Minnesota Physician January 2012 by Minnesota Physician Publishing

Volume XXV, No. 10

January 2012

The Independent Medical Business Newspaper

Something to build on

A 2012 legislative preview By H. Theodore Grindal, JD, and Nate Mussell, JD

egislators and Gov. Mark Dayton got an early Christmas present in December when the November state fiscal forecast showed an unexpected $830 million surplus. Coming on the heels of the longest government shutdown in the state’s history and partisan tension that rose to heights not seen in the past, the surplus could help bring about a quick session as legislators look to the fall with every seat up again for reelection. However, a number of issues are still hanging over the Legislature, even with a short session. How and if any of these issues get resolved over the next three months is anyone’s guess, particularly in an election year.

t all started with Julia. About seven years ago, a 16-year-old girl who had some mild depression, but otherwise was perfectly healthy, began having back pain. The urine analysis was normal. When the pain began radiating to her right upper quadrant, she then was evaluated with multiple tests. Her liver function tests were slightly elevated, her BUN/creatinine normal, her white count elevated with a lymphocytosis, a SED rate and CRP both elevated, amylase and lipase normal, and electrolytes normal. A CAT scan of her abdomen revealed a very abnormal-looking and contracted-appearing gall bladder. Her primary physician focused in on the gall bladder, as did the consultants

ERRORS to page 10

PAID

By Phillip M. Kibort, MD, MBA

PRSRT STD U.S. POSTAGE

Patient safety’s next frontier

Surplus is only the beginning

By all accounts, the 2012 legislative session is likely to be a short session PREVIEW to page 14

IN THIS ISSUE:

Minnesota Health Care Roundtable Page 20

Detriot Lakes, MN Permit No. 2655

Diagnostic errors

in hematology/oncology, gastroenterology, infectious disease, and surgery. Everyone thought it was most likely the gall bladder that was causing her pain and elevated LFTs. An ERCP revealed no stones in her biliary tract but an abnormal-looking gall bladder. The patient then went to surgery for a cholecystectomy; it was a successful surgery. She was then transferred from recovery room to her hospital room on the medical/surgical floors. Within hours, she bled to death. What happened was that Julia’s doctors got caught in the trap of confirmation bias: They all went down the same road and no one challenged anybody else’s thinking. It turned out that Julia had Epstein-Barr virus hepatitis and was slowly

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CONTENTS

JANUARY 2012 Volume XXV, No. 10

FEATURES Diagnostic errors Patients safety’s next frontier

MINNESOTA HEALTH CARE ROUNDTABLE

By Phillip M. Kibort, MD, MBA

Something to build on A 2012 legislative preview

1 T H I R T Y- S E V E N T H

By H. Theodore Grindal, JD, and Nate Mussell, JD

Minnesota Health Care Roundtable Accountable Care Organizations

SESSION

Specialty pharmacy

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

OPHTHALMOLOGY Opening eyes to new options

Controlling the cost of care 28

By Y. Ralph Chu, MD

MEDICINE AND THE ARTS Beyond decoration 30 By Megan Hatch

Rep. Eric Paulsen U.S. House of Representatives

PROFESSIONAL UPDATE: Orthopedics 32 By Steven W. Meisterling, MD

BEHAVIORAL HEALTH Autism update

By George Realmuto, MD, and Israel Sokeye, MD

The Independent Medical Business Newspaper

Thursday, April 19, 2012 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access. Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care.

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CAPSULES

Fairview, Zipnosis Partner to Offer Online Services

Hennepin Health System Acquires HFA

Fairview Health Services has announced it will provide an online care service in partnership with St. Paul-based Zipnosis. Officials say the services will cover a number of conditions, including cold and flu symptoms, sinus infections, acne, seasonal allergies, yeast infections, and tobacco cessation. More serious conditions will be referred to a Fairview clinic. With the move, Fairview joins other health organizations like HealthPartners and Blue Cross and Blue Shield of Minnesota, which have also set up online health care services. “Together, Fairview and Zipnosis are making high-quality health care convenient and affordable for consumers,” says Terry Martinson, Fairview Medical Group executive regional medical director. “When patients need care for specific conditions, we are just a click away.”

Hennepin Health System (HHS) and Hennepin Faculty Associates (HFA) have finalized a deal that merged the physician practice with the health system that runs Hennepin County Medical Center (HCMC) and its affiliated clinics. On Nov. 29, the Hennepin County board, which owns HHS, voted to approve the merger, which dissolves HFA and makes its members employees of the health system. The change became official Jan. 1. Officials say the move integrates two organizations that already had a close relationship. “It is in the interest of HCMC and the physicians who provide care to operate as a single organization, rather than separate entities, in order to best serve patients in these new models of care delivery,” says David Jones, HHS chair. The move might also be seen as another example of how independent physician practices no longer are practical in

today’s health care environment. Many practices, both in the metro area and in Greater Minnesota, have been absorbed by larger health systems as regulatory and market changes make independent practice more difficult to sustain. And the new arrangement has a historical precedent: HCMC physicians were directly employed by the hospital before the creation of HFA in 1984. “As health care reform takes shape, state and federal health care programs across the nation are being redesigned to shift the financial risks of caring for patients to the people and entities that are providing the care,” says Lawrence Massa, Minnesota Hospital Association president and CEO. “To survive economically, providers must find ways to increase efficiency and contain costs. Integrated delivery systems offer one way to achieve these financial goals while preserving the quality of patient care.” Officials say that because HFA is a nonprofit corporation, no direct payment is involved

in the merger. The group’s assets, including facilities used for clinical care, administration, and parking, will be transferred to HHS. Officials add that HFA has no outstanding debt. The Minneapolis Medical Research Foundation, currently owned by HFA, will become a nonprofit subsidiary of HHS.

Health Rankings Show Rise in Chronic Diseases A new United Health Foundation report on the nation’s health raises alarms about the rise in rates of chronic diseases such as obesity and diabetes, saying that the increase in such conditions is undermining the country’s health. The annual America’s Health Rankings has consistently gotten attention for its grading of individual states’ health status, but it also presents an overall snapshot of the nation’s health, and foundation officials say they are concerned about trends shown by recent data.

Supporting Our Patients. Supporting Our Partners. SupportingYou. A 2011 trip to the remote mountainous region of Central Honduras, Central America, provided hope and healing for many children and a rewarding experience for Dr. William and Lauren Schneider and their daughters, Nikolett and Hannah. The Holy Family Surgery Center opened in 2009 to serve orphaned and abandoned children who have no other way of affording medical care. Dr. Schneider and a volunteer team had the opportunity to examine 200 and perform surgeries on 58 children, involving ACL reconstruction and the repair of many neglected fractures.

Pictured (l-r) are Lauren and Dr. William Schneider and their daughters Nikolett and Hannah. The family spent time caring for orphans and patients in Central Honduras.

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MINNESOTA PHYSICIAN JANUARY 2012

states, but we’re still following the same general trend—we’re getting heavier.”

MHA Gets Grant For Patient Safety The Minnesota Hospital Association (MHA) is part of a $218 million effort to prevent injuries and complications at hospitals across the country. The Partnership for Patients initiative recently announced that 26 hospital systems and organizations will work together as hospital engagement networks to improve patient safety. The networks will develop collaborative efforts to train hospital staff and provide support and technical assistance to hospitals to improve patient safety and promote quality improvement goals. The efforts will be monitored by the Centers of Medicare & Medicaid Services (CMS) to ensure that the program’s goals are being met. Officials at the U.S. Department of Health and Human Services (HHS) say the Partnership for Patients consists of more than 6,500 members, which include hospitals, providers, consumer groups, employers, and unions. Among the goals of the initiative is a target of reducing the number of hospital-acquired conditions by 40 percent and reducing hospital readmissions by 20 percent by 2014. MHA officials say the federal funds will allow the group to add three staff members to its patient safety team, to provide members with training and technical assistance to address hospital-acquired conditions, readmissions, and safety-culture issues. According to MHA communications director Jan Hennings, the new partnerships will ensure that Minnesota hospitals will continue to be at the forefront of delivering highquality care. “We in Minnesota have always had a very good working relationship with partners such as Stratis Health and ICSI [Institute for Clinical Systems Improvement]. This

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2012 Winter Conference

The report says areas of improvement, such as improved smoking cessation, reduced hospitalizations, and a decline in cardiovascular deaths are offset by increasing rates of obesity, diabetes, and the number of children in poverty. Officials with United Health Foundation say that in response to the trends, the group will launch a campaign called “Take Action for Change,” that will use social media such as Facebook to encourage individuals to make health-promoting decisions. The campaign is cosponsored by the foundation, the American Cancer Society, Campaign for Tobacco-Free Kids, and YMCA. The rankings find Minnesota as the sixth-healthiest state in the nation. The ranking marks three years in a row the state has finished sixth, which is also the lowest grade Minnesota has received. Minnesota was ranked No. 1 in the nation for seven of the report’s 21 years. It was ranked in the top five every year until 2009. The United Health Foundation report says Minnesota’s strengths are its low rates of deaths from cardiovascular disease, its low rate of uninsured residents, and the state’s high rate of high school graduation. Challenges include a high incidence of infectious disease, low per-capita public health funding, and a high prevalence of binge drinking. The report also finds that obesity in Minnesota has increased from 17.4 percent to 25.4 percent of the adult population, and that diabetes increased from 4.9 percent to 6.7 percent of the population in this state. Luke Benedict, MD, an endocrinologist at Allina Hospitals and Clinics and a board member of the American Diabetes Association–Minnesota, says the United Health Foundation report confirms what health experts have been seeing for some time. “We’ve been trumpeting this for years, that there’s a huge problem with obesity. It is a true epidemic and this report echoes that,” he says. “Minnesota is doing better than a lot of other

Announcing: Minnesota Medical Group Management Association

2012 Winter Conference Tuesday – Wednesday, March 6-7 Please join us at our semiannual meeting as we discuss a wide range of health care business topics. $275 members ($325 after Feb. 3) $500 non-members Saint Paul RiverCentre, St. Paul, Minnesota For registration or more information,

please visit our website at: www.mmgma.org or call 651-999-5359

CAPSULES to page 6 JANUARY 2012

MINNESOTA PHYSICIAN

CAPSULES

Capsules from page 5 grant is going to help us really solidify and build upon those partnerships,” she says. “We’re extremely excited about it and I think that Minnesota is in good shape to use that grant money to the fullest.”

Medtronic to Pay $23.5 Million in Kickback Case The U.S. Department of Justice announced last week that Minneapolis-based Medtronic would pay $23.5 million to settle accusations that it paid kickbacks to physicians for using the company’s medical devices. The case follows several others in which medical device manufacturers have paid large settlements in recent years. The Justice Department says Medtronic paid physicians through post-market studies and device registries to implant Medtronic pacemakers and defibrillators in patients on Medicare and Medicaid insurance plans. The cases in ques-

tion involved data and information about Medtronic devices, collected by physicians participating in the studies or registries, for which Medtronic paid a fee ranging from $1,000 to $2,000 per patient. Justice officials say the Medtronic payments were a way of soliciting physicians to switch from competitors products to Medtronic devices. “Medicare and Medicaid beneficiaries depend on their physicians to make decisions based on sound medical judgment, especially when they are choosing which pacemaker or defibrillator to implant,” says B. Todd Jones, U.S. Attorney for the District of Minnesota. “Medical device manufacturers must not be permitted to use improper payments to cloud that judgment.” For its part, Medtronic says the settlement does not indicate the company did anything improper or unlawful. “Medtronic is happy to have this investigation behind us, so we can continue designing and executing clinical trials that

2012 CME Courses

generate evidence to improve patient care, outcomes, and cost effectiveness,” says Marshall Stanton, MD, vice president of clinical research and reimbursement for the Cardiac and Vascular Group at Medtronic.

MDH Grants Go to Community Health The Minnesota Department of Health (MDH) will give grants totaling $11.3 million to communities throughout Minnesota for health improvement efforts. The grants are part of the Statewide Health Improvement Program (SHIP), which was created by the Legislature as part of health reforms passed in 2008. The grant programs will cover 51 counties, four cities, and one tribal government over the next 18 months, officials say. That is down from the first round of grants, which covered all 87 counties and nine tribal governments. MDH officials note that funding for SHIP was reduced in the 2011 legislative session, resulting in fewer

grantees this year. “To improve health in Minnesota, we have to think in terms of prevention, not just treatment,” says Edward Ehlinger, MD, Minnesota Commissioner of Health. “In Minnesota and nationally, the two main causes of chronic disease and premature death are obesity, caused by poor nutrition and insufficient physical activity, and commercial tobacco use. We must do something to address these problems as individuals, as communities, and as a state.” The recent rise in obesity levels in Minnesota, paired with data that show anti-smoking efforts have become less effective, is part of a national trend of an increase in chronic disease and unhealthy habits. “Not only do chronic diseases reduce the quality of life and life expectancy for Minnesotans, but the costs of treating them create a substantial burden for our health care system,” Ehlinger says.

www.cmecourses.umn.edu

(All courses in the Twin Cities unless noted)

Care Across the Continuum: A Trauma & Critical Care Conference May 11, 2012

SPRING COURSES Urology for Primary Care March 15, 2012

Global Health Training May 14-28, 2012

Lillehei Symposium April 5-6, 2012

Advanced Pediatric Dermatology May 18, 2012

Cardiac Arrhythmias April 13, 2012 Integrated Care Conference: Integrating Behavioral Health into the Health Care Home April 13, 2012

Intensive Care Unit (ICU) Team Training April 23-25, 2012 North Central Chapter Infectious Diseases Society of America (NCCIDSA) Annual Meeting April 28, 2012

Bariatric Education Conference May 23-24, 2012 Workshops in Clinical Hypnosis May 31-June 2, 2012 Topics & Advances in Pediatrics June 7-8, 2012

FALL COURSES

ONLINE COURSES (CME credit available) For more information: www.cme.umn.edu/online U Fetal Alcohol Spectrum Disorders (FASD) U Global Health (7 Modules), to include: - Introduction to Health Care for Immigrant and Refugee Populations - Parasitic Infections - Travel Medicine

Psychiatry Review September 2012 National Pediatric Hypnosis Training Institute (NPHTI) September 20-22, 2012 Twin Cities Sports Medicine October 5-6, 2012 Practical Dermatology October 2012

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MINNESOTA PHYSICIAN

JANUARY 2012

MEDICUS

Twin Cities Orthopedics has added five new orthopedic surgeons to its medical staff. Jason Barry, MD, is a sports medicine fellowshiptrained orthopedic surgeon who specializes in total joints, fracture care, and general orthopedics. His special interests include ACL reconstruction and arthroscopy of the shoulder, knee, and hip. He will see patients at the Coon Jason Barry, MD Rapids, Fridley, and Shoreview locations. Scott Holthusen, MD, is a fellowship-trained foot and ankle specialist from the University of Washington/Harborview Medical School. He will see patients at the Chaska and Waconia locations. Allan Hunt, MD, specializes in sports Scott Holthusen, MD medicine and treats athletes of all ages. His areas of expertise include arthroscopic shoulder reconstruction and adult shoulder, knee, and hip reconstruction. He will see patients at the Edina and Plymouth locations. Daniel Marek, MD, is a fellowship trained hand surgeon from the University of Washington who treats Allan Hunt, MD conditions of the hand, wrist, and elbow in both adults and children. He will see patients at the Chaska, Glencoe, and Waconia locations. Corey Wulf, MD, specializes in sports medicine, multiligament knee reconstruction, cartilage transplant, and general orthopedics. He will see patients at the Edina and Eden Prairie locations. Daniel Marek, MD Brian D. Patty, MD, vice president and chief medical informatics officer for HealthEast Care System, has received a national award from the Association of Medical Directors of Information Systems (AMDIS). The 2011 AMDIS awards salute excellence and outstanding achievement in applied medical informatics, honoring individuals and organizations that have successfully Corey Wulf, MD applied information systems and computer technology into the practice of medicine. Patty was honored as a strong advocate for the effective use of health care IT and innovation to improve quality, safety, and efficiency. AMDIS is a nonprofit organization representing more than 2,000 physician health-care information technology leaders. Ben Bache-Wiig, MD, has been named vice president of medical affairs for Abbott Northwestern Hospital. Bache-Wiig, who is board-certified in internal medicine, most recently was president of North Clinic PA, a multispecialty clinic with more than 50 physicians. He also served on the board of trustees of North Memorial Hospital and is a board member of Medica Health Plan. Bache-Wiig succeeds Robert Wieland, MD, who is now executive vice president of Allina’s Ambulatory Services. James Mohn, MD, has joined St. Luke’s Cardiology Associates in Duluth. Mohn received his medical degree from the University of Minnesota Medical School and completed his internship and residency in internal medicine at Hennepin County Medical Center. He completed his fellowship as chief cardiology fellow at the University of Iowa Hospitals and Clinics in Iowa City and completed his fellowship in interventional cardiology at the U of M. Previous to this position, Mohn was a clinical instructor at the University of Minnesota Medical School and a hospitalist at Hennepin County Medical Center’s Division of Cardiology.

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Bringing business solutions to health care JANUARY 2012

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INTERVIEW

Defending a Minnesota success story ■ Could you tell us a little about the work that you

do with the Medical Technology Caucus?

Rep. Eric Paulsen U.S. House of Representatives Rep. Eric Paulsen is a two-term member of the U.S. House of Representatives from Minnesota’s third congressional district. Paulsen sits on the House Committee on Ways and Means and is a founder and co-chair of the House Medical Technology Caucus. Paulsen has been active in working on issues such as reforming the medical device regulatory process and has called for repealing the medical device tax that was part of the Affordable Care Act. In addition, Paulsen is co-chair of the Congressional Wellness Caucus, which works to promote wellness and preventive health programs among businesses in Minnesota and across the nation.

and bring them to market. We’ve seen the approval process become a much longer time frame, and primarily it’s because the goalposts get moved on these companies during that process. It is a real issue now, where a lot of the medical technology start-ups are no longer starting in Minnesota or the United States. The investment has traveled to Europe or even Brazil and China now, where the clinical trials might be done in Europe, for instance, because those countries have a much more streamlined regulatory process. So that’s the other issue—working bipartisan and bicamerally on what is the best way to streamline and modernize the FDA, so that it’s consistent and predictable.

As co-chair of the House Medical Technology Caucus, I’m a passionate advocate for protecting and defending and helping what is not only a Minnesota success story, but an American success story. The work of the committee is not only about the jobs that are created by these device companies or in this industry but really about helping to save lives and improving lives. There are approximately 60 to 70 members right now that are members of the caucus, from various areas of the country that represent similar ecosystems or corridors where medical technology is strong and vibrant. There aren’t many voices in Congress that care about this issue, and that’s why ■ There has been bipartisan support for a lot of I’ve taken a leadership role and talk about why it’s the issues in the caucus. How are you reaching so important. We have periodic meetings with legconsensus on some of these issues? islative and congressional staff, and with the FDA, These are issues that are not Republican issues or to loop them in. Democratic issues. They’re With the caucus, I can American issues, affecting all help educate Congress about In addition to being the of our constituents. The way the medical device industry. I I’ve been successful is, numalways tell people that, in Land of 10,000 Lakes, ber one, just building relaaddition to being the Land of Minnesota is the land tionships with my colleagues 10,000 Lakes, Minnesota is the land of 400 medical techof 400 medical technology on these issues. Things are working in Washington, nology companies that procompanies that provide especially in this area. It’s vide 35,000 jobs. still slow and frustrating 35,000 jobs. ■ What are some of the because you have to get biggest issues that your momentum, and you have to caucus has been looking at recently? convince a larger number of folks. But we are making progress. The best opportunities come from There are really two issues that are front and cenbeing results-oriented and solution-oriented. ter right now that are impacting the industry or actually threatening the medical device community. No.1 is the upcoming medical device tax. I call it the medical innovation tax. It’s the tax that starts in a little over a year and was part of the new health care reform law, the Affordable Care Act (ACA). More than 220 cosponsors—that’s more than half the Congress—have signed legislation to repeal that tax before it actually goes into effect. This $20 billion medical innovation tax is an ill-conceived tax on innovation that could reduce access to life-saving technologies for Americans. We think it’s a very wrong-headed approach. Studies have shown it’s going to have a 10 percent reduction of the workforce in the industry, with 43,000 jobs lost nationwide. That does not even count the supply chain or ecosystem with indirect jobs that would be affected. The other issue, quite honestly, is the inconsistent and unpredictable and less-transparent approach from the FDA toward the medical device industry. The approval process for medical devices is badly in need of reform. It’s just become a lot more difficult for doctors working with new technologies and the entrepreneurs and engineers developing these products that are life-saving and life-improving to gain approval of these devices

MINNESOTA PHYSICIAN JANUARY 2012

■ What do Minnesota medical device manufac-

turers tell you they are most concerned about when it comes to government regulations? In terms of the regulatory situation, what I hear about most often is having the goalposts moved in the middle of the process. This isn’t about cutting regulations. The industry wants consistent regulations, but it wants a relevant process. We’re hoping to create a gold standard that is streamlined and effective. Part of the frustration is getting the FDA to understand why this is central to keeping jobs here in Minnesota and the United States. One of the problems we’ve seen is that questions get asked during the FDA approval process that do not apply to the product itself. There are also issues with the disparity between what we call “FDA time” and real time when it comes to tracking medical device approvals. This has a real impact on jobs. In Minnesota we have a number of small employers who want to become the next Medtronic but they’re not yet profitable, and the fact is that we’re making it more difficult for them to grow here. The regulatory issues are definitely on their minds, and of

course, the medical device tax on the horizon is also a concern. Congress has the oversight capability to focus attention on the FDA and we’re working with the energy and commerce committee to find ideas on how to modernize and streamline the regulatory process. I’m the author of one bill to allow more third-party review processes, and there is language about keeping a more consistent time clock during the process. This legislation has bipartisan support; the goal in the House is that we’re really working on trying to have these ideas rolled together as one package early next year. ■ When it comes to the ACA, if both

political parties agree health care has significant problems, why does considering the solutions generate so little bipartisan support? Health care reform was needed, but I really did not agree with how it was done. When the bill was being debated, I argued that the bill was flawed because it did not address the issue of health care costs. There was a lot of emphasis on access but costs were not addressed, and those costs are still rising. I think the ACA is going to collapse of its own weight. The truth is there is, and was, a lot of bipartisan support for some ideas such as liability reform, risk pools for small busi-

nesses, not excluding people for preexisting conditions, and insuring younger adults. But we needed a 90-page bill, not a 2,000page bill. We do need a more consumer-driven approach to health care. We need new models where consumers know what health care costs are, because some of these are hidden. We should look at health savings accounts. With HSAs, costs come down as consumers are paying attention to where they are directing their dollars. We can bend the cost curve by doing things in different ways so that we are reimbursing providers for things like disease management and prevention. One of my other responsibilities here is that I am co-chair of the congressional Wellness Caucus. There are real opportunities in that area: for example, sharing success stories from companies that are providing wellness programs for employees. ■ How do you see health care issues

factoring into the coming elections? Health care premiums have been a pocketbook issue for individuals and families and small businesses alike. The issue is not going to go away. We in Congress need to be paying attention to that. That’s why I’m really trying to champion some of Minnesota’s successes, whether it’s in medical technology or with wellness initiatives, and educate my colleagues about how we can replicate and

share these stories and save money as part of the federal health care reform efforts. This sort of one-size-fits-all approach that was done a year and a half ago was the wrong direction, and then the public lashed out in the last election. But Congress is going to be forced to deal with this because of the cost issue going forward, just from a sustainability standpoint. It’s going to weigh in during the election. My constituents are looking for thoughtful, results-oriented, solution-oriented approaches to some difficult issues and challenges. ■ What would you like physicians in

Minnesota to know about how they can make a difference in federal health care policy issues? I would like physicians to know that I’m always in a listen-and-learn mode. The real stories, the real anecdotes from the experience level that they have, are very meaningful to me. I do talk to quite a few physicians and doctors on a regular basis, and it means a lot more to me when I share stories with my colleagues, or when I’m speaking at a town meeting and I’m sharing these types of real-world experiences, instead of just statistics and numbers. I keep an open door, because that is how I’m going to be able to even better represent my district and my constituents in Minnesota.

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Errors from cover going into DIC (disseminated intravascular coagulation); by the time this was noticed, it was too late. Every day, in every country, patients are diagnosed with conditions they don’t have, or their true condition is missed. But Julia was the turning point in

able or when the correct diagnosis is completely missed. Thankfully, not all diagnostic errors lead to harm. Diagnostic errors constitute more than 17 percent of all medical adverse events. In 1999, patient safety expert Lucian Leape, MD, estimated that 40,000 to 80,000 deaths occur

We need to use patients as partners in thinking through and testing the diagnostic hypotheses. my career as a chief medical officer, leading me to become passionate about how we make decisions in medicine and in management.

Defining diagnostic errors A diagnostic error occurs when a correct diagnosis is unintentionally delayed (e.g., if another diagnosis is made first) when sufficient information is avail-

each year because of misdiagnoses. However, diagnostic errors tend to go unrecognized and underreported, and we live with an underdeveloped science in trying to figure them out. The root causes of diagnostic errors are difficult to study, as errors tend to be defined only in hindsight and it’s impossible to reconstruct mental processes with complete accuracy. It is

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natural for us to attempt to separate errors into those due to knowledge deficits versus those resulting from thinking errors, but both factors likely contribute. Another difficulty is that more than 10,000 specific illnesses have been identified and are diagnosable. The more cases you see that are in the primary care arena, the higher the uncertainty about your diagnoses; the more specialized you are, the more you have a little uncertainty removed. Normal accident theory holds that accidents are inevitable in complex and tightly coupled systems—like medicine. Physicians apply imperfect knowledge and lab data that are typically nonspecific and incomplete, working in a dynamic situation, to somehow make sense out of a case presentation. A series of interdependent decisions and/or actions are often required to reach a goal; the situation changes over time, sometimes very rapidly; goals shift or are redefined; and decisions that clinicians make change the dynamics, resulting in new challenges to resolve. Given the complexities of caring for patients, what can we do to reduce the incidence of diagnostic errors? There are two ways of approaching the question: systems issues and cognition issues.

Systems issues

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In the case of medicine, the system issues that cause us to make diagnostic errors include: (1) breakdowns in delivery of functions, such as the follow-up of an abnormal or critical lab or imaging result, (2) productivity pressures, (3) discontinuous care, (4) handoff problems, (5) poor standardization processes and policies, (6) poor communication, and (7) lack of essential, patient-relevant information. Clinicians do their work while embedded in a complex milieu of people, artifacts, procedures, and organizations. All of these factors can contribute to or detract from diagnostic performance. Even well-trained individuals are at risk of making serious errors while working in

a poorly designed system.

Cognitive issues Research has shown that deficiencies of medical judgment, rather than deficiencies in medical knowledge, lead to more diagnostic errors in clinical settings. Cognitive psychology is the study of how we reason, how we formulate judgments and make diagnostic decisions based on data gathering, data synthesis, and data verification, each of which may be prone to error. Diagnostic errors thus arise from failure in systems and failure in cognition. The cognitive errors can result from failures in heuristics and from biases. Heuristics are intuitive (“common sense”) judgments based on experience-based techniques for problem-solving and learning—efficient methods to get to an answer. Humans are evolutionarily hardwired to use heuristics in decision-making; and, in fact, decisions based on heuristics are correct 80 percent to 85 percent of the time. The problem is, our experiencebased intuition is not infallible. The novice needs more experience to use heuristics well, and the expert tends to use this type of reasoning wisely, but in the process sometimes forgets to be more analytic-minded in reaching a decision. In addition to heuristics, our decision-making can be affected by numerous biases, in the form of: • Overconfidence • Premature closure/anchoring • Availability bias • Base-rate neglect bias • Representativeness bias • Confirmation bias • Commission bias • “Satisficing” Overconfidence bias. The first and most important bias is overconfidence: believing you have more ability than you really do. Generally it is considered a weakness and sign of vulnerability for clinicians to appear unsure or to disclose uncertainty to patients. Furthermore, as physicians get older and more experienced, their confidence increases, often resulting in a decreasing felt ERRORS to page 13

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Errors from page 10 need for updating their knowledge. This reinforcing overconfidence cycle is the nail in the coffin of robust learning that would allow clinicians to improve diagnostic problem-solving over time. Premature closure or anchoring bias describes the tendency to stop too soon and not order critical tests or gather critical information. Or it can result in deciding that the patient’s current problem is related to the first thing you’ve diagnosed. These biases lead us to jump to a conclusion and neglect to do a broader search for other possibilities. Availability bias is the tendency to judge a diagnosis as more likely if it is more easily retrievable from your memory; that last patient you saw had measles, so this one must have it as well. All of us give more credence to recent events. Base-rate neglect bias is the tendency to ignore the true rate of disease and pursue rare but more exotic diagnoses. When you hear hoof beats, you think of horses, but how often do you want to go to zebras? Representativeness bias is the tendency to be guided by prototypical features of disease and miss atypical variances. What we often forget is that classic features of a disease occur only about a third of the time. (Not all heart attacks come in with classic chest pain, jaw pain, and pain radiating down the left arm.) When we get a test result, we may forget to keep the false positives and negative rates in mind. Confirmation bias is our tendency to seek only data that confirm rather than refute our hypothesis. Remember Julia’s case, in which everyone went down the same road of thought. We tend to give more credence and legitimacy to data that support our diagnosis—and ignore data that don’t. Commission bias reflects our need to do something rather than just stand there. We feel better when we do something, even when it may be wrong. But sometimes it is better not to act

right away. Sometimes it’s better to “go to the balcony” to oversee things before acting. “Satisficing.” This bias, which combines the verbs “satisfy” and “suffice,” involves intentionally making a suboptimal decision in order to satisfy competing demands. When resources are limited, people choose a “good enough” solution that partially satisfies multiple goals. In medicine, satisficing bias is seen when clinical encounters are constrained by time and uncertain or absent data and clinicians juggle multiple problems, prioritizing some over others.

Other factors Other important factors influencing decision-making are decision fatigue and lack of feedback. Decision fatigue. When you have to make more and more decisions during the day, you become fatigued. Your decision-making ability drops significantly; in fact, you tend not to make decisions or to delay them as the day goes on, though that may cause more problems. How many of you, when taking call at night covering for others, have delayed a decision, hoping to let your colleague make it (recalling the resident mantra, “Keep ’em alive to 8:05.”)? Lack of feedback is a huge problem in medicine. We all know that learning and feedback are inseparable. But in medicine, the reality is that somebody else may hear, down the line, what the diagnosis was or what the lab test was—and you may never get the feedback you need to learn whether your diagnosis was right or wrong.

Can we become “debiased”? Aiming to produce completely unbiased decisions is a fool’s errand, as many biases are preconscious and cannot be overcome by simply willing ourselves to ignore them, any more than we can will ourselves to be taller. So, what can we do to reduce bias in medical decision-making on the individual, system, and colleague/mentor levels? On an individual level, we can:

• Be aware of our base rates. • Consider whether data are truly relevant rather than just salient. • Seek reasons why decisions may be wrong and entertain alternative hypotheses. • Ask questions that would disprove rather than confirm the current hypothesis, keeping in mind we are wrong more often than we think. On a system level, we can ask: • How can we control systems to be better? • How can we train people to do a better job? • How can we use information technology better? With regard to systems improvements, for example, we can begin measuring categories of errors, as we have in other areas of patient safety, by measuring harm rather than just the misdiagnosis. We can also try to build workflow computer-based tools such as web-based diagnosis decision-support systems. Unfortunately, computer-based clinical decision-support systems

have not proven to work effectively yet, because they are not fully coupled with the electronic medical record. On a practice/hospital/ colleague/mentor level: • Remind your partners, students, and colleagues that while “the simplest explanation tends to be the best” (according to Occam’s Razor principle), it is not always the best. Encourage learners to find clinical data that don’t fit the provisional diagnosis, and to always ask why if we can’t explain the diagnosis. • Encourage learners to slow down. Help them understand that unless the clinical situation is a true emergency, taking a little time may help you avoid biases. • Acknowledge our mistakes. No one is infallible, and we need to teach future generations that they, like us, will make mistakes. • Use scenario planning as a methodology to help decrease errors and keep in mind what other diagnoses should be ERRORS to page 38

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Preview from cover given the election year, redistricting, and a general desire to limit the time spent at the Capitol following the long and arduous 2011 session and subsequent special session. The prospect of an unexpected state surplus also changes the session dynamics as legislators wrangle over the easier, but still contentious, question of where the money goes, should any be left over after the required paybacks to the state’s cash-flow account and budget reserve. One of the key factors contributing to the surplus was a significant decrease in health and human services spending, largely attributed to lower than expected enrollment in the state’s Medical Assistance (MA) program. With the surplus in hand, expect any supplemental budget discussions to turn to the question of repaying the K–12 education shift, an issue that neither Republicans nor Democrats want to own heading into an election year. Proposals will most certainly be brought forward to repay the shift in the

current year, but those could come at the expense of an effort to make further cuts in the budget. Either way, the previously anticipated stalemate and partisan fighting over even a small budget deficit will be avoided, at least for one year. There are considerable questions about what, if anything, will be moved forward regarding health care policy in the 2012 session. Committee leaders in both bodies began putting together their 2012 agendas in November and December in hopes of moving quickly come January to get in and out of session in a 10-week time frame. Leadership in both bodies put together a legislative package they are calling Reform 2.0. While the reforms are largely centered on streamlining government functions, there may be a few health policy initiatives that emerge, including potential reforms to the current claims data reporting performed by health plans in the state. With the exception of the Reform 2.0 package, and a potential partisan fight over a

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health insurance exchange, the legislative agenda remains a question mark. Republican leadership will likely move forward a few ballot question initiatives, but given the contentious election year ahead, it’s reasonable to expect significant political gamesmanship. Getting a head start on the Legislature

The Dayton administration wasted no time this fall waiting for the legislative session to begin, taking a hands-on approach to a number of significant MA reform initiatives. Going back to last session, there has been increased focus on where the almost $4 billion funding the state’s Medical Assistance program was being spent, particularly in managed care programs. Last year, the governor announced early on his desire to move toward a competitive bid pilot program for MA managed care, starting with a pilot project in the Twin Cities seven-county metro area. In October, Gov. Dayton and Department of Human Services Commissioner Lucinda Jesson announced the results of the competitive bid, awarding contracts to HealthPartners and UCare for the Twin Cities’ managed-care population. The competitive bid pilot, which was included in the 2011 HHS budget, is projected to generate savings of about $175 million. However, there are still significant questions about whether those savings will be achieved through greater efficiencies in managing that population or whether the savings will be obtained solely through further reductions in provider reimbursement. The latter result would have an even greater impact on already razor-thin payment rates for the state’s public programs. Politics and the health insurance exchange

One of the more public debates likely to take place in the 2012 session is the discussion over whether legislation is required for a state-run health insurance exchange. Under the federal Accountable Care Act (ACA), states are required to have in

place, by Jan. 1, 2014, the framework for a state health insurance exchange, or states will be forced to use the federal insurance exchange. The tension between the Republican legislative majorities and the Dayton administration only intensified over the fall months as the governor moved forward on implementing a health insurance exchange. In late October, Gov. Dayton issued an executive order establishing a Health Insurance Exchange Task Force through the Department of Commerce to begin implementing a state-based insurance exchange. The insurance exchange issue became a political hot button last session for Republican leadership in the House and Senate, as a number of caucus members opposed moving forward on an exchange out of opposition to federal health care reform. Rep. Steve Gottwalt (R–St. Cloud), chair of the Health and Human Services Policy Committee, went so far as to propose a bill implementing the exchange. In an interesting twist, the insurance exchange bill was scheduled for a hearing on the same day as another bill authored by Gottwalt that called for a ban on the use of state funds to implement any provisions of the ACA. Opposition to the health insurance exchange concept may be even greater in the Senate, where Sen. David Hann (R–Eden Prairie), chairman of the Senate Health and Human Service Policy and Finance Committee, has taken a strong position opposing the exchange. In spite of their opposition, Republican legislators will likely find themselves in a difficult catch-22 should they move forward with efforts to thwart implementation of a state-run exchange. Without a state insurance exchange, they would be forced to accept one run by the federal government, a position even more perilous given Republicans’ disdain for federally run health care. A question of constitutionality

One of the questions hanging over legislators’ heads in the 2012 session is how the U.S. Supreme Court will rule on the

What district are you in?

If fights over budget and policy weren’t enough already, the uncertainty surrounding the redistricting process and what the new legislative boundaries will look like will certainly shape the 2012 legislative session. As a result of the Legislature and the governor failing to come to an agreement on a redistricting plan, the task once again was put into the hands of the courts. Over the fall months, a fivejudge redistricting panel took input from around the state from the public and other interested stakeholders to assist in the process of drawing new legislative and congressional districts. The judicial panel will release the newly drawn lines on Feb. 21, a full two weeks after the local caucuses are scheduled. The timing puts legislators and candidates in a precarious position as they begin recruiting local delegates without actually knowing whether any of those delegates will be in their newly drawn districts. The 2010 census data certainly provided details regarding

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population growth that have proved controversial in the redistricting debate. Significant growth areas included the Interstate 94 corridor and large portions of Scott and Carver counties. As an example, Rep. Michael Beard’s current district in Shakopee saw such significant population increases over the last 10 years that his current House district has the population of a Senate district. On the other side of the equation, the core cities of Minneapolis and St. Paul saw population reductions over the past 10 years, potentially forcing the boundaries on some of these districts out into the inner-ring suburbs. Democrats have long argued that the interests of core city residents often vary significantly from those of suburban residents and that every effort should be made to ensure that communities of interest are not divided. Nevertheless, the redistricting process is sure to once again leave some pleased and others not so much, as a new political reality takes shape in February. The urgency to end the

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Accountable Care Act’s constitutionality. The ACA continues to generate significant political opposition, largely from many first-term Republican Senate and House members. Although the Supreme Court is not scheduled to reach a decision until after the legislative session ends, the mere threat of an “unconstitutional” ruling could put the brakes on many of the ACA programs that the state would otherwise begin implementing beginning in 2013, including the aforementioned health insurance exchange. The Supreme Court’s decision could also have a significant impact on the future of the state’s Medical Assistance program. In the Supreme Court’s announcement that it would hear the ACA case, the court chose to address not only the question of the individual mandate, but also the question of whether Medicaid expansion was constitutional as well. However the court rules, the decision will again be front and center in campaign season next fall, in both Minnesota and the rest of the country.

session early and allow legislators to get back to their districts and begin a long campaign season will be in full swing once the new district maps are released. What can my practice do?

The best way to ensure that your practice’s or clinic’s opinions are heard is to reach out to your state senator or state representative. The state’s website at www. leg.state.mn.us lists contact information for all members of the Minnesota House and Senate and provides up-to-date information on legislation, as well as descriptions of all bills introduced during the legislative session. You can call Senate Information at 651-296-0504 or House Information at 651-296-2146 for more information. Contact information for the governor’s office can be obtained through www.governor.state.mn.us. H. Theodore Grindal, JD, and Nate Mussell, JD, are with the Minneapolis law firm of Lockridge Grindal Nauen PLLP. They provide government relations services for health care providers.

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MINNESOTA PHYSICIAN

BEHAVIORAL

Autism update

arents are often shocked and scared when they are told their youngster has autism. The word “grief” hardly conveys the gut-wrenching reevaluation of their hopes and dreams for their child as they soldier forward to find services. The primary care provider (PCP) will be an important resource to parents as they seek to navigate the highly complex mental health and disability services systems in education, health, mental health, and specialized services, including occupational therapy and behavioral interventions. PCPs are sensitive to and knowledgeable about the developmental delays of language and reciprocal interaction and the narrow range of interest and behaviors that are the hallmarks of this disorder. They are knowledgeable consultants to the family on clinical care choices. In the past decade, a groundswell of interest in autism has led to an increase in federal and private research to explore new ways of examining

H E A LT H

An expanded role for primary care providers By George Realmuto, MD and Israel Sokeye, MD

and modifying autism. This enormous scientific investment and resultant array of information about autism have created a role for primary care physicians that goes beyond screening and referral. For example, medical workups that include sophisticated genetic testing and pharmacological treatments may soon become standards for primary care. This report highlights some of the newest information about autism that may be important to primary care physicians in their role as educators of parents, selectors of laboratory tests, providers of medically based treatments, and referrers to medical subspecialists for specific medical interventions.

Etiology

The identification of autism and the spectrum of deficits associated with this neurodevelopment disorder is improving as hightech diagnostic assessments are employed. While the etiology of autism is complex, research studies increasingly suggest that interactions among the physical environment (infections, toxins), genes, and in utero insults result in disordered central nervous system cytoarchitecture, leading to profound deficits in higherlevel cortical functioning and devastating consequences to social, language, and imaginative abilities. Genetic studies. Some of the most recent genetic studies, rather than looking for specific

alleles associated with the disorder, take a broader view. For example, a recent study detected a significant increase in copy number variations (CNVs) in autism. Like Fragile X disorder, in which a small portion of the X chromosome is expanded by a repetition of three base pairs (CGG), in autism there are multiple sites within the genome where these copy number repeats may be found. One study showed that about 38 percent of children diagnosed with autism spectrum disorder (ASD) had a significant increase in these CNVs and 7.4 percent had pathogenic CNVs. This subgroup of the larger population of individuals with autism presented with multiple congenital abnormalities and dysmorphism. This specific type of genetic abnormalities (CNVs) in autism supports the disorder’s association with Fragile X, which represents the largest single genetic disorder with an outcome consistent with autism. Technological advances in genetic sequencing, microarray analysis, and exome sequencing

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may more rapidly identify genetic abnormalities contributing to the expression of the disorder. These advances will be available to primary care physicians within the next few years. Neuroimaging studies. Other avenues for exploring the etiology of autism include neuroimaging studies. While the studies have not yet produced a neuro-anatomical signature, they have shown anomalies affecting different areas of the brain (brain stem, cerebellum, limbic system, and association cortex) of children with ASD. Beyond the specific structures, highly sophisticated neuroimaging studies that can follow nerve tracks support the notion of disruption in the functional connectivity among these structures during the childhood phase of brain development in ASD. Neurochemical studies. Neurochemical studies have investigated the well-known role of serotonin, epinephrine, and norepinephrine in messaging through the brain. New information has added more weight to an old hypothesis about the role

The enormous scientific investment and resultant array of information about autism have created a role for primary care physicians that goes beyond screening and referral. of oxytocin in autism. Oxytocin’s well-known role in birthing and orgasm has been extended to include its ability to enhance social reciprocity and bonding. These very socially advanced capacities are deficient in autism, consistent with new information that suggests changes in oxytocin neurotransmission in autism. Oxytocin was one of the first hormones synthesized, and ongoing clinical trials are investigating its potential to alter behavior in individuals with autism. Parental factors influencing risk. New information suggests that age of conception may influence the risk for autism. While mother’s age is not associated with increased risk, fathers older than 35 years of age conferred greater risk, and that risk

increased as father’s age increased. This information may be of special interest to families considering additional children who already have an affected child, as the father’s age is an additional risk to an already increased risk signaled by the proband. Other family planning issues have come to light in connection with studies demonstrating increased risk due to short intervals between pregnancies. In addition, recent studies have shown that mothers taking antidepressants (SSRIs) in the year prior to their delivery have a twofold increased risk of having children with ASD, with a higher risk if these SSRIs were taken during their first trimester. Epidemiology research. Epidemiology studies in Ireland have shown that the number of

immigrant children being referred for services with diagnosis of ASD has dramatically increased, predominantly in children born to immigrants from sub-Saharan Africa. This correlates with the increase in incidence in the same population in Minnesota. The reason(s) for this increase in incidence are unclear, and more studies are needed to further investigate this result. Finally, the relationship between immunizations and autism continues to be a common question. Multiple studies, including a definitive investigation by the Institute of Medicine, have found no association and, further, have uncovered scientific fraud in the study that purported to find a relationship. In summary, the prevailing view is that autism is caused by a pathophysiologic process arising from the interaction of an early environmental insult and a genetic predisposition. Therefore, it is strongly recommended that all children with autism/ ASDs be considered for clinical AUTISM to page 18

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Autism from page 17 genetic evaluation and genetic testing so that families can be counseled regarding recurrence risk, prognosis, and associated medical comorbidities. Treatment of autistic spectrum disorders

Management of autism symptoms can be divided into three main approaches: parental education, behavioral therapy, and pharmacotherapy. The latter two are discussed below. Behavioral therapy. Multiple treatment options have been suggested, with differing degrees of evidence, for individuals with ASD. It appears that with only a primitive view of etiology, theory-based approaches have missed the mark. A recent meta-analytic review of behavioral and medical interventions found that medication had a very limited place in overall management of core symptoms but could be useful for irritability and, perhaps, perseverative behaviors. The same review suggested that while a variety of behavioral programs, such as

Since no medications are autism-symptom-specific, medication therapy should be selected with a specific behavioral target in mind. applied behavioral analysis, are useful for some children, questions remain about for whom, for how long, at what intensity, and at what age these highly resource-intensive interventions are appropriate. More research needs to be done on this topic to further determine the most suitable patient population that will benefit from applied behavioral analysis intervention. To date there are no medical treatments that affect the core symptoms of the disorder. Some of the newest approaches are reviewed here. Pharmacotherapy. Prior to initiating medications on individuals with ASD, it is essential to get a thorough medical evaluation, as evidence is mounting that medical disorders have a significant effect on behaviors, level of functioning,

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and response to educational therapies. Since no medications are autism-symptom-specific, medication therapy should be selected with a specific behavioral target in mind. Clinical and research literature can guide effective intervention for behavioral problems such as aggression, self-injurious behavior, agitation, hyperactivity, anxiety, poor sleep, and repetitive or stereotypic behaviors that interfere with learning and social interactions. Many physicians in primary care have experience with challenging behaviors from their management of other mental health disordersâ&#x20AC;&#x201D;for example, treatment of hyperactivity in ADHD children or physiological tension in children with separation disorderâ&#x20AC;&#x201D;that may be transferable in treating these phenomena in children with autism.

ADHD is an often recognized comorbidity with ASD. Reluctance to treat these symptoms separately has been rooted in the concern that stimulant medication treatment for ADHD would cause or exacerbate seizures. Nonetheless, there is a high rate of ADHD-autism comorbidity, and recent findings suggest that psychostimulant treatment combining extendedrelease methylphenidate (MPH) in the a.m. with immediaterelease MPH in the p.m. are associated with significant behavioral improvements in multiple settings. Perhaps more to the point was the finding that there was very little evidence for behavioral deterioration at higher doses. A study supported by the National Institutes of Health identified risperidone (Risperdal) and, through randomized clinical trials, aripiprazole (Abilify) for treatment of irritability associated with autistic disorder. Both atypical neuroleptics were found to be effective for these associated symptoms at low doses and are FDA-

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approved for that indication. While management of this problem may be significant for family and child functioning, these medications are not without very concerning side effects. Current research is looking at genetic predictions of atypical neuroleptic medication-induced metabolic syndrome in autism. In adults, previous data suggest that differential risk for obesity and antipsychotic-induced weight gain is influenced by common variants in the dopamine D2 receptor (DRD2), the serotonin 2C receptor (HTR2C), and the central cannabinoid receptor gene 1 (CNR1). A recent study shows that in children with autism, the variance predicted by CNR1 was modest (9.1 percent), suggesting that other pathways and gene variants may be important. Ongoing efforts include additional samples and variants to replicate and expand these analyses. The latest effort to translate etiology into intervention is based on a premise that abnormalities in the GABA neurotransmitter system may underlie

the abnormal cytoarchitecture, both because it is a major trophic stimulus in embryonic development and because it may account for the sensory abnormalities noted in childhood and beyond. One study that exploits this theory is a 12-week, doubleblind, randomized, placebo-controlled study of N-Acetylcysteine (NAC) in 24 children with autism. Subjects randomized to NAC were initiated at 900 mg daily and finally titrated up to 2700 mg per day. Compared to placebo, NAC resulted in significant improvements in Aberrant Behavioral Checklist (ABC) total (p=0.007), ABC irritability (p<0.001), ABC stereotypy subscale (p=0.019), and Repetitive Behavioral Scale (RBS) (p=0.027). This preliminary trial has supported the utility of NAC in reducing irritability as well as repetitive and stereotyped behaviors, which are among the core symptoms of autism. Other studies have explored mecamylamine, a nicotinereceptor-active agent in treating core autism symptoms. This theory-driven project is based on

postmortem findings of nicotinic receptor aberrations. Although mecamylamine appears safe for children with autism, data did not suggest a benefit. Extending the recent advances in understanding the epigenetic abnormalities in Fragile X syndrome (FXS) to autism may provide an interesting intervention direction. A recent double-blind, placebocontrolled crossover trial exploring the safety and efficacy of arbaclofen, a GABA-B agonist, in FXS showed significant improvement on the ABCLethargy/Social Withdrawal scale. Also, clinicians and parents reported that subjects were more socially engaged and more communicative. Due to the association of FXS with autism, Arbaclofen shows promise for treating behavioral symptoms in FXS and, possibly, for treating core social deficits in autism. Primary care physicians may have an additional role in autism management as more of the health-related disabilities of autism come to light. For example, it has recently been reported

that boys with ASD have decreased bone cortical thickness. The question has been raised about dietary intakes that would result in this outcome. It was found that ASD children consumed less than 68, 60, 60, and 57 percent of DRI for calcium, magnesium, vitamin D, and vitamin K, respectively. Therefore, it is critical to monitor bone-health nutrient intake of children with ASD. Some nutrient insufficiencies, perhaps Vitamin D, also may have implications for brain function. A critical role for primary care

Though much work needs to be done to further understand, prevent, modify, and manage autism, one thing is clear: Primary care physicians will continue to play a critical role in the identification, diagnosis, education, care management, and possible referral of autism/ASD cases. George Realmuto, MD, is a professor of psychiatry at the University of Minnesota. Israel Sokeye, MD, is a child and adolescent psychiatry fellow at the University of Minnesota.

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MR. CHRISTENSON: What is an ACO? DR. MOEN: ACO is a legislative construct that enables change in health care. The way I view it, it enables us to begin to balance individual health and population health appropriately in a system and drive accountability to both. DR. WECKWERTH: An ACO is a formless collaborative entity intending joint accountability for measurable quality improvements and to reduce rates of health care spending.

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About the Roundtable Minnesota Physician Publishing’s 36th Minnesota Health Care Roundtable examined the topic of accountable care organizations. Seven panelists and our moderator met on Oct. 13, 2011, to discuss this issue. The next roundtable, on April 19, will explore the subject of specialty pharmacy and its role in controlling the cost of health care.

MR. WATSON: It’s the latest way to bend the cost curve. MR. CHRISTENSON: What is a shared savings payment program? What does it mean? DR. MOEN: It’s a mechanism to allow a different style or type of contracting that rewards or allows alignment of incentives for managing cost care, not just producing volume of services. DR. THORSON: The intent of the shared savings program is to say, how do we reduce the waste and maintain the quality and allow for more efficient utilization of both limited resources and dollars? Is it really going to transition the payment from being hospital-centric to more outpatient-centric? MR. WATSON: It makes the assumption that there will be savings. The savings supposedly come from the elimination of episodic independent activities, and therefore you’re pooling something, and therefore it should cost less in the aggregate. That’s the assumption. Whether or not it’s true, I don’t know. DR. AINSLIE: One of the problems is, the regulations from CMS have an after-thefact payment. You don’t even know what patients are in your ACO, so you don’t know who you’re taking care of and how you’re taking care of them, and it will be decided after-the-fact by CMS who can arbitrarily say, you did a good job and we’ll pay you that money, or no, you’re getting nothing. It’s all controlled by CMS. MS. SORENSEN: I would also like to add that it is still considered voluntary. So patients will be passively enrolled into an ACO, which they may or may not be familiar with, or be forced based on demographics or where they live. If they choose to opt out, the ACO group may or may not know that patient has opted out.

MINNESOTA PHYSICIAN JANUARY 2012

Accountable Care Organizations Accountable to Whom? MR. CHRISTENSON: What is critically important for doctors to know about ACOs? DR. AINSLIE: I define an ACO as an HMO without the money. They are trying to save money, and that is the bottom line. It’s not to improve patient care, it’s not to improve physicians’ well-being. It’s for CMS to save money. I tell physicians that if they go into it, they certainly have a right to do so and a right to compete and a right to see whether this might work. What bothers me more than anything else is that if they do, their patients are going to automatically be included, and they have no say in the process. DR. KLODAS: The overwhelming thing that we need to come to terms with is how rapidly everything is changing. The way I practice medicine now may not be tenable in five years because these types of forces are making it almost impossible. I like to spend time with my patients, and have a practice style that is more preventative. We’re going to have a very difficult time existing independently. I think the thing that independent practitioners need to think about is a way to smartly consolidate within this marketplace. As far as specialists go, frankly, a

lot of specialists are now part of ACO-type systems. They’re very affiliated with hospitals. Already, most cardiology practices in this environment here are owned. They already belong to systems. DR. THORSON: ACO is a technical change that has been made to try to drive cultural change at the delivery of health care. I think it is trying to get physicians to realize that the way we provide care needs to change. I don’t think there’s any question that we can’t continue to do what we’ve been doing and have a health care system that will stay afloat. The government is trying to do a technical change to force cultural change within clinics. And cultural change is hard. Technical change is a lot easier. The thing we talk about all the time is how we have to change the culture of how we deliver care. This is an awkward time because we’re trying to change culture before payment has been changed. It’s taking a very big leap of faith. DR. KLODAS: I think that a big thing not being addressed is that, as a society, we’re getting sicker. No amount of this piddling with the way we pay for health care really addresses some unbelievable statistics that we haven’t faced up to. I’m a cardiologist, so I know cardiovascular care. The current expenditure every year for cardiovascular care in this country, just care, is $270 billion a year. In 2030, on the current trajectory, it’s expected to reach $810 billion a year. That’s a stimulus package thrown at a disease year after year that is unsustainable. That’s a public health issue. It’s not necessarily how we pay for this. The ACO is projected to save $5 billion over the next eight years. That’s the CBO [Congressional Budget Office] estimate. That’s nothing in this giant pool of a problem. I totally agree with you. We need to refocus on how we truly deliver care, how we can truly impact this cost curve, because I don’t think this is going to do it. MR. CHRISTENSON: Vern, what are the best things we can say about ACOs? DR. WECKWERTH: The intents are very good. We are going to improve population health, and that’s to be done because everyone is supposed to have a personal health plan that will be intervened by the particular health care specialty most appropriate for it. Secondly, it’s therefore going to benefit individuals, and if individuals are benefited, the

group is. There will no longer be separate episodic care. The care that’s appropriate for the individual at that point in time takes the judgment of more than just a single discipline. If the ACO can pull it off, if we change the practitioner’s view of what collaboration means, then this will work. It isn’t clear to me what the incentives for collaboration are. MR. WATSON: They elevate primary care in our health care system up on the front end. I’m looking at our member community health centers, safety net clinics working together now among themselves and also looking to partner with mental health providers and with hospitals on a more formalized basis. I think with that communication and collaboration, it’s what we’ve been saying we have to do for the last 30 years, and we’ve never done it. I think it is forcing some of those discussions. MS. SORENSEN: It’s an opportunity for clients and patients to be served on a continuum of care versus a fragmented piece of care that we currently deal with. All of our systems are required to speak to each other, yet we don’t. Patients get lost time and time again. We need to talk to the other players across the table because this is part of the whole care plan, and yours is no more important than the other player. DR. MOEN: There might be an opportunity to decrease the number of regulations. If you could actually get into a population system that had a better goal and focused on an outcome, maybe you wouldn’t need some of the governors we have in place today. I think there’s an opportunity to reduce clinical variation, and there’s good research that demonstrates that a tremendous amount of the cost of health care is due to clinical variation, variation in decision making, variation in the types of things that people do for certain conditions. Some of that variability is hard to manage, but there’s really good evidence that a lot of variation in today’s system isn’t justified. There isn’t a great reason why Medicare costs so much more in New York than it does in Minneapolis or Davenport. How long are we going to pretend that it’s about how much we pay nurses instead of facing the fact that it’s about the variability and the practice and the incentives that are in place?

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MR. CHRISTENSON: What are the three worst things about ACOs? DR. AINSLIE: The biggest problem is that it’s another command-andcontrol mechanism that will be imposed on physicians and will cause them to consolidate. I feel sorry for the primary care docs who are single practitioners in this state. They’re going to have to work with other people in other organizations. While it may cut down on individual variability, that’s fine, but most of the progress in medicine has been from people who are thinking outside the box, not inside the box, and this program and others will just make someone say, well, we’ve got to practice this way, or your computer tells me I’ve got to do this X, Y, and Z, and I’ll do that. It may tell me to have good diabetes control, since I take care of kids with diabetes. I can’t have anybody with an A1c over 8, for example, and every year it’ll be screwed down to 7 or 6. Well, what’s my first response? Get rid of the patients who are 12s and 14s because they’re screwing up my average? That’s not good patient care. I do much more for a 12 or 13, I feel, than for a 7 or 8, but that skews my statistics, and so I won’t like it if I’m paid on the basis of my A1c. The basic problem with ACOs is, it gets between the patient and the physician, and we’re not orienting ourselves to where the real problem lies—in the physicianpatient interaction. DR. KLODAS: The biggest thing to me that is amazing about this reform is that it completely leaves out the linchpin for success, which is the patient. There is no accountability on the part of the patient. You can do everything right, you can follow every single guideline, you can provide all the education, all the medications, everything—but ultimately, if that patient walks out of the door and doesn’t follow your advice, you’re the one who’s penalized, not the patient. None of this can succeed if patients are not accountable. I’m not saying it’s their fault, but they have to be part of the solution. MR. WATSON: There are really three kinds of problems we need to overcome with the ACOs. The first is the start-up cost, for nonprofits especially. You have to look at IT systems. You have to look at governance of your ACO. All sorts of changes to your practice in that sense that do cost money while you’re still trying to survive finan-

R O U N D T A B L E A B O U T T H E PA N E L I S T S

Michael Ainslie, MD, is a pediatrician and a pediatric endocrinologist with Park Nicollet Clinic, where he has practiced since 1977. He served as the chair of the Board of Trustees of the Minnesota Medical Association. He has served on Park Nicollet committees for salary and bonus, systems research, risk management, ethics, and recruitment. He was chief of pediatrics at Methodist Hospital from 1992 to 1998 and served on the Administration Committee for Methodist Hospital. David Moen, MD, is president of the Fairview Physician Associates (FPA) provider network (affiliated with Fairview Health Service), an integrated health system of more than 20,000 employees and 3,000 physicians. As FPA president, Moen leads the development of Fairview Health Network, an integrated multispecialty provider network. He and his team developed a team-based primary care model—the Medical Home Model—that is now deployed across 41 primary care clinics. Moen also is chief medical officer of NetClinic, a Web-based interactive health portal for clinicians to deliver virtual care to patients. Moen earned his medical degree from the University of Wisconsin and completed his residency in family medicine at the University of Minnesota. Elizabeth Klodas, MD, FACC, is a board-certified cardiologist with more than 15 years of experience treating patients with heart disease. Klodas completed fellowships at both the Mayo Clinic and Johns Hopkins University. She specializes in noninvasive cardiac imaging, including stress testing, echocardiography, nuclear, CT, and MRI imaging. Klodas founded Preventive Cardiology Consultants and sees patients at her independent practice in Edina. She has led several patient education initiatives at the American College of Cardiology (ACC) and spearheaded the formation of ACC’s patient education website, www.cardiosmart.org. Klodas is a medical editor for webMD, and also serves as director of the Heart Disease Prevention Program at General Mills. Jennifer Sorensen, MEd, is executive director of the Minnesota HomeCare Association (MHCA), which represents 250 members, including business affiliates and providers. Prior to joining the MHCA, Sorenson worked for the Mesa County (Colo.) Department of Human Services, overseeing programs including the Area Agency on Aging, Adult Protection services, Adult Resource for Care and Help, Community Services Block Grants, and Medicaid home and community-based services programs. She had a significant role in the collaborative development and implementation of programming for seniors, Care Transitions programming, and the regional Medicaid Accountable Care Organization. Sorenson has a master’s in education (guidance and counseling) from North Dakota State University. David Thorson, MD, is a board-certified family physician who practices at Family HealthServices Minnesota PA in St. Paul. He received his medical degree from the University of Minnesota Medical School, Minneapolis, and has a Certificate of Added Qualifications in sports medicine. He currently is chairman of the Minnesota Medical Association Board of Trustees. In addition, Thorson has served as chair of Family HealthServices Minnesota’s Neuromusculoskeletal Services Clinical Practice Committee, and as team physician for the St. Paul Saints baseball team, U.S. Ski Team, U.S. Freestyle Team, Mahtomedi High School, and the Twin Cities Marathon. He is a former president of the Minnesota Academy of Family Physicians. Jonathan Watson, MA, has worked with the Minnesota Association of Community Health Centers (MNACHC) since 1996, and currently serves as associate director and director of public policy. MNACHC represents 17 community health centers in Minnesota that serve more than 190,000 patients in medically underserved communities. Prior to joining MNACHC, Watson was a budget and policy analyst for the Wisconsin Department of Health & Family Services. He has also served on a number of statewide committees and task forces. Watson has a BA in economics from St. Olaf College in Northfield, Minn., and a master’s degree in public and international affairs from the University of Pittsburgh. Vernon Weckwerth, PhD, is a retired professor at the University of Minnesota, where, over a career of more than 50 years, he held joint appointments and taught in the School of Public Health, Medical School, School of Nursing, College of Pharmacy, Carlson School of Management, and Humphrey Institute. He earned his master’s and PhD in biostatistics at the U of M. His research specialties include effects of variables on health service delivery, design of research, inductive methods, and distance executive education. Weckwerth is director emeritus of the U of M’s ISP Off-Site Executive Study Programs in Healthcare Administration. He also serves on the editorial board of the Journal of Health Administrative Education. Robert Christenson has 40 years of experience in health care policy and consulting. He helps solo and small-group practitioners build a full practice of ideal clients and improve their net revenue. JANUARY 2012

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M I N N E S O T A cially. Second, a lot of these ACOs that have been talked about and proposed are largely based on urban, highly integrated systems. How does this play in greater Minnesota? I don’t know. I see a lot of problems with that, given the different geographic distances between providers and small population base. That’s a problem for some of our health centers. Lastly, it’s silent on mental health and dental/oral health issues. In my book, that’s all part of someone’s health, and these ACOs are driven a lot just on the medical side. Incorporating more of those provisions would beef up the ACO model. DR. THORSON: Part of the problem with ACOs has been talked about earlier, which is the expected transform before payment changes. The one thing that we forget in Minnesota is we have a different perspective. [Mayo Clinic health care policy expert] Doug Wood has said that if everybody else in the country practiced medicine like it’s practiced in Minnesota, there would be $13 trillion saved over 10 years. So we look and say, gee whiz, an ACO doesn’t necessarily work well in some areas because we have a jaded perspective. We need to realize that the weakness in the ACOs is they're treating Minnesota like the rest of the country. If you start talking to them about shared savings, they’re going to start me out with where I am right now and have this be my baseline and measure me where I’m going to be in three years. I’d be better off waiting a year and getting a lot worse at what I do, because it’s going to be hard to do a lot better in some areas than we are currently doing. There are other parts of the country that are so far behind where we are in Minnesota that their ability to change is dramatically different. MR. CHRISTENSON: Another issue that frequently comes up when ACOs are addressed is that it puts the physician in the insurance business. How is that possible? DR. AINSLIE: ACOs are defined that way; that’s what they do. You don’t want to come to me for your insurance needs. We have professionals out there who do it a lot better than I do and know it a lot better. What insurance should do is to insure risk. We’ve gotten so far away from that definition that now we’re talking about insurance covering first-dollar things, and should it cover this or that or the other thing, without any appreciable looking at the risk and the cost of it. We’re trying to control those costs by this mechanism. And again, for those of you in

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practice in a large group like mine— Fairview and others—we can absorb some of those losses. Those of you out in Virginia, Minnesota, can’t do that. You have one catastrophe and you’re out of business. DR. KLODAS: There is some data about the fact that it doesn’t work. The demonstration projects were done with very large systems in an attempt to demonstrate how well this was going to all turn out—and this was done with Geisinger Clinic, very integrated systems. On average, they spent $1.7 million the first year just getting their organizations up to speed, so they had funding or had the wherewithal to put that type of resource in. Well, in the first year, eight of 10 of those participants didn’t get any savings. They got no return. The second year, it was only six out of 10. In the last year of the three years, only half had received any return on their investment. This is a big and expensive undertaking, and the way the savings were being calculated, I’m not sure it’s going to work for a lot of people. MS. SORENSEN: I would also say, here in Minnesota, we are the HMO capital. We have large HMOs that are integrated into our systems currently. You throw in an ACO concept, and then how does the HMO fit in within the physicianACO realm? I think that’s going to convolute our payment structure. The way it is, reimbursement issues and individualized contracts that outside providers currently have with certain HMOs, such as in the home health field, all of our providers end up having to do or sign up every year with one of the plans to make sure that they can see patients that are within that HMO realm. Now you’re bringing in a larger HMO system and this ACO piece. MR. CHRISTENSON: Do you see things within this ACO program that actually provide incentives for the withholding of care for financial gain? DR. THORSON: I’ve heard that criticism. I personally do not see that. I think that if we look at the relationships we have with patients, shared decision-making that we are going to be doing, it’s the shared decision-making that’s going to influence the cost of care. When you sit down and talk to

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people about the science of the care you’re proposing, the rationale for it, and have them participate in that decision, people often make the choice that is least expensive, not most expensive. I kind of joke [that] I have a biology degree and philosophy degree: I use my biology rarely and my philosophy every day in clinic, because it really is working on that shared decisionmaking and how you inform patients and reach that collaborative relationship of looking at how you deliver care. DR. MOEN: A question like that almost assumes that people are getting the care they want today. We overtreat people and kill them every day because of our system. That’s the reality. There’s almost an inherent belief that today’s system is ethical because people choose what they want. There’s an assumption that people are actually choosing to be in the ICU at age 87, intubated, just having a CABG [coronary artery bypass graft surgery], knowing what they were actually heading into. There’s great evidence that shows that we do a horrible job of engaging

Patients will be passively enrolled into an ACO. Jennifer Sorensen, MEd

people in understanding what they just signed up for. MR. WATSON: We’re trying to withhold care under ACO, the care that happens unnecessarily in the emergency room or in a hospital that doesn’t need to occur. That’s kind of the intent of the ACO. So it depends on how you frame that question: Is it necessary care or is it ineffective and should not have happened in the first place? That’s why I think I’m somewhat in support of the ACO model in terms of elevating that primary care and avoiding those costs, ER visits, and the like. MR. CHRISTENSON: The establishment and operation of ACOs would necessarily involve the creation of financial arrangements between

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MINNESOTA PHYSICIAN JANUARY 2012

M I N N E S O T A physicians and other entities that would otherwise be prohibited by current laws. How do you respond to this conundrum? DR. MOEN: That’s an issue that we’re discussing with the government almost every day. There are a number of things that need to change. Some of those rules were put in effect because of the abuse of the fee-for-service system. It’s fascinating that as we start to change incentives, some of those regulations don’t make sense because they are regulating something that’s no longer an issue. The question will be, what raft of new regulations will we have if this keeps going, which I’m sure it will. I also think that as physicians, we tend to—and I’m a victim of this—think either/or. We have to be perfect before we start. We have to have the answer before we do anything. We’ve got to get out of that mindset. This is an iterative process. An ACO is perhaps the beginning of a different system, but there’s a lot of work to be

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going to do those waivers as they say they are, because they would shoot themselves in the foot if they didn’t. We have to realize that transforming care is what this is about. We have to get critical mass so that the offices can afford to change how they do care. It’s not going to happen with 18 percent Medicare alone. This has to happen across the board. It has to happen with third-party payers. We have to recognize that this change has to happen. You have to embrace it and say, we can’t continue to do what we’re doing. DR. WECKWERTH: The irony is that nobody said collusion wasn’t effective. It’s just that collusion, by our terms, is what we didn’t want to do at that point in time. Now, under ACO, collusion is good because it will arrive at the intent—only we won’t then call it collusion. So here’s the irony. When you were on it for yourself, that was bad. Now if you’re on it being together, that’s good.

You don’t even know what patients are in your ACO.

MR. CHRISTENSON: Can we adjust for risk in these shared services programs? Is there a way to do that?

MR. WATSON: We do have to adjust for risk. This is No. 1A on my list of things for ACOs. Thirty percent of our patients who use a community health center don’t speak English. Seventy percent are not white. We have Somali immigrant clinics in the Cedar-Riverside neighborhood. This is a huge issue for us. The state right now is doing some risk adjustment on some their reporting, and it only looks at insurance status, which is unfortunate. We need to expand that to nonclinical issues— homelessness, poverty, English as your first language—all those sorts of variables fit into the patients we see every day and understand why they have troubles negotiating the system as it exists today. Again, this is probably the biggest issue for us in terms of risk adjustment, and getting to do it requires resources. I understand why the State of Minnesota only does it on insurance status at this point, because they don’t have the resources to go beyond that. There is a pretty heavy cost to doing this correctly.

Michael Ainslie, MD

done around regulation, payment, the way care is provided. We have to continue to transform over time. I think what I see is a sense or recognition that the time has come for us to change gears. DR. THORSON: As an independent singlespecialty group, there is no way that we could do an ACO without violating Stark regulations. The same thing came up three or four years ago. How many of you were involved in the baskets of care stuff that happened in the state of Minnesota? That was going to violate the same type of Stark [regulations], and we have to be able to think outside the box. I think we have to—it sounds hard—trust that the government is

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DR. MOEN: There is potential for some of our partners, such as academic health cen-

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ters, being penalized for caring for some of the most ill patients where there’s a ton of cost and there’s work that needs to be done, but the current risk stratification model doesn’t do a good job of characterizing that risk. MS. SORENSEN: You can do all the risk adjustment in the world, and at the end of the day you might not have met the mark. You could have spent all the time, all the resources, and invested a lot of dollars into risk adjustment and planning for the future, but we’re dealing with human beings. Human beings are not the square pegs that fit into a square hole. They are individuals, and they ebb and flow, and they change every day. We can’t set a perfect model to fit everybody. MR. CHRISTENSON: How will components of our health-care delivery system that are not physician groups be affected by ACOs? MS. SORENSEN: That is a very intricate piece that is missing in total care. How do we care for people in their homes at the time of their need? It’s completely wiped off the map in regard to this. We have all of these programs about reducing rehospitalization, transitions of care, and all of those things, but every time it’s discussed, home care is an afterthought. Maybe we should have pulled the home care agencies in to see how that would fit? They’ve had Mr. Smith for the last six years. We probably could have gotten some great information on how that family works. What are the social networks? What are the other ways that this patient can be served other than from a medical need and more from a holistic care need. A lot of my providers that are within my network don’t get paid for that, but they do it because it is in the best interest of the patient and their client. DR. AINSLIE: I think one of the basic philosophic problems we’re having is we’re moving from an acute care model, which is a fee-for-service model, to a chronic care model which has no model at this point. When you want to innovate or try something different such as keeping the patient in their home—probably much better than a hospital bed, I would suspect— there’s no reimbursement for that. They’re just kind of left out of equation. Unfortunately, I think CMS and some of the others that are putting down these regs for the ACOs are still in the acute care model. They want to control cost because the acute care model is

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I would love to see a transition to measurements around well-being. Dave Moen, MD move forward, will become unconstrained as we begin to really look at what’s optimal in the continuum.

going way up, and those of us in the chronic care model are getting nothing. MS. SORENSEN: As you know, home care is the smallest slice of the pie but the one that keeps getting cut the most. There are always concerns about fraudulent use and those types of things, and yet we are on the hook for faceto-face visits with CMS. It’s the physician we’re supposed to be communicating with, and it’s the physician who needs to sign off on the paperwork, but it’s the home care agency that gets nailed for the refusal of payment. That to me is a dysfunctional piece of the system, and I don’t know how to fix that right now until we start communicating. DR. MOEN: You have to have parts of the continuum that become part of the model and are rewarded for being part of the model. Home care, in my view, has been tremendously underutilized appropriately. In my background as an emergency physician, there were tons of people I could have sent home every day, but we didn’t get paid to do that so we put them in the hospital. I think there’s an opportunity, if we take it on and really try to serve a population, to develop different relationships with home care and other agencies such as the Courage Center, other kinds of community resources that absolutely are critical but today are not engaged in ways that are sustainable, and also they’re not leveraging all that they could offer potentially. They’re very constrained because of today’s payment and regulatory models, and hopefully, as we

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DR. KLODAS: One of the things that I’m really struck by in the definition and the goal for ACOs: It is reliant on bringing stuff together and making it bigger. Sometimes making things bigger isn’t necessarily better. I think this push sets up for too-big-to-fail systems where you get so large and it costs so much, but it can’t go out of business because it takes care of our entire community. Now that system holds a community or an area hostage, and you just have to keep feeding it. Sometimes bringing things together is not more efficient. DR. THORSON: The limitation with that by the federal regulations saying, you can only belong to one ACO—that’s why that part has to change. In a population area as an independent group, it would be to my benefit to participate in multiple ACOs because my choices will be better and broader, and my patients live in a big area. Our only choice, again, is to be our own ACO to prevent the problem of saying we can only belong to one, which will drive the alignment that will eventually prevent the groups from staying independent.

cians. It completely ignores other nurse practitioners or physician assistants, and that’s really the model the community health centers use a lot in terms of expanding access to care. It pretty much ignores those provider types in making that decision. That’s problematic from our end as well. MS. SORENSEN: The assignment process being at a CMS level is so far removed from the actual patient. It’s kind of like reading a piece of paper and making a complete judgment on an individual and saying, I think you need to go to Dr. A’s group versus Dr. C’s group. They don’t even know the patient; they’ve never seen the patient. It’s so arbitrary and not patient-centered. DR. THORSON: I think that attribution of patients is a struggle no matter who’s trying to do the attribution, if it’s the third-party payers, the government. They look at where the visits occurred, where more than 50 percent of the dollars were spent. When you’re a primary care doctor and you generate very few dollars taking care of a chronic disease patient, when they go in to have a very expensive procedure, that throws things off. MS. SORENSEN: This comes down to a fundamental piece of patient choice as well. As we live in a society of individual choices and being thoroughly informed of our choices,

There comes a point where personal accountability has to step in. Jonathan Watson, MA

MR. CHRISTENSON: What are the pros and cons of patients being assigned or attributed to an ACO by CMS? DR. WECKWERTH: CMS can’t even explain it. It should be pretty clear. They will tell you where you go. That’s step 1. As only first children do, that’s the way the world runs, and of course the back side of that is that nobody will be happy because who among you ever wanted the elder sibling to tell you what to do? That’s what I expect will happen. They’ll just do it. MR. WATSON: It’s based on claims for physi-

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what are the ramifications of an ACO that doesn’t show or explain someone’s choices? It’s easy enough to get an attorney and then sue the ACO because they weren’t provided the information and given patient choice or

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directive on their options. You come into another layer of care called case management in regard to making sure that everybody has their options laid out for them prior to being engaged into a program.

you’re in another bucket, you’ll be analyzed there.

DR. KLODAS: Patients may not know that they’re in an ACO, but they actually retain the right to go see other specialists that may not be part of the ACO. That can completely throw off the whole reason behind the experiment.

DR. WECKWERTH: That’s where the attribution comes in. You have those patients whom you then analyze and see what made them high use. And then you figure out which variables are associated with that and what then became high risk. I think we’re running under the assumption that there’s going to be a risk model, a multivariate one, by which you assign some kind of cumulative score and therefore you allocate it to different ACOs. Nobody said that was going to happen. It may, but it certainly isn’t in the works right now.

MR. CHRISTENSON: How should CMS address high-risk patients affecting utilization within an ACO?

MR. CHRISTENSON: In effect, a patient could be assigned to an ACO and never see any doctors within that ACO and get all their care elsewhere. But the effect that’s going to have on the shared savings program for that ACO will be manifested, is that right? DR. MOEN: Not necessarily. The attribution model is defined by where primary care takes place, and if the majority of it takes place within a certain system, then costs are attributed to that system. There are going to be a lot of people that aren’t attributed at all. There are going to be a number of people who change their attribution based on who they’ve decided to go see. DR. WECKWERTH: Assignment and attribution are totally different things. I never saw that assignment was something that was going to be done beforehand. Attribution is just an analytic way of taking a look to see

There is no accountability on the part of the patient. Elizabeth Klodas, MD, FACC

where people have been, to use that as one of many sets of multivariables for analysis. Assignment has nothing to do with where you are told to go. You can go wherever you want, show up, and if you’re in the right bucket you’ll be analyzed over there. If

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DR. AINSLIE: I’m sorry, but why would we have preexisting conditions? Why would we have people being dropped out of health plans when they’ve hit certain things? It’s because of the business model. The actuaries have figured out when to drop people off and how to make price products based on that information. The uninsured problem is due to the way health plans operate, the way they use analytics, and the fact that overall, the cost of care is not sustainable. The powers that be certainly like to blame the physicians for this cost overrun. There were about 42 to 45 million uninsured in 1965 before Medicare started, and today there are exactly about the same. Even places that tried to go from 94 percent to between 96 percent and 98 percent insured have had a tremendous cost increase to get that few percentages, in Massachusetts. I think that we can go to a different model and have insurance do what it’s supposed to do, which is to insure risk, and move to a different model where patients have control of some of that first-dollar coverage that they now enjoy without any thought of cost. What happens in economics when costs go to zero? Demand goes to infinity, and that’s what we’re seeing. DR. WECKWERTH: I think he used a critical term. We were talking about the insurance, the risk. When you have first-dollar coverage, you no longer have insurance. You have prepayment. It isn’t insurance; people are talking about prepayment. If, in fact, the events will occur with virtual certainty, that’s a prepayment of the service; that’s not insurance. For insur-

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ance to exist, it has to have a risk. If we don’t have a risk, then we aren’t talking about insurance. Really, prepayment is what goes on. MR. CHRISTENSON: What are the benchmarks of quality that are going to be measured in the ACO and determining shared savings? DR. AINSLIE: As with many things in medicine, they will measure what they can measure. I will be measured on my hemoglobin A1c values because you can measure that. I won’t be measured on how many carbs they take in a day, whether they take the appropriate insulin, all that. The idea is that if your A1c is good then you must be doing all the other stuff very well. That may be a fallacious argument and not be good quality care. The problem is, what’s your benchmark? I guess I’m going to have to have a terrible benchmark for the next three years before I get into it, because then I’ll look great when I improve all that. That’s terrible medicine. We’re measuring something that we can measure, but it has no sense in how we apply it. If the quality measurements are done correctly, they certainly can be, but physicians haven’t been involved in that much, and I think we need to look at that and how CMS comes up with these benchmarks. MS. SORENSEN: I think the other thing is, too, currently as it’s set up, there are 65 quality measures. You’re going to have to have a quality improvement team, which is another layer of management within your own organization just to be able to gather the data. I can’t even imagine the time that it’s going to take, one, to capture that data, and two, to get your patients to fill out the questionnaires that are required. And then how does it all fit within this magical formula that none of us really know yet? DR. WECKWERTH: This isn’t 65 things that you’re running out and doing that you aren’t doing now. They, in fact, are supposedly things that come because of the summary of care provision that is done. DR. MOEN: I would argue that the measurement actually reinforces the model of sickness. I would love to see a transition to measurements around well-being, which I think speak much more to the social connections people have in their lives, their financial stability, how they feel about their lives, the quality of their lives. The paradigm needs to shift, and I think it could be simpli-

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M I N N E S O T A fied as well if we engage patients in defining well-being. I think it would help orient the system toward a more holistic view of what actually constitutes health. DR. KLODAS: If we look at our community now, whatever we’re doing, and I don’t care how you measure it, it’s not working. We are getting sicker and sicker, and no matter how much money we’re throwing at this, it’s not working. This is beyond what an ACO can do. This is an entire community effort where you have food manufacturers who are stepping back and saying, wow, maybe we shouldn’t make so much of that, and you have communities getting together and saying, wow, we should probably build some more walking parks, and companies getting together and saying, hey, you know, maybe we should be giving people time during the day to go for a walk and do something. MR. CHRISTENSON: Who do you see being winners and losers when accountable care organizations are fully operational? Who are the winners going to be? DR. THORSON: My hope is the patients are the winners. I’m not sure that’s been proven yet, but that’s what my hope is, that the patients are the winners. I think if you talk about, in the health care professions, who are the winners and the losers, I think outpatient delivery of health care is going to be the winner. And I think the inpatient model of health care delivered through hospitalizations and emergency rooms will be the loser. DR. AINSLIE: I think the winners are going to be the CMS, because they rigged the system, and they will benefit from it primarily because that’s what they want. The losers, I’m afraid, are going to be the physicians and patients, especially in areas where we’re already doing a lot of this. As we’ve said, in Minnesota, we’re up on the ladder and I’m afraid that we’ll be judged. They’re going to look at the rate of change, of improvement. It’s going to look awful for Minnesota because we’re already pretty good. A place like Texas or Louisiana is going to look wonderful because they have a long way to go. I don’t think large groups or small groups or the whole state of Minnesota is going to come out [well] in this no matter how we set up an ACO. MR. WATSON: Highly integrated systems that exist now, that can understand the rules of the game as they’re entering the game,

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are going to be big winners. Small, independent, autonomous practices that are just trying to feel their way right now are going to be at a disadvantage. I see hospitals potentially being losers. Empty beds don’t translate to revenue. I see greater Minnesota potentially being a loser. I think who’s on the bubble, not a winner or a loser, are health plans. I really don’t see what the role of the health plan is exactly under an ACO model. I don’t know if they’re kind of backroom support or will transition to something else, but I think they’re on the bubble. DR. KLODAS: The winners are going to be administrators and compliance officers. I think this is going to have an awful lot of rules and regulations and new layers of bureaucracy that are going to employ an awful lot of people who will be doing an awful lot of paperwork. The losers are ultimately, at least in the near term and probably in most of my lifetime, are the taxpayers. I honestly don’t think this addresses true cost of care. The costs are because our population is changing, we’re getting older, the rates of diabetes and obesity are unbelievable. You can’t squeeze money out of a system when everybody’s sick. DR. MOEN: I hope my kids are winners in that they inherit a society that is actually sustainable. I would hope that we would all take the long-term view that this isn’t so much about accountable care organizations as it is about facing the things that we’re all alluding to. That is, we’ve got a public health problem that is unmanageable, and a health care system isn’t an adequate way to address much of what we’re talking about. If we don’t do this well, our whole society is at risk. We’re looking much different, and I don’t think in very positive ways. If I worry about one thing when I go home and go to bed at night, it is what kind of world we’re leaving for our children. MR. CHRISTENSON: How will allied health professionals be affected by this? DR. MOEN: They’re critical parts of the system. If we look at chiropractors and acupuncturists, which today are called

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complementary medicine providers, there’s good evidence that in some corridors those professions provide value. The trick is, how do you begin to define that value, and then how do you connect in ways that are meaningful to those groups of providers and professionals to help improve the health of a population. It starts with looking at the role of nursing and the changes that need to happen and the leadership we need out of the nursing community to actually drive to a different model. It starts with the chiropractic profession being honest with itself about some of the things that have gone on in that profession. MR. CHRISTENSON: How do you see health plans being affected by ACOs? Are they win-

The irony is that nobody said collusion wasn’t effective. Vernon Weckwerth, PhD

ners, are they losers, or neutral? DR. AINSLIE: Obviously, patients will need insurance, and obviously even the largest ACO in the state is going to need reinsurance for catastrophic risk, so they will provide that insurance—I’m sure, happily—at a cost. It will probably help them to some extent in the short term and perhaps in the long term also. What happened in the HMO model is that they were first developed by physicians, as you know, and pretty quickly morphed into health insurance models and consolidated and so on, and physicians lost control and lost their shirts. MR. WATSON: I think, quickly, health plans could potentially do a lot of the backroom claims processing. There seem to be a lot of analytics that need to occur in the ACO methodology. We talked about the 65 meas-

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M I N N E S O T A ures, you know, you need some sort of backroom office support for that. Secondly, health plans, I think, do a good job of setting up networks in terms of specialists. If you do set up your own ACO, your own primary care doctor, you’re going to need your network, and I think health plans can provide that expertise in terms of establishing those networks. DR. THORSON: I think that this past legislation has been more insurance reform than really health care reform. I think the insurance industry is somewhat vulnerable. I think you could imagine a world where accountable care organizations are big enough and cover enough patients that they can market directly to business. They can market directly to communities and bypass

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not going to be very successful with this process. Also, I think probably one of the biggest things that keeps resonating in our answers is that there’s no patient incentive for participation, and I think we really need to be looking at this through this developmental process. What is the incentive for the patient to participate in this? MR. WATSON: We need to have the ability to communicate across different systems and different care venues. I think the one aspect where you could pull the plug legitimately is if we have massive market consolidation that actually leads to higher prices and higher premiums. Then I think it’s clearly time to pull the plug. MR. CHRISTENSON: What will ACOs need to do in order to succeed in fulfilling the “triple

We have to realize that transforming care is what this is about. David Thorson, MD

aim” of better care for individuals, better health for populations, and reducing per capita costs?

insurance plans. The nature of insurance plans may well change from being insurance companies to become analytical companies where they will be administering stuff but not insuring risk. But to be honest, the insurance people haven’t been insuring risk, they’ve been trying to minimize risk and make money. I mean that somewhat seriously. They don’t pool risk anymore. They try to identify people who are high risk and exclude them. I think that’s where things are going to have to change. MR. CHRISTENSON: What are legitimate grounds for abandoning this whole ACO concept as a failed effort? MS. SORENSEN: At the end of the day, if we can’t all work together or all our common interests aren’t on the table and we’re willing to give in a little across the board, we’re

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MR. WATSON: What they need to do is prevent folks from falling through the cracks. When they do fall through the cracks, identify them and case manage, whatever the terminology, carecoordinate their life. We need the interoperability, we need the flexibility, and we also need the proper risk adjustments. Those are my three big goals for an ACO to be successful. DR. THORSON: We need to have patient engagement. We can’t do this just as physicians or health-care delivery systems forcing it onto patients. We have to change the payment structure that allows for a wide variety of care delivery to happen on an outpatient basis and realize that we have a changing state of health of our population. We have to figure out how we’re going to fund the illness load that is going forward in a way that allows us to care for them as well.

DR. AINSLIE: We need to teach ACOs how to walk on water because that’s what they’ll have to do in order to succeed. My guess is that they won’t, and we’ll be onto the next iteration. And you heard it here first: It’s going to be a nice euphemism for “two weeks to live” because CMS has realized that they spend half of their money or more on the last two weeks of a patient’s life. If we can figure out what two weeks those are and do something about it, we’ll be all set. What the ACO has done is go in a retrospective payment model and a quality model that they set up and judge and pay for, and guess what, they’re going to do that for the last two weeks of someone’s life also. You will or won’t be paid for taking care of somebody with a terminal illness or other problems. DR. WECKWERTH: Public health has had the answer the whole time. We know in public health what to do. We know good and well that population is where the action is. In terms of individuals, they have to be accountable. The accountable party is the individual. That’s what it ought to be. We know what to eat, what not to eat, what to do, what not to do, everything else. I don’t know how we’re going to get people to do it that way, but the public health principles are there. The individual accountability has to be there, and that may sound strange from an academic. Finally, we know that 95 percent of the health status of anybody, by every analysis that’s ever been done, has nothing to do with the medical hospital establishment. That only accounts for about four percent of health status. The rest is diet. Of course, the most important thing is choosing your ancestors, so that’s what I think we should work on most. What are we going to do? Public health: Follow what we know, do it for yourself, don’t blame somebody else, don’t pass it off.

DR. KLODAS: I don’t think this is going to work, or anything is going to work, unless patients have skin in the game. I don’t know what that looks like, I don’t have a formula, but they have to be part of the solution. It has to be real, and they have to be accountable.

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OPHTHALMOLOGY

early 20 million Americans suffer from dry eye syndrome (keratoconjunctivitis sicca) and its burdens, including blurred vision, itchiness, redness, foreign body sensation, and overall irritation. About four out of 10 Americans (37 percent) experience symptoms of dry eye syndrome on a regular basis. But because the symptoms can mimic other syndromes, chronic dry eye often goes undiagnosed, which can lead to serious ocular complications, including eye inflammation, infection, and even scarring on the surface of the cornea. Traditionally, the most common treatments for dry eye syndrome have included lid hygiene, artificial tears, cyclosporine drops, steroid drops, nonsteroidal drops, topical and systemic antibiotics, vitamins, and lid shampoos. Punctal occlusion can also be used to preserve tear output on the ocular surface. A recent development, intense pulsed light (IPL) treatment, has expanded the treat-

Opening eyes to new options Intense pulsed light treatment for dry-eye patients By Y. Ralph Chu, MD ment options available, and is discussed below. Causes and mechanisms of dry eye syndrome

The natural aging process can exacerbate dry eye; in fact, a

Because intense pulsed light therapy originally was intended for dermatological treatments, IPL treatment for dry eye may offer patients additional skin benefits. majority of people over the age of 65 experience some symptoms of dry eye. Women are more likely to develop dry eye because of hormonal changes

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during pregnancy and menopause. Medications can also be to blame; antihistamines, blood pressure medications, and antidepressants can reduce the amount of tears the eyes produce.

MINNESOTA PHYSICIAN JANUARY 2012

External factors such as exposure to smoke, wind, and dry climates can also increase the risk of dry eye, as can certain procedures (e.g., refractive eye surgeries, LASIK) and even long-term use of contact lenses. In the past, chronic dry eye was defined as a problem involving insufficient tear production, but research has altered this understanding. Today, ophthalmologists classify dry eye as an ocular surface disease because we have found that many patients with adequate tear production are also suffering from dry eye. The real culprit can be poor-quality tear film on the surface of the eye. This tear film is made up of proteins and electrolytes that help minimize the symptoms of chronic dry eye. But when those components are unbalanced, dry eye can result. This is why many patients with dry eye don’t find relief from over-the-counter artificial tear solutions such as eye drops. The meibomian glands, located at the base of the lashes on both the upper and lower eyelids, are an important component of tear balance because they secrete a fine layer of oil that keeps the water element of tears from evaporating, which contributes to dry eye. The meibomian glands can become

abnormal with age or because of certain conditions, such as ocular rosacea. Then, instead of producing the necessary smooth, olive oil-like secretions, the glands produce thick secretions with the consistency of butter or toothpaste. The oily secretions get stuck, resulting in a deficient tear film and tear production and leading to dry eye syndrome. Over the last several years, ophthalmologists have discovered that low-grade inflammation on the surface of the eye can also damage the ocular surface and lead to decreased tear production. While Restasis, the only FDA-approved topical cyclosporine, is prescribed to reduce inflammation and prompt the natural production of tears, its integration into treatment plans has not solved the problem of abnormal meibomian gland secretion. Development of IPL treatment for dry eye

In 2003, ophthalmologists began noticing that patients with chronic dry eye who had received intense pulsed light (IPL) therapy as a dermatologic treatment for rosacea were experiencing a reduction in their dry eye symptoms. Ophthalmologist Rolando Toyos, MD, of Memphis, Tenn., was the first to quantify the relationship between IPL and chronic dry eye in several clinical studies. Toyos has said that he discovered this potential use of intense pulsed light by accident after opening an aesthetics clinic in his practice in 2002. He had been using IPL for patients with rosacea and acne. In an interview, Toyos recalled that “my rosacea patients who had the IPL treatment would return with their skin looking much better—but some also mentioned that their eyes felt better. On examination, their eyes really were better, even though the IPL treatment wasn’t done directly on the glands.” In 2005, Toyos received a research grant from the American Society of Cataract and Refractive Surgery to study the procedure. He discovered that IPL can eliminate the symptoms of dry eye for patients who have

struggled for years with the uncomfortable condition. Toyos’ research showed that the IPL treatment gently stimulated the meibomian glands, improving the quality of secretions, and successfully decreasing the presence of dry eye. Over the past decade, Toyos has refined the IPL technology to achieve optimum results in patients with dry eye syndrome. For example, the IPL machine used for treatment of dry eye uses lower energy settings than similar machines used for dermatological procedures. There is less energy variability on the IPL machine, to protect dry eye patients while still ensuring the efficacy of the procedure. IPL for dry eye is an offlabel use of IPL, which is FDAapproved for dermatological use. Currently, about 15 clinics in the U.S. are participating in the treatment regimens for dry-eye patients. IPL treatment

IPL is a simple outpatient treatment. The first step includes cleansing the patient’s face and

Dr. Chu performs IPL procedure on a patient with dry eye. placing shields on both eyes to protect the lids and lashes. A cooling gel is then applied to the eye area and surrounding skin. Next, the IPL hand piece is passed across the skin, allowing the pulse of energy to heat the meibomian glands (see photo). The treatment also seals the delicate blood vessels at the lid. The complete procedure typically lasts less than 15 minutes and is painless. Patients need two to four treatments, separated by a month between treatments. Studies show an increase in tear function after the fourth or fifth treatment.

Since I began offering IPL therapy in 2011, many of my patients have reported noticeable relief in as few as two or three treatments. The number of treatments needed depends on the severity of the patient’s dry eye condition. Once the glands stabilize, patients may need maintenance therapy at least once a year. Because intense pulsed light therapy originally was intended for dermatological treatments, IPL treatment for dry eye may offer patients additional skin benefits. For example, IPL helps to develop collagen, lighten dark

spots, and tighten and plump skin. Although side effects and complications are rare, they include but are not limited to bruising, swelling, purpura, and blistering. Caution is advised for patients with a history of herpes simplex near the treatment area. Contraindications also include sun exposure two to four weeks prior to treatment, active infections, compromised immune system, coagulation disorders, photosensitivity or allergy, use of aspirin/anticoagulants, pregnancy, moles, and tattoos. Dry eye syndrome is a common ophthalmic condition that can have deleterious effects on patients’ quality of life. The potential of intense pulsed light technology to treat this condition is an exciting development for patients and ophthalmologists alike. Y. Ralph Chu, MD, is medical director and founder of Chu Vision Institute in Bloomington and is an adjunct associate professor of ophthalmology at the University of Minnesota Medical School, Minneapolis.

A Diverse and Vital Health Service Welcome to Boynton Health Service

Physician

>ŽĐĂƚĞĚ ŝŶ ƚŚĞ ŚĞĂƌƚ ŽĨ ƚŚĞ dǁŝŶ ŝƟĞƐ ĂƐƚ ĂŶŬ ĐĂŵƉƵƐ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ Ă ǀŝƚĂů ƉĂƌƚ ŽĨ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ĐŽŵŵƵŶŝƚǇ͕ ƉƌŽǀŝĚŝŶŐ ĂŵďƵůĂƚŽƌǇ ĐĂƌĞ͕ ŚĞĂůƚŚ ĞĚƵĐĂƟŽŶ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŽ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ĨŽƌ ŶĞĂƌůǇ ϵϬ ǇĞĂƌƐ͘ /ƚ͛Ɛ ŽƵƌ ŵŝƐƐŝŽŶ ƚŽ ĐƌĞĂƚĞ Ă ŚĞĂůƚŚǇ ĐŽŵŵƵŶŝƚǇ ďǇ ǁŽƌŬŝŶŐ ǁŝƚŚ ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ƚŽ ĂĐŚŝĞǀĞ ƉŚǇƐŝĐĂů͕ ĞŵŽƟŽŶĂů͕ ĂŶĚ ƐŽĐŝĂů ǁĞůůͲďĞŝŶŐ͘ ŽǇŶƚŽŶ͛Ɛ ŽƵƚƐƚĂŶĚŝŶŐ ƐƚĂī ŽĨ ϮϱϬ ŝŶĐůƵĚĞƐ ďŽĂƌĚ ĐĞƌƟĮĞĚ ƉŚǇƐŝĐŝĂŶƐ͕ ŶƵƌƐĞ ƉƌĂĐƟƟŽŶĞƌƐ͕ ƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ͕ D Ɛͬ>WEƐ͕ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚƐ͕ ĚĞŶƟƐƚƐ͕ ĚĞŶƚĂů ŚǇŐŝĞŶŝƐƚƐ͕ ŽƉƚŽŵĞƚƌŝƐƚƐ͕ ƉŚǇƐŝĐĂů ĂŶĚ ŵĂƐƐĂŐĞ ƚŚĞƌĂƉŝƐƚƐ͕ ƌĞŐŝƐƚĞƌĞĚ ĚŝĞƟƟĂŶƐ͕ ƉŚĂƌŵĂĐŝƐƚƐ͕ ƉƐǇĐŚŝĂƚƌŝƐƚƐ͕ ƉƐǇĐŚŽůŽŐŝƐƚƐ͕ ĂŶĚ ƐŽĐŝĂů ǁŽƌŬĞƌƐ͘ KƵƌ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌǇ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ŚĂƐ ďĞĞŶ ĐŽŶƟŶƵŽƵƐůǇ ĂĐĐƌĞĚŝƚĞĚ ďǇ , ƐŝŶĐĞ ϭϵϳϵ͕ ĂŶĚ ǁĂƐ ƚŚĞ ĮƌƐƚ ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƚŽ ŚĂǀĞ ĞĂƌŶĞĚ ƚŚŝƐ ĚŝƐƟŶĐƟŽŶ͘ ƩĞŶĚŝŶŐ ƚŽ ŽǀĞƌ ϭϬϬ͕ϬϬϬ ƉĂƟĞŶƚ ǀŝƐŝƚƐ ĞĂĐŚ ǇĞĂƌ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƚĂŬĞƐ ƉƌŝĚĞ ŝŶ ŵĞĞƟŶŐ ƚŚĞ ŚĞĂůƚŚ ĐĂƌĞ ŶĞĞĚƐ ŽĨ h ŽĨ D ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ǁŝƚŚ ĐŽŵƉĂƐƐŝŽŶ ĂŶĚ ƉƌŽĨĞƐƐŝŽŶĂůŝƐŵ͘

Boynton Health Service

ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŚĂƐ ĂŶ ŝŵŵĞĚŝĂƚĞ ŽƉĞŶŝŶŐ ĨŽƌ Ă ĨƵůůͲƟŵĞ ƉŚǇƐŝĐŝĂŶ ƚŽ ƉƌŽǀŝĚĞ ƐĞƌǀŝĐĞƐ ŝŶ ƚŚĞ WƌŝŵĂƌǇ ĂƌĞ ĂŶĚ hƌŐĞŶƚ ĂƌĞ ůŝŶŝĐƐ͘ ĂŶĚŝĚĂƚĞƐ ƐŚŽƵůĚ ĞŶũŽǇ ǁŽƌŬŝŶŐ ŝŶ Ă ĐŽůůĞŐĞ ŚĞĂůƚŚ ĞŶǀŝƌŽŶŵĞŶƚ ǁŝƚŚ Ă ůĂƌŐĞ ĂŶĚ ĚŝǀĞƌƐĞ ƉŽƉƵůĂƟŽŶ ŽĨ ƐƚƵĚĞŶƚƐ ĂŶĚ ƐƚĂī͘ dŚĞ ƋƵĂůŝĮĞĚ ĂƉƉůŝĐĂŶƚ ŵƵƐƚ ďĞ D^ ďŽĂƌĚ ĐĞƌƟĮĞĚͬĞůŝŐŝďůĞ ĂŶĚ ŚĂǀĞ ƚƌĂŝŶŝŶŐ ĂŶĚͬŽƌ ĞǆƉĞƌŝĞŶĐĞ ŝŶ ĂŶ ŽƵƚƉĂƟĞŶƚ ƉƌĂĐƟĐĞ ĂŶĚ ƵƌŐĞŶƚ ĐĂƌĞ͘ <ŶŽǁůĞĚŐĞ ŽĨ ĞůĞĐƚƌŽŶŝĐ ŚĞĂůƚŚ ƌĞĐŽƌĚƐ ǁŽƵůĚ ďĞ ďĞŶĞĮĐŝĂů͘ dŚŝƐ ƉŽƐŝƟŽŶ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌǇ͕ D ŽƉƉŽƌƚƵŶŝƟĞƐ͕ ĂŶĚ Ă ŐĞŶĞƌŽƵƐ ĂĐĂĚĞŵŝĐ ƐƚĂƚƵƐ ƌĞƟƌĞŵĞŶƚ ƉůĂŶ͘ WƌŽĨĞƐƐŝŽŶĂů ůŝĂďŝůŝƚǇ ĐŽǀĞƌĂŐĞ ŝƐ ƉƌŽǀŝĚĞĚ͘ dŽ ůĞĂƌŶ ŵŽƌĞ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ,ŽƐĞĂ KũǁĂŶŐ͕ ,ƵŵĂŶ ZĞƐŽƵƌĐĞƐ ŝƌĞĐƚŽƌ͕ Ăƚ (612) 626-1184, hojwang@bhs.umn.edu ƉƉůǇ ŽŶůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽǇŵĞŶƚ͘ƵŵŶ͘ĞĚƵ and reference ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 175782͘ dŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ŝƐ ĂŶ ƋƵĂů KƉƉŽƌƚƵŶŝƚǇ͕ ĸƌŵĂƟǀĞ ĐƟŽŶ ĚƵĐĂƚŽƌ ĂŶĚ ŵƉůŽǇĞƌ͘

ϰϭϬ ŚƵƌĐŚ ^ƚƌĞĞƚ ^ ͻ DŝŶŶĞĂƉŽůŝƐ͕ DE ϱϱϰϱϱ ͻ ;ϲϭϮͿ ϲϮϱͲϴϰϬϬ ͻ ǁǁǁ͘ďŚƐ͘ƵŵŶ͘ĞĚƵ

JANUARY 2012

MINNESOTA PHYSICIAN

MEDICINE

s an oncologist, David King, MD, talks with many cancer patients in his office at the Virginia Piper Cancer Institute on the Unity Hospital campus in Fridley. The conversations typically start with treatment protocols and what patients can expect. But the conversation often takes another turn when patients ask about the impressive artwork hanging on the wall. The abstract acrylic painting, which covers the entire wall above the doctor’s desk, looks like it could be a sea or a forest. King explains that it’s called “Reflections on Gunflint Lake” and that he bought it at the annual Art-A-Whirl that’s held each spring in northeast Minneapolis. Coincidentally, the artist, Peggy Thompson, is also a chaplain at Unity Hospital. Focusing on the painting might seem like a nice diversion from the difficult talk about cancer treatment. In fact, it’s not an accident but rather the result of a purposeful program at Allina Hospitals & Clinics to infuse the

AND

THE

ARTS

Beyond decoration The power of art in healing By Megan Hatch

power of art—both visual art and music—in the healing process. King observes that the arts often help optimize a patient’s condition to better tolerate the

Allina is part of a national trend in health care facilities to implement arts programs as a core strategy to alleviate pain and to improve care and patient satisfaction. About 50 percent of

Research has shown that in addition to improving patient outcomes, visual art can increase patient satisfaction. many side effects of chemotherapy and radiation. “The placebo effect is an example of how the mind can be a powerful force in the healing process. Healing does not just happen on a physical level; the arts help engage patients in the healing process on a psychological, emotional, and mental level,” he says.

Urgent Care Mankato Clinic is looking for exceptional Physicians, Physician Assistants and Nurse Practitioners to work in our busy Urgent Care Department. Customer service skills and the very best patient care are essential for these professionals who are the first point of contact for some patients. You will work with a team of highly skilled support staff in an efficient, fast-paced environment. There are full-time and casual shift opportunities available. Hours are weekdays 8 a.m.–8 p.m., Saturdays 8 a.m.–5 p.m., and Sundays noon–5 p.m. Care is provided in three locations, two full-service urgent care/occupational medicine facilities and one express service clinic located in Mankato’s shopping mall. Providers in full-time positions will enjoy an excellent benefits package including generous CME expense and time-off allowances; 401(k) profit sharing plan; EAP; employee discounts and more. Apply online at www.mankato-clinic.com, or contact Dennis Davito, Director of Provider Services at dennisd@mankato-clinic.com; Phone: 507-389-8654; Fax: 507-625-4353; Mankato Clinic, 1230 E. Main St., Mankato, MN 56001. Mankato Clinic is an Affirmative Action/Equal Opportunity employer.

hospitals in the U.S. have arts programs, according to the Center for Health Design, in Concord, Calif. Allina developed a healing arts policy two years ago for its 11 hospitals and nearly 100 clinics. Allina’s healing arts program is modeled on an initiative begun seven years ago at the Penny George Institute for Health and Healing, which is based at Abbott Northwestern Hospital in Minneapolis. The vision was to use patient and public areas at the Penny George Institute as exhibit spaces for local artists. New exhibits of original art are installed monthly, with related interactive arts programming open to patients, staff, and community members. Choy Leow, director of Allina design and construction, developed a healing arts policy that embraces nature as a primary subject and emphasizes regional artists. The exhibits are part of what has grown to be the largest hospital-based integrative medicine program in the nation. Unlike alternative medicine, which is typically used in place of conventional medicine, the Penny George Institute’s integrative services are offered in conjunction with traditional Western medicine for both inpatient and outpatient care. Pain relief

www.mankato-clinic.com

MINNESOTA PHYSICIAN JANUARY 2012

Last year, Allina published the first study showing that nontra-

ditional therapies relieve pain among a broad cross-section of hospitalized patients by as much as 50 percent. Results of the study were published in the March 5, 2010, issue of the Journal of Patient Safety. The study included 1837 cardiovascular, medical, surgical, orthopedics, spine, rehabilitation, oncology, and women’s health patients at Abbott Northwestern. The treatments included nonpharmaceutical services: music and art therapy and mind-body therapies designed to elicit the relaxation response, including acupuncture, massage therapy, and healing touch. The study expands on earlier studies that focused on the effectiveness of integrative therapies in managing pain in cancer or surgical patients. “Western medicine is highly skilled at treating illness and disease with procedures,” says Lori Knutson, RN, BSN, HN-BC, executive director of the Penny George Institute. “Effective health care acknowledges the difference between curing and healing and the therapeutic properties of the creative process.” Positive distraction and symptom management

Historically, environmental design in health care has focused on trying to minimize negative factors in the environment such as noise, light, and the risk of infection. In the past few decades, however, the focus has changed to how hospitals can create and reinforce positive experiences. Designers have recognized that environmental factors can also provide a positive distraction, allowing patients to shift attention away from negative factors in the health care environment and toward more restorative aspects from the nonmedical world. A 2006 review of scientific literature published in the Journal of Perinatology examined the role of positive distraction as a means of mitigating stress for patients and caregivers in neonatal intensive care units. The review found that the environmental variables that are most commonly known to con-

tribute to positive distraction are visual art, access to nature, and music. Results of a study published in the March 2003 issue of the medical journal Chest showed that adult patients in a procedure room reported better pain control when they were exposed to a nature scene and heard nature sounds broadcast from the ceiling. A 1992 study published in the Journal of Burn Care & Rehabilitation found that using murals as a therapeutic distraction resulted in a significant decrease in pain intensity, pain quality, and anxiety reported by burn patients. In a 2003 study published in CyberPsychology and Behavior Journal, breast cancer patients reported reduced anxiety, fatigue, and distress during chemotherapy when the patients were exposed to virtual reality intervention displaying underwater scenes. Patient and staff satisfaction

Healing arts programs in health care are also gaining favor as a way to improve patient satisfac-

tion. The Centers for Medicare & Medicaid Services (CMS) has published patient satisfaction scores since 2008. In 2012, CMS will up the ante by basing Medicare reimbursement in part on patient satisfaction scores. Research has also shown that in addition to improving patient outcomes, visual art can increase patient satisfaction. A 2002 study of six different hospitals owned by Intermountain Health Care in Utah sought to determine the extent to which environmental sources played a role in overall patient satisfaction. Nearly 400 patients were interviewed by telephone shortly after hospital discharge and were asked questions about their level of satisfaction with six environmental aspects of the hospital. Those surveyed reported that inside the patient rooms, interior design—including visual art—was the most satisfying

Mandala by Richard Bonk at the Penny George Institute for Health and Healing at Unity Hospital. Cancer patients make mandalas at George Institute art classes called Power Shields.

feature. Outside the patient rooms, hospital interior design —again, including visual art— was second only to maintenance as an environmental source of patient satisfaction. Researchers noted that when former patients were talking about their hospital rooms, they often commented on the artwork. While patients and the public are the primary reasons many hospitals have arts programs, 55 percent of the programs surveyed by the Center for Health Design also focus on using the arts to reduce

stress and burnout among staff members, a significant problem in health care. The visual arts can facilitate cultural competence as well: Artwork from different cultures can sensitize providers, contribute to an inclusive environment, and serve as a form of cross-cultural communication. As the role of art in health care evolves from art as decoration to art as a core component of healing environments, a growing body of research is expected to firmly establish evidencebased design and provide a scientific basis for healing art as a necessary part of medicine. Megan Hatch is clinic manager and arts program coordinator at Allina's Penny George Institute of Health and Healing in Minneapolis.

A Diverse and Vital Health Service

Boynton Health Service

Psychiatrist

Welcome to Boynton Health Service >ŽĐĂƚĞĚ ŝŶ ƚŚĞ ŚĞĂƌƚ ŽĨ ƚŚĞ dǁŝŶ ŝƟĞƐ ĂƐƚ ĂŶŬ ĐĂŵƉƵƐ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ Ă ǀŝƚĂů ƉĂƌƚ ŽĨ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ĐŽŵŵƵŶŝƚǇ͕ ƉƌŽǀŝĚŝŶŐ ĂŵďƵůĂƚŽƌǇ ĐĂƌĞ͕ ŚĞĂůƚŚ ĞĚƵĐĂƟŽŶ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŽ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ĨŽƌ ŶĞĂƌůǇ ϵϬ ǇĞĂƌƐ͘ /ƚ͛Ɛ ŽƵƌ ŵŝƐƐŝŽŶ ƚŽ ĐƌĞĂƚĞ Ă ŚĞĂůƚŚǇ ĐŽŵŵƵŶŝƚǇ ďǇ ǁŽƌŬŝŶŐ ǁŝƚŚ ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ƚŽ ĂĐŚŝĞǀĞ ƉŚǇƐŝĐĂů͕ ĞŵŽƟŽŶĂů͕ ĂŶĚ ƐŽĐŝĂů ǁĞůůͲďĞŝŶŐ͘ ŽǇŶƚŽŶ͛Ɛ ŽƵƚƐƚĂŶĚŝŶŐ ƐƚĂī ŽĨ ϮϱϬ ŝŶĐůƵĚĞƐ ďŽĂƌĚ ĐĞƌƟĮĞĚ ƉŚǇƐŝĐŝĂŶƐ͕ ŶƵƌƐĞ ƉƌĂĐƟƟŽŶĞƌƐ͕ ƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ͕ D Ɛͬ>WEƐ͕ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚƐ͕ ĚĞŶƟƐƚƐ͕ ĚĞŶƚĂů ŚǇŐŝĞŶŝƐƚƐ͕ ŽƉƚŽŵĞƚƌŝƐƚƐ͕ ƉŚǇƐŝĐĂů ĂŶĚ ŵĂƐƐĂŐĞ ƚŚĞƌĂƉŝƐƚƐ͕ ƌĞŐŝƐƚĞƌĞĚ ĚŝĞƟƟĂŶƐ͕ ƉŚĂƌŵĂĐŝƐƚƐ͕ ƉƐǇĐŚŝĂƚƌŝƐƚƐ͕ ƉƐǇĐŚŽůŽŐŝƐƚƐ͕ ĂŶĚ ƐŽĐŝĂů ǁŽƌŬĞƌƐ͘ KƵƌ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌǇ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ŚĂƐ ďĞĞŶ ĐŽŶƟŶƵŽƵƐůǇ ĂĐĐƌĞĚŝƚĞĚ ďǇ , ƐŝŶĐĞ ϭϵϳϵ͕ ĂŶĚ ǁĂƐ ƚŚĞ ĮƌƐƚ ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƚŽ ŚĂǀĞ ĞĂƌŶĞĚ ƚŚŝƐ ĚŝƐƟŶĐƟŽŶ͘ ƩĞŶĚŝŶŐ ƚŽ ŽǀĞƌ ϭϬϬ͕ϬϬϬ ƉĂƟĞŶƚ ǀŝƐŝƚƐ ĞĂĐŚ ǇĞĂƌ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƚĂŬĞƐ ƉƌŝĚĞ ŝŶ ŵĞĞƟŶŐ ƚŚĞ ŚĞĂůƚŚ ĐĂƌĞ ŶĞĞĚƐ ŽĨ h ŽĨ D ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ǁŝƚŚ ĐŽŵƉĂƐƐŝŽŶ ĂŶĚ ƉƌŽĨĞƐƐŝŽŶĂůŝƐŵ͘

ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ ƐĞĞŬŝŶŐ Ă WƐǇĐŚŝĂƚƌŝƐƚ ƚŽ ǁŽƌŬ ǁŝƚŚ Ă ůĂƌŐĞ ĂŶĚ ĚŝǀĞƌƐĞ ƉŽƉƵůĂƟŽŶ ŽĨ ƐƚƵĚĞŶƚƐ Ăƚ ƚŚƌĞĞ ůŽĐĂů ĐŽůůĞŐĞƐ͕ ŝŶ ĂĚĚŝƟŽŶ ƚŽ ƚŚĞ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ͕ ĂƐ Ă ƌĞƉƌĞƐĞŶƚĂƟǀĞ ŽĨ ƚŚĞ ŵĞŶƚĂů ŚĞĂůƚŚ ĐŽŶƐƵůƚĂƟŽŶͬŽƵƚƌĞĂĐŚ ƉƌŽŐƌĂŵ͘ dŚĞ WƐǇĐŚŝĂƚƌŝƐƚ ǁŝůů ĂůƐŽ ƐĞƌǀĞ ĂƐ Ă ĐŽŶƐƵůƚĂŶƚ ƚŽ ŽƚŚĞƌ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƐƚĂī ŵĞŵďĞƌƐ͕ ĂƐ ǁĞůů ĂƐ ƚŚĞ ĨĂĐƵůƚǇ ĂŶĚ ƐƚĂī ŽĨ ƚŚĞƐĞ ŽůůĞŐĞ ĂŶĚ hŶŝǀĞƌƐŝƚǇ ĐŽŵŵƵŶŝƟĞƐ͘ ůŝŵŝƚĞĚ ĂŵŽƵŶƚ ŽĨ ƉƐǇĐŚŽƚŚĞƌĂƉǇ ǁŝůů ĂůƐŽ ďĞ ŝŶǀŽůǀĞĚ͘ ƉƉůŝĐĂŶƚ ŵƵƐƚ ďĞ WE ďŽĂƌĚ ĐĞƌƟĮĞĚͬĞůŝŐŝďůĞ ŝŶ ƉƐǇĐŚŝĂƚƌǇ͘ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌǇ ĂŶĚ Ă ƌĞǁĂƌĚŝŶŐ ƉƌĂĐƟĐĞ ĞŶǀŝƌŽŶŵĞŶƚ͘ WƌŽĨĞƐƐŝŽŶĂů ůŝĂďŝůŝƚǇ ĐŽǀĞƌĂŐĞ ŝƐ ƉƌŽǀŝĚĞĚ͘ dŽ ůĞĂƌŶ ŵŽƌĞ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ 'ĂƌǇ ŚƌŝƐƚĞŶƐŽŶ͕ D͘ ͕͘ DĞŶƚĂů ,ĞĂůƚŚ ůŝŶŝĐ ŝƌĞĐƚŽƌ (612) 624-1444͘ ƉƉůǇ ŽŶůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽǇŵĞŶƚ͘ƵŵŶ͘ĞĚƵ and ƌĞĨĞƌĞŶĐĞ ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 174055͘ dŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ŝƐ ĂŶ ƋƵĂů KƉƉŽƌƚƵŶŝƚǇ͕ ĸƌŵĂƟǀĞ ĐƟŽŶ ĚƵĐĂƚŽƌ ĂŶĚ ŵƉůŽǇĞƌ͘

ϰϭϬ ŚƵƌĐŚ ^ƚƌĞĞƚ ^ ͻ DŝŶŶĞĂƉŽůŝƐ͕ DE ϱϱϰϱϱ ͻ ;ϲϭϮͿ ϲϮϱͲϴϰϬϬ ͻ ǁǁǁ͘ďŚƐ͘ƵŵŶ͘ĞĚƵ JANUARY 2012

MINNESOTA PHYSICIAN

PROFESSIONAL

ith spring comes the start of baseball season—and, for thousands of athletes, from youth baseball organizations through professional leagues—the promise of a winning season or the hope for personal achievement on the field. Unfortunately, along with that promise and hope come increasingly familiar reports of pitchers lost to throwing-arm injuries, often requiring surgical reconstruction (including the well-known Tommy John surgery that cost former Minnesota Twins’ reliever Joe Nathan a season). The anterior band of the ulnar collateral ligament (UCL) is the primary static restraint to valgus force in the elbow from 30 to 120 degrees of flexion. This ligament courses from the medial epicondyle of the humerus to the sublime tubercle of the ulna along the medial aspect of the elbow. In the overhead throwing motion, valgus torque across the elbow can exceed the ultimate tensile strength of the UCL, resulting in tears of the ligament and signifi-

U P D AT E :

ORTHOPEDICS

A pitch for prevention Ulnar collateral ligament injuries are on the increase in younger athletes By Steven W. Meisterling, MD cant elbow injury in the overhead athlete. This injury has become commonplace in collegiate and professional baseball pitchers and often requires surgical reconstruction. These types of elbow injuries are also becoming more common in younger baseball players. UCL tears can also occur, though less commonly, in athletes involved in other overhead sports such as tennis, football, gymnastics, and javelin throwing. This article focuses on the symptoms and risk factors associated with UCL injuries, as well as the diagnosis, prevention, and treatment of these injuries. Symptoms

Overhead athletes with injuries to the ulnar collateral ligament will present to their coach,

trainer, physical therapist, or doctor with a variety of symptoms. Some will develop symptoms from chronic overuse and attenuation of the ulnar collateral ligament, while others will report with more acute pain from a single event. Athletes with chronic overuse injuries will typically present with elbow pain, neurologic symptoms, and/or complaints related to decreased performance. These injuries are often partial tears of the UCL. The pain is usually located about the medial aspect of the elbow at the site of the ulnar collateral ligament. Pain is most commonly experienced during the acceleration phase of the throwing motion and often occurs following a game or performance. Neurologic symptoms con-

sistent with ulnar neuritis or cubital tunnel syndrome are often associated with UCL injuries. These symptoms include numbness and tingling located about the ulnar one and a half digits or pain about the ulnar nerve within the cubital tunnel. Loss of athletic performance is often experienced as a decrease in throwing velocity and accuracy as well as a pitcher’s lost ability to effectively throw and control his or her usual variety of pitches. Acute injuries are often the end result of chronic UCL tears. These events are frequently preceded by complaints related to chronic overuse as outlined above. The acute injury is heralded by sudden and often severe medial elbow pain during the throwing motion. Pitchers often report feeling or even hearing a “pop.” Ulnar nerve irritation is also common at the time of injury. Risk factors and prevention

Overhead athletes of all ages are at risk for UCL injury. Those at UCL INJURY to page 34

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Live in the relaxed lake country of Mille Lacs and practice medicine where you will make a difference. We’re looking for a Family Physician to join us at Mille Lacs Health System in Onamia, Minnesota. Loan forgiveness options may be available. Contact: Fern Gershone: fgershone@mlhealth.org or Dr. Tom Bracken: tbracken@mlhealth.org

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UCL injury from page 32 particular risk include baseball pitchers and catchers, especially those that play both positions. Professional pitchers that throw at a higher velocity may have additional risk for UCL injury. Recently, research has focused on identifying risk factors in an effort to prevent injury in younger athletes. Adolescent athletes have begun focusing on a single sport and/or a single position at younger ages. This early sports specialization has been implicated as a factor in the rise in adolescent athletic overuse injuries. The true risk of serious injuries to youth overhead athletes is unknown, and the risk factors leading to these injuries are unproven, though several risk factors have been associated with significant elbow injury. The factors with the strongest associations with injury are overuse and fatigue. Overuse and fatigue can occur on a daily, seasonal, or annual basis. Also associated with adolescent elbow injuries are increased weight and height; number of

pitches thrown during a season, game, or week; satisfaction with performance; and playing outside of the athlete’s primary league. High pitch velocity and participation in showcases are also associated with increased risk for injury. Other risk factors include participation in a single sport year round, throwing at maximum velocity for a radar gun, and improper throwing mechanics. The consequences of throwing breaking pitches and curve balls at the youth level are unknown. Debate and controversy continue to surround this subject. Since the 1970s, sports medicine experts have warned that prepubescent athletes should not throw curve balls because of increased risk of elbow injuries. There has been little clinical data to support this warning to date. In fact, biomechanical data has shown that a throwing a curve ball may create less elbow varus moment compared to a fastball. Nonetheless, throwing curve balls prior to skeletal maturity continues to be considered a risk factor for

elbow injuries by most sports medicine experts. Injury prevention has become an important focus within the sports medicine community. Proper warm-up and stretching exercises should occur prior to any athletic activity. Overuse and fatigue should be avoided. USA Baseball has published recommendations in an effort to reduce the risk of injury and maximize the younger player’s ability to perform and advance to higher levels. These recommendations include limiting pitch counts and discouraging excessive throwing for the young athlete. Throwing curve balls is also discouraged. Early development of proper mechanics is emphasized, and coaches and parents should listen and react appropriately to an athlete when he or she complains of pain. The specific recommendations are available at www.usabaseball.com. Diagnosis

The diagnosis of UCL injury is made with a careful history and clinical examination as well as

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UCL INJURY to page 36

Family Medicine

Opportunities available in the following specialty:

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appropriate imaging studies. Concomitant pathology must also be identified. The examiner must be careful to identify the status of the UCL when focusing on other elbow pathology, as loss of elbow stability due to UCL insufficiency can lead to other pathology. Important points in the history include asking about those symptoms mentioned above. The athlete should also be questioned about his or her seasonal situation and career goals and desire to continue to compete in overhead athletics. The physical exam should evaluate upper extremity strength and range of motion, neurovascular status, and swelling, and specific points of tenderness should be identified. Elbow stability can be evaluated by placing a valgus stress about the elbow. This test will elicit pain by subjecting the injured UCL to stretch. Standard elbow radiographs are an important part of elbow evaluation. Anterior to posterior valgus stress x-rays may demonstrate increased medial joint

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MINNESOTA PHYSICIAN JANUARY 2012

Fairview Health H Servicees Opportunities O pportunities es to fit yyour our life Fairview H Fairview Health ealth SServices ervices seeks physicians to impr improve ove the health of the communities w serve. We We have havve a vvariety ariety of oppor tunities that allo w wee serve. opportunities allow yyou ou to focus on inno vative and d quality car e. SShape hape yyour our practicee to innovative care. fit yyour our life as a par tionally recognized, recognized, patient-centered, patient-centerred, partt of our nationally evidence-based car caree team. Whether yyour our focus is work-life work-life fe balance or par ticipating in clinical cal participating quality initiativ es, w opportunity that is right for yyou: ou: initiatives, wee hav havee an opportunity Dermatology Dermatology Medicine FFamily amily M edicine General G eneral Surgery Surgery y Geriatric G eriatric Medicine Medicine Hospitalist H ospitalist IInternal nternal Medicine Medicine Med/Peds M ed/Peds

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JANUARY 2012 MINNESOTA PHYSICIAN

UCL injury from page 34 space opening and are helpful in identified medial laxity and UCL injury. MRI arthrogram is the radiographic gold standard to identify a UCL tear; it is the study of choice to verify the diagnosis and can help identify other pathology. Treatment

The treatment for UCL injuries depends on many factors, including the extent of UCL tearing, patient desires and athletic goals, seasonal timing, and response to prior treatments. Nonoperative treatment is a good option for partial UCL tears, though often UCL reconstruction is required in order for an athlete to return to competition. Nonoperative programs include a period of “active rest” and should be initiated immediately upon injury to the UCL. This period lasts from two to six weeks depending on the severity of the tear. During this time of rehab, the athlete should refrain from all throwing activities and any other activities that recreate

the patient’s pain. Core strengthening as well as a shoulder and elbow rehab program should be instituted during this time. Patients are encouraged to be as active as possible, provided such activities do not elicit elbow pain. An interval throwing program is initiated after the active rest period and proper mechanics are emphasized. Return to play is allowed provided the patient remains asymptomatic. Surgery is the preferred treatment for athletes who have a complete UCL tear and wish to continue to compete in overhead activities. Surgery is also indicated for those who have a partial tear and have failed to respond to a nonoperative program. Ulnar collateral reconstruction (Tommy John reconstruction) is the treatment of choice for most UCL injuries requiring surgery. This surgery is done via a medial elbow incision to expose the injured UCL. The ulnar nerve is identified within the operative field and must be carefully managed. An anterior subcutaneous ulnar nerve transposition is often per-

formed, depending on preoperative symptoms and surgeon preference. The UCL is then identified and drill holes are placed at the site of UCL attachment at both the ulna and the humerus. Next, the native UCL is repaired prior to graft placement. Graft selection is a matter of availability and surgeon preference. The most common grafts used are the palmaris longus and the gracillis tendons. The graft is passed through the bone tunnels and overlies the repaired ligament. Finally, the graft is appropriately tensioned and secured with the elbow at 30 degrees of flexion. Postoperatively, the elbow is splinted for one to two weeks before initiation of elbow range of motion. Full range of motion is expected at six weeks. Shoulder and core strengthening are an important aspect of rehab and these exercises are begun soon after surgery. Overhead throwing is not permitted until four months after surgery, at which time an interval throwing program is initiated. Expected return to play for a baseball

pitcher is approximately one year following surgery, though overhead athletes with less demanding positions may return to play several months earlier. Goals: Reducing UCL injuries, improving treatment

Injuries to the UCL are common in overhead athletes, with baseball pitchers at greatest risk for this injury. Recently, efforts have been made to identify risk factors and prevention strategies to prevent elbow injuries, particularly in adolescent athletes. Many patients with partial UCL tears can be successfully treated conservatively. UCL reconstruction is a good option for athletes who do not respond to nonoperative care or those with complete UCL tears. Future research efforts will continue in an effort to decrease the incidence of this injury as well as to improve treatment options. Steven W. Meisterling, MD, is an orthopedic surgeon and fellowship-trained sports medicine physician in practice with St. Croix Orthopaedics, PA.

Family Medicine w/ OB Opportunities in 2 Wonderful Rural Locations Altru Health System is seeking Family Practitioners to join our existing and thriving practices in Crookston, MN and Roseau, MN. Crookston, MN, a strong community of 8,000, is located along the Red Lake River in the heart of the fertile Red River Valley. Altru Clinic—Crookston is a well-established, collegial medical group with 3 Family Practice Physicians, 3 Internists and 4 Mid-Level Providers. We have an ongoing partnership with RiverView Hospital in Crookston that is a 25-bed, critical-access hospital connected to our clinic. Call is 1:10.

Altru is a physician-led, not-for-profit integrated health system that serves a referral population of more than 225,000. More than 180 physicians representing 44 specialties serve this population base. Altru Health System provides competitive compensation, reviewed annually with specialty-specific industry data, along with an extensive benefits package including generous pension and profit-sharing plans.

Roseau, MN, which is just 20 minutes from beautiful Lake of the Woods, is a Family Practice clinic consisting of 6 Family Practice Physicians and 3 Mid-Level Providers. The town of Roseau has over 2,500 residents. LifeCare Medical Center is a 25-bed, criticalaccess hospital just adjacent to our clinic. Our friendly community is safe and welcoming. Call is 1:7.

Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org www.altru.org

www.altru.org 36

MINNESOTA PHYSICIAN JANUARY 2012

Practice Well. Live Well.

Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner.

Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • General Surgery

• Hospitalist • Internal Medicine • Pediatrics

For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

www.lrhc.org

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • General Surgery • Geriatrician/ • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

For additional information, please contact:

Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366

Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

www.acmc.com

Look for the friendly doctor in a MN based physician staffing service ...

Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff

Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us

P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

JANUARY 2012 MINNESOTA PHYSICIAN

Errors from page 13 thought about. In the crystal ball method, for example, somebody gives you an idea or an answer, and you tell the person you have a crystal ball that says, “This is wrong.” You tell them they must identify the flaws in their own thinking. • Become a devil’s advocate or have one when you are making a decision. Someone should always be assigned to say, “This diagnosis [or decision] doesn’t make sense to me, because of these factors” or “Why is my thinking wrong?”

rect diagnosis. How can patients help you avoid diagnostic errors? • Make sure they tell you the whole story. • Ask them to ask you three vital questions as you search for answers: (1) Is there anything in my medical history that doesn’t fit the hypothesis? (2)

technology, so system “repairs” will always lag behind to some extent and will fall short of achieving perfection. The key lessons here are that diagnostic errors will occur; they are caused by both system and cognition causes; and we have unavoidable biases that affect our diagnostic process. Our ability to come up with

Our ability to come up with solutions requires an understanding of how thinking errors and system weaknesses are intertwined in contributing to diagnostic errors.

The patient’s role In addition, we need to use patients as partners in thinking through and testing the diagnostic hypotheses. Patients have an important role to play, whether in regard to the temporal keys you are looking for, knowledge of whether or not the treatments are working, or new developments or perceptions that can help you reach a cor-

critically review our own conclusions, assumptions, and beliefs about a problem. Unfortunately, no matter how good we become in understanding how we make diagnoses, it will be impossible to eliminate all diagnostic errors. Almost all doctors, even the best clinicians, make mistakes because they take cognitive shortcuts or jump to conclu-

What else could it possibly be? (3) Might more than one thing be wrong?

Systems, cognition issues are intertwined Esssentially, what I’ve been talking about is metacognition, or “thinking about thinking.” Decision-making must include the ability to reflect upon our own thinking process and to

MINNESOTA PHYSICIAN JANUARY 2012

sions too soon. In addition, system improvements degrade over time, and correcting one system problem may introduce new opportunities for errors. (An example: Giving residents less call to decrease errors but then having handoffs go up, thereby increasing errors.) Systems evolve in step with the evolution of health care

solutions requires an understanding of how thinking errors and system weaknesses are intertwined in contributing to diagnostic errors. Our goal must be to decrease the likelihood of the loss of more Julias. Phillip M. Kibort, MD, MBA, is vice president of medical affairs and chief medical officer of Children’s Hospitals and Clinics of Minnesota.

You wouldnâ&#x20AC;&#x2122;t give a 1-year-old a beer, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.

www.mofas.org

View your home in a new way.

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