Minnesota Physician October 2011 by Minnesota Physician Publishing

Volume XXV, No. 7

October 2011

The Independent Medical Business Newspaper

Payment incentives Next-generation models will emphasize total cost of care By Ann Robinow

Terms of engagement evolving focus on the need for he world used to be Co-creating longitudinal support of health much simpler, or at issues, requiring increased our future least it seems that way involvement of our patients. to many of us who practiced with patients While we may use different health care in the ‘70s and terms—engagement, involveBy Gary ‘80s. The prevailing paternalisment, empowerment, activaOftedahl, MD tic attitude that permeated the tion—in our discussions, all of health care system at that them speak to time meant that patients the need to have active particiwould enter our facilities seeking an expert pation from patients and, in opinion, be given a definitive diagnosis, and many cases, their family and sent on their way. The assumption on both other caregivers. But while we sides was that the wisdom and expertise often have a clear understandimparted at the clinic or hospital visit ing as citizens of our role as would be passively transferred, pending the we interact with mechanics, next acute intervention of our patient with lawyers, or financial advisers, the health care system. the roles and responsibilities Today, we physicians are confronted of physicians and patients with an explosion of new technology, increasingly complex interventions, and an ENGAGEMENT to page 10

hanges in health care payment incentives are slowly creeping into physician consciousness, though many physicians are still oblivious, in denial, or believe we’ve been here before and this, too, shall pass. Is a change in payment incentives for real this time? Right now and for the foreseeable future, this market is in transition, creating contradictory messages to the health care delivery system. For physicians trying to navigate between the old world (fee-for-service) and new world (total cost of care) of payments, it’s a challenging time. Why should physicians care about preparing for changes in incentives? Two reasons: First, it matters to your patients. Second, it IN THIS ISSUE: matters to you. Health care Premium and costreform sharing affordability is a Page 20 growing problem for patients. Physicians are PAYMENT to page 12

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CONTENTS

OCTOBER 2011 Volume XXV, No. 7

FEATURES Terms of engagement Co-creating our future with patients

By Gary Oftedahl, MD

Payment incentives Next-generation models will emphasize cost of care

By Ann Robinow

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

View your home in a new way.

PRACTICE MANAGEMENT Transforming billing practices 28 By Brian Kueppers and Nels Peterson

PATIENT PERSPECTIVE Shared decision-making 30

Vijay Eyunni, MD, MPH

By John Malan

Minnesota Occupational Health

PRACTICE MANAGEMENT The pre-visit interview 34 By Thomas Rieser, MD

PAIN MEDICINE Principles of pain management

By Cory J. Ingram, MD

SPECIAL FOCUS: HEALTH CARE REFORM Changes ahead

By Sarah Duniway, JD, and Gregory A. Larson, JD

Immigrant access to health care

Getting off the escalator 24 By Mary Ellen Wells, FACHE

Making headway in mental health 22

By Sue Abderholden, MPH

By Jessie Kemmick Pintor, MPH, and Lynn A. Blewett, PhD

The Independent Medical Business Newspaper

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Mary Scarbrough Hunt mshunt@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; e-mail mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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OCTOBER 2011 MINNESOTA PHYSICIAN

CAPSULES

DHS Names Kerber As New Inspector General The Minnesota Department of Human Services (DHS) has announced it will coordinate its fraud prevention and recovery efforts under the Office of Inspector General (OIG), similar to models used by the U.S. Department of Health and Human Services and 16 other states. Officials say the reorganization will improve DHS’ fraud prevention and recovery efforts and more effectively structure staff who investigate and audit DHS programs. They add that the OIG model has traditionally had greater independence from the areas it monitors and stronger mechanisms to monitor and report abuse. In fighting fraud, the OIG will work closely with the Office of the Minnesota Attorney General and other agencies who have a role in combating fraud and abuse. “Fraud prevention and recovery is a critical part of

what we do every day at DHS,” says DHS Commissioner Lucinda Jesson. “Every dollar of waste and fraud is one less dollar that goes to the people we serve. All Minnesotans deserve to know that DHS takes its role as stewards of its public dollars seriously, and will not tolerate those that misuse them.” Currently, fraud prevention and recovery efforts are located in the program areas they monitor. With the reorganization, such efforts will be consolidated into a single office and operate out of the office of the commissioner. This includes health care, child care, and food support fraud detection and recovery efforts. Jerry Kerber, current DHS licensing director, will head the OIG office as Inspector General.

Shorter Hours for Residents Not Helping, Study Finds Despite a reduction in the hours that residents need to be on duty, many doctors in training

report feeling burnt-out, a national study from Mayo Clinic has found. The report, published in the Sept. 7 issue of the Journal of the American Medical Association, surveyed more than 16,000 residents in internal medicine training programs, a number representing 75 percent of internal medicine residents in the U.S. The study was overseen by Mayo Clinic general internist and biostatistician Colin West, MD, PhD, co-director of the Mayo Department of Medicine Program on Physician WellBeing. It found that 51.5 percent of residents reported burnout symptoms, 45.8 percent noted emotional exhaustion, and 28.9 percent had feelings of depersonalization. A significant number of residents also reported a low quality of life, the survey found. Of the responding residents, 14.8 percent rated their quality of life either as “bad as it could be” or “somewhat bad.” On work-life balance, 32.9 percent reported being somewhat or

very dissatisfied. “Physician well-being is extremely important for the physician, but also for patients,” West says. The study’s authors say that physician burnout, depression, job dissatisfaction, and low quality of life can harm patient care by contributing to major medical and medication mistakes, poor care practices, and patient dissatisfaction. Residency programs have attempted to reduce burnout among students by reducing hours, but the study did not find the efforts thus far to be effective. West says the findings suggest more action needs to be taken to reduce stress on residents. “We hope that now that we have established national numbers for these distress variables, we can perhaps focus less effort on documenting the problem and turn greater attention to how best to improve the situation,” he says.

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MINNESOTA PHYSICIAN OCTOBER 2011

UCare Teams Up With CaringBridge Minneapolis-based UCare has announced it will begin working with CaringBridge, an online service that allows people with serious medical conditions to update friends and families through a personalized website. CaringBridge websites are free and not only allow patients and their families to get information out about health conditions, they provide a place for people to leave messages of support. It also lessens some of the stress in clinical situations, when in the past medical staff might have to help notify loved ones. According to Jeri Peters, clinical services director for UCare, the new partnership will allow CaringBridge officials to train UCare support staff in how to talk to patients during difficult health situations and help them explore various options for informing others or seeking support. â&#x20AC;&#x153;It will be one more resource for us when we have members who are challenged with a very serious health condition,â&#x20AC;? Peters says. â&#x20AC;&#x153;CaringBridge removes some of the burden from primary caregivers from communicating with a long list of individuals. It also helps ensure that accurate information and the same information is given. And people donâ&#x20AC;&#x2122;t have the cost of all of those phone calls.â&#x20AC;? With the announcement, UCare becomes the third insurance company to establish an official partnership with CaringBridge. Minnetonkabased Medica is another insurance partner with CaringBridge, and there is a long list of health systems and hospitals that work with the group in Minnesota as well.

Mayo Clinic, Altru Announce Partnership Mayo Clinic has announced a new relationship with Altru Health System, based in Grand Forks, N.D.

Rochester-based Mayo Clinic created the Mayo Clinic Care Network, of which Altru is the founding member, to provide Mayo expertise to clinics not owned by Mayoâ&#x20AC;&#x2122;s official network of facilities, the Mayo Clinic Health System. â&#x20AC;&#x153;For many years, Mayo Clinic has enjoyed collaborative relationships with hospitals, group practices, and providers around the world. By developing formal connections with high-quality, culturally aligned practices, the Mayo Clinic Care Network takes these natural collaborations even further,â&#x20AC;? says David Hayes, MD, medical director of the Mayo Clinic Care Network. The two groups announced in May that they would work more closely together, and the Sept. 14 announcement signaled that the Mayo brand will be more prominent in western Minnesota and North Dakota. Sioux Falls-based Sanford Health has also been very active in the same market, acquiring or partnering with numerous facilities in western Minnesota.

Minnesota Best At Long-Term Care, Report Says A new report lists Minnesota as No. 1 in the U.S. for delivery of long-term care services and support to state residents. The report, Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, was released by AARP, the Commonwealth Fund, and the SCAN Foundation on Sept. 8. The analysis finds wide variation in the quality of services and support delivered to seniors and families. It examines four key elements of long-term care delivery performance: affordability and access, choice of setting and provider, quality of life and quality of care, and support for family caregivers. Officials say that some of the long-term care indicators were measured in the study for

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CAPSULES to page 6 OCTOBER 2011

MINNESOTA PHYSICIAN

CAPSULES

Capsules from page 5 the first time. “This report will help states make and sustain targeted improvements so that people can live and age with dignity in their own homes and communities,” says Susan Reinhard, AARP senior vice president for public policy. Minnesota, Washington, and Oregon were found to be the top three states in delivering long-term care services and support. However, officials say, even the top states need to do more work to create higher-performing systems of services and support for seniors. “All states need to vastly improve in areas including home care, assisted living, nursing home care, and support for family caregivers, and more efficiently spend the substantial funds they currently allocate to long-term services and support,” the groups say in a statement. Officials say the report shows the top-scoring states have policies that improve access to services and choices, such as providing alternatives

MINNESOTA PHYSICIAN

to nursing homes. Another positive factor is establishing a single point of entry into the longterm care system. Finally, the highest-scoring states have improved support for family caregivers by offering legal protections and other services that address caregiver needs. “This scorecard is a critical first step toward creating a much more person- and familycentered system of care that delivers services honoring each individual’s dignity and choices,” says Bruce Chernof, president and CEO of the SCAN Foundation. “To fully realize the vision of a high-performing, long-term services and support system, we must measure performance, track improvements, and create opportunities for states to learn from each other.” Minnesota ranked fourth nationally in affordability and access of long-term care services and support, third in choice of setting and providers, fourth in quality of life and quality of care, and fourth in support for family caregivers.

OCTOBER 2011

Vaccination Numbers Up for Teens, State Officials Say Data from the Centers for Disease Control and Prevention (CDC) show that a greater number of teens in Minnesota are receiving recommended vaccinations, state officials say. However, officials with Minnesota Department of Health (MDH) say Minnesota can do better, noting that the rates of vaccination during teen years are still not as high as they should be. The CDC report shows that immunization rates for the relatively new tetanus-diphtheriapertussis booster (Tdap) increased from 52 percent in 2009 to 70.3 percent in 2010. In addition, immunization with meningococcal vaccine, which protects against a serious form of meningitis, increased from 43.9 percent to 57.0 percent. And 37.8 percent of adolescent girls had completed the three-dose series of human papilloma virus (HPV) vaccine, which prevents

cervical cancer, up from 27.0 percent in the prior year. “We’re pleased that Minnesota continues to show improvement in coverage rates for these important vaccines,” says Kristen Ehresmann, director of Infectious Disease, Epidemiology, Prevention and Control for the Minnesota Department of Health (MDH). “We’re making progress, but these results also tell us we still have much work to do before we can say our young people are sufficiently protected from these diseases.” Officials note that Minnesota vaccination rates for the diseases have risen at a pace that is similar to national averages. State health officials say it’s important for teens to get these vaccines because they are at an age of increased risk for the diseases. Also, the standard adolescent health check-up recommended at 11 or 12 years of age is a good time to receive these vaccines from their regular health care provider, officials add.

MEDICUS

Alan Johns, MD, MEd, has been appointed assistant dean for medical education and curriculum and assistant professor in the Department of Family and Community Medicine at the University of Minnesota Medical School Duluth. Johns has taught clinical medicine at the University of Minnesota Medical School Duluth since 1982. He has practiced internal medicine at SMDC Health System (now Essentia Health East) since 1981. He was a member of the first class of medical students who began their education on the Duluth campus in 1972, graduating in 1976. He also was one of the first American Indians to attend that medical school. He achieved his master’s degree in education in 2009 from the University of Minnesota Duluth. Respiratory Consultants welcomes two new providers, Madhu Kannapiran, MD, and Kristen Hasson, MD, to their pulmonary, critical care and sleep medicine practice in Robbinsdale, Maple Grove, and Monticello. Kannapiran attended The Ohio State University College of Madhu Kannapiran, MD Medicine, completed his internal medicine residency at Hennepin County Medical Center (HCMC), and completed his fellowship in pulmonary and critical care medicine at the University of Minnesota. Hasson attended the University of Wisconsin Medical School, completed her internal medicine residency at HCMC, and completed her fellowships in sleep medicine as well as pulmonary and critical care Kristen Hasson, MD medicine at the University of Utah. Junger Tang, MD, a board-certified neurologist, recently joined the Minneapolis Clinic of Neurology. He received his medical degree from Northwestern University in Evanston, Ill. He completed his internship, neurology residency, movement disorders fellowship, and multiple sclerosis fellowship at the Mayo Clinic in Rochester. Tang is seeing patients at the Multiple Sclerosis Treatment and Research Center at the Minneapolis Clinic of Neurology in Golden Valley and at the Minneapolis Clinic of Neurology’s Burnsville office. P.J. Flynn, MD, has been elected to the executive committee of the Alliance for Clinical Trials in Oncology. Flynn, who is board-certified in medical oncology and hematology, is Minnesota Oncology’s research director and principal investigator for Metro-Minnesota Community Clinical Oncology Program. The Alliance merges three National Cancer Institute clinical trials cooperative group programs: CanP.J. Flynn, MD cer and Leukemia Group B, North Central Cancer Treatment Group, and American College of Surgeons Oncology Group. The purpose of the group is to reduce the impact of cancer by uniting a broad community of scientists and clinicians from many disciplines that are committed to discovering, validating, and disseminating effective strategies for the prevention and treatment of cancer. In addition, several researchers with Mayo Clinic in Rochester were named to leadership roles. Edith Perez, MD, was named Alliance vice-chair; Daniel Sargent, PhD, was named group statistician; Jan Buckner, MD, was named director of cancer control, prevention, and health outcomes program; and Heidi Nelson, MD, was named director of the American College of Surgeons clinical research program. Fredericus (Erik) van Kuijk, MD, PhD, has been appointed head of the Department of Ophthalmology within the University of Minnesota Medical School, where he began his duties on Oct. 1. Van Kuijk earned both his MD and PhD (biochemistry) from the University of Nijmegen, the Netherlands. He completed his internship, residency, and fellowship at the University of Texas Medical Branch, Galveston, where he was a professor in the Department of Ophthalmology and Visual Sciences until accepting the U of M appointment. Van Kuijk also completed an additional year of training in retinal degenerative diseases at Moorfields Eye Hospital, London.

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INTERVIEW

Keeping employees safe at the workplace ■ What is occupational medicine?

■ How do occupational medicine physicians work

In simple terms, occupational medicine is taking care of employees. It’s a branch of medicine that aims to produce high quality medical care and injury prevention for anyone who’s working. Our goal is to advise both employees and employers about how to keep workers safe at the workplace and productive, and to take care of any health issues that rise out of their employment. ■ How does one become an occupational

medicine physician? Vijay Eyunni, MD, MPH Minnesota Occupational Health Vijay Eyunni, MD, MP, is a board-certified occupational medicine physician with Minnesota Occupational Health, one of the largest occupational health clinics in the state. He is also a staff physician with St. Paul-based Summit Orthopedics. Eyunni received his medical degree from Kasturba Medical College in Manipul, India. He received a master’s in public health degree from the University of Minnesota. He currently is a team physician with the Minnesota Twins and the Minnesota Swarm, a professional lacrosse team.

Two ways: One, occupational medicine physicians will work as consultants to primary care physicians. When a primary care physician does not know what to do, or has done as much as he or she can do and there are still issues, then they consult an occupational medicine physician. The second way we interact with physicians is to send people to other specialties. An example could be, somebody got a twisted knee at work stepping off the ladder and has a torn meniscus and obviously needs surgery. I would send him to an orthopedic surgeon. If they’ve been exposed [to something and] have got a rash that’s not getting better, I send them to a dermatologist to do some allergy testing. So if it’s something we can’t treat to a conclusion, then we use other are doing subspecialists to resolve it.

It used to be you’d get people who are already working in other fields of medicine that are interested in occupational medicine, and they would gravitate toward that field of medicine. In the last 25 years there has been an established residency system for occupaEmployers tional medicine physicians. They have a residency promore and the injury gram just like any other subrate is down. There’s specialty. And they take the boards and become a certibeen a 40 percent drop fied occupational medicine in the injury rate in the physician. ■ If someone gets hurt at

last 10 to

work, do they see an occupational medicine doctor, or their own doctor? It’s kind of split right now. Under Minnesota law, they have the right to go see their own doctors. On the other hand, employers also have contracts with occupational clinics, and the employer can ask employees—can’t force them, but can ask them—to go see the occupational medicine doctor. And that’s where we come into play. We have contracts with employers, so when employees get injured, they usually come to us because they get good care and they get immediate care. If they call their doctors, a lot of times they will say, “Come in next week.” Whereas occupation medicine providers are geared toward taking care of employees with a very aggressive approach, so we see them right away. ■ Do most of your patients come from larger

businesses? Not necessarily. We do have contracts with smaller companies. A lot of times it just depends on the company. One of the things that employers are doing is cost containment. Sometimes the company’s insurer will tell them, “Your costs are too high; you need to send to an occupational clinic if you have an injury.” Or they will do some evaluation of your site to see what can be done to prevent injuries—or even before you hire, do pre-employment screening to make sure you’re hiring the right person for the right job so they’re not getting hurt.

with other types of physicians?

MINNESOTA PHYSICIAN OCTOBER 2011

■ How are the costs of

occupational medicine services covered?

There are two ways. One is called employer-paid services. The employer pays directly. 15 years. These services include a physician exam or a drug test before hiring. Let’s say you’re working under asbestos standards: you have to see the doctor every couple years to have a chest x-ray. All that comes under this area. The employer pays. Sometimes we do a fitness-for-duty exam if the employer is not sure the employee can do the job. These exams are employer-paid. The second one that is equally big is workers’ compensation. That is when an employee gets injured or ill at work, whether from exposure, a fall, or any kind of injury—that is paid by workers’ comp insurance. They will submit a claim, just like anything else. It’s a fee-for-service type of thing, so if somebody gets hurt and I see them four times, we charge the employer for four visits to the office and get paid for the office visits. ■ Which type of payment is more common?

It’s a balance. I would say probably it used to be more work comp—I’d say 60/40—because employers were not doing much and people were getting hurt more. Now, employers are doing more and the injury rate is down. There’s been a 40 percent drop in the injury rate in the last 10 to 15 years. People are not getting hurt as much as before; the employers are doing a better job of prevention and a better job of hiring people qualified to do the job physically, so the injury rate is significantly down. Right now I would say 40 to 45 percent is injury care and maybe 50 to 55 percent employerpaid services.

■ What made the difference?

Premium costs kept going up; businesses were leaving the state because costs were going up, so the employers had to do something to get their costs down. Practices have changed. About 15 to 20 years ago we used to see patients hurting their backs and saying, “I don’t want to work for a month,” and that was perfectly OK. Those kinds of things don’t happen now. People stay right on top of it. The lost-time rate is down, the injury rate per thousand is down. There is a lot of automation, so you don’t see the repetitive work that you used to see, so that has also created fewer injuries. And there’s better education; a lot of companies have safety personnel. We have a program called ergonomic evaluation; we go to companies and show employees how to do proper lifting and proper bending, so they’re in better shape. It’s a combination of all these things that has really decreased the injury rate. ■ What are some of the services occupa-

tional medicine provides that most physicians probably are unaware of? I think the belief is that occupational physicians just take care of injuries. We do drug testing, which is getting very big in the business community. Many companies are doing pre-hire drug testing.

Also, once they’re hired there is a lot of testing done for any injuries or things like that. We do ergonomics, evaluate the jobs, and recommend programs for companies. We also do a lot of pre-placement evaluations and we do what is called isokinetic testing. Especially for heavy industries, you want to make sure the employee is able to do the job. Once people go through isokinetic testing, the incident rate for injury goes down significantly. I think a lot of physicians are not aware that we do a lot of regulatory exams, like OSHA-mandated exams for people working with chemicals or asbestos or noise or confined spaces. ■ What role does the wellness and

prevention movement play? One area where employers are still kind of hesitant is wellness programs, where you go in and look at the population and work with them on their blood pressure, diabetes, and cholesterol problems. Because that falls under their private insurance, employers are not real excited about that. They don’t see the result immediately; it’s a long-term result, so employers are a little hesitant to spend up-front dollars. A lot of employers also have transient employees and they don’t want to spend the money on them because they’re gone in a couple of years.

The ergonomic programs, or where they put the stretching programs in place, or do the isokinetic testing—that’s getting busier because they’re seeing the results instantly. ■ Is there ever a conflict between treating

the patient and meeting the needs of an employer? First and foremost you want to take care of the employee. On the other hand, we have to work with the employer. If there is some light duty, then the employee can go back to work instead of staying out for a week. They can answer phones or look at training videos for a few days. I think of it as a dual responsibility: you want to take care of the patient, but on the other hand, you have some responsibility to the employer. It’s a little bit like sports medicine. We want to be aggressive in our treatment and be right on top of it, but at the same time want to give the best treatment so they’re back on the job. Going back to work is positive as long as it’s not aggravating the part that’s hurt. It’s better psychologically, and movement is good. I think these are all medically positive things. So, sometimes you see that conflict. But it’s very rare, because most employees know that what we’re trying to do is what’s best for them.

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MINNESOTA PHYSICIAN

A shift to patient-centered care â&#x20AC;Ś will often require a rewriting of the rules that have held us in good stead for years.

Engagement from cover have become somewhat blurred. The work on health care homes over the past few years has clearly identified the need for patient engagement and involvement as a critical element in successful implementation of the model. But as we continue to design and incorporate these new approaches into our delivery of health care, it would behoove us to consider exactly what â&#x20AC;&#x153;engagementâ&#x20AC;? looks like in the context of improving care. Jessie Gruman, PhD, president of the Center for Advancing Health (CFAH), defines patient engagement as â&#x20AC;&#x153;actions individuals must take over time to obtain the greatest benefit from the health care services available to them.â&#x20AC;? This concept of patient engagement addresses the specific actions our citizens/patients will have to incorporate into their lifestyles in attempting to maintain their health. Far from the acute, episodic practice of the past, the notion of patient engage-

ment in health care requires components of physicianpatient teamwork and patient participation unimaginable not so long ago. Engagement and health care redesign

There are several reasons we need to focus on the need for engagement as we continue our work in redesigning health care. First, patients are being given increasing responsibility for both finding and making use of the resources we in the health care system offer. Questions of how we provide that information to patientsâ&#x20AC;&#x201D; and, at the same time, simplify the effort required for them to obtain itâ&#x20AC;&#x201D;are important. Second, the increasing demands on our patients mean that the disparity between those

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MINNESOTA PHYSICIAN OCTOBER 2011

who are engaged and involved and those who arenâ&#x20AC;&#x2122;t engaged will grow. The unintended consequences to those who are or become â&#x20AC;&#x153;unengagedâ&#x20AC;? (e.g., due to social and intellectual issues) will require significant attention. It may lead to these groups suffering even more significant health issues due to their inability to access care and participate with the terms weâ&#x20AC;&#x2122;ve identified supporting engagement. Third, the 21st-century focus on â&#x20AC;&#x153;patient-centeredâ&#x20AC;? care provides an opportunity to institutionalize the elements necessary for successful patient engagement. As we talk about developing engagement, there are at least two overlying issues that we providers need to consider. To begin with, what are the â&#x20AC;&#x153;rules of engagementâ&#x20AC;?? Do our clinics and health care systems clearly articulate to our patients, in a resource that is readily accessible and understandable, what we expect when they interface with usâ&#x20AC;&#x201D;whom to call for an appointment, when services are available, whom to call in the middle of the night, what to do with a billing concern, whom to see when their preferred provider is unavailable? I suspect many would have difficulty in identifying such a resource document that would establish even those basic â&#x20AC;&#x153;rules.â&#x20AC;? More fundamentally, have these rules been developed in consideration of what our patients might need, or are they still designed for the benefit of those of us working within the health care setting? A shift to patient-centered care, in an effort to drive engagement, will often require a rewriting of the rules that have held us in good stead for years. Whereas in the past, the provider has assumed that merely telling a patient what action was necessary was sufficient, in todayâ&#x20AC;&#x2122;s patient-cen-

tered world we will need to provide specific actions that would be helpful, framed against an understanding of the patientâ&#x20AC;&#x2122;s values and resources. Ensuring there will be access to the system when the patient needs itâ&#x20AC;&#x201D; not when itâ&#x20AC;&#x2122;s convenient for the providerâ&#x20AC;&#x201D;will require a shift in our thinking about schedules and availability. But as we change the models used to deliver health care, and even as we rewrite the rules, we need to fundamentally begin to identify and create the terms of engagement. It is in this area that groups such as the CFAH and other patient advocacy groups have focused much of their work. We are talking about creating an understanding and agreement between the health care provider and the patient/family that lay out the roles and responsibilities for all, and that recognize the increasing need for mutual interdependenceâ&#x20AC;&#x201D; acknowledging that neither of us alone can solve the problem; we need to work together. [See the Patient Perspective article on page 30 for an example of an engaged patient working with physicians as partners.] Behavioral elements of engagement

In a white paper published in 2010, the Center for Advancing Health outlines 10 behaviors that will be needed at some point, in some combination, by citizens during their experiences with the health care system. [The paper may be downloaded from the CFAH website, www.cfah.org, by choosing â&#x20AC;&#x153;Supporting Patientsâ&#x20AC;&#x2122; Engagement in Their Health and Health Careâ&#x20AC;? in the â&#x20AC;&#x153;Recent CFAH Publicationsâ&#x20AC;? menu.] In brief, patients must: 1. Find safe, decent care 2. Communicate with health care professionals 3. Organize their health care

4. Pay for health care 5. Make good treatment decisions (elements of shared decision-making) 6. Participate in treatment 7. Promote health 8. Get preventive care 9. Plan for end of life 10. Seek health knowledge For all of these behaviors, there are lists of specific activities that provide concrete examples of how they might play out in practice. This behavioral definition of engagement has the potential to address several critical areas. If we expect our patients to meet these elements of engagement, it is imperative that we evaluate how we as organizations provide the environment that supports this level of involvement. Do we provide the resources that support those seeking to become involved and engaged, or is the complexity of our system non-navigable to the average person? Beyond the availability of educational materials, sharing opportunities, and technical support, do we as cli-

nicians demonstrate behaviors that would support patients who are actively participating in maintaining their health? Take, for example, patients’ use of the Internet. How many physicians continue to express frustration, often manifested by rolling eyes, body language, or terse comments, when confronted with a patient carrying a thick bundle of printed material from the Internet? Rather than consider what we might be missing in meeting the needs of our patients, we are critical of them for seeking information from other sources. How we react, the questions we ask, the invitation we send through many different actions—all these will be critical in supporting the engagement we’re expecting, and needing, in the new world of health care. There are at least three types of activities that are critical in patient engagement: sharing information, shared decisionmaking, and

responsibility for care. As we expect our patients to move from the traditional, passive role to becoming active, questioning, participating partners, this behavior change will present a significant challenge to many practitioners. In recognition of that challenge, it is critical that we in health care begin to think concretely and actively about our role in creating the environment that is essential in leading to engagement. Reframing roles

We can argue philosophically the need for an empowered patient. But there is little debate about the need to create an environment and a culture that will lead to the engagement of our patient population in becoming and staying healthy. The 10 behaviors cited by Dr. Gruman are a framework for the discussion. They allow us to consider what it is we’re asking of our patients, but also what we will need

to create and provide within our health care system—and across the community—if we’re to successfully accomplish the vision of a healthy population. So as we continue our work in reframing the health care system in which many of us reside professionally, we need to address not only the roles we will have in this new world of health care, but also how we can begin to move from what has been a provider-centric model to one that focuses on the patient. Only by including patients at many levels of our planning and, in effect, co-creating that future, will we begin to understand what it will take on all sides to ensure that we have the engagement of everyone in achieving the healthy tomorrow we all desire. Gary Oftedahl, MD, is chief knowledge officer at the Institute for Clinical Systems Improvement in Minneapolis.

OCTOBER 2011

MINNESOTA PHYSICIAN

Payment from cover better positioned to help than anyone else. That means considering the value of care from the perspective of the patient. And, as provider payment incentives evolve, and benefit and network design changes develop, the efficacy of resource utilization (e.g., medication usage, outpatient visits, diagnostic testing, emergency room admissions) will increasingly affect how much physicians earn, their market share, and their access to patient populations. Physicians usually don’t know how they perform on cost measures. Initiatives to make both patients and doctors aware of the cost of individual services and the total cost of caring for patient populations are proliferating. While the methodologies vary, the intent is the same: to improve care delivery while maximizing value. Consumer information about unit costs and total care costs is increasingly available through plan websites and provider data-sharing. Plans, public purchasers, and employ-

Helping patients decide about the value of health care services will become an important role for physicians. ers are coupling benefit designs that create incentives for consumers to shop for better value with tools to support that effort. Together, these initiatives will affect a critical mass of your patients. Patients, plans look for value

Total cost of care (TCOC) is a widely used metric that ties patients back to primary care groupings and measures all costs of providing care across the full continuum of services. TCOC analyses consider the illness attributes of patients using risk-adjustment tools, so the analyses consider that sicker patients require more resources to treat and healthier patients require fewer resources. Total cost of care can be high because of primary care unit prices, the unit prices of the other providers involved in a patient’s care, and the relative number and intensity of ser-

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MINNESOTA PHYSICIAN OCTOBER 2011

vices used to manage similarly ill patient populations. Exceptionally high unit prices (typically achieved through successful plan negotiations) now have a direct, negative impact on patients—an impact that will be felt by physicians and medical practices as well. Some physicians will find themselves on the outside looking in when plans feature “value networks” or “tiered networks,” coupled with benefit or premium incentives for using the most cost-effective providers. Health insurance exchanges, in which price-sensitive individual purchasers see the full premium variation among plan choices, will further stimulate growth of “value network” products. In addition, plans are sharing more performance data (although detailed data-sharing is still very limited) and public sites are making it easier to evaluate a physician’s performance relative to his or her peers. Both the best and worst performers will need to understand how they are doing in order to understand how to optimize their future positioning. The dizzying array of methodologies used to measure performance can be frustrating for physicians. But the unifying vision is to think about care from the perspective of patient value. In other words, how can physicians help keep care affordable overall and help patients use their scarce health care dollars to buy the most health possible? Helping patients decide about the value of health care services will become an important role for physicians. Most patients are too overwhelmed or intimidated to ask questions about treatment recommendations, but that doesn’t mean they aren’t concerned. For example, patients need to know whether the tests or interventions recommended (which will cost them hundreds or thousands of dollars out of pocket) are the best use of their scarce

dollars, and they will want their trusted physicians to help them make those decisions. (Visit costsofcare.blogspot.com for some compelling examples of these issues.) Today, in the absence of information about variation in price/cost among different service site choices and with limited information about comparative effectiveness, physicians aren’t particularly well equipped for “the value conversation”—and, in many cases, even feel conflicted about playing this role. Much of this information is already transparent on health plan websites geared to consumers, and plans are increasingly willing to share this information and will become more so as providers request it. However, even when armed with this information, most physicians will need to think though how they discuss this value issue with their patients. Framing it in terms of cost vs. benefit may be helpful, i.e., “We could perform that imaging service now, but based on what we already know, it won’t change our treatment recommendations and could cost you as much as $XX.” If physicians and their teams can’t help their patients make good value decisions, patients will look elsewhere for information. When that happens, physicians position themselves poorly with respect to their role as patient advocates, and trust may erode when the high cost or low yield of a physician recommendation comes into question through another party. What to do?

How can physicians position themselves to deliver the most value for patients? Here are a few suggestions: Don’t fixate on the methodological details of costof-care metrics. Many physicians are frustrated by the lack of uniformity of analyses among plans, the state, CMS, etc. But what really matters is that these analyses are directionally consistent and drive the same incentives. Reducing readmissions, ER visits, complications, using the lowest-cost care

setting and generic drugs, etc., will improve your performance under virtually every analysis. Stay focused on patient value and the big picture, and you will do well no matter what the methodological details. Rethink your pricing position. After decades of cloutbased negotiations, there are big disparities in contracted rates within the same plan networks. Negotiating a higher fee level may have been advantageous in the past, but now, above-market contract rates are a barrier for patients. It’s time to get competitive with your pricing—especially for scheduled and commodity-type services (lab, imaging, etc.). Evaluate your practice style. Will you take phone calls, emails, or Web visits from patients? Does every patient inquiry require an office visit? Can others on your team provide certain services at lower or no cost to patients? Do you require a set of diagnostics before even evaluating a patient? Do you pride yourself on being “thorough,” as reflected in the number of tests you order? If your patients were paying for every service themselves and understood the yield and treatment impact of your recommendations, would they think they were getting enough value? Are low-yield and falsepositive tests driving your patients into a cascade of care that isn’t really improving their health status? In a market that is defined by total cost of care, inefficient resource use drives your total cost of care up, making you unaffordable and inaccessible to your patients. Consider the price and practice style of the physicians and facilities where you send patients. When you send patients to a high-priced doctor or facility, it increases their financial exposure and affects your TCOC. If there is no compelling reason to use a more expensive source, patients will appreciate your consideration for their wallets, especially when it comes to routine services like imaging, lab, and scheduled procedures such as a colonoscopy. For patients attributed to you or your practice (meaning

the data indicates that they are most likely your patients), your TCOC performance is directly affected by care provided to that patient by others. This payment incentive is intended to make referring physicians aware of the impact of their preferences in providers of health services. Are you sure that the highpriced and/or high-utilizing physicians or facilities you send patients to are worth it in terms of better outcomes or patient experience? Is it time to have a conversation with your colleagues or facility leadership about how you can work together to improve? If you lose patients because you aren’t delivering enough value, they will, too; and, conversely, if others in your practice aren’t delivering value, that will affect you as well. Your prescribing patterns have a similar impact. Most patients have plan coverage that makes generics much more affordable to them. Prescribing generics whenever possible has benefits for physicians as well, because when the cost of prescription drugs is included in TCOC, optimizing generic drug use makes a significant difference in performance metrics. Manage your patient population even when they aren’t sitting in your exam room. Do your patients effectively “vaporize” when they leave your sight? It is critical to reach out to your chronically ill patients to make sure they are getting the care and support they need to achieve the best outcomes. Your patients will appreciate that you are tracking them. And better outcomes reduce TCOC by avoiding admissions, readmissions, and complications. Further, in TCOC models, because you achieve the best performance when chronically ill patients are well managed, you will want to make sure that those patients are identified as yours. Most attribution models look back on 12 to 18 months of claims to evaluate where patients have received care, so you need to make sure your patients are showing up in your data. Currently, that means they have been seen in your office.

(Future analytic methods likely will evolve to enable tracking of other types of patient interactions, such as phone calls and Web visits.) If it is difficult for patients to see you and they end up with another primary care site or in the ER, that will work against you. Accurately and fully code comorbidities. There are two compelling reasons to make sure you are accurately and completely coding for all relevant diagnoses for every patient. First, quality of care is affected. If you have lost track of a significant comorbidity, you may not be completely meeting the care needs of that patient. With busy schedules, it isn’t easy to keep track of patient complexities, but good care requires it. Audits of coding for comorbidities or chronic conditions typically reveal big gaps in diagnosis coding. If that isn’t motivation enough, there’s also this: Evaluation of physician performance on TCOC considers how sick (or not sick) their patients are. The information to perform

risk adjustment to reflect differences in the illness burden of patient populations comes from claim data. If your ICD coding doesn’t include a diagnosis code during a 12-month analytic period, it won’t be considered in the risk adjustment process and your patients will look less sick in the performance analysis. And if your patients appear less sick than they really are in your performance analysis, your TCOC will appear higher than it really is. As payment incentives evolve and change, it’s a confusing time and difficult transition for physicians. But the good news is that payment models are now being designed to create an environment in which doing the best thing for the patient finally makes economic sense for everyone. Ann Robinow is president of Robinow Health Care Consulting. She has more than 30 years of experience in health financing, management, and policy, with an emphasis on innovative redesign of health care markets and provider incentives for cost and quality performance.

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PAIN

eriously ill and dying patients request that you and I care well for them— and one mark of caring well is managing their pain well. In my field, palliative medicine, managing pain is a cornerstone of treatment. People often attempt to explain palliative medicine with academic principles and healing platitudes. But after practicing palliative medicine for only a short while, I came to the conclusion that palliative medicine is simply a medically sound approach to pain management. That realization led me to develop what I call guiding principles that provide a practical approach to pain management specific to opioids (see sidebar 1). To illustrate how these principles work in practice, this article briefly describes various scenarios involving pain management. Note that the principles and scenarios in the article rest on the assumption that the patients being treated have opioidresponsive pain and no contraindications to opioid use.

MANAGEMENT

Principles of pain management A practical approach to treatment with opioids By Cory J. Ingram, MD

Introduction of opioids (guiding principles 1–3)

There are three guiding principles for the introduction of opioids to patients with normal liver and kidney function. Guiding principle #1 is to address whether or not the patient is opioid-naïve. If the patient has not been on opioids consistently for three to seven days, then the patient is opioidnaïve and may be started on a short-acting opioid only, to be used as needed. (Long-acting opioids such as fentanyl patch, MS Contin, and OxyContin have no role in an opioid-naïve patient.)

The one exception to this guiding principle comes into play for people with cognitive impairments, who are unable to report their pain accurately and in a timely manner. Applying guiding principle #2 (“dose by mouth and by the clock”) in this scenario, we would prescribe a scheduled, lowdose, short-acting opioid, preferably by mouth, with close monitoring. When initiating opioid therapy, guiding principle #3 advises us to initiate a bowel regime with sennas and Miralax to manage constipation, the most frequent side effect associated with long-term opioid therapy. Long-term management (guiding principles 4–10)

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In patients successfully initiated and responding to opioid therapy, careful titration of the opioids is often necessary. Guiding principle #4 reminds us that the titration of a short-acting opioid should be carried out in increments of 50 percent to 100 percent, based on the patient’s pain score of less than or equal to 6, or greater than 6, respectively. When patients are taking frequent doses of short-acting opioids throughout the day and night, it may be time to introduce a long-acting opioid. Guiding principle #5 advises that when transitioning a patient from short-acting to long-acting opioids, the goal is to have the patient on both a long-acting and a short-acting opioid. The goal is never to have a patient on a long-acting opioid only. Following guiding principle #6 regarding morphine equivalents, we can transition our patient from frequent, shortacting opioids to long-acting opioids with minimal breakthrough dosing (i.e., as-needed

dosing to manage breakthrough pain). Breakthrough dosing is likely the most common error we see on palliative care rounds (followed closely by the lack of use of morphine equivalents). As an example, our team recently saw a man with a pathological fracture of his jaw; he was using multiple shortacting forms of opioids, equaling 54 mg of oral morphine a day. We recommended using a 12 microgram-per-hour fentanyl patch, which is equal to 36 mg of oral morphine a day. Using guiding principle #7, we then determined his breakthrough dosing. In this case, the breakthrough dose would be 10 percent to 15 percent of his total daily morphine equivalent, which is 3.6 mg to 5.4 mg of oral morphine for each dose. Importantly, if an increase is made in long-acting medication, the breakthrough dose also must be adjusted. The goal in managing the long-acting opioid is to ensure that the patient has good pain control without sedation. It is never the goal to increase the longacting opioid so that the patient doesn’t have to use a breakthrough dose. The dose of long-acting opioid is likely correct if the patient is using two to four breakthrough doses a day. It would be an unusual situation to schedule a short-acting opioid with long-acting opioids. Following guiding principle #8, when a patient is on a longacting opioid and a short-acting opioid, it is often necessary to add another medication as an adjuvant. For example, in the situation of bone pain, it would be reasonable to consider bisphosphonates or steroids to reduce the pain and perhaps reduce the amount of opioid needed. Guiding principle #9 applies to dose end failure— pain that occurs toward the end of the time frame in which a medication dose is intended to be effective. One common scenario is a patient experiencing increasing pain on the third day of a fentanyl patch, or perhaps midday pain when on MS Contin or OxyContin. In this situation, the clinical decision

Guiding principles to management of opioids Introduction of opioids in patients with normal liver and kidney function GP #1: Determine whether the patient is opioid-naïve GP #2: Dose by the mouth and by the clock GP #3: Initiate a bowel regime Long-term management of opioids GP #4: Titrate short-acting opioids in 50–100% increments GP #5: Transition to long-acting from short-acting opioids GP #6: Determine morphine equivalents GP #7: Determine breakthrough dosing (10–15%) GP #8: Add an adjuvant medication GP #9: Deal with dose end failure GP #10: Manage incomplete cross-tolerance Parenteral opioids GP #11: Calculate PCA dose at 50–150% of basal rate GP #12: Confirm basal-rate steady state for 8 hours GP #13: Titrate the PCA in increments of 50–100% GP #14: Limit basal rate increase to a maximum of 100% Special populations GP #15: Choose the correct opioid for patients with renal and hepatic failure GP #16: Permit dying patients to use PCAs GP #17: Titrate down at 50% to prevent withdrawal

would be to change the patch every 48 hours or add an MS Contin or OxyContin in the middle of the day. Finally, guiding principle #10 draws attention to management of incomplete crosstolerance when switching a patient from one opioid to another. The basis of this principle is that patients may experience more effective analgesia from a lower rather than an equivalent dosage of another opioid. Practically, then, the dose of the new opioid needs to be 25 percent to 40 percent less than what the equivalent calculation would suggest. Parenteral opioids (guiding principles 11–17)

When managing opioids for patients with serious, lifethreatening illness, it is likely that the need for parenteral opioid management will arise. One common type of error occurs when a patient on high-dose opioids is placed on starting-dose, standard-order, patient-controlled analgesia (PCA), which would typically

be reserved for opioid-naïve patients who require parenteral opioids. In determining the parenteral dosing morphine equivalents, guiding principle #6 must

be used. A walk-through example is given in sidebar 2. When managing a PCA with a basal rate to provide continuous pain relief, it is important to recognize that patients do

not immediately feel changes in the basal rate. Guiding principle #12 reminds us that it takes at least eight hours after a basal rate change for the patient to be in steady-state at the new dose. The clinical translation is that basal rate changes generally should be made no more often than once every eight to 12 hours. Orders with basal-rate ranges for nurses to titrate lead to dose-stacking and an unclear picture of what dose the patient is actually getting. If a patient is in pain, the recommended way to titrate the pain is with the PCA. According to guiding principle #13, the PCA dose can be increased by 50 percent to 100 percent. Certainly, if a patient is having pain and you are titrating the PCA over the course of an hour or two, it is very possible for the PCA dose to be higher than the basal rate. Your patient will be comfortable, and you may then change the basal rate after evaluating the amount of drug used in the last eight to 12 hours. It would now be time to increase PAIN MANAGEMENT to page 16

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Determining parenteral dosing morphine equivalents: an example A 35-year-old man with advanced colon cancer is on 120 mg of MS Contin BID with 6 mg of po Dilaudid for breakthrough pain. He has used four doses of po Dilaudid in the last 24 hours. His pain has

been well controlled. He has lost his oral route, and you want to transition him to a PCA. To calculate the appropriate dosage, follow these steps:

1. Calculate morphine equivalents: 120 mg x 2 = 240 mg po morphine daily (donâ&#x20AC;&#x2122;t include the breakthrough) 2. Convert to iv drug of choice: Use Dilaudid (GP #6: determine morphine equivalents) 240 mg po morphine/24 [hrs?] x 1 mg po Dilaudid x 1 mg iv Dilaudid_ = 12 mg iv Dilaudid/24 hrs 4 mg po morphine 5 mg po Dilaudid 0.5 mg iv Dilaudid/hr 3. Incomplete cross-tolerance: 0.4 mg iv Dilaudid/hr (GP #10, 25â&#x20AC;&#x201C;40% reduction; this is only a 20% reduction) 4. Choose the PCA dose: 0.2 mg iv Dilaudid q 15 min (GP #11: PCA dose 50â&#x20AC;&#x201C;150% of basal rate) 5. Choose the frequency: q 15 min 6. Choose the lock out dose: Basal 0.4 mg/hr x 4 hrs = 1.6 mg in 4 hrs PCA: 0.2 mg x 2 hits/hr x 4 hrs = 1.6 mg in 4 hrs I would choose 3.2 mg. Pain management from page 15

your basal rate, and guiding principle #14 will remind you that you may not increase the basal rate more than 100 percent. Set the new PCA dose according to guiding principle #11, in keeping with the new basal rate. Special populations

Guiding principle #15 reminds us of the importance of choosing the correct opioid when treating patients with hepatic and renal failure. In renal failure, the safest drugs are fentanyl and methadone; other

common choices, to be used with caution, are Dilaudid and oxycodone. Morphine and codeine should be avoided in renal failure. In hepatic failure, morphine, oxycodone, or Dilaudid may be used with caution, but methadone should be avoided. Fentanyl is likely the safest choice. In caring for dying patients, all of the guiding principles apply. Guiding principle #16 permits the use of the PCA button by professional nursing staff for dying patients exhibiting signs of suffering from pain or dyspnea but are too ill to push the PCA button.

If titrating downward, or in the event of loss of route for whatever reason, Guiding principle #17 reminds us that patients can withdraw from their opioids. Typically, patients need at least 50 percent of their previous opioid dose to prevent withdrawal. So if a delirious patient removes his fentanyl patch, you need to find a way to replace at least 50 percent of his opioid needs. Opioid management guided by resources

elucidated by these guiding principles. Regardless of our experience and knowledge, we should consider using an equivalents chart, a calculator, and a colleague to check our work when managing opioid medications. Cory J. Ingram, MD, is an assistant professor of family and palliative medicine at the Mayo Clinic College of Medicine in Rochester, Minn., and is medical director of palliative medicine at the Mayo Clinic Health System in Mankato, Minn.

Opioid management in all patient populations requires careful attention to the details

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MINNESOTA PHYSICIAN OCTOBER 2011

OCTOBER 2011

MINNESOTA PHYSICIAN

Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

MINNESOTA PHYSICIAN

OCTOBER 2011

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2

OCTOBER 2011

MINNESOTA PHYSICIAN

SPECIAL

FOCUS:

H E A LT H

CARE

REFORM

and Affordable Care Act

Changes ahead

(ACA) was signed into

A road map for long-term care

The Patient Protection

law just over 18 months

By Sarah Duniway, JD, and Gregory A. Larson, JD

ago. This month’s special focus articles survey the changes that have already occurred and that are expected to occur as national health reform provisions take effect. The articles examine four different aspects of health care: long-term care, health care for immigrants, the health care workforce, and mental health access and treatment.

ealth law reform is like major highway construction: All the signs point to something big happening not far down the road, but it is often difficult to track when it starts, know what you should do to prepare for it, and, once it arrives, know the precise nature of the projects absorbing the attention of various knots of government workers (whether hard-hatted or business-suited). If you are attempting to go about your business, the only specifics you are likely to demand can be summed up simply: How does this affect me? If you are a provider of long-term care services, the Patient Protection and Affordable Care Act (ACA) includes a patchwork of provisions that will—or already do—affect you.

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Many of the provisions are aimed at improving the integrity of the Medicare program. Others are intended to improve the quality and efficiency of care offered and/or protect patient populations served by long-term care facilities. The following is a brief snapshot— taken at highway speed—of the most important changes. Accountable care organizations

Accountable care organizations (ACOs) are a new way for health care providers across the care continuum to coordinate care with each other, thereby reducing costs to the Medicare system. The ACO legislation includes financial incentives for providers to form ACOs and to share in the savings created by

their coordinated efforts. The details of how ACOs are formed, how they are to work, and how they will get paid are still being formulated. Although much of the policy discussion about ACOs has focused on hospitals, long-term care providers should be paying attention to this development, too. With their unique ability to serve as an early-warning system to identify and address pending health care issues for individuals, as well as their critical role in providing posthospital acute care, long-term care providers could play a critical role in an ACO and be instrumental in the organization’s ability to create savings for Medicare, in addition to improving health outcomes for patients. Elder Justice Act

The Elder Justice Act (EJA) was enacted as part of the ACA and became effective on the date of enactment, March 23, 2010. The EJA authorized a wide range of initiatives intended to curb elder abuse, neglect, and

exploitation in long-term care facilities. Self-reports of elder abuse. Particularly noteworthy is the EJA’s requirement for long-term care facilities that annually receive at least $10,000 in federal funds to self-report instances of elder abuse. The reporting requirement applies to nursing facilities (NFs), skilled nursing facilities (SNFs), hospices that provide services in long-term care facilities, and intermediate care facilities for people with mental retardation, as well as to each individual who is an owner, operator, employee, manager, agent, or contractor of any such facility. The reports must be made immediately to the state survey agency. “Immediately” is defined to mean within two hours if the incident results in serious bodily harm, or within 24 hours if the incident does not involve serious bodily harm. Minnesota providers are already familiar with the state law that requires reporting of maltreatment of vulnerable adults. However, not only does the EJA’s requirement apply to a broader class of reporters; it also imposes a stricter standard, with higher stakes. First, “any reasonable suspicion” of abuse must be reported, which is arguably a lower threshold than the state law’s knowledge standard. Second, significant fines may be assessed on any provider that fails to report: from $200,000 to $300,000 per violation. Finally, those who are subject to the reporting requirement may be excluded from participation in federal health care programs for failing to make a required report. In a memorandum related to the EJA’s reporting requirement, which was issued to state survey agencies in June, the Centers for Medicare & Medicaid Services (CMS) makes clear that it expects long-term care facilities to “comply with the law as it is plainly written, without any delay” occasioned by waiting for clarifying regu lations. The CMS memorandum goes on to outline long-term care facilities’ responsibilities for compliance with the EJA’s

This increased funding signals a serious intent on the part of government regulators to step up enforcement activities regarding elder abuse. requirements, including “required functions” and “advisable functions.” Long-term care facilities must: • Determine annually whether the facility received at least $10,000 in federal funds in the preceding year, causing the EJA’s requirements to apply. • Annually notify each covered individual of that individual’s reporting obligations (if the facility determines it is subject to the law). • Conspicuously post a notice for its employees specifying the employees’ rights, including the right to file a complaint against a facility that retaliates against an employee for making a report required by the EJA. • Refrain from retaliating against an individual who lawfully reports a reasonable suspicion of abuse. The CMS memorandum indicates that it is “advisable” for a facility to: • Coordinate with state and local law enforcement to determine what actions are considered to be criminal conduct in the jurisdiction. • Conduct a review of existing policies and procedures to ensure adherence to existing CMS and state policies and procedures for reporting incidents and complaints. • Develop and maintain policies and procedures to ensure compliance with the EJA’s new requirements. Increased enforcement ahead. The EJA also provides for funding of a number of initiatives that create infrastructure to combat elder abuse. The Secretary of Health and Human Services (HHS) is instructed to distribute $26 million in grants through 2014 to establish forensics centers that will develop forensic markers to determine when elder abuse, neglect, or

exploitation has occurred; provide victim support and advocacy; and build capacity among health care providers and law enforcement officials to collect and examine forensic evidence. The EJA authorizes an additional $400 million in grants through 2014 to support the efforts of state and local protective services programs that investigate reports of abuse, neglect, and exploitation of elders, and $72.5 million in appropriations for state longterm care ombudsman grants and training. The EJA also authorizes the expenditure of $12 million each year through 2014 to create a National Training Institute to improve the training of surveyors who investigate allegations of elder abuse. This increased funding

signals a serious intent on the part of government regulators to step up enforcement activities regarding elder abuse. Long-term care facilities’ exposure to state and federal penalties in this area is almost certain to increase. Accordingly, such facilities would be well advised to conduct a thorough review of their existing policies and procedures to ensure compliance with the EJA. Nursing home transparency and improvement

Public disclosure. The ACA also includes a number of new disclosure requirements for Medicare skilled nursing facilities and Medicaid nursing facilities, presumably in an effort to increase public accountability of these facilities. Effective now, nursing home facilities must disclose to HHS the identity of each member of the governing body; each officer, director, member, partner, trustee, or managing employee; and each “additional disclosable party” CHANGES to page 38

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OCTOBER 2011

MINNESOTA PHYSICIAN

SPECIAL

mmigrants and their children make up the fastestgrowing group in the United States, representing 12 percent of the population in 2009. The proportion of Minnesota residents that are immigrants has increased by 38 percent over the past decade, and in 2009 the foreign-born represented 6.8 per-cent of the state’s population, or 360,000 residents. Numerous federal policies enacted over the past two decades have had a significant impact on immigrants’ access to health care, and the 2010 Patient Protection and Affordable Care Act (ACA) is no exception. This article reviews the key provisions of national legislation pertaining to access to care for immigrants, highlighting the most recent provisions of the ACA.

Immigrants in Minnesota

As shown in Figure 1, Minnesota is home to immigrants from around the world. Almost onefifth of the state’s immigrants come from Mexico (17 percent),

H E A LT H

CARE

REFORM

Immigrant access to health care Fewer resources, less political will to provide safety net service By Jessie Kemmick Pintor, MPH, and Lynn A. Blewett, PhD

the largest single category of immigration, followed by immigrants from Europe (13 percent). Africa is also a leading source of immigration, making up 18 percent of the immigrant population in the U.S. when all African categories are combined (see sidebar.) Legal immigrants can be in the U.S. as either naturalized citizens or legal non-citizens. Non-citizens may be here either with- or without authorization. In general, non-citizens are more likely to be from young, working families: Over twothirds of non-citizens in the U.S. and in Minnesota are in the 18 to 44 age range; more than half

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of non-citizens are married; and two-thirds reside in households with children present. While most immigrants are working, non-citizens are much more likely to have incomes below the poverty level. Across the U.S. and within Minnesota, noncitizens are four times more likely to be uninsured than their citizen counterparts (U.S. Census Bureau, 2010). Federal policies on immigrant access to coverage

Prior to 1996, legal immigrants and their children were eligible for health coverage under the Medicaid program if they met state-specific income- and asset eligibility criteria. Undocumented immigrants were not eligible for Medicaid or any other federally funded public programs, and they remain ineligible to this day. In 1996, President Clinton signed the Illegal Immigration and Immigrant Responsibility Act and the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), which restructured the U.S. welfare system and had a significant impact on legal immigrants’ access to federally funded programs. Under the legislation, legal immigrants lost eligibility for all means-tested, federally funded programs— including Medicaid—for the first five years they were in the U.S. After 1996, states had to proactively enact their own legislation to cover undocumented immigrants or legal immigrants subject to the five-year ban, and few states opted to do so. Policies constructed over the next decade attempted to open up coverage for immigrant pregnant women and children. The State Children’s Health Insurance Program (CHIP) Unborn Child Amendment of 2002 provided

states with the option of federal matching funds to cover care for pregnant women regardless of immigration status. Once again, however, coverage would be extended only to states proactively pursuing (and passing) legislation to cover prenatal care for these women, and care was “officially” provided or justified only for the “unborn child” whose immigration status was unknown—not the pregnant woman herself. Legislation passed in 2009— the Immigrant Children’s Health Improvement Act—once again gave states the option to cover “legal” immigrant pregnant women and children currently subject to the five-year ban and to receive federal financial matching payments to assist with the cost of coverage. As of January 2011, six states had opted to cover legal immigrant children, and 21 states including Minnesota covered pregnant women during the five-year waiting period. Finally, the ACA—signed into law in March 2010—will increase access to affordable health insurance for millions of Americans, but has specifically excluded many immigrants. Improved access to affordable coverage, both public and private, will be facilitated through the implementation of federal and state health insurance exchanges; Medicaid expansions for all persons under age 65 with family incomes up to 138 percent of the federal poverty level (FPL); and an individual mandate that will require all U.S. citizens (and legal permanent residents) to purchase health insurance coverage in 2014. Despite these far-reaching coverage expansions, some 20 million people will continue to be uninsured, including a substantial proportion (about 25 percent of all uninsured adults) of the population due to their immigration status. Under the ACA, legal immigrants are, in most circumstances, still subject to the fiveyear ban, and undocumented immigrants—regardless of length of time in the U.S.—will remain ineligible for public program coverage through

Medicaid or CHIP. Undocumented immigrants are also specifically prohibited from purchasing coverage in federal and state insurance exchanges, as the ACA requires that individuals purchasing exchange-based coverage meet citizenship/legal eligibility requirements. Undocumented immigrants are exempt from the individual mandate, along with a small group of individuals including, for example, American Indians and those with financial hardship or religious objections.

Immigrant status among non-citizens in Minnesota (2009) â&#x20AC;&#x153;Non-citizensâ&#x20AC;? include legal immigrants, non-immigrants, and undocumented immigrants. â&#x20AC;˘ Legal immigrants are legal permanent residents (â&#x20AC;&#x153;green cardâ&#x20AC;? holders), asylees and refugees, and other immigrants with unique situations. â&#x20AC;˘ Non-immigrants are individuals in the U.S. on a temporary tourist, student, or work visa. â&#x20AC;˘ Undocumented immigrants* are people who (1) have entered the country without approval from immigration authorities, or (2) have violated the terms of a temporary admission (e.g., overstaying a tourist/student visa without status adjustment*). *It is estimated that of all undocumented immigrants currently in the U.S., slightly more than half entered without approval, while others have overstayed a temporary visa.

FIGURE 1. Minnesotaâ&#x20AC;&#x2122;s immigrants. Significant barriers to access to care

Since 1996, significant restrictions on access to public health benefits have been placed on both legal- and non-legal immigrants. The five-year ban on access to public health insurance coverage for all immigrants that exists today results in a significant barrier to access to needed care. The ACA has not addressed the health care needs of immigrants under health reform; in fact, non-legal immigrants are specifically excluded from the individual mandate and the health insurance exchanges. States have had some flexibility in providing coverage for excluded pregnant women under the reauthorization of the Childrenâ&#x20AC;&#x2122;s Health Insurance Program, but few states have opted for this specific and targeted expansion. Several states, including Illinois, New York, and Massachusetts, have pursued state-only funded childrenâ&#x20AC;&#x2122;s health insurance programs following a â&#x20AC;&#x153;Cover All Kidsâ&#x20AC;? strategy, with no federal financial support. The expansion of state-sponsored childrenâ&#x20AC;&#x2122;s programs is highly unlikely given the downturn in the economy, state budget deficits, and the growing political divide between the two governing political parties. So who will provide care to our immigrant population? Interestingly, while the U.S. explicitly restricts access to private and public health insurance coverage for immigrants, both legal and non-legal, we implicitly rely on our formal and

Europe 13%

Mexico 17%

Canada 5% Central America and Caribbean 6%

Other Africa 10%

Other South America 6% Somalia/ Ethiopia 8%

Laos 8%

Thailand/Vietnam 8% Other Asia 15%

facilitating care for immigrants, providing basic primary care as legal residents wait for the fiveyear ban to expire and as undocumented families get their children the basic checkups and primary care services needed in the first years of life. In light of the growing restrictions under health reform, CHCs will play an even more pronounced role in covering insurance gaps among immigrants. Itâ&#x20AC;&#x2122;s a difficult time to be talking about doing more when there is less funding at both the state and national levels, and less political will to provide the basic safety-net services to those in need. We are likely to see lower state and federal tax revenue, targeted to fewer and more narrowly defined U.S. populations. Jessie Kemmick Pintor, MPH, is a doctoral student and Lynn A. Blewett, PhD, a professor in the University of Minnesota School of Public Health, Division of Health Policy and Management.

India 6%

Source: 2009 American Community Survey, U.S. Census Bureau.

informal safety nets to provide medical care when it is needed. Hospitals that provide services to Medicare and Medicaid patients must triage all patients and admit those who are in an emergency situation, regardless of legal status and health insurance coverage status. Those without coverage often wait until their situation has reached a crisis state before seeking careâ&#x20AC;&#x201D;often in the emergency room of a community hospital or at the tax-supported local public hospital whose mission is to provide care to the poor and underserved. Community Health Centers (CHCs, also known as Federally Qualified Health Centers)â&#x20AC;&#x201D; nonprofit clinics located in medically underserved areas, both urban and ruralâ&#x20AC;&#x201D;share a mission of making comprehensive primary care accessible to anyone regardless of insurance status, immigrant status, or ability to pay. The small but growing network of 17 CHCs operating in over 70 locations in Minnesota has played an essential role in

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MINNESOTA PHYSICIAN

SPECIAL

hile giving talks on change leadership, I’ve often referenced exercises that help the audience realize the need to think outside the box. There’s a humorous YouTube vignette of two people on an escalator that stops unexpectedly (go to YouTube and type in “escalator fail”). Their panicked reactions, while overly dramatic, make incisive points regarding entrenched thinking and what happens when we fail to recognize the need to change and find new solutions. People who work in the health care industry are no strangers to change—from advances in diagnostic technology and treatment options to new reimbursement and regulatory requirements. Over the past 50 years, most health care organizations have embraced incremental, system-sustaining innovations that have required accommodating the existing system rather than making revolutionary changes. Clayton Christensen and Michael Overdorf of the Harvard Business School have written

FOCUS:

REFORM

Health care reforms will require new workforce strategies Mary Ellen Wells, FACHE

about “disruptive innovation” that creates transformational changes beyond the capabilities of existing systems. But the impending changes due to health care reform, coupled with large economic and demographic shifts, portend an era that has the potential to be very disruptive. Without question, there is a great deal of interplay between the coming reforms and changes to the workforce. Whether or not political forces undo the planned reforms, most experts agree that the long-predicted economic and demographic changes that have begun will mandate a very different approach to health care and the

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H E A LT H

MINNESOTA PHYSICIAN OCTOBER 2011

health care workforce. Therefore, it’s imperative that physicians and other providers pay attention to the coming needs and begin to address them aggressively. What planned health care reforms are on the horizon? What demographic and economic changes are coming? And how will the health care workforce need to adapt to succeed during these disruptive times? In short, how can health care organizations get off the escalator? Key elements of health reform

Much has been written regarding the reforms that were enacted in 2010 as part of the Patient Protection and Affordable Care Act (ACA). The key elements of the ACA address three main areas: cost (affordability), access (availability), and quality (appropriateness). Among the specific strategies that will affect providers are: • New payment mechanisms • A large increase in the number of people with insurance coverage, along with improvements in coverage • Greater emphasis on prevention and on care that is datadriven and based on best practices First, as accountable care organizations (ACOs) take shape, providers will be expected to develop population-based models that span every aspect of care—from birth to death, prevention to episodic, acute to long-term. Even in those communities where these models may not be required (i.e., <5,000 lives), it’s expected that many of the tenets of accountable care will be implemented. Greater emphasis will be placed on prevention, chronic disease management, and continuity of care as medical homes become a

necessity for successful practices. Payment will move away from volume-driven formulas; outcomes and population management formulas will expand. Second, 32 million more people will have access to health insurance. More people will be seeking care, putting greater strains on the already undersized care structures. Finally, health care is finally entering the information age, as hospitals, insurance companies, and physicians adopt electronic health records and decision support systems. These will allow providers to access patient information quickly, record patient conditions and treatments with greater accuracy, and create databases that will help ensure that best practices are followed. Pay-for-performance and meaningful use incentives will provide even greater motivation for adopting EHRs and other hightech systems. While telemedicine applications have been around for almost 20 years, only recently have we seen broader acceptance of this type of caregiving. Store-and-forward techniques have been used in radiology and dermatology for years. Now, advances in videoconferencing and monitoring technology are spurring increased use and acceptance of telemedicine. Also, as network speeds improve, home applications will also grow, helping to extend prevention efforts and reduce unnecessary office and hospital visits. Changing demographics and the workforce

Now, consider the following demographic changes: • The U.S. population is expected to increase 13 percent by 2025, with greater ethnic and racial diversity. • The aging of baby boomers is resulting in greater health care utilization. The first boomers turn 65 this yea; within 20 years, more than 20 percent of the U.S. population will be 65 or older. Of note, people over the age of 65 use twice as many physician resources as those under 65. • Chronic diseases and unhealthy behaviors are creating

unprecedented utilization demands. By 2030, half the population will have at least one chronic condition. These patients average at least twice as many physician visits each year, compared to those without chronic conditions. According to the Centers for Disease Control and Prevention, more than one-third of U.S. adults are obese, leading to increases in chronic disease and disability and reduced productivity. • A significant portion of health care workers are entering the age of retirement. More than 36 percent of registered nurses will be between 50 and 64 years old in 2015, and 25 percent of physicians are 60 or older. • Half of the current graduates of physician training are women, many of whom are seeking better work/life balance as they have and raise children. According to Brian Day, MD, president of the Canadian Medical Association, female doctors “will not work the same hours or have the same lifespan of contributions to the medical system as males.” These changes, coupled with the pending health care reforms, will have a tremendous impact on the American health care workforce. Most notable is the shortage of caregivers. Prior to passage of the ACA, the Association of American Medical Colleges projected a shortage of 124,000 physicians by 2025. Given increased coverage resulting from the reform initiative, many believe there will be a need for 155,000 physicians by 2025. At the same time, the U.S. will be facing a shortage of more than 500,000 nurses. Though medical and nursing school enrollments will increase and more will be able to enter the medical field thanks to loans and grants from the ACA, shortages will remain. Modified models of care delivery

The expected shortages of providers, in combination with the increasing need for care coordination and utilization

oversight, has led many groups and systems to begin to modify their delivery models. For example, midlevel providers—nurse practitioners, certified registered nurse anesthetists, nurse midwives, and physician assistants— are taking on greater caseloads and care coordination. Many organizations are developing medical homes where physicians provide greater oversight and consultation services rather than concentrating on treating individual patients. There is still wide variation in the licensed scope of practice in every category of midlevel providers. Acceptance of the expanding role of these providers also varies among physicians, so tensions often exist as demonstration pilot projects expand and groups experiment to find the most effective systems. It is clear, however, that the most successful groups will be those that have learned how to best utilize each provider’s skills and abilities to the maximum of his or her license. Solo practitioners are almost nonexistent in Minnesota, and the number of independent practices has steadily declined. Many predict that there will be even further erosion of the independent groups as they give way to systems through employment or contractual arrangements. In addition, the site of care has gradually changed over the past 10 years, from heavily capitalized hospitals to ambulatory and other sites. Reform and demographic changes will bring about a new paradigm of care. Hospitals will no longer be the bastions of financial strength and control that they are today. They are quickly becoming cost centers—the least favored access point for the care people will seek throughout their lifetime. Hospital leaders are realizing this and are struggling with the new reality, where more admissions and expensive procedures are not the desired outcomes. Clinics will take on important roles in the integrated systems. Senior care services are expanding as well. Campuses where elders can move between independent or assisted settings

through rehab or long-term care facilities have become standard in most communities. Nurses and ancillary staff will need to shift away from the acute settings and into continuum-ofcare facilities. Drastic change is also occurring in administrative and support positions in the health care workforce. With the adoption of electronic health records, the need for medical records and transcription staff has declined as IT staffs have expanded. Up to 50,000 more HIT workers may be needed to implement EHRs in hospitals, clinics, and long-term care facilities and to satisfy criteria for meaningful use. And with greater emphasis on outcomes and best practices, there is a great need for data analysts and decision support specialists in every area of health care. The implementation of ACA-mandated insurance exchanges will create new roles in the insurance field and expand services offered by businesses that help individuals pick their best health-care insurance options.

Adapt to survive and thrive

The many changes coming to the health care workforce reflect both the implementation of health care reforms and the demographic changes that are now upon us. Several provisions in the reform legislation will help address the shifts that are occurring. However, physicians and health care leaders will be expected to make drastic, potentially disruptive changes in the way care is provided to manage the projected demands. To paraphrase Darwin, it’s not the strongest or the smartest that will survive; rather, it’s those who can adapt. Health care leaders will need to develop strategies to deal with health reform— or they’ll end up stuck on the escalator. Mary Ellen Wells, FACHE, is vice president of client development at Experienced Resources, LLC, which places health care leaders in interim roles and project assignments. She has spent over 30 years in various leadership positions at some of Minnesota’s top health care organizations, and is a fellow of the American College of Healthcare Executives.

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OCTOBER 2011

MINNESOTA PHYSICIAN

SPECIAL

he National Alliance on Mental Illness (NAMI) has long supported strong health care reform legislation that expands coverage to the millions of Americans who live with a mental illness. It is hard to think of any other illness that has faced such a long history of discrimination under health insurance, ranging from being unable to obtain insurance to having insurers refuse to cover mental health treatment. Three important pieces of recently enacted federal legislation will begin to make some headway in breaking down barriers and addressing discriminatory practices in mental health care: the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Act (Wellstone-Domenici Parity Act); the Patient Protection and Affordable Care Act (ACA); and the Health Care and Education Reconciliation Act of 2010. Eligibility and access

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Act will affect all

FOCUS:

H E A LT H

CARE

REFORM

Making headway in mental health Breaking down barriers and addressing discriminatory practices By Sue Abderholden, MPH health plans, including selfinsured plans. [A majority of Minnesotans are covered under self-insured plans, to which Minnesota’s parity law, passed in 1995, did not apply.] It’s impor-

the insurer has to cover it in the same way that it covers physical health care. The act takes into account financial limitations (copays, deductibles, and out-ofpocket limits), treatment limits

Under health care exchanges, all plans must cover mental health services—which is a first—and they must be covered in the same way as other health care conditions. tant to note that the federal parity act still doesn’t require coverage for mental health treatment; however, it does state that if an insurer covers such treatment,

MINNESOTA PHYSICIAN OCTOBER 2011

(number of visits, length of stays), and nonquantified limits (prior authorization and medical necessity criteria). As the regulations are implemented, we expect to see improved access for mental health treatment. The two health care laws expand eligibility for health insurance and thus will also increase access to mental health treatment. Probably one of the most significant items is the simplification of federal Medicaid eligibility (called Medical Assistance (MA) in Minnesota). In 2014, people with incomes below 133 percent of poverty will be able to qualify automatically for Medicaid. Because Minnesota had General Assistance Medical Care (GAMC) at the time, our state was one of 11 that could take advantage of early “opt-in” of Medicaid, allowing people who were on GAMC (incomes at 75 percent of the federal poverty level or $8,168) to be eligible for MA. There was quite a bit of a debate over this provision during the 2011 legislative session, but in the health and human services bill enacted during the special session, MA for people without disabilities with very low incomes remained in place. Basing eligibility on income rather than disability status

helps streamline enrollment and fosters earlier intervention. The process for certifying that you have a disability is a long and arduous, especially for people with a mental illness. Finding and keeping the documentation and paperwork when you live in abject poverty and mostly on the streets is nearly impossible. People who have a mental illness are frequently denied benefits by Social Security, often as many as three times before they are approved. For people with mental illnesses who end up in our criminal justice system, the early opt-in will make it far easier to connect them with mental health care services as soon as they are released. For young adults, perhaps experiencing their first psychiatric hospitalization, the early opt-in will enable them to access treatment in the community without having to prove to the Social Security Administration that they are so disabled by their mental illness they cannot work. Now they will be able to qualify for MA, obtain care, and begin to work as part of their recovery. Under the health reform legislation, unmarried young adults will be able to continue to be covered under their parents’ coverage until they are 26 years of age. [Minnesota has a law providing coverage up to 25 but it does not include self-insured plans or state employees.] The 18–26 age group is one of the largest uninsured groups—and these are key ages when mental illness strikes. An increasing number of young adults with mental illnesses are attending college—some part-time. Their part-time status has made it impossible to be covered under their parents’ health plan; and purchasing a single plan has often meant high deductibles, coverage of only generic medications, and limited coverage of mental health treatment. Any reader with a recent college or high school graduate knows how hard it is to find a job with health care coverage. Having coverage results in improved access to appropriate and timely mental health treatment during years when there is a significant risk of developing a mental illness.

Effects of mental health reform on providers: People with mental illnesses die 25 years earlier than their peers—their life expectancy is the same as that of people who live in Bangladesh. Minnesota has launched the “10 x 10” campaign to increase people’s life expectancy by 10 years in 10 years. Its efforts to promote integrated care will be supported by provisions in the ACA through grants for co-locating primary and specialty care in community-based mental health settings. Co-location offers an opportunity to provide coordinated care to individuals with mental illnesses and co-occurring primary care conditions and chronic diseases. The ACA established health care exchanges—a marketplace to purchase health insurance. Under health care exchanges, all plans must cover mental health services—which is a first—and they must be covered in the same way as other health care conditions, as set forth in the Wellstone-Domenici Parity Act. This will provide access to mental health care to individuals seeking single policies and those who work for small businesses. NAMI will be advocating for a full continuum of mental health services (in-home, day treatment, residential services, etc.) to be included in the essential benefit set. The new law assures eligibility for health coverage by prohibiting the practice of excluding people with pre-existing conditions in all health plans. This went into effect right away for children under age 19, and will expand to everyone else in 2014. NAMI has learned of people being denied coverage for non-severe forms of anxiety and depression—even if they had never been hospitalized. For people with more serious forms of mental illness, having coverage for treatment provides hope for recovery. Using Minnesota’s option for people denied coverage, the Minnesota Comprehensive Health Association, with its high deductibles, premiums, and copayments, was not feasible for many. Preventive health services

The ACA requires that in the

• Opportunities for earlier intervention • More integrated care, especially for comorbid diseases (e.g., depression and diabetes/heart disease/cancer) • Co-located primary care with specialty mental health care • Additional mental health professionals and paraprofessionals as a result of training/education opportunities • More home and community-based services for people with mental illnesses future, all health plans will be required to cover preventive health services—evidence-based items or services that have, in effect, a rating of ‘A’ or ‘B’ in the current recommendations of the U.S. Preventive Services Task Force. This would include depression screenings for adults, children, and adolescents. More than 500 people die by suicide in Minnesota every year, most as a result of untreated mental illness, particularly depression. Earlier intervention and access to effective treatment can help prevent these deaths. Depression often co-occurs with other health conditions, such as cancer (10 to 30 percent of people with cancer are found to be clinically depressed), heart disease (depression is more prevalent in heart patients than in the general population, especially in young women with acute heart disease), and diabetes. The ACA includes funding for five-year grants to establish national centers of excellence for treatment of depressive disorders. Additionally, there is funding to support education and research on postpartum depression. Minnesota has a severe shortage of mental health professionals—especially from diverse communities, in rural areas of our state, and in certain types of professionals (psychiatrists, clinical nurse specialists). This is particularly true for the provision of children’s mental health services. The new law includes funding for mental and health education and training grants and authorizes grants to colleges and universities to support the recruitment and education of students in social work programs, interdisciplinary psychology training programs, and internships or field placement programs in child and adolescent mental health. There are also grants available to state licensed mental health organiza-

tions to train paraprofessional child and adolescent mental health workers. Several new opportunities to try new approaches under Medicaid are also included in the ACA. These include an expansion of home and community-based services for people with disabilities (including those with a serious mental illness); alternatives to institutional level of care; and coordinated care for people with multiple chronic health conditions, including serious mental illnesses. Minnesota is looking at several of these options as an alternative to more costly institutional care and to prevent hospitalizations. Much of the funding that was lost this year in Minnesota’s legislative session was grant

funding to counties to pay for mental health care and treatment for people who were uninsured or underinsured (e.g., through nonparity covered plans or high-deductible plans) and for services not typically covered by health plans. The more we can move toward universal coverage and toward full coverage of mental health care and treatment, the less we will have to rely on block grants to counties and the less people will have to “wait in line” for care that they need. NAMI is looking forward to the implementation of many of the provisions of these three new laws. The time of discriminating against children and adults with mental illnesses is coming to an end. Accessing mental health care and treatment means that people will be able to better function in school, work, home, and the community. Sue Abderholden, MPH, is the executive director of NAMI Minnesota.

OCTOBER 2011

MINNESOTA PHYSICIAN

PRACTICE

ost health care providers are seeing an increase in the number of self-pay patients. And if your practice is like most, your level of accounts receivable from self-pay patients is increasing faster than your revenue. Re-evaluating your patient statement and billing process can help improve both self-pay collections and patient satisfaction. The traditional focus areas in health care billing—coding and compliance—are essential but insufficient when it comes to self-pay patients. There’s a greater need for clear and concise communication whether in print or online. Self-pay patients demand administrative ease. Younger patients in particular indicate they are willing to change providers to gain that ease. Consider these dramatic survey results released this spring by Intuit Health: • 59 percent of Gen Y patients (i.e., those born between 1980 and 1992) say they would

Transforming billing practices Billing design can improve self-pay collections and patient satisfaction By Brian Kueppers and Nels Peterson

switch doctors for one with better online access. • 41 percent of all patients do not have confidence that the billed amount is correct.

• 45 percent of patients wait more than a month to pay their doctor bill. The last statistic indicates that health care providers have

A billing statement should inform, not overwhelm. • 28 percent of Gen Y patients are unsure whether to pay their doctor or the insurance company. • 57 percent of patients have had at least one medical bill go to a collection agency.

Mankato Clinic is looking for a full-time Nurse Practitioner or Physician Assistant to work in our Mapleton satellite 20+ hours/week, and rotating weekday/every third weekend shifts in our Urgent Care Department. Qualifications include but are not limited to: NP: Masters Degree in nursing encompassing specialized classroom and experiential learning as a nurse practitioner OR grandfathered in as an NP if certified prior to 1995. Current licensure by the State of Minnesota and Advanced Practice Certification by ANCC, ACNP, National Certification Board of Pediatric Nurse Practitioner and Nurses, or other certification agencies to practice as a registered nurse and Nurse Practitioner. PA: Graduate of an approved Physician Assistant Program, Certification by the NCCPA, and current Minnesota Registration with the State Board of Medical Practice. For both: Current authorization from the MN Board of Nursing/Physician Assistants to prescribe drugs and therapeutic devices; current Basic Life Support and Advanced Cardiac Life Support certifications; three years of employment experience preferred; effective interpersonal skills necessary for providing patient/family instruction and collaboration with health team members. You will enjoy an excellent benefits package including generous CME expense and time-off allowance, 401(k) profit sharing plan; EAP; employee discounts; six paid holidays 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.

www.mankato-clinic.com

MANAGEMENT

MINNESOTA PHYSICIAN OCTOBER 2011

an excellent opportunity to improve their bottom line by taking simple steps to improve the clarity and accuracy of their patient statements. Increasing the value of the patient statement

Nurses, doctors, and administrative professionals work hard to satisfy patients during a visit. Clear communication is a big part of the perceived service provided in any in-person patient interaction; just look at the billboards along any metropolitan freeway and you can see health care providers emphasize their staff’s attentiveness to patient needs. But what happens after the patient leaves the facility? For self-pay patients, the billing statement becomes an important “after-care” communication mechanism. The billing statement is an expression of the health care provider’s brand— for better or for worse. Considering the Intuit Health survey results noted above, it seems that too often it’s “for worse, and the statement fails to strengthen the provider’s brand and the patient’s experience. The best statements not only result in patient satisfaction through clear communication, but also improve cash flow and decrease collections. It’s important to realize that just like good customer service

inside a provider’s facility, a clear and concise patient statement is beneficial for both patients and providers. So how does a health care provider set up the billing statement as a value driver? Here are the basics. Be clear and bold. Brand your statement. Patients come to associate your brand characteristics—logo, type, colors, words—with their experiences at your facility. Branding expresses who you are, so your brand should be consistent everywhere. Remember that patients may visit more than one facility or specialist. Present your logo and colors on the statement exactly the same way you do on all your materials. Ensure that the brand is expressed both in the body of the statement and on the tearoff stub. Use legible, consistent fonts. Choose easy-to-read fonts and font sizes. APEX’s statement design studio manager Joe Fyten recommends that organizations: • Use a sans serif typeface throughout the statement (sans serif typefaces do not use serifs, which are small lines at the ends of characters; popular sans serif fonts include Helvetica, Arial, and Geneva). • Limit serif fonts to message areas (popular serif fonts include Times Roman, Palatino, and Garamond). • Stay consistent with whatever fonts they choose. • Never use more than two fonts within the statement design. • Keep type sizes consistent within each area of the form. • Use boldface type, larger type, or all capitals sparingly and only for messages that need extra emphasis. Make sure patients don’t have to search for their reading glasses to review the basic information. Enlarge the font sizes of the account or guarantor number, amount due, statement due date, and remittance address. Be concise. State only what is necessary. Self-pay patients

are not experts in coding and compliance. It’s better to provide enough information to satisfy most patient’s informational needs than to overwhelm all patients with data relevant for only a few. Those few can call— and can receive quick and precise answers when your office or call center has ready access to electronic patient billing data. When patient support representatives have electronic access to the exact same document the patient is viewing, calls are likely to be shorter and more productive and will reinforce the provider’s commitment to offering a quality “aftercare” experience. Revise carefully. Consider again the staggering survey results noted above—41 percent of patients believe their bill may be inaccurate. A patient who questions a bill is much more likely to be among the 57 percent of patients who keep a bill outstanding so long that it goes to a collection agency! Providers typically get a strong financial return on the modest investment of time it takes to get the statement design right. Once you have a draft design, ensure its accuracy in a rigorous proof-and-correction process that involves running a full month of statements. In summary, a statement should inform, not overwhelm. The provider’s brand should be prominent. Key information should be highlighted, and all aspects of the patient’s financial responsibility should be crystal clear. Customer service representatives should have ready electronic access to the exact document the patient receives. All of these can increase the value of the patient statement in both collections and one-call resolution when patients do call with questions. Online billing

Online billing is essential to younger patients. Remember, 59 percent of Gen Y patients said they would switch doctors for one with better online access. Your practice may have invested in software that allows patients to access their medical data through an online portal.

It’s important also to ensure easy online bill payment. Ideally, online billing means two things. First, patients are able to enroll in electronic statements—which are more convenient for patients (and all but demanded by younger patients)—and, furthermore, cost providers only about half the outlay for paper statements. Second, an ideal online billing system provides a portal for patients to visit and make payment. The electronic statement. The primary guidance for electronic statements is straightforward: Your electronic statement should exactly match your printed statement. You build your brand by clear and consistent communication. Your statement design (both printed and electronic) should stress the availability of online services, including bill payment. Consider using QR (“quick response”) codes that patients can photograph with their smart phones and be taken directly to the online billing portal. All these aspects of billing have the double benefit of making payment easier for patients and lowering costs for providers. Electronic payments. By now, most people are familiar with online payment portals, whether for utility companies or online merchants. In addition to offering a seamless customer experience, the online billing portal should be fully branded to feature your organization. Patients should feel they are interacting directly with their “own” provider and not with an anonymous third party. Ideally, patients should have at least three options for making electronic payment: via the online billing portal, by phone with a customer service representative, and by a one-time quick payment from a paper statement. Other considerations

Health care providers often use third-party firms to help achieve the financial and patient-satisfaction benefits of clear, effective billing. Whether printed or electronic statements are processed in-house or by a

third party, it’s essential for the health care provider to maintain direct access to the exact statement sent to patients. When customer service personnel can review both past and current statements, the check-in process can become an opportunity for patients to resolve questions, thereby saving call center resources later. When patients do call customer service, calls are smoother and more efficient when staff members can review current and past statements. Typically, patient statements should be archived for at least 12 months. Some organizations may wish to maintain statement archives for longer periods, matching the duration to medical records maintained under HIPAA requirements. By archiving statements, providers can also improve their ability to track cash flows. Finance managers can view exactly when payments were received and aggregate statement and payment data for more robust reporting.

When providers do elect to work with a third party for the printing and distribution of statements, it’s essential to keep in mind the primary message of this discussion: Patient statements and online payment portals should be branded communication mechanisms designed to strengthen the bond between patient and provider. Technological transformation

The patient billing statement can drive value for health care providers and should not be overlooked. In recent years, technology has transformed the billing practices in industries across the board. Now, health care providers who put patient satisfaction first can reduce their own costs, improve service, and increase collections from self-pay patients. Brian Kueppers is founder and CEO and Nels Peterson is a sales consultant for Apex Print Technologies, based in St. Paul.

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OCTOBER 2011

MINNESOTA PHYSICIAN

PAT I E N T

Shared decision-making

n September 2009 I felt an ache and pressure in my chest one evening as I walked home from work. Over the next couple of weeks it recurred with mild exertion. At first I thought it might be indigestion or the remnants of a bad case of bronchitis. When it didn’t go away, I went to see my primary care doctor, who diagnosed my chest pain as angina caused by insufficient oxygen to my heart, and sent me to a cardiologist. A stress test and an EKG showed that, not yet 60, I had had two nontransmural infarcts. I knew that an infarct was a heart attack, but I did not know what nontransmural meant. I learned it means that the damage to the heart muscle did not go all the way through the wall of the heart. “Mild” heart attacks, in other words. Next I had an angiogram that showed significant blockage (99 percent and 85 percent) in two major arteries and lesser blockage (65 percent) in another. My cardiologist wanted to insert stents, but I had reservations, primarily because I know they

Wary cardiologist, leery patient work it out By John Malan can close up again and, even if they worked perfectly, would require me to be on a blood thinner for the rest of my life. He was not at all open to talking about alternatives. He started me on Lipitor for my cholesterol

always do when I’m scared) and looked around. Dean Ornish’s book “Dr. Ornish’s Program for Reversing Heart Disease” caught my eye, and his holistic approach, which involves a very low-fat diet, exercise, and stress

My cardiologist wanted to insert stents, but I had reservations, primarily because I know they can close up again. and lisinopril for my blood pressure. And that was it. If I wanted his input or help, we’d be talking stents. Some years back, I had discovered I had borderline high blood pressure. I went to the bookstore (as my wife says I

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PERSPECTIVE

MINNESOTA PHYSICIAN OCTOBER 2011

management, was very much to my liking. Unfortunately, I did not take my condition seriously enough to follow through. Now that I had had a much sterner warning, I went back to the book with renewed commitment. But my doctor said the diet was too difficult, that I wouldn’t be able to stay with it. He also implied that—despite favorable reports in journals including JAMA and Circulation, among others—he doubted Ornish’s claim that adherence to the diet could reverse blockage in the arteries. Then, demonstrating just how little he understood of what I was saying, the doctor suggested that I was in denial. I disagreed vehemently, saying I believed I could die at any minute. He looked at the angiogram and said, “No, I don’t think so.” Neither of the arteries with major blockage was the socalled widow-maker. Seeking direction

The next two weeks were very hard. My wife wanted me to do whatever needed to be done as quickly as possible; if that meant getting stents, then that’s what I should do. I, on the other hand, saw stents as a last-ditch measure. One night it came to a head: We could not go on without some sense of direction. Suddenly we remembered that

a friend from church was married to a cardiologist. I called her and she put her husband on the phone. He spent the next 30 minutes talking to me. He prescribed metoprolol, a beta blocker that lowers blood pressure and reduces the heart’s metabolic needs, and nitroglycerin, in case I experienced chest pain that didn’t go away, and told me to call his office for an appointment. His compassion that night was a godsend. He gave me another stress test. This time I did pretty well, with no angina. He reassured me that my heart was stable and that I could follow the Ornish program if I wished while staying on the prescriptions, which I was happy to do. Differing views

Then something unexpected happened. Within a couple of weeks of completing the stress test without pain, I began to have serious angina just walking. My new cardiologist’s nurse had told me how to use the nitroglycerin: As soon as I felt chest pain, I was to rest and breathe deeply for five minutes. If the pain did not stop, I was to put a nitro tablet under my tongue and wait five more minutes. If the pain continued, I was to do it again. If I got to the third tablet, I was to go to the emergency room. I never had to take the first tablet, and because of that I never thought to report this development to my doctor. Over the next two months I maintained the Ornish diet, did yoga, meditated, and gradually began exercising on a stationary bicycle, carefully maintaining my level of effort so that I experienced only mild angina that quickly went away when I stopped to rest. Gradually, the amount of exercise I could tolerate increased. When I eventually told the cardiologist about all this, he seemed disappointed that I had not called. The reason, I explained, was that I had read that the heart responds to angina by developing new arteries, called collaterals, that grow around the SHARED to page 32

NEW POSITIONS:

Minneapolis VA Medical Center

Family Practice Urgent Care

Medical Director of Community-Based Outpatient Clinics The Minneapolis VA Medical Center (MVAMC), affiliated with the University of Minnesota, is seeking a dynamic leader for the position of Medical Director of the Community-Based Outpatient Clinics (CBOCs).The Director supervises the clinical operations and providers of 10 clinics throughout Minnesota and Wisconsin, and oversees the development of several new clinics in both metropolitan and rural settings.We seek a physician with experience in ambulatory medicine and administration who will provide leadership and clinical duties for the CBOCs.The CBOCs provide primary care, and mental health care onsite and through telemedicine to more than 20,000 veterans.This position would include an academic appointment at the University of Minnesota. Applicants must be board-certified in Internal Medicine and experience working in VA facilities is preferred. Competitive salary, possible recruitment incentive, and benefits with performance pay.

Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •

Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned

Please contact or fax CV to: Joel Sagedahl, M.D. 1495 Highway 101 North, Plymouth, MN 55447 763-504-6600 • Fax 763-504-6622

Interested candidates should contact Don Rainwater, 413-584-4040, ext. 2907, or don.rainwater@va.gov.

Visit our website at www.NWFPC.com

Equal Opportunity Employer

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional part-time or full-time BC/BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Previous electronic medical record experience is preferred but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals.

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

Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent benefit package, a rewarding practice and a commitment to providing exceptional patient-centered care. St Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

Caring for body, mind and spirit. Onamia, MN • mlhealth.org • 877 - 535-3154 7 FAMILY PHYSICIANS • 8 PAs • 1 GENERAL SURGEON • CRITICAL ACCESS HOSPITAL ER STAFFED 24/7 • ATTACHED GERIATRIC UNIT & LTC FACILITY • 4 CLINICS

healthpartners.com ©

OCTOBER 2011

MINNESOTA PHYSICIAN

Shared from page 30 blockage into the area that is not getting enough blood flow. In short, the heart heals itself. He offered me a new pill that would suppress angina and allow me to be more active. I asked him if this would prevent my heart from knowing it needed to develop collaterals and he said it would. Thus, taking the medication would relieve my symptoms—but thwart the heart’s natural ability to heal itself. No thanks, I said. The central question

While my relationship with this cardiologist was much more supportive and open than with my first cardiologist, we still struggled with a fundamental question: Could I improve my heart’s health through lifestyle changes? Or was the best I could hope for to manage the symptoms of a sick heart by relying on traditional medicine? For me, the necessary changes in my way of life were not onerous. We had eaten a largely vegetarian diet for years. The biggest difference in the

I have hedged my bets by carefully following my cardiologist’s instructions, which his flexibility has enabled me to do without any major compromises. Ornish diet was the limit on fats—only 27 grams per day, of which only nine may be saturated. I lost 20 pounds in the first month or so and have never put it back on. Bill Clinton has recently done likewise, I hear. I have a sweet tooth and I was afraid I would not be allowed to satisfy it, but there are many recipes for low-fat desserts that use fruit and other complex sugars that the diet allows. My other weakness is for things salty and crunchy. I have had to accept some loss there, though there are some crackers with low fat and sodium that I have found are quite good when dipped in salsa. My total cholesterol in January 2010 was 108, well within the desirable range. We checked it again in December and it was still 108. The only

concern was that my HDL, the “good” cholesterol, was too low. I am addressing that with Omega 3 supplements. (Omega 3 is a naturally occurring lipid that increases HDL.) A workable compromise— for now

I have hedged my bets by carefully following my cardiologist’s instructions, which his flexibility has enabled me to do without any major compromises. So things have gone well. I am exercising four or five times a week now and rarely experience any angina. I continue to believe that I might be farther along if I had a cardiologist who supported the complete Ornish program, which includes group sessions in which patients can talk with each other and a caregiver about their struggles and receive emo-

A Diverse and Vital Health Service

tional support and encouragement, as well as a greater willingness to discontinue meds when it is safe to do so. I plan to visit an Ornish-friendly cardiologist in Chicago before year’s end. I once had dinner with a man who told me he had heart disease with at least one stent, as I recall. He had steak and potatoes and ordered a side dish of gravy. Even the waitress looked shocked. He said, “I’m a great believer in pills.” I do understand that doctors see more of this kind of patient than they do people like me— but I am, as it turns out, a person like me. I look forward to the day when doctors are trained and supported in working with patients who make a serious effort to be informed, who are willing to make significant lifestyle changes, and who want to be a full partner in the process of healing. John Malan has a desk job in Springfield, Ill., where he is known to the local medical community as a well-read, engaged patient with a strong desire to know what’s going on and a strong will to live.

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

MINNESOTA PHYSICIAN OCTOBER 2011

Opportunities available in the following specialty:

Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

Family Medicine Rochester Northwest Clinic Rochester Southeast Clinic St.Charles Clinic Internal Medicine Southeast Clinic Occupational Medicine Southeast Clinic Dermatology Southeast Clinic

Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities.

Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 1650 4th Street SE

Bemidji, Minnesota, located in northwestern Minnesota, is a beautiful resort community offering exceptional schools, a state university, and yearround cultural activity as well as great access to the outdoors for year-round recreation activity. To learn more about this excellent practice opportunity contact: Kathie Lee, Director Physician Placement Phone: 701-280-4887 Fax: 701-280-4136 Email: Kathie.Lee@sanfordhealth.org

Rochester, MN 55904

Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Two BC/BE Orthopaedic Surgeons wanted to join four orthopaedic surgeons at Sanford Bemidji Orthopaedics Clinic in Bemidji, Minnesota. Part of an 85-physician, multi-specialty group practice and 118 bed acute care hospital. 1:6 call anticipated. Competitive compensation/benefits package, paid malpractice, relocation assistance and more. Sanford Health of Northern Minnesota has 1,450+employees and is part of Sanford Health system based in Fargo, ND and Sioux Falls, SD.

email: egarcia@olmmed.org Phone: 507.529.6610

AA/EOE

Fax: 507.529.6622 EOE

www.olmstedmedicalcenter.org

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ƉƌĂĐƟĐĞ͕ //ĨĨ ǇǇŽƵ ŽƵ ĂĂƌĞ ƌĞ ŝŝŶƚĞƌĞƐƚĞĚ ŶƚĞƌĞƐƚĞĚ ŝŝŶ Ŷ Ă ĐĐŽŶĮĚĞŶƟĂů ŽŶĮĚĞŶƟĂů ůůŽŽŬ ŽŽŬ ĂĂƚƚ ƚƚŚŝƐ ŚŝƐ Ɖ ƌĂĐƟĐĞ͕ ƉůĞĂƐĞ Ɖ ůĞĂƐĞ ĐĐŽŶƚĂĐƚ͗ ŽŶƚĂĐƚ͗ ϮϭϴͲϲϯϭͲϳϰϲϮ Žƌƌ ũũƵĚǇ͘ĞƌĚĂŚůΛƚƌŝĐŽƵŶƚǇŚŽƐƉŝƚĂů͘ŽƌŐ ::ƵĚǇ ƵĚǇ ƌĚĂŚů ƌĚĂŚů ĂĂƚƚ Ϯ ϭϴͲϲϯϭͲϳϰϲϮ Ž ƵĚǇ͘ĞƌĚĂŚůΛƚƌŝĐŽƵŶƚǇŚŽƐƉŝƚĂů͘ŽƌŐ Žďďŝ ĚĂŵƐ͕ D͘ ͘ ďŽďďŝ͘ĂĚĂŵƐΛƚƌŝĐŽƵŶƚǇŚŽƐƉŝƚĂů͘ŽƌŐ Žďďŝ ĚĂŵƐ͕ D ͘ ͘ ĂĂƚƚ ď Žďďŝ͘ĂĚĂŵƐΛƚƌŝĐŽƵŶƚǇŚŽƐƉŝƚĂů͘ŽƌŐ

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OCTOBER 2011

MINNESOTA PHYSICIAN

PRACTICE

The pre-visit interview

ere’s a familiar scenario; A new patient arrives at the clinic to be seen for an acute or worrisome condition (in my office, it would be related to back and/or neck pain). Upon checking in, the patient is asked to fill out a written history before seeing the physician. Sometimes the patient manages to do so; sometimes not. Even if the patient has time to finish filling out the form before the appointment, he or she may neglect to include relevant information or may provide inaccurate or incomplete information, especially if the patient’s medical history is complex. The physician may have time to glance through the history before entering the room, but it will probably be only a cursory review as he or she steps into the examining room. Valuable time may be spent checking for accuracy and adding details that the patient may have forgotten to include. Both the physician and the patient feel rushed and frustrated, since they both want the same thing: to find out what is wrong with the

MANAGEMENT

Understanding the patient’s story By Thomas Rieser, MD

patient and determine the best course of treatment. This scenario plays out every day in medical clinics, from small family practices to multispecialty facilities to subspecialty groups. Every physician would agree that there’s no substitute for an accurate, thorough patient history—and every patient’s medical story is unique. But patients and physicians alike are dealing with busy schedules and competing demands on their time and attention. In our practice, we have found a solution to this dilemma by developing a process in which an “interview historian” takes the patient’s history by telephone several days prior to

the patient’s initial visit. By implementing this process, we have been able to obtain complete and accurate information from the patient, especially as it relates to any condition or injury that may have occurred as a result of a motor vehicle accident or a work-related accident, in addition to comprehensive detail relative to the problem at hand. We have found that the pre-visit interview enhances the usefulness of the patient history, reduces time spent reviewing and completing the history during the clinic visit, and increases patients’ satisfaction with their health care experience.

Managing complex information

Our practice began using what we called “personal historians” in the mid-1980s. The original impetus for the service was a need to obtain detailed information for injury cases for which the details were often omitted during a rushed or brief visit. Insurance companies for auto workers’ compensation, and other professionals such as attorneys, were requesting specific information so that accurate and fair decisions could be handed down. This process eventually worked so well in acquiring valuable information for injury cases that it was gradually incorporated into the initial evaluation for all of our new patients. In its first incarnation, the previsit interview began with a telephone call to the patient, at which time the historian would record the patient’s history so it would be available for the patient’s initial visit with the physician. Originally, the historINTERVIEW to page 36

A Diverse and Vital Health Service Welcome to Boynton Health Service

Boynton Health Service

Medical Director

>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

ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŚĂƐ ĂŶ ĞǆĐŝƟŶŐ ŽƉƉŽƌƚƵŶŝƚǇ ĨŽƌ Ă DĞĚŝĐĂů ŝƌĞĐƚŽƌ͘ dŚŝƐ ƐĞŶŝŽƌ ůĞĂĚĞƌƐŚŝƉ ƉŽƐŝƟŽŶ ŝƐ ƉƌŝŵĂƌŝůǇ ƌĞƐƉŽŶƐŝďůĞ ĨŽƌ ĚŝƌĞĐƟŶŐ ŵĞĚŝĐĂů ƐĞƌǀŝĐĞƐ͕ ĞŶƐƵƌŝŶŐ ƐƚĂī ĂĚŚĞƌĞŶĐĞ ƚŽ ƌĞůĞǀĂŶƚ ƌĞŐƵůĂƟŽŶƐ ĂŶĚ ŚŝŐŚĞƐƚ ƉƌŽĨĞƐƐŝŽŶĂů ĂŶĚ ĞƚŚŝĐĂů ƐƚĂŶĚĂƌĚƐ͕ ĂŶĚ ĐŽůůĂďŽƌĂƟŽŶ ǁŝƚŚ ƚŚĞ ŝƌĞĐƚŽƌ ŝŶ ĨŽƌŵƵůĂƟŶŐ ůŽŶŐ ƌĂŶŐĞ ƐƚƌĂƚĞŐŝĐ ƉůĂŶŶŝŶŐ ĂŶĚ ƉŽůŝĐŝĞƐ͘

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

dŚĞ ŝĚĞĂů ĂƉƉůŝĐĂŶƚ ǁŝůů ŚĂǀĞ ƐƚƌŽŶŐ ůĞĂĚĞƌƐŚŝƉ ƐŬŝůůƐ͕ ĂŶĚ ĂŶ ĂďŝůŝƚǇ ƚŽ ǁŽƌŬ ǁŝƚŚ Ă ĚŝǀĞƌƐĞ ƉŽƉƵůĂƟŽŶ͘ ǆƉĞƌŝĞŶĐĞ ŝŶ Ă ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƫŶŐ͕ ĂŶĚ ŬŶŽǁůĞĚŐĞ ŽĨ ĞůĞĐƚƌŽŶŝĐ ŚĞĂůƚŚ ƌĞĐŽƌĚƐ͕ ƚŚŝƌĚ ƉĂƌƚǇ ĂĐĐƌĞĚŝƚĂƟŽŶ ƐƚĂŶĚĂƌĚƐ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ĂƉƉƌŽĂĐŚĞƐ ƚŽ ŵĂŝŶƚĂŝŶŝŶŐ ĂŶĚ ŝŵƉƌŽǀŝŶŐ ĐŽŵŵƵŶŝƚǇ ŚĞĂůƚŚ ǁŽƵůĚ ďĞ ďĞŶĞĮĐŝĂů͘ dŚĞ DĞĚŝĐĂů ŝƌĞĐƚŽƌ ǁŝůů ĂůƐŽ ƉƌŽǀŝĚĞ ƐŽŵĞ ƉĂƟĞŶƚ ĐĂƌĞ ƟŵĞ ĞĂĐŚ ǁĞĞŬ͘

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

dŽ ůĞĂƌŶ ŵŽƌĞ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ĂǀŝĚ 'ŽůĚĞŶ͕ ŝƌĞĐƚŽƌ͕ WƵďůŝĐ ,ĞĂůƚŚ ĂŶĚ ŽŵŵƵŶŝĐĂƟŽŶƐ (612) 626-6738, dgolden@bhs.umn.edu ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌǇ ĂŶĚ ĞǆĐĞůůĞŶƚ ďĞŶĞĮƚƐ ŝŶĐůƵĚŝŶŐ D ͘ ƉƉůǇ ŽŶůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽǇŵĞŶƚ͘ƵŵŶ͘ĞĚƵ ĂŶĚ ƌĞĨĞƌĞŶĐĞ ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 173177͘ 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

MINNESOTA PHYSICIAN OCTOBER 2011

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

Minneapolis VA Medical Center Primary Care Provider The Minneapolis VA Health Care System (MVAHCS) is seeking a Primary Care Provider. Applicants must be board-certified in internal medicine. Clinical work involves taking care of Veterans in the outpatient setting with options to do inpatient attending, working with internal medicine residents.A faculty appointment in the Department of Medicine at the University of Minnesota is possible. Competitive salary and benefits with potential for a recruitment incentive.

Send CV and application to: Human Resources Management Service Attention: Brittany Buck MVAHCS One Veterans Drive Minneapolis MN 55417 or, email Brittany.Buck@va.gov. EEO Employer

www.lrhc.org

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/ BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multi-specialty 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: • Family Medicine • General Surgery • Geriatrician/ Outpatient Internal Medicine • Hospitalist • Infectious Disease

• Internal Medicine • Oncology • Orthopedic Surgery • Pain Management • 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

OCTOBER 2011

MINNESOTA PHYSICIAN

Interview from page 34 ian would type up the history, which would be added to the other paperwork in the patient’s file. Today, the interview is recorded and transcribed electronically. In today’s health care environment, the historian typically works from templates that are used with electronic health records. Though the historian asks the standard health history questions, a personal telephone interview allows the patient to expand on and explain his or her particular history. We are able to obtain information with more accuracy and depth as it relates to the patient’s chief complaint, history of present illness, factors that make the problem better and worse, past medical history, social history, review of systems, and medications. In addition to completing the standard history components, the historians are able to more thoroughly record the patient’s story in a more personal manner. The pre-visit interview takes approximately 30 to 60 minutes, depending upon the complexity

of the case. Over the years, we have tweaked the process to keep pace with improvements in technology and practice management including development of templates and electronic health records. Currently, the historian initiates contact via a phone call, usually a few days prior to the visit. At the time of the patient visit, a draft history has already been prepared and stored in the electronic health record for the physician(s) to review in detail with the patient during the initial patient visit. Our historians are medical transcriptionists who begin working in our clinic environment to learn the office process. They may perform daily transcription for our providers and then begin to transition into conducting telephone interviews. Once historians are fully trained, they usually work from their homes accessing our electronic health record via our secure network. In order to best meet the availability of our patients, their work hours vary accordingly. We started with one historian and now employ four.

Because the new patient pre-visit interview is considered a part of the in-person newpatient visit, patients are not billed separately for it. Although this process is more costly to our practice (because we do not charge separately for this visit), I feel the personal touch that it provides results in a product that is superior to the typical system and makes new-patient visits more efficient and comfortable for the patient. Improved patient, physician satisfaction

Patient satisfaction with the patient pre-visit interview process has been extremely high. Many patients have noted that this is the first time that someone actually talked with them for an extensive period of time to listen to their story. We hear over and over again how grateful they are that they could have a “live“ conversation about their history and upcoming visit. The benefits to physicians and other providers is that the pre-visit interview provides a deeper level of documentation

of the history, condition or injury, timeliness, and past medical information—all of which are extremely valuable in making an assessment regarding treatment. The process also provides for a first visit that engages the patient while we review the recorded history in an efficient manner while verifying its accuracy with the patient. Using the pre-visit interview streamlines the exam without compromising quality. I believe that this previsit interview process can be very helpful in any other medical specialty by providing an effective, efficient, and meaningful use of time and resources for both the patient and the provider at each new-patient visit. Thomas Rieser, MD, is the founding physician at Minnesota’s Midwest Spine Institute, an independent medical clinic treating spinal disease and disorders, and is involved in research on new techniques and advances in spine care.

St. Cloud VA Health Care System is accepting applications for the following full or part-time positions:

• Internal Medicine

• Neurology (St. Cloud) • Dermatology (St. Cloud) • Disability Examiner (IM or FP) (St. Cloud) • Weekend Medical Officer of the Day (IM or FP) (fee for service

(Alexandria, Brainerd, St. Cloud)

• Family Practice (Alexandria, Brainerd, St. Cloud)

• Psychiatrist (Brainerd, St. Cloud)

Freedom to Care and Freedom to Thrive with Allina Hospitals & Clinics

appointment, St.Cloud)

• ENT (St. Cloud) • Geriatrician

• Medical DirectorExtended Care & Rehab (IM or Geriatrics)

(Nursing Home—St. Cloud)

• Hematology/Oncology

(St. Cloud)

(St. Cloud) US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.

We make a difference in the lives of our patients, our staff, and our communities. Physicians can focus on patient care and can professionally thrive in Allina, and the result is the quality of care for which we are known. We are based in Minneapolis, and have comprehensive services throughout Minnesota and in western Wisconsin. Become a part of the Allina team, joined together with a common purpose and uncommon caring.

Excellent benefit package including: Favorable lifestyle 26 days vacation

CME days Competitive salary

13 days sick leave Liability insurance

Interested applicants can mail or email your CV to VAHCS Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-255-6436 or Telephone: 320-252-1670, extension 6618

For more information, please contact: Kaitlin Osborn, Allina Physician Recruitment Toll-free: 1-800-248-4921 | Fax: 612-262-4163 Email: Kaitlin.Osborn@allina.com Website: allina.com/jobs EOE 10127 0811 ©2011 ALLINA HEALTH SYSTEM. ®A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM

MINNESOTA PHYSICIAN OCTOBER 2011

Growing multi-specialty group practice in Northern Minnesota is looking for a BC/BE Family Practice Physician, Internal Medicine Physician, Emergency Room Physician, OB/GYN Physician, Urologist as well as an Orthopaedic Surgeon. Join an existing group practice and take over existing practices from departing physicians. Grand Itasca Clinic & Hospital in Grand Rapids, Minnesota has recently opened a new state of the art clinic & hospital. Excellent salary guarantee with outstanding income potential, full benefits and sign-on bonus. Community located in the beautiful northern Minnesota lakes area.

Contact: Gail Anderson (218) 999-1447 gail.anderson@granditasca.org.

Come home. Where organizational strength lies in the diversity of people who call SANFORD HEALTH – home. Sanford Health – Fargo Region is redefining health care. Serving northwestern Minnesota and eastern North Dakota, we offer innovative technology, support of a multi-specialty organization, and dependable colleagues. Excellent practice opportunities exist in family-oriented communities that offer year-round outdoor activities, cultural events, and superior education districts that will allow you to balance your work & life. Our employment model features competitive salaries, a comprehensive benefits package, paid malpractice insurance, and a generous relocation allowance. Contact: Jean Keller Physician Recruiter Phone: (701) 280-4853 Jean.Keller@sanfordhealth.org

Cardiology Dermatology ENT Emergency Medicine Family Medicine Gastroenterology Hospitalists Internal Medicine Neurology Occupational Medicine Oncology Orthopedic Surgery Pediatric Specialties Psychiatry Pulmonology (Sleep) Rheumatology Urology

Fairview Health H Servicees Look for the friendly doctor in a MN based physician staffing service ...

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 variety variety of opportunities opportunities that allow allow wee serve. yyou ou to focus on innovative innovative and d quality car e. Shape Shape yyour our practicee to 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 participating participating in clinical cal quality initiativ es, w have an opportunity opportunity that is right for you: you: initiatives, wee have

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

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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Visit fair fairview.org/physicians view w.orrg/physicians to explor exploree our curr current ent oppor opportunities, tunities, nities, then apply online, call 800-842-6469 42-6469 or e-mail rrecruit1@fairview.org. ecruit1@fairview iew w.orrg. Sorry, Sorr ry, no n J1 oppor opportunities. tunities.

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Changes from page 21 (see definition below). The disclosure must also include a description of the organizational structure of each additional disclosable party to the facility and the relationship of each such additional disclosable party to the facility and to one another. The ACA defines “additional disclosable party” to mean any person or entity who exercises operational, financial, or managerial control over all or a part of a facility, or provides financial or cash management services to the facility; leases or subleases property to the facility, or owns a whole or part interest of at least 5 percent of the value of the property; or provides management or administrative services, management or clinical consulting services, or accounting or financial services to the facility. This definition, construed broadly, could include not only individuals and entities with an ownership interest in or operational control of a facility, but

also nearly any other person or organization that contracts with the SNF or NF to provide services or supplies—whether food service, housekeeping, accounting, or pharmacy services. With this expanded scope of disclosure, there is potential for “additional disclosable parties”—even those without operational control of the facility— to be named as parties in litigation against a nursing facility, since the information will become public record and available to plaintiffs’ counsel. Final regulations, which may help clarify this issue, are due by no later than March 23, 2012. Mandatory compliance programs and quality improvement plans. The ACA requires nursing homes to establish compliance and ethics programs. Compliance plans must be effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality of care. Forthcoming regulations from HHS may include a model compliance plan.

The ACA requires that HHS publish regulations by Dec. 31, 2011, that establish standards relating to quality assurance and performance improvement for nursing homes. Within a year after these regulations are published, nursing homes will be required to submit to HHS their plans for meeting the standards. Incentives for home and community-based services

Medicaid has traditionally paid for long-term care services for low-income Americans in institutional settings such as nursing homes. Effective October 1, 2011, states will have the option to offer home and communitybased services and supports to Medicaid beneficiaries who would otherwise require a level of care offered in a hospital, nursing facility, or intermediate care facility for the mentally retarded (ICF/MR). States that choose this option (called the Community First Option) will be eligible for a federal match of an additional 6 percent for

reimbursable expenses in the program. The ACA also removes barriers to home- and communitybased services by allowing states to provide more types of support services (such as home health visits, adult day care, training in life skills, and durable medical equipment) through a state Medicaid plan rather than through waivers. Minnesota has been a leader in using waivers to provide home and community-based services to the elderly and disabled, so it will be interesting to see how Minnesota takes advantage of this new funding opportunity. Sarah Duniway, JD, and Gregory A. Larson, JD, are principals in the law firm of Gray Plant Mooty. They specialize in working with nonprofit organizations and health care providers.

continuing medical education Pediatric Conferences • Best Practices – Managing the Pediatric Patient in the Urgent Care Setting • Pediatric Update: Beyond the Basics 12th Annual Women’s Health Conference

November 4, 2011

Emergency Medicine and Trauma Update: Beyond the Golden Hour

November 17, 2011

Otolaryngology for Primary Care

November 18, 2011

33rd Annual Cardiovascular Conference Fundamental Critical Care Support Dermatology for Primary Care

December 1-2, 2011 February 23 - 24 and July 19-20, 2012 February 24, 2012

26th Annual Family Medicine Today

March 8- 9, 2012

30th Annual OB/Gyn Update

April 12-13, 2012

The Mind of a Child: Psychiatric Challenges for Today’s Youth

April 19, 2012

Psychiatry Update: Selected Topics for the Non-Psychiatrist

April 20, 2012

education that measurably improves patient care 38

October 28, 2011 October 29, 2011

MINNESOTA PHYSICIAN OCTOBER 2011

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