minnesota physician august 2015

Health care’s movement toward a value-based model increases the pressure to reduce costs.

Two cost reduction targets immedi-ately come to mind: 1) eliminating unnecessary or ineffective care, and 2) addressing high utilizers. It has long been recognized that a small group of patients (of every age) account for a disproportionate amount of care. For health care organizations, pa-tients who use a lot of services pose a problem. High utilizers have become

pariahs because they make dispropor-tionate demands for care that make poor economic sense in a fixed-price environment. Even if payers cover their costs, high utilizers challenge clinicians to find ways to address their multiple complex interactive needs.

Care providers seek effective ways of managing these complex cases. Continued effort is feasible (and desirable) if value-based payment

Reducing hospitalization for seniors to page 12

Dealing with high utilizers to page 10

Vo lum e X X IX , N o. 5Au gus t 2015

As the impetus for value-based care con-tinues to grow, reducing hospital admis-sions for seniors remains a top priority

for payers and providers alike. According to the 2014 Healthcare Cost and Utilization Project Statistical Brief on hospital stays, spending on hospitalizations accounted for 29 percent of all health care expenses, making them one of the most expensive types of health care treatments.

In 2014, nearly 18 percent of Medicare patients who were hospitalized were readmit-ted within a month, costing an estimated $26 billion, with $17 billion coming from potentially avoidable readmissions. For Minnesota, the impact has hit 27 percent of the hospitals with 36 being penalized for high readmission rates. There remain large-scale opportunities for further reductions and cost savings.

While physicians have readily available solutions for acute problems, there have been inadequate and often unmeasured solutions for chronic and complex health and social prob-lems, especially in the community. The easy way out was all too frequently to send them to the Emergency Department (ED). In fact, new

Reducing hospitalization

for seniorsThe role of a life care manager

By Joel Theisen, RN, and Dave Moen, MD

Dealing with high utilizersNo easy solution

By Robert L. Kane, MD

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. © 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G0933

L ife. We help people get back to it!

Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.

To make a referral or for more information, call us at (866) GSS-CARE or visit www.good-sam.com/minnesota.

Features

August 2015 Minnesota Physician 3

August 2015 • Volume XXiX, No. 5

www.mppub.com

Publisher Mike Starnes | [email protected]

editor Lisa McGowan | [email protected]

AssociAte editor Richard Ericson | [email protected]

Art director Joe Pfahl | [email protected]

office AdministrAtor Amanda Marlow | [email protected]

Account executive Stacey Bush | [email protected]

DePARtmeNts

The skyways of cancer 20By Emil Lou, MD, PhD

Cancers of the neck and head 22By Deepak Kademani, DMD, MD, FACS

sPeciAl Focus: oNcology

cAPsules 4

meDicus 7

iNteRVieW 8

Policy 14The future of health careBy Timothy A. Johnson, JD, and Julia C. Marotte, JD

PeDiAtRics 16Electronic health careBy Jeffrey Weness, MBA, and Laura M. Gandrud, MD

HeAltH DisPARities 18Health equity for the LGBTQ communityBy Mary Beth Dahl, RN

RADiology 24Radiation oncologyBy Elizabeth H. Cameron, MD, MPH

PHARmAcology 26Physician/pharmacist collaborationBy Cory Nelson, PharmD; Kyle Turner, PharmD; and Jaskiran Sandhu, MD

ADmiNistRAtioN 28A new era in codingBy David K. Haugen, MA, and Terence Cahill, MD

Jim Schowalter, MPP

The Minnesota Council of Health Plans

Dealing with high utilizers 1No easy solutionBy Robert L. Kane, MD

Reducing hospitalization for seniors 1The role of a life care managerBy Joel Theisen, RN, and Dave Moen, MD

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; email [email protected]. 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 re-place medical, legal, tax, business, or other professional advice and counsel. no part of the publication may be reprinted or reproduced without written permission of the publisher. annual subscriptions (12 copies) are $48.00/ individual copies are $5.00.

Background and Focus: Increasing evidence supports the link between access to mental health care and reducing health care costs. Primary care physicians often lack the expertise to diagnose behavioral health correctly and are not always able to easily refer a patient to a mental health care provider. Many initiatives nationwide are addressing this issue. It is so important that the ACA stipulated the development of the Behavioral Health Home in 2015. Some states, including Minnesota, are also creating Behavioral Health Home programs.

Objectives: We will review numerous initiatives that support the development of new pathways to behavioral health care. We will introduce new ideas and discuss how to incorporate them into our health-care delivery system. We will examine the value they can bring and the challenges they will face. Our panel of industry experts will outline the steps that must be taken to increase the overall access to mental health care and the broad improvement in population health that this increased access will bring.

Panelists include: • Sarah Anderson, MSW, LICSW, CEO, Psych Recovery, Inc.

• Lee Beecher, MD, President, Minnesota Physician-Patient Association

• Judge Kerry W. Meyer, Hennepin County Criminal Mental Health Court

• Jane Pederson, MD, Medical Affairs Director, Stratis Health

• Jeff Schiff, MD, MBA, Medical Director, MN Dept. of Human Services

• L. Read Sulik, MD, Chief Integration Officer, PrairieCare

Sponsors include: • MN Dept. of Human Services • PrairieCare • Psych Recovery, Inc. • Stratis Health

MINNESOTA HEALTH CARE ROUNDTABLE

Please mail, call in, or fax your registration by 11/5/2015.

Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub.com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable.

Name

Company

Address

City, State, ZIP

Telephone/FAX

Card # Exp. Date Check enclosed Bill me Credit card (Visa, Mastercard, American Express or Discover)

Signature

Email

Thursday, November 12, 2015 • 1:00-4:00 PMDowntown Minneapolis Hilton and Towers

FORTy-FOURTH SESSION

Behavioral Health IntegrationNew pathways to care

capsules

4 Minnesota Physician August 2015

HealthPartners Offering Online Treatment for Anxiety and DepressionhealthPartners has implemented an online self-help program to treat patients with mild and mod-erate depression and anxiety.

the program, called Beating the Blues, is based on cognitive behavioral therapy. Patients go through eight weekly ses-sions that take about 50 min-utes each. they identify their specific problems, determine what causes them, and learn techniques and skills to cope and break the cycle of negative thinking and behaviors. the patients’ physician will receive progress reports after each session, but otherwise all the information they enter into the program is anonymous.

according to Beating the Blues, the research shows that the program is just as effective

as drugs in treating mild and moderate anxiety and depres-sion, and is more effective at preventing the problems from reoccurring.

healthPartners is the first in the region to offer it.

Abortions Increase After Several Years of Declinethe number of abortions per-formed in the state rose by 2.2 percent last year, according to an annual report from the Min-nesota Department of health. there were 9,903 abortions in 2013 and 10,123 in 2014. this was the first time Minnesota’s abortion rates increased since 2006, when 14,000 abortions were performed.

the highest increase in abortions was among ameri-can indians, at 5 percent. Rates also rose slightly among asian americans and decreased

slightly among whites and af-rican americans. however, the majority of abortions performed were among white women, at 5,336. about 90 percent of all abortions took place in the first trimester of pregnancy; the rest took place in the second trimes-ter. obstetrics and gynecologists performed about 69 percent of the procedures; the rest were performed by general or family practice practitioners with the exception of three cases that were performed by emergency medical workers.

according to the report, 85 percent of women who had abortions in 2014 were un-married; 91 percent were from Minnesota; 76 percent were between 20 and 35 years old; 60 percent had never had an abortion before; 58 percent had previously given birth to at least one child; and 66 percent didn’t use contraceptives at the time of conception. the most common reason women gave for having an abortion was that

they did not want children at this time, while 74 women said the reason was that their preg-nancy was a result of rape and 13 said it was a result of incest.

Preventable Health Care Visits Added $2 Billion in CostsMore than 1.2 million emer-gency department visits and 72,000 hospital admissions that were potentially preventable cost Minnesota employers, health plans, and individuals almost $2 billion in 2012, according to a study from the Minnesota De-partment of health (MDh).

“Minnesota has one of the most efficient and cost-effec-tive health care systems in the nation, but this study shows we still have room for improve-ment,” said ed ehlinger, MD, Minnesota commissioner of health. “equipped with these findings, we will work with


providers and community lead-ers to ensure patients more con-sistently receive the right care, in the right place at the right time.”

Researchers analyzed data from the Minnesota all Payer claims Database to estimate how many patients made poten-tially preventable hospital and emergency department visits. Potentially preventable health care events were defined as those that “possibly could have been avoided under the right cir-cumstances such as timely ac-cess to primary care, improved medication management, greater health and health system literacy, and better coordination of care among clinicians, social service providers, patients, and families,” according to the re-port. these visits accounted for about 4.8 percent of total health care spending in Minnesota in 2012. however, the authors note the potential savings could be misleading because not all events were actually prevent-able, and that prevention mea-sures that could have been taken would have meant added costs in other areas.

Results of the study show that as many as 50,000 Minne-sotans each had at least four potentially preventable emer-gency department visits each in 2012, and that Medicaid pa-tients accounted for 40 percent of emergency department visits though they only make up 14 percent of the population. the most common diagnoses for po-tentially preventable emergency department visits were infec-tions of the upper respiratory tract (9 percent), abdominal pain (7 percent), and musculo-skeletal system and connective tissue diagnoses (7 percent).

Within preventable hospi-tal visits, about 50,000 were regular admissions and about 22,000 were readmissions. the most common conditions for potentially preventable hospital admissions were pneumonia, excluding when it is related to bronchitis and respiratory syncytial virus (13 percent), heart failure (12.1 percent), and coPD (8.1 percent). the most common conditions for poten-tially preventable readmissions were heart failure (6.6 percent),

blood infection and dissemi-nated infection (5.1 percent), and major depressive disorder and other unspecified psychosis (3.5 percent).

“Minnesota’s providers, in-cluding hennepin health, are very focused on improving out-comes and reducing high-cost care that is not good for pa-tients,” said Ross owen, direc-tor of hennepin health. “this work requires approaches that look not just at coordinating medical care but at addressing social factors and preventing these events from happening in the first place. this MDh report is an important statewide step toward understanding that opportunity.”

Health Care Organizations Recognized for IT Excellencethe american hospital associ-ation has recognized eight Min-nesota hospitals and health sys-tems on its hospitals & health networks magazine’s 2015 health care’s Most Wired list.

Participating organizations took part in an industry stan-dard benchmark study designed to measure the level of it adoption in U.s. hospitals and health systems. the survey was conducted by health Forum, an american hospital associa-tion information company, who distributed, collected, and an-alyzed the data and developed benchmarks for measuring it adoption. organizations were identified as foundational, core, advanced, expert, or leader in each of four focus areas for use of it—infrastructure; busi-ness and administrative man-agement; clinical quality and safety; and clinical integration. More than 740 respondents representing 2,200 hospitals participated in 2015, and a total of 338 were recognized on the Most Wired list, which is in its 17th year.

the Minnesota organiza-tions recognized on the 2015 Most Wired list include health-

Capsules to page 6

Center at HealthEast St. Joseph’s Hospital in

right after treatment.

liver, brain and other tumors and metastases.

To learn more or to find out if CyberKnife is an option for you:

651-232-3111 | healtheast.org/cyberknife

REAL HOPE with

6514-122457 CyberKnife Star Tribune ad.indd 1

Cancer is life changing and some cancers are harder to fight with traditional treatments. CyberKnife Center at HealthEast St. Joseph’s Hospital in St. Paul offers exclusive treatment in the Twin Cities metro area. CyberKnife targets tumors with superior accuracy, has fewer treatments, and minimal side effects. Many patients return to their usual activities right after treatment.

CyberKnife treats cancers such as prostate, lung, liver, brain and other tumors and metastases.



REAL HOPE with

Treatment

6514-122457 CyberKnife Star Tribune ad.indd 1 3/10/14 11:06 AM





REAL HOPE with

Treatment


to fight with traditional treatments. CyberKnife Center at HealthEast St. Joseph’s Hospital in

right after treatment.

liver, brain and other tumors and metastases.



6514-122457 CyberKnife Star Tribune ad.indd 1





REAL HOPE with

Treatment






REAL HOPE with

Treatment


To learn more or refer a patient to CyberKnife:


Cancer is life changing and some cancers are harder to fight with traditional treatments. HealthEast CyberKnife at St. Joseph’s Hospital in St. Paul is proud to have over 10 years of experience and has performed more than 6,000 treatments. CyberKnife targets tumors with superior accuracy, has fewer treatments, and minimal side effects. Many patients return to their usual activities right after treatment.



Partners, based in Bloomington; Kittson Memorial healthcare center in hallock; Mahnomen health center; Mayo clinic hospital in Rochester; Per-ham health; and Windom area hospital. in addition, River-View health in crookston was recognized as on the Most Wired–small and Rural list, and Winona health was recognized on the Most improved list.

“after more than a decade of building the foundational elements of a digitized health care environment, and billions of dollars in federal and pri-vate sector spending, hospital and health systems are tapping into the power of the bits and bytes they’ve been collecting,” hospitals & health networks magazine said in a statement. “this coincides not only with the requirement to meet federal standards for meaningful use of health information technol-ogy, but also the push toward value-based payments, popula-

tion health management, and cost-efficiency.”

according to the survey results, 96 percent of the Most Wired hospitals use intrusion detection systems, compared to 85 percent of all participants; almost 80 percent of Most Wired hospitals conduct inci-dent response exercises each year, compared to about 40 percent of all participants; and more than 75 percent of Most Wired hospitals use portals and electronic health records to exchange results with other organizations, while only 56 percent of all participants do so. overall, the most significant improvement in 2015 was in patient engagement.

New Risk Factors for Long-Term Opioid Use Identifiedone in four patients who are prescribed opioid painkillers

for the first time progress to long-term prescriptions, ac-cording to results from a study at Mayo clinic.

the increase in opioid addic-tion and accidental overdoses prompted researchers to iden-tify which patients are at the highest risk. “Many people will suggest it’s actually a national epidemic,” said W. Michael hooten, MD, anesthesiologist at Mayo clinic. “More people now are experiencing fatal overdoses related to opioid use than com-pared to heroin and cocaine combined.”

Researchers used a random sample of 293 patients from the Rochester epidemiology Project, funded by the national institutes of health. each pa-tient had received a new opi-oid painkiller prescription in 2009. after analyzing the data, researchers found that 21 per-cent of the sample group had progressed from short-term use to prescriptions lasting three to four months. and 6 percent

progressed even further to a prescription lasting more than four months.

Patients who had a history of tobacco use or substance use were at the highest risk for long-term use of opioids. hooten says this is because the neurobiology related to chronic pain, chronic opioid use, and addiction is similar. he says it’s important for physicians to be careful about prescrib-ing opioids to patients with a history of tobacco or substance use and to use a minimal dose and limit the duration of opioid use in order to lessen the risks of patients progressing to long-term use.

“the next step in this re-search is to drill down and find more detailed information about the potential role of dose and quantity of medication pre-scribed,” said hooten. “it is pos-sible that higher dose or greater quantities of the drug with each prescription are important pre-dictors of longer-term use.”

Capsules from page 5

Gregory L. Barth, M.D.

Merrill A. Biel, M.D., Ph.D.

Carl A. Brown, M. D.

Thomas E. Christenson, M.D.

Karin E. Evan, M.D.

William J. Garvis, M.D.

Matthew S. Griebie, M.D.

Michael B. Johnson, M.D.

Nissim Khabie, M.D.

Jeffrey C. Manlove, M.D.

Darren R. McDonald, M.D.

Michael P. Murphy, M.D.

Michelle C. Naylor, M.D.

llya Perepelitsyn, M.D.

Julie C. Reddan, M.D.

Benhoor Soumekh, M.D.

Jon V. Thomas, M.D.

Rolf F. Ulvestad, M.D.

Larry A. Zieske, M.D.

Ear, Nose & Throat SpecialtyCaretakes pleasure in announcing

Micah A. Berman, M.D.IN THE PRACTICE OFPediatric Otolaryngology — Head and Neck Surgery

Minneapolis • St. Paul • Burnsville • Coon RapidsEdina • Fridley • Maple Grove • Plymouth

Administrative Office:2211 Park Avenue South, Minneapolis, Minnesota 55404612-871-1144

www.entsc.com


Charlie Lakin, PhD, has received the Minnesota

Department of health (MDh) and the Minnesota

Board on aging’s Policy award at the 2015 Min-

nesota age & Disabilities odyssey conference in

Duluth. the award is in recognition of Lakin’s 40

plus years of work improving policies for people

with intellectual and developmental disabilities,

which also effected change at national and

international levels. Lakin served as director of

the Rehabilitation Research and training center on community

Living at the University of Minnesota’s institute on community

integration for more than 30 years and as director of the national

institute on Disability and Rehabilitation Research for three years

before retirement. he earned his doctor of philosophy degree in

educational psychology at the University of Minnesota and master

of arts and master of education degrees in special education from

teachers college, columbia University in new york.

Cindy Firkins Smith, MD, has been elected

as the new president and ceo of affiliated

community Medical centers. smith has been

with acMc for 25 years, practicing dermatology

and dermatologic surgery. she also serves as a

clinical professor at the University of Minnesota

in the department of dermatology and was

appointed to the Blue Ribbon commission on

the University of Minnesota Medical school by

Gov. Mark Dayton in 2014. smith previously

served as president of the Minnesota Medical association and is

currently an alternate delegate for the american Medical asso-

ciation. she earned her medical degree from the University of

Minnesota, where she also completed her dermatology residency,

and completed a transitional internship with hennepin county

Medical center. smith will step into the role on Jan. 1, 2016, suc-

ceeding Ronald holmgren, MD, who has served in the position for

15 years and recently announced plans to retire in late December.

William Roberts, MD, MS, FACSM, professor of

family medicine at the University of Minnesota

and director of the st. John’s hospital Family

Medicine Residency Program, has received

the american college of sports Medicine

(acsM) 2015 honor award in recognition of his

outstanding contributions to the field. Roberts

earned his medical degree at the University of

Minnesota, where he also completed a residency,

and received a subspecialty certification in

sports medicine through the american Board of Family Medicine.

Roberts has been the medical director for the twin cities Mara-

thon since its inception and has spoken internationally on mara-

thon medicine. he has been a member of acsM since 1982, where

he has served as president of acsM and the acsM Foundation

Board, and is currently the editor of acsM’s clinical journal.

Medicus

Charlie Lakin, PhD

Cindy Firkins Smith, MD

William Roberts, MD, MS, FACSM

minnesotaorchestra.org612.371.5656 / Orchestra Hall

Media Partner:PHOTO McDonald: Autumn de Wilde

SEE JANE SING! (WITH JANE LYNCH)Sun Oct 25 7pm

SEASON OPENING

OSMO VÄNSKÄ AND AUDRA McDONALD Fri Sep 11 & Sat Sep 12 8pm

Osmo Vänskä /// Music Director

Coordinating agendas, promoting ideas

Jim Schowalter, MPP

The Minnesota Council of Health Plans

Mr. Schowalter joined the Min-nesota Council of Health Plans as its president/CEO in January 2015. In this role, he works with all of the state’s nonprofit health plans to pursue high quality and affordable health services for all Minnesotans.

Prior to assuming this role, Mr. Schowalter served in leadership roles for the state of Minne-sota. Most notably, he was appointed by Gov. Dayton as his commissioner at Minnesota Management & Budget as a key advisor on critical fiscal, budget, and policy issues.

Mr. Schowalter received his master’s degree in public policy from the Kennedy School of Government at Harvard Univer-sity and his bachelor’s degree with a major in economics from Macalester College.

What is the mission of the Minnesota Council of Health Plans?

The Council is a collaborative effort to enable Minne-sota’s health plans to work together and connect with the broader community to improve our health care system. We are grounded in a vision of high standards of care; broad access to health care coverage; affordable health care ser-vices; and information and attitudes to constantly improve our system.

What’s unusual about the Council is that we have perspectives that span the entire health care system, from the clinic or hospital where service is delivered, to the treatments, devices, and drugs that heal and manage disease all the way up to population health. Our connections with people who manage all of these services make the discussions at the Council unique. We want to use our understanding and connections to keep making our community healthier.

Fortunately, I came into this role with our team already doing well. The Minnesota Business Partnership recently released a McKinsey study that showed Minnesota at or near the top in quality and access. My job is to lead the Council so that we continue that success and build support for policies and ideas where we need to do better.

What unique perspectives does your expe-rience at Minnesota Management & Budget bring to your current position at the Council?

I am acutely aware that the spending growth is not sus-tainable and have seen firsthand how the growth in health care spending substantially closes off options for other priorities like education or community supports. I believe that change is coming and that connectors like the Council will help us better prepare and manage that change.

My work of coordinating agendas and promoting ideas also transfers to the Council. As a key adviser to the gover-nor on critical fiscal, budget, and policy issues, I identified and managed the concerns of 23 cabinet agencies and dozens of smaller organizations. The process of listening, prioritizing, and communicating is at the heart of the Council’s work and a big part of my new job.

Finally, I bring a growing appreciation of cross-sector solutions to tough policy issues. In health care, progress will have to come from everyone so the public and private sectors build upon each other’s strengths, not just shift the costs or blame.

What is the Council of Health Plans working on that would be of special interest to physicians?

The first area of collaboration is in building the next phase of MinnesotaCare. We have enjoyed the benefits of roughly 20 years of sound public policy that has led to broader coverage and more opportunities for Minnesotans. However, with the planned phase-out of the provider tax looming, we need to assess the future. The provider tax was the most broad based, and therefore the most fair fund-

ing source. MinnesotaCare didn’t have to compete with other state priorities and revenue increased as health care costs increased. If the repeal of the tax remains, how is the benefit going to be paid for? We need to come together to ensure that current successes are sus-tainable in the future.

Council members are also actively looking at the drug prior authorization (PA) process and how it can work bet-ter. We initiated a discussion among the health plans that has led to an ICSI (Institute for Clinical Systems Improve-ment) project to assess what prior authorization does, what it misses, and how it works end to end. Though the Council is not part of the group, its efforts will help clarify problems and potential solutions. I do not want anyone to think we will completely eliminate PA. It is a tool used by many purchasers, including the federal government and self-insured companies. It simply cannot be swept out of the marketplace, as there are cost and patient safety con-cerns that it can address.

What can you share with us about the work that the Council does with the Minnesota Legislature?

The Council’s work at the Legislature is to explain the policies and challenges that the health plans see in the marketplace. For the last several years, the discussion has revolved around implementation of the Affordable Care Act (ACA) and its many operational and policy impacts. The facts are confusing and with so much changing it is even harder for legislators to make an informed decision. Thankfully, they keep trying to learn and we keep trying to help connect the dots.

What goals do you have for your tenure as the president and CEO of the Council?

My goal is for the Council to be a connection point. We have tremendous, local organizations delivering coverage and care. The Council’s unique viewpoint, understanding of market information, and history of collaboration can help our state improve.

IntervIew

8 Minnesota Physician AuguST 2015

Tens of thousands of Minnesotans have health coverage who didn’t have it before.

The trick is understanding the health care “sys-tem.” When we work together with other experts, we can better diagnose the system’s problems. If we just do that one thing well, our public policies will provide improvement that people will see in their day-to-day lives.

Tell us about the Center for Community Health (CCH).

The CCH brings together 21 local public health agencies, hospitals, and health plans in the seven-county metro area to improve the health of our community. CCH serves as a catalyst to align the community health assessment process and create action plans to address top public health concerns. The Council is proud to be a part of this important work.

From a health plan perspective, what are the biggest pros and cons of the Af-fordable Care Act as it moves forward?

The ACA makes a profound change by ensuring that everyone can access health insurance. We in Minnesota have been somewhat shielded from this concern because we had a successful high-risk of-fering, but as a nation this is a huge improvement.

The biggest con is the oversized expectations of the reforms. The changes in the market are

difficult to implement and carry with them some level of uncertainty. You need look no further than MNsure and the individual market to see that forecasting the future isn’t easy. That doesn’t mean that we are necessarily on the wrong track, but it does underscore the work before us to stabilize insurance markets.

What are some of the successes and problems the health plans have faced when working with MNsure?

Our success is simple—tens of thousands of Minnesotans have health coverage who didn’t have it before. The challenge is holding together the enrollment process so that people get the insurance services they deserve. There are a lot of technical problems on the state side that are slowly being worked out and we all hope for a better end-to-end product this year. But no matter what, physicians should understand the level of effort and personal sacrifice that has been made at the county, state, and partner health plans. It’s thanks to the hard work of many individuals that more Minnesotans than ever before have health insurance coverage.

What changes are occurring in how Minnesotans get health care coverage?

For some Minnesotans the change is huge.

For others, not much has changed. The increase in income guidelines ($16,105 for an individual) and the elimination of the asset test provides more ac-cess to Medical Assistance through ACA’s Medicaid expansion. Funding from MNsure to community organizations that offer in-person enrollment help has also increased coverage.

On the commercial side, the change continues for individuals and families who buy coverage on their own in the individual market—about 6 percent of Minnesotans. The ACA defines their coverage and lets them choose a health plan with-out fear of being denied because of a pre-existing condition. With that peace of mind for individuals comes unpredictability as health plans learn more about the health care needs and associated costs of new enrollees and price premiums to reflect the cost of care.

While more than 70 percent of Minnesotans aren’t seeing much change because the ACA didn’t significantly alter self-funded employer or Medi-care coverage, these groups aren’t immune from the effects of the unsustainable growth of health care costs. With the ACA’s substantial reforms, we all must turn our attention to the more thorny issues around the cost of care.


Three patients.Who is at risk for diabetes?

When there are no signs or symptoms, you may not know until it’s too late. Act now.

Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk.• Refer your at-risk patients to a proven

lifestyle change program and help cut their risk of developing type 2 diabetes in half.

• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications.

Find groups in Minnesota at www.health.mn.gov/diabetes/programs

Minnesota Department of HealthDIABETES PROGRAM

1 in 3 adults are at risk!

adequately recognizes the costs involved. Within a closed system of capitation payments, an internal business case holds that it makes sense to improve primary care for high utilizers if it will reduce hospital and post-hospital care. In more tra-ditional fee-for-service systems, payers (especially government payers) are offering rewards and inducements to take on the tough cases. The health care home is an example of such a program, although the price may not yet be correctly set.

High utilizers use a lot of medical services, whether measured by volume or cost. They are often referred to as “frequent flyers.” Any good spreadsheet can flag them. Superficially they share some basic characteristics. They tend to have multiple diagnoses and chronic conditions. For exam-ple, the 14 percent of Medicare beneficiaries with six or more conditions accounted for 46

percent of Medicare spending. When it comes to younger patients, who are on average typically healthier, the dispro-portionate utilization is even more obvious. Here, other fac-

tors like addiction and mental illness play a larger role. These comorbidities make it less likely that these patients will play a productive role in addressing their care.

High utilizers typically see a lot of doctors because they have a lot of problems. Presumably,

no one has taken charge so they visit a lot of doctors because their problems are not being adequately managed. This is the rationale for aggressive coordinated management

strategies. Emerging models of proactive primary care closely monitor patients (at home) and track their status by computer. As long as the patient stays on the expected clinical trajecto-ry, nothing is done. But if the patient’s status deviates out-side the confidence limits, the patient is seen immediately and evaluated to understand the developing problem before it be-comes a crisis. In patients with multimorbidity, each condition can be monitored. This ap-proach eschews the scheduled return appointment in favor of seeing patients when their change in condition dictates. It is obviously feasible only with patients who can cooperate but it reinforces the concept of patient-centered care.

Treating a high utilizerDescribing the high utilizer problem is much easier than fixing it. High utilizer patients across the age spectrum share a common bond. They are hard to treat effectively. Managing an individual chronic disease can be challenging, but dealing with the interaction of several is a much greater task. The challenge is more multiplicative than additive; some would even suggest it is exponential. Older patients with multimorbidity are virtually walking chemistry sets, and are at risk for poor medication compliance and drug interaction problems. The obvious answer is that some-one needs to take charge and

coordinate the care, but that is no easy task. Alas, treating all of their problems well (i.e., fol-lowing the guidelines for each problem) threatens to do more harm than good. While every guru of chronic disease man-agement exhorts us to actively involve the patient in his or her care, younger patients with mixed portfolios of medical and mental disease and older patients with cognitive impair-ment are hard to involve in self-management plans.

The downside for providersAt the very least, health care programs should not be penal-ized for taking on (or being assigned) high utilizers. The traditional payment remedy for high utilization has been case mix adjustment, but providers complain with good cause that this is an inexact science. Pre-dicting utilization works pretty well for groups, but poorly for individuals. This problem may be less of an issue for health care corporations that enroll large numbers across a population because averages may indeed average out; but it is a big problem for individual practices with limited clientele where a big variation around a modest-sized set of cases can make a big difference in pay-ment error. To entice clinicians into aggressive innovative care management, estimates of the extra demand used to create risk adjustments should err on the generous side, at least until they can be honed.

Addressing high utilizersPrograms to address high utilizers have existed for a long time. Coming up with a solu-tion typically involves teams with representatives from many different professions. Such “big team” care is not efficient, espe-cially if the team needs to meet often to coordinate its efforts. Nor is it necessarily effective. The jury is still out on the various approaches to address-ing complex care, and the early returns do not offer much optimism. At the moment, enthusiasm has replaced evi-dence because we rely on what feels right without necessarily

10 MINNESOTA PHySICIAN August 2015

Dealing with high utilizers from cover

Describing the high utilizer problem is

much easier than fixing it.

gpmlaw.com | Minneapolis | St. Cloud | Fargo, ND | Washington, DC

The Gray Plant Mooty Health Law team is unmatched when it comes to knowing your health care business. Our expertise and specialization provides you a resource for all legal issues big and small.

We know health care law like the back of our dorsum manus.

August 2015 MINNESOTA PHySICIAN 11

testing it. As reflected in the projects funded by the Cen-ter for Medicare & Medicaid Innovation, the key phrase is scalability. Can a program be operationalized and replicated?

While there is some room for many different opinions, I believe that we still have a long way to go. The overall picture is not encouraging, although a few programs have been care-fully tested. (A more complete list of project summaries is available from the author.)

The GRACE program The GRACE Team Care pro-

gram, developed at the Univer-sity of Indiana, is built around home-based care management of frail older patients by a nurse practitioner and a social worker collaborating with a primary care provider and a geriatrics interdisciplinary team. The underlying rationale holds that more effective primary care will prevent expensive catastro-phes. To aid the primary care team, the program developed 12 care protocols:

• Difficulty walking/falls

• Memory loss

• Urinary incontinence

• Depression

• Malnutrition/weight loss

• Chronic pain

• Visual impairment

• Health maintenance

• Hearing loss

• Advance planning

• Medication management

• Caregiver burden

The initial demonstration project showed better results in four of the eight SF-36 scales, which are commonly used to assess function and quality of life. There were no differences in activities of daily life or death; there were fewer emergency department visits; and hospitalizations were not different overall but were lower in the high-risk group.

Guided Care Guided Care, a model devel-

oped at Johns Hopkins, relies on non-physician clinicians and encompasses patient education and referral to community

resources: coaching, caregiver workshops, and support group meetings. It showed no effect on frequency of use of emergen-cy departments, hospitals, or skilled nursing facilities.

IMPACT Variations of the IMPACT

approach to coordinating primary care and depression treatment have reported some success (especially in treating the depression), but the Min-nesota version, the DIAMOND project, could not be sustained because of problems coordinat-ing payment.

In addition, a number of larger organizations, like Kaiser Permanente and Geisinger, have implemented models that address the high utilizer problem, but they have not been formally evaluated. The Cen-ter for Medicare & Medicaid Innovation is investing millions of dollars in projects that will be hard to evaluate in a rush toward scalability. It is not clear if 1,000 flowers or 1,000 weeds will bloom.

ConclusionChronic disease and multi-morbidity remain the clinical challenges of our decade. Some clinical groups will take up the challenge because they recognize its social significance. The rest will find themselves struggling with the problem whether they want to or not. We need to find more effective ways to address the issue. We need good evidence of what constitutes good care in this arena. Unfortunately the research results have not been encouraging. But neither can we afford to wait for someone else to find the solution.

An underlying question in this process to create effec-tive care is what constitutes evidence. Medicine likes to de-scribe itself as evidence-based but how strong is that base

and how strong does it need to be? Randomized trials work in many areas but are harder to pull off around complex interventions. In contrast to medicine, the business world relies on a very different empirical basis for strategic decision-making. Their rate of innovation is incompatible

with strict trials. They rely on rapid cycling. So is compre-hensive care in response to high utilizers more like drug therapy (which needs a strong causal effectiveness foundation of proof) or more like a new product ready to market? The projects currently funded by the Center for Medicare & Medic-aid Innovation seem to reflect this style of thinking.

No one disputes that the key to success is learning how to manage high utilizers, not just because they use resources but also because they have the most problems. Ultimately the ques-tion is how to do it on a budget, but maybe we have to do it first and then worry about efficiency later.

Robert L. Kane, MD, is a professor who holds the Minnesota Chair in Long-term Care and Aging at the University of Minnesota School of Public Health, where he also directs the Center on Aging and the Minne-sota Evidence-based Practice Center.

Fourteen percent of Medicare

beneficiaries … accounted for 46

percent of Medicare spending.

cushwakenm.com

WOODLAKE CENTRE6601 & 6625 Lyndale Ave. S., Richfield, MNUp to 20,000 Sq. Ft. available in the heart of the Twin Cities.

BILL ROTHSTEINExecutive [email protected]

DAN WICKERSenior Director [email protected]

NEWLY RENOVATED MEDICAL OFFICE SPACE FOR LEASE

research published in the Annals of Internal Medicine (June 2015) shows that ED re-visits after an initial ED encounter actually more than double (8 percent above the previously reported rate of 3 percent) and are often more costly.

This drive toward fewer hos-pitalizations and ED visits has created a shift toward providing more care in the community where people live their day-to-day lives. Community-based care has been, in many ways, a black hole for physicians with few practitioners working in the community and getting brief, if any, glimpses into effective models. While outcomes from programs such as Medicare home health agencies have be-come standard, few programs outside the Medicare realm are producing outcomes, and yet this private-pay arena for non-medical care is not only one of the fastest growing in the

country, it is pivotal for affect-ing readmissions.

Measurable community-based outcomesValue-based contracts reward providers for paying attention to all factors that influence a person’s health and well-being. Social isolation and a person’s purpose (reason for being) play roles that are as important as physiological risk factors such

as high blood pressure, obesity, or physical inactivity. Under new payment structures, pro-viders will need to go beyond physical ailments to identify such issues as grief, social isolation, and lack of purpose as contributing factors for poor outcomes and increased rehospitalizations. For exam-ple, to fix Betty Ann’s broken

hip, providers may first have to identify grief as an issue and heal her broken heart. Accord-ing to the National Institutes of Health, with the shift toward providing more care in the community there is a need “for proven treatments and ap-proaches that not only provide measurable outcomes but also take into account patients’ wishes and preferences.”

Physicians—as health care leaders—need to be able to eval-uate different options based on measurable outcomes. How can they know what works unless providers measure their results and track them over time?

The best way to avoid over-using the ED and hospital is to create accessible and capable community-based teams that build relationships with pa-tients and families over time. Care plans informed by a clear understanding of patient and family goals help physicians address inevitable changes that people will experience once they’re home. In the new home care frontier, smart teams sup-ported by engaged and account-able physicians are emerging as a key driver of value, especially for the highest-cost patients.

Tracking hospitalization and ED visitsWithin this environment, Life-sprk has been providing popu-lation health management for seniors through a combination of care management and home care services in the Twin Cities metro for 10 years. In response to marketplace dynamics, we have developed a whole-person senior care model designed to respond to these problems. In 2014, we undertook a comprehensive effort to fine-tune this model and develop ongoing outcomes management protocols through surveys and other work.

We work with partners and industry leaders to define which

key indicators to track. From a long list of options important to different stakeholders, we settled on tracking hospitaliza-tions and ED visits along with quality-of-life indicators includ-ing connectedness, happiness, control, and engagement. As we set up the capabilities and technology to track these out-comes on a more sophisticated ongoing basis, we undertook a baseline study.

For the baseline, our com-pany gathered the data through client/family interviews using an external evaluator and reviewed our medical records. The study looked at client experience one year prior to working with our organization and then during a year while working together. The baseline study included clients who had initiated services within the last two years. Longer-term clients were eliminated due to the challenge of gathering accurate, self-reported data regarding their experience prior to using our services. The study involved 221 people and examined their actual experiences. Clients lived in a variety of settings spanning from single-family homes to se-nior campuses where we served as the in-home care provider. The study found a 73 percent reduction in hospitalizations and a 52 percent reduction in ED visits for community clients (n=58) and a 42 percent reduc-tion in hospitalizations for all clients regardless of setting with a 37 percent drop in ED visits.

Starting in December 2014, we instituted an ongoing outcomes tracking effort to measure rehospitalizations and ED visits for all new clients as well as quality-of-life indicators using the National Institutes of Health’s PROMIS (Patient Reported Outcomes Measure-ment Information System) tool. PROMIS is a responsive assess-ment tool that is used globally. Efforts are also underway to enhance the risk stratification of client data. Our overall goal is to prove the efficacy of our whole-person senior care approach, while simultaneously providing continuous data to refine the model.


Seniors experience other life challenges beyond physical challenges.

Reducing hospitalization for seniors from cover


Reducing rehospitalizationSeniors experience other life challenges beyond phys-ical challenges. When left unchecked, these life issues can lead to frequent ED visits and hospitalizations. This isn’t just a “health care” issue, it is a life issue. A study by researchers at Boston’s Beth Israel Dea-coness Medical Center (Annals of Internal Medicine, June 2015) found that many of the risk factors for readmissions, especially those occurring eight days or longer post-discharge, are beyond the typical scope of hospital efforts, and include such issues as socioeconomic status or access to support systems. yet once the patient is home, these changing risk factors play a very real role in the potential for rehospitaliza-tion, especially when chronic conditions are present. These risk factors create the need for a comprehensive approach that goes beyond the scope of trans-actional home care services.

Our whole-person senior care model builds patient engagement right from the very start with a goal to “spark lives,” which means to actively engage people in identifying and achieving their priorities for living a richer, more fulfill-ing life with as much indepen-dence as possible. The model, which includes private-pay home care services as needed, is also designed to plug in to many different types of partner organizations—from health systems and physician clinics to senior living campuses, and even employers and associa-tions—to expand their reach into the communities where patients live. We achieved these outcomes through several key program components:

Assigning a life care managerAll clients are assigned a

dedicated Life Care Manager (LCM). A registered nurse, the LCM becomes an ongoing guide and coach for all aspects of well-being, not just health issues. LCMs collaborate closely with physicians, clinics, hospi-tals, home health, and hospice providers, as well as any other service involved in supporting the client and family.

An often missing, or short-term, component in other approaches, the LCM becomes a hub for the team of providers involved in the client’s care. LCMs cross all settings and work with every type of pro-vider. They become the eyes and ears in the client’s home, providing hands-on support to implement the physician’s care plan at home and address such critical needs as support for physician appointments and medication management. LCMs

also examine the broader realm of psycho-social and non-med-ical needs along with client wishes. A growing body of research points to the need for a long-term coordinated team approach to reduce hospitaliza-tions and foster patient success at home.

LCMs also partner with clients and families to provide a wide range of practical, pro-active support and services to safeguard seniors against life challenges and improve their quality of life. The end result is that issues and crises are caught early.

Having a purposeA whole-person discovery

process is designed to engage clients. Our whole-person approach uses a structured, collaborative discovery process that engages clients to identify and prioritize their preferences as the main focus of their individual life plan. The discov-ery tools use specific questions to review seven elements of well-being, including 1) identity, 2) social support, 3) purpose and passion, 4) finances, 5) health and wellness, 6) home and safety, and 7) thinking and memory.

The issues of social support and client engagement explored through discussions of peo-ple’s purpose in life are often missing in traditional provider

services. Through our experi-ence, we have seen how these discussions effectively engage clients’ enthusiasm and active participation in their life plans, which helps to achieve positive outcomes. One 105-year-old client was so enthusiastic about her well-being she decided she wanted to regain the strength to be able to walk into her 106th birthday party, and she did, pro-ducing health ramifications that tied directly to her outcomes.

Avoiding gaps in careA flexible, long-term

approach eliminates gaps in support. Most reimbursed services are episodic with limits to their duration and scope. These limits create gaps

with little support, ongoing guidance, or continuity for the client beyond a 30- or 90-day post-acute period. Our model provides ongoing, long-term support that adjusts based on a client’s need to ensure there are no gaps in support.

Addressing social isolationA combination of evi-

dence-based algorithms and creative approaches is used. Clinical pathways are well established for conditions such as heart failure and pneumonia, but lacking for emerging issues such as social isolation. Sev-eral studies in JAMA Internal Medicine (formerly the Archives of Internal Medicine, July 2012) detail how factors such as social isolation undermine health and well-being, and need to be addressed to stop rehospitalizations and improve outcomes. yet few physicians address it, or even ask patients about it. Our model not only

A growing body of research points to the need for a long-term coordinated team approach to reduce hospitalizations.

Reducing hospitalization for seniors to page 38

American Diabetes Association EXPO Healthcare Professional Breakfast

Saturday, October 11, 2014 at 7:00am Minneapolis Convention Center

Meeting Room 103 DEF

What are the Most Effective Weight Loss Interventions for Diabetes and Prediabetes

Presentation by Dr. Charles Billington, MD

Losing a few pounds can dramatically improve health and quality of life especially for people with diabetes and prediabetes. Effective weight loss can involve multiple techniques and strategies including lifestyle changes, medication and surgical options. Please join us for an informative discussion on the most effective weight loss interventions for those with diabetes and prediabetes as well as how to guide your patient through the weight loss process. Objectives:

Compare the range of approaches for weight loss Describe the body’s physiologic mechanisms to protect against weight loss

Identify ways to support a patient working to lose weight

7:00 am - 8:15am Breakfast, Networking, Presentation and Discussion

RSVP on-line at http://diabetesmn.wufoo.com/forms/hcp-breakfast-rsvp/ Space is limited. Please RSVP by Friday, October 3, 2014

Event is free of charge and open to all healthcare professionals to attend

Policy


Despite the challenge of the fast-changing pace of the health care

industry, it is imperative that physicians keep current with the changes to be properly prepared. increased consum-er demands, the evolution of technology, and ever-increasing pressure from lawmakers and regulators to reduce health care costs are pushing the industry into new realms. While physi-cians may wish to fight some of the changes, it appears that such a strategy is generally not successful in the long term—it is inevitable that the industry today will look very different from the industry in five, 10, or 20 years. this article touches on five general categories where the industry is expected to experience continued change. these categories include: 1) reimbursement, 2) care delivery models, 3) practitioner licensure, 4) technological advances, and 5) fraud and abuse enforcement.

Reimbursementit is well-recognized that the growth in health care spending is not sustainable. historically, federal and state governments have tried various approaches to control this growth. Unfortunately, most of these approaches have shown limited success.

the most recent govern-ment initiative to try to reduce health care spending was the enactment of the affordable care act (aca) in 2010. the aca represented a major shift by the federal government in

controlling health care spend-ing by focusing on ways to shift health care reimbursement from a fee-for-service approach, which encouraged providers to offer more services, to an approach that paid providers based on the quality or out-comes of their services. the aca was the impetus for the development of accountable care organizations (aco) as well as centers for Medicare & Medicaid services’ (cMs) new and ambitious goals for shift-ing provider reimbursement from volume based, such as fee-for-service, to value-based reimbursement (see Minnesota Physician article, June 2015).

Given the amount of atten-tion and government funding to this value-based reimburse-ment approach, it is only a matter of time before these approaches are adopted by commercial plans. in addition to the transition to value-based reimbursement, employers and health plans will continue to shift health care costs on to the patient. as a result, consumers will become more frugal and make more thoughtful deci-sions regarding their medical care.

in light of the expected health care reimbursement changes, physicians should spend time thinking about their practice and how they can best be prepared. Physicians should become familiar with these up-coming reimbursement changes and plan a course of action that best suits their practice.

New care delivery modelsWhile the growth in health care costs are causing employers, plans, and the government to reassess their reimbursement

strategies, it has also resulted in the outgrowth of new delivery models. in response to con-sumer demands for easy access to low-cost health care ser-vices, innovative providers are introducing new care delivery models. a classic example is the introduction of retail clinics such as Minuteclinic at cVs and target clinic. these clinics have grown exponentially in recent years. they appeal to consumers because they offer efficient and low-cost services, provide flexibility by way of walk-in appointments, and have undeniably convenient locations. While, historically, the services provided by retail clinics have been limited, it is likely that with technological advancements and consumer acceptance of such arrange-ments, the retail clinic model will move beyond providing just a few limited services to pro-viding more complex diagnostic and treatment services. For example, orthopedic providers have discovered that certain emergent and urgent orthope-dic services are well suited to being marketed and delivered to consumers using the retail clinic model.

in addition to retail clinics, the internet is fertile ground for innovative parties to develop creative ways to provide health care services. today, the inter-net is probably a consumer’s greatest resource for informa-tion about health care condi-tions and illness. as a result, internet-based providers of di-agnosis and treatment services have become readily accepted. For example, the use of health-Partners’ virtuwell product by consumers has grown signifi-cantly since its introduction. the virtuwell product bills itself as a 24/7 online clinic, combines retail clinic principles with online accessibility, and is in perfect harmony with today’s technology-driven consumer. Physicians should think about how their current practice can meet the needs of this evolving consumer, which may mean ex-ploring innovative care delivery models that provide flexible and convenient health care services.

The future of health careWhat lies ahead for physicians

By Timothy A. Johnson, JD, and Julia C. Marotte, JD

Do you have patients with trouble usingtheir telephone due to hearing loss, speechor physical disability?

If so…the TED Programprovides assistive telephoneequipment at NO COSTto those who qualify.

Please contact us,or have your patientscall directly, for moreinformation.

1-800-657-3663www.tedprogram.org

The Telephone Equipment Distribution Program is funded through theDepartment of Commerce Telecommunications Access Minnesota (TAM)and administered by the Minnesota Department of Human Services

Duluth • Mankato • MetroMoorhead • St. CloudTe

lepho

neEq

uipm

ent

Dis

trib

utio

n(T

ED)

Prog

ram


Practitioner licensureas the health care industry evolves, so does the regulation of health care professionals. one common trend that is expected to continue is the expansion of regulatory author-ity of non-physician providers. as regulatory agencies begin recognizing that certain health care services may be provided by qualified non-physicians, these agencies are more willing to expand the services these non-physicians may provide. For example, most states now have laws regulating the scope of services that may be pro-vided without physician super-vision by one or more types of advanced Practice Registered nurses (aPRns), which include nurse practitioners, clinical nurse specialists, nurse anes-thetists, and nurse midwives. For example, starting in 2015, Minnesota permits qualified licensed aPRns to practice independently, without physi-cian supervision. in addition to the expansion of authority of aPRns, there has been sig-nificant growth in the types, programs, and use of provider “assistants” such as physician assistants, physical thera-pist assistants, and medical assistants.

this trend can be attribut-ed to many factors, including both the shortage of primary care physicians as well as the reduction in reimbursement for such services. Regardless of the reason, the use of aPRns and provider assistants is expected to increase as more state agen-cies become comfortable with granting them greater authority to provide care. as a result, phy-sicians should explore how they may use these professionals for the benefit of their practice, such as to improve efficiency or shift their focus to more com-plex services that receive higher reimbursement.

Technologythere is no question that technology plays a critical role in the health care industry. While advancements in med-ical technology are credited with improving the care pro-vided to patients, advances

in technology have also been cited as a primary reason for the increased cost of care. While there will continue to be advances in expensive diagnos-tic and treatment technology such as the use of robotics in surgeries and more advanced imaging capa-bilities, for most physicians it is more import-ant to monitor advancements that impact their spe-cific medical specialties.

For primary care physicians, their time should be spent monitoring the significant technology advancements that not only help patients monitor and improve their health, but also diagnose medical conditions. the focus on wellness programs has prompted a significant growth in products and services. For example, there has been a surge of wearable accessories for individuals such as fitness tracking devices made by Fitbit, Jawbone, nike, apple, and others to help patients monitor their fitness activities. similarly, there has been a large growth in downloadable medical-related applications used by individuals.

the innovation and devel-opment of personalized, tech-nology-driven health solutions will be a significant focus of the industry in years to come. Because of their popularity, it is important that physicians stay current on these innovations. some of these new services and products may be useful aids for physicians in treating patients, especially as ways to encour-age patients to increase their exercise regimen, participate in weight loss programs, and better monitor health goals.

Fraud and abuse enforcementalong with the vast growth in health care spending, there has been an increased focus on enforcement actions to reduce fraud, waste, and abuse by pro-viders. this focus will continue

and physicians should expect to see new and innovative uses of technology to investigate and recoup improper payments. For example, cMs’ Fraud Preven-tion system uses predictive algorithms and other sophis-ticated analytics to evaluate

billing patterns against every Medicare fee-for-ser-vice claim. the Fraud Prevention system has the capability to stop payment of improper claims elec-tronically by

sending a denial message to the provider’s claims payment system. in only its second year of operation, this program recovered or prevented more than $210 million in improper payments. as a result, cMs plans to extend the application of the Fraud Prevention system and has other pilot projects

underway to combat health care fraud and abuse. With this increased focus on cutting-edge enforcement technology, physi-cians should continue to mon-itor their billing procedures to ensure standard practice is in line with federal and state laws and regulations.

Planning for the futurethe transformation of the health care landscape is unavoidable. the good news is that, armed with the right tools, the future is exceptionally bright. With good education and appropriate planning, physicians have the ability to ride the wave and take their practice into new domains.

timothy A. Johnson, JD, is a prin-cipal at Gray Plant Mooty and a member of its Health & Nonprofit Organization Practice Group. Julia C. Marotte, JD, is an associate at Gray Plant Mooty and a member of its Health & Nonprofit Organization Practice Group.

The growth in health care

spending is not sustainable.

WESTIN GALLERIAEDINA MN

PAIN CONFERENCESATURDAY NOV. 14th, 2015

10th ANNUAL

www.painphysicians.com888.901.7246 (PAIN) / 608-604-4659

For conference registrati on and CME programinformati on contact Ginny Cairns at:

[email protected] or 608-604-4659

REGISTER NOW!

LIMITEDSEATS

AVAILABLE

CONT

INUING MEDICAL

E D U C A T I ON

Pediatrics

If you walk down the health technology aisle of a major retailer you’ll observe a

tremendous variety of activ-ity tracking devices—Fitbit, Jawbone, Garmin, Misfit, and others. But look closer and you’ll see the emergence of the next generation of devices that address more specialized areas: Kinsa, a smart thermometer; Mimo, a smart onesie; Sprout-ling, a “Fitbit” for babies; and the iHealth suite of products including blood pressure cuffs, scales, and glucometers. Online you’ll find products like Alive-Cor, a smartphone connected ECG or CellScope, and a smart-phone connected otoscope. All of these products can be allur-ing for the tech-savvy parent. But all of the data from these devices can be overwhelming to a health care provider.

Until recently the data from these sensors had little use in a clinical setting. The data lived in a proprietary app and cloud with little connectivity to any clinical setting. Advances in secure integration are turning that disconnected data into

actionable information when coupled with proper clinical oversight.

Pediatrics and health technologyAs these emerging health man-agement tools gain greater trac-tion, they will impact clinical interactions across the patient spectrum—none more so than for pediatrics. As parents adopt these technologies with their children, particularly those with chronic conditions such as diabetes and asthma, clini-cians will need to become adept at using these new sources of information. Through this persistent connectivity, we can

improve health outcomes and lower costs for many patients.

Three years ago, fitness trackers were primarily for “early adopters.” Now fitness trackers are everywhere, from wrist-worn bands to those embedded in phones, watches, clothing, and even car seats. Consumer-grade pediatric health devices will likely follow a similar path. As we think of innovation in health devices, who better than kids and young parents to lead the charge? Kids love technology, as do many young parents. Neither group has a fear of technology; in fact, they embrace technology more than any other generation.

Plus, they give honest feedback. Mobile technology is firmly en-trenched in their everyday lives.

It’s entirely possible that a baby born today could have every heartbeat in their lifetime monitored and digitized. From a baby’s smart onesie to wear-able heart rate monitors to in-tegrated sensors in mattresses, automobiles, and other every-day items, every aspect of their life might be quantified, and available to their health care team at the touch of a button.

The challengesCreating meaningful action from this onslaught of data is a tremendous challenge. Text alerts for sports scores, online posts, and weather are ubiq-uitous, but you are a passive recipient of that type of infor-mation. Parents, kids, and providers will need to become engaged and responsive users of health care data. Systems to alert the parent of a chronically ill child of a meaningful health event are not readily available. Until recently, the parents of a diabetic child had to “hack”

Electronic health care

Logging on to your children

By Jeffrey Weness, MBA, and Laura M. Gandrud, MD


Trust your issues to a savvy team of legal experts 763-225-6000 • www.gislason.com

Providing counsel and guidance in all Medical Malpractice issues, including:• Surgical Issues • Anesthesia Issues • Medication Issues • Nursing Issues

• Appearances before professional licensing boards

Medical Malpractice defense

Barry [email protected]

angela [email protected]

Matt [email protected]

Jennifer [email protected]

ryan [email protected]

into their children’s glucose monitor to access the informa-tion in real time. Providing this relevant health information (glucose levels, pollen count, etc.) at the right time and in a format that achieves the great-est engagement for parents and health care providers is a top priority for many digital health companies today, however this is not without challenges. Four primary challenges exist in the pediatric health monitoring space: regulation, market size, data security, and connectivity to the care team.

RegulationMost connected health devices are making only general well-ness claims, thus avoiding FDA regulation. This results in mar-keting the devices that track a baby’s respiration, heart rate, O2 saturations, and sleep posi-tion as “smart baby monitors.” Just as a medication can be used off label, devices are also used off label. There are stories of parents removing the motion sensors from the smart onesie

and sewing them into larger pajamas as a means of notifica-tion that their nine or 10 year old was having a seizure during the night. Parents have learned how to “hack” a product or system and create something that better fits their needs. Nightscout is a widely used data sharing cloud-based system that

came out of parents “hacking” an FDA-approved continuous glucose monitor (CGM). Parents are clamoring for ways to better manage their kids with chronic conditions.

Market sizeThe pediatric market for health management tools is small in comparison to the adult market. Since kids are not simply small adults, tightening the strap on an adult Fitbit doesn’t make it work for kids. Dedicated design

of a health device for infants and children is crucial for accuracy and ease of use. Given that the market is small (and the regu-lations more complex), major manufacturers have made the pediatric market a lower prior-ity, but we are now starting to see products come to market.

Data securityPhysicians must address and prioritize the privacy of patient data from remote sources. Hav-ing secure transfer and inte-gration methods are important factors when choosing health management partners such as Validic, and companies like it. They make secure integration of data in the patient record possible. As we consider remote monitoring in pediatrics, many complex issues must be addressed: security on the

monitoring device; security in the transmission of data to the cloud; and rights and controls in accessing the data in the clinic and by parents/guardians. Parents and caregivers can’t act on data if it isn’t available or communicated.

Connectivity to a care teamDiseases that require daily management such as diabetes, asthma, heart disease, and eating disorders all lend them-selves to daily remote monitor-ing and care team connectivity. In most existing care models, intervention happens between clinic visits only. With emerging connected technology, health care providers can access data between scheduled clinic visits. In the case of a type 1 dia-betic child, connected glucose monitors (intermittent and continuous) allow real-time transmission of blood glucose data to both parents and the clinic. When paired with a con-nected insulin pump or “smart insulin pen,” caregivers can

Real-time management of our patients will become a viable reality.


Electronic health care to page 34

62

35W

35W

35W

35E

35E

394

94

94

494

494

69449436

36

95

212

12WAYZATA

ARDENHILLS

EDENPRAIRIE

APPLEVALLEY

NOT TO SCALE

MINNEAPOLIS

STILLWATERMAHTOMEDI

SAINTPAUL

77

51

Tickets to SPCO concerts start as low as $10! With performance venues throughout the Twin Cities, we are sure to be near you.

Visit thespco.org to view a full schedule of performances at venues throughout the metro area.

NOW ON SALE – ORDER TODAY

SPCO VENUES

Tickets start at just $10! Ticket Office:

651.291.1144Monday – Friday from 12:00 – 5:00pm Saturday from 11:00am – 3:00pm

thespco.org

HEALTH DISPARITIES


even though Minnesota consistently ranks as one of the healthiest states

in the U.s., opportunities for high-quality health care are not equally available to all Minne-sotans. For our lesbian, gay, bi-sexual, transgender, and queer (LGBtQ) community in partic-ular, unique health inequities exist that can lead to negative health outcomes and lifelong health problems.

the U.s. Department of health and human services national healthy People 2020 initiative notes that LGBtQ health requires attention from health care and public health professionals to address a num-ber of specific disparities:

• transgender individuals have a high prevalence of mental health issues and suicide, and are less likely to have health insurance than heterosexual or LGB individuals.

• elderly LGBtQ individuals face additional barriers to health because of isolation and a lack of social services

and culturally competent providers.

• LGBtQ populations have the highest rates of tobacco, alcohol, and other drug use.according to the 2014 Rain-

bow health initiative report, Voices of health: A survey of LGBTQ health in Minnesota, of the 1,859 people surveyed who identified as LGBtQ:

• twenty-five percent smoked every day or some days per week.

• thirty-three percent report-ed binge drinking in the past two weeks.

• sixty percent of LGBtQ respondents report being diagnosed with depression and 50 percent report being

diagnosed with anxiety.“When you are a member of a minority that experiences stress, that has a negative net effect on all kinds of long-term health issues,” said John azbill-salisbury, MPh, director of programs for the Rainbow health initiative (Rhi).

another factor is accessing health care. “We were able to collect our Voices of health survey data in 2013 and 2014, both before and after the im-plementation of the affordable care act in Minnesota,” said azbill-salisbury. “and what we saw was that the overall unin-sured rate in Minnesota went down to about 4 to 5 percent, and for LGBtQ folks it went

down too, but from a much higher 16 to 12 percent, so the overall decrease in the number of uninsured had less effect on LGBtQ folks.” economics plays a role as well, and azbill-salis-bury pointed out that more LGBtQ people live in poverty, experience job insecurity, or are underemployed based on their education level than their non-LGBtQ counterparts.

Confidence and open communication are vitalResearch also suggests that these negative outcomes and lack of access may be due to low cultural competence in the health care system, which can sometimes be articulated in an unwelcoming and negative atti-tude expressed by staff toward people in this community.

the 2014 Voices of health survey reported that after mental health, a full third of LGBtQ respondents identified health care provider’s knowl-edge of LGBtQ issues as a top health issue. carrie Link, MD, assistant professor at the

Health equity for the LGBTQ community

Advancing the quality of care

By Mary Beth Dahl, RN

See 3 or more operas and save up to 25%! La

tra

via

ta, 2

011

© M

ich

al D

anie

l

mnopera.org 612-333-6669Ticket Office: M–F, 10am–5pm

The 2015–2016 Season


University of Minnesota and family medicine physician at smiley’s Family Medicine clinic, describes the problem more directly. “smoking and depression rates are twice as high in the LGBtQ community as in the general population. For the trans and gender non-conforming community, the suicide attempt rate is 41 percent compared to less than 2 percent for the general population,” said Link. “But the biggest problem is that people aren’t seeking care because they don’t feel safe or comfortable. that’s based on both real and perceived discrimination. once they’ve experienced discrimina-tion they’ll start to anticipate it. you could be the most open and awesome doctor in the world, but they have to interact with four or five people before they interact with you.”

Because of this avoidance of care, health issues can often go undetected in the LGBtQ community. For example, data show that lesbian and bisexual women receive less routine care

than other women, including breast and cervical cancer screening. it is important for LGBtQ people to feel welcome and comfortable enough to seek care and routine health screen-ings, and for health care provid-ers to be positive and accepting of sexual and gender diversity. this is vital to improving care.

Knowing how to create and maintain that kind of open environment is not something many providers are taught. azbill-salisbury cites a 2011 study from the stanford Uni-versity school of Medicine published in the Journal of the american Medical associ-ation, which said, on average, medical students spend just five hours learning about the health care needs of the LGBtQ

community, despite evidence that these patients often face a unique set of health risks.

“We know that most pro-viders are going out into the field and unless they’ve made an effort to access some sort of training, they don’t have very much education on LGBtQ,”

said azbill-salisbury. “that being said, there are quite a few organizations, Rhi includ-ed, that do offer training and resources to providers. We have a program that works to help providers understand what they need to create inclusive spaces for LGBtQ folks. it’s a little bit less about ‘here is the specif-ic medical training you need’ but more about asking how do you create an environment in a

clinic so when someone who is LGBtQ comes in the door they feel comfortable and supported.”

Becoming more inclusiveLink and staff have been work-ing to make University of Min-nesota Physicians smiley’s Fam-ily Medicine clinic an inclusive and welcoming place for all patients, including LGBtQ. “i think physicians have the power to influence change to access to care. Patients come in and fill out forms with an “M” and an “F” to identify their gender and have no other options,” Link said. “Research shows that things like gender-neutral bathrooms, and forms that have more options for partner and gender, make a big difference. it doesn’t feel like the traditional job of the physician to redesign the forms, but it is our job to treat everyone respectfully, and when you think about it from that framework it becomes a lot easier. We changed our forms so you fill in your gender,

“People aren’t seeking care because they don’t feel safe or comfortable.” Carrie Link, MD

Health equity for the LgBtQ community to page 32

Many Faces oF coMMunity HealtH tenth AnnuAl ConferenCe

Thursday – Friday, October 22 – 23, 2015 • Marriott Minneapolis Southwest – Minnetonka, MN

Keynote: Pedro Jose Greer, Jr., MD Assoc. Dean of Academic Affairs and Chair of Dept. of Humanities, Health and Society, Florida Int’l University School of Medicine

Keynote: John R. Finnegan Jr., Ph.D Dean of the School of Public Health, Epidemiology & Community Health, University of Minnesota

Join us for a two-day conference that explores ways to improve care and health equity in under-served populations and among those living in poverty. It brings information and resources on chronic disease prevention and care, public policy and health innovations to Minnesota’s health

care community, with a focus on safety net providers. The conference offers two tracks: Management / Policy and Clinical.Continuing Medical Education credits applied for.

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

manyfacesconference.orgFor more information contact Sean Schuette at 952-564-3077 or [email protected]

sPeaKeRs incluDe:

SPECIAL FOCUS: OnCOLOgy

I have spent many winters in upstate New York, but when I was being recruited to

work at the University of Min-nesota, I didn’t know what to expect. In fact, I had never been to Minnesota before my first interview. As is the case with people from the East Coast, our vision of Minnesota includes the Mall of America (and its famous indoor roller coaster), the films “Fargo” and “Grumpy Old Men,” ice fishing, and all those lakes. What fascinated me the most, however, were the skyways. The reason is simple. Studying skyways at the cellular level has become my life’s work.

In upstate New York, we did not have skyways; at best, there were a few basement-level tunnels to protect us from the vicious winter cold. I have many ruined sets of dress pants splattered with black snow to attest to the messiness of it all. Skyways are a unique and simple concept: an aboveground pedestrian tunnel that connects buildings and allows car traffic

to flow underneath at the street level. Most important, skyways are a highly efficient way for people to walk from building to building without having to venture out into the cold or inclement Minnesota weather. It is notable that while you can on occasion find skyways in other parts of the country, they are most often found in cold-weather states like Minnesota.

Tunneling nanotubesThe reason that skyways fasci-nate me is that they represent a macrocosm of what happens in cancer cells. Skyways exist in cancer; they are called tunnel-ing nanotubes.

I first stumbled upon this field while doing my postdoc-toral research and clinical fellowship at Memorial Sloan Kettering Cancer Center in New York. My initial task was to iso-late and characterize malignant cells from patient-derived tu-mors, and to study their ability to perpetuate despite drug treat-ment. While looking at these cells under the microscope, I saw long, drawbridge-like exten-sions that cancer cells formed between themselves, especially between cells that were locat-ed long distances from each other. Uniquely, these exten-sions seemed to be hovering, much like a tightrope. I had access to world-class experts in cell and cancer biology, and nobody could explain or verify what these structures were. We delved into the research literature, and found that a research team in Heidelberg, Germany had published on this phenomenon a few years prior, and called these structures tunneling nanotubes. The word “tunnel” is self-explanatory; “nano” refers to the fact that these extensions were unusu-ally narrow. The descriptions in the journal Science in 2004 matched what we were seeing under the microscope. Because our focus was on invasive can-cers, our team pursued work on characterizing nanotubes (or TNTs) in the aggressive cancers we were working on at the time, such as malignant pleural meso-thelioma and lung cancers. We found that nanotubes formed spontaneously and served as direct pipelines connecting distant cells, not just in cell lines but also in cells we derived directly from pleural effusions and ascites from patients with advanced cancers.

By that time, a few groups worldwide had published

further work demonstrating the unique functions of nanotubes in the propagation of infection or in facilitating communica-tion between immune cells. For example, a group in Paris showed that neurons could form nanotubes and facilitate intercellular transfer of pri-ons, the causative agent for Creutzfeldt-Jakob (mad cow) disease. Other groups showed direct cell-to-cell transmis-sion of HIV and other forms of viruses, and that immune cells (e.g., B lymphocytes) could communicate directly with macrophages. The field was opening, but the question remained of in vivo relevance. The biggest criticism of the field was that this was an in vitro phenomenon that was not present in disease in actual liv-ing beings. We then addressed that question by imaging intact tumors resected from human patients with mesothelioma and lung cancer. Taking advantage

of new technology and software allowing for three-dimensional reconstructions of individual microscopic images, we visual-ized nanotubes in all six of our initial tumor samples. This rep-resented a big breakthrough for this new field of cancer biology, and launched my interest in pursuing this further. I took in-spiration from seeing skyways for the first time, as this gave me a real-life full-scale model to consider as I imagined the next steps to study the function of nanotubes.

microRNAsOver the past decade, there has been a true revolution in understanding and targeting the genomics of cancer, and in identifying targets for more effective therapy. In addition, there have been advances in

The skyways of cancer

How cancer cells communicate

By Emil Lou, MD, PhD

20 MINNESOTA PHYSICIAN August 2015

[Nanotubes] would create a new

approach to targeting cancers for therapy.

understanding the cell biology of cancer that have facilitated studies that, while not yet ready for human clinical trials, have provided building blocks for understanding formation and advancement of human can-cers. The field of microRNA biology is one prime exam-ple. microRNAs are short, non-coding forms of RNA that can alter (upregulate or down-regulate) target genes. There are more than a thousand forms of microRNAs, each of which has the potential to affect different sets of genes, including those that instigate increased growth of cancer, metastasis to dis-tant sites, and development of resistance to drug therapies. The widely-held assumption has been that microRNAs are inherited from parent cells following cell division. In recent years, an advancement in cell biology has been the identifi-cation of exosomes or microve-sicles—small pockets of cells that can be extruded by the larger cell, and serve as small “shuttles” for intercellular cargo transfer. This cargo can include messenger signals (such as microRNAs) that can be trans-mitted to other cells to alter their behavior. No group had yet shown that microRNAs—or any genetic material—could be exchanged in this manner from cell to cell via nanotubes. Thus, I initiated a collaboration with experts in the field of micro-RNAs at the University of Min-nesota, in order to determine whether this was the case.

A communication network for cellsOur team had to first overcome some technical challenges in working with such small genetic codes, but we were able to first identify forms of microRNA that were overex-pressed or altered in cancer cells resistant to chemotherapy. We then marked these forms of microRNA with a fluorescent tag that allowed us to visualize them under the microscope. Using this approach, we were able to successfully witness direct intercellular transfer of these microRNAs through nanotubes not only connect-ing cancer cells, but also

connecting cancer cells directly to benign (e.g., epithelial) cells. This latter observation had been hypothesized, but was none-theless surprising, and opened up an entirely new avenue of research and potential conse-quences. As we have learned how malignant cells interact among themselves in the vast and complex tumor micro-environment, we have also learned how they interact with nonmalignant cells in their “neighborhood,” which in bio-logic terms is called the tumor microenvironment. There is more evidence than ever before to suggest that nonmalignant stromal cells (e.g., fibroblasts, vascular endothelial cells, etc.) play a critical role in cancer growth and invasion. Our finding that microRNA genetic materials can be shared in an efficient manner via nanotube conduits provides evidence to support that a communication network between cells can help facilitate this.

In this era of social media and instantaneous (specific) communication, it does make sense that cancer cells can adopt similar methods quite ef-fectively. In the way our society communicates, we have gradu-ated from the pony express to switchboard phone calls to mo-bile phones instantly capable of connecting us selectively with anyone in the world, whether it be by voice, text, email, or Face-book. If cells use nanotubes as a network to convey signals and with great skyway-like efficiency, we propose that they represent a promising topic of study. Of even more relevance, if disrupting the lines of com-munication prevents cells from organizing and synchronizing within a tumor, then this would create a new approach to target-ing cancers for therapy. Cur-rent standard forms of cancer

treatment include chemother-apies, many of which target genetic material (e.g., DNA) but are not selective for cancer cells alone; newer biologic agents target other mechanisms of tumor growth, including blood vessels induced by cancer cells to facilitate their own nutrition and growth through a process called angiogenesis. Cellular communication is important to all aspects of cancer growth and advancement. There are no current standard therapies targeting this mechanism,

but elucidating mechanisms of nanotube communication in cancer may lead to ways to prevent this unique form of tumor cell communication. In the Land of 10,000 Lakes, sky-ways provided the inspiration for studying something much smaller, but perhaps critical to our understanding of how can-cer cells communicate.

Emil Lou, MD, PhD, is a physician-scientist and medical oncologist at the University of Minnesota.

August 2015 MINNESOTA PHYSICIAN 21

We have learned how malignant

cells interact among themselves.

special focus: oNcoloGY


tumors of the head and neck are the fifth most commonly occurring ma-

lignancy with 50 percent of all head and neck tumors appearing in the oral cavity. this accounts for approximately 615,000 new cases worldwide with 300,000 being primary oral cavity squa-mous cell carcinoma (ocscc) each year. ocscc accounts for 2 to 3 percent of all malignancies. in the U.s., recent seeR data suggests that 43,500 new cases and approximately 9,000 deaths will be attributable to oral, head, and neck cancer this year. this makes oral cancer the sixth leading cause of cancer-related mortality, accounting for one death every hour in this country. Unfortunately, despite advances in screening tools, imaging tech-nology, and access to primary care physicians there continues to be a significant burden of pa-tients presenting with advanced stage disease.

Symptoms and detectionclinical signs and symptoms of head and neck tumors are often discreet and may be mistaken for other common ailments. Patients often seek care from

primary care physicians and dentists regarding complaints within the oral cavity. it is im-perative that providers are aware of the increasing incidence of oral malignant disease, partic-ularly in young patients without traditional risk factors of alcohol and tobacco abuse, and are vigi-lant in screening all patients for oral mucosal lesions. although the presence of an oral lesion is quite common, the ability to pre-dict which lesions will progress to invasive carcinoma and which will remain stable and follow an indolent clinical course is a continuing challenge.

Patients with occult oral lesions may be asymptomatic and require detection with rou-tine screening. however, when patients are symptomatic they

typically present with nonspe-cific symptoms including pain, loose teeth, bleeding, dysarthria (difficulty in speech articu-lation), dysphagia (difficulty swallowing), odynophagia (pain on swallowing), otalgia (ear pain), sensory and motor nerve compromise, mass lesions at the primary site, or cervical lymph-adenopathy. Given that the oral cavity is amenable to physical examination requiring limited sophisticated equipment, the persistence of patients present-ing with advanced stage disease is troubling.

Premalignant lesions typi-cally present with a leukoplakia (white), erythroplakia (red), and/or an erythroleukoplakia (red and white) discoloration on the oral mucosa. early ocscc often

originates from one of these premalignant conditions. as the lesion matures, it can become centrally ulcerated with indis-tinct, indurated borders. Lesions may have concerning exophytic or endophytic growth with time. the early presentation of ocscc is typically painless and asymp-tomatic. however, with cancer maturation, symptoms will develop prompting self-directed referral. the most common sites of ocscc are the dorsal and lateral borders of the tongue (40 percent), followed by the floor of the mouth (30 percent), followed by the retromolar trigone, buccal mucosa, and the maxillary and mandibular gingiva.

Risk factorshistorically, ocscc has been associated with males older than 60 who regularly consume to-bacco and alcohol products. this patient demographic is changing with a steady increase in the incidence of ocscc occurring in patients under 40, and in partic-ular females without identifiable risk factors. there has been a tremendous interest in recent years focusing on the role of viruses in the development of

Cancers of the neck and head

Early detection and treatment methods

By Deepak Kademani, DMD, MD, FACS

The integration of St. Croix Orthopaedics and Twin Cities Orthopedics!

WE ARE EXCITED TO ANNOUNCE...

The integration allows for us to expand the services we offer across the entire metro area and into western Wisconsin with a team of more than

100 orthopedic surgeons and 35 locations.

Both St. Croix Orthopaedics and Twin Cities Orthopedics share a similar vision of providing exceptional care and outstanding service.

Visit TCOmn.com or stcroixortho.com to learn more


ocscc. in particular, human papilloma virus (hPV, 16, 18, and 31 subtypes) is now consid-ered an independent risk factor for development of oral cancer. hPV 16 and 18 have been found in 22 percent and 14 percent of oropharyngeal tumors and have shown to increase the risk of ocscc by approximately three- to five-fold. Fortunately, the prognostic implications of hPV presence are favorable, with hPV positive oropharyngeal tumors having improved responsiveness and survival as compared to hPV negative tumors.

tobacco use has a long, well-established causative rela-tionship to the development of ocscc with the development of field cancerization. approx-imately 80 percent of ocscc patients smoke or have used to-bacco products, and they are at a five to seven times greater risk of developing malignant head and neck tumors.

DiagnosisDiagnostic approaches to ocscc include dental, head, and neck evaluation and direct-ed biopsy of concerning areas. Diagnostic imaging including an

orthopantogram, ct, and MRi scanning is useful for staging. Positron electron tomography (Pet) has an increasing role in tumor surveillance. Pet scan-ning uses a radiolabeled glucose isotope (18-FDG) to label areas of hypermetabolism. this is a valuable tool in oncologic stag-ing and surveillance.

the tnM classification sys-tem has proven to be a reliable indicator of patient prognosis, with primary tumor size and cervical lymph node status being the two most significant fac-tors affecting patient survival. however, biologic aggressiveness resulting in early regional metas-tases and death has been found in a number of clinically small or undetectable primary tumors. conversely, some large tumors may be slow to metastasize both regionally and distantly. typical-ly, t1–t2 lesions are associated with a risk of regional metasta-sis of 10 percent to 30 percent

respectively, whereas t3–t4 lesions have significantly higher risk of regional neck disease. the overall five-year survival rate for ocscc for all stages is between 45 to 72 percent in most large series studies. early stage tumors (t1–t2) are associated with a 60 to 80 percent five-year survival rate. the status of the

cervical lymph nodes is the single most important prognos-tic factor in ocscc, with the development of neck metastases reducing five-year survival by a further 50 percent.

Treatment

Surgical resectionthe mainstay of treatment

for ocscc continues to be primary site surgical resec-tion. Posterior oropharyngeal, laryngeal and hypopharyngeal tumors are typically treated with “organ-preservation” utiliz-ing chemoradiotherapy as the initial mode of treatment. in

these cases, surgery is reserved for the management of small primary tumors, and persistent or recurrent disease. the goal of all curative primary resection is complete eradication of local disease with adequate treatment of the cervical lymph nodes.

Patients with clinically and radiographically staged n0 neck disease are treated with pro-phylactic staging lymph node neck dissections when the risk of occult neck disease is greater than 15 percent. in essence, this means all patients with >4 mm tumor depth of invasion, t2 (2–4 cm), t3 (>4 cm), and t4 (invasion into adjacent critical structures such as bone) are treated with a staging neck dissection. typi-cally, if neck dissection speci-mens are histologically negative no further adjuvant therapy is initiated. in situations of occult neck disease, with one or more metastatic lymph nodes, multi-level disease, or the presence of extracapsular spread, regional radiotherapy with either con-ventional 2- or 3-Dimensional or intensity-modulated radiation

The importance of smoking and alcohol cessation cannot be overemphasized.

Cancers of the neck and head to page 37

The source for Diamondhead Property

� Custom homes � Lake view, golf course views, � Lake front, Vista views or Interior lots

� Rental programs available � Live in or use as nightly rental Income

We offer a wide range of outstanding real estate investment and/or retirement opportunities. Build-able lots start as low as $10,000 with many options ranging to new 5-bedroom 4,000 SQ FT lakefront homes for $490,000.

A glittering jewel of a community on the shores of Lake Catherine and with the panorama of the Ouachita Mountain range, Diamondhead Resorts 2,300 acres are known as a golfer’s paradise and a fisherman’s dream. Our temperate year-round climate will be welcomed by all Minnesotans.

Hot Springs National Park unparalleled value, quality of life and natural beauty

1-800-599-7249 • www.diamondheadcommunity.net www.seediamondhead.com

101 Catherine Park Rd., Hot Springs National Park, AR 71913

RADIOLOGY

What exactly is radia-tion therapy and how does it work? To most,

it is a black box in a weird de-partment hidden somewhere in the basement. To find out we need to step back and take a closer look.

Radiation is defined as en-ergy that comes from a source and travels through material or space. Obvious examples of ra-diation include light, heat, and sound. As we all dutifully mem-orized in our premed physics classes, these examples of radi-ation differ in their energy and wavelength.

Many of us think of radi-ation as a scary, weird, and therapeutic modality, but we must remember that radiation existed long before humans did. Humans adapted and lived un-knowingly with this constant flow of radiation that emanated from space or from the ground.

The discovery of X-raysThe story of radiation begins with the famous 1895 image of

Wilhelm Roentgen’s wife’s hand with her wedding band. This skeletal image was the result of a stream of electrons in a vac-uum tube that produced a ray that had not yet been defined. These mysterious rays were eventually called X-rays where “X” signified the unknown. This discovery earned Roentgen a Nobel Prize in 1901.

In the wave of excitement following Roentgen’s discovery, Henri Becquerel noticed that a particular rock seemed to have similar rays emanating from it. This rock was a uranium-rich mining castoff called pitch-blende ore and it developed a photographic plate exactly like the mysterious X-rays did. But, how could a stream of electrons in a vacuum tube and a rock

produce the exact same result?The thought that energy

could be “locked up in a rock” captured the interest of Marie Curie, a PhD student in Paris. During the process of charac-terizing and measuring this energy she and her husband, Pierre, discovered and isolated radium after an arduous ex-traction from pitchblende ore. Marie and Pierre Curie, along with Henri Becquerel, shared the 1903 Nobel Prize in physics for the discovery and character-ization of radiation.

Roentgen’s rays from a cath-ode tube and Becquerel’s rays from pitchblende highlight the difference between X-rays and gamma radiation. Sim-ply put, the two are defined by the source. If the energy comes from a stream of electrons they are X-rays; if the energy comes from a decaying nucleus in a rock they are gamma rays. Oth-er than the source, the energy is similar. If the energy is simi-lar, then the radiation is similar because radiation is defined as energy traveling in space.

Therapeutic applicationsHow did the discovery of X-rays and gamma rays lead to ther-apeutic applications? Fact and fiction are difficult to tease out. Focusing on gamma radiation, Pierre Curie was found to have erythema on his chest where the tube of radium he carried in his shirt pocket rested. If this energy could produce a reaction on normal skin, then the next logical target was cancerous skin. It worked; tumors shrank when exposed to gamma radiation.

Radium as a source of radi-ation for therapeutic applica-tion was expensive in the early 1900s. A cheaper and more plentiful supply of radiation was found in cobalt (known as cobalt-60). A simplistic model of gamma radiation is to think of it as a radioactive rock in a box. The constant is the half-life

of the source as measured by the decay constant, while the variables are created by the dis-tance from the source and the exposure time.

Expanding therapeutic use and deliveryAs therapeutic applications of radiation expanded, the need to add more variables arose. The gamma energy from cobalt-60 was relatively low, about 2.8 MV. The lower the energy the less it is able to penetrate the skin and reach deeper tissue. Attempts to dose deeper tissue led to significant skin reactions or burns because longer expo-sure time was necessary for the dose to reach a deeper depth.

Therapeutic applications of radiation do not involve ther-mal energy and do not involve heat transfer. The common term “burn” used in relation to radia-tion is a bit of a misnomer. Both thermal injury and radiation injury produce similar reactions on the skin, but the sources are completely different. If a tem-perature probe is placed in the tissue and then subjected to radiation it will only register a temperature change from the vasodilation. The tissue is not “cooked.”

When it came to using X-rays, radiation from stream-ing electrons produced in a cath-ode ray tube didn’t have much therapeutic application because of its inability to dose deeper tissues. Eventually this prob-lem was solved by accelerating the stream of electrons to make them more energetic, which led to the creation of the modern ra-diation therapy machine known as a linear accelerator. By accel-erating electrons along a linear path and smacking them against tungsten—which acts as a dense target in the head of the ma-chine—the kinetic energy of the electrons transforms into energy traveling out of the head of the linear accelerator. This higher energy radiation is now referred to as photon radiation rather than X-rays.

The advantage of using an accelerator is that higher ener-gies can be produced so instead of the 2.8 MV radiation from cobalt-60, linear accelerators can produce 6, 10, and 15 MV

Radiation oncologyA closer look

By Elizabeth H. Cameron, MD, MPH


NOW OPEN!

of radiation. With higher ener-gy, therapy can be delivered to deeper tissues without as much of a skin reaction. The ener-gy needed for more superficial breast cancer may use only 6 MV, whereas a deep-seated pros-tate cancer may need 10 MV.

Another way to improve radiation delivery is to tweak other variables, like the number of beams. If 100 percent of the dose is delivered by one beam then 100 percent of the dose has to transverse all the inter-vening normal tissues to get to the deeper target tumor. If four equal beams are used to inter-sect at the target, where each beam is only 25 percent of the total dose needed, then there will be less damage to normal tissue. The number of beams that a radiation oncologist can choose is infinite. Increasing the beam number also shapes the dose volume. Four equal beams result in a box shape. If you add beams to the corners of the box to soften them you get a more circular dose volume until the beam finally becomes an arc.

Linear accelerators can also use other variables such as dose intensity modulated radiation therapy (IMRT) and motion volume modulated arc therapy (VMAT) to create a more cus-tomized dose distribution.

IMRT uses more beams and varies the dose intensity of each beam, which further shapes the dose. VMAT varies the dose in-tensity and increases the beam number delivering so many beams that an arc is produced. All of these variables improve the ability to target and shape a dose. In radiation oncology, we deliver doses in a three-di-mensional volume and some-times add the variable of time to create a four-dimensional volume. This becomes import-ant in tumors that move, like lung cancer.

Targeting radiationIn medicine in general, there is an emphasis on targeting and radiation oncology is no excep-tion. All of the above-mentioned variables, energy, number of beams, intensity, and motion can be manipulated in combi-nation with target visualization

to improve the aim of the radi-ation to hit the tumor but just as importantly to avoid normal tissue.

Radiosurgery (literally radia-tion as sharp as a knife) is a term that is often misunderstood outside of radi-ation oncology. The targeting capabilities can be taken a step further so the field edges become as sharp as a scalpel enabling it to remove cancerous tissue without actu-ally cutting the skin. Radiosur-gery is an outpatient procedure. With sharp field edges, higher doses can be used for each frac-tion of radiation delivered. Just as with standard radiation, the source defines the name. For example Gamma knife involves the use of cobalt radiation, while Cyberknife uses a linear accelerator. Gamma knife uses cobalt-60 strategically placed in a space that delivers a pre-cise dose to a static target. Cy-berknife is a linear accelerator on a robotic arm that can aim very precisely when delivering radiosurgery to static and mov-ing targets.

The mix of variables is po-tentially endless and the pace of radiation technology is moving faster than our ability to evalu-ate it. An example of this is with particle radiation therapy. Gam-ma and photon radiation have neither mass nor charge so are not particles. Particles include neutrons, which have mass but no charge and protons, which have both mass and charge. Each variable has a unique ef-fect on the dose distribution. We are not sure, however, if the effects of particle radiation on dose matters clinically. It has taken considerable financial investment in these new tech-nologies because the mass of the particles requires very ex-pensive facilities to accelerate them ($100+ million compared to $10+ million). This is a very controversial topic in the field of radiation oncology because of the high cost of protons and the seeming lack of clinical superi-ority except in the case of some very specific types of cancer. To date, for example in prostate

cancer, despite many attempts to show the advantage of pro-tons there is no convincing data

that proton ther-apy translates into improved outcomes. This has resulted in the closure of one proton ra-diation facili-ty and concern

as other facilities are slated to open. At least two-thirds of the volume of these centers is from patients with prostate cancer. The good news is that with the exception of a very few cancers, nonparticle (i.e., photon not proton) radiation is able to de-liver very targeted radiation that is clinically equivalent to proton or other particle radiation.

With the ability to target radiation therapy more effec-tively, radiation oncology has completely evolved and the old adage that once radiation is giv-en it can never be given again is no longer true. We are now re-treating sites never before

imagined using all the avail-able and emerging radiation technologies.

ConclusionRadiation oncology is evolving and the variables are endless. We are learning how to make the best use of our targeting capabilities. The energy we deposit simply drives chemical reactions in normal and tumor cells alike. Normal cells recover if we fractionate and target correctly. Tumor cells cannot recover so they die. If you think about it, radiation is one of the most “natural” therapies available, as it merely involves the transfer of energy. Put your previous assumptions about radiation therapy aside and talk to your radiation oncology colleagues—we are listening.

Elizabeth H. Cameron, MD, MPH, is medical director of radiation onco logy at HealthEast and is boardcertified in radiation oncology, and hospice and palliative care.

The variables are endless.

August 2015 MINNEsoTA PhysICIAN 25

Psychiatric Care evolved.888-9-prairie prairie-care.com

Pharmacology

Health care is seeing changes in payment from fee-for-service to

pay-for-performance (shared risk models) here in Minnesota and across the country. This shift opens the door for inno-vative team-based patient care. One very natural relationship as a result of this change is col-laboration between physicians and pharmacists. Both profes-sions work together to identify and treat acute and chronic conditions by using optimal, cost-conscious therapies that effectively improve the health of patients.

Physicians and pharma-cists already work together in almost all patient care settings. For years pharmacists have communicated with physicians to ensure there is clarity in medication orders. This inter-action continues today between the community pharmacist and the ordering physician and has expanded in some settings to in-clude therapeutic interchanges,

answering questions about medication, and monitoring for diversion.

In the latter half of the 20th century, hospitals began placing pharmacists throughout hospitals to perform clinical services such as anticoagulation monitoring, antimicrobial stewardship, and drug therapy monitoring. According to a 2014 National Pharmacist Workforce Study prepared by the Midwest Pharmacy Workforce Research

Consortium, 33 percent of a hospital pharmacist’s time is spent in non-dispensing related clinical services (roles outside of preparing and verifying medications). These services place pharmacists side by side with physicians to help initiate, adjust, and monitor drug therapies. This service is now being mirrored in the outpatient setting with pharma-cists providing comprehensive medication management.

Pharmacists around the country often look to Minnesota because it is progressive when it comes to the practice of phar-maceutical care in a primary care setting. A recent case study by the University of Minnesota called Integrating Medication Management (https://z.umn.edu/mncasestudies) showed the commitment and investment that six integrated health care systems in Minnesota made in pharmacist-run medication management programs.

No longer in our silosAs the health care landscape continues to evolve, health systems will need to find ways of delivering high-quality, evidence-based care at a lower cost to patients and payers. Effective use of care team members to provide the highest level of care can save money and improve the patient experience. The benefits of working with other care team members, however, is only effective if team members communicate. It is no different when it comes to communication between physicians and pharmacists.

Historically, physicians have conferred with pharmacists when they needed answers to difficult questions about medications or drug therapy. In these instances, pharmacists were asked for a “curbside” consultation where they only briefly became involved in a patient’s care. Once the phar-macist answered a specific question, he or she returned to their traditional and separate role. This system has been utilized for many years and has the potential to improve patient care, however this is often not the most efficient use of any-one’s time—the pharmacist’s, the physician’s, or the patient’s. It is also not an effective model for care as the expertise of the pharmacist is employed in a limited way and often without the full details and history of the patient.

Pharmacists and physicians could continue to maintain these separate roles, but health care in the future is going to demand more of each team member. Physicians and phar-macists are ready to answer the call to work together to improve patient care.

Physician feedbackAt our team-based clinical practice sites, we have collected information about collaborat-ing with physicians. Here is a cross-section of experiences that physicians have shared with us.

“Having a pharmacist avail-able in clinic means having an extra set of eyes to review our care, ensuring that med-ication management is up-to-date, avoiding medication interactions, and reinforcing patient education.”

“As a physician, I feel that the physician/pharmacist col la bo ra tion is a practice that can optimize patient out comes, by identifying and manag ing a pa tient’s drug-related problems.”

“The increasing complexity of medication therapies and newer drug regimens requires the need for a strong working relationship

Physician/pharmacist

collaborationAn opportunity to improve patient care

By Cory Nelson, PharmD; Kyle Turner, PharmD; and Jaskiran Sandhu, MD


612.338.2029 | 218.727.8446

Healthcare Planning and Design

St. Joseph Medical Center - Waiting Area

between pharmacists and physicians to optimize patient care.”

“I hope to have a pharma-cist working in my future practice.”

A win-win situationInteraction between the doctor and pharmacist must be seam-lessly integrated to improve patient care and avoid dupli-cation of work and inaccurate or incomplete utilization of information. Physicians will be able to work more efficiently knowing that they can count on this partnership to serve as a safety net in their work and to help them provide the best patient care. This includes the ever-increasing number of new therapies that come to market each year.

Many hospitals in this state and around the country already have protocols in place to include pharmacists in certain aspects of a patient’s care. This includes anticoagulation in and out of the hospital, antibi-otic stewardship, psychiatric services, oncology, and more. In addition, many health care systems in Minnesota have invested in medication management programs that make it easy for providers to refer patients to these services. Certain patients—those just discharged from the hospital, those not reaching chronic dis-ease goals, or those whose poor health affects quality metrics important to the clinic—get system-driven referrals to med-ication management programs to ensure that their medications are optimized.

A well-integrated pharma-cist/physician collaboration doesn’t only take place in large health organizations. Many examples of well-designed relationships exist between physician groups and a commu-nity pharmacist, where broad or protocol-driven agreements are in place. Some pharmacists working in community-based retail pharmacies provide dis-ease-focused or protocol-driven interventions as well as com-prehensive medication therapy

management (MTM) services to patients through these types of arrangements. The framework of these arrangements often rests in a collaborative practice agreement (CPA), which is a legally binding document that describes which responsibilities pharmacists have under the

physician’s medical license. These agreements are not without challenges however:

• Trusting that each part-ner will fulfill his or her responsibility.

• Determining the scope that the pharmacist has in initiating, changing, and monitoring drug therapy and keeping the physician informed of these actions.

• Engaging the patient in this type of collaborative care can be a challenge since it’s out of the norm of what they are accus-tomed to.

Each perceived barrier can be overcome as physicians and pharmacists work together for the benefit of the patient.

Another issue that must be addressed is whether a pharmacy workforce is trained and ready to practice in this new health care environment. Minnesota is again at the forefront of this effort through PharmD curriculum and residency training. Students and residents who train at the University of Minnesota College of Pharmacy, Minnesota’s only pharmacy school, are all taught from Cipolle, Strand, and Morley’s “Pharmaceutical Care Practice,” in which each drug is evaluated for indication, effica-cy, safety, and convenience. The practice of pharmaceutical care is pushing the pharmaceutical profession to deliver a well de-fined, reproducible, and quality

clinical service that aligns with the principle and practices of team-based care. This is in contrast to the pharmacist’s previous role where they only dispensed drugs in commu-nity-based and hospital phar-macies. Pharmacy residents at the College’s Ambulatory Care

Residency Program use this method each day in collabo-rative practice sites across the state and learn from expert preceptors who have spent their careers providing this type of care. After completing their residency training, they are fully prepared to work with physicians to optimize medi-cation use, control costs, and achieve patient care goals.

Starting the conversationFirst, find out what opportuni-ties already exist in your clinic, hospital, or health system for partnering with pharmacists to improve patient care. There might already be a program or protocol in place for how pharmacists can improve your workflow and enhance patient care. Ask a pharmacist in your work environment how they can help you manage your patients’ many medications and multiple conditions. If there is no pro-gram in place for physicians to partner with pharmacists where you work, ask administrators why this service is not avail-able. If a partnership program already exists, don’t be afraid to approach administrators with suggestions for how these programs can be improved to make collaborating easier. In addition, let the pharmacist know how the collaboration can be more effective when it comes to patient care.

The relationship between physicians and pharmacists

continues to grow.

Physician/pharmacist collaboration to page 36


For more information: Email: [email protected]

Telephone: 651-426-6995

• ExcellentopportunitytotransitionfromtraditionalOBpractice

• Strongpotentialforgrowth

• Servingover2,800patients

• LocatedinEdina,MN

• Fullrangeofaestheticservicesforwomen

• FullyequippedmedicalofficewithEMR

• Stateoftheartlasertechnology

• Willingtoexploreofferstofityourbusinessplan

• SellerwillingtoassistthepotentialMDbuyerintransition&aestheticlasertraining

Established Gynecology & Aesthetic

Practice for Sale

Email – [email protected] Telephone-651-426-6995

ADMINISTRATION

After four delays, the fed-erally mandated tran-sition from the current

medical diagnoses and inpa-tient hospital procedure coding system, ICD-9, to its successor, ICD-10, is now only weeks away from an Oct. 1, 2015 implemen-tation deadline.

According to the federal Centers for Medicare & Med-icaid Services (CMS), because “ICD-9 codes are used in almost every clinical and administra-tive process” in health care, the change to ICD-10 will require corresponding significant “sys-tem and procedural changes … to implement and correctly use the new codes.” Not sur-prisingly then, the transition to ICD-10 requires planning and follow-through, with only a lit-tle time now remaining to meet the October implementation deadline. The relatively short time remaining before imple-mentation will be cheered by some who feel prepared and are anxious to move forward, but may be daunting to others who

are behind or uncertain of what to do to meet the deadline.

It’s time to update ICD-9 While ICD-9 has served as a valuable tool and resource, much has changed in the three decades since it was adopted. Procedures that are now com-mon, such as laser and lapa-roscopic surgeries, and many others, were virtually unknown in practice when ICD-9 was adopted. As new waves of med-ical advances and complexity roll across the health care sys-tem, ICD-9’s coding structure is already at capacity in many categories and cannot accom-modate new diagnoses and procedures. New forms of care delivery and financing, includ-ing value-based purchasing,

accountable care, and greater emphasis on population health, require much more sophisti-cated, nuanced information regarding patient conditions and care. As a result, health care’s reliance upon increas-ingly more detailed, specific data for complex decision-mak-ing is rapidly outpacing what CMS has described as ICD-9’s “outdated and obsolete termi-nology” and “outdated codes” that can result in “inaccurate and limited data.”

ICD-10 offers better specificityOverall, ICD-10 features much more coding detail and speci-ficity, and is structured to allow for a significantly expanded number of descriptive diagnosis and procedure codes that can grow over time. According to CMS, the new coding system offers: 1) improved reporting of laterality; 2) inclusion of clinical concepts that do not exist in ICD-9 such as under-dosing; 3) blood type and blood alcohol level; and 4) expansion of codes for such important topics as injuries, diabetes, sub-stance abuse, and postoperative complications.

For example, as reported by CMS, ICD-9 has only two major codes for diabetes, “diabe-tes” and “secondary diabetes” respectively. ICD-10 separates type 1 diabetes from type 2, and eliminates the broad cat-egory of “secondary diabetes” in favor of more relevant and descriptive secondary options for underlying conditions or causes, along with additional subcategories to convey infor-mation regarding complications and affected body systems.

Similarly, ICD-9 has only a single code for angioplasty; ICD-10 has 854 codes for detailed reporting of the procedure approach, body part, and device. ICD-9 has nine pressure ulcer codes that can distinguish broad

location, but not the depth of the ulcer. ICD-10 has 150 codes that can show more specific location, as well as depth.

While much of the focus on ICD-10 has centered on its ex-panded code set, in some cases, as with hypertension, end-stage renal disease, and chronic respiratory failure for example, the number of ICD-10 codes has been reduced to bring about simpler reporting of meaning-ful data.

These improvements in coding detail and structure are foundational to lon-ger-term, far-reaching health care research, organizational and system-wide transforma-tions. However, ICD-10 is an important part of the medical armamentarium that will be available Oct. 1, 2015 to com-municate key patient data for immediate uses and benefits.

Even in the absence of other medical chart information, knowing the ICD-10 codes as-signed to the patient, with their greater detail regarding severi-ty, location, and other specifics of the patient’s condition, will serve as an initial guide to help physicians more rapidly and ac-curately assess and meet patient care needs. Significantly for physicians, ICD-10’s improve-ments provide greater coding specificity and clinical informa-tion, for a much more complete picture of the patient and their needs at this time.

CMS has described ICD-10’s more granular, robust medical data as a gateway to:

• Improving patient care

• Measuring the quality, safety, and efficacy of care

• Reducing the need for attachments to explain the patient’s condition

• Designing payment systems and processing claims for reimbursement

• Conducting research, epidemiological studies, and clinical trials

•Setting health policy

• Devising operational and strategic plans

• Designing health care delivery systems

•Monitoring resource use

A new era in codingICD-10 becomes effective October 1, 2015

By David K. Haugen, MA, and Terence Cahill, MD


Quality Transcription, Inc.

Settingthe

standardsfor

excellence

Quality Transcription (located in Minnesota)maintains a professional office environment,thus the confidentiality of your work is strictlymaintained. We provide medical transcriptionservices on a contract or overload basis.

Our equipment is state of the art with 24 hourdictation lines and nationwide accessibility.

We are experts in our field. We deliver ontime. We have experienced staff. We monitorthe quality of our work.

We provide services tailored to your needs andwill do whatever it takes to get the job done.

Quality Transcription, Inc.8960 Springbrook Drive, Suite 110Coon Rapids, MN 55433Telephone 763-785-1115Toll Free 800-785-1387Fax 763-785-1179e-mail [email protected] www.qualitytranscription.com

• Improving clinical, finan-cial, and administrative performance

• Preventing and detecting health care fraud and abuse

• Tracking public health and risks

Not ICD-10 ready?CMS and many other payers, including the Minnesota Depart-ment of Human Services’ (DHS) Minnesota Health Care Pro-grams (MHCP), have published guidance that claims that have ICD-9 codes for dates of service on or after the October deadline will be denied. Those who are not ICD-10 ready will not realize the coding system’s benefits already described, and will risk immediate delays or losses in revenue that could significantly affect their bottom line and their relationships with patients, business partners, and others.

The results of several recent national surveys by organiza-tions such as the national Work-group for Electronic Data Inter-change (WEDI)—a broad-based coalition of providers, payers, and other industry stakeholders serving as a federally autho-rized advisor to the secretary of the federal Department of Health and Human Services (HHS)—show that these finan-cial risks are very real for some providers, especially in smaller and solo practices. For example, the WEDI survey, conducted in the early spring of 2015, found that all industry segments must make a “dedicated and aggres-sive effort to move forward with their [ICD-10] implementation efforts” … to prevent “significant disruption to industry claims processing on Oct 1, 2015.”

Other national polls from approximately the same time period also reported indica-tions that many in the industry, particularly smaller provider groups, were behind in their ICD-10 readiness. A national survey by one industry vendor reported for example that only 21 percent of physician practic-es felt that they were “on track” for moving to ICD-10.

Steps you can take nowWhile the clock to ICD-10 readiness is rapidly ticking

down, there is much that can and should be done to prepare for the conversion to the new coding system and to mitigate any risks associated with its implementation.

Clinical documentationPhysicians, coding profes-

sionals, and billing managers all have important functions in implementing ICD-10. A primary role of physicians in the transition to ICD-10 will be to assure the consistent, high

levels of clinical documentation needed for quality patient care that are also prerequisites for equally high quality ICD-10 coding. According to CMS, an important role of the coder is to assure that “coding is consis-tent with the documentation,” and the business manager will help assure that “billing is accurately coded and support-ed by the documented facts.” The three functions together are essential for successful outcomes, but are so dependent on appropriate documentation that ICD-10 readiness has often been described not as a medical coding issue, but as a clinical documentation issue.

Keeping ICD-10 in perspectiveIn moving rapidly to become

ICD-10 compliant, it will be important to keep ICD-10 in perspective, and to remember what is changing and what is not in order to focus efforts where they will have the most impact. For example:

• ICD-10 has many more codes, but providers will continue to use only a subset of them. The greater specificity and exten-siveness of ICD-10 has been lik-ened to a large, comprehensive dictionary. ICD-10-CM is a sim-ilar large reference tool, with 68,000 codes, compared with ICD-9’s 13,000. Some of ICD-10’s numerous codes have attracted considerable negative attention as subjects of lampoons and satire, but will have little actual use or relevance in practice.

• ICD-10 does not change CPT codes and their use. The main-stay for the majority of physi-cian billing and payment is the Current Procedural Terminol-ogy (CPT) code system and the related Healthcare Common Procedure Coding System (HCPCS). CMS has stated that when “ICD-10-CM/PCS is imple-mented on Oct. 1, it will not affect physicians’, outpatient fa-cilities’, and hospital outpatient departments’ use of CPT codes

on Medicare Fee-For-Service claims. Providers should con-tinue to use CPT codes to report these services.” CMS further clarified that when ICD-10-CM codes replace ICD-9-CM codes, it will not impact how CPT and HCPCS codes, including CPT/HCPCS modifiers for physician services, are reported. While

ICD-10-CM codes have expand-ed detail, including specifica-tion of laterality for some condi-tions, CPT and CMS guidance should continue to be followed when reporting CPT/HCPCS modifiers for laterality.

•The logic and process of finding and using the appropriate ICD-10 codes will be familiar, and tools are available to help. As with ICD-9, ICD-10 code sourc-es will include both a tabular listing and an alphabetic listing of codes. The disease/condition of interest will correspond to an alpha-numeric code that can be confirmed in the tabular list, which displays relevant ICD-10 codes by chapter, category, and subcategory. There are a variety of online tools to learn more about and find appropriate ICD-10 codes.

•There are still opportunities to test your ICD-10 codes be-fore the go-live date. CMS has issued guidance clarifying that ICD-10 acknowledgement testing is open to all Medicare

ICD-10 does not change CPT codes and their use.

A new era in coding to page 30


Urgent Care

We have part-time and on-call

positions available at a variety of Twin

Cities’ metro area HealthPartners

Clinics. 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.com/careers and

follow the Search Physician Careers link

to view our Urgent Care opportunities.

For more information, please contact

[email protected]

or call Diane at: 952-883-5453;

toll-free: 1-800-472-4695 x3. EOE

healthpar tners .com© 2014 NAS(Media: delete copyright notice)

MN Physician4" x 5.25"


fee-for-service (FFS) electronic submitters, and acknowledg-ment testing can be undertaken at any time. This type of testing will not confirm payment or return an electronic remittance advice (ERA) to the provid-er, but it will return a 277CA or 999 acknowledgement, as appropriate, to confirm that the claim was accepted or rejected by Medicare. For more informa-tion see “MLN Matters Num-ber: SE1501” (http://go.cms.gov/1hfLml2).

Additional resources and helpCMS maintains a wide range of ICD-10 tools and resources on its ICD-10 website (www.cms.gov/Medicare/Coding/icd10/). Its “Road to 10” collec-tion in particular is geared to smaller providers and can be accessed from the main ICD-10 webpage. Providers who feel especially late in their prepa-rations or are unfamiliar with ICD-10 at this time may want to start with CMS’ “ICD-10 Quick

Start Guide” (http://go.cms.gov/1FxeQir).

In addition, CMS and the American Medical Association (AMA) released a joint press release on July 6 announcing new efforts to help physicians transition to ICD-10 by the Oct. 1 deadline. The parallel assis-tance will include webinars, on-site training, educational

articles, and national provider calls to help providers learn about the updated codes and prepare for the transition. CMS also announced that it is taking a number of steps to promote ICD-10 readiness, including establishing an ICD-10 commu-nications and coordination cen-ter, and creating the position of an ICD-10 ombudsman to triage and answer questions about the submission of claims.

CMS reiterated that Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after Sep. 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes. How-ever, CMS also issued addition-al ICD-10 guidance intended to ease providers’ transition to the new coding system by:

• Creating a one-year grace period during which claims with incorrect ICD-10 di-agnoses codes will not be denied, so long as the claim includes a valid ICD-10 code from the right family.

• Suspending penalties asso-ciated with several quality reporting programs for pro-gram year 2015 if the penal-ty was related to the use of

ICD-10 coding, and so long as a valid ICD-10 code from the right family is used.

• Announcing the availability of “advance payments” to providers if Part B Medicare Contractors are unable to process claims within estab-lished time limits because of administrative problems such as contractor system malfunction or implementa-tion problems.

For further information, see the CMS ICD-10 website and the AMA’s website (http://bit.ly/1DVGyq3).

David K. Haugen, MA, is the director of the Center for Health Care Pur-chasing Improvement at the Minne-sota Department of Health. terence Cahill, MD, is a family physician in Blue Earth, Minn. and is medical director at United Hospital District Clinics. He is working with CMS as physician champion for ICD-10 implementation.

ICD-10’s improvements provide greater coding specificity.

A new era in coding from page 29

OBJECTIVE, INNOVATIVE HEALTHCARE REAL ESTATE SOLUTIONS

For more than 25 years, the CWN Healthcare Real Estate Advisory team has exclusively represented healthcare clinics and systems, delivering unbiased and uncommon real estate solutions tailored specifically to your unique priorities, not ours. Call or visit us online, and take the first step toward a healther practice through real estate.

952.837.8517 healthcare.cushwakenm.com

OBJECTIVE, INNOVATIVE HEALTHCARE REAL ESTATE SOLUTIONS

For more than 25 years, the CWN Healthcare Real Estate Advisory team has exclusively represented healthcare clinics and systems, delivering unbiased and uncommon real estate solutions tailored specifically to your unique priorities, not ours. Call or visit us online, and take the first step toward a healther practice through real estate.

952.837.8517 healthcare.cushwakenm.com

952.837.8517healthcare.cushwakenm.com

April 2015 Minnesota Physician 37

BIGFORK, MN • COOK, MN

Located throughout beautiful Northern Minnesota, Scenic Rivers Health Services is a provider-driven not-for-profit organization. Currently, we are seeking a Family Practice Physician at our location in Cook, MN. This position focuses on local family healthcare, in a well- established modern facility helping to support our growing patient needs. You will quickly develop a gratifying panel of patients. Participation in on-call schedule, inpatient and after- hours care is shared (no OB), BC/BE and current or eligible for MN license required.

Work – Life Balance:

Northern MinnesotaPhysician Opportunities

•4 day work weeks•Significant starting and residency bonuses •Competitivesalaries•Fullbenefitpackage•20vacationdays•12sickdays•10CMEdays•6holidays•3personaldays

SCENiC RivERS HEaLTH SERviCES

Ski, hike, run, fish, canoe, kayak, camp, or hunt in your own

backyard or in the Boundary Water

Canoe Area, Voyageur’s National Park, Superior

National Forest and countless State Parks

For more information or to send a resume:

Cook Area Health Services, Inc. Travis Luedke20 5th St. SE, Cook, MN 55723 | [email protected] | 218-361-3190

National Health Service Corps Loan Repayment Potential

Eric Scrivner, MD


and you fill in what you would prefer to be called, and that enhances the relationship and their physician and physician team knows that.”

Link stressed that even if providers don’t feel empow-ered enough to change forms or whole processes, or change to gender-neutral bathrooms, the main thing that physicians can do is to make no assump-tions. “When someone comes into your office, don’t assume that the person they’re with is their partner, or that the per-son is not their partner,” Link said. “Let the patient fill in the blanks—‘Who’s here with you today?’ ‘What do you go by?’ i often ask which pronouns to use (he/him, she/her).”

it’s important to train staff to ask questions in ways that invite the patient in. “it’s an on-going thing,” said azbill-salis-bury. “We talk about inclusion and diversity training as this ongoing process that people

should constantly be thinking about because it’s tough. We’re set up in a lot of ways to think about sexual orientation and gender as binary: you’re either gay or straight or you’re male or female. But for LGBtQ folks, that binary construction is not descriptive of their experience, so it’s important to be aware of how often you use gendered language when you’re not certain of someone’s gender or their partner’s or family member’s gender.”

smiley’s started with regular education for all staff—providers, lab personnel, medical assistants, front desk personnel, administrators, everyone—about LGBtQ health issues. then they added gender-neutral bathrooms, enhanced forms, and worked on changing their approach in how they talk to patients to try and remove some of the assumptions. they also asked the vendor for their electronic medical record program to add a preferred name that will

appear at the top of a patient’s electronic record.

“i want all my patients—all genders, all backgrounds—to feel that their doctor’s office is a safe space, and i can individual-ize the care from there, but if i start from that super-open spot, then patients will be able to talk about what their real concerns are,” said Link.

Conclusionthere are many skills needed to provide LGBtQ culturally competent and supportive care.

the most essential one centers on maintaining an awareness of our own preconceptions of the nature of gender and sexual identity, and sustaining and displaying an openness towards how LGBtQ patients see and identify themselves.

Mary Beth Dahl, RN, leads health equity initiatives at Stratis Health. She also provides oversight to the culturecareconnection.org website.

Health equity for the LgBtQ community from page 19

Resources for providers

Family tree Clinic: familytreeclinic.org LGBTQ sexual and reproductive health care access

Minnesota transgender Health Coalition: mntranshealth.org Transgender-focused LGBTQ training and resources

Rainbow Health Initiative: rainbowhealth.org LGBTQ training and resources

smiley’s Family Medicine Clinic: umphysicians.org/Clinics/smileys-family-medicine-clinic LGBTQ-friendly primary care clinic

training to serve: trainingtoserve.org/about-us Elder-focused LGBTQ training and resources

Voices of Health: bit.ly/1IL4LGS A survey of LGBTQ health in Minnesota, 2014 Data

Sioux Falls VA Health Care System

Sioux Falls VA HCS, SD

(605) 333-6852 www.siouxfalls.va.gov

Applicants can apply online at www.USAJOBS.gov

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

Cardiologist EndocrinologistENT (part-time)Emergency MedicineGeriatrician (part-time) HospitalistNeurologist

Oncologist/Hematologist Orthopedic SurgeonPrimary Care (Family Practice or Internal Medicine)PsychiatristPulmonologistUrologist (part-time)

The perfect matchof career and lifestyle.

www.acmc.com |

FOR MORE INFORMATION:

Kari Lenz, Physician Recruitment | [email protected] | (320) 231-6366

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

• ENT• Family Medicine• Gastroenterology• General Surgery• Geriatrician• Outpatient

Internal Medicine

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

• Psychiatry• Psychology• Pulmonary/

Critical Care• Rheumatology• Sleep Medicine• Urgent Care


MAYO CLINIC HEALTH SYSTEM is a family of clinics, hospitals, and other health care facilities serving more than 60 communities in Minnesota, Iowa, and Wisconsin. Mayo Clinic Health System links the expertise of Mayo Clinic in practice, education and research with the health-delivery systems of our local communities.

The Northwest Wisconsin Region opportunities include:

Dermatology Occupational Medicine Emergency Medicine Ophthalmology (General & Glaucoma) Family Medicine Orthopedics General Surgery Pediatrics Hospitalist Psychiatry (Adult & Child) Internal Medicine Pulmonary/Critical Care Nephrology Urgent Care Neurology Urology

Mayo Foundation is an affirmative action and equal opportunity employer and educator.

If you wish to learn more or to express interest in these positions, please contact us at 800-573-2580; email

[email protected]; or apply at http://www.mayoclinic.org/jobs/physicians-scientists

U:\MN Physician AUGUST 2015.docx















www.glacialridge.org

Family or Internal Medicine Physician

An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required.

GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites.

For more informationCall Kirk Stensrud, CEO320.634.4521

Mail CV to:Kirk Stensrud, CEO10 Fourth Ave SEGlenwood, MN 56334

Email CV to:[email protected]

Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.

Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefi t package, paid malpractice and a commitment to providing exceptional patient-centered care.

Apply online at healthpartners.com/careers orcontact [email protected]. Call Diane at 952-883-5453; toll-free:800-472-4695 x3. EOE

healthpartners.com

© 2014 NAS(Media: delete copyright notice)

Please contact or fax CV to:

Joel Sagedahl, M.D.5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

www.NWFPC.com

Join the top ranked clinic

in the Twin CitiesA leading national consumermagazine recently recognizedour clinic for providing the bestcare in the Twin Cities based on quality and cost. We are currently seeking new physicianassociates in the areas of:

• Family Practice

• Urgent Care

We are independent physician-owned and operated primaryclinic with three locations in theNW Minneapolis suburbs. Work-ing here you will be part of anaward winning team with partner-ship opportunities in just 2 years. We offer competitive salary andbenefits. Please call to learn howyou can contribute to our innova-tive new approaches to improvinghealth care delivery.


start to see a more complete picture. through smartphones and secure cloud-based portals, real-time management of our patients will become a viable reality in the coming years.

When connected devices can securely transmit data to a con-nected care team, the model of care starts to shift dramatical-ly. interesting emerging models include Glooko and Marucci.

Glooko is a connected diabetes management system allowing for near real-time remote management of patients with diabetes. When a patient performs a glucose test using their standard glucose meter, they connect and sync through the Glooko device and transmit their results to a secure pa-tient-management platform. in addition to glucose data fitness, activity data also syncs to the management tool. a clinician (or parent) can log in and review the glucose and activ-ity data. Parents can now ask their child about a math test or afterschool practice instead

of opening every conversation with “What were your num-bers?” and clinicians can man-age patients between scheduled quarterly visits. Glooko is add-ing continuous glucose moni-toring (cGM) and insulin pump data in future versions of their software, which will enhance the functionality and useful-ness of the service. Research is underway to start creating data sets that may eventually enable more advanced machine-based, real-time disease management.

Marucci is a sporting goods manufacturer. their Boditrak

system integrates in-helmet concussion sensing, locker room baseline testing, and virtual clinical care. Many helmets are now incorporating impact detection, but the true innova-tion at Marucci comes after the

player is pulled from the field of play. once a hit of significant force is detected, and the player is removed from the game, a diagnostic assessment via a tab-let can take place in the locker room. an immediate, virtual connection, with impact and baseline data, will be made to a concussion specialist through the MDLive care platform. By the time the child leaves the locker room, they’ve been evalu-ated by a concussion specialist, have a care plan in place, and an appropriate follow-up scheduled.

Conclusiontechnology is moving forward at an increasingly rapid rate. Dramatic changes to care models will emerge as these advances in health monitor-ing become more ingrained in

pediatrics. as hardware and software merge with smart systems, physicians will have access to information not pre-viously available. For children with chronic conditions, these tools could be game changers. smart connected systems could alert the patient, the parent, and the provider to potentially harmful health events such as an abnormally low glucose reading. For otherwise healthy kids, connected technology could quantify an impact to the head that needs ongoing treatment and allow that child to recover and return to school more quickly. the technology, in all cases, is simply another tool to keep children healthy and safe.

Jeffrey Weness, MBA, is senior di rector of Innovation and Partnerships at Children’s Hospitals and Clinics of Minnesota. Laura M.

gandrud, MD, is a pediatric en docri no logist at the McNeely Pediatric Diabetes Center at Children’s Hospitals and Clinics of Minnesota.

Electronic health care from page 17

A baby born today could have every heartbeat in their lifetime

monitored and digitized.

Boynton Health Service

Boynton Health Service

Welcome to Boynton Health Service

Located in the heart of the Twin Cities East Bank campus, Boynton Health Service is a vital part of the University of Minnesota community, providing ambulatory care, health education, and public health services to the University for nearly 100 years. It’s our mission to create a healthy community by working with students, staff, and faculty to achieve physical, emotional, and social well-being.

Boynton’s outstanding staff of 400 includes board certified physicians, nurse practitioners, registered nurses, CMAs/LPNs, physician assistants, dentists, dental hygienists, optometrists, physical and massage therapists, registered dietitians, pharmacists, psychiatrists, psychologists, and social workers. Our multidisciplinary health service has been continuously accredited by AAAHC since 1979, and was the first college health service to have earned this distinction.

Attending to over 100,000 patient visits each year, Boynton Health Service takes pride in meeting the health care needs of U of M students, staff, and faculty with compassion and professionalism.

Gynecologist/Clinical SupervisorBoynton Health Service is seeking a gynecologist or primary care physician with extensive experience in women’s health to serve as Assistant Director of Primary Care in charge of the Women’s Clinic. The Assistant Director will provide clinical services, ensure staff adherence to relevant regulations, assure the highest professional and ethical standards, and work with the Director of Primary Care and Chief Medical Officer to formulate long range planning and policies.

This position offers a competitive salary and a generous academic status retirement plan. Professional liability coverage is provided. Apply online at www1.umn.edu/ohr/employment, select “External Applicants” and then search for keyword: Gynecologist. Job ID#: 300363

To learn more, please contact Hosea Ojwang, Human Resources Director 612-626-1184, [email protected].

The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer

A Diverse and Vital Health Service

410 Church Street SE • Minneapolis, MN 55455 • 612-625-8400 • www.bhs.umn.edu


Join our teamAt Allina Health, we’re here to care for the millions of patients we see each year throughout Minnesota and western Wisconsin.

From rural to urban settings, you’ll find a practice and community that is right for you, with ideal staff support and the widest range of clinical practice options, physician leadership opportunities and competitive benefits.

Make a difference. Join our award-winning team.

1-800-248-4921 (toll-free) [email protected]

physicianjobs.allinahealth.org

EO M/F/Disability/Vet Employer

MB

041

5 ©

2015

ALL

INA

HE

ALT

H S

YST

EM

. TM

- A

TR

AD

EM

AR

K O

F A

LLIN

A H

EA

LTH

SY

STE

M.

www.lakewoodhealthsystem.com

Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with fi ve primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and benefi ts. Relocation and sign-on bonus available.

Visit www.lakewoodhealthsystem.com, or contact Brad Anderson at 218-894-8587 or [email protected].

POSITIONS AVAILABLE:INTERNAL MEDICINE– No call

EMERGENCY MEDICINEFAMILY MEDICINE– Full-scope practice avail. (ER, OB, C-Section, Hospitalist, Clinic)

SURROUNDED BY LAKESWORK-LIFE BALANCE

Erik Dovre, OB/GYN

Opportunities for full-time and part-time staffare available in the following positions:

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/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 recruitment bonus. EEO Employer.

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:Visit www.USAJobs.gov or contact

Nola Mattson, [email protected] Resources

4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

• Associate Chief of Staff

• Dermatologist

• Hematology/Oncology

• Internal Medicine/ Family Practice

• Occupational Health/Compensation & Pension Physician

• Ophthalmologist

• Physician (Pain Clinic)/Outpatient Primary Care

• Psychiatrist

• Urgent Care

Applicants must be BE/BC.

St. Cloud VAHealth Care SystemBrainerd | Montevideo | Alexandria


if no formal process is set up at your place of work, you’ll need to take a different approach. if you’re considering how to better integrate a pharmacist you probably already have a good working relationship with a pharmacist. Figure out which area of your practice that you feel a pharmacist could help the most. no one else knows more about your patient population. Do you struggle with getting your patients’ diabetes numbers under control? Do you have many patients with polyphar-macy? Go to a pharmacist with a vision for how they could systematically solve the problems you are facing. then ask them if they can help you achieve your vision. Be ready to help formalize the process.

Multiple options exist for this enhanced collaboration including having pharmacists

provide direct patient care within established protocols in an organization, as well as formalized cPas between phy-sicians and pharmacists where they don’t necessarily have to be coworkers. cPas allow pharma-cists to manage drug therapy

for acute and chronic condi-tions more efficiently. they also allow pharmacists to provide certain aspects of a patient’s care—generally drug selection, modification, and monitoring after diagnosis.

the cDc, the U.s. surgeon general, and a recent article by the national Governors association (nGa) recom-mended that all states adopt

cPas to potentially reduce cost and improve care for chronic disease. Minnesota law current-ly allows for broad physician/pharmacist cPas. the nGa article also highlighted efforts within Minnesota to care for Medicaid patients and state

employees through the use of cPas. analyses of that program showed an improvement in diabetes measures and modest cost savings for patients who were cared for with a model of care that utilizes cPas.

The futureas health care continues to focus on improved patient care, better outcomes, and lower

cost, teams of health care pro-fessionals practicing at the top of their licenses will be essen-tial. it is key that the relation-ship between physicians and pharmacists continues to grow. Working in either formal or informal collaborative models to take advantage of both pro-fession’s unique expertise can only serve to improve the lives of patients here in Minnesota and across the country.

Cory Nelson, PharmD, is a phar-maceutical care leadership resident at the University of Minnesota and practices at North Memorial’s Camden Clinic. Kyle turner, PharmD, is a pharmaceutical care leadership resident at the University of Minneso-ta College of Pharmacy and practices in an interprofessional care team at the HealthEast Maplewood Clinic. Jaskiran sandhu, MD, is a resident at the University of Minnesota and is board-eligible in family medicine.

Pharmacists around the country often look

to Minnesota.

Physician/pharmacist collaboration from page 27

www.olmstedmedicalcenter.org

Olmsted Medical Center, a 220-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. 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. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties:

Send CV to: Olmsted Medical CenterHuman Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: [email protected] • Phone: 507.529.6748 • Fax: 507.529.6622

Family MedicineSpring Valley Clinic

OB/GYNHospital – New Women’s

Health Pavilion

Pain MedicineRochester Northwest Clinic

Psychiatrist – Child & Adolescence

Rochester Southeast Clinic

Sleep MedicineRochester Northwest Clinic

UrologyHospital


therapy (iMRt) may be initiated. Furthermore, the violation of the lymph node capsule (extracapsu-lar spread) has been associated with a worse prognosis contrib-uting to an increased rate of regional failure, distant metasta-sis, and death.

several recent quality-of-life studies have determined that the most important function-al outcomes for patients after ablative head and neck surgery are the preservation of speech and swallow. the now common use of microvascular free tissue transfer has significantly im-proved the functional outcomes of ablative oral cavity tumor sur-gery. one of the major advances in the treatment of patients with oral and maxillofacial cancers has been the use of vascularized bone and/or tissue transplanta-tion for reconstruction. Ulti-mately, the goal is to reestablish normal function and appearance as quickly as possible.

Radiation therapyPrimary radiotherapy is gen-

erally reserved for those patients

with significant comorbidities or in situations where the primary tumor or patient is not amena-ble to surgery. additionally, the presence of high-grade histol-ogy, close or positive margins, multiple metastatic lymph nodes, extracapsular extension, peri-neural or angiolymphatic inva-sion, and stage iii or iV disease are indications for postoperative radiotherapy. Using 2-Dimen-sional, 3-Dimensional conformal or intensity Modulated Radio-therapy (iMRt), therapeutic doses of 60–66 Gy are delivered to the primary tumor site and involved cervical lymph nodes for optimizing local and regional disease control.

Chemotherapychemotherapeutic regimes

are also used more frequently as a radiosensitizer and for patients with locoregional recurrence, distant metastases, or as a neo-adjuvant preoperative treatment with chemoradiotherapy in patients with gross t4 disease to improve resectability. the role of postoperative chemotherapy in the treatment of oral cavity squamous cell carcinoma is

continuing to evolve. Recently, trials have shown a clear surviv-al benefit of 11 percent improve-ment with the use of concurrent single agent chemoradiotherapy (cisplatin) in the postopera-tive high-risk advanced stage oropharyngeal tumor patient. currently, it is common for pa-tients with advanced stage oral cancer to receive multimodali-ty treatment with surgery and chemoradiotherapy. although this has improved locoregional control rates, when recurrence occurs in a previously treated field this can be a significant sur-gical challenge. increased rates of complications due to fibrosis, hypovascular tissue, and lack of donor vessels for microvascular free flap reconstruction result in complex patient management.

Conclusionthe best opportunity for a cure is at the time of initial diagno-sis. For continued improvement in survival rates from ocscc the complex interrelationships between patient, tumor, previ-ous treatment rendered, type of recurrence, salvage options, functional outcome, quality of

life, and overall prognosis need to be considered and individual-ized in order to optimize patient outcomes. the greatest im-provement in survival from oral cancer in the future will likely be due to increased public and practitioner awareness resulting in diagnosis at an earlier stage. the importance of smoking and alcohol cessation cannot be overemphasized as it plays an important role in reducing the risk of second primary tumors.

as the treatment needs for patients diagnosed with ocscc continue to become increasingly complex, the needs of these pa-tients are best suited to tertiary care institutions with multidis-ciplinary teams established to support the surgical, medical, and psychosocial needs of the patient and families.

Deepak Kademani, DMD, MD, FACs, is a board-certified oral and maxil-lofacial surgeon. He is the fellowship director of the Oral/Head and Neck Oncologic Surgery and Reconstructive Surgery Program at North Memorial Medical Center and The Humphrey Cancer Center.

Cancers of the neck and head from page 23

Family Medicine & Emergency Medicine Physicians

• ImmediateOpenings• Casualweekendoreveningshiftcoverage• Setyourownhours• Competitiverates• PaidMalpractice

Great Opportunities

763-682-5906|[email protected]

www.whitesellmedstaff.com

fairview.org/physicians TTY 612-672-7300EEO/AA Employer

Sorry, no J1 opportunities.

Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail [email protected]

• Dermatology

• Emergency Medicine

• Endocrinology

• Family Medicine

• General Surgery

• Geriatric Medicine

• Hospitalist

• Hospice

• Internal Medicine

• Med/Peds

• Ob/Gyn

• Orthopedic Surgery

• Pediatrics

• Psychiatry

• Rheumatology

• Sports Medicine

• Urgent Care

• Vascular Surgery

Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team.

We currently have opportunities in the following areas:

Opportunities to fit your lifeFairview Health Services

•Dermatology

•EmergencyMedicine

•FamilyMedicine

•GeneralSurgery

•GeriatricMedicine

•Hospitalist

•Hospice

•InternalMedicine

•Med/Peds

•Ob/Gyn

•OrthopedicSurgery

•PainMedicine

•Psychiatry

•Rheumatology

•UrgentCare

addresses and measures social isolation through the PROMIS tool but has also developed other creative approaches.

Creating a life planA customized whole life plan

is important. Broader in scope than a typical patient medical record, the Lifesprk Life Plan is created to build a pathway toward achieving the client’s individual goals, incorporat-ing best practices and best fit resources. The plan is then con-tinually measured and adapted to assess outcomes and address new goals and issues.

Preventing hospitalizationWhile we currently serve many people who are over the age of 65 and who have already experi-enced one hospitalization, the model is designed for earlier involvement to prevent even ini-tial hospitalizations. Based on experience with our model, the

team has learned that there are key opportunities for improve-ment in home and communi-ty-based care to further reduce hospitalizations and ED visits. Practitioners need options that go beyond traditional reactive home care services to:

• Address psychosocial issues that are beyond the scope of other models or covered services.

• Provide proactive guid-ance to catch issues early, preventing avoidable hospitalizations and ED visits rather than provid-ing services after an initial health event or crisis.

• Provide ongoing guidance and support over the long-term, which closes gaps in patient support where problems or issues can germinate into major health events.

• Provide long-term continu-ity of coordination between discrete programs of care, crossing all settings.

The next step for physiciansGoing forward, physicians can help patients and families make effective decisions on how to invest limited resources, even a patient’s own private-pay funds, by seeking outcomes data from home and community-based

providers. Our model with its measurable outcomes provides a baseline benchmark they can use to evaluate other home and community-based options. Physicians can use our services for their patients who may be at risk for higher rates of hospital-ization as well as for any senior even before a health crisis to establish an ongoing proactive plan to keep patients as healthy and independent as possible in the community.

Physicians also have an opportunity to become more actively involved in home and community-based care and help shape those measurable outcomes in the community by participating in task forces and collaborative efforts to more fully develop community-based population health programs.

Joel Theisen, RN, is founder and CEO of Edina-based Lifesprk. Dave Moen, MD, is principal consultant for MoenMDConsulting.

Eighteen percent of Medicare patients who were hospitalized were

readmitted within a month.

38 MInnESOTA PhySIcIAn AugusT 2015

Reducing hospitalization for seniors from page 13

After discovering I needed hearing aids, I wanted the best-trained, most competent and experienced audiologist I could find. I also wanted the widest selection of quality products and finest follow-up services. After information-seeking visits with several recommended audiologists, Dr. Paula Schwartz easily rose to the top of my list. Paula and her excellent group of audiologists, all with doctorates, have given me outstanding care over the past eight years.

www.audiologyconcepts.com

6444 Xerxes Ave South Edina, MN 55423 (952) 831-4222

14050 Nicollet Ave South, Suite 200 Burnsville, MN 55337

(952) 303-5895

Refer Your Patients to Audiologists that You can Trust!

You’ll love what you hear!

X 21% of diabetics have hearing loss – compared to 9% of non-diabetics

X Hearing loss is tied to three-fold higher incidence of injury-causing falls, as well as more frequent and longer hospitalizations

X Untreated hearing loss can affect cognitive brain function – and is associated with the early onset of dementia

DID YOU KNOW?

is looking for primary and specialty physicians who want to help create a cure for the common coverage.

Is your health plan making you SICK?Introducing: PrimaCare Direct

++One low, monthly fee of $75.

+Unlimited primary care access

+A personal doctor, focused on your wellness

+No deductibles, copays or surprise bills

Is your health plan making you SICK?Introducing: PrimaCare Direct

+

Join Us612-444-6600

Primacaredirect.com

Physicians, are you SIcK of: Feeling like you work for insurance companies instead of patients?Declining reimbursements while your patients pay higher premiums?Hospitals dictating where you refer patients?Patients delaying or avoiding much needed care because of high deductibles?

At MMIC, we believe patients get the best care when their doctors feel confi dent and supported. So we put our energy into creating risk solutions that everyone in your organization can get into. Solutions such as medical liability insurance, physicianwell-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care.

To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.

Looking for a better wayto manage risk?

Get on board.

minnesota physician august 2015

Documents