money, rather than the family physician you see in the exam room.

receiving the best care possible by a variety of providers “in network.” That These contracts mean that physicians have no choice but to spend restricted network is a group of medical providers in either private practice or more time on coding than they do on individualized care. Behind every large health systems who negotiate their fee schedule 15-minute appointment addressing the patient’s with the insurance carrier. These negotiations can symptoms is another 15–30 minutes of coding take months or even years to achieve and are rarely or analyzing how to work around the terms and in favor of the patients. What’s more, they’re also conditions of the insurance company to treat the rarely in favor of the private practice groups. I’ll patient appropriately. The insurance carrier is expand more on that topic later. What’s more: the insurance company will telling the physician how The exam—and the bill often mandate that less costly methods of care are to practice medicine. Let’s discuss the current relationship between a prescribed, instead of allowing the physician to physician and patient before we go further. In the decide—or the insurer will not allow the physician right setting, a physician would see their patient, to order an approved test at a high value, lowassess the symptoms, and treat as their medical degree, cost location that is out of network. This means knowledge, and experience deemed appropriate. doctors either are forced to lump every patient into a standardized medicine practice, or find ways around coding and billing Instead, physicians are forced to weed through tens of thousands of to treat their patients. But neither the physician nor the patient has any codes per appointment to meet the negotiated terms of the insurance knowledge of what these services will cost. contracts, rather than use their expertise on best care for the patient. These thousands of codes were created for the sake of giving a physician permission to treat their patient and to have a service covered. I want to emphasize this point: in the current system, the insurance carrier is telling the physician how to practice medicine with financial incentives. It’s incredibly unsettling to understand that medical care is being highly regulated by an executive in a corner office of an insurance company whose

If we applied this health care payment model to any other business, it would be considered vehemently foolish. Imagine if Apple had a third party dictating prices, giving permission to offer certain features, deciding who can buy and how often, and creating a complicated way of pricing their products using complex codes that required consultants and expensive software. Not to mention that, under this scenario, neither Apple nor the customer would know the price until weeks after purchase. But this is what happens in health care, so is it any wonder prices are out of control, or that physician creativity is suppressed?

The growth of large systems Let’s circle back to that discussion about private physician groups versus large health systems. As a private practice physician, I know what my costs are to run the practice. I also know that I can run a profitable business with my current prices listed for my patients clearly to see before they schedule an appointment. This is operating on a cash-based system, not in agreement with any commercial insurance companies, resulting in significantly lower overhead costs. However, when I operated under contracts with insurers, I knew for a fact that the large health systems got paid, on average, at least 40% more than I did for the same services with the same quality. I was told by a large local insurer in a face-to-face meeting that it was because they have better contracts due to how large they are. I took away from that meeting one undeniable truth: insurance companies reward volume-based medicine that costs more than patient-focused care that costs less. I thought the economy of scale would allow the large companies to be less expensive, but not in health care. What’s more: employers and individuals are paying these inflated prices because there is no price transparency.

The decline of small practices Independent clinics are selling out, not because they are more expensive to operate, but because they get great buyout offers and physicians are better compensated when they work for the larger health systems. Private practices have a hard time getting contracts from the insurance companies—the payors say, “We don’t need you because you are small.” I’ve seen this firsthand. The black fog grows thicker by the day.

DECEMBER 2019 MINNESOTA PHYSICIAN

Physicians who become employed by the large health systems lose control of their practices. They are forced to treat patients in a certain standardized way and get financial incentives to do so. They lose the ability to individualize treatment, or they may be penalized for doing so. This is misnamed as pay for performance. Sure, it sounds great—but the reality is that medical care becomes very generic. I remember being financially penalized for taking a patient off a medication that caused potentially life-threatening side effects. My medical assessment that the value of my patient’s life was greater than standardized medicine protocol by the insurance company resulted in a financial timeout in the penalty box.

Summing up

Patients pay large monthly premiums to see their physicians, who have spent months negotiating contracts with insurance providers. Large health systems are paid more for the same services than small private practice physicians because the volume is advantageous for the insurance company. Physicians are directed to treat quickly and with the least amount of intervention possible, and neither the physician nor the patient has knowledge or access to what Physicians ... spend more time these services cost the patient.

on coding than they do on individualized care.

One of my former partners was listed by a large insurance company as being in the bottom 10% of physicians because he was ahead of the rest of us with new medical recommendations. The insurer was not up to date and so he failed the “pay for performance” test. As I mentioned earlier, physicians are spending more time doing computer work instead of seeing patients to get paid by the insurance companies. Physician burnout is on the rise and patients feel like they are on an assembly line. It’s a myth that insurance companies are looking out for their customers by negotiating discounts. This spurred the trend of the highvalue clinics selling out and the large health systems becoming larger, thus increasing the cost of health care for patients. But many still wonder why costs are rising. Personally, my own health care premiums are increasing an average of 10% to 15% every year, and my choices are decreasing. Being a physician, I know that salaries for doctors and nurses are not rising that fast. Additionally, the industry is seeing the costs of technology decrease; so where is all that money going?

The black fog has done one thing well: kept people from seeing what’s really behind the curtain of the insurance company practices. It’s time to take a stand, rip back the curtain, and begin implementing real change with price transparency that will bring autonomy back to the patient/physician relationship.

Merlin Brown, MD, a board-certified independent primary care physician with Southdale Physicians, believes that his fee-for-service practice allows him to provide quality medical care, develop longterm relationships with adult patients, and charge them only for the services they need. He has been in private practice in internal medicine for 20 years.

Price disparities Here are a couple of real examples taken from actual claims data. Cardiac stress echocardiogram: an employer paid over $7,000 through the insurance contracted prices. A local independent high-quality cardiologist charges $500 for the same test using the same machines in a more patient-friendly environment. Another patient of mine paid $2,300 for a knee MRI as he was in his deductible, but an independent imaging center charges $613 for the same service, using the same machines and physicians.

Price transparency The solution to all of this is simple: price transparency. We need health plans where patients care about the prices, and patients and doctors have easy, immediate access to the prices. If a patient needs an MRI and one location costs $4,000 and the other one costs $600, the patient and the ordering physician need to know the cost before ordering it. If legislation were to provide any sort of aid in clearing the black fog, they could start by implementing laws that would require price transparency for bundled services. Here’s an example: when I shop for a vehicle, there is a base price with a few added features bundled together. I don’t get a listing of all the separate parts of the car. Tying this into a medical example: an average cholecystectomy should have one price. Listing 30 separate charges for this service is both inefficient and insane, but that’s how it’s done today.

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BEHAVIORAL HEALTH

Minnesota’s leading edge Creativity and collaboration BY TODD ARCHBOLD, LSW, MBA

ur nation is amidst a mental health crisis. For the last decade we have seen an increase in the prevalence of psychiatric conditions, deaths from opioid overdoses, and suicide rates, coupled with a drastic increase in people with mental illness who are homeless or incarcerated. All too often, barriers to accessing care result in individuals and families enduring crisis and experiencing traumatic events that could have been prevented. We are also facing a substantial shortage of psychiatrists as well as access to inpatient beds and specialized psychiatric care. Studies demonstrate a public perception that mental illnesses are linked to dangerousness or violence. Funding strategies are constantly shifting at the federal and state levels, and the insurance reimbursement for psychiatrists is, on average, 21% less than for primary care physicians. The grim reality is that our current approach to mental health care, shaped in the late 20th century, will not continue be effective today. Effective models for mental health care require radical change and transformation. Bruce Schwartz, MD, president of the American Psychiatric Association, stated recently that, “We have to marshal the entire workforce who cares for

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people with mental illness. That includes social workers, advanced practice nurses, psychologists, mental health counselors, and peer counselors. It comes down to collaboration and putting aside some of the guild issues about which we all have valid concerns.”

The local angle Minnesota, on the other hand, has led the way with creative and collaborative new care models. Since the early 2000s, the state has consistently ranked among the top 10 states in health care, education, quality of life, cost of living, social welfare, entertainment—and in mental health. Even before the passage of the Affordable Care Act (ACA) in 2010, nearly 95% of Minnesotans had insurance coverage, and mental health parity was noticeably salient for residents. Today, more Minnesotans than ever have greater access to care, and more children and families are proactively seeking health care through annual checkups and wellness visits. Creativity and collaboration have been key factors as Minnesota addresses our mental health crisis in various settings, including hospitals, schools, advocacy groups, and nonprofits. Initiatives to meaningfully manage mental health needs span the continuum of care: resiliency coaching, crisis prevention, trauma response, integrated care, and acute care. This includes service providers and new screening and diagnostic tools.

Prevention and wellness Examples of Minnesota’s initiatives include Allina Health’s Penny George Institute—the largest integrative health center in a health system in the country—which focuses on holistic health and wellness. The University of Minnesota offers a bachelor’s degree program in Health and Wellbeing Sciences, as well as a graduate degree in Professional Studies of Integrated Behavioral Health. These educational programs, along with the investment into services and infrastructure, help Minnesotans prepare for the future; they are an invitation to change the way we currently react to mental illnesses and crisis, preparing us to prevent and better understand mental health. Many more schools and community-based organizations have started programs that focus on mental well-being, resiliency, and peer support. Seventy percent of mental illnesses have an onset of symptoms before age 14. Programs that can help kids and parents identify these symptoms earlier can help prevent or lessen the potentially devastating impact that untreated mental illnesses can have on the academic and social development of youth. This can be done through screening, conversations with school staff, and breaking down the stigma that often prevents individuals from reaching out for help. Many local charities and non-profit organizations have supported schools in these endeavors through grants and in-kind access to professional mental health resources. Employers have brought mental health resources, education, and support into the workplace. Studies show that nearly 63% of individuals with a diagnosed mental illness have not disclosed it to their employer.

Companies’ Support without Stigma program allows for open conversation and sharing about mental health issues. Similarly, one large local retailer now hosts monthly educational events and has established a mental health ally program that allows employees to connect with peers who have gone through special training. The Minnesota chapter of the National Alliance on Mental Illness has helped support funding for countless mental health programs, along with the ongoing development of new programs, such as school-linked mental health. When the state did face cuts and setbacks to mental health programs, NAMI Minnesota’s persistent and staunch advocacy remained intact. And in 2014, Healthpartners launched an awardwinning anti-stigma campaign called MakeItOK that is supported by 11 local health systems, mental health providers, and media.

Minnesota has three metro-based Intermediate School Districts with special designations that support integrated services in vocational education, special education, and, increasingly, in the area of mental health. Since summer 2018, five Intermediate School Innovation Grants were awarded with the goal of improving clinical outcomes for students, helping them return to their home school district, reversing the disproportionate impact on students of color, and providing support and training for school staff and parents. Intermediate School District #287 Our current approach to has prioritized funding strategies to have boardmental health care … will not certified child and adolescent psychiatrists onsite to continue be effective today. integrate care with the families and learning teams. The shortage of these specialists, along with the barriers in accessing care, would otherwise mean that many of these youth in need would likely never receive the care required.

Integrated behavioral health Many individuals in need of treatment for mental health and substance abuse disorders will never be identified in primary care—and, even if they are identified, will then have to rely on referrals to outside agencies. Less than 50% of these patients follow through on their referrals. In response, many health systems now offer onsite, integrated behavioral health services. This can reduce expenditures, since treating a medical condition can cost upwards of 200% more when an untreated mental health condition also exists. South Lake Pediatrics, an independently operated and physician-owned medical group, has nourished a culture of listening closely to parents and kids to understand and identify signs of mental illnesses. They have partnered with behavioral health providers to integrate psychotherapy and psychiatry at their sites, allowing for easy referrals, increased communication, and optimized coordination of care. This model delivered a 28% increase in follow-through for initial referrals and a 10% decrease in no-show rates. Clinicians and patients have praised the ease of referrals and resulting quality of care.

Some schools have even built health clinics on-campus. Brooklyn Center schools offer wellness visits, vaccinations, and mental health counseling. Minnesota Community Care operates clinics in nine St. Paul public high schools, providing mental health case management as well as trauma-focused cognitive behavioral therapy (TF-CBT) therapists. A new grant extension of these programs now includes federal funding to pilot onsite psychiatry. Minnesota’s leading edge to page 284

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Similarly, Ridgeview Medical Center has partnered with PrairieCare Medical Group to establish a jointly managed behavioral health division offering integrated outpatient care and inpatient consultations to their hospital. This partnership will offer expedited access to mental health care to thousands of individuals in the community, through coordination with primary care providers.

School-based innovations Minnesota school systems—long revered as leaders—have often been the “canary in the coal mine,” the first ones to observe and experience changes in youth behavior and engagement. Starting in 2006, the Minnesota Department of Human Services (DHS) supported legislation to help fund school-linked mental health services aimed at reducing barriers to care and to promote early identification and intervention. Newer state-sponsored innovation grants continue to help identify new ideas and creative ways in which school districts can better support students whose academics and futures are jeopardized by unidentified or untreated mental illnesses.

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CARE TEAMS

Behavioral health consultants A valuable new member of the care team BY JENI KOLSTAD, MSW, LICSW

ntegrated care, as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA), is “The care that results from a practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.” The goals of behavioral health integration within the medical and dental settings are to increase access to behavioral health services, help primary care providers and dentists manage behavioral health conditions that arise during patient appointments, and provide whole person-centered care.

Primary care: the front line Behavioral health problems are common within primary and dental care. Primary care is often the first place a patient will go when they have mental health symptoms, and primary care providers are often the first to identify that their patient has a potential mental health issue. The National Alliance on Mental Illness (NAMI) suggests that patients may feel stigma or shame in seeking a mental health counselor, but feel comfortable in raising concerns with a trusted primary care physician during the course of a routine visit

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or annual physical, both of which often include screening with PHQ-9s or similar patient health questionnaires. The Centers for Disease Control and Prevention (CDC) estimates that one-fifth of primary care visits address mental health concerns, often resulting in a prescription for psychiatric medications or a referral—although patients often fail to follow through on referrals. Studies show that 50% of Americans will have a diagnosable mental health disorder in their lifetime. Only 29% of those people seek out specialty mental health services, and 21% are treated in primary care. Many mild to moderate mental health diagnoses, such as anxiety and depression, can be managed within the primary care setting. Fifty-nine percent of those with a diagnosable mental health disorder receive no treatment at all. For those who want specialty behavioral health care, the wait times can be long— up to three or more months for psychiatry or psychotherapy. With these lengthy wait times, it is imperative that primary care providers feel equipped to manage multiple mental health symptoms. In the dental department, patients may present with a multitude of mental health conditions that make it difficult for the dental staff to complete treatment. Not only is there the typical anxiety that many people have when visiting the dentist, but there are patients that have had traumatic experiences that make being in this vulnerable position (lying back, mouth open, hands/tools in the mouth) difficult. There is a perceived loss of control and potential for triggering trauma responses, which could include yelling at the dentist in an effort to regain control. Dentists may have someone present after a sexual or physical assault that damaged their mouth/teeth or perhaps a sexually transmitted disease in the mouth due to an assault. Additionally, substance use can cause oral cancers or teeth that break or fall out. Delta Dental reports that people with mental health concerns may have poor oral health due to limited motivation for performing self-care activities, like brushing teeth. Depression can also cause people to have unhealthy diets, and conditions like canker sores, teeth grinding, temporomandibular disorders, and dry mouth related to certain types of medications. Another area of concern that presents in primary and dental care is the behavioral components of medical conditions—for example, the patient with diabetes who does not test their blood sugar. These situations can be frustrating for a primary care provider. The patient may be labeled as noncompliant with medical treatment, when in fact there might be barriers, either socially or mentally, that inhibit a patient’s ability to follow through on the recommendations. There is a high correlation between chronic diseases and behavioral health concerns. All these issues are likely well-known to primary and dental care providers. Providers may feel ill-equipped to manage such complex conditions during their short office visits. Integrating a behavioral health provider into the medical and dental departments can help address these concerns without adding to the medical or dental provider’s workload.

Backing up the front line

Referrals could be for typical psychological complaints such as mood disorders and substance use, or for multiple medical conditions such as headaches, insomnia, chronic pain, and chronic diseases. Additionally, the BHC could help with socio-emotional problems like domestic violence, bereavement, or marital problems, along with parenting or behavioral problems in children. The list of possible reasons for referral is endless, and certainly all medical clinics have patients come in with many if not all of the above concerns.

Behavioral Health Consultants (BHCs) are behavioral health providers who serve as medical or dental team members. The embedded BHC can assess, diagnose, and treat mental health conditions and work with patients on behavioral concerns, all while staying within the medical department—and, since oral health can affect overall health, dental departments. The BHC can provide diagnostic clarification on behavioral health concerns to the primary care Primary care is often the first place provider and work with the medical and dental a patient will go when they have providers on an integrated plan of care, which mental health symptoms. might include medication management and/ or returning for follow-up visits. This approach reduces the need for patients to visit multiple facilities, since referrals can be made inhouse. The scope of the BHC practice is a population management approach. They share the patient panel and plan of care with the medical provider. Their goal is to provide small changes in large numbers of patients. They are also able to respond to crisis mental health situations that could derail a medical provider’s schedule due to the multiple care coordination needs. The BHC can help determine if a patient is safe to leave the clinic, develop safety plans, and arrange transport to the hospital if it is unsafe for the patient to leave the clinic.

Within the scope of this population management approach, visits with a BHC mimic those of primary care. A BHC will see a patient for 15–30 minutes per visit and work to target one specific patient need. Just as the medical and dental providers have to wade through lengthy problem lists to determine the course of the visit, so does the BHC. If the visit is about diabetic management and is with an uncontrolled diabetic patient, then the BHC works with the patient on behavioral changes to improve their condition. This type of intervention is called a Health and Behavior Assessment/Intervention, and there is a list of billable CPT codes for the BHC to use for this type of visit. There is potential, though, that the BHC may see the patient and learn that significant mental health concerns pose a barrier to managing diabetes. If

The mantra for the BHC is “There are no wrong referrals.” The BHC accepts all referrals, which could range from very specific to very vague.

Behavioral health consultants to page 304

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SENIOR AND LONG-TERM CARE

Trends in older adult residence design Emphasizing quality of life BY GAIUS G. NELSON, MA

Older misconceptions

he past 30 years have seen a significant shift in both the populations and the designs of long-term care facilities. A once-homogenous cohort of older adults with a limited range of personal care and chronic medical needs has evolved into a diverse group of patients and residents in multiple settings: short-stay, post-acute, and rehabilitation. Assisted living has become a residence of choice for those seeking help with activities of daily living such as dressing and eating, as well as what gerontologist and environmental psychologist Lorraine G. Hiatt, PhD, terms “bio-care”: personal attention to the body related to toileting, bathing, grooming, and hygiene. And with an increasing population of elders with cognitive difficulties such as Alzheimer’s disease and other dementias, safe, secure living environments where exit seeking and agitation can be redirected have been well received.

During a 2018 segment of the PBS NewsHour, 95-year-old Hazel Cross said that moving into a nursing home “would be the end—of my life!” This is a common response from seniors. Many others have no desire to even visit a nursing home, which still retains the stigma of being a place of sickness and dependency, or simply a place to die—a reputation similar to that of hospitals in years past. This reputation is perpetuated in large part by the design of the physical environment. When Medicare and Medicaid became dominant payment methods for long-term care, the regulatory agencies charged with implementing these programs, unfortunately, adopted an institutional model based upon hospital care and design concepts.

Careful planning and design of environments for each population group can greatly improve the quality of life for patients and residents, while also improving the efficiency and satisfaction of care providers. Understanding the differences and the similarities among the variety of users within any environment can help determine design strategies for both new and remodeled facilities.

That model typically included a hub-and-spoke design focused on a centralized staff station, with direct observation of long, double-loaded corridors lined with rows of patient rooms. The rooms offered limited privacy and forced occupants to share all aspects of their intimate lives with strangers. This design was an efficient method for staff to oversee large numbers of patients that either stayed in their room (often in bed), or were gathered together into large centralized dining or activity rooms. Patient/ resident satisfaction was not the prime directive in this scenario.

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Over the past 30 years, however, there has been a slow but steady shift in the methods and locations for providing long-term care services. Beginning with the passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87) and the Nursing Home Reform Act, the focus has changed from quality of care to quality of life. Long-term care residents are now entitled to a set of rights that include privacy, individuality, and dignity, in addition to medical care. Self-determination and resident-focused or resident-directed care are key concepts. At the same time, rising costs of care and the desire for alternatives to nursing homes led to what were, at the time, innovative care settings unhindered by strict state and federal regulations. Minnesota was at the forefront in the development of assisted living settings with projects such as the Elder Homestead of Minnetonka. Using homecare services to provide personal care and nursing assistance meant that residents could live in the setting of their choice, whether that be in their traditional family home or a purpose-built elder community. By bypassing the constraints of an institutional building code classification and restrictive health department rules, living arrangements and provision of care were no longer linked. Interestingly, the State of Minnesota maintained a light touch in regulating these evolving models of care. In many ways, Minnesota encouraged the evolution of alternative care settings with policies that incentivized the transition of residents to less restrictive (home or assisted living) environments. This led to the reduction in the number of low-acuity residents within traditional nursing home settings. Additional policies

led to a significant reduction in the number of Minnesota nursing home beds. Nursing homes have become the dwelling place for individuals with significant medical and nursing needs, either on a long- or short-term basis.

Responding to market demands Ten thousand baby boomers reach retirement age each day, according to a 2012 Pew Research Center report. Life experiences and expectations of today’s retirees are much different than those of older generations, and these consumer expectations have helped fuel major trends in design and construction. The uncoupling of care services from the physical environment now allows a wide range of choices. Universal Design concepts—which stress design that meets the needs of all users, despite age or disability—proliferate in new housing construction, providing an increasing stock of accessible housing options with broad appeal. Larger scale age-limited independent living settings provide similarly accessible accommodations, with or without the opportunity to procure home-delivered services. Independent living is often available on campuses with a full range of activities and services, up to and including long-term and end-of-life care. Many of these Life Plan Communities provide resort-style amenities, with activities and food service options. As designers plan out apartment design and detailing comparable to market rate housing, they should also organize activity locations in a manner that helps to support a sense of community. Proximity to activities is one of the prime determinates in frequency of use by residents. Low scale, spreadout community campuses must provide opportunities for socialization and participation within manageable walking distance to resident apartments. Taller, denser structures with smaller footprints are often more successful in providing access to community spaces, as elevators provide excellent and dependable transportation to otherwise remote locations.

incremental changes to service-enriched residential apartment living, the nursing home industry has undergone a revolutionary transformation in the delivery of care. Driven by the rejection of the traditional institution as a viable model to ensure resident quality of life, a culture change movement focused on person-centered care developed. The physical environment is integral to this reconceptualization of what a nursing home should be. For those requiring long-term care, designers and elder care advocates now stress “home and household” models. Small-scale living environments—ideally with 10 to 12 resident rooms, at times up to 20—are clustered around open, sun-filled living, Trends in older adult residence design to page 264

When loved ones need to be close

Transitioning to extra services As personal care needs increase, individuals often transition to some form of assisted living. Although some choose to bring private care directly into their independent living apartments, care can be managed more cost effectively in an environment designed as a service-enriched setting. Private living spaces are often slightly smaller than independent living units—allowing residents to manage them more easily—but market demand for larger accommodations has increased. Service packages in assisted living facilities normally provide three daily meals. Unit kitchens are typically small in size, often limiting cooking appliances to a microwave oven. Additional safety features typically include emergency call systems, safety shut-off devices for appliances, and, in some cases, specialized motion sensing or video systems that are capable of interfacing with artificial intelligencedriven software that can detect changes in behavioral patterns, alerting family or doctors of possible health changes. It is not unusual for apartments to be outfitted with various assistive devices to maximize independence.

THE SAINT PAUL HOTEL has a long-standing special pricing policy for guests with loved ones that require hospital stays. If you have patients from either out of state of suburbs that require hospitalization at any of the outstanding St. Paul area hospitals, please let them know that family members and loved ones are welcome to our discounted health care stay pricing.

A wide variety of social and wellness-based areas become the focus of activity for residents outside of their private spaces. A lively activity program should be included to encourage participation and a sense of community and connection. Acoustics and lighting quality become important considerations in designing comfortable spaces.

Nursing homes: new models While independent living and assisted living settings have focused on

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SENIOR CARE

Age-friendly health systems Providing care that matters BY JAMES T. PACALA, MD, MS

here are currently 700,000 to 800,000 people over the age of 65 in Minnesota. In 20 years, that number will grow to 1.3 million. With that figure on the rise, we need to make it a priority to know how to care for those individuals. The last 30 years of geriatric research has elucidated treatments and approaches to care for older adults that result in better health care outcomes, yet they have not all been implemented. At the University of Minnesota, we are working to close that implementation gap and improve the health care and health of older adults across the state. We recently received the support of a five-year, $3.74 million Geriatrics Workforce Enhancement Program (GWEP) award from the U.S. Health Resources and Services Administration (HRSA) to help in these efforts. The resulting Minnesota Northstar GWEP project calls for partnership with the HRSA-funded National Center for Interprofessional Education and Practice, which will perform all of the evaluations. In addition to our GWEP interprofessional team, consisting of University of Minnesota experts from the Medical School, College of Pharmacy, School

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of Nursing, School of Public Health, School of Dentistry, and Department of Rehabilitation, as well as the Community–University Health Care Center (CUHCC), we have partnered with seven community organizations that represent a wide swath of services and outreach to older adults across Minnesota.

The four “Ms” A major initiative of the HRSA GWEP program is the promotion of what are known as the Age-Friendly Health Systems. The Institute for Healthcare Improvement (IHI) reviewed all of the literature in geriatrics over the past 30 years and identified 11 interventions that have been shown to improve health in older adults. They categorized them into four groups and created the 4 M’s of Age-Friendly Health Systems: What Matters, Mentation, Mobility, and Medications. These 4 M’s indicate effective interventions for successful Age-Friendly Health Systems: 1. What matters to the patient needs to influence the care provided. As physicians, we need to focus on goal-oriented care. However, there is a gap between what matters to our patients and the care they are receiving. There are patients who receive care that they don’t want and others who want care but don’t receive it. An alltoo common scenario is an older adult becoming ill and receiving unwanted, technologically intensive procedures, resulting in further morbidity and functional decline. These situations could be obviated if older adults were first asked what they want out of health care. Elucidating goals and care preferences is particularly important for patients in the last stages of their lives. 2. Mentation addresses problems such as dementia, delirium, and depression, and the importance of preventing, identifying, treating, and managing those diseases. One prominent example of the importance of addressing mentation concerns delirium in hospitalized older adults. Delirium is not just observed in the patient down the hall who is “out of their head” and screaming. Those patients represent a minority of hospitalized patients who are delirious. For most, the delirium is subtle and isn’t something a casual observer can easily identify. Unrecognized delirium is a risk factor for terrible outcomes such as institutionalization, severe complications, readmission to the hospital, and even death. Several evidence-based interventions for detecting and treating delirium have been developed but are not always being implemented. 3. Mobility highlights the importance of attending to topics such as physical mobility, the importance of exercise, and the risk of falls. It is important to screen for mobility limitations to ensure patient safety and maintain physical functioning. We know that gait speed, or how fast somebody walks, is a good marker of their health, and that slowed gait speed is a marker of frailty and the likelihood to become hospitalized or have functional decline. While it is not routine practice in caring for older adults, screening for slow gait speed could identify older adults at risk and prompt therapies to mitigate associated hazards.

4. Medications need to be age-appropriate and carefully prescribed to older adults. Older adults are often prescribed multiple medications, some of which aren’t always necessary, placing them at an increased risk to suffer harm from their medications. Periodically performing a standard medication-reconciliation and deprescribing harmful or unnecessary medications would help to lower the risk of adverse drug events.

Specific projects

Measuring success

A large part of the project is evaluation. We will measure how many health care learners we are reaching with our educational interventions and how confident they feel caring for and approaching elderly problems. We will also measure how many patients, families, caregivers, and direct care workers we reach with our outreach programs. Finally, we will measure specific health outcomes in the patients served in the transformed Age-Friendly primary There is a gap between what care clinics, including the eight family medicine matters to our patients and the clinics, CUHCC, and across the primary service care they are receiving. line at M Health Fairview.

Over the next five years of the Minnesota Northstar GWEP, we will work to improve the health care and health of older adults across the state through addressing the implementation gaps and promoting Age-Friendly Health Systems, educating both the formal and informal health care workforce and providing support to patients, their families, their caregivers, and their direct care workers. Our projects include:

• Creating a geriatrics education and training (GET) repository. The online clearing house repository will serve as a resource for state-ofthe-art, up-to-date educational materials that health care learners can undertake, course directors at the University can use, and people outside the University can access. We have also set up an interesting set of experiences that will offer unique and exciting learning opportunities, such as a case competition where students work in teams to devise a plan that addresses a complex case in geriatrics. • Transforming all of the residency training clinics in the University of Minnesota Medical School’s Department of Family Medicine and Community Health into Age-Friendly Health Systems. This will include eight of the 11 Family Medicine training clinics in the state, the Community–University Health Care Center in south Minneapolis, and all 60-plus clinics in the primary care service line at M Health Fairview. Our goal is to alter the processes of care at all the clinics to systematically address the 4 M’s: changing workflows, modifying the electronic medical record, altering how older patients are roomed, and collecting appropriate data on every patient for the implementation gaps previously described.

Closing thoughts The MN Northstar GWEP is a breakthrough at the University. As one of 63 GWEP sites across the country, we are the only one in Minnesota. As the older adult population will continue to increase in the state, there is a great need to educate our workforce on the best ways to take care of them, and the MN Northstar GWEP is helping us do that. James T. Pacala, MD, MS, is a professor and head of the Department of Family Medicine and Community Health at the University of Minnesota Medical School. He is also a family medicine physician who cares for geriatric patients at M Health Fairview Clinic–Smiley’s.

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• Performing outreach activities in every one of the 87 counties in the state. Joe Gaugler, PhD, professor and Robert L. Kane Endowed Chair in Long-Term Care and Aging at the School of Public Health, is leading the implementation of a series of outreach and support activities for families, patients, caregivers, and care workers serving the elderly in Minnesota. One activity is the Caring for a Person With Memory Loss program, which provides practical information and group support to families dealing with Alzheimer’s disease and other dementias. We will also reach the public through Minnesota Public Radio and the Medical School’s Hippocrates Cafe, a melding of spoken word, art, and music intended to enlighten and educate the public on a particular health care topic. • Promoting the Dementia Friends program, an educational and attitude-orienting experience where participants learn to value the strengths that people dealing with dementia have to offer. It facilitates more respectful and humane treatment and fosters inclusion of them in society.

“We wouldn’t hesitate to work with Engan Associates again.” (Matt Reinertson, Heartland Orthopedic Specialists)

ADDICTION MEDICINE

The resurgence of methamphetamine A dual epidemic BY TYLER WINKELMAN, MD, MSC; JULIE BAUCH, MS, RN, PHN; AND CHRISTINE HAUSCHILDT

he early and mid-2000s saw a rise in use and production of methamphetamine which generated a substantial policy and public health response. The federal government passed the Combat Methamphetamine Epidemic Act (CMEA) of 2005 to regulate retail over-the-counter sales of ephedrine, pseudoephedrine, and phenylpropanolamine products and to curtail the illicit production of methamphetamine and amphetamine (https://tinyurl. com/mp-1219-01). These efforts aimed at curbing methamphetamine supply resulted in a significant decrease in the availability and an increase in price of methamphetamine, decreased primary methamphetamine treatment admissions, and reduced emergency room visits associated with methamphetamine (https://tinyurl.com/mp-1219-02). Despite these measures, methamphetamine is now seeing a resurgence. Law enforcement officials have curtailed most in-state manufacturing of the drug, but Mexican cartels now supply more pure and cheaper methamphetamine to Minnesota, fueling a rise in use and abuse.

Increase in methamphetamine use In recent years there has been a stark increase in methamphetamine use. Government officials, researchers, and health care professionals have noted increases in methamphetamine-related hospitalizations, death rates, co-use with other substances, and methamphetamine drug seizures. Amphetamine use is now the fourth most common reason to seek drug treatment in the United States after alcohol, opioid, and marijuana use. Hospitalization rates related to methamphetamine use increased 270% from 2008–2015 and have increased at a faster rate than for other substances (See Figure 1 and background at https://tinyurl.com/mp-121903). These rates correspond with reports from law enforcement; the State of Minnesota Violent Crime Enforcement Teams (VCET) reported that methamphetamine drug seizures in the state have increased nearly fivefold, from 233 pounds in 2014 to 1,145 pounds in 2018 (https://tinyurl. com/mp-1219-04). The increase in methamphetamine use has grown disproportionately in the Western United States but all regions have seen substantial growth (https://tinyurl.com/mp-1219-03). Additionally, co-use of methamphetamine has increased among individuals with opioid use disorder. In 2011, 18.8% of treatment-seeking opioid users reported also using methamphetamine. This percentage rose to 34.2% in 2017. In a survey of individuals with opioid use disorder who co-use methamphetamine, respondents said that they used meth because it balanced out their high, was easier to obtain and less expensive than opioids, and induced euphoria (https://tinyurl.com/mp-1219-05). The increase in methamphetamine use among individuals with opioid use disorder may further complicate the opioid crisis. As such, the U.S. Department of Health and Human services has described a fourth wave of the opioid crisis, which is primarily characterized by increasing co-use with methamphetamine.

Health risks and treatment Methamphetamine carries a variety of health and social risks. Individuals with opioid use disorder who co-use methamphetamine are at greater risk of adverse health outcomes and fatal overdose compared to opioid use alone (https://tinyurl.com/mp-1219-05). In addition to any health impacts of opioid use, health outcomes related to methamphetamine use alone include psychosis and other mental disorders, cognitive and neurological deficits, cardiovascular and renal dysfunction, disease exposure such as HIV transmission and viral hepatitis, and increased mortality (https://tinyurl.com/mp-1219-06). It is difficult to treat methamphetamine use disorder because there are no pharmacological interventions for methamphetamine use disorder. Contingency management—which reinforces and rewards patients who exhibit positive behavioral change—provides incentives such as food items, movie passes, or other goods or services to reduce substance use, and has been shown to be somewhat effective for treatment of stimulant-related disorders, including methamphetamine use (visit https://tinyurl.com/ mp-1219-07 for details on this approach). There are treatments for opioid use disorder—buprenorphine, methadone, and use of extended-release

DECEMBER 2019 MINNESOTA PHYSICIAN

All amphetamine-related hospitalizations

200,000

150,000

Weighted Hospitalizations, Numbers

Amphetamine plus 1 or more substance

100,000 Amphetamine only 50,000

Amphetamine plus opioid

2003 2004 2005 2006 2007 2008 2009 2010

2011

2012 2013 2014 2015 Year

Figure 1. Amphetamine-Related Hospitalizations in the United States, 2003-2015 .

naltrexoneâ&#x20AC;&#x201D;which can be used to treat opioid use disorder for individuals who co-use opioids and methamphetamine. These medications are not FDA-approved for the treatment of methamphetamine use disorder, although there is some preliminary evidence that extended-release naltrexone may reduce methamphetamine use. Individuals who co-use opioids and methamphetamine are encouraged to carry naloxone to treat opioid overdose, but it will not reverse methamphetamine intoxication.

overdose. Because methamphetamine can be cut with fentanyl, health care professionals may consider providing naloxone to patients using methamphetamine alone. Patients who have hepatitis C should be referred to treatment to reduce transmission risk.

The resurgence of methamphetamine to page 274

What we can do Screen for methamphetamine use in at-risk populations. One way health care professionals can identify and help individuals who use methamphetamine is by screening for methamphetamine use during health care visits. Health care professionals in entry-point care settings, such as primary care and emergency medicine, are well positioned to identify patients at high risk of adverse health events related to methamphetamine. However, specialty providers, such as psychiatry, infectious disease, cardiology, and gastroenterology, may also find enhanced screening to be valuable given the known health risks of methamphetamine use. Health care professionals can also incorporate trauma-informed care practices during patient visits given the high levels of trauma many individuals who use methamphetamine have experienced. Provide resources. Individuals who use methamphetamine often have multiple health and social needs. Health systems, clinics, and health care professionals can provide referrals to social service organizations, state and county programs, and addiction and recovery specialists. Additionally, health systems could choose to invest in peer supports, like community health workers, to help patients manage appointments and services and to provide informal counseling and encouragement. Recovery requires a team approach. Harm reduction. For patients who are not ready to stop using methamphetamine, several services can still be provided to reduce infectious risks. Patients who inject drugs can be referred to clean needle exchanges and counseled on the safe use of needles and equipment. Naloxone should be provided for patients who are using both opioids and methamphetamine and counseling should be provided about how to recognize an opioid

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MINNESOTA PHYSICIAN DECEMBER 2019

HEALTH CARE POLICY

The 2020 Minnesota legislative preview Divided body faces a large surplus BY TOM HANSON, JD, AND JOHN REICH

lection-year politics and surplus dollars will be the center of attention when the Minnesota Legislature convenes at noon on Feb. 11, 2020. With 2020 being an all-important election year, the Governor and the Legislature must decide how to use a budget surplus of $1.322 billion.

Because a biennial budget was adopted at the end of the 2019 legislative session, the 2020 Legislature will likely consider supplemental changes to this budget along with a bonding bill and major policy changes.

Politics will play a big role To accomplish anything in 2020, DFL Gov. Tim Walz, the DFL House, and the Republican Senate will once again need the type of compromise they achieved at the end of the 2019 legislative session. This may prove difficult. With control of the House and Senate up for grabs in November of 2020, partisan politics will play a big role in most issues discussed. Of note, Minnesota is currently the only state in the nation with a split Legislature. While the DFL controls the House with a 74–58 margin and two open seats, and the Republicans control the Senate 35–32, both chambers will

be contested in 2020. Whoever controls the House and Senate after the election will be able to write the legislative redistricting plan, which will set legislative districts until 2032. Because this is a big prize, it is expected that both parties will be jockeying to position themselves for the fall campaign while working to resolve their differences.

Key issues The 2019 legislative session came to a conclusion when Gov. Walz, the House, and the Senate agreed to a $48.3 billion biennial budget for fiscal years 2020–2021. This budget contained the following provisions: continuing the provider tax indefinitely while lowering it from 2% to 1.8%, an increase to K–12 education funding, and a cut to the second-tier income tax bracket. A number of issues remain to be addressed in the 2020 legislative session, including the following: Supplemental Budget. According to Minnesota Management and Budget (MMB)’s November 2019 Economic Forecast, Minnesota’s budget and economy have improved over the last six months. Citing increased revenue collections and reductions in estimated spending, MMB predicts a budget surplus of $1.332 billion in the FY 2020–21 biennium. While MMB Commissioner Myron Frans cautioned against spending the entire surplus, lawmakers voiced a variety of different ideas, ranging from cutting taxes to increasing spending on health care, school safety, and road and bridge repairs. Gov. Walz is expected to submit a supplemental budget to the Legislature by early March of 2020. Department of Human Services (DHS). Beginning with the resignation of Commissioner Tony Lourey, it has been a turbulent summer and fall for DHS. Gov. Walz appointed Pamela Wheelock as Interim Commissioner to replace Lourey before Jodi Harpstead, former Lutheran Social Services CEO, assumed the Commissioner’s role in September. In addition, it was revealed that DHS had awarded the White Earth Nation and Leach Lake Band of Ojibwe tribes $29 million in overpayments for opioid addiction treatments, going back a decade or more. Because the payment of this $29 million was ruled improper by the federal government, the full amount will have to be reimbursed to the federal Medicaid program by the tribes or the State of Minnesota. Additional overpayments to counties and chemical dependency treatment providers have also been identified, bringing the total amount of overpayments to more than $100 million. The Legislature will debate the best way to pay this money back, and will discuss plans to reform DHS with Harpstead at the helm. Provider Tax. In 2019, the sunset on the provider tax was removed, and the tax was reduced from 2% to 1.8%. The provider tax funds the Health Care Access Fund, which is forecasted to have a $539 million balance at the end of the FY 2020–2021 biennium. Because this balance exists, House Republican Leader Kurt Daudt (R-Crown) has advocated an additional reduction to the provider tax. Gov. Walz opposes the idea, while Senate Republicans are focused on other tax-cutting measures. While this reduction is unlikely to occur, the provider tax will again be part of budget discussions.

DECEMBER 2019 MINNESOTA PHYSICIAN

Minnesota Health Records Act Reform. Health care providers and House Public Information Services provides several ways to receive business groups will continue their efforts to reform the Minnesota Health nonpartisan news about the Legislature. Sign up for electronic notification Records Act. These groups support conforming Minnesota law to HIPAA at www.house.leg.state.mn.us/hinfo/subscribesw.asp. for purposes of authorizing the release of health records for treatment, Key Senate publications can be found at www.senate.mn/publications/ payment, or health care operations. Proponents index.php#header. argue that the efficiencies that providers would To learn more about individual House realize by conforming to HIPAA would benefit or Senate bills, or to track bills that may be the health care system. Privacy advocates and introduced during the 2020 session, visit www. certain legislators concerned with patient privacy leg.state.mn.us/leg/legis. will oppose this effort. Partisan politics will play a big role in most issues discussed. Insulin. Since the end of the 2019 legislative Tom Hanson, JD, a Shareholder with Winthrop & session, House and Senate negotiators have Weinstine, represents clients before the Legislature worked to resolve differences in competing and regulatory bodies. Prior to joining the firm, he proposals to improve access to insulin. Concern worked for the Republican caucus in the Minnesota has risen among lawmakers as reports of House of Representatives for eight years and served increasing insulin prices have caused diabetics for eight years in Gov. Pawlenty’s administration, including four years as the to ration their insulin, causing significant health issues. The House proposal places a fee on manufacturers of insulin and uses the proceeds Commissioner of Minnesota Management and Budget. to pay for emergency doses of insulin for people in need. The Senate proposal would require manufacturers to supply doctors with insulin at John Reich, Director of Government Relations at Winthrop & Weinstine, has no cost. The main point of contention in this issue will be the source extensive experience in lobbying and strategy management. Prior to joining the of the funding for the proposals. Gov. Walz has asked legislators to not firm, he worked for the DFL Caucus in the Minnesota House of Representatives wait for the legislative session, but to resolve their differences as quickly for five years and served for four years in Gov. Dayton’s administration. as possible. Bonding Bill. If anything is accomplished at the Legislature this session, it will be the bonding bill. While the bill will not have a direct impact on health care, nothing further will happen at the Legislature unless the bonding bill is passed. State agencies and local units of government have submitted more than $5.2 billion in bonding requests for capital improvements to MMB. Higher education, housing, transportation, and environmental spending highlight the long list of requests. Gov. Walz is required to submit recommendations to the Legislature by Jan. 15, 2020. There is significant support for passage of a bonding bill in 2020 amongst Republicans and DFLers. The challenge for these decisionmakers will be the size of the bonding bills. Republicans will want a smaller bill, likely under $1 billion, while DFLers will want a larger bill, probably around $1.5 billion. Legalization of marijuana. With the help of House Majority Leader Ryan Winker (DFL-Golden Valley), advocates for legalizing recreational marijuana have been preparing for months to advance a legalization bill in 2020. Rep. Winkler has been holding community meetings on the issue around Minnesota. He has also consulted with a variety of stakeholders, and even reached out to officials from Colorado, which legalized marijuana five years ago. It is likely Winkler will receive help from Gov. Walz, who supported legalization during the 2018 election campaign and has ordered state agencies to begin planning for the day when marijuana is legalized. Legalization will face strong opposition in the Senate, as Majority Leader Paul Gazelka (R-Nisswa) opposes the idea. Currently, 11 states and the District of Columbia have legalized marijuana.

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MINNESOTA PHYSICIAN DECEMBER 2019

3Trends in older adult residence design from page 19 be required. Electronic charting eliminates the need for traditional nursing dining, and kitchen spaces, creating a living space for a family-sized stations. Resident personal care is delegated to the direct care providers, group. Single bedrooms with bathroom suites provide a private retreat, freeing licensed nursing professionals to manage medical care within while group activity areas offer opportunities for multiple household locations. social interaction. Independence is encouraged Minnesota also encouraged innovation through the design of spaces that are safe and by developing new rules for food preparation easily negotiated, using wide door openings and within residential household kitchens and adaptive accommodations where appropriate. through preference for Household Model nursing Electronic charting Bio-care spaces are designed to enhance ease of home construction under the Nursing Home eliminates the need for use (reducing staff time) and to foster dignity. Moratorium Exception Process. These initiatives traditional nursing stations. Supplies and equipment are close at hand for staff have been adapted and used as exemplars within providing resident assistance in daily activities. other jurisdictions. Walking distances for staff and residents are While long-term care settings focused on a reduced to manageable distances. home-style congregate living model, short-term, Some advocates promote the â&#x20AC;&#x153;Household post-acute, and rehabilitation care looked to the hospitality and medical Model,â&#x20AC;? which incorporates familiar settings for the care of those with markets to provide high-tech, high-touch environments where patients dementia or other cognitive impairments. Paired with activity-enriched feel they are receiving the best, leading edge services. The goal for this Town Center activity areas, including multiple positive distractions, population is to achieve independent functioning and return to the provides a helpful combination of familiar and life-enriching environments. comfort of their own home as soon as possible. Small-scale groupings of patient rooms, similar to the Household Model, is also an appropriate Technology organization of space for short-term settings and provides the flexibility Today the nursing and care staff no longer need to be tied to a physical to shift populations based upon market demands. location to receive calls for assistance. Wireless call systems allow calls for assistance to be received anywhere. And sophisticated programming allows transferring of calls to alternative staff should additional attention

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Rehabilitation suites with state-of-the-art equipment and warm water aquatic therapy pools with underwater treadmills are therapeutic amenities within many settings. Catered services are becoming standard options, offering room service and customized care. The main distinction is that long-term settings are based upon the concept of creating a household environment for residents, while short-term patients are in transition back to their personal home and are working to be discharged as soon as possible.

Meeting individual needs While it is possible to provide long-term care services within any physical setting, a variety of building typologies have evolved to serve distinct population groups. It is important to evaluate the specific needs of each population group to determine the most appropriate organization of spaces and elements to provide within each setting. Building construction is an expensive and time-consuming endeavor. Understanding the common conceptual elements among various design approaches has the potential to provide flexibility for future changes in demographic or market considerations. Gaius G. Nelson, MA, president of Nelson Tremain Partnership, PA: Architecture and Design for Aging, has over 35 years of experience as an

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architect and frequent presenter of innovative design concepts for elder living and care environments. He created and implemented the first Household/ Neighborhood model nursing home in the country while working with Evergreen Retirement Community in Oshkosh, Wisconsin.

3 The resurgence of methamphetamine from page 23 Tyler Winkelman, MD, MSc, is a board-certified internist and pediatrician, Reducing stigma related to substance use. Health care professionals caring for adults and children in outpatient settings. He conducts health policy can destigmatize methamphetamine use disorder by recognizing that it research in collaboration with partners locally and across the country at is a chronic disease and can be treated like other Hennepin Healthcare Research Institute with a focus common conditions. For example, patients with on criminal justice and health care intersection. He diabetes who are not able to increase their exercise is also an assistant professor at the University of can be counseled on additional ways to reduce Minnesota Medical School and a physician at the their cardiovascular risk through diet, blood A fourth wave of the Hennepin County Jail. pressure control, and potentially medications. opioid crisis … is primarily Promoting first person language (i.e., “people characterized by increasing who use methamphetamine”) instead of terms Julie Bauch, MS, RN, PHN, is the Opioid co-use with methamphetamine. like “addict” or “user,” in interactions with Response Coordinator for Hennepin County. She patients, students, staff, and other health spearheads initiatives to address the opioid crisis care professionals can also help destigmatize by marshalling relevant research and accurate substance use. Substance use disorder treatment, data to help influence decision making. She works like other chronic conditions, is characterized by collaboratively with a variety of stakeholders in a leadership role to develop its relapsing and remitting and should be expected on the path to longstrategic interventions to further the role of local government addressing this term recovery. public health epidemic.

Addressing the fourth wave of the opioid crisis A public health approach to the rise in methamphetamine use should focus on key drivers of demand, like poverty, lack of opportunity, and parental substance use, and should provide improved access to interventions that reduce associated harms. Health care professionals play an important part in recognizing and supporting individuals with methamphetamine use disorder.

Christine Hauschildt is a master’s student at the University of Minnesota School of Public Health and part of the public relations and marketing team at Hennepin Healthcare.

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3Minnesotaâ&#x20AC;&#x2122;s leading edge from page 15 Statewide psychiatric consultation

six-month follow-up study confirmed PALâ&#x20AC;&#x2122;s efficacy and the overall positive experience of the providers, individuals, and families that utilized it. The psychiatric consultation service was recently honored by the American Psychiatric Association (APA) and the Association of Medicine and Psychiatry (AMP). Several other states and outstate health systems continue to express interest in partnering with PAL.

In 2010, the Minnesota Legislature directed DHS to make psychiatric consultation available statewide to primary care providers. The goal was to create rapid access to psychiatrists for consultation on cases, triage, and referral, and to provide ongoing education to primary care providers. Nearly half of the states In addition to psychiatric consultation and Creativity and collaboration have in the nation have some form of a psychiatric education, an online tool called the Fast-Tracker made Minnesota a leader consultation service, ranging from telephonic was developed to link people to mental health and [in mental health care]. consults to brick-and-mortar clinics based in substance use disorder services and resources with academic medical centers. Minnesotaâ&#x20AC;&#x2122;s Psychiatric real time availability. This online tool, which is Assistance Line (PAL) has provided thousands of free to the public, uses sophisticated search tools consultations to primary care providers across the and algorithms to help identify niche services for state, and has trained hundreds of pediatricians individuals seeking care. and nurse practitioners. PAL can be accessed weekdays via a toll-free Future considerations and improvements number or online. This service is supported by DHS, PrairieCare Medical While creativity and collaboration have made Minnesota a leader, there Group, and the Minnesota Community Mental Health Foundation. In are still critical needs that require attention. It has been said that our addition to the core clinical team members at PAL, clinicians at Pregnancy mental health system is not broken, because it has yet to be built. The & Postpartum Support Minnesota are available for mothers who have aforementioned innovations have helped many patients, but are just a part specific needs requiring their expertise. of the necessary transformation, which still needs to grow and adapt to Most of the consultations are with youth, who otherwise would future needs. endure delays in getting specialized treatment and suffer from the adverse developmental impact that mental illnesses can have during childhood. A

While the ACA and mental health parity have moved us forward in some ways, concerning trends in the behavior of many health insurance companies suggest that adequate coverage for services is still in our distant future. High-deductible plans have become more popular, and large employers have elected to carve out mental and chemical health coverage to lower premiums, perpetuating both barriers in accessing care and the stigma surrounding mental illnesses. Many individuals and families are simply finding themselves under-insured. Communication between health providers continues to lag, especially with regard to mental health. While electronic health records allow for the possibly of a seamless community, expensive integrations between systems often prohibit this from happening, and release of information and consent laws create confusion around what information is released. Some patients may bounce between several providers, and the refusal to disclose past mental health information can be common and detrimental to care. Minnesota is indeed a leader in mental health care, as we have continued to demonstrate through our creativity and collaboration. However, we have a long journey ahead of us, and we must have the perseverance and gumption required to move our local communities and the rest of the nation forward. Todd Archbold, LSW, MBA, is a licensed social worker and the chief executive officer at PrairieCare.

DECEMBER 2019 MINNESOTA PHYSICIAN

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3Behavioral health consultants from page 17 so, they may instead do brief psychotherapy or a brief diagnostic assessment to determine the mental health diagnosis.

Interventions, outcomes, and barriers A BHC could perform many interventions. For hypertension, a BHC might teach the patient relaxation skills, problem-solve barriers to an improved diet, work on motivation to increase physical activity, and explore barriers to medication adherence. For chronic pain, interventions might help the patient shift the focus from pain avoidance to pain acceptance, develop skills for pain management like pacing activities, and clarify their values so that they may focus more on what they value than the amount of pain they are experiencing. Core interventions include motivational interviewing, cognitive behavioral therapy, psycho education, and goal setting. The benefits of an integrated approach to patient care are many. The first is that medical and dental providers will have someone to refer to in these challenging situations. They can hand off the patient to the BHC and then continue on to their next patient. This team-based approach will help to improve care outcomes as the providers are able to address medical and mental health conditions in an interdisciplinary approach. This approach also helps with the reduction of cost of care as we can catch and treat conditions before they turn into emergency situations requiring an expensive emergency department visit or hospitalization.

Sioux Falls VA

While the concept of integrated care has been discussed for many years, organizations are just now working to implement these ideas. Barriers to implementation often come from the administration level regarding the question of “How to pay for it?” The BHC is a clinical-level staff member who may not be in the organization’s budget. The recommendation would be to look at the big picture of what value integrated care can bring to the clinic. There is an increase in patient and provider satisfaction, an increased use of primary care, and improved patient outcomes. In addition, there is reduced emergency department utilization, reduced hospital admissions, and a reduction in specialty referrals, all of which are costly services for the organization. BHCs are often able to bill for their services, which can help cover the expenses of hiring a provider.

Summary Behavioral health integration is a rapidly growing field. Medical and dental providers are increasingly utilizing behavioral health consultants to manage complex mental health and behavioral concerns, and patient outcomes are improving. Patients are more readily able to access mental health services and are satisfied with the whole-person care approach. Jeni Kolstad, MSW, LICSW, is a Licensed Clinical Social Worker with a master’s degree in social work. She also has a certificate in nonprofit leadership. She practices as a behavioral health provider at Open Door Health Center in Mankato and is the organization’s Behavioral Health Integration Coordinator.

HEALTH CARE SYSTEM

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

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DECEMBER 2019 MINNESOTA PHYSICIAN

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

Cuyuna Regional Medical Center is seeking two full-time Family Medicine physicians for its Crosby Clinic. Located in the heart of the Cuyuna Lakes Area, CRMC’s Crosby clinic has recruited 22 New and dedicated, quality physicians & APC’s in the last 2 ½ years that, along with the required up-to-date technology, have developed CRMC into a regional resource for advanced diagnostic and therapeutic healthcare services. Our Family Medicine opportunity: • MD or DO • Board Certified/Eligble in Family Medicine, Internal Medicine or IM/Peds • Full-time position equaling 36 patient contact hours per week • Work 4.5 days a week. • 1 in 11 Peds call. (Majority of calls handled by phone consultation) • Practice supported by 14 FM colleagues, APC’s and over 35 multi-specialty physicians • Subspecialty providers—Internal Medicine, OB/GYN, Orthopedics, Urology, Surgery, Oncology, Pain Management and more • Competitive comp package, generous signing bonus, relocation and full benefits • New Residients are encouraged to apply A physician-led organization, CRMC has grown by more than 40 percent in the past three years and is proudly offering some procedures that are not done elsewhere in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by an ever-increasing range of services offered.

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

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

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THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 05

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

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

Physician/employer direct contracting

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

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

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

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3Comprehensive medication management from page 11

time, and you’ll likely make it home for dinner. This collaboration with the pharmacist, compounded over time, could certainly improve not only patient care and quality outcomes, but your work-life balance and burnout.

may be limited. While all of these limitations exist, acknowledging the evolving health care team and the importance of team-based care on outcomes and quality cannot be understated.

Kyle Walburg, PharmD, is a second-year

Summing up

pharmaceutical care leadership resident at the

The scenario at the opening of this article could be re-written with examples provided from the study. Your day starts as you scan your schedule and see that your extremely complex patient is coming in. Adding a pharmacist to the You feel a sense of relief when you notice that the primary care team can be one patient has a visit scheduled with your clinic-based strategy [to reduce burnout]. primary care pharmacist immediately prior to the patient’s visit with you. The pharmacist gives you a warm handoff—she has cleaned up the medication list, resolved a patient’s concern about a potential side effect of an existing medication, and recommended a newer antiglycemic medication covered by the of Pharmacy. patient’s insurance that would likely help the patient reach his A1c goal. After your discussion with the pharmacist, you’re pleased that you’ve learned a bit more about this newer medication. Your visit with the patient runs smoothly and you notice that the patient is also satisfied with this teambased care. Now, you are on time to see your next patient and also feel better about your work and your day. Because of the help with frequent follow ups and more complex patients, your patients are happy, you are on

University of Minnesota College of Pharmacy, North Memorial Camden Family Medicine Clinic.

Sara

Massey,

PharmD,

second-year

pharmaceutical care leadership resident at the University of Minnesota College of Pharmacy, MOBE, LLC

Kylee Funk, PharmD, BCPS, is an assistant professor at the University of Minnesota College

Randy Seifert, PharmD, is professor and associate dean at the University of Minnesota College of Pharmacy.

Todd Sorensen, PharmD, is professor and associate dean at the University of Minnesota College of Pharmacy.

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Urgent Care Physicians HEAL. TEACH. LEAD.

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy:

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• Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Maly at 952-883-5425 or maly.p.yang@healthpartners.com. EOE

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

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

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763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com MINNESOTA PHYSICIAN DECEMBER 2019

3Serving behavioral health patients from page 9 how diabetes is treated. A number of changes were Behavioral Health Parity (BH Parity) is legislation designed to ensure there is equity with a patient’s insurance policy so that the benefit structure, limits, and processes are no more restrictive on the behavioral health services than they are on the medical side. It does not ensure that a patient’s policy includes behavioral health benefits. There was a recent legislative change to require BH Parity in the areas of Non-Quantitative Treatment Limitations, which include, for example: medical management standards limiting or excluding benefits based on (i) medical necessity or medical appropriateness, or (ii) whether the treatment is experimental or investigative; formulary design for prescription drugs; fail-first or step therapy protocols; and limitations on inpatient services for situations where the enrollee is a threat to self or others. Substance Use Disorder (SUD) Reform is a package of changes designed to move the treatment services for SUD from an episodic model to a set of services more effectively designed to provide ongoing care using a chronic care model, similar to

made to the SUD service continuum, including treatment coordination and Peer Support services, as well as withdrawal management. Another key change is that the system will allow direct access, which should enable patients to get into treatment with fewer hurdles. Workforce: Psychiatry, psychology, clinical social work, psychiatric nursing, marriage and family therapy, and professional clinical counseling are considered the “core” mental health professions. Licensed Alcohol and Drug Counselors and Peer Support/Certified Peer Specialists have recently been added to that cadre. For many years, Minnesota has experienced a shortage of providers of behavioral health services. This shortage has been felt most profoundly in rural areas of the state. There is also an ongoing shortage of culturally competent and culturally specific providers. For physicians, this means that people have fewer specialists available to them, so the place that they will often go to get support will be the primary care setting. It is important to work together to support primary care, to not

overwhelm this resource, and to provide needed support to members. What goals do you have for the future of UCare’s behavioral health services?

My goal is for UCare to firmly be established as the leading health plan that provides excellent behavioral health support for members and the community. I foresee a model that includes: direct access for members and family members; ongoing support for members and family members who may need short-term or long-term services; key collaborations with partners, such as providers, counties, regulators, and advocacy groups; and innovations to help fill the gaps for all members and family members. This would also include successful integrated care models, impacting the overall quality of life for members, including supporting them in areas such as social determinants of health. And ultimately this will fit hand in glove with managing overall claims costs while members receive effective and efficient health care. Jennifer J. Garber, LICSW, is Associate Vice President of Behavioral Health Services at UCare.

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3 things every Minnesota physician should know about treating chronic pain.

1. Opioids are a problem. They can also be part of the solution. According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability offered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

2. There is no silver bullet. One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn off their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve

found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we offer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.

3. Learn more about chronic pain while earning CME credits. Together with the Minnesota Medical Association, Nura is sponsoring a Chronic Pain Conference where a variety of specialists will share tools, strategies and expertise on managing pain patients. This year’s CME conference takes place on Friday, November 8, at the Westin Galleria Edina, and will provide new perspectives on providing care in the midst of the opioid epidemic. To learn more about our comprehensive approach to chronic pain or to register for the Chronic Pain Conference, please visit nuraclinics.com or call our Provider Hotline at 763-537-1000.

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MINNESOTA PHYSICIAN DECEMBER 2019

CHOOSE CONVENIENCE WITHOUT COMPROMISE When you refer to M Health Fairview, your patients can have access to top docs and the latest treatments – right in their backyard. That’s just one way we’re building breakthrough care closer to home.

JUDITH ECKERLE MD, FAAP, ADOPTION MEDICINE PHYSICIAN, PEDIATRICIAN

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