minnesota physician may 2013

Volume XXVll, No. 2

May 2013

The power of partnershipForging a unique local response to local health needs

By Charlie Mandile and George Wagner, MD

Between doctors and their pati ents lies an insurmount-able gap for many people

without health insurance. Despitehistoric health insurance reforms,institutional barriers and a complexsystem make entry difficult, even for the savviest health care con-sumers. Even more historic is thealarming burden of chronic diseaseaffecting generations of familiesacross our entire community.

HealthFinders Collaborative(HFC) is a free community healthcenter that has shown how to meetlocal needs for health access andchronic disease management in waysthat don’t necessarily rely on newhealth system reforms. Through acommitment to collaboration, andthe motivation to connect the needsof communities with organizations

HEALTHFINDERS to page 12

The Independent Medical Business Newspaper

The need to actively address obesity reduction—both in the clinic setting and through communityinitiatives—has reached the “burning platform”

stage, to borrow a well-established concept from organi-zational change literature. “An organizational burningplatform exists when maintaining the status quobecomes prohibitively expensive,” says Daryl R. Connerin the business management book “Managingat the Speed of Change.” He adds, “Majorchange is always costly, but when the presentcourse of action is even more expensive, aburning-platform situation erupts.”

The burning platform concept can beaptly applied to the issue of managing obesity.In terms of costs, the Centers for DiseaseControl and Prevention estimated that themedical care costs of obesity in the UnitedStates costs totaled about $147 billion in 2008;the costs for people who are obese were

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MAY 2013 MINNESOTA PHYSICIAN 3

CAPSULES 4

MEDICUS 7

INTERVIEW 8

PRACTICE MANAGEMENT Claims processing 14By Russel Campbell

MEDICINE AND THE LAW Final rule on the “Sunshine Act” 16By David M. Aafedt, JD, andChristianna L. Finnern, JD

TRANSPLANTATION Bone marrow vs. peripheral blood 18By Dennis Confer, MD

INFECTIOUS DISEASES Minnesota tickborne disease update 26By Hannah G. Friedlander, MPH;Elizabeth K. Schiffman, MA; and David F. Neitzel, MS

WOMEN’S HEALTH Promoting healthy pregnancy 28By Nicole Chaisson, MD, MPH,and Chrystian Pereira, PharmD

Reducing obesity 1Strategies for motivating patientsBy Peter Dehnel, MD

The power of partnership 1Forging a unique local response to local health needsBy Charlie Mandile and George Wagner, MD

DEPARTMENTS

C O N T E N T S MAY 2013 Volume XXVII, No. 2

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Ouraddress 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 pub-lication. All views and opinions expressed by authors of published articles are solely those of theauthors and do not necessarily represent or express the views of Minnesota PhysicianPublishing, Inc., or this publication. The contents herein are believed accurate but arenot intended to replace legal, tax, business or other professional advice and counsel. Nopart of this publication may be reprinted or reproduced without written permission ofthe publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

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OFFICE ADMINISTRATOR MaryAnn Macedo [email protected]

ACCOUNT EXECUTIVE Iain Kane [email protected]

The

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Business

Newspaper

www.mppub.com

Bill McDonoughMMIC

A new paradigm of depression care 20By Michael Trangle, MD, and Amy LaFrance, MPH

The intersection of neuro-logy and chiropractic 22By Richard Golden, MD, and Vivi-Ann Fischer, DC

Oncology-plus 24By Robert Delaune, MD

SPECIAL FOCUS: CROSS-SPECIALTY COLLABORATION

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MINNESOTA HEALTH CARE ROUNDTABLE MINNESOTA HEALTH CARE ROUNDTABLE

Background andfocus: For the major-ity, end-of-life is themost medically man-aged part of life. With it come complex issuesthat involve economics,ethics, politics, medicalscience, resources andmore. Advances in technology are extend-ing life expectanciesand require a redefini-tion of the term “end-of-life.” It now entails alonger time frame thanone’s final weeks orhours and debate as to when life is reallyover. Mechanisms existto facilitate personal

direction around this topic, but there is a need for improvedcoordination among the entities that provide end-of-lifesupport.

Objectives: We will discuss the significant infrastructurethat supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontol-ogy, and hospice. We will review the elements that go into creating advanced directives, societal issues thatmake having them necessary, and the difficulties encoun-tered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improvedin the future.

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota

Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

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4 MINNESOTA PHYSICIAN MAY 2013

Sanford, Fairview End Merger TalksSanford Health and FairviewHealth Services quickly endedmerger talks in April after statelawmakers and regulators raisedquestions about the possibleventure.

On March 26, AttorneyGeneral Lori Swanson an -nounced that Sioux Falls, S.D.-based Sanford was in mergertalks with Minneapolis-basedFairview. Swanson’s officeimmediately raised regulatoryquestions about the proposedmerger. At the same time, it wasrevealed that the University ofMinnesota was considering anacquisition of Fairview, whichpurchased the University’s med-ical center in 1997.

At an April 7 hearing in St. Paul, Swanson called wit-nesses who questioned Sanford’stransparency and financial prac-tices, and who pleaded withSwanson to make sure thatFairview, and the “jewel in thecrown” facilities it owns at theUniversity of Minnesota, wouldnot be taken over by an out-of-

state company. State lawmakers also

vowed to slow down or halt any merger, and on April 10,Sanford Presi dent and CEOKelby Krabbenhoft pulled theplug on the merger discussions,saying his company has a policyof “only going where we areinvited.”

Discussions of a U of Macquisition of the health systemhave also ended, but questionsremain about Fairview and theU of M’s future in a health caremarket where more consolida-tion seems likely. Fairview officials pledged they would con tinue efforts to improve the company’s relationship withthe University.

MNsure ExchangeBecomes OfficialOne of the most controversialand anticipated pieces of healthcare legislation in the state’s history, a measure to create ahealth insurance exchange forMinnesota, was signed into lawon March 20. But even with thelandmark legislation passed,

questions remain among indus-try leaders and policymakers onhow an insurance exchange willwork in this state.

The exchange law couldaffect more than 1 millionMinnesotans, providing coveragefor 300,000 people who are currently uninsured. State agen-cies say the exchange, calledMNsure, will save Minnesotafamilies and businesses $1 bil-lion in health care costs by 2016.With ACA tax credits, officialssay, individual consumers couldsee an average 34 percent de crease in premiums for insur-ance purchased through theexchange.

State agencies have beenworking to set up the ground-work for the exchange, andrecently announced a MNsureweb site, www.mn.gov/hix. Thesite is tailored for individualsand small employers, who willbe the main customers of thenew exchange. Consumers willbe able to compare health insur-ance products, find out aboutsubsidies and tax credits, andview data on quality. The statewill also have a toll-free tele-

phone customer service line.“This is the most significant

health care reform in the last 50 years,” says Rep. Joe Atkins(DFL–Inver Grove Heights), whoauthored the bill in the House.“Individuals, families, and smallbusinesses will be able to getquality, affordable health cover-age that saves them money andfits their budget. This is real,positive progress for the peopleof Minnesota.”

Opponents of the bill cited a range of objections, from notenough consumer choice in thefinal product to the financialburden of the exchange on thestate’s budget.

Dave Renner, director ofstate and federal legislation forthe Minnesota Medical Associ-ation, says his group is support-ive, but cautious, about the newexchange. “There’s a lot of workto be done before this is up andrunning,” he says. “It did getcaught up in some partisanshipbut in the long run, we stillbelieve this is going to make iteasier for individuals andemployers to shop, compare,and purchase coverage.”

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MDH Data Shows“Alarming” IncreaseIn Cases of DiabetesApproximately 80,000 adults inMinnesota may have diabetesand not know it, officials withMinnesota Department ofHealth (MDH) said recently.

MDH officials released dataon diabetes in the state as partof the national Diabetes AlertDay on March 26. Officials no -ted that the percentage of adultsin Minnesota with diabetesnearly doubled between 1994and 2010 and that these num-bers underrepresent the truenumber of people living with the condition. About 290,000adults in Minnesota, or 7.3 percent of the state’s adults,have been diagnosed with dia-betes, but officials say nationaldata suggest that another 80,000Minnesotans may have the disease and not be aware of it.

“Given the alarming increase of diabetes, we areencouraging Minnesotans to usethis day to think about whetherthey or someone they love mighthave diabetes or prediabetesand not even know about it,”says Minnesota Health Com-missioner Ed Ehlinger, MD.“Diabetes is a very treatable disease and it is important thateveryone with diabetes takesteps to get their blood sugarunder control and lead a health-ier life.”

North Memorial,MultiCare AssociatesOpen Urgency CenterNorth Memorial, along withMultiCare Associates, recentlyannounced plans to open anemergency room at BlaineMedical Center. Officials say theNorth Memorial Urgency Centerwill be similar to a regular hos-pital emergency room, and willbe staffed by physicians fromNorth Memorial’s Level ITrauma Center.

A stand-alone emergencyroom at a medical office build-ing is new to Blaine, but theidea has been cropping up inthe Twin Cities metro area, mostrecently with the AbbottNorthwestern–WestHealth

Emergency Department inPlymouth, which opened inJanuary.

The North Memorial facilitywill be able to care for the samekinds of illnesses and injuriesERs see, officials say. Patientsthat need hospitalization can betransferred to North MemorialMedical Center in Robbinsdale.

“The Urgency Center willallow us to treat almost everykind of emergency except thoserequiring a transport in byambulance, such as cases ofsevere trauma,” says Amy Kolar,MD, medical director of NorthMemorial’s Emergency Depart-ment. “For many things thatpeople traditionally go to theemergency room for—such asjoint dislocation, broken bones,abdominal or chest pain, etc.—they can go to the UrgencyCenter instead.”

Spending Up, ProfitsDown for HealthInsurance PlansHealth spending was up andprofits were down for healthplans in Minnesota in 2012,according to a yearly reportfrom the Minnesota Council ofHealth Plans (MCHP). Healthplans spent $19 billion on healthcare services, an increase of 7 percent over 2011. Overall,health plans had an operatingmargin of 1 percent last year.

The MCHP annual reportlooks at data from private healthinsurance plans as a wholerather than on an individualizedbasis. Health plan results canvary from year to year and com-pany to company. For example,Blue Cross and Blue Shield ofMinnesota released a separatestatement saying the Eagan-based insurer had a negativeoperating margin of .06 percentfor 2012, while Bloomington-based HealthPartners reported a margin of 4.4 percent for thesame time period.

MCHP officials note thatspending for health care servicesrose $1.3 billion among all plansin 2012, compared with 2011.Health spending trends havebeen flat in recent years, possi-bly because of restrained spend-ing by consumers in a poor eco-

CAPSULES to page 6

With our finger on the pulse of today’s constantly changing health-care industry, we focus on helping our health-care clients protect their interests, overcome their challenges, and meet their business goals. No legal issue, emergent, urgent or otherwise, is too small or large for our expert care. We are here to help.

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C A P S U L E S


nomic climate. The increase inspending on 2012 care resultedin the lowest operating marginsfor health plans since 2008,MCHP data shows.

Income from state programsin 2012 was $4.1 billion forhealth plans in Minnesota,resulting in a 1.4 percent operat-ing margin. MCHP officials saythe average operating margin forstate health programs over thepast 10 years is 1.8 percent.Healthy margins on public pro-grams have led to intense scru -tiny of government plans such as Medical Assistance, which areadministered by the state’s pri-vate health insurance compa-nies. A recent audit said that thestate overpaid insurance compa-nies by $207 million over a nine-year period ending in 2011.

Majority of PhysicianSpouses Happy, Mayo Survey ShowsA survey by Rochester’s MayoClinic found that a strong major-ity of spouses or partners of

physicians say they are happy intheir relationships.

The national survey of 900spouses and partners of physi-cians found that 85 percent ofthose surveyed said that theywere satisfied in their relation-ship and 80 percent said theywould choose a physicianspouse or partner again if given the choice. Officials saythe findings are similar to othersurveys of married adults in the U.S. overall.

Questions about stress andphysician burnout have beenraised in recent years, and somehave suggested that physicians’family lives may suffer as aresult of career choices. But thesurvey shows little evidence tosuggest physicians have lower-quality relationships or are morelikely to become divorced, saysTait Shanafelt, MD, primaryauthor of the study and a Mayo Clinic hematologist andoncologist.

“The findings challenge anumber of stereotypes aboutphysician relationships,” saysShanafelt. “While every relation-ship has challenges, our

research shows that on thewhole, doctors’ spouses and partners are extremely happy in their relationships.”

Three State GroupsReceive Grants from“Choosing Wisely” Three Minnesota health organi-zations have received grantsfrom the Philadelphia-basedABIM Foundation aimed atreducing unnecessary tests andprocedures.

The Institute for ClinicalSystems Improvement (ICSI),the Minnesota Health ActionGroup, and the MinnesotaMedical Association (MMA)were re cently given grants aspart of the “Choosing Wisely”campaign. ICSI, a health qualityorganization, and the MinnesotaHealth Action Group, an associ-ation of health care purchasers,are both based in Bloomington.The MMA is based in St. Paul.

Officials say the ChoosingWisely campaign seeks toencourage physicians andpatients to think and talk about

medical tests and proceduresthat may be unnecessary or mayeven cause harm. ChoosingWisely draws on the expertise of medical specialty societies in identifying unnecessary oroverused procedures. In aneffort to expand the campaign,21 groups around the countryhave received grants funded bythe Robert Wood JohnsonFoundation.

Sanne Magnan, MD, PhD,president and CEO of ICSI, saysthe Minnesota groups can worktogether to reduce unnecessaryprocedures and thereby holddown health care costs. “We areuniquely positioned to reachphysicians and patients inMinnesota, educate them on the specialty societies’ recom-mendations, and engage them in the Choosing Wisely cam-paign to help ensure patients getappropriate care,” she says.

Capsules from page 5

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Gaurav Guliani, MD, has joined the NeurologyDepartment at Hennepin County Medical Center(HCMC). Guliani attended medical school at theUniversity of Illinois in Chicago, and completeda residency in neurology at the University ofMinnesota and a fellowship in neuromuscularmedicine and electromyography at WashingtonUniversity in St. Louis. He is an assistant profes-sor and clinical scholar at the University of Minnesota Department of

Neurology. Paul Nystrom, MD, has joined theDepartment of Emergency Medicine at HCMC.Nystrom went to medical school at the Univer-sity of Iowa and completed his emergency medi-cine residency at HCMC. Nystrom has a specialinterest in tactical EMS and is an EMS Fellowin the Department of Emergency Medicine.

John Manion, MD, has received the 2013Trustee of the Year Award from Aging Servicesof Minnesota. Since 1994, Manion has served on the board of direc-tors at Saint Therese, a nonprofit that provides senior care servicesand housing in the Twin Cities metro area. He established a palliativecare unit at Saint Therese, the first of its kind in the Upper Midwest.

Essentia Health has announced several physician hires. RandallMillikan, MD, has joined Essentia Health Cancer Center in Duluth.He previously was a physician-scientist and associate professor atM.D. Anderson Cancer Center at the University of Texas in Houston.He earned his medical degree from the University of Miami andserved a residency in internal medicine and a fellowship in medicaloncology at the Mayo Graduate School of Medicine in Rochester.Jean Hoyer, MD, has returned to Essentia Health–St. Mary’s- Superior Clinic, where she practiced from 1993 to 2007. Hoyer earnedher medical degree from the University of Wisconsin School of Medi-cine and Public Health in Madison. She served a residency in familymedicine at the Sioux Falls (S.D.) Family Practice Center. JaidevBhoopal, MD, joined Essentia Health–St. Mary’s Medical Center in Duluth as a hospitalist. He earned his medical degree from Sri Ramachandra Medical College in Chennai, India, and served a resi-dency in internal medicine at St. Joseph’s Regional Medical Center inPaterson, N.J. Rheumatologist Frank Vasey, MD, has joined EssentiaHealth St. Joseph’s–Brainerd Clinic. Most recently, Vasey served aschief of the Rheumatology Division at Wayne State University Schoolof Medicine in Detroit. His 36-year career in academic and researchposts includes chief of rheumatology at the University of SouthFlorida College of Medicine in Tampa, Fla., as well as work at nearbyJames A. Haley Veterans Administration Hospital.

Emily Anderson, MD, has joined Lake Superior CommunityHealth Center, Duluth, as medical director. Aboard-certified family physician, Anderson attended medical school at the University ofMinnesota, Minneapolis, and completed her residency through the Duluth Family MedicineResidency Program.

Glacial Ridge HealthSystem, Glenwood, has recently added two physi-cians. Brett Adams, MD,

has joined the Emergency Department, workingwith eEmergency and telestroke technology. Hegraduated from the University of MinnesotaMedical School, Minneapolis, and has practicedfamily medicine in Tanzania and New Zealand.Erin Dahlke, MD, graduated from the Univer-sity of Minnesota Medical School, Minneapolis, and completed herresidency training with the Sioux Falls (S.D.) Family Medicine Resi-dency Program.

M E D I C U S

Gaurav Guliani, MD

Paul Nystrom, MD

Erin Dahlke, MD

Brett Adams, MD


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■ Tell us a little about MMIC and how you workwith physicians.

We help physicians serve patients in more effective,efficient, and safe ways. Data is critical to supportthese new ways. Physicians are scientists by train-ing, and they need to see there is evidence to sup-port shifts in clinical practice and thinking. Wehave the data to help support that.

In addition, some institutions have adopted a “just culture,” which essentially means that it is a very open culture, that reporting problems isencouraged and normal. If there is a problem inthe aviation industry, employees are not onlyencouraged but required to report it, and they dis-seminate the findings throughout the industry.

That doesn’t happen as much in health care. If there is a medical incident or mistake, people arereluctant to come forward because of the concernabout liability. What MMIC is trying to do is tochange that mindset, so that when people comeforward, we support them and use the incident tohelp enhance patient safety.

■ What can you tell us about the impact of professional liability insurance on the costof health care?

The cost of liability insurance inMinnesota is the second lowest in the country. Ouraverage cost of liability insurance for Minnesotaphysicians is around $5,500 annually. We haveworked really closely with the plaintiff bar and the defense bar to mitigate those costs over a longper iod of time.

A lot of physicians pay more for their autoinsurance than they do for their professional lia-bility insurance. I don’t think it’s a major driver ofcosts.

■ Could you talk about your recent efforts to usedata to improve patient safety?

We have 30 years of professional liability data:underwriting data, claim data, patient safety-typedata. That warehouse of data can be used in differ-ent ways. If hospitals or physician groups want toimport their data and have us do data analytics onit, we have that capability.

Recently, we entered into a relationship withCRICO, the insurance company to the Harvardmedical systems. There are 15,000 physicians inthat database and about two dozen large teachinghospitals. It is affiliated with a lot of other largeteaching hospitals: Stanford University, Universityof Pennsylvania—a variety of large health systems,primarily in the East.

First, we will combine our data and use it toiden tify variances in clinical practice. We will helpour phy sicians and our clinics to identify best prac-tices and, where there are variations in clinicalpractice, we’ll show physicians the data to helpthem to have better outcomes.

Second, we can use that data to support ana-lytics and foster an open and transparent culture.Right now, we have been looking at claims data,and that is too late in the process. Once somethinghappens it gets reported to us, and that makes upthe bulk of our data. What we really want is tohave physicians, hospitals, and other clinics reportto us when there are near misses, medical misad-ventures, or system issues, so that we can developa culture within these organizations where thatkind of reporting is encouraged, so that it is notpunitive. We then can help them to identify thethings they can do to mitigate and improve thoseoutcomes going forward.

Finally, we’ll have the ability to access aninventory of proven safety innovations and solu-tions. Harvard and CRICO have been doing this formore than 20 years; they have identified a varietyof things that have driven safety innovations andhave improved clinical outcomes.

This will allow us to partner with our physi-cians in ways that we never couldbefore. We are moving from beingan insurance company they counton when they have a problem tobeing a partner every day in theirclinical practice, helping them toenhance patient safety and to

increase their reimbursement from third-partysources.

■ What challenges and opportunities does health care reform present for professional liability insurance?

Personally, I have significant concerns. We have the best health care system in the world and it cer tainly can be improved—but it seems to me theincentives in our systems are not aligned properlyand I don’t see that changing.

For example, Minnesota’s health care qualityranks among the best in the country, yet Medicarereimbursement is among the lowest. It doesn’tappear to me to be as much about health carereform as about health insurance reform. The bigconcern is that, at a time when the system isalready stressed and individuals within the systemare stressed, we intend to add millions of peopleinto that system. This could lead to more medicalerrors and problems, not fewer. I think there issome value in health care reform, but this is actu-ally insurance reform, in my view.

■ Some states have enacted jury award limits onclaims, others are considering them, and somehave removed them. What can you tell us abouthow this impacts your industry?

If reforms are reasonable and have strong biparti-san support, they can be very effective. In Califor-nia, for example, when they enacted the MedicalInjury Compensation Reform Act (MICRA), it wasa very broad approach and not just caps on eco-

Bill McDonoughMMIC

Bill McDonough, MBA,RPLU, is CEO of MMIC, a Minneapolis-based professional liabil ityinsurance company.

MMIC bills itself as thelargest policyholder-

owned medical liabilityinsurance company in the

Midwest, and offers arange of insurance and

consulting services. The company has recent-ly expanded, acquiring

the Utah MedicalInsurance Associationand partnering withBoston-based CRICO.

McDonough joined MMICas CEO in 2008 and has

more than three decadesof experience in the

insurance industry. Priorto his arrival at MMIC, heserved as COO of Medical

Mutual of Maine andpresident and CEO ofPrinceton Insurance.

Pursuing a “just culture”


I N T E R V I E W

We have 30 years of professional liability data.

nomic damages. They have been effective.Professional liability rates in California havebeen relatively low for dec ades and there isa very competitive market there.

Patients must be compensa ted fairly fortheir injuries when the standard of care isn’tmet; plaintiff attorneys also need to be com-pensated fairly. A recent example of a politi-cal solution, rather than a long-term solu-tion, happened in Missouri, where a packageof reforms was passed and then overturnedin a relatively short time. That creates chaosin the market.

That said, a reasonable cap on non-economic damages—essentially pain andsuffering—is helpful for everybody. It pro-vides stability and prevents shock-type juryawards.

■ What is the impact when large health systems self-insure and provide professional liability insurance directly?

In a market like we have had over the lastfive years, it probably makes sense for thosesystems. My concern is that often, this is ashort-term economic decision, and I wonderif this is really the best use of capital forhealth care systems. Systems have the capi-tal, but they don’t have the necessary spreadof risk, nor the expertise in claim handlingrequired for difficult cases. I don’t believethey understand the risk they are assuming.

I understand that coming from an insur-ance comp any CEO this might sound likesour grapes, but it is important to look atthe numbers. The last six years, the entireindustry has been profitable, but in the first30 years there were only two years wherecompanies like MMIC were profitable.

So, if you think that the last six yearsrepresent what is going to happen going for-ward—then you double down your bet andtake on more risk. If it were me, I certainlywouldn’t bet that it is going to continue.

■ What made the change from 30 years ofnot being profitable to six years of beingprofitable?

If we could answer that question, we couldpredict what is going to happen. It is a com-bination of things. There has been a lot ofpress about tort reform that has enhancedpeople’s understanding of the issue. Effortsaround patient safety within these organiza-tions and within companies like ours haveprobably played some role.

No one knows what drove this change.The likelihood of it continuing is not thatgreat, given reforms in health care and themany patients coming into an alreadystretched system. There are likely to bemore problems going forward than we haveseen in the last six years.

■ What developments are coming to theprofessional liability insurance industry?

You might think I have a dour outlook—Idon’t. There are many things coming to theforefront that can help. Everybody wants toreduce patient injuries and to create a saferenvironment for patients. The more that wecan work together and do that, the better itwill be going forward.

I also see medical technology playing asignificant role going forward. We have seentremendous improvement in surgery andmedical imaging. Surgeons can, in somecases, have a person out of the hospital inone day, compared to 10 or 15 years ago,when there was more chance of infection,longer hospital stays, blood loss, and otherissues.

There will be continued improvement inelectronic health records that will help phy -sicians make better medical decisions. Wewill get to a point where we make decisionsbased on evidence-based medicine.

Technology is really helping in ruralmedicine. We have rural customers alreadythat have the ability to have a patient on amonitor, with a physician in an emergencyroom hundreds of miles away managingtheir care, and with a chance of a much better outcome.


For a full activity listing, go to www.cmecourses.umn.edu2013 CME Activities(All courses in the Twin Cities unless noted)

MAY - OCTOBERTopics & Advances in Pediatrics in cooperation with MN-AAPMay 30-31, 2013

Midwest Cardiovascular Forum: Controversies in CVDJune 1-2, 2013

Bariatric Education Days (9th Annual) June 5-6, 2013

Workshops in Clinical HypnosisJune 6-8, 2013

Update in GI Surgery (77th Annual) June 7-8, 2013

Lillehei Symposium: Cardiovascular Care for Primary Care PractitionersSeptember 5-6, 2013

ONLINE COURSES (CME credit available)www.cme.umn.edu/online

Fetal Alcohol Spectrum Disorders (FASD) - Early Identification & Intervention

Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health

Care Across the Continuum: A Trauma & Critical Care ConferenceSeptember 27, 2013

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$1,429 higher than for those ofnormal weight (www.cdc.gov/obesity/data/adult.html). Andincreasingly, in physician prac-tices, we are seeing that the rising incidence of obesitythreatens to over-whelm efforts byclinicians or clinicsystems to achievewhat the Institutefor HealthcareImprovement callsthe Triple Aim of improving patients’ experi-ence of care,improving thehealth of populations, andreducing the per cap ita cost ofhealth care. Indeed, evidenceshows that obesity is increasing-ly leading to the opposite effects.

To that end, it is time thatphysicians in Minnesota getmuch more serious about reduc-ing the present and future harmdue to adult obesity. Why? Twoessential reasons: • The health care challenges that

our patients will face as they

approach the age of Medicareeligibility is significantlygreater if they are obese, witha body mass index (BMI) of 30or higher.

• As the population ages, therelikely will not be nearlyenough health care resourcesto optimally manage all of the complications related toobes ity—from cardiovasculardisease, to type 2 diabetes, to cancer, to joint problems,and more.

Thus, the essential questionsfor physicians are: How can wemitigate the impact of obesityon individual patients? How canwe best prepare for the expectedtidal wave of obesity that threat-ens to engulf our population?This article focuses on strategiesand opportunities for physiciansto be involved in reducing obes -ity on both the individual andthe broader community levels.

Creating an opportunity for improvement How people get to the point ofhaving a BMI of 30 or higher isobviously multifactorial, and it

is likely to have occurred overan extended period of time.Reversing that trend will be similar in terms of influencesand timeframe. That said, thereare some specific and importantopportunities that clinics andclinicians can employ as cata-

lysts in theirpatients’ transfor-mations.

The first is creating a clinicculture of accept-ance for the personand anticipatedimprovement in hisor her health.Obesity is a major,

independent health-risk factorand will lead to significant mor-bidity and premature mortality.An explicit attitude of concern,support, and helpfulness by allclinic staff is critical.

Having materials andresources readily available in thewaiting room is also essential.Providing links on the clinic’swebsite to reliable onlinesources of information and alibrary of recommended appsfor smartphones will aid manypeople.

Discussing obesity with your patients can be an awkwardand uncomfortable experience atfirst, but you will become muchmore adept over time. Theaccompanying sidebar presentsscenarios that illustrate thebreadth of clinical challengesinvolved in addressing obesitywith patients. Two constructiveapproaches that can resonatewith your patients are discussedbelow.

Motivational interviewing.Motivational interviewing is amethod of finding out patients’priorities and then, based onthose identified priorities, help-ing them target stepwise im -provements in their health sta-tus. Short of pharmacologicintervention or surgery, physi-cians can help patients improvetheir BMI and its associatedcomorbidities by focusing onthree main topics:• Weight reduction: Is there a

specific weight goal or clothingsize that they wish to achieve,and how can that goal beachieved through incremental,weekly efforts?

Obesity from cover


Patient intervention scenarios

Consider obesity in the context of the following scenarios for some perspective on the clinical challenges in improving patient outcomes:• Arnie is a 28-year-old weight lifter who is looking to compete in an

upcoming bodybuilding contest. He wants you to prescribe some topical testosterone gel to enhance his chances of winning this year’scontest. He does disclose that in addition to the requested testosteronegel, he is also using some “locker room–purchased” anabolic steroidsas well as growth hormone. You have an extended and candid conver-sation with him outlining the risks and dangers of his current choicesto increase muscle mass.

• Irena is a 23-year-old graduate student who is requesting to have her oral contraceptives refilled. She does admit to smoking—“because it helps me control my weight”—and she reports a familyhistory of “some sort of a clotting problem.” You have a significant discussion with her about the risk factors involved with her current situation, and she agrees to try a smoking cessation program and adifferent form of birth control.

• Jitesh is a 32-year-old midlevel executive who comes in for evalua-tion of headaches. His blood pressure is measured at 160/110. Hereports having at least three to four “quad shot” espressos eachday, and this is often supplemented with two to three cans of an ener-gy drink. He has a family history of hypertension, and his father diedat age 46 from a massive heart attack. His condition prompts you totake the time to discuss ways of reducing the risk of following in hisfather’s footsteps.

• Christina is a 42-year-old who comes in for evaluation of back pain.This started when she slipped on the ice and landed on her left buttocktwo weeks ago. She has no neurologic findings and has an area ofresolving bruising on her left buttock. You also notice that her BMI iscalculated at 38.7 and that her blood pressure is 158/98. You recom-mend some ibuprofen, prescribe a muscle relaxant, suggest twice dailylocal heat, and recommend a physical therapy evaluation for backpain. As she is leaving, you mention that “we should really start work-ing on your weight issue,” to which she agrees as she hobbles out ofthe exam room.

• Increased activity:Thirty minutes a dayof moderate physicalactivity can be liter-ally life-saving. Isyour patient willingto start by walking10 to 15 minutes,three times a week?

• Dietary improvements: TheNew England Journal ofMedicine reported in itsFebruary 2013 issue that forpeople at high cardiovascularrisk, a Mediterranean diet sup-plemented with extra virginolive oil or nuts reduced theincidence of major cardiovas-cular events. Is your patientwilling to consider small, step-wise changes in his or her dietand cooking patterns?

Other, more global motiva-tional priorities can includebeing there for a daughter’s orson’s wedding; being an activegrandparent; having a healthierretirement; or not wanting tofollow the family tradition of amajor cardiovascular event byage 55. These priorities all canbe tailored to the motivationalinterviewing process.

The 5-2-1-0 improvementplan. Up to this point, this planhas been applied primarily inpediatric settings, but it can beeasily adapted for adults. Thenumbers stand for:5: Five (or more) servings of

fruits or vegetables per day 2: No more than two hours of

screen time per day1: At least one hour of moderate

(or vigorous) physical activityper day

0: No sugar-sweetened bever-ages. For adults, alcohol-based drinks could be includ-ed in this category.

Based on these four maincategories, physicians can usethe motivational interviewingprocess to help patients chooseone or more goals that they wishto work on. For example, is thepatient willing to cut back on hisscreen time from four hours perday to three? Is she willing toconsider adding a fruit or veg-etable serving to each meal? Canthe patient reduce his pop con-sumption from five cans per dayto three, or even two, and drinkwater instead?

Whatever choices patientsbegin with, modifying andadding to them as they seeimprovement is the key. Cele -brating successes, howeversmall, is a key motivator formany people. The ability ofphysicians and clinic staff tomonitor and record progress willbe key to providing reinforce-ment for patient. Tracking actualoutcomes of the interventionmeasures will also be importantfor clinicians.

Other clinic interventionsThere are numerous other,office-based interventions,although they likely will requiremore resource expenditure. Forexample, creating a specificweight loss program mayrequire a fair investment of timeand may not get reimbursed byinsurance plans; self-pay wouldbe an option, or the clinic couldrefer patients to existing, provenweight loss programs.

Additional staff resourcesfor intervention strategiesinclude: • Having a dietitian as part of

the clinic team, to providenutrition education

• Having a physical therapist on-site, to foster increasedphysical activity

• Providing psychologicalresources on-site, or at least asan easy referral source, forpatients who may want addi-tional counseling support

Beyond the clinic wallsBecause obesity takes time todevelop and has many triggers,physicians have a unique abilityto partner with others in thecommunity to help stem theobesity tide. Physician involve-ment in community health andwellness initiatives can boostpatients’ efforts in seeking outand tapping community-basedresources to combat their obes -ity. Interfacing with schools andcommunity education programscan contribute to patients’ success. Bloomington, Edina,

Richfield, Northfield, New Ulm,and Moorhead are among theMinnesota communities thathave launched initiatives toimprove the health and healthcare of their residents, and anumber of Minnesota city councils are currently consider-ing healthy community initia-tives. Physician support will be influential in those councildiscussions.

Embrace clinical challengesCreating a new paradigm of obesity reduction will requiresignificant change within mosthealth care settings. One impor-tant change is that physiciansand clinics will need to embrace the clinical challenge of patientobesity, just as they approachthe clinical challenge of anyother significant medical condi-tion. They can no longer consid-

er intervention for obesity as “optional,”just as it is not optionalfor treating diabetes orheart disease.

Every day, in essen-tially every clinic set-ting, physicians see

patients experiencing the harmof obesity. The opportunities forimprovement that we physicianscan prompt are real and can besuccessful in mitigating this cur-rent and future harm in ourpatients. Equipped with arenewed attitude, and a fewbasic tools, today’s physicianscan help launch our patients—and their communities—on anew trajectory of health.

Peter Dehnel, MD, is a medical directorfor utilization management at Blue Crossand Blue Shield of Minnesota, immediatepast president of the Twin Cities MedicalSociety, and a practicing physician.


Savvy and practical

legal solutions by

attorneys with decades

of health care experience

To that end, it is time that physiciansin Minnesota get much more serious

about reducing the present and futureharm due to adult obesity.

that can help meet those needs,HFC has established itself as acritical access point to margin-alized families in southeastMinne sota. Ten years after tak-ing insurance off the table, HFCis forging ahead in a new space,mobilizing neighborhoods, and connecting institutions tocreate a local response to localhealth needs.

With a population of over60,000, Rice County is bothdiverse and rich in resources.Northfield, Faribault, and sur-rounding communities in southcentral Minnesota are home tofamily farmers, agriculturalprocessing plants, food andtransport industries, and manu-facturing hubs fed by a vibrantI-35 corridor and two liberal-arts colleges. The local work-force supporting these localeconomies is a mix of intergen-erational farmers, owners ofsmall businesses, academics,metro commuters, and growingpopulations of Latino immi-grants and Somali refugees.

HFC is a free communityhealth center that provides

quality health care, advocacy,and wellness education to thosein our community who havelimited health care alternatives.HFC leverages community voiceand local re sources to providean access point to health andwellness for the uninsured andunderinsured. Our primary careservices and medication assis-tance programs address imme-diate and ongoing medicalneeds; an extensive patientadvocacy program actively connects patients with long-term resources; and a thrivingarray of wellness programsbreaks down the walls of theclinic to put patients in chargeof their health.

History of the collaborative

HFC is a collaborative builtfrom the ground up—a strategyas fundamental to our businessstrategy as it is a part of ourvision and model of care. In thesummer of 2002, a group ofleaders from St. Dominic parishin Northfield began meetingafter mass to identify ways toaddress a growing need foraccess to health care and pre-

scription medications. Parish-ioners and church leadersapproached the community at-large, convening medical professionals, local healthadministrators, public healthand business leaders, socialservice providers, faith-basedorganizations, and civic groupsto come together to fill this gap.At the time, the collaborativewas unique in how it transcend-ed cultural groups and geo-graphic boundaries to address apressing local health care need.

HFC found its first home inthe basement of Little PrairieUnited Methodist Church, lo -cated on a rural highway equi-distant from Faribault andNorthfield. Volunteers fromacross the county went to workremodeling the physical spaceand acquiring lab and equip-ment donations. Agreementswere developed with all localclinics and hospitals for in-kinddiagnostic and laboratory serv-ices. All area pharmacies simi-larly came on board to establisha prescription drug program.

In early 2005, HFC openedits doors to patients, staffed byone full-time employee and thededicated services of volunteerphysicians, nurses, social work-ers, interpreters, and reception-ists who came after work, out ofretirement, and as a part oftheir schooling to support theeffort. HFC bloomed into acorps of volunteers whobrought the free clinic and itsallied programs into being,establishing collaborations andpartnerships fundamental to itscurrent existence.

Today: beyond the clinic walls

Since then, HFC has grown intoa staff of 10 supporting morethan 75 dedicated volunteersand dozens of student interns.In our first eight years of opera-tion, HFC has seen over 5,000patients and filled thousandsmore prescriptions. Patients areseen at locations in Dundas,Northfield, and a newly openedspace on Central Avenue inFaribault. Nearly all patientsare within 200 percent of thefederal poverty line. Across allservices, approximately 60 per-cent of HFC patients are Latinoimmigrants, 25 percent areCaucasian, and 15 percent are

Somali refugees. The clinic seespatients of all ages, childrenthrough adults, and uses volun-teers not only to provide carebut also to motivate their peersto health. Imagine how motivat-ing it might be to sit knee-to-knee with your neighbor who isgiving her time and expertisefor you to be healthy.

Reflecting the growing epidemic in the overall popula-tion, HFC patients experience adisproportionate burden ofchronic diseases such as dia-betes, hypertension, overweightand obesity, and teen preg -nancy. To meet these evolvingneeds, HFC has expanded itsservices to our communities.

Our comprehensive diabetesmanagement program reachesmore than 90 families thatreceive supplies and medica-tion, along with monthly groupeducation. The program usesculture, dance, food, and cur-riculum to support and engagefamilies in the management oftheir own disease.

Our Pura Vida HealthyLifestyles Program grew out ofneighborhood walking groupsfacilitated by HFC in targetneighborhoods. The groupsstarted walking to the localYMCA—and a partnership wasborn. The program uses fitnessinstructors, coaches, and stu-dents from the YMCA and localcolleges to teach exercise andnutrition through Zumba, yoga,and everything in between.Groups also meet at theFaribault Community Center,and a women’s group is held inpartnership with the SomaliCommunity Service.

The disparity in teen preg-nancies among local Latinas,combined with the HFC’s posi-tion as a community-basedorganization representingLatino families, brought a comprehensive teen pregnancyprevention program to HFC.Collectively called MESA(Mejoando la Salud de losAdolescentes/ImprovingAdolescent Health), this pro-gram was recently recognizedand expanded by an Elimi -nating Health Disparities grantfrom the Minnesota Depart -ment of Health Office ofMinority and MulticulturalHealth. MESA not only sup-


HealthFinders from cover

ports teens in making healthydecisions; but also, through theTeen Outreach Program, putsyouth in charge of community-service learning projects, im -proving educational and healthoutcomes. Other programsfocus on environmental deter-minants of teen pregnancy, suchas family meals, school policy,and parent engagement, and arecoordinated through a Latinofamily leadership council.

Connecting communities

The immigrant health paradoxobserves how immigrants andrefugees, whatever their countryof origin, come to the UnitedStates in superior health com-pared to the average American.But over time, these immigrantsand refugees not only assimilateto have the same health as theaverage American, but in manyareas (such as diabetes and obesity), experience health dis-parities and worse health thannative-born Americans. Thisphenomenon not only impli-cates the environmental andother social determinants ofhealth in the U.S. but also posesthe question: What is it aboutthese immigrant groups thatmade them initially healthierthan us, often coming from sit-uations of poverty? The answer:community connections andcultural health knowledge.

Effective health access andchronic disease care recognizethe important contribution offamilies, social networks, andcommunities to individualhealth. Therefore, HFC engagesthese groups as equal partnerswith biomedicine and mobilizescommunity voice through lead-ership and engagement oppor-tunities. Connecting institutionsto community need creates abroad movement for health.

Institutional support

HFC’s safety net services wouldnot be possible without the sup-port of the formal health caresystem. Two independent com-munity hospitals have a longhistory of supporting HFC. Inanticipation of opening a cus-tom-built space in downtownFaribault, District One Hospital(DOH) in Faribault and HFCcame together to deepen ourpartnership and develop an

innovative plan to serve theneeds of the entire community.

The first year of this plan(2012) enabled HFC to researchand develop a comprehensiveWellness Plan that integratesHFC wellness with clinical pro-gramming, coordinating ser -vices around patient-centeredcare. The results combinedWagner’s Chronic Care Model,the Health Belief Model devel-oped in the 1970s and ’80s, andMinnesota’s health care homestandards. The HFC WellnessPlan aims not only to improvequality of care at HFC, but alsoto increase connections be -tween HFC and the formalhealth care system.

At the same time, DOHleveraged support from Mayoand Allina health systems.These organizational connec-tions not only support carecoordination and wellness serv-ices at HFC, but also have con-nected hard-to-reach popula-tions to the hospital, and set thestage for regular and coordi -nated information exchange.For example, HFC has broughtcommunity voice to hospitalinitiatives around Somalibirthing practices, mentalhealth, an upcoming commun -ity assessment, and its DiversityAdvisory Committee.

This year, HFC’s first nursepractitioner will join the clinic,and clinic hours will begin indowntown Faribault. HFC iscontinuing to implement anelectronic medical records sys-tem (with servers housed in theNorthfield Hospital data cen-ter), as well as a comprehensive evaluation model to monitorprocess and health outcomeneeds and successes in the com-munities we represent.

Community leadership

As much as HFC looks to thehealth system, we break pastthe walls of the clinic to developsustained partnerships withpatients’ families and their com-munities. Health and wellnesshappens at home and is sup-ported by families, cultures, and neighborhoods. HFC hasentered this space with a grow-ing patient engagement andcommunity leadership initia-tive. Rather than starting byplacing patients on the board of

directors, HFC is going to itsprograms to cultivate patientengagement and communityleadership through on-the-ground community organizing,community wellness meetings,and coalition-building. We areidentifying leaders withinpatient communities and HFCprograms to organize FamilyHealth Councils. This strategyplaces communities in controlof identifying health needs andsolutions, partnering to meetthese needs, and creating anorganized voice in the commu-nity. These councils will eventu-ally bring their voice to serve onthe HFC board of directors, aswell as contribute to commun -ity-wide discussions abouthealth and diversity.

Evolving needs, evolving organization

As local needs have evolved, sohas HFC. We are not just posi-tioned, but embedded in thecommunities that have thepower to change the alarmingtrajectory of chronic diseaseand conditions associated withlack of health access. It is only

because of our collaborativenature, and our lasting partner-ships with a broad base of committed stakeholders, thatwe can do this. Together, we areforging a unique and powerfullocal response to local healthneeds—because it is not med-ical providers who will preventteen pregnancy or manage diabetes, but the teens andpatients themselves.

With visionary institutionalsupport, HFC is using the man-ageable size of our rural com-munities to build an organizedand effective voice for commu-nity health, both inside and out-side of the clinic. HFC is notonly helping to connect patientswith resources, but also usingthe power and partnership ofboth to develop a model of carefor everyone.

Charlie Mandile is executive director of HealthFinders Collaborative; he is com-pleting a master of public health degreein community health promotion at theUniversity of Minnesota. GeorgeWagner, MD, a family practice physi-cian in Faribault, is medical director ofHealthFinders Collaborative.


P R A C T I C E M A N A G E M E N T

Health care providers sub-mit more than 12 billionclaims for processing

annually to commercial payersand government payers (Councilfor Affordable Quality Health -care 2012). About 2 percent ofthose claims are rejected. While2 percent of the entire claim vol-ume may not seem like a largenumber, these claims may be thehigh-dollar claims, and yourbilling staff may be spending ahigher percentage of their timeresolving them.

My claims processing busi-ness continually analyzes theproblems with claims that aresubmitted. Unfortunately, onething we’ve found is that regard-less of the types of claims sub-mitted and whether they arebilled to commercial payers orgovernment payers, manyproviders’ billing staffs aren’tgetting the job done.

Of course, every providerknows that errors often occur at the insurer’s end of the claimsprocess, rather than at theprovider’s office. Since thosetypes of errors are beyond thedirect control of the provider,

this article focuses on the re jected claims that never getpast the payers’ front-end editsand fail to enter the adjudicationsystems. The discussion belowcovers three main reasons whyhealth care claims are rejected,and the steps providers and theiroffice staff can take to reduceerrors in billing procedures.

Reason #1: Patient ineligibility

The No. 1 reason claims arerejected is that the insurerdeems that the billed serviceswere provided to patients whoare not eligible or cannot beidentified as being eligible toreceive services. Our company’smost recent analysis identifiedalmost 37 percent of the rejectedclaims as having an eligibilityissue. The reasons for theserejections run the gamut, from

the patient having no coverageat all, to having no coverage forthe stated date of service, to amismatch of data identifying thepatient or subscriber. The bot-tom line is that the payer hasdeemed that the claim submittedis not going to be processed orpaid.

Today, because the eligibilityresponse transaction containsmore data than in the past, pay-ers are closely scrutinizing thedemographic data submitted onthe claim.

Though many providerscontract for eligibility verifica-tion services, problems still willarise unless all of the datareceived in the eligibilityresponse from the payer hasbeen loaded into the provider’sbilling system and used whensubmitting the claim to theinsurance payer.

To give a common example,not only the member/subscriberinsurance ID, but also thepatient’s address and name, needto match the ID in the payer’ssystem, or the claim may berejected. In November 2012,some Medicare claim processorsstarted to reject claims becausethe Medicare subscriber’s lastname did not exactly match theCMS demographic record onfile—even though the MedicareID for the patient was correct.Common mismatch rejectionsare associated with hyphenatedlast names (e.g., Mary Smith-Jones) or with double last namesthat are not hyphenated (e.g.,Mary Smith Jones).

Your office can reduce thesekinds of rejected claims by mak-ing sure that the patient dataentered by the billing staff exactly matches the payer’s infor-mation for the patient. Be sureyour billing staff compares thedemographic data that isreturned from the payer againstthe information that is stored inyour billing system. If the mem-ber/subscriber ID does notmatch, payers will reject that

claim during their initial pro-cessing, and rightfully so. Ourcompany uses systems to ana-lyze the subscriber/member IDnumbers that fail. These toolscan identify which data entrystaff have problems, such astransposing numbers, that maycause front-end rejections.

The most successful way toensure that a claim passes thepayer’s front-end edit is to usethe data that the payer provides.

Reason #2: Claim coding

The second largest category offront-end claim rejections relatesto the coding on the claim. Inour analyses, just over 30 per-cent of all errors are related tocoding. A few of the challengesfor providers’ offices are dis-cussed below.

Procedure coding and diag-nosis coding. Currently, errorsin procedure and diagnosis cod-ing account for only a small por-tion of claims that are rejectedfor coding errors. However, thenumber of diagnosis rejectionslikely will increase dramaticallywith the transition to ICD-10coding, effective Oct. 1, 2014.The change in the codingmethodology will be similar tothe recent HIPAA claim formatchange from 837 version 4010 tothe current version 5010. Themandated Jan. 1, 2012, imple-mentation date for that transi-tion stretched from November2011 to March 2012. Our com-pany upcoded claims and remit-tance files from 4010 to 5010and downcoded claim andremittance files from 5010 to4010; in fact, we are still upcod-ing claims for some providergroups.

The transition from ICD-9 toICD-10 will follow the same sortof variable timeline. Again, somepayers will not enforce the dead-line by which to accept ICD-10only; others will accept bothICD-9 and ICD-10 beyond thedeadline. Additionally, certainpayers (e.g., the entire propertyand casualty industry, i.e., workers’ comp andauto/medical) will be exemptfrom the mandate to use ICD-10,though they may decide to doso.

This means that providers’offices will have to be ready todeal with multiple claims pay-

Claims processingOffice-based strategies

for reducing rejected claims

By Russel Campbell


ment scenarios: Some payerswill require ICD-10 on all claimson the ICD-10 cutover date ofOct. 1, 2014; others will allowboth ICD-9 and ICD-10. Somepayers will not be ready to makethe transition; others will nothave to participate in the transi-tion at all.

In the case of the ICD-9 vs.ICD-10, there is no upcode,there is no downcode, and thereis no “crosswalk” between thetwo methodologies. In theFederal Register, CMS hasadvised strongly against anyattempt to develop a crosswalkbetween the ICD-9 and ICD-10coding system.

NDC numbers. A larger per-centage of the errors in the cod-ing category are related to theNational Drug Code (NDC) num-bers. These errors include miss-ing data, missing segments, andincorrect NDC numbers.

Procedure descriptions.Another new feature of theHIPAA version 5010 claim for-mats is the addition of proce-dure descriptions beyond theclaim notes that existed in theversion 4010. Any procedure

code (CPT or HCPCS) that isidentified as “unspecified” or“miscellaneous” should be sub-mitted with a description in theelectronic claim. The linkwww.dmepdac.com/crosswalk/2013.html will be useful in sort-ing out these new requirements.To minimize delays in payment,monitor the claim processingguidelines published by thepayer and supply additionalinformation during the initialclaim submission.

P&C (property & casualty)claims. Workers’ compensationclaims are especially proble -matic to the staff that submitthe usual medical claims. Be cause the topic is so complex,this article touches on just a fewissues related to workers’ compclaims.

The main problem with

these claims occurs when thepatient, instead of the employerof the patient, is listed as thesubscriber on a P&C claim. Thisis especially tricky because thepatient is listed as the subscriberwhen a claim is submitted to apayer such as Medicare orBCBS. For P&C claims, the datarelated to the patient is submit-ted in the “patient” section ofthe form; it is never submittedin the “subscriber” section.

Workers’ comp claimsalways require claim attach-ments and a P&C file number.The P&C file number essentiallyequates to the member insur-ance ID number on standardclaim forms—but it is entered ina different place in the P&Cclaim. The attachments have tobe identified within the submit-ted claim, and the attachment

must be submitted within a fewdays after the claim file is ac cepted by the payer. For theclaim to be processed success-fully, the best approach is tosubmit the claim and the claimnote attachments at the sametime.

Billing staff should also be aware of a couple of otherpotential claims snags:• Many P&C claims require

patients’ social security num-bers, though they are oftenunnecessary, or not allowed,on Medicare and commercialpayer claims.

• For services provided in Minn-esota, providers must submitP&C claims electronically tocomply with Minnesota statute62J, which states that suchtransactions “must be trans-mitted electronically amongproviders, payers, and clear-inghouses using a single, uni-form, standard data contentand format.”

Reason #3: Errors in provider information

The third largest category of


CLAIMS to page 38

The No. 1 reason claims are rejected is that the insurer deems that the billed

services were provided to patients who are not eligible or cannot be identified as

being eligible to receive services.

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M E D I C I N E A N D T H E L A W

Just in time for spring:Sunshine. On Feb. 1, 2013,the Centers for Medicare &

Medicaid (CMS) issued the finalrule on the “Sunshine Act.” TheSunshine Act requires drug anddevice companies to reporttransfers of value to physiciansand teaching hospitals. CMSissued its proposed regulationsin December 2011. The final ruleincludes 35 pages of regulations,preceded by 251 pages of expla-nations, showing CMS’s thought-ful analysis of the nearly 400comments it received during thecomment period. The final rulerevises and clarifies a number ofprovisions.

We first wrote about theSunshine Act’s implications forMinnesota physicians in theNovember 2012 issue of Minne-sota Physician (“Sunshine andscrutiny: managing compliancewith ACA’s Sunshine provisionsfrom a provider perspective”).Here, we provide Minnesotaphysicians with updated guid-ance based on CMS’s final rule.This article outlines the defini-tions, timeline, exclusions, ruleson meals, and reporting cate-

gories set out in the final rule;and explains how the final ruleaffects Minnesota’s existing partial gift ban and reportingrequirements.

Definitions

The final rule clarifies certaindefinitions:

An “applicable manufac-turer” (AM) is (1) an entity oper-ating in the U.S. that is engagedin making or selling a coveredproduct. Distributors that do nothold title to the covered product

are not AMs. Or an AM is (2) anentity under common ownershipwith an entity in part (1), whichassists in making or selling acovered product.

An “applicable group pur-chasing organization” (AGPO)is an entity operating in the U.S.that arranges for the purchase ofa covered product.

“Physician” is defined asprovided in the Social SecurityAct, which includes licenseddoctors of medicine and osteo-pathy, dentists, podiatrists,optometrists, and chiropractors.It excludes physicians who areemployees of an AM andexcludes residents.

“Teaching hospitals” aredefined as those that receiveCMS funding for graduate medical education; CMS says it will publish, annually, the listof teaching hospitals.

Timeline

The final rule establishes a new timeline for the Sunshinereporting requirements. Thestart date for data collection isAug. 1, 2013. Applicable manu-facturers and applicable grouppurchasing organizations musttrack transfers of value to physi-cians or teaching hospitals. Theymust also track ownership orinvestment interests held byphysicians or their immediatefamily members.

The data collected from Aug. 1–Dec. 31, 2013, must besubmitted to the CMS’s OpenPayments website by March 31,2014. Physicians will be able toregister with Open Payments in2014 to review the reported data

before it is made public so thatthey can dispute and correct any mistakes. This data will be made publicly available on Sept. 30, 2014.

Exclusions from reporting

The final rule sets out clearexclusions from reporting. Key exclusions include transfersof value less than $10, exceptwhere the annual total wouldexceed $100. Small incidentalitems under $10 (e.g., pens)given away at large conferencesdo not count toward the annual total.

Other exclusions are:• Transfers of value because of

existing personal relationships(e.g., where an AM employeegives a gift to her physicianspouse)

• Educational materials thatdirectly benefit patients (such as anatomical models,but not medical textbooks)

• Discounts and rebates• In-kind items for providing

charity care• Product samples (including

vouchers intended to defraypatient costs)

• The loan of a medical devicefor a short-term trial period,not to exceed 90 days

In the final rule, CMS carefully explains what fits anddoes not fit within each of theseexclusions. For example, physi-cians accepting items for charitycare should be sure that thepatients receiving this care trulycannot pay for it. If it would notbe a hardship for a patient topay for this medical care, thendonated items are consideredtransfers of value to the treatingphysician.

Rules on meals

The final rule also explains howmeals must be reported. Often,an AM’s sales representativesprovide meals for an entire prac-tice. If a physician partakes inthe meal, it is considered atransfer of value and must bereported; however, the initialregulations were unclear on howthe cost of the meal would beallocated.

According to the final rule,the total cost of the meal is to bedivided by the total number of

Final rule on the“Sunshine Act”

Be ready to comply

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The final rule establishes a new timeline forthe Sunshine reporting requirements. The

start date for data collection is Aug. 1, 2013.

individuals who partake in themeal (including physicians andnon-covered individuals such asnurses or staff). This number isthe reportable transfer of value,but only for the physicians whoactually partake in the meal. If apractice has three physiciansand 10 nurses and the mealcosts $240, but only two physi-cians partake, the value is $240divided by 12, or $20 per person.The AM must report transfers ofvalue of $20 each for those twophysicians.

This rule allows physiciansto avoid a reportable transfer ofvalue by choosing not to partakein a meal supplied by an AM.

Reporting categories

The final rule also specifiesexactly what must be reported.The AMs will be reporting thephysician’s full name, specialty,business address, NationalProvider Identifier (NPI) num-ber, and the state professionallicense number. The reportsmust include the amount, form,date, and nature of the payment,and the name of the related cov-ered product. If there is not arelated covered product, AMscan report a related non-coveredproduct or “none.” Paymentscan be eligible for delayed publi-cation if made pursuant toresearch on new drugs ordevices in order to keep thisresearch confidential while itfirst gets under way. If the pay-ment was made to an entityother than the physician at therequest of that physician, thename of this entity must bereported. Lastly, payments tophysician owners or investorsmust be reported.

When AMs report the costsrelated to a physician’s atten-dance at a medical conference,the AM cannot bundle thesecosts. This means that a physi-cian who travels to a medicalconference can incur many dif-ferent transfers of value—andeach will be specified in the pub-licly available reports. There will be separate lines for travel,meals, honoraria, and speakingfees if applicable. Though thesetransfers of value may be en -tirely appropriate, physiciansshould be aware that each ofthese costs will be reported as aseparate payment and the appli-

cable drug or device’s name willbe attached to each.

This means that if a physi-cian flies business class, stays in a five-star hotel, eats at aMichelin-starred restaurant, andis paid a high honorarium whileattending a meeting about a par-ticular stent, and then begins touse this particular stent, thephysician should be aware thatthis invites scrutiny under thefederal Anti-Kickback Statute(AKS). It remains illegal underAKS to pay physicians in orderto influence their choice of adrug or device (42 U.S.C.§1320a-7b, “Criminal penaltiesfor acts involving federal healthcare programs”). Prosecutorscould easily interpret an $800flight, $500 hotel, $300 meal,and $1,500 honorarium as influ-encing a surgeon’s decision touse a new stent.

Effect on state partial gift banand reporting requirements

Many Minnesota physiciansalready are familiar with some of the requirements of theSunshine Act because of Minne-sota’s partial gift ban and report-ing laws (Minn. Stat. §151.461and §151.47, subd. 1(f) (2012)).Minnesota bans gifts worth morethan $50 annually to physicians(this applies to drug—notdevice—manufacturers and dis-tributors) and requires thesecompanies to report payments,honoraria, reimbursement, orother compensation to physi-cians totaling more than $100.However, in light of the CMS’sfinal rule, the Minnesota Boardof Pharmacy has announced thatit will amend its disclosurerequirements.

In a Jan. 8, 2013, letter,Board of Pharmacy ExecutiveDirector Cody Wiberg, notedthat the “vast majority of datathat is reported under Minne-sota law is information coveredby the Sunshine Act”; and, thus,the Board of Pharmacy hasdetermined that it will “notrequire wholesalers and manu-facturers to report any data forcalendar year 2012” (letter available at www.medispend.com/documents/MN-RepealofReporting.pdf).

Additionally, the Board ofPharmacy will ask the Minne-sota State Legislature to repealthe state’s reporting require-ments in 2013. The board willnot be asking for a change toMinnesota’s partial gift ban.

This means that Minnesotaphysicians must check only thefederal Open Payments website(see sidebar) to review reportedtransfers of value. Using OpenPayments, Minnesota officialswill be able to keep track oftransfers of value from drugcompanies that would be disal-lowed under the partial gift ban.Physicians should be careful notto allow AMs to exceed the $50annual limit on gifts—and thisincludes meals. For physicianswho interact only with drugcompanies, Sunshine is a newparadigm. All Minnesota physi-cians should evaluate what payments they are comfortablereceiving as this data becomespublic in a little over a year.

David M. Aafedt, JD, andChristianna L. Finnern, JD, are attorney shareholders at Winthrop &Weinstine, PA, Minneapolis.


Resources and additional information

• CMS’s final rule on the Sunshine Act: www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-medicaid-child re n s-he alth-insurance-programs-transparency-reports-and-reporting-of

• Physician Payment Sunshine Act Final Rule: Definitions, Policy andMedicine, Feb. 5, 2013: www.policymed.com/2013/02/physici an-payment-sunshine-act-final-rule-definitions.html

• Physician Payment Sunshine Act Final Rule: Quick Reference Guide,Policy and Medicine, Feb. 13, 2013: www.policymed.com/2013/02/physician-payment-sunshine-act-final-rule-quick-referenceguide.html

• Minnesota Statute §151.461 (“Gifts to Practioners Prohibited”):www.revisor.mn.gov/statutes/?id=151.461

• Minnesota Statute §151.47 (“Wholesale Drug Distributor LicensingRequirement”): www.revisor.mn.gov/statutes/?id=151.47

• CMS’s National Physician Payment Transparency Program: OpenPayments: www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/index.html

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T R A N S P L A N T A T I O N

What is now calledhematopoietic celltransplantation (HCT)

used to be called bone marrowtransplantation because the onlyavailable graft source was mar-row extracted from a donor’spelvis. Today, when performingHCT with an unrelated donor(URD HCT), a transplant physi-cian may choose among threegraft sources that he or shebelieves will be best for a patientundergoing HCT: bone marrowcells, peripheral blood stem cells(PBSCs), or umbilical cordblood cells. Each stem cellsource has its advantages anddisadvantages, and the ultimateselection involves several clinicalfactors, including patient age,disease, and disease stage.

In the past decade, trans-plant physicians have shown apreference for PBSCs over mar-row because early studiesshowed that PBSC collectionscontained more blood progeni-tor cells than did bone marrowharvests. In addition, PBSCgrafts resulted in faster engraft-ment, thus restoring immunefunction faster and reducing the

concurrent risk of opportunisticinfections. Donors also seemedto prefer PBSC donation, whichinvolves an apheresis procedurerather than the anesthesia andneedles involved in a marrowharvest.

However, this shift towardPBSC transplantation in the last10 years has occurred withoutsolid clinical evidence thatPBSCs were an overall betterstem cell choice for URD HCT.Now, solid clinical evidence onthis issue is available, through alandmark study coordinated bythe National Marrow DonorProgram and the Blood andMarrow Transplant ClinicalTrials Network (BMT CTN) andpublished in the Oct. 18, 2012,issue of the New England

Journal of Medicine. This study,led by Claudio Anasetti, MD, ofthe Moffitt Cancer Center inTampa, Fla., has demonstratedthat bone marrow transplanta-tion has a significant advantageover PBSC in one importantregard.

Although the study found nosignificant difference in two-yearoverall survival between the twograft sources, marrow recipientsexperienced significantly lowerincidence of chronic graft- versus-host disease (GVHD).Chron ic GVHD can be a debili-tating side effect of URD HCT,and occurs when donated stemcells recognize the recipient’sbody as foreign and mount animmunological attack against it.

This result has the potentialto change clinical practice in theHCT field, namely, by shiftingthe general clinical preferencetoward bone marrow grafts andaway from PBSC grafts for themajority of patients. Although it is too soon to determinewhether such a shift is occur-ring, there are several reasons,explained in the “Discussion”section, to believe that it willeventually occur.

Study methodology

This large-scale, phase 3 studyexamined outcomes of 551adults transplanted using unre-lated donors at 48 transplantcenters affiliated with the BMTCTN in the United States andCanada. Both donors and trans-plant recipients were random-ized to donate/receive eitherbone marrow or PBSC grafts.More than 90 percent of thepatients received a transplantfrom the assigned, randomizedgraft source.

Patients were adultsyounger than 66 years of age,and the primary end point of thestudy was two-year overall sur-vival. Secondary end pointsincluded post-transplant inci-

dences of engraftment failure,neutrophil and platelet engraft-ment, acute and chronic GVHD,infections, and relapse.

The trial was conductedbetween March 2004 andSeptember 2009, and had amedian follow-up of 36 months.The marrow and PBSC groupswere well balanced in age, sex,Karnofsky scores, diagnosis, disease risk, cytomegalovirus(CMV) serostatus, and race.

Patients were eligible to beenrolled in this intention-to-treatstudy if they were scheduled toundergo transplantation foracute myeloid or lymphoblasticleukemia, myelodysplasia,chronic myeloid or myelomono-cytic leukemia, or myelofibrosis.Together, these diseases repre-sent approximately 75 percent ofunrelated-donor transplanta-tions in North America duringthe study period. Acute myeloidleukemia was the most commonindication in patients, account-ing for 47 percent of the trans-plants performed.

Bone marrow cells were har-vested using established collec-tion protocols from the posterioriliac crests of a donor’s pelvis.Peripheral blood stem cells werecollected via apheresis followingfive or six days of daily injec-tions of filgrastim (10 µg perkilogram of body weight), whichinduces bone marrow stem cellsto migrate from the marrow intothe peripheral blood. A secondapheresis procedure was per-formed on day six only if the dayfive collection contained insuffi-cient CD34+ cells.

A majority (78 percent) ofthe pre-transplant conditioningregimens were myeloablativeand utilized cyclophosphamidewith or without total body irradi-ation. Twenty-two percent of theconditioning regimens containedfludarabine and were consideredreduced-intensity regimens.

Study results

As shown in Table 1, patients inthe marrow and PBSC cohortshad comparable overall survivalat two years post-transplant. Theincidence of chronic GVHD wassignificantly higher in patientsreceiving PBSC grafts comparedto those receiving marrowgrafts. Incidence of graft failurewas significantly higher in mar-

Bone marrow vs.peripheral blood

Which is better for allogeneic transplant?

By Dennis Confer, MD


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row recipients compared toPBSC recipients. There were nosignificant differences betweenthe two patient groups onrelapse, non-relapse mortality,and incidence of acute GVHD(GVHD appearing in the first100 days post-transplant).

Engraftment of neutrophils(>500/mm3) and platelets(>20,000/mm3) was significantlyfaster in PBSC recipients com-pared to marrow recipients.Median time to neutrophilengraftment was five days shorter (p<0.001), and med iantime to platelet engraftment wasseven days shorter (p<0.001), inPBSC recipients.

Relapse was the most common cause of death in the marrow and PBSC patientcohorts: 50 percent and 48 percent, respectively (p>0.05).Deaths due to chronic GVHDwere significantly higher in thePBSC group than in the marrowgroup: 21 percent vs. 10 percent(p=0.002). Deaths due to graftfailure were significantly higherin the bone marrow group thanin the PBSC group: 8 percent vs.0 percent, respectively (p=0.002).

Discussion

These results have several impor-tant clinical implications, all ofwhich give patients, donors, andphysicians more concrete evi-dence to consider when decidingon the course of an unrelateddonor allogeneic transplant.

Because this study showedno distinct survival benefit foreither stem cell source, a deci-sion on using either a marrow orPBSC graft should be based onspecific clinical aspects of indi-vidual cases. For example,because engraftment is signifi-cantly faster when using PBSCgrafts, patients who have beenheavily pre-treated and have sys-temic infections might benefitfrom PBSC transplantation.

Similarly, PBSCs might alsobe the best graft source forpatients at high risk of experi-encing graft failure, such asthose undergoing reduced-intensity conditioning withoutprior exposure to intensivechemotherapy. However, bonemarrow may be the best graftchoice for patients who do nothave a high risk of graft failure,such as those who are immuno-

suppressed from prior chemo-therapy.

But clearly the most impor-tant finding of this study is thatPBSC grafts significantlyincrease the risk of chronicGVHD. The authors concludethat PBSCs should therefore notbe the default choice for mostunrelated donor transplants, andshould only be considered inpatients for whom the benefitsof a PBSC graft outweigh theincreased risk of developingchronic GVHD.

It’s hard to predict how andwhen this main result will affectclinical practice in the field ofHCT, but anecdotal reports fromthe field give a strong hint.These study results garneredwidespread attention amongtransplant physicians both afterthe NEJM report was published,and, prior to that, when thestudy was presented as anabstract in a plenary session atthe American Society of Hema-tology Annual Meeting inDecember 2011.

Transplant physicians—andmany of their patients consider-ing allogeneic HCT—are there-fore aware of the higher risk ofchronic GVHD after unrelateddonor PBSC transplantation.Considering how debilitatingchronic GVHD can be, it’s likelythat transplant patients andtheir physicians will now bothbe motivated to select marrowgrafts over PBSC grafts when -ever possible.

However, there are also fac-

tors at work that might preventa shift toward a preference formarrow over PBSC grafts. Aspreviously mentioned, mostdonors prefer the apheresis pro-cedure required in a PBSC col-lection over the anesthesia andneedles involved in a marrowharvest. Transplant physiciansmake their requests for either

marrow or PBSC grafts fromdonors, but it is the donorsthemselves who decide whatdonation procedure they arewilling to undergo. It is there-fore easy to imagine that trans-plant physicians may makemany more requests for marrowthan will be accommodated.

A second factor that mayprevent a shift toward moremarrow transplants was high-lighted in an editorial byFrederick Appelbaum, MD, thataccompanied the NEJM report.Dr. Appelbaum, a transplantphysician from the FredHutchinson Cancer ResearchCenter, wrote: “While this studyshould change practice, it willbe interesting to see if it reallydoes. The benefits of peripheralblood are seen early, under thewatchful eyes of the transplanta-tion physician, whereas the dele-terious effects occur late, oftenafter the patient has left thetransplantation center.”

Dennis Confer, MD, is the chief medicalofficer of the National Marrow DonorProgram, and was senior author of theNEJM article reporting these study results.


Key points

• There are three graft sources for patients undergoing allogeneichematopoietic cell transplantation (HCT): bone marrow cells, peripheral blood stem cells (PBSCs), or umbilical cord blood cells.

• In the last 10 years, transplant physicians have preferred PBSCs to marrow, despite a lack of solid clinical evidence that PBSCs werean overall better stem cell choice for unrelated donor HCT patients.

• A recent study demonstrated that bone marrow recipients experi-enced a significantly lower incidence of chronic graft-versus-host disease (GVHD) than PBSC recipients.

• The study also showed that the incidence of graft failure was signifi-cantly higher in marrow recipients compared with PBSC recipients.

• Because the study showed no distinct survival benefit for either stemcell source, a decision on using either a marrow or PBSC graft shouldbe based on specific clinical aspects of individual cases.

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TABLE 1. Two-year outcomes of unrelated donor transplants by graft source.

Outcomes at two years PBSC Marrow p-valueOverall survival 51% 46% 0.29

Chronic GVHD 53% 41% 0.01

Extensive chronic GVHD 48% 32% <0.001

Graft failure 3% 9% 0.002

S P E C I A L F O C U S : C R O S S - S P E C I A L T Y C O L L A B O R A T I O N

Depression can hide in plain sight. Consider a patient who

came for care because his wifepushed him to tackle his irri-tability, sleep problems, andstress. He wasn’t subjectivelyeven feeling sad. Generally hewas not in touch with his feel-ings unless he was angry. He felthopeless, pessimistic, and irrita-ble and angry. Depression madehim feel so stuck that nothing inhis life was going well.

The man began using anti-depressants and improved some-what, but he was still quite anxious. Using a second medica-tion and talk therapy helped tochange his outlook and habits.

As he got better he was fretting less, and he could con-sciously leave work earlier andfocus on his family interactionsmore. He started to get moreexercise, which helped his anxi-ety and sleep.

That patient understood theimpact of his depression moreas he recovered. He wasn’t evenaware of it before treatment, yetit was significantly affecting hismarriage, his enjoyment of be -ing a father, and his career. Hesays his life is much better today.

This patient’s experience isnot unusual.

A partnership for fighting depression

Depression is very common. It often grows imperceptibly and can ruin people’s lives inways that are so subtle andundra matic that it is almost likea silent disease. One barrier totreatment is the unhealthy andinaccurate idea that peopleshould just “buck up” and usetheir willpower to get over it. It’swrong. Depression is not a signof weakness or moral failure.These attitudes must shift somore people get adequate treat-ment and get into remission.

A proactive team of pro -viders and engaged patientsmakes a powerful partnership tofight depression. By far the bestoutcomes are obtained whenusing a collaborative care model.

In this model, depressedpatients are put in a registry,and their symptom intensity isperiodically measured using aquantitative tool, typically aPHQ-9 (Patient Health Question-naire–9). A care manager rou-tinely educates the patient, fol-lows the patient closely to iden-tify and overcome problems and obstacles, and engages thepatient in behavioral activationand self-management.

Under the collaborativecare model, a psychiatristspends some time advising thecare manager and primary carephysician, and outcomes aremeasured.

Another example of collabo-rative care in action is a patientwho spoke with her primarycare provider a few months after finalizing a divorce. Thepa tient’s complaint was insom-nia; in fact the patient was anxious and depressed.

The primary care providerprescribed a sleep medicationand referred the patient to thecare manager for review. ThePHQ-9 scores confirmed thepatient had depression.

The case manager explainedto the patient that she hadsymptoms of depression: Shewas moderately anxious, sociallyisolating herself, not feeling pro-ductive at work, and drinkingone to two drinks each eveningto fall asleep.

The provider started thepatient on a low-dose antide-pressant. The care managerworked with her to re duce herdrinking, first from two drinks a night to one, then from onedrink a night to a watered-downhalf-drink a night. The patientstarted walking for exercise, andadded the social support ofwalking with a friend. Shedecreased her caffeine intake.

Initially the care managerhad weekly contact with thepatient for a few months. Overtime the patient stopped drink-ing completely, maintained herlow intake of caffeine, andachieved remission from herdepression.

A new doctor-patient paradigm

In the past, the doctor-patientrelationship was sometimesviewed more like a mechanic-carrelationship—the attitude wasthat the patient could just pas-sively wait for the doctor to per-form the tune-up. Now thatmore clinics are implementingbest practices for depressioncare and using the PHQ-9, it iseasy for patients and providersto jointly monitor symptomseverity and improvement.

That changes the whole par-adigm. The patient is more likelyto be an equal, active partner.

A new paradigm of depression care

Collaborative approach aids patients, physicians

By Michael Trangle, MD, and Amy LaFrance, MPH


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With health reforms

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quality and cost-effec-

tiveness in care, we

are seeing increased

collaboration across

medical specialties.

The special focus this

month looks at three

different types of

cross-specialty collab-

oration taking place

in Minnesota: between

behavioral health

and primary care

providers; between

neurologists and

chiropractors; and

among a wide variety

of specialties in

managing complex

oncology cases.

There’s evidence to showthat patients who are moreengaged and active in their owntreatment tend to have betteroutcomes. Engaged patients aremore likely to reach remissionfrom their depression and alsoto stay in remission.

Improved treatment/outcomes

Addressing depression can alsohave additional benefits, espe-cially for patients with complexconditions. Patients with dia-betes, recent heart attacks andstrokes, cancer, chronic pain,and substance abuse and depen -dence all have higher rates ofdepression and significantly

worse outcomes if the depres-sion is not treated. Communitystandard is that most medical orspecialty clinics treating theseconditions do not routinelyscreen for depression. A few do,and most should. People withdepression deserve for this to berecognized and treated as muchas any other disease.

As a physician, your out-comes will be deservedly betterif you recognize and treatdepression too.

Michael Trangle, MD, is a psychiatristand associate medical director forBehavioral Health at HealthPartners. Amy LaFrance, MPH, is manager ofstrategic partnerships at MN CommunityMeasurement.


Collaborative care models in Minnesota

Efforts to enhance collaborative care models areunder way throughout the state and nation, andthe scope is getting broader.

“The depression projects like DIAMOND werea proof of concept that you could do behavioralhealth in a systematic way in a primary care clinicand get good results. Now people are broadeningthat in recognition that behavioral health overallshould be integrated into primary care,” says C.J.Peek, PhD, associate professor in the University ofMinnesota Medical School’s Department of FamilyMedicine and Community Health.

A few efforts to support or expand collabora-tive care models in Minnesota are described below. • Dr. Trangle helped to develop “Help and

Healing: Resources for depression care andrecovery” (www.mnhealthscores.org/?p=depression_resources) with MN CommunityMeasurement and the Minnesota Health ActionGroup to share useful materials with providersand patients. The Help and Healing toolkit canput useful, patient-centered materials and tools inpatients’ hands. Trangle recommends that both

patients and providers access the resources todetermine what may be most useful for an indi-vidual patient.

• The Institute for Clinical Systems (ICSI) has a pro-gram that unites a physician, care manager, andconsulting psychiatrist to provide better care topatients with depression in the primary care cli -nic. Called DIAMOND (Depression ImprovementAcross Minnesota, Offering a New Direction),the model has expanded to address patients withrisky substance use, as well as those with bothmental health and chronic physical conditions. Itis available at more than 60 primary care clin-ics. Details are available at www.icsi.org/health_initiatives/diamond_for_depression/.

• Integrating behavioral health overall into primarycare is very important. The Agency forHealthcare Research and Quality (AHRQ)devotes a full website to detailing how to accom-plish this integration and providing supportiveresources (http://integrationacademy.ahrq.gov/). The initiative is directed in part by theNational Integration Academy Council, which

includes three Minnesotans: C.J. Peek, PhD;Macaran Baird, MD, MS, professor and head of the University of Minnesota Medical School’sDepartment of Family Medicine and CommunityHealth; and Roger Kathol, MD, president ofCartesian Solutions, Inc. and board-certified in internal medicine, psychiatry, and medicalmanagement.

• Mayo Family Clinic Northeast in Rochester hasintegrated behavioral health into its primary care services, beginning in 2008 when the clinicbegan participating in the DIAMOND program.The integrated team includes primary careproviders; two full-time licensed clinical socialworkers; a clinical psychologist who is on-siteone day a week; and two post-doctorate psy-chology fellows who work with patients under thesupervision of the clinical psychologist. Over thepast three years, the clinic has shown both con-sistent improvement and high performance in itsability to address depression care. (source: MNCommunity Measurement 2012 Health CareQuality Report, p. 114)

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Although treatment collab-oration between chiro-practors and neurologists

began informally about 30 yearsago, the pace of collaboration is accelerating with the currentfocus on health care cost andquality. This type of interdisci-plinary collaboration makessense, as neurologists oftentreat chronic and incurable conditions that can benefitfrom both a medical and chiro-practic care model. With recentchanges in the health caremodel, and research datademonstrating the benefits ofchiropractic care, interdiscipli-nary collaboration is increas -ingly important as it expandsinto multiple allopathic disci-plines, including orthopedics,spinal surgery, rheumatology,and internal medicine for mus-culoskeletal conditions.

In addition to the cost andquality issues, another driver ofincreased use of chiropractorsfor treatment and diagnoses ofneurological disorders is theavailability of providers. Undercurrent health care reforms,patients may find it more diffi-

cult to schedule time with med-ical specialists, and may look toother types of providers, includ-ing chiropractors, as the firstline of care and diagnosis.

Health payers like this typeof collaboration because of the

potential for improved effici -ency, lower costs, and betterpatient outcomes. Payers under-stand the value of doctors com-

municating and sharing skill sets for treating certainconditions.

Collaborative care examples

Collaboration between neurolo-gists and chiropractors can ben-

efit patients suffering from avariety of common neurologicalconditions, including head -aches, vertigo, and symptomsrelating to brain-stem traumasuch as that sustained from anautomobile collision or sportsinjury. Other neurological con-ditions such as sciatica, carpaltunnel syndrome, and weaknessof the arms or legs also benefitfrom this collaboration.Chiropractors are trained torecognize neurological condi-tions that need medical man-agement and to make appropri-ate referrals to specialists basedon these assessments.

Patients with headaches.Unfortunately, migraine head-aches are a common occur-rence. The World HealthOrganization reports that halfto three-quarters of adults18–65 years of age have hadheadaches in the past year—andamong those individuals, morethan 10 percent have reportedmigraines. Treatment of thesesevere headaches is one exam-ple of collaboration betweenneurologists and chiropractorsthat may provide synergisticbenefit to the patient.

Recognizing the type ofheadache a person is experienc-ing can determine whether chi-ropractic or medical interven-

tion should be the first courseof treatment. Recent researchhas shown that when receptorsin neck muscles are overstimu-lated, changes in the part of the brain stem that generatesmigraines can occur. Some -times, spinal manipulationreducing muscle tension andrestoring joint function canrelieve migraine symptoms. The same can be true for most types of muscle tensionheadaches. Chiropractic manip-ulation to treat migraines alsomay be particularly attractive topatients who do not like takingmedication.

Some types of migrainesrespond best to medicine. In Dr. Fischer’s experience, about10 percent to 20 percent ofheadaches are best treated witha combined medical and chiro-practic intervention. In suchcases, collaborative care mayprovide a much more efficientapproach to headache care.

Patients with dizziness orvertigo. Vertigo episodes occurin 20 percent to 30 percent ofthe adult population. Vertigocan be caused by a number ofinner-ear conditions. In somecases, such as those involvingtumors, surgery is required.Others result from musclespasms in the neck, which canbe treated by a chiropractor.

If a vertigo diagnosis ismade and the dizziness likely isexplained by neck spasm, areferral to a chiropractor mightbe indicated. The referralshould include the diagnosisand a recommendation that thechiropractor confirm the diag-nosis and treat accordingly. It isalways important and appropri-ate to receive periodic progressreports and for the neurologistto follow the patient at regularintervals.

Patients with closed head trauma. Head trauma isanother health condition that is treatable via care coordina-tion between neurologists andchiropractors. The AmericanAssociation of NeurologicalSurgeons reports that 1.7 mil-lion cases of traumatic braininjury (TBI) occur in the U.S.every year, and that 50 percentto 70 percent of TBI accidentsare caused by motor vehiclecrashes.

The intersection of neurology

and chiropractic Collaborative care on the rise

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When a person experiencestrauma to the brain stem, suchas harm incurred in an autoaccident or a severe sportsinjury, the body reacts by tryingto freeze the muscles. A chiro-practor begins with a less inva-sive approach, working toimprove joint mobility andfunction, followed by exercisesthat rebuild muscle. Neuro -logists need to step in for painmanagement, second opinions,or for evaluation of more severedisease.

Ideally, if the chiropractorbelieves a second opinion orpain management medicationwould be useful in an injurycase, a referral would be madeto a neurologist, providingdetails regarding the injury,diagnostic imaging, and treat-ment that has occurred to date,and requesting a neurologicalevaluation. The consulting neurologist would then proceedwith a complete neurologicalworkup, including further diag-nostic imaging if appropriate,and provide findings and rec-ommendations to the referringchiropractor.

Patients with radicularsymptoms such as sciatica orcarpel tunnel syndrome.

Sciatica can be caused by amuscle spasm, joint impinge-ment, or nerve impingement.These conditions can be treatedby a chiropractor throughmanipulation, active care exer-cises, and adjunct physiother -apy such as acupuncture, ultra-sound, or muscle stimulation. A severe nerve impingementwould call for collaborationwith a neurologist. Orthopedicand neurologic exam findingssuch as a loss of reflex, or imag-ing findings (MRI or CAT scan)demonstrating a severely com-pressed nerve, would be a rea-son for a referral to a neurolo-gist or neural surgeon.

Jobs requiring heavy com-puter use or work based on

repetitive motion can contributeto carpal tunnel syndrome.Unless the symptoms aresevere, chiropractic care isoften a good starting place.Chiropractic care mobilizes the wrist and arm joints,loosens the muscles, and pro-vides the patient with exercisesto recondition the arm andwrist. In some cases, the symp-toms associated with carpaltunnel syndrome, such as handor arm numbness, originatefrom a nerve impingement inthe neck, and the condition isnot, in fact, carpal tunnel syn-drome. The exam findings willprovide this differential diagno-sis, and if the cause is deter-mined to be a neck condition,chiropractic care would thenfocus on relieving the neckimpingement to improve the

arm symptoms. In either carpaltunnel syndrome or neckimpingement, if the patientdoes not improve or the condi-tion is severe, referral of thepatient to a neurologist wouldbe indicated.

Collaboration can benefitpatients, curb costs

Collaborative care between neurologists and chiropractorsallows the providers to helpeach other, and patients end upwith the best combination ofcare for the lowest possiblecost. The authors have collabo-rated on patient care for years.Our hope is that more neurolo-gists and chiropractors estab-lish relationships of trust andcollaboration to benefit patientsand achieve the goal of morecost-effective care.

Richard Golden, MD, is a neurologistat Noran Neurological Clinic,Minneapolis. Vivi-Ann Fischer, DC, is chief clinical officer for Chiropractic Careof Minnesota, Inc., in Shoreview.


Collaborative care between neurologists and chiropractors allows the providers to help each other, and patients end up

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Multidisciplinary careteams have become thenorm in health care,

especially in the subspecialty ofmedical oncology. This transi-tion is a result of more patientspresenting with multiple comor-bidities. These patients moreroutinely require cross-specialtycollaboration to effectively man-age their complex cases. Onco -logists recognize that proactivelypartnering with other specialistscan improve patient outcomes.Multidis ciplinary teams facili-tate communication amonghealth care professionals, help-ing to minimize costs and expe-dite time from diagnosis totreatment initiation.

Tumor conferences

Minnesota Oncology’s Maple -wood Cancer Center currentlyhosts two different tumor con-ferences that are based uponmultidisciplinary care-teammodels. One conference focuseson colorectal cancer patients;the other reviews head and neckcancer cases. The conferencesare held one or two times amonth and include specialists

from the various disciplinesthese patient populations oftenencounter throughout their cancer journey. Conference participants include medicaloncologists, radiation oncolo-gists, ENT and colorectal specialists, radiologists, patholo-gists, pharmacists, dieticians,genetic counselors, speechpathologists, and care coordina-tors. This holistic approachhelps ensure that all of thepatient’s needs are met.

The multidisciplinary tumorconferences provide a consistentopportunity for specialists tocollaborate on developing treat-ment plans. Physicians presentcases that include new cancerdiagnoses, patients with diseaseprogression, or tumors that areunresponsive to treatment. The

group then reviews the casesand discusses treatment options.

This cross-collaboration isinvaluable. It allows all the spe-cialists to use their expertise and offer their own perspectives,and it helps prevent treatmentoptions from being overlooked.For example, a medical oncolo-gist may not be aware of surgi-cal and radiation options while,conversely, a surgeon may notbe aware of all the potentialchemotherapy regimens andradiation treatments. In essence,the plans are individually orch -es trated to give each patient thebest possible outcome.

To truly function as a multi-disciplinary care team, it isimperative that representativesfrom all of the disciplines—including support services suchdieticians, genetic counselors,speech pathologists, and carecoordinators—be involved intreatment. The absence of a spe-cialty creates a weak link indeveloping a comprehensivecare plan. For example, geneticcounselors are present at thecolorectal tumor conference tohighlight genetic changes thatcould be attributed to a patient’sdiagnosis or to discuss the needfor familial testing. Without par-ticipation from genetics, familymembers with the same geneticmutations may go undetectedand miss the opportunity toreceive prophylactic care. Simi -larly, registered dieticians arecritical members of the headand neck care team. They be -come connected with patientsearly in the treatment process toensure proper nutritional plan-ning occurs, including facilitat-ing the placement of feedingtubes and determining appropri-ate nutritional supplements.

This comprehensive ap -proach to treatment planning isfar superior to having healthcare providers treating inde-pendently.

Benefits for patients, physicians

The cross-specialty tumor con-ferences benefit both patientsand physicians. A team modelpromotes numerous efficienciesin care. For example, the radiol-ogist can determine the bestscan for a particular area of thebody to be looked at and savetime spent getting multiple dif-ferent exams/tests. Also, ques-tions come up around stagingand treatment options that canbe discussed with the partici-pants so that all the informationis present to make decisions. If apatient is not eligible for sur-gery, that step or evaluation canbe eliminated and the patientcan move onto other specialties.

Most importantly, it facili-tates care coordination andexpedites care delivery. This isan enormous benefit in theoncology world, where hearingthe word “cancer” fills patientswith anxiety and fear. Colla -boration minimizes time be -tween diagnosis and initiatingtreatment, whether it involvessurgery, radiation therapy,chemotherapy, or nutrition ther-apy. A work-up plan is deter-mined upfront and by the multi-disciplinary team, eliminatingtime delays associated with hav-ing patients consult with indi-vidual specialists and determin-ing a plan along the way. This iscomforting to patients and cre-ates the sense that their health isa priority to those treating them.

The tumor conferences yieldbenefits in testing, communica-tion, and education as well.

Collaboration helps ensureappropriate testing is com -pleted. It reduces the likelihoodof ordering incorrect or dupli-cate diagnostic testing, offeringcost savings to patients andinsurance companies. This isparticularly important in today’sworld of accountable careorganizations, underinsuredpopulations, health savingsplans, and reimbursement cuts.Nobody wants to go throughunnecessary scans or duplicatedprocedures. Participation byradiologists at these conferencesensures that tests are orderedaccurately and helps expeditepatient work-up in a timelymanner.

Oncology-plusCare conferences reflect a holistic

approach to meeting patients’ needs

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The regular tumor confer-ences also minimize communi-cation barriers among the spe-cialists. It is not uncommon forhealth care providers to use different patient charting sys-tems that require providers topersonally communicate statuschanges. This can be time-con-suming and create delays incare. The care conferencesreduce the need for physiciansto reach out to other specialistsindividually to gain their per-spective. In addition, the confer-ences help keep team memberscurrent, since all stakeholdersare present at the same time toupdate the entire team on thepatient’s status and care plan.

Multidisciplinary confer-ences also serve as a forum forongoing education, providinghealth care professionals withaccess to emerging trends, dif-ferent treatment approaches andstrategies. Participants often discuss data on new and emerg-ing surgical techniques; newinformation on specific types oftumors (for example, molecularprofiles that may help individu-

alize care for a particularpatient’s tumor); and new drugtherapies specifically targetingcertain patient populations.Continuing education credits areavailable to participants of themultidisciplinary care confer-ences at the Maplewood CancerCenter, giving health care pro -fessionals additional impetus toattend.

Challenges and goals

In addition to the benefits ofmultidisciplinary care teams,there are some challenges.Among them is the availabilityof the specialists. As notedabove, there are many playersinvolved in these teams. Eachperson has a complex schedulewith clinic and/or surgical obli-gations. It can be an arduous

task to organize calendars andfind a convenient time for every-one—but without representationfrom all disciplines, the teamcannot attain a comprehensivecare model.

In addition, these types ofcare conferences are not reim-bursable services by third-partypayers. According to the Centersfor Medicare & Medicaid Ser-vices, the patient needs to bepresent in order for a physicianto report time spent in a teamconference. This is unfortunate,since these conferences addvalue to the patient’s experienceof care and require physicianexpertise and time.

With the graying of the pop-ulation in the United States, theneed for cancer care serviceswill continue to rise in the years

ahead. At the same time, newnational health care mandateswill increase Medicare regula-tions and decrease reimburse-ment in many cases. These factors create a “perfect storm”that will require health care professionals and organizationsto employ every method at theirdisposal to collaborativelystreamline health care protocolsand increase efficiencies.

Our goal must continue tobe to provide the best, mosteffective and cost-efficient treat-ment plans possible for ourpatients. At Minnesota Oncology,we sum it up this way: “Our mis-sion is to combine the strengthof hope with the power of sci-ence, one patient at a time.”

Robert Delaune, MD, is board-certifiedin medical oncology, hematology, andinternal medicine. He practices atMinnesota Oncology’s Maplewood CancerCenter.


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I N F E C T I O U S D I S E A S E S

Despite a high level ofawareness of Lyme dis-ease among Minnesota

residents and medical providers,persistent misperceptions aboutdiagnosis and treatment remain.Five additional tickborne dis-eases (TBDs), with varying levelsof public and provider aware-ness, are also endemic toMinnesota. Medical providersthroughout the state should beaware of TBD clinical presenta-tions, recommended laboratoryassays, treatment guidelines, andshould feel comfortable speakingwith their patients about how tominimize risk.

Epidemiology of tickborne diseases in Minnesota

Lyme disease (LD) (Borreliaburgdorferi); babesiosis (Babesiaspp.); human anaplasmosis (HA)(Anaplasma phagocytophilum), aform of human ehrlichiosis (HE)(Ehrlichia muris-like agent); andPowassan disease (POW virus)are considered endemic toMinnesota and Wisconsin,where they are associated withbites from Ixodes scapularis(blacklegged tick or “deer tick”).

Although more common insouthern states, Rocky Mountainspotted fever (RMSF) (Rickettsiarickettsii) is known to occur inthe Upper Midwest. UnlikeMinnesota’s other TBDs, the pri-mary tick vector of RMSF isDermacentor variabilis (Ameri-can dog tick or “wood tick”).

When considering a TBD di -agnosis, physicians should de ter -mine patient exposure to tickhabitats, as tick bites often gounnoticed. I. scapularis ticks aremost abundant in hardwood for ests or brushy areas and are act ive during most warmmonths of the year. Disease riskfrom I. scapularis is highestfrom mid-May through mid-July,coinciding with the primaryfeeding period of the tick’s

nymphal stage. Lower diseaserisk occurs during spring andfall months when adult I. scapu-laris feed. RMSF risk is highestduring spring and early summerin wooded and grassy habitatswhere D. variabilis ticks areactive.

In recent years, I. scapularishas emerged in formerly non-endemic regions of the state,particularly to the north andwest of historically endemiceast-central Minnesota. TheMinnesota Department ofHealth (MDH) has confirmed I.scapularis presence as far northas the Canadian border and inmany western Minnesota coun-ties with suitable wooded habi-tat. Figure 1 shows the tickbornerisk in Minnesota’s counties.

Diagnosis and management

Lyme diseaseLyme disease is caused by infec-tion with the bacteria Borreliaburgdorferi. The incubation peri-od for LD is 3–30 days, thoughdisseminated infections may not be recognized or diagnoseduntil weeks or months later. The pathognomonic erythemamigrans (EM) rash is present inthe majority of early localizedcases of LD. The rash expandsin size over time, although itmay lack the central clearing orthe characteristic “bulls-eye”appearance. Disseminated B.burgdorferi infections mayinvolve dermatologic, rheumato-logic, cardiac, peripheral nerv-ous system, or central nervoussystem manifestations.

The recommended diagnos-tic testing procedure for LD isby two-tiered serology—anELISA or IFA followed byWestern blot (if ELISA is posi-tive or equivocal). However, if apatient has a single EM andsym ptoms began in the last 2–4weeks, antibody testing is notrecommended due to low sensi-tivity at this stage of infection. If

Minnesota tickbornedisease update

Providers can help patients minimize risk

By Hannah G. Friedlander, MPH; Elizabeth K. Schiffman, MA; and David F. Neitzel, MS


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a patient has been symptomaticfor >1 month or did not developan EM, clinical diagnosis shouldbe supported with evidence of IgG antibodies by Westernblot. An IgG-positive result is ex pected in patients with symp-toms lasting longer than onemonth.

Long-term or repeated anti -biotic courses for the treatmentof “chronic” LD are not neces-sary, safe, or recommended.Persistence of viable B. burgdor-feri after proper antibiotic treat-ment (2–4 weeks duration) is notsupported by scientific litera-ture. Continued symptoms fol-lowing treatment may resultfrom lingering inflammatoryprocesses, an unrecognized tick-borne co-infection, or an unre-lated process.BabesiosisBabesiosis is a potentially fatal,malaria-like disease resultingfrom infection with intra-ery-throcytic parasites of the genusBabesia. Unlike LD, where infec-tion is seen in all age groups,babesiosis is most commonlyobserved in elderly or immuno-compromised patients, who may

present with fever, chills, sweats,myalgias, arthralgias, anemia,and/or thrombocytopenia up toeight weeks after an exposure.Severe complications, includinghemolysis, respiratory distress,and organ failure, have beenknown to occur in infected individuals.

If babesiosis is suspected,confirmatory testing by PCR orthrough a combination ofperipheral blood smears andserology is recommended, asblood smears alone fail to cap-ture all cases, especially ininstances of low parasitemia.Serologic testing is less reliablein early infection, and determin-ing whether positive serologicresults indicate a past exposureor a current infection on anacute specimen can be difficult.A fourfold increase in antibodytiter between acute and conva-lescent specimens may be sug-gestive of current infection.

Transfusions are a knownsource of babesiosis transmis-sion, and transfusion-associatedillness should be considered inpatients who develop fever and


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Minnesota Department of Health — Infectious Disease Epidemiology, Prevention and Control Division

April 2013

W O M E N ’ S H E A L T H

According to the most re -cent data, there were 4.1million live births in the

United States in 2009. Whilepregnancy rates have declined innearly all age groups, the pro-portion of women over 35 yearsof age continues to increase.This shift in pregnancy rates to ward older women has led toan increase in the proportion ofpregnant women with chronicdiseases. Furthermore, inc reas -ing rates of obesity at youngerages in the U.S., to gether withassociated comorbidities such as diabetes and chronic hyper-tension, have contributed tohigher-risk pregnancies.

Consideration of drug ther -apy in pregnant women is acommon medical decision.Though several existing re -sources can help determine thesafest medications to be usedduring pregnancy, these refer-ences are mainly designed tohelp with decision-making at theinitiation of therapy after a preg-nancy has been diagnosed. At this point, the provider canweigh the risks/benefits of alter-native options and choose a

medication associated with thelowest risk.

Providers face a different,and somewhat harder, decision-making process when a patientis already on medication(s) andthen becomes pregnant. Here,the provider must also weigh the risks/benefits of the patient’shistory with the medication(s)and control of symptoms incombination with the potentialharm/benefit of changing to adifferent medication.

Preconception care: A missed opportunity?

Improving women’s healthbefore conception and recogniz-ing the effects of chronic condi-tions and treatment for those

conditions on a pregnancybefore conception can result inimproved reproductive healthoutcomes. Yet, preconceptioncare is often a missed opportun -ity. Though approximately 50percent of pregnancies in theU.S. are unplanned, studies indi-cate that more than 80 percentof women of reproductive agevisit a health care provider during the year prior to theirpregnancy. There is opportunityfor primary care providers toengage women in proactive dis-cussions about future reproduc-tive health plans, either to assistwith decisions about contracep-tion or to prepare for a healthypregnancy in the near future.

The 2011 National Women’sHealth Survey Data of women18-44 years old noted that 9.2percent had asthma, 30.2 per-cent were hypertensive, 11.4 per-cent had diabetes, and 62.1 per-cent were overweight or obese;all of these rates have increasedover the past decade. A repro-ductive health plan can reflect awoman’s intentions regardingfuture pregnancies in the con-text of personal health, values,and life goals. For women withchronic medical conditions, itcan also help direct treatmentand inform expectations of theimpact of a pregnancy on thecondition(s).

Good and consistent pre -conception counseling includesreviewing chronic health condi-tions, chronic medications, anduse of over-the-counter or herbalmeds, and how these factorsmay affect future pregnancies.Clearly, if a patient is consider-ing a pregnancy in the nearfuture, avoiding medicationswith known harm in pregnancyis ideal unless the potentialmaternal benefits outweigh thefetal risks. Alternatively, dis-cussing delaying conception

with use of effective contracep-tion may be warranted if mater-nal conditions are more severeand treatment is riskier with aconcurrent pregnancy.

Many medical conditionsmay be affected by a concurrentpregnancy or may increase therisk of adverse pregnancy out-comes for women and/or theirinfants. Decision-making is com-plicated by the pharmacother -apy used for these conditionsand the limited data regardinguse of chronic medications during pregnancy. This articlereviews some common chronicconditions encountered duringpregnancy.

Asthma

Asthma can adversely affectboth maternal quality of life andperinatal outcomes. Pregnantwomen with asthma are at significantly increased risk ofseveral adverse perinatal out-comes, including preterm labor,pre eclampsia, low birth weight,neonatal hypoxia, and stillbirth,particularly if the woman’s as -thma is uncontrolled. A women’sasthma may stay the same, wor -sen, or even improve duringpregnancy; however, patientswith more severe asthma to startwith are the most likely to wor -sen during pregnancy.

Management of asthma during pregnancy is generallythe same as management priorto pregnancy. Updating thepatient’s Asthma Action Plan atthe beginning of the pregnancycan help reinforce the idea that“staying in control” is safest forthe outcome of the pregnancy.Fortunately, while severalchanges in the respiratory sys-tem occur in pregnancy, there isno change in FEV1 or PEF;therefore, these measures can beused to monitor response totherapy during pregnancy.Patients also can be prepared tonotice possible exacerbations inthe third trimester and to under-stand that it is safe to treat theseexacerbations if they occur.

Generally, the medicationsmost commonly used to treatasthma are quite safe duringpregnancy. Studies indicate thatthe risk of uncontrolled asthmaon perinatal outcomes is muchgreater than the theoretical risksof asthma medications. Inhaled

Promoting healthy pregnancy

Chronic medical conditions and the pregnant patient

By Nicole Chaisson, MD, MPH, and Chrystian Pereira, PharmD


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corticosteroids and short-actingbeta agonists have proven safetyand efficacy. Long-acting betaagonists such as salmeterol andformoterol have not been wellstudied in pregnancy and areknown to have associated risksof worsening exacerbationswhen used as monotherapy out-side of pregnancy; therefore, it is recommended that these beavoided during pregnancy.Maternal use of oral corticos-teroids has some associationswith low birth weight andpreeclampsia; however, they aregenerally considered safe forasthma exacerbations and formanagement of severe asthma inorder to prevent maternal death.

Diabetes

Gestational diabetes, both pre -existing and pregnancy related,occurs in approximately 7 per-cent of all pregnancies in theU.S.; these rates have steadilyincreased, as has the rate of diabetes affecting all women ofreproductive age. The perinataleffects of poorly controlled diabetes on the fetus are wellknown and include neonatalhypoglycemia, respiratory dis-tress syndrome, hyperbilirubine-mia, congenital malformations,and stillbirth. Maternal effectsinclude preeclampsia, birth trauma, and hypertension.

Preconception care for dia-betes is critical, as perinatal out-comes are best when glycemiccontrol is achieved before con-ception. Studies have linked anincreased rate of congenital mal-formations and spontaneousabortion to poor pregestationalglycemic control. Therefore,contraceptive status and repro-ductive intent should bereviewed with all diabeticwomen of reproductive age attheir routine diabetes visits.

Pregnancy outcomes areclearly related to how well con-trolled the patient’s diabetes wasbefore pregnancy. But even pa -tients with well-controlled dia-betes need to step up their glu-cose monitoring during preg -nancy and visit their providermore frequently to determinewhether their medications needadjustment. Pregnancy is char-acterized by increased insulinresistance and reduced sensitiv -

ity to insulin, largely due to theeffect of placental hormones onthe system. As insulin resistanceincreases throughout the preg-nancy, the body’s requirementsfor exogenous insulin canchange over time, with thegreatest insulin requirementsoccurring in the third trimester.

The gold standard for phar-macotherapy in pregnancy is ini-tiation of or conversion to acombination of NPH and regularinsulin. Insulin, due to itsmolecular size, does not crossthe placental barrier; therefore,it helps control maternal glucosebut does not affect the fetal sys-tem. Newer insulin formulationssuch as Glargine have not beenapproved for use in pregnancy,but share the same characteris-tics as older formulations andare not known to pass the pla-cental barrier.

More recently, oral hypo-glycemics have received atten-tion as a treatment option.Glyburide does not pass the placental barrier and has beenrecognized as safe during preg-nancy. Metformin does pass theplacental barrier, but studiesduring pregnancy have generallydemonstrated no significantadverse events with its use; nevertheless, it has not beenwidely recognized as adequatemonotherapy during pregnancy.

Depression

In the U.S., it is estimated thatmore than half a million preg-nancies annually involve womenwith psychiatric illnesses. It isalso estimated that one-third ofpregnant women are exposed topsychotropic medications atsome point in their pregnancyand more than 70 percent ofpregnant women report symp-toms of depression during preg-nancy. Clinical management ofdepression must be individual-ized to account for the risk ofthe medications on the fetus andnewborn and the potential effectof untreated maternal illness onthe pregnancy; and to review

any available alternative thera-pies. Untreated depression may result in poor utilization ofprenatal services and poor self-care during pregnancy and canaffect maternal-newborn bond-ing after delivery. Maternal de -pression during pregnancy hasbeen linked to intrauterinegrowth restriction (IUGR), low birth weight, and postnatalmorbidities.

While psychotherapy shouldbe considered a mainstay fortreatment of depression duringpregnancy, some women willneed to remain on or restartantidepressant medications inorder to remain mentally heal -thy. Some early studies foundincreased risks of birth defectsspecifically associated with tri-cyclic antidepressants (TCAs);however, more recent studiesindicate that these may be con-sidered safe, though not neces-

sarily first-line treatment fordepression. The selective sero-tonin reuptake inhibitors(SSRIs) have been linked toneonatal hypoglycemia and res-piratory problems; however, themajority of that evidence wasassociated with the use ofparoxetine (Paxil) in particular.SSRIs generally are consideredsafe, and the benefits of treat-ment nor mally outweigh thesmall known risk of use duringpregnancy.

All psychotropic medica-tions used to treat depressioncross the placenta and mayenter human breast milk even insmall amounts; however, chang-ing meds throughout the preg-nancy may increase the expo-sure to the fetus and should beavoided if possible. For womenalready taking a medication, it ispreferable to increase the doseof one medication rather thanswitch to a different medicationor start a second one.

Hypertension

Chronic hypertension affectsapproximately 3 percent of preg-


PREGNANCY to page 30

A reproductive health plan can help directtreatment and inform expectations of the

impact of a pregnancy on the condition(s).

www.altru.org

• Dedicated Team Approach

• Competitive Salary & Benefits

• EPIC Healthcare Information System

Idylic Practice Opportunitieslocated in family friendly

communities with close access to some of Minnesota’s most beautiful lakes.

FAMILY PRACTICE w/OB

Warroad, MNRoseau, MN

Crookston, MN

Contact:Kerri Hjelmstad, Physician Recruiter

Altru Health SystemPO Box 6003

Grand Forks, ND 58201-6003

1-800-437-5373 Fax: [email protected]

nant women. Pregnancies com-plicated by chronic hypertensionmay be associated with superim-posed preeclampsia or eclamp-sia, cardiovascular compromise,worsening renal dysfunction, orstroke. Risks to the fetus includepreterm birth, IUGR, and fetaldemise. Poor control of bloodpressure prior to pregnancy ishighly correlated with poor peri-natal outcomes.

Preconception counselingshould focus on dietary changesand weight loss and shouldinclude discussion of the effectsof hypertension, any associatedend-organ damage, and hyper-tensive medications on a preg-nancy. For women who are earlyin pregnancy or considering apregnancy soon, there is insuffi-cient evidence to recommendtight control of blood pressure(<140/90) vs. less tight control(<160/100) in order to maintainadequate perfusion of the pla-centa during pregnancy. Forwomen whose blood pressurehas been tightly controlled priorto pregnancy, the more lenient

goal of 160/100 during preg -nancy may affect the dosing ofcurrent medications or allowdiscontinuation or withdrawal of some medications duringpregnancy.

The ACE inhibitor class ofantihypertensive medicationshas become increasingly popularas a first-line treatment forchronic hypertension, especiallywhen women have other comor-bid conditions such as diabetes.However, these medications arestrongly linked to several con-genital defects and fetal death,and they should be discontinuedin the event of pregnancy andshould be discouraged if awoman is considering gettingpregnant in the near future.Methyldopa has long been con-sidered the safest medicationduring pregnancy, but labetaloland nifedipine have been used

frequently for both inpatient andoutpatient control. While diu -retic therapy generally has beenavoided in order to avoid vol-ume depletion, data indicatethat women taking HCTZ priorto pregnancy did not have anyadverse effects from taking themedication during pregnancy aswell. However, Furosemideshould be avoided because ofassociations with birth defects.

Migraine headache

Migraine headaches generallyoccur less frequently duringpregnancy, and breastfeedingmay continue that decreasedrate of migraine exacerbation.About 80 percent of pregnantwomen with migraine will no -tice a decrease in the frequencyof their headaches. This patternis so predictable that an increasein the frequency of migraines

should potentially prompt aninvestigation of other conditionssuch as preeclampsia or other,rarer conditions.

Women who are already on prophylaxis with the beta-blocker propranolol or ribo-flavin may continue these med-ications, as they are consideredsafe during pregnancy. However,initiating or continuing the useof other chronic daily prophy-laxis (e.g., topamax) should beavoi ded, as they are likelyunnecessary during pregnancy.Inter mittent treatment withbiofeedback or other behavioraltechniques may be useful.

If intermittent pharmacolog-ical treatment is preferred, thereare several options for abortivetreatments. Opioids are safe andeffective, though short-actingforms are preferable (e.g.,Tylenol with codeine or hydro-codone). Oral serotonin receptoragonists (triptans) are very effec-tive for acute treatment ofmigraine, and accumulated datain the pregnancy registry sug-gests they are safe during preg-


PREGNANCY to page 36

Pregnancy from page 29 Incorporating care and input from psychotherapy, nutrition, and Pharm D, in

addition to medical care, can promote ahealthy pregnancy environment for patients.

Excellent benefits package including Paid Malpractice and Tail CoverageCompetitive compensation and generous incentive

For more information, contact:Mary Jo Burkman, Physician Placement AssociateSanford Health(605)328-6996 or (866)[email protected]

Sanford Health is the largest not for profit rural integrated health care system with over 1200 primary and specialty care physicians in over 140 clinic locations. The following communities are looking for BE/BC Family Medicine Physicians:

Aberdeen, SD:• Large newer clinic attached to brand new

48-bed hospital• Current call 1:7• OB is optional• Numerous onsite hospital services• Specialty physicians include

Anesthesiologists, General Surgeons, and Interventional Cardiologists

• Population over 25,000• SD has no state income tax

Windom, MN:• Current call is 1:7 for admits only and

shared with community physicians• OB is a must

• Population over 4,300• MN Medical school loan repayment

available• J1 physicians may apply

Worthington, MN:• Medical staff of primary care and

some specialists• Current call 1:4• Population over 10,000, service area

35,000• City is 200 miles Southwest of

Minneapolis/St. Paul• MN Medical school loan repayment

available

Visit: www.practice.sanfordhealth.org

Dedicated to the work ofhealth and healing


Urgent Care

We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We will be opening a new Urgent Care clinic in Hugo, MN in the spring of 2013! Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact [email protected] or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

hea l thpa r tne r s . com

Spine Surgeons, join our team and set thestandards for patient care.Orthopaedic Associates of Duluth is seeking a highly motivated

passionate and experienced SPINE SURGEON to provide

outstanding orthopaedic care to its patients. The successful candidate

will be part of our expanding and growing, well-respected team that

serves patients from Duluth to northern Minnesota.

Orthopaedic Associates of Duluth is a group of nine orthopaedic

surgeons that provide comprehensive orthopaedic services ranging

from specialty specific exams and diagnosis to state-of-the-art in-

office MRI and imaging and surgery at their physician-owned surgery

center.

Email CV to [email protected] call 800-461-8843 (Sue) or 218-625-2731 (June)

AIRFORCE.COM/HEALTHCARE

© Paid for by the U.S. Air Force. All rights reserved.

Family PracticeUrgent Care

NEW POSITIONS:

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

• Partnership opportunity after 2 years

• Competitive salary with incentives

• Excellent benefits, 401k/employer paid pension

• Practice at one site/one hospital

• Physician-owned

Please contact or fax CV to:Joel Sagedahl, M.D.

5700 Bottineau Blvd., Crystal, MN 55429763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

anemia after receiving cellularblood products. Suspected trans-fusion-associated cases shouldbe reported promptly to associ-ated blood banks and MDH.Human anaplasmosis andhuman ehrlichiosis Although infections of humananaplasmosis and several formsof human ehrlichiosis share sim-ilar clinical presentations, taxo-nomic changes in disease classi-fication have led to frequentmisuse of the two terms. Ende-mic to Minnesota, HA is trans-mitted by I. scapularis and leadsto the infection of granulocytesby the bacteria Anaplasmaphagocytophilum. In contrast,Ehrlichia chaffeensis, endemic tosouthern states and not typicallyobserved in Minnesota, is trans-mitted by Amblyomma ameri-canum (Lone Star tick) andresults in infection of mono-cytes. The newly identifiedEhrlichia muris-like agent istransmitted by I. scapularis andcauses a clinical syndrome simi-lar to that seen in cases of HAand other human ehrlichioses.

With an incubation period of3–21 days, most HA and HEpatients will present with anacute onset of high fever, chills,headache, myalgias, leukopenia,thrombocytopenia, and/or elevat-ed aminotransminases. Sympto-matic infections are more fre-quently observed in adults thanin children. Due to sero logiccross-reactivity, assays for bothAnaplasma and Ehrlichia shouldbe ordered when infection witheither agent is sus pected.Though less frequently used,PCR has greater sensitivity andspecificity than available anti-body tests and identifies thespecies of Anaplasma orEhrlichia present. Peripheralblood smears for Anaplasma mayalso be performed, but sensitivityis low. Regardless of testingmodality, patients with symp-toms consistent with HA or HE

should be treated empiri callywhile results are pending.

As with babesiosis, transfu-sion-associated cases of anaplas-mosis have been documented inMinnesota and should be con-sidered in patients who developa fever and thrombocytopeniapost-transfusion.Powassan diseasePowassan virus, a tickborne flavivirus transmitted by I. scapularis and related to WestNile virus, can cause severe neuroinvasive disease and death.Twenty-one cases, including onefatality, were identified in Minnesota residents in the years2008–2012. Although most iden-tified POW cases to date nation-wide have had encephalitis ormeningitis, POW virus can alsocause an acute febrile illnesswithout neurologic involvement,and many infections are likely

subclinical. The incubation per -iod is 3–21 days. No antiviralsare approved for treatment ofPOW virus; clinical managementusually involves supportive careand rehabilitation for patientswith neurologic involvement.

Serum or CSF specimensfrom patients with central nerv-ous system disease can be sub-mitted to the MDH PublicHealth Laboratory for arboviraldisease testing, including POWvirus. No commercial laborato-ries currently offer serologictesting for POW virus. Rocky Mountain spotted fever Rocky Mountain spotted feverresults from infection withRickettsia rickettsii and is themost widespread rickettsial disease in the United States.Though rare in Minnesota, 2–11 cases have recently beenre ported each year, many withlikely in-state exposure; the firstconfirmed RMSF fatality in thestate was documented in 2009.Signs and symptoms commonlypresent 2–14 days after exposureand include fever, headache,maculopapular or petechial


TICKBORNE to page 34

Tickborne from page 27

Fairview Health ServicesOpportunities to fit your life

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. Shape your practice to fit your life as a part of our nationally recognized, patient-centered, evidence-based care team.Whether your focus is work-life balance or participating in clinical quality initiatives, we have an opportunity that is right for you:

Dermatology

e

fairview.org/physicians

[email protected], no J1 opportunities.

fairview.org/physicians

Additional information

• For information on the clinical assessment, treatment, and preventionof Lyme disease, anaplasmosis, and babesiosis, refer to the IDSA’sclinical practice guidelines at: www.idsociety.org/Lyme/

• For information about ehrlichiosis and RMSF: www.cdc.gov/ticks/diseases/index.html

• For more information about tick-transmitted diseases in Minnesota:www.health.state.mn.us/divs/idepc/dtopics/tickborne/index.html

THE STRENGTH TO HEAL

Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference.

© 2010. Paid for by the United States Army. All rights reserved.

and stand by those who stand up for me.


Avera Marshall Regional Medical Center300 S. Bruce St.Marshall, MN 56258

www.averamarshall.org

Physician Practice OpportunitiesAvera Marshall Regional Medical Center is part of the Avera systemof care. Avera encompasses 300 locations in 97 communities in afive-state region. The Avera brand represents system strength andlocal presence, compassionate care and a Christian mission, clini-cal excellence, technological sophistication, an array of specialtycare and industry leadership.

Currently we are seeking to add the following specialists:

General Surgery

Orthopedic Surgery

Radiology/Oncology

Internal Medicine

Psychiatry

Pediatrics

Obstetrics/Gynecology

Family Practice

Emergency Medicine

Ophthalmology

Optometry

For details on these practice opportunities go tohttp://www.avera.org/marshall/physicians/

For more information, contact Dave Dertien,Physician Recruiter, at [email protected]

Family Med/ER Physicians

Small Town, Big Impact!

We’re recruiting Family Med physicians with Emergency Room experience for our full-time practice in the western Wisconsin community of Amery. Utilizing a team of fi ve dedicated FM/ER physicians, Amery Regional Medical Center’s ER has an annual volume of 6,000 and provides backup to ARMC’s 12,000 visits/year Urgent Care unit. Our FM/ER physicians work 32 hours per week in a block schedule of 12-hour (weekday) and 24-hour (weekend) shifts.

BC/BE Family Med physicians with ER experience and an interest in pursuing alternative EM board certifi cation are preferred; ABEM-certifi ed EM physicians are also welcome to apply. You must have or be eligible for WI medical licensure.

Nestled near the WI/MN border, Amery offers abundant outdoor recreation, affordable housing and excellent schools — all just 60 minutes east of Minneapolis/St. Paul, MN.

As part of the HealthPartners Medical Group,our Amery FM/ER physicians receive a competitive comp and benefi ts package, paid malpractice coverage and the security of being part of a successful multi-specialty medical group.

Apply online at healthpartners.jobs or email your CV and cover letter to sandy.j.lachman@ healthpartners.com. EO Employer

h e a l t h p a r t n e r s . c o m

Orthopaedic Surgery

OpportunityLive in Beautiful

Minnesota Resort Community

An immediate opportunity is avail-able for a BC/BE orthopedic surgeon in Bemidji, MN. Join threeboard certified orthopedic surgeonsin this beautiful lakes community.Enjoy practicing in a new Orthopedic& Sport Medicine Center, openingspring 2013 and serving a region of100,000.

Live and work in a community thatoffers exceptional schools, a stateuniversity with NCAA Division Ihockey and community symphonyand orchestra. With over 500 milesof trails and 400 surrounding lakes,this active community was ranked a “Top Town” by Outdoor LifeMagazine. Enjoy a fulfilling lifestyleand rewarding career. To learn more about this excellent practiceopportunity contact:

Celia Beck, Physician RecruiterPhone: (218) 333-5056Fax: (218) 333-5360Email: [email protected]

AA/EOE - Not subject to H1B Caps

www.lrhc.org

Practice Well. Live Well.Lake Region Healthcare is located in a magnificent, rural,and family-friendly setting in Minnesota lakes countrywhere we aim to be the state’s preeminent regional healthcare partner.

Our award winning patient care and uncommon medicalspecialties set us apart from other regional health caregroups. Lake Region’s physicians and their families alsoenjoy an unmatched quality of professional and personal life.

Current opportunities including competitive salary andbenefit packages available for BE/BC physicians are:

• Dermatologist• Family Medicine• Emergency Medicine• Internal Medicine

• Orthopedic Surgeon• Pediatrics• Psychiatrist• Psychiatric NP or PA

712 Cascade St. S., Fergus Falls, MN736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

For more information contactBarb Miller, Physician [email protected] • (218) 736-8227

rash, myalgias, nausea and vom-iting, and/or thrombocytopenia.In 80 percent of cases, a rashappears 2–5 days after feveronset; however, the rash may beatypical in appearance or absentaltogether. As a result, patientspresenting with a combinationof fever, thrombocytopenia, andexposure to tick vectors shouldprompt consideration of RMSFand empiric treatment of sus-pected cases.

Diagnostic tests for RMSFinclude PCR or immunohisto-chemistry on skin biopsies fromrashes. Because R. rickettsii doesnot widely circulate in theblood, except in the most severestage of infection, PCR testingon whole blood is not usuallyrecommended. Serologic testingby IFA can be used but may benegative within 7–10 days ofsymptom onset. In certain cases,MDH will work with providersto arrange for additional testing,including culture, through CDC.

PreventionMDH recommends personalprotective measures, including

tick repellents, for anyone whospends time in tick habitatsanywhere in the state. Whiletick checks are an importantcomponent of prevention, eventhe most careful checks mightmiss ticks, and the duration oftick attachment to transmit theagents of some TBDs is shortenough (e.g., 15 minutes or lessfor POW virus; 12 hours for HA,HE, and babesiosis vs. 1–2 daysfor LD) that late-day tick checksmight take place after transmis-sion has occurred. Repellentscontaining DEET (up to 30 per-cent), which is sprayed on clo-thing or skin, or permethrin,which is pre-applied to clothingand lasts through multiplewearings and washings, are recommended.

During physicals and otherhealth care visits, medicalproviders should discuss TBD

risk and prevention withpatients who live, work, orspend time in endemic areas.Patients should be counseledthat although I. scapularis isresponsible for most transmis-sion of TBDs in Minnesota, riskof RMSF infection from D. vari-abilis also exists. TBD risk ishighest from May through mid-July, although disease transmis-sion is possible during anywarm month. Providers shouldinform patients of non-LD TBDrisk; any acute febrile illnessoccurring within one month ofexposure to tick habitat, evenwithout known tick bites, maybe suggestive of a TBD.

Certain aspects of LD diagnosis and treatment may be confusing to some patients,particularly in regard to the resolution of symptoms and/orpersistence of antibodies post-

treatment; misinformation about“chronic” LD or co-infectionshas been widely disseminated.When treating TBDs, providersshould take the opportunity todiscuss antibody testing, diag-nostic challenges (e.g., whethertreatment is empiric or sup -ported by laboratory evidence),and balancing risks and benefitsof antibiotic therapy withpatients.

All TBDs are reportable inMinnesota. Reports to MDHshould include demographic,clinical, and laboratory informa-tion. Providers are also encour-aged to contact MDH for diagnostic assistance with sus-pected cases of POW or RMSF.

Additional informationabout tickborne diseases is avail-able at the websites listed in thesidebar on page 32.

Hannah G. Friedlander, MPH;Elizabeth K. Schiffman, MA; andDavid F. Neitzel, MS, work in theMinnesota Department of Health Divisionof Infectious Disease Epidemiology,Prevention and Control.


Tickborne from page 32 During physicals and other health care visits, medical providers should discuss

TBD risk and prevention with patients wholive, work, or spend time in endemic areas.

Applicants can apply online atwww.USAJOBS.gov

Sioux Falls VA Health Care SystemWorking 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.

Sioux Falls VA HCS, SD

Sioux Falls VA HCS(605) 333-6858

www.siouxfalls.va.gov

Chief of Primary

& Specialty Medicine

Psychiatrist

Hospitalist

Podiatrist

Cardiologist

Neurologist

Endocrinology

Emergency Medicine

Primary Care (Internal

Medicine or Family Practice)

Here to care

At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 11 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.

Make a difference. Join our award-winning team.Madalyn Dosch, Physician Recruitment ServicesToll-free: 1-800-248-4921 Fax: 612-262-4163 [email protected] allinahealth.org/careersEOE/AA10127 0213 ©2013 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM


Emergency Medicine

Hibbing

Little Falls Park Rapids Alexandria Austin

For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:[email protected] or visit our website at www.epamidwest.com

Your Emergency Practice Partner

Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:

Emergency Room Physicians

Looking for leisure work hours?

• Immediate openings

• Casual weekend or eveningshift coverage

• Choose from 12 or 24 hourshifts

• Competitive rates• Paid malpractice

Attention Physicians

763-682-5906 • 1-800-876-7171

F-763-684-0243

[email protected]

• Set your own hours

• No contract

• No obligations

Great Emergency Department in Southern Minnesota

www.olmstedmedicalcenter.org

Olmsted Medical Center, a 150-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 comprehensivebenefit package.

EOE

Opportunities available in the following specialties:

DermatologySoutheast Clinic

Family MedicineCannon Falls Clinic

and Pine Island Clinic

HospitalistRochester Hospital

Internal MedicineSoutheast Clinic

Send CV to:Olmsted Medical Center

Administration/Clinician Recruitment102 Elton Hills Drive NW

Rochester, MN 55901email: [email protected]

Phone: 507.529.6748Fax: 507.529.6622

The perfect matchof career and lifestyle.

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

For additional information, please contact:

Kari Bredberg, Physician [email protected], (320) 231-6366

Julayne Mayer, Physician [email protected], (320) 231-5052

www.acmc.com

• ENT• Family Medicine• Geriatrician/Outpatient

Internal Medicine• Hospitalist• Infectious Disease

• Internal Medicine• Med/Peds Hospitalist• OB/GYN• Oncology• Orthopedic Surgery• Psychiatry

• Psychology• Pediatrics• Pulmonary/

Critical Care• Radiation Oncology• Rheumatology

nancy. Sumatriptan in particularhas the most evidence support-ing safety. Several antiemeticshave noted safety: For example,ondansetron carries a pregnancycategory B rating; and prochlor-operazine, while rated CategoryC, has received safer ratings inTERIS, a computerized databasedesigned to assess teratogeniceffects of medications and pro-vide guidance to medicalproviders. Other options duringpregnancy include daily supple-mentation with vitamin B6and/or the intermittent use ofdoxylamine or hydroxyzine.

Other medical conditions

Thyroid disease is the secondmost common endocrine disor-der affecting women of repro-ductive age. When untreated,both hyperthyroidism andhypothyroidism have beenlinked to pregnancy complica-tions. For hyperthyroidism,propylthiouracil is the preferredtreatment during pregnancy. Forhypothyroidism, levothyroxinedoses may need to be adjusted

during the pregnancy, as manywomen will require nearly a 50 percent increase in thedosage over the course of thegestation. It is recommendedthat the TSH be checked everytrimester in order to assesswhether adjustments are needed.

Hyperlipidemia is a cardio-vascular risk in patients withdiabetes and those with otherknown disease. Treatment forthis condition should beapproached with some cautionin reproductive-age women.Statins carry a pregnancy cate-gory X and are contraindicatedin pregnancy. Although terato-genicity is most likely to occurin later stages of pregnancy, it isbest to discontinue statins med-ications as soon as possible. Theissue may be addressed in pre-conception planning by consid-ering alternative drug therapysuch as niacin, or by focusing onlifestyle changes if the woman isactively trying to become preg-nant. Benefit from statin therapyshould be considered a long-term gain, and interruption ofthis therapy due to pregnancymay be a minor loss compared

to the overall gain.Women with seizure disor-

ders are at risk for complicationsduring pregnancy if theirseizures are not well controlled.However, many seizure medi -cations have been linked to congenital defects. It is recom-mended that these patients beon the fewest medications andat the lowest dose possible toprovide seizure control prior toconceiving. Close consultationwith the patient’s neurologistmay be warranted to achievethis goal.

Keys to improved reproductive health

Increasing preconception healthoverall can result in improvedreproductive health outcomes.For physicians who treat womenof reproductive age: • Consider developing a repro-

ductive health plan for allwomen of reproductive agewith chronic medical condi-tions and incorporate repro-ductive health discussions intoroutine visits.

• Be aware of common medica-tions that are contraindicated

in pregnancy not only when awoman is pregnant, but alsofor women who may becomepregnant during the course oftheir therapy.

• Weigh the risks of no treat-ment vs. treatment whenassessing a pregnant womanwith acute illness or exacerba-tion of chronic illness.

• Embrace a team-basedapproach to the care of preg-nant women with chronic con-ditions. Incorporating care andinput from psychotherapy,nutrition, and Pharm D, inaddition to medical care, canpromote a healthy pregnancyenvironment for patients.

Nicole Chaisson, MD, MPH, is a family medicine physician with UMPhysicians at Smiley’s Clinic and an assistant professor in the Department of Family and Community Health at theUniversity of Minnesota Medical School.Chrystian Pereira, PharmD, is a clinical pharmacist at Smiley’s Clinic, andis an assistant professor in the Universityof Minnesota College of Pharmacy.


Pregnancy from page 30

Shar GrigsbyHealth Center - East

20 Burdick Expressway Minot ND 58702

Ph: (800) 598-1205, Ext 7860 Pager #0318

Email: [email protected]

For immediate confidential consideration, or to learn more, please contact

www.trinityhealth.org

Physicians are offered a generous guaranteed base salary. Benefits also include a health and dental plan, life and disability insurance, 401(k), 401(a), paid vacation, continuing medical education allowance and relocation assistance.

Ambulatory Internal MedicineGeneral Surgery

PsychiatryUrology

Trinity Health One of the region’s premier healthcare providers.

Based in Minot, the trade center for Northern and Western North Dakota, Trinity Health offers the opportunity to work within a dramatically growing community that offers more than just a high quality of life.

Comprised of a network of nearly 200 physicians in hospitals, clinics and nursing homes, Trinity Health hosts a Level II Trauma Center, Critical Care Helicopter Ambulance, Rehab Center, Open Heart and Lung Program, Joint Replacement Center and Cancer Care Center.

Currently Seeking BC/BE

Contact us for a complete list of openings.


St. Cloud VA Health Care System

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

Associate Director, Primary & Specialty Medicine (IM)

Dermatologist

ENT

Geriatrician/Hospice/Palliative Care

Internal Medicine/Family Practice

Medical Director, Extended Care & Rehab (Geriatrics)

Orthopedic Surgeon

Pain Specialist

Psychiatrist

Urgent Care Physician (IM/FP/ER)

Applicants must be BE/BC. Since 1924, the St. Cloud VA Health Care System has delivered excellence in health care and compassionate service to central Minnesota Veterans in an inviting and welcoming environment close to home. We serve over 38,000 Veterans per year at the medical center in St. Cloud, and at three Community Based Outpatient Clinics located in Alexandria, Brainerd, and Montevideo.

Located sixty-five miles northwest of the twin cities of Minneapolis and St. Paul, the City of St. Cloud and adjoining communities have a population of more than 100,000 people. The area is one of the fastest growing areas in Minnesota, and serves as the regional center for education and medicine.

Enjoy a superb quality of life here—nearly 100 area parks; sparkling lakes; the Mississippi River; friendly, safe cities and neighborhoods; hundreds of restaurants and shops; a vibrant and thriving medical community; a wide variety of recreational, cultural and educational opportunities; a refreshing four-season climate; a reasonable cost of living; and a robust regional economy!

Our Community

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] Human Resources

4801 Veterans Drive St. Cloud, MN 56303

(320) 255-6301 EEO Employer

Opportunity Announcement

front-end claim rejections iscompletely avoidable. Thisgroup of errors relates to theprovider information submittedon the claim. Incorrect, missing,or redundant informationaccounts for nearly 23 percentof claims rejections. Our staffsees claims with missing billingoffice employer identificationnumbers (EIN), missing billingNPI (National Provider Identi-fier) numbers, and incompleteaddress information. This is theinformation about your office,submitted by your office; yourbilling staff needs to get it right.

That said, there are somepitfalls related to addressesentered on claims forms. • One of the most significant

changes in the HIPAA ANSIX12 837 format (version 5010)is the ZIP+4 requirement—meaning that a nine-digit ZIPcode is required for both thebilling office information andthe outside service address. On the claim form, “outsideservice address” refers to alocation where providers per-form services that are not ren-

dered at the same location astheir billing office location.

• ZIP+4 is not required in theoptional “pay-to” address andis not a requirement for thepatient or subscriber address.

• Importantly, if the billingoffice supplies address infor-mation that is redundant, thatis a reason for the payer toreject the claim. So if the outside service address is thesame as the billing officeaddress, or if the optional pay-to address is the same as thebilling office address, you maynot submit that information—or the claim can be rejected.Though some payers have chosen not to enforce theredundant address restriction,they are in the minority and,in the end, complicate theissue by not adhering to theclaim standard.

Other issues affecting billing procedures

Over the past 10 years, improve-ments in technology and stan-dardized transactions havechanged the way we do businessin health care. Yet, though com-

puters are faster and data trans-mission is faster, we have notmanaged to solve the basic prob-lem of getting doctors paid forthe services they provide. Inpart, this is because the billingsystems used by providers havenot kept up with the times.Work with your claim submis-sion partner to make sure yourcomputers and software applica-tions are up to the task of meet-ing complex and changingindustry standards for claimssubmission and processing.

On the staffing and servicesside, choose a claim-submissionpartner with a proven trackrecord that will work with youand your staff on the issues dis-cussed above; and make trainingof data entry and billing staff apriority. Having the right staff inyour office and supporting yourbilling procedures will go a longway toward easing the inherentchallenges of submitting claims.

Benefits for staff, patients, and the bottom line

Roughly 90 percent of the healthcare claims that are rejected arewithin the control of you andyour staff.

To minimize errors on yourend:• Ensure that your office data is

correct and compliant. • Verify the patient’s eligibility

and update your system’s dataso it reflects the payer’s demo-graphic data for the patient.

• Use correct diagnosis and pro-cedure coding.

• Staff your claims processingdepartment with accurate andefficient workers, and trainthem well.

• Choose a skilled, experiencedclaims submission partner.

Accomplishing these objec-tives will yield multiple benefits.Your dedicated claim processingstaff will have time to focus on the real claim issues. Yourpatients will be happier becausethey will receive fewer state-ments from your office andfewer “explanation of benefits”forms from their payer(s). Andyou will see your revenueincrease—and your accountsreceivable decrease.

Russel Campbell is president and CEO of ClaimLynx, Inc., based inPlymouth, Minn.


Claims from page 15

continuing education

Education and research to improve the health of our community HealthPartnersInstitute.org

Fundamental Critical Care Support July 18-19, 2013

Simulation Facilitator Course August 20-22, 2013

Trauma Education: The Next Generation* * Formerly Emergency Medicine and Trauma Update: Beyond the Golden Hour September 5, 2013

Managing Life Limiting Illness and End of Life Care (two-day event) October 1 and October 3, 2013

Primary Care Update: Pathways to Knowledge October 10-11, 2013

Fundamental Critical Care Support October 24-25, 2013

Simulation Facilitator Course November 6-8, 2013

Pediatric Fundamental Critical Care Support November 14-15, 2013

35th Annual Cardiovascular Conference: Current Concepts and Advancements in Cardiovascular Disease December 12-13, 2013

“Let’s Keep this Confidential”Finally, you can text and email your peers with the highest level of hipAA security

required. that’s the power of NoticeMed. the only peer-to-peer messaging network exclusively for health professionals’ day-to-day patient care collaboration.

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learn more and sign up at www.noticemed.com

for more information, Call toll-free 855-884-5952

It’s time to see beneath the surface.

September 8–10, 2013

http://www.mayo.edu/transform/

At MMIC, we believe patients get the best care when their doctors feel calm and confi dent. So we put our energy into creating risk solutions designed to eliminate worry. Solutions such as medical liability insurance, physician well-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.

Relax.Discover solutions thatput you at ease.

minnesota physician may 2013

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