Minnesota Health care News August 2013 by Minnesota Physician Publishing

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August 2013 â&#x20AC;˘ Volume 11 Number 8

GERD Benjamin Mitlyng, MD

Gambling addiction Catherine Perrault, MBC

Choosing Wisely Tim Hernandez, MD

Eating disorders are complex, and itâ&#x20AC;&#x2122;s not always obvious if and when to seek help. If you think you or someone you care about may be struggling with an eating disorder, the experts at Melrose Center can help you find answers.

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CONTENTS

5 6 8

AUGUST 2013 • Volume 11 Number 8

PEOPLE

PERSPECTIVE Samuel Moose, MTAG

CALENDAR Mental Health First Aid

HEALTH CARE ROUNDTABLE Patient Engagement

TAKE CARE Choosing wisely

INSURANCE Affording long-term care

10 QUESTIONS Candace S. Simerson, COE, CMPE Minnesota Eye Consultants, PA

MINNESOTA HEALTH CARE ROUNDTABLE

Catherine Perrault, MBC

NEWS

Mille Lacs Band of Ojibwe

BEHAVIORAL HEALTH Gambling addiction

DIGESTIVE HEALTH GERD Benjamin Mitlyng, MD

OPHTHALMOLOGY Retinal tears

Tim Hernandez, MD, Kris Soegaard, and Howard Epstein, MD, FHM

Michele Kimball

Polly Quiram, MD, PhD

FORTIETH

SESSION

Advance care planning Addressing end-of-life issues Thursday, October 24, 2013 1:00 – 4:00 PM • Symphony Ballroom Downtown Mpls. Hilton and Towers

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, and more. Advances in technology are extending life expectancies and require a redefinition of the term “end-of-life.” It now entails a longer time frame than one’s final weeks or hours, and provokes debate as to when life is really over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Objectives: We will discuss the significant infrastructure that supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontology, and hospice. We will review the elements that go into creating advanced directives, including societal issues that make having them necessary, and the difficulties encountered 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 improved in the future. Panelists include:

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Ed Ratner, MD, University of Minnesota Center for Bioethics Suzanne M. Scheller, Esq., Scheller Legal Solutions, LLC

PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com

Cheryl Stephens, PhD, MBA, President, CEO, Community Health Information Collaborative Tomás Valdivia, MD, MS, CEO, Luminat Sponsors: Community Health Information Collaborative Luminat • Scheller Legal Solutions

ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Amanda Marlow amarlow@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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AUGUST 2013 MINNESOTA HEALTH CARE NEWS

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MINNESOTA HEALTH CARE NEWS AUGUST 2013

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PEOPLE Gunda Georg, PhD, professor and head of the Department of Medicinal Chemistry at the University of Minnesota, has received the Volwiler Research Achievement Award for 2013, chosen by her peers for outstanding contributions to the field and awarded by the American Association of Colleges of Pharmacy. Georg co-invented Lusedra, a commercial anesthetic; Gamendazole, Gunda Georg, PhD

a male contraceptive agent in preclinical develop-

ment; and Minnelide, awaiting FDA approval for use in clinical trials against pancreatic cancer as this issue went to press. Georg directs the Institute for Therapeutics Discovery and Development at the university. Paul Gigante, MD, a neurosurgeon who specializes in movement disorders, has joined Central Minnesota Neurosciences in St. Cloud, a private practice with privileges at St. Cloud Hospital, part of the CentraCare health system. Gigante graduated from Harvard Medical School and completed a neurological surgery residency at Columbia University. Adnan Qureshi, MD, has joined St. Cloud-based CentraCare as chair of cerebrovascular diseases and interventional neurology for CentraCare Health. Qureshi, an interventional neurologist, earned his medical degree from Quaid-e-Azam University, Islamabad, Pakistan. He completed a neurology residency at Emory University School of Medicine, Atlanta; a neurocritical care fellowship at Johns Hopkins Hospital, Baltimore; and an endovascular neurosurgery fellowship at State University of New York, Buffalo. Previously, he was the associate head of neurology at the University of Minnesota Medical School. Barbara N. Malone, MD, a board-certified otolaryngologist, has joined

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Children’s ENT and Facial Plastic Surgery, part of Children’s Hospitals and Clinics of Minnesota. Malone earned her medical degree from the University of Michigan, Ann Arbor; completed a residency in otolaryn-

When it comes to your child, getting help early is your priority.

gology at the University of Minnesota; and completed a fellowship in pediatric otolaryngology at Children’s Hospital of Michigan, Detroit. Malone will practice at both the Minneapolis and St. Paul campuses, each of which has full-service ENT clinics. She has served at Children’s for nearly 25 years. Thomas Scott, MD, has been awarded the 2013 Distinguished Service Award by the Minnesota

Barbara N. Malone, MD

Chapter of the American Academy of Pediatrics. Scott, a clinical professor and interim residency director for the Developmental-Behavioral Pediatrics Program in the Department of Pediatrics at the University of Minnesota, has a long history of program development to support children, teens, and their families. He currently serves on

It’s ours too.

the Minnesota Governor’s Task Force on the Prevention of School Bullying. Michael Harold Wall, MD, FCCM, will become Michael Harold Wall, MD, FCCM

head of the Department of Anesthesiology at the University of Minnesota in late summer 2013.

Wall is currently chief of clinical anesthesiology at Barnes-Jewish Hospital, and a professor of anesthesiology and cardiothoracic surgery at Washington University, in St. Louis. He earned his medical degree from Dartmouth Medical School; completed an anesthesiology residency and a cardiothoracic anesthesia fellowship at the University of Washington in Seattle; and completed a critical care medicine fellow-

Our Pediatric Therapies partner with families to help children gain skills and improve functioning through: s Occupational Therapy s Speech and Language Therapy s Feeding Therapy s Music Therapy

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ship at Stanford University. AUGUST 2013 MINNESOTA HEALTH CARE NEWS

NEWS

HMO Reserves Exceed $1.9 Billion Minnesota HMOs continue to amass large cash reserves, a new study shows, as premium revenues continue to outpace medical spending. Analyst Allan Baumgarten’s twice-yearly report on Minnesota’s health care marketplace focuses on insurers in its latest release (Part 1, Minnesota Health Market Review 2013). According to his data, Minnesota’s nonprofit HMOs have added $769 million to their reserves since 2008 and have $1.3 billion more than the amount required by law. State health plans had an overall net income of $241 million in 2012. HMOs are required by law to maintain financial reserves to protect the companies and their enrollees. However, Baumgarten has tracked increasingly higher reserves by Minnesota plans, and his latest report finds that plans in the state now have more than $1.9 billion in reserves. That

would allow HMOs to pay 3.2 months in claims with no additional income, up from 2.4 months in 2009. Minnesota Council of Health Plans executive director Julie Brunner responded to the study with a statement saying that the minimum level of reserves set by the state is inadequate and that much of the health-plan reserves are on paper only. “State contracts with HMOs allow the state to delay, withhold, and shift payments due to the plans,” she says. “For the HMOs this year, it’s nearly $1 billion in costs they have to cover until the state pays the money owed.” Baumgarten does not disagree that such issues exist, but questions the size of the reserves nonetheless. “If you say to me health plans need adequate reserves, great—but I think we need to have a discussion of what constitutes adequate,” he says.

Don’t Suffer Alone

Volunteers Sought For Diabetes Study Volunteers are being sought for a study on the long-term benefits and risk of four diabetes drugs that are used in combination with metformin, the most common first-line drug for the disease. The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) Study looks at drugs that are used in combination with metformin, if that drug alone is not enough to manage a person’s type 2 diabetes. “While metformin is the standard first-line medication for diabetes, it has not been as clear which second-line medication is most effective with metformin,” says John Misa, MD, chief of primary care, Park Nicollet Clinic, and co-investigator at the site. “Through this large, long-term study, we will learn which medications work best with metformin, improving our care for all patients with type 2 diabetes.”

The study will compare drug effects on glucose levels, adverse effects, diabetes complications, and quality of life over an average of nearly five years. GRADE aims to enroll about 5,000 patients nationally. Investigators at the Minnesota-based study sites and 35 other sites across the nation are seeking people diagnosed with type 2 diabetes within the last five years. More information about the study is available at https://grade.bsc.gwu.edu.

MNsure Outlines Plans for Customer Service MNsure, the state’s health insurance exchange, has announced plans to open a call center for the consumers and small businesses served by the exchange. April Todd-Malmlov, executive director of MNsure, says the call center will open Sept. 3 and will provide Minnesotans with a common “front door” by which to access the exchange. The cen-

Gambling Addiction Is Lonely

RecoveRy is Not

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MINNESOTA HEALTH CARE NEWS AUGUST 2013

ter will open a month before enrollment begins, and will operate from 7:30 a.m. to 8 p.m. Monday through Friday. The announcement is the latest step as the stateâ&#x20AC;&#x2122;s health insurance exchange continues to roll out features before enrollment officially begins in October. Todd-Malmlov says the MNsure call center will feature the latest customer-service best practices, including â&#x20AC;&#x153;warm transfersâ&#x20AC;? that ensure callers talk to a living person and donâ&#x20AC;&#x2122;t get stuck with automated responses. â&#x20AC;&#x153;When you have someone on the phone who has a question you canâ&#x20AC;&#x2122;t answer, the call center person will transfer from MNsure to an [insurance] carrierâ&#x20AC;&#x201D;to an actual live person,â&#x20AC;? Todd-Malmlov says. â&#x20AC;&#x153;Best practices include getting someone to a live person and not getting stuck in no-manâ&#x20AC;&#x2122;s land.â&#x20AC;? Insurance companies and government agencies often have a less than stellar reputation for customer service. But the exchange will work to overcome that perception, according to Todd-Malmlov. â&#x20AC;&#x153;I think the proof is in the pudding; weâ&#x20AC;&#x2122;re opening the call center early because we know people will have questions.â&#x20AC;? She adds that early feedback will give MNsure time to address any initial problems. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re gearing ourselves to provide the best customer feedback we can,â&#x20AC;? ToddMalmlov says. â&#x20AC;&#x153;I think customers will be pleased.â&#x20AC;?

Mayo Researchers: Devices Need Not Affect Sleep Patterns Reading your iPad at night in bed doesnâ&#x20AC;&#x2122;t have to affect your sleep patterns, researchers with Mayo Clinic reported recently. At the annual meeting of Associated Professional Sleep Societies in Baltimore, Mayo researchers presented a study examining how light from the screen of a smartphone, tablet, or other personal computing device could affect sleep. Sleep experts had questioned

whether the light-emitting diodes in mobile devices might interfere with melatonin, a hormone that helps control human sleep cycles. The Mayo researchers found that moderate or low settings of screen brightness and keeping the device at least 14 inches away helped prevent sleep problems. â&#x20AC;&#x153;In the old days people would go to bed and read a book. Well, much more commonly people go to bed and they have their tablet, on which they read a book or newspaper â&#x20AC;Ś The problem is, itâ&#x20AC;&#x2122;s a lit device, and how problematic is the light source from the mobile device?â&#x20AC;? says co-author Lois Krahn, MD, a psychiatrist and sleep expert with Mayo Clinic. â&#x20AC;&#x153;We found that only at the highest setting was the light over a conservative threshold that might affect melatonin levels.â&#x20AC;?

ACA Will Increase Medicaid Enrollment, U of M Says A study from the University of Minnesota says that implementation of the Affordable Care Act (ACA) could result in a significant increase in enrollment for public health programs such as Medicaid and MinnesotaCare. The study looks at a common problem for states: A large number of people who qualify for public health insurance programs do not participate in them, for a variety of reasons. Considering the changes in health care policy brought about by the ACA, such as fewer barriers to enrollment, the â&#x20AC;&#x153;individual mandateâ&#x20AC;? requirement to have insurance coverage, and outreach efforts built into the reforms, researchers are trying to estimate how participation rates will change. In the U of M study, researchers looked at the case of Massachusetts, which implemented a health-care reform law in 2006 that is similar in many respects to the ACA. Researchers found that among low-income parents eligible for Medicaid in Massachusetts, enrollment

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News to page 9 AUGUST 2013 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Mille Lacs Band works to help members keep tobacco sacred Gego Zagaswaaken: Don’t smoke

raditional tobacco (Asemaa) is very important to Native People. Our tradition says it was given to the people by the Great Spirit, to be used with specific instructions. As instructed, Ojibwe peoples use Asemaa in ceremonies as a form of communication with the Great Spirit, and as an offering to those who are asked to pray or seek wisdom. Asemaa is also used as a way to honor the many gifts given to all living creatures on Earth.

Samuel Moose, MTAG Mille Lacs Band of Ojibwe

Samuel Moose, MTAG, (master’s degree in Tribal Administration and Governance, University of Minnesota–Duluth) has served as commissioner of health and human services for the Mille Lacs Band of Ojibwe for more than nine years. He oversees the Band’s three clinic locations and other services in the areas of public health, behavioral health, family services, and community support services. Previously, Moose served as the Band’s commissioner of community development and its director of housing. Moose is a community member of the Mille Lacs Band’s District 2 (McGregor area) and is an active participant in traditional activities in his community.

We were taught how to gather Asemaa from the earth, and what properties were essential in the processing of Asemaa. It was a powerful gift. It was never intended to be a habit, but rather, a resource to be used for cultural, spiritual, and ceremonial practices. Perhaps this, more than anything, separates Asemaa from commercial tobacco. Root of the problem

Advocating for change Gego Zagaswaaken is a program on the Mille Lacs Band of Ojibwe Reservation that aims to decrease commercial tobacco usage statistics and to improve overall community health through education and policy changes. The program is funded through a grant from ClearWay Minnesota. The Gego Zagaswaaken program helps Band members advocate for changes in smoking policy, such as encouraging the Band to consider making events smoke-free, including powwows and the State of the Band address. Gego Zagaswaaken also works with Band members to educate them about the dangers of secondhand smoke.

What’s unique about a smoking cessation program like Gego Zagaswaaken is that it differentiates between traditional and commercial tobacco. The program respects the cultural use of traditional tobacco—both pure Asemaa as well as Kinnikinnick, which is Five of the six leading Asemaa mixed with bark causes of death among stripped from the red willow—and encourages Native People in Minnesota Mille Lacs Band members are related to the use of to keep tobacco sacred.

Unfortunately, Native People’s gift of Asemaa has been commercialized into a billion-dollar industry. Over the years, the tobacco industry enhanced and chemically altered tobacco commercial tobacco. It is difficult for a Native to be more addictive. As community to reduce the more addictive comtobacco use, because ceremercial tobacco found in pipe tobacco and cigarettes grew in popularity, its monial use of traditional tobacco permeates our culture. However, the program’s long-term goal is use, and addiction, spread among Native People. Today, the convenience and use of commercial to see the Band become a community that is free tobacco products among the tribes has replaced of commercial tobacco. the traditional form of tobacco. A survey of Mille Lacs Band members has shown that as many as 48.4 percent of Band members use commercial tobacco on a daily basis, with 90.6 percent of respondents reporting they have used commercial tobacco at least once, and 20.3 percent reporting they smoked their first cigarette at age 12. Commercial tobacco and Native health According to research by the Great Lakes EpiCenter, a coalition of 12 tribes of Wisconsin and Upper Michigan based in Lac du Flambeau, Wis., five of the six leading causes of death among Native People in Minnesota—cancer, coronary heart disease, diabetes, stroke, and lower respiratory disease—are related to the use of commercial tobacco. Smoking-related illnesses are the most preventable causes of death. As a tribe, we recognized the need to help our people keep tobacco sacred by breaking the addiction to commercial tobacco products. That’s why, in 2007, we started the Gego Zagaswaaken (don’t smoke) program.

MINNESOTA HEALTH CARE NEWS AUGUST 2013

The Gego Zagaswaaken program has produced two DVDs that are used to provide education on the dangers of commercial tobacco and secondhand smoke. Both DVDs were filmed on the Mille Lacs Reservation and used Band members to deliver the messages. The program has produced policy changes within the Band’s Health and Human Service Department and an increase in the number of smoke-free events, including a smokefree tiny tots’ dance at our annual powwow. Ending addiction The Mille Lacs Band are a strong people, but nobody should have to face addiction alone. Together, through programs like Gego Zagaswaaken and by helping one another, we are working to end the commercial tobacco addiction that has become all too common among Native People. Editor’s note: More than 2,300 of the Band’s 4,300 members live on its reservation in east central Minnesota.

News from page 7 increased by 19.4 percent in comparison to other states, after the law was implemented. “It’s widely anticipated that the implementation of the ACA as a whole will have an impact on Medicaid participation of people who are currently eligible but who aren’t enrolled for some reason,” says Julie Sonier, MPA, a senior research fellow in the U of M School of Public Health and deputy director of the university’s State Health Access Data Assistance Center. “Because Massachusetts is the only state that has implemented reforms of similar scope and scale to what’s going to happen in the ACA, we looked to that example to see if we could quantify the effect of what happened to Medicaid participation.” In Minnesota, which has embraced the Medicaid expansion and the health insurance exchange concept, researchers predict results comparable to the Massachusetts case study.

State officials say the study fits with their expectation of a significant increase in enrollment in Medical Assistance (Minnesota’s version of Medicaid) and MinnesotaCare. “We’re projecting, for parents and children, about a 24 percent increase [in public program enrollment],” says Lucinda Jesson, commissioner of the Minnesota Department of Human Services. “Between the effect of the mandate and, more significantly, changes made by Legislature to make it easier to enroll and stay enrolled in public programs, we project over the next two years having about 200,000 more people enrolled, of the people who are already eligible today.”

Health Disparities Are Shrinking, DHS Report Says A new report on health care disparities in Minnesota finds that gaps in health care delivery are

shrinking, but officials say more improvements are needed. The sixth annual Health Care Disparities Report, published by the Minnesota Department of Human Services (DHS), brings together statewide data from providers tracked by MN Community Measurement. The report looks at data for patients in the managed care component of Medicaid programs, including Medical Assistance and MinnesotaCare. Minnesota public health officials say that the gap in care delivery between people covered by Medicaid and those who have commercial insurance is one of the state’s top health care issues. The new report finds that despite progress, gaps remain: 11 of 13 health care measurements being tracked show significantly lower outcomes for people covered by state programs, compared with those on private insurance. The report says the largest disparities are in optimal diabetes care, optimal vascular care, and colorectal

cancer screening. Even within the Medicaid population, disparities exist, officials say. For example, African Americans have a significantly lower rate for controlling blood pressure than the average rate for patients in state programs. But the report also shows steady improvement in addressing disparities. The report finds that disparities are being reduced in the areas of children’s asthma care, childhood immunizations, sore throat care, and cervical and breast cancer screening. “The progress made in asthma care and other areas is encouraging, but it also shows how critical it is to keep our focus on reducing health care disparities,” says Human Services Commissioner Lucinda Jesson. “This annual report gives us an important update on where we stand.”

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AUGUST 2013 MINNESOTA HEALTH CARE NEWS

10 QUESTIONS

Clinic administration Candace S. Simerson, COE, CMPE Ms. Simerson is president and COO (chief operating officer) of Minnesota Eye Consultants, PA, based in Bloomington. What kind of work does a clinic administrator do? A clinic administrator manages the business aspects of a medical practice. The clinic administrator is typically the primary liaison between the staff, physicians, and external resources, so it’s imperative to have strong communication skills. The essential skill set includes clinic operations, finance and accounting, information systems and technology, marketing, human resources, and customer service. The administrator also monitors risk management activities and compliance with regulatory requirements. These include compliance with billing and coding guidelines, chart documentation, adherence to federal and state regulations, patient privacy and data security, and reporting requirements. A clinical administrator also needs to keep an eye on marketplace changes. How does one become a clinic administrator? Clinic administrators generally have a degree in business administration or health care administration. In addition, health-care work experience can facilitate learning the practical aspects of the profession. Many times, someone will be promoted from within a clinic to the administrator’s role. Please tell us about the infrastructure needed to run a clinic. Clinics today must ensure that patients have a good experience. This typically starts with a phone call to the clinic, so the appointment scheduling staff must be pleasant, polite, and trained to schedule appointments, answer questions, and triage calls. Clinics invest in phone technology, scheduling software, and staff to facilitate scheduling of the appointment by type (emergency, annual physical, etc.) and by physician in addition to recording/updating all of a patient’s demographic information and insurance plan benefits. When a patient is seen at the clinic, the practice has invested in the facilities, equipment, and clinical staff to support the visit. Clinics also must constantly evaluate and invest in new equipment and software. Please tell us about Medical Group Management Association. Minnesota Medical Group Management Association (MMGMA) is a state chapter of the national organization Medical Group Management Association (MGMA). MMGMA supports medical practices and other organizations involved in delivering health care by providing networking opportunities for sharing best practices and ideas for improving practice operations. MMGMA also sponsors educational events for its members throughout the year to keep them apprised of new issues and trends. In addition, MMGMA is actively involved in lobbying state policy decisionmakers to ensure patients maintain access to care and to improve quality of care. Photo credit: Bruce Silcox

What are examples of legislative activities clinic administrators are involved with? It is vital for clinic administrators to be aware of health care policy and regulatory requirements. Ideally, a clinic administrator meets with her or his

MINNESOTA HEALTH CARE NEWS AUGUST 2013

state legislators at least annually to make them aware of concerns and issues from the clinic and patient perspective.

Clinics today must ensure that patients have a good experience.

Please tell us about the evolution of the profession. Over the years, the payment system for health care has become progressively more complex, with ever-changing rules and guidelines and increasing scrutiny by auditing agencies. Electronic software systems are replacing manual processes, so the clinic administrator must stay up to date about such tools. As a result of these changes, certification programs have evolved to validate administrators’ competency and expertise. MGMA members can earn certification as a medical practice executive (CMPE). Specialty organizations have created similar but more specialized programs. The American Society of Ophthalmic Executives, for example, offers a Certified Ophthalmic Executive credential (COE). Many clinics specifically seek these credentials when recruiting administrators. Do administrators play a role in hiring physicians? Frequently the administrator is the initial contact listed in recruitment ads, so the administrator must be well informed about the position opening, what it requires in terms of medical skill, and what opportunity it offers the applicant. The administrator must also identify that the applicant’s personality meshes with the medical practice and its patients. The administrator is typically involved in the interview process and may extend or negotiate an employment agreement.

What are ways administrators and physicians work together? Physicians and administrators must work together to manage the business and clinical functions of the clinic so that the practice is economically successful while also delivering good patient care. Physicians must have a basic understanding of their practice’s business model while the clinic administrator must have a basic understanding of the clinical services that the practice delivers. What are some areas in which there is conflict between administrators and physicians? Controversy can occur over where to invest the practice resources or how to handle a human resource matter. Administrators and physicians may have different perspectives on how to prioritize various projects. Personality or style conflicts can also create dissension.

What does the future of the profession hold? Market demands and expectations are ever changing as we move from a feefor-service to a value-based reimbursement system. Today many clinics or medical practices are owned by or part of a bigger system. This requires additional management skills. Even a relatively small practice may have additional entities or other lines of business to manage, including an ambulatory surgery center(s); real estate, such as the building it occupies; imaging or other specialty service centers; and, perhaps, retail components. This is not a profession for the faint of heart. Clinic administrators need to find ways to improve quality of care and patient outcomes despite diminishing economic resources.

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DIGESTIVE HEALTH

Gastroesophageal reflux disease (GERD) Self-management tips and when to seek help By Benjamin Mitlyng, MD

astroesophageal reflux disease (GERD) is the most common gastrointestinal disorder in the United States. It affects 25 percent to 40 percent of U.S. adults and it’s estimated that one of five Minnesotans experience its symptoms at least weekly. Those symptoms can be wide-ranging, but the most specific ones are heartburn and regurgitation. These symptoms happen when acid that is normally contained within the stomach backs up into the esophagus, which is the tube that food goes through on its way to the stomach. Normally, this backflow, or reflux, is prevented by a band of muscle (a sphincter) that encircles the bottom of the esophagus and tightens after you swallow, keeping whatever you swallowed in the stomach. If this band relaxes incorrectly or becomes weak, backflow occurs and causes symptoms. Backflow exposes the tissue lining the esophagus to acid, which can cause inflammation of the tissue, a condition called esophagitis. Over time, esophagitis can erode the esophagus, injuring it to the point of causing bleeding or problems with breathing.

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Treatment Lifestyle modifications are often the first step for managing GERD that is not accompanied by weight loss, anemia, trouble swallowing, or bleeding (those symptoms can suggest the presence of gastrointestinal cancer or other serious disease and should prompt you to contact a physician). The first modification people can make to try to get rid of symptoms on their own is to avoid foods that precipitate reflux in many people, such as coffee, alcohol, chocolate, and fatty foods. The second modification is to avoid acidic foods such as citrus fruit, spicy foods, and carbonated beverages. Third is to adopt behaviors that may help keep stomach acid in the stomach instead of letting it travel upward into the esophagus: weight loss, smoking cessation, raising the head of the bed, and avoiding lying down for two to three hours after meals. These lifestyle modifications can be very effective, but some patients find them too restrictive. However, patients who are overweight/obese and experience reflux may be encouraged to know that symptoms often improve significantly, and occasionally disappear, after weight loss. The rising prevalence of obesity in the U.S. likely is contributing to the rising prevalence of GERD nationwide. Medical management with acid-blocking medications is usually the next step for GERD that does not respond to lifestyle modifications. Patients likely will be prescribed either proton pump inhibitors (PPIs) or Histamine-2 receptor antagonists (H2RAs). Both medications are remarkably safe and are tolerated quite well by most patients. Upper endoscopy. For the 30 percent to 40 percent of patients with GERD whose symptoms are not completely controlled by medication, the next step is for the physician to examine their esophagus in a procedure called an upper endoscopy. This nonsurgical procedure involves inserting a flexible tube with an attached camera and light through the mouth and into the esophagus. This permits visual inspection of the esophagus, stomach, and upper part of the small intestine and can rule out possible diagnoses such as peptic ulcer disease, esophageal cancer, or other causes of esophagitis. Surgery. There is good evidence that patients who don’t respond to medication and have inflammation that’s detected by upper endoscopy respond well to anti-reflux surgery. The most common procedure is called a Nissen fundoplication. In this procedure, the surgeon wraps the upper part of the stomach around the base of the esophagus and stitchGERD, for es the wrapped area in place to act as a sphincter. This preserves normal swallowing and is many people, done on an inpatient basis. can be A recent surgical development is the successfully LINX System. LINX is a small, flexible treated by band of interlinked titanium beads with self-managed magnetic cores and is inserted laparoscopically at the base of the esophagus. It helps lifestyle the lower esophageal sphincter to resist modifications. reflux while allowing normal swallowing and is done on an outpatient basis. Barrett’s esophagus Specific groups of patients with chronic GERD may be at increased risk for Barrett’s esophagus, a premalignant condition that can progress to esophageal cancer. People who notice changes in their GERD symptoms and/or who have new trouble swallowing, bleeding, weight loss, or persistent symptoms should consult their physician and may need upper endoscopy. If Barrett’s esophagus is found, fur-

ther therapy may be warranted. The amount of tissue affected by Barrett’s esophagus, patient preference, and the presence or absence of advanced precancerous cells help determine further therapy. Patients with advanced precancerous cells are at the greatest risk for progression to esophageal cancer, and are often candidates for radiofrequency ablation of the precancerous tissue. This procedure carries an 80 percent to 95 percent success rate of complete normalization of esophageal tissue with a very low rate of recurrence of advanced precancerous cells. Screening The American College of Gastroenterology suggests that people at high risk for Barrett’s esophagus—those over age 50, male, Caucasian, with chronic GERD, overweight, and diagnosed with hiatal hernia; and people with GERD and a family history of esophageal cancer—have an upper endoscopy at age 50. Currently, there is insufficient data to recommend this routinely for all patients with chronic GERD. Screening is important because it can detect the type of esophageal cancer that has the fastest growing incidence rate of all cancers in the U.S., adenocarcinoma of the esophagus. Self-management Gastroesophageal reflux is a common GI condition that, for many people, can be successfully treated by self-managed lifestyle modifications. If GERD symptoms persist, however, it’s important to contact a physician to assess risk factors for Barrett’s esophagus that should prompt endoscopic evaluation. Benjamin Mitlyng, MD, is a board-certified gastroenterologist and practices at the Esophageal Center of Excellence at Minnesota Gastroenterology.

Tick-Borne Disease Specialty Clinic Tick-borne disease can result in disabling consequences that may resist treatment and even diagnosis. We have been successful in the rehabilitation of many patients with unique cases of chronic tick-borne illness. No medical referral is required.

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612-287-8781 AUGUST 2013 MINNESOTA HEALTH CARE NEWS

OPHTHALMOLOGY What is the retina?

Retinal tears

Floaters, flashes, and what to do about them

The retina is a thin, transparent sheet of tissue that lines the back of the eye. Attached to the retina is vitreous gel that, when we are younger, functions as a thick shock absorber and is firmly attached to the retina. However, as we age, the gel liquifies and separates from the retina. The process of turning from a dense gel to a liquid (liquefaction) is part of the natural aging process of the eye and usually occurs when someone is between 50 and 70 years of age. Age-related spontaneous separation of the gel from the retina, called posterior vitreous detachment (PVD), typically occurs without causing symptoms or visual problems. Sometimes, though, it can lead to a tear in the retina (Figure 1). How retinal tears form Although PVD formation is part of the normal aging process, it can also occur in people whose gel is abnormally attached to the retina. In those cases, the gel can pull on and create a tear in the retina (Figure 2). If the tear is along a blood vessel it can cause bleeding in the gel, which is called a vitreous hemorrhage. To the person experiencing it, this event looks like a spray of floaters and loss of vision. A tear in the retina can allow fluid to travel behind the retina and loosen the retina’s attachment to the back of the eye. Once loosening progresses to the point that the retina separates from the back of the eye, it is called a retinal detachment. A retinal detachment appears as a shadow or curtain in the vision and is a serious eye problem that can lead to irreversible loss of vision.

By Polly Quiram MD, PhD Symptoms Retinal tears have painless symptoms that include flashes of light and floaters. Flashes are usually described as lightning in the outer field of vision that lasts for a split second. They are more noticeable at night. A flash is caused by the gel tugging on the retina. Patients say that if they look very quickly to the right or the left, they can elicit a flash; this happens because rapid head turning causes the gel to move within the eye. Seeing a flash does not mean that you have a retinal tear. It is merely a symptom of the gel pulling on the retina. Flashes Graduate School of Health & Human Services often spontaneously cease without further symptoms or consequences. Floaters appear to people experiencing them as specks, cobwebs, or pieces of debris that float in the center of their vision. They are caused by the gel turning from a dense gel to liquid; as the gel liquifies, pieces of the gel can break SMU offers bachelor completion off and float in the central vision. Flashes and floaters can happen and master’s programs in the at the same time or separately. health & human services areas. However, if flashes are associated with a sudden increase in the number or size of floaters it can be a warning sign that a retinal tear =PZP[ \Z VUSPUL [V ÄUK V\[ TVYL may have occurred or may be in progress. Another symptom of a retinal tear is a sudden loss of vision. If a tear in the retina involves tearing through a blood vessel, you may notice lines and dark floaters in your vision that make it difficult to see. Experiencing flashes and floaters is not necessarily cause for alarm. Fortunately, there is only about a 10 percent chance of having a retinal tear when new floaters occur. However, if symptoms become more severe or are associated with loss of vision, the risk of a retinal tear is 85 percent and you should see your eye doctor immediately. If

Retinal detachment can lead to irreversible loss of vision.

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FIGURE 1 you experience new flashes and floaters without a loss of vision, see your eye doctor within 72 hours for a dilated examination of your eyes, which will reveal if a tear is present.

FIGURE 1. Abnormal pulling of vitreous gel on the retina can lead to retinal tear during formation of a posterior vitreous detachment (PVD). FIGURE 2. This shows the formation of a retinal tear requiring treatment.

Risk factors and prevention Risk factors for retinal tears include aging, previous eye surgery, head trauma, and being significantly nearsighted (i.e., requiring glasses for distance vision at a young age). There are no vitamins or exercise that will prevent FIGURE 2 the gel from aging. Someone who is Potential tear nearsighted has an eye that is strucVitreous tugging on retina turally at risk for developing retinal tears because the eye is not round (baseball shaped), but is more elongated (football shaped). This longer shape stretches the retina and causes the formation of thin, weak areas. These weak areas are more susceptible to the pulling of the vitreous gel and a resulting tear. About two-thirds of the cases of retinal tears occur in nearsighted patients. People who have had cataract surFloaters gery have a 1 percent increased risk of retinal tear or detachment. Head trauPhoto credit for both figures courtesy Polly Quiram, MD, PhD ma can increase the risk of retinal tears by causing the gel in the eye to pull violently on the retina. Having had a retinal tear in one eye carries a 15 percent increased risk for developing a tear in the other eye. Retinal tears do not occur as a result of using your eyes, bending, or heavy lifting. Lifetime risk of developing a retinal tear is approximately 5 percent. Prevention relies on awareness of the symptoms of a PVD. If you have symptoms—flashes, floaters, or a shower of floaters—it is important to be seen by your eye doctor. Fortunately, the majority of PVDs do not cause retinal tears.

heal. Fortunately, most retinal tears can be successfully treated with a success rate greater than 95 percent. After this treatment, patients may have some temporary eye irritation, headache, and blurred vision. What should you do? Retinal tears occur as a result of aging and nearsightedness. If you notice symptoms of a PVD, including a sudden increase in flashes and floaters, seek prompt examination by your eye doctor. Polly Quiram MD, PhD, is board-certified in ophthalmology and practices as a vitreoretinal surgeon with VitreoRetinal Surgery, PA, which has multiple Twin Cities locations.

A diagnosis of

Cancer

Most retinal tears can be successfully treated with a greater than 95 percent rate.

Treatment

If a retinal tear is treated before it becomes a retinal detachment, patients have a much better visual prognosis. Retinal tears can be sealed with either laser treatment or cryotherapy, which is a freezing treatment. These procedures can be done in the office with topical anesthesia in a matter of minutes. Both of these procedures are designed to create a scar that seals the tear so that it does not detach the retina. Sealing prevents fluid from traveling through the tear and causing a retinal detachment. A retinal detachment is a serious, vision-threatening eye problem that requires repair in an operating room and can take weeks to

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It raises many questions few of us are prepared to answer, such as: • How can I take time off from work? • Can I get help paying bills? • What is the difference between a health care directive and a power of attorney? • Can I keep my health insurance even if I lose my job? • And many others. If you or a loved one is facing cancer, we are here to help.

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B E H AV I O R A L H E A L T H

Gambling addiction Free treatment is available By Catherine Perrault, MBC

ost people agree that behaviors associated with alcohol and drug addiction are not attributable to weak willpower and that most people with those addictions need some form of help to achieve recovery. However, ask people about gambling addiction and you’re more likely to get looks of confusion. The truth is that gambling addiction, while having its own unique manifestations, is more similar to substance addiction than not, and the consequences and results are as devastating as any substance addiction. Consider the following: “As a child, you’re in need of security and stability, but having a parent that gambles provides neither. In good times, things were okay, but still untrustworthy. In the bad times, it felt like we were in freefall, never

knowing when we’d hit bottom or if things would get better again.” “It seemed like every time we wanted to do something as a family, all of a sudden he was gone. For the kids, it was one broken promise after another.” Anyone who has had a family member or friend with a gambling problem can relate to these comments and the distress felt by both problem gamblers and their significant others. Indeed, gambling addictions can blindside families and destroy lives. Whether it’s called problem gambling, compulsive gambling, or gambling addiction, the results are the same. A gambling problem often begins with a good experience, perhaps a night of fun or a big win. But, inevitably, the winning stops and losses begin to pile up.

Chemical dependency in older adults is hard to recognize We help them live a healthier life Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older. Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

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MINNESOTA HEALTH CARE NEWS AUGUST 2013

Types of compulsive gambling While chasing those losses can become a driving factor in compulsive gambling, money is not the reason behind the need to gamble. It’s the feeling that gamblers experience while playing that drives them to continue. Gambling becomes an all-consuming obsession that takes over every aspect of their life, causing them to neglect essentially everything, including job, faith, family, and recreational outlets. Fortunately, the state of Minnesota sets aside funds to counsel and treat compulsive gamblers and to provide support for affected family members. And, as with other, better known addictions, recovery is possible for those with a compulsive gambling disorder. The popularity of gambling in Minnesota is borne out by the numbers. Approximately 75 percent of the state’s residents have participated in a gambling activity in the last year. And while most people enjoy gambling as a healthy form of recreation, it is estimated that between 1 percent and 4 percent of the population is at risk gambling addiction.

There are two primary types of problem gamblers: action gamblers and escape gamblers. Action gamblers are often assertive, persuasive, loud, and energetic. They are typically younger men and see themselves as friendly, sociable, gregarious, and generous. In spite of this, they usually have low self-esteem. Action compulsive gamblers gamble primarily at so-called “skill” games such as poker, craps, racing, and sports betting. Action gamblers are playing for the thrill of the game. They attempt to lose themselves in the excitement of the gambling experience. Escape gamblers are more typically women, and while they often exhibit some of the same characteristics as action gamblers, there are important differences. They tend to develop a gambling problem later in life and gamble to escape problems. They prefer games of luck, such as slot machines, video poker, bingo, lottery, other machines, and online games. When gambling, they may be in a numb, almost hypnotized state. for

Risk Gambling is an equal opportunity employer; there is no typical problem gambler. The risk of addiction is the same regardless of age, gender, or socioeconomic status. The stunning revelation that Maureen O’Connor, former mayor of San Diego, had a casino gambling addiction that caused her to misappropriate more than $2 million put a high-profile face on problem gambling. But it can just as easily affect anyone. Causes and risk factors vary, and for most people, there is no one identifiable cause. Like many other mental health conditions, compulsive gambling is considered to result from a combination of biological vulnerabilities, thoughts and attitudes, and social stressors. Factors can include behavior or substance abuse problems or other mental health disorders. It is also known that if your parents have a gambling problem, the chances are greater that you will too. Within the past few years it has been determined Recovery is possible that some people develop compulsive gambling behavior after for those with taking medications for treata compulsive ment of Parkinson’s disease or gambling disorder. restless leg syndrome, including the drug Mirapex.

• Gambling for longer periods of time than originally planned • Bragging about wins, but not talking about losses • Pressuring others for money as financial problems arise • Lying about how money is spent • Escaping to other excesses (alcohol, drugs, sleep, Gambling addiction to page 19

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Symptoms Identifying someone with a gambling problem is not easy. It’s known as the “hidden” addiction because there are no obvious outward signs as there are in the case of excessive alcohol or chemical use. However, there are warning signs that can alert you to a potential problem: • Increased frequency of gambling activity

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• Increased amount of money gambled AUGUST 2013 MINNESOTA HEALTH CARE NEWS

August Calendar 8

Health Screenings Health Fair 11 in the “Q”mmunity is a collaboration between KARE 11 TV, UCare, North Memorial, Medtronic, and Southside Community Health Services, Inc. The program brings easy and accessible basic health screenings to the public. Nurses perform health checks aboard a 37-ft. RV on a first-come-first-served basis. Free. No registration required. Visit www.Kare11.com, keyword: ”Q”mmunity, for more information. Thursday, Aug. 8, 5–8 p.m., 34th Avenue & Victory Memorial Drive, Minneapolis Lupus Foundation Workshop— Stress to Success The Lupus Foundation of Minnesota hosts life coach Elizabeth Dickenson, who will be teaching strategies for reducing stress. Attendees will also learn about the neuroscience underlying stress—its causes and effects on the nervous system—with a focus on how to eliminate it altogether. To register or for more information, contact Cheryl Como at ccomo@lupusmn.org or (952) 746-5151. Registration ends August 11. Monday, Aug.12, 1–2:30 p.m., LFM Office, 2626 E. 82nd St., Bloomington Diabetes Prevention Class HealthPartners teaches people at risk for developing type 2 diabetes how to take preventive steps in their day-to-day activities. The class will focus on creating healthy lifestyle changes surrounding weight management, healthy eating, and effective exercise. Registration is required, and there is a $20 fee. Call the HealthPartners Appointment Center at (952) 967-7616 to register. Thursday, Aug 15, 6–7:30 p.m., 2500 Como Ave., St. Paul Total Joint Education This Fairview Health Services class provides valuable information to individuals expecting joint-replacement surgery in their future. Hospital staff and social workers will explain the pre- and post-operative procedures involved, and provide a picture of the rehabilitation process after surgery. Free, registration encouraged. Find out more or register at www.fairview.org/classes or

leave a message at (952) 924-1397. Monday, Aug. 19, 9:20 a.m.–12:15 p.m., 5th Floor Lounge, Fairview Southdale Hospital, 401 France Ave. S., Edina

Mental Health First Aid The Centers for Disease Control and Prevention reports that approximately 63.3 million Americans—an estimated 1 in 5 adults—contact health providers, hospitals, and emergency departments due to a primary diagnosis of mental illness. It is quite likely that someone you know suffers from mental illness. Are you prepared to respond in a mental health crisis? Mental Health First Aid (MHFA) seeks to better equip Americans to identify, understand, and intervene on a “first aid” basis during mental health emergencies. The certification process teaches individuals how to recognize and support people at any stage of mental illness. Likened to CPR or First Aid courses, the curriculum is designed for the layperson who may or may not have encountered mental illness in the past. The program creators, Australian professor Anthony Jorm and nurse Betty Kitchener, specialized in mental health literacy and health education, respectively, and assisted the MHFA-USA collaborative in bringing training to the United States. Because family members, friends, and colleagues are the people most likely to notice changes in behavior, it is important these same people know how to help. Newly enacted mental health policies recommend escalating MHFA training in order to provide the general public with the tools and information for understanding and taking positive action to protect community health. Visit www.mentalhealth firstaid.org or contact Margaret Jaco with general inquiries at (202) 684-7457 x263. 13–14 MHFA Training NAMI MN will hold a two-day Mental Health First Aid class for people interested in learning to recognize and address the symptoms of mental illness, and how to respond in a crisis. Attendees who complete the 12-hour training will receive MHFA certification. Register through www.namihelps.org. Free; however, participants are encouraged to bring their own lunch or cash for food. For more information, contact Donna at (651) 645-2948 x101. Tuesday & Wednesday, August 13–14, 9 a.m–4 p.m., Basilica of St. Mary, 88 North 17th St., Minneapolis.

Older Adult Caregiver Support Group Senior Community Services invites caregivers of an older adult to a free caregiver support group. Group sessions focus on helping individual caregivers as they care for themselves and loved ones. No registration required. Call Krystal Wiebusch, LSW, at (952) 746-4028 for more information. Wednesday, Aug. 21, 3-4:30 p.m., The Heathers Manor, 3000 Douglas Drive N., Crystal

Deaf Zumba Tula Yoga & Wellness provides fitness classes that incorporate ASL into activities like yoga, kickboxing, and Zumba. Classes are donation-based, with a minimum requirement of $5 (suggested donation of $10–$15). Visit www.tulayogawellness.com for more information, as well as a comprehensive list of offerings. Tuesday, Aug. 27, 6:45–7:45 p.m., Tula Yoga Studio, 99 Snelling Ave. N., St. Paul

Sept. 5 HOT Air Minnesota Oncology offers this support group for individuals affected by lung cancer as a patient, family member, friend, or caregiver. HOT (Helping Others Through Lung Cancer) Air meets on the first Thursday of every month. Free, and parking vouchers are provided. Register via wellness.allinahealth.org/events. Call (612) 884-6300 for more information. Thursday, Sept. 5, 5:30–7 p.m., Minnesota Oncology Conf. Rm., 910 E. 26th St., Minneapolis

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to (612) 728-8601 or email them to amarlow@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

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MINNESOTA HEALTH CARE NEWS AUGUST 2013

Gambling addiction from page 17

food, etc.) • Denying there is a problem

Medical research has clearly shown compulsive gambling to be a brain disease.

Additional signs of problem gambling may include frequent absences from home and work, excessive phone use, withdrawal from family, personality changes (increased irritability/hostility) and diversion of family funds. A two-minute risk test that can help determine the existence of a gambling problem can be found on the Northstar Problem Gambling Alliance website (www.NorthstarProblemGambling.org). Treatment

Medical research has clearly shown compulsive gambling to be a brain disease. The newly released DSM-V (the Diagnostic and Statistical Manual of the American Psychiatric Association) classifies problem gambling as an addiction disorder similar to alcohol and drug addiction. Treatment has evolved based on alcohol and drug addiction models. Cognitive behavioral therapy has proven helpful, as have motivational interviewing techniques and self-help group participation. Continued medical research on pharmacological interventions has found that certain medications, including antiseizure medications, mood stabilizers, and antidepressants, may have the potential to reduce gambling urges. As with other addictions, there is no magic remedy for the complex physical, psychological, social, and spiritual aspects of addiction.

Free treatment

In Minnesota, treatment is available free of charge to qualifying individuals and their families. This is particularly helpful given that most gamblers exhaust all financial resources during the course of their addiction. If you’re concerned about your gambling or the gambling of others, you may call the state’s 24/7 gambling helpline at (800) 333-HOPE. This helpline is the best starting point for someone seeking personal help or help for someone else. Early diagnosis and treatment is especially important for people with gambling addiction. The longer an addiction persists, the greater the likelihood that retirement and lifetime savings will be depleted. A gambling addiction is also accompanied by a higher than average rate of suicide. The National Council on Problem Gambling cites numerous studies in reporting that one in five compulsive gamblers attempts suicide, a rate higher than for any other addictive disorder. The key to treating a gambling addiction is early intervention. It is important that the stigma associated with gambling and other addictions be eliminated so that people feel comfortable asking for help before the addiction progresses to dire circumstances. Catherine Perrault, MBC, is the executive director of the Minnesota Northstar Problem Gambling Alliance, Minnesota’s affiliate to the National Council on Problem Gambling. Northstar provides programming to create awareness about problem gambling in the community, educate treatment professionals, and advocate for treatment funding.

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Editor’s note: A medical emergency prohibited Peter Mills, MD, PhD, from participating on this panel. His comments were added after the initial edit of the conference transcript. Panelists participate in a three-phase curriculum development survey for every session of the Roundtable, and Dr. Mills’ active involvement in that process was an important part of this conference.

DR. VAN ZYL YORK: Patient engagement is where the patient is in terms of their interest in their own health. It’s broader than any one provider, broader than any single health issue. A patient’s relationship with one provider may be very different than with another provider. There’s not a single patient engagement status; it’s what the patient brings to the relationship. You can have an engaged patient and not have an engaged health care provider or health care system,

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Minnesota Physician Publishing’s 39th Minnesota Health Care Roundtable examined the topic of patient engagement. Six panelists and our moderator met on April 25, 2013, to discuss this issue. The next roundtable, on Oct. 24, will address end-of-life topics.

DR. MILLS: It’s a patient’s willingness to actively participate in decisions about their health and care needs. DR. FISCHER: I define patient engagement broadly. It is the sharing of responsibility for care between patients and their families and guardians; health care providers—the entire health care team; and, when applicable, the health-care insurance payer. “Insurance payer” includes the insurance company, employer, TPA, and federal and state governments. The engagement must occur at every step of the health care process, including but not limited to education, evaluation of options, care delivery, and financial support. MR. STARNES: Patient engagement is receiving more attention than before. Why?

Patient engagement Creating measures that work

DR. KLODAS: It’s the constructive and helpful participation of a patient in their own care.

DR. GANDRUD: It’s family engagement: Does that family work together as a unit? Are there different levels of motivation and engagement between the child and the parents? How can I help them connect and be on the same page? We work a lot with family dynamics to improve patient engagement.

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About the Roundtable

MR. STARNES: The contentious battles surrounding health care reform have somewhat subsided and yielded a new operating system to which we all must adapt. ACOs will reward improved population health; health insurance exchanges will allow consumers more affordable access; and ICD-10 codes will provide better compensation to physicians for spending more time with their patients. Central to the success of these new models is engaging patients and creating tools to let each of their individual stories count toward improved aggregate wholes. Today we will discuss the topic of patient engagement and determine ways it can be developed to its full potential. Let’s begin with a definition of patient engagement.

DR. NERSESIAN: A motivated patient has a desire to do what’s necessary to change their lifestyle in order to achieve certain goals. We can usually determine that subjectively or objectively. Subjectively, there’s body language: the patient looking at you and their posture; and there are objective measures like the patient activation measure.

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and that patient can still thrive, or they can be defeated because of not having a good relationship. Many times, parts of the health care system see patient engagement as patients engaged to do what the health care system thinks they ought to be doing rather than what the patient may see as the best course of action. A health care provider may prescribe treatment as the best action for the patient. The employer may want the patient to reach particular goals because they see it as fulfilling their goals for health cost containment and population health status. The patient, on the other hand, may be looking at what is best suited to choices they have to make day to day, and see it differently. Medication is a good example. Patients may be prescribed a particular medication but because of the side effects, cost, management routine, how it reacts with other things, they may not be as sold on that as the path to health as their provider may be. DR. VALDIVIA: Patient engagement is the degree to which an individual acts in an informed manner to achieve and maintain optimal health.

MINNESOTA HEALTH CARE NEWS AUGUST 2013

DR. FISCHER: There are a couple of reasons. The health of all Americans has become a core national strategy. We know that if we’re going to change the health of America today, it’s going to require patient engagement. Secondly, data show that an engaged patient has better outcomes and at a lower cost. DR. MILLS: The main reason is the inexorable rise in health care costs over the last two decades and the fact that America has gotten to the point where, as a nation, it just cannot afford the proportion of GDP—18 percent— that is spent delivering care. This, coupled with the fact that there is increasing evidence to support lower costs and better outcomes for individuals and populations that are active participants in when, where, and how their care is delivered. DR. VALDIVIA: It’s ineffective for health plans or other third parties not directly involved in patient care to intervene and make changes. Another reason is change in reimbursement models. Fee-for-service encouraged us to engage patients around the level of visit but not necessarily in terms of their behavior. Now that we’re moving to population-based payment models, we have a different incentive. We need to think not only about the most complex cases where we can intervene but also about those who are well and how to keep them well. DR. KLODAS: Patient engagement is a hot topic because there’s a perfect storm. We’re facing unsustainable costs that we can’t afford. Insurance companies are realizing that they can’t ignore prevention anymore. Smoke? You have a higher payment. Quit

smoking, and your payment goes down. That’s going to engage patients. For a long time, individuals were passive recipients of care and it didn’t matter how many MRIs you had, how many procedures you had, or how many drugs you were on, because somebody else paid for it. Insurance companies are realizing that they can’t ignore prevention any more. They didn’t used to pay for that; they didn’t used to be interested in that. All insurance companies cared about was minimizing the number of people with disease. Now they’ve got to make sure that people without disease are truly healthy because eventually, those people may come back to the same insurance company, even if they switch insurance carriers for a while.

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correlation between those two things. DR. VAN ZYL YORK: Patient engagement and outcomes aren’t just related to physicians. Patients get to where they are by a variety of means. Assuming that the health care system has a high level of control over patient engagement is going to lead us down the wrong road. DR. MILLS: One thing we may not be very good at is recognizing when we don’t have good rapport with a patient and giving them the opportunity to see a colleague. Having a measure of patient engagement recorded may help make this more tangible and could help improve engagement across the whole provider community.

DR. GANDRUD: Success isn’t focused solely on the provider but also on how well providers utilize resources outside MR. STARNES: the clinic to What makes help certain paWe shouldn’t need patient engagetients. In our ment worth financial incentives to do clinic, a lot of it pursuing? the right thing. has to do with DR. KLODAS: selection bias. Peter Mills, MD An engaged One provider patient has a might be hard to better quality of life. I don’t know get in to see, so patients who go to how to measure that, but patients that provider are those that are orinvolved in their own care are ganized enough to schedule the aphappier, on fewer medications, see pointment in time. Those doctors’ the doctor less, have better metrics, dashboards look better because their and feel better. patients are more engaged to begin with. Many variables play into this; DR. NERSESIAN: Outcomes. If my pait’s hard to use just one number to tient population looks better overall, describe the success of one provider. that’s a good way to assess engageWe have a provider in our clinic that ment. The PAM (patient activation sees all the adolescents. In that measure) is in all Fairview records. provider’s measured success, they The problem is that it’s not used very may be just as good at engaging the often. It needs more physician patient, but the outcomes may not be awareness; three-quarters of physias clear as for a provider caring for a cians don’t understand the term. If 3-year-old whose parents oversee that that’s true community-wide, we need child. not only more patient engagement; we need more provider education. MR. STARNES: Laura, you see diabetic DR. MILLS: We know outcomes are better for engaged patients. MR. STARNES: Can we discern why a given doctor has better results with certain patients? How do we translate that across the provider community? DR. VALDIVIA: It’s difficult to measure. Short term, you might see a change in specific behaviors. Long term, you might see changes in cultural norms. The journal Health Affairs showed a

children. Is part of success in patient engagement attributable to a psychosocial match between patient and provider? DR. GANDRUD: Definitely. Certain providers work better with certain age groups. Certain providers are better at motivating and asking engaging questions. MR. STARNES: What are the best ways to create a more engaged patient?

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A B O U T T H E PA N E L I S T S Vivi-Ann Fischer, DC, is chief clinical officer at ChiroCare (Chiropractic Care of Minnesota, Inc.), a nonprofit independent chiropractic provider network based in Shoreview, Minn. ChiroCare serves more than 1 million managed care members throughout Minnesota, North Dakota, South Dakota, Iowa, and Wisconsin. A practicing chiropractor, she owns Plymouth Grove Chiropractic and serves on the Northwestern Health Sciences University board of trustees. With more than 25 years’ experience in providing clinical care and 20 years of managed health care experience, she is a strong advocate of collaboration with medical doctors, focused on improving patient experience, community health, and reducing health care costs. Laura Gandrud, MD, is a clinician in pediatric endocrinology and diabetes at Children’s Hospitals and Clinics of Minnesota. In addition, she serves as primary or co-investigator on multiple research projects that investigate type 1 and type 2 diabetes in children and adolescents. Previously, she was a staff physician in the Division of Pediatric Endocrinology and Diabetes in the Department of Pediatrics at Stanford University School of Medicine and an instructor in the Stanford University School of Medicine. While at Stanford, she pursued research focused on the use of glucose sensors in children with diabetes. Elizabeth Klodas, MD, FACC, is a board-certified cardiologist with more than 15 years of experience treating patients with heart disease. Klodas completed fellowships at both the Mayo Clinic and Johns Hopkins University. She specializes in noninvasive cardiac imaging, including stress testing, echocardiography, nuclear, CT, and MRI imaging. Klodas founded Preventive Cardiology Consultants and sees patients at her independent practice in Edina. She has led several patient education initiatives at the American College of Cardiology (ACC) and spearheaded the formation of ACC’s patient education website (www.cardiosmart.org). Klodas is a medical editor for webMD, and also serves as director of the Heart Disease Prevention Program at General Mills. Peter Mills, MD, PhD, is a specialist in respiratory medicine who practices part time at the Whittington Hospital in London. He also co-founded and actively participates in nGageHealth as its CEO. nGageHealth creates patient engagement and health management solutions for health care providers to help them address the new challenges brought about by health care reform. Mills was part of the founding team at global health management consultancy vielife, acquired by CIGNA in 2006. He has also worked extensively with Minneapolis-based RedBrick Health, helping create some of RedBrick’s market-leading health management solutions. William Nersesian, MD, MHA, is chief medical officer at Fairview Physician Associates, where he leads clinical quality efforts for a health care network of 2,000 providers. A board-certified pediatrician, he has served as the chairman of pediatrics at Fairview Southdale Hospital and as a member of Minnesota Community Measurement committees on patient satisfaction surveys and asthma. He is a member of a workgroup that, under the auspices of the Institute for Clinical Systems Improvement, studies ways to reduce avoidable hospital readmissions. His published works include those that address the impact of diabetes outpatient education and changing lifestyle behaviors. Tomás D. Valdivia, MD, MS, an internist and medical informaticist with 20-plus years’ executive experience in health care, is co-founder and CEO of Minnesota-based Luminat and Valquist, LLC. Previously, Valdivia founded Advanced Informatics, a company providing evaluation technology used by health care organizations. As chief medical officer for Definity Health, he led development of consumer activation strategies and services. As president of Carol, he helped develop the first direct-to-consumer health services exchange, used by many large providers nationwide. Pamela Van Zyl York, MPH, PhD, RD, LN, has been involved in health promotion programs for more than 20 years. She has worked in local public health agencies, including the Minnesota Department of Health (MDH), and has held faculty positions at the University of Minnesota and St. Catherine University. York has worked in the areas of nutrition and physical activity across the age span and currently works on prevention and management of chronic disease, health promotion for adults, healthy aging, and adult falls prevention at MDH. She also directs MDH’s implementation of the Stanford Chronic Disease Self-Management Program. Mike Starnes has been the publisher at Minnesota Physician Publishing since 1986. His duties include the production of Medfax, Minnesota Physician, Employee Benefits Planner, and Minnesota Health Care News; directing the Minnesota Health Care Consumer Association; and hosting the Minnesota Health Care Roundtable.

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DR. FISCHER: I would like to see it go AUGUST 2013 MINNESOTA HEALTH CARE NEWS

M I N N E S O T A beyond interactive websites and electronic health records. To engage the patient, we have to come to a conclusion about the clear role that the patient is going to play in engagement, and we have to find its value to the patient. What’s important in their life to get them to achieve these health care goals? It’s going to require good communication that’s consumer friendly, timely, persistent, and specific to the patient’s needs. DR. MILLS: When I ask a patient to do something, such as monitor their blood pressure or report back to me about side effects from a new medication, this is the first step along the road to being an engaged patient, being involved in care and decisions that are made about that care. Have a greater number of “touch points” between physician and patient over the course of a year. These interactions don’t have to be face-to-face. MR. STARNES: What problems do physicians have in getting patients engaged? DR. KLODAS: I think it’s doctors’ own education and it’s about time and money. No. 1 is education. I didn’t have training in engaging a patient. Plus, it always comes down to time and money. We don’t have enough time to sit and ask people how they live, where they are, what their personal goals are around their health. It’s very hard to know how patients live, how their lives really are. One of the greatest losses in care has been the decline or disappearance of the house call. In two seconds after you walk into someone’s home, you know so much about where they’re coming from. You can’t possibly ascertain the same information when they’re sitting in a clinical setting in a chair outside of their environment, trying to describe their life to you. We don’t sometimes have a really good sense of where patients are, so we have a tough time meeting them where they live. The other problem is money. Lifestyle-based disease is going to bankrupt our country. Also, here’s almost a disincentive to engage a patient: I spend a lot of time talking to my patients about what they eat and counseling them on a personal plan. But when I submit for payment, the insurance company says the only way it could make my payment reflect the time I put into an appointment would be if I had prescribed medication. It enforces a paternalistic attitude on the part of the doctor: “Do this and I'll see you back in three weeks.” DR. NERSESIAN: I don’t think society has the money resources, and doctors don’t have the

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time, to coach all the people who need coaching in better eating and getting rid of drugs and alcohol and more exercise and so forth. At FPA we have several health coaches. One’s a nurse, one’s a kinesiologist, and one’s a registered dietitian. For over seven years we’ve coached people on healthy eating, and about 40 percent of our people lose weight. That’s pretty good when you look at the literature. Even the ones who don’t lose weight often maintain their weight, or at least they feel better about themselves or are exercising more. We physicians have to educate ourselves on what’s necessary to assess patient motivation and to improve it. Then we have to hand off those patients to people who are, quite honestly, better than I am, and maybe better than you are, at motivating patients. That’s their job. They’ve studied it, they’ve done it, and they have a lot of experience in it. Quite honestly, from what I’ve learned in the last few years, although I considered myself a pretty good

talking about what we can do as physicians, it helps to ask families what their obstacles are: Financial? Psychological? We have a lot of children with mental health issues. We may identify them, but unfortunately, they may not be seen for six months. We don’t have availability in our hospital for mental health evaluations. Do families have transportation to the clinic? My role is to make insulin dose adjustments and educate the family about how to manage diabetes but also to identify obstacles so I can appropriately triage them to the right community services. DR. VAN ZYL YORK: It is hard to have an engaged relationship with a health care provider when other stuff is in the way. They may be seeing a physician but insurance isn’t going to pay for it, or they couldn’t get the referral, or the last bill they got has never gotten paid. MR. STARNES: How should health care literacy improve to create a more engaged patient? DR. VAN ZYL YORK: There’s health literacy, and there’s health care literacy. Health care literacy is how to negotiate the system and make sure you get to where you need to

We have difficulty measuring patient engagement. Pamela Van Zyl York, PhD

motivator as a physician I’m outclassed by some of the people who do this for a living. MR. STARNES: What should we avoid in creating an engaged patient? DR. NERSESIAN: In the past we told patients what to do; that’s not the key to patient engagement. They may have different motivations than we have. The key is to find out what motivates patients and to work with them to find common goals and common ground, so we can achieve their goals and our goals. Five of the top 10 causes of death—heart disease, cancer, strokes, accidents, diabetes—can be changed by altering lifestyle. MR. STARNES: Are there reasons that people with every reason to be engaged aren’t? DR. GANDRUD: There are a lot of obstacles. In

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go. You learn by the seat of your pants. Increasingly, patient navigators help you figure out who to call and how to make this happen. We’ll probably see more of that because the health care system isn’t getting less complicated any time soon. Health literacy is a responsibility on both sides. We don’t communicate well in patient-friendly, consumer-friendly language, and that is something we need to pay better attention to. DR. NERSESIAN: So far, we haven’t made the distinction between primary prevention, secondary prevention, and tertiary prevention. If I wait till I have heart failure and my cardiologist tells me to stop smoking or lose weight, that’s good, but that’s tertiary prevention. I might see a kid with a BMI of 33, and I try to tell him or an adult who needs a little more exercise to get on the ball; that’s sec-

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M I N N E S O T A ondary prevention. MR. STARNES: What is the benefit of having a patient engagement measurement in the medical record? DR. FISCHER: Defining patient engagement lets the patient identify what’s of value to them and lets them monitor and measure their progress. It also gives the practitioner an idea if the patient is making progress, and if not, it gives you an opportunity to change the plan. DR. MILLS: A measure of patient engagement would help providers tailor the way they interact with their patients and the type of information they provide them. Rather than the trial-and-error approach we often use in engaging our patients in monitoring and managing their conditions, a finite measure could potentially streamline this process and lead to patients better managing their lifestyle and medical issues earlier.

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DR. GANDRUD: Disconnect between child and parent is hard to sum up with one number; disconnect can lead to issues in care. MR. STARNES: How would we address patients who don’t want to be engaged, particularly if providers are going to penalized for this? DR. NERSESIAN: If a patient is unmotivated, there is usually some reason. If they’ve failed in the past, the coach’s or provider’s job is to make sure they understand that they can be successful now. If the patient has other issues to deal with—divorce or their kid’s on drugs or failing school—those concerns need to be addressed before the patient wants to exercise more or lose weight. MR. STARNES: One of the biggest hurdles that increased emphasis on patient engagement faces is convincing physicians that it’s worthwhile. Why are doctors hesitant to embrace this? DR. GANDRUD: As a clinician, it’s tough to measure something when we feel we don’t have the resources to address deficiencies. We need

MR. STARNES: Could it be problematic to have a measure of patient engagement in the medical record? DR. VAN ZYL YORK: We have difficulty measuring patient engagement. There’s the

Find out what motivates patients and work with them to find common goals. William Nersesian, MD

Patient Activation Measure, but that’s a single number that is on a multidimensional scale. I can look at that number but not know what contributes to it. Also, the assumption we may make about where the patient is and what they’re willing to do based on that score may not be valid. It depends on when the score was done, and in what context. If I’m seeing that patient as a cardiologist, for example, and that patient is in a very different place than they were when that score was developed before a diagnosis, it may have no validity. DR. VALDIVIA: The downside to the patient engagement score is its pigeonholing effect, which can backfire. If it labels somebody as not engaged, does that prevent us from engaging them? If they have a wonderful score, I may feel like I don’t need to do anything.

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resources to be able to address those things, both with our medical training and with health coaches and educators, social workers, mental health providers. The patient activation measure is just the starting point. DR. VALDIVIA: Until we move down the path of beginning to pay ourselves for something other than piecework, there is going to be a continuous disincentive, especially when you think about the temporal disconnect between what we do today and the value that we’re going to reap from our actions as a system. It’s not like tomorrow things get better and costs drop and roses bloom. One of the big issues is how do we further payment model shifts to allow us the time and the tools to do patient engagement. DR. FISCHER: Providers are concerned about training. Who’s going to provide the training;

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are we all going to get the same training? Are we going to be out of our office, and does that mean decreased revenue? Will our staff need training? Tools are nice for implementing change, but who’s going to produce the tools? Who’s going to pay for them? Do we have enough time to spend with the patient? And if measurements become a requirement, are we going to be spending too much time in front of the computer measuring patient measurements and doing electronic health records? Are we going to have quality time left with the patient? DR. MILLS: With new regulations and reporting requirements being mandated for physicians, a potential challenge is keeping on top of all of the new things we have to do while remaining focused on the patient. Remunerating physicians based on outcomes is one key that will focus physicians on this area. MR. STARNES: Patients still trust their doctor. How can we leverage this to create a more engaged patient? DR. NERSESIAN: Remove financial and transportation barriers. DR. KLODAS: Patients need to feel that something comes of their being engaged. I try to get my patients with high blood pressure to buy their own blood pressure monitor and start checking their readings. It’s amazing how often that can change their medication regimen to something simpler. It’s not just engagement for the sake of engagement, but having a goal around that engagement, that helps. DR. FISCHER: We have to be able to reward the patient and the provider for accomplishments. If we make everything a penalty, patients are more likely to not be honest with their provider. MR. STARNES: In order for patient engagement measures to work, what needs to be measured? DR. NERSESIAN: What I’m looking for is something like an Apgar score of motivation. An Apgar score is simple; all nurses and physicians learn it. A baby could have been delivered in Australia, and if I hear that he had Apgars of 7 and 8, it gives me a rough idea of how that delivery went. PAM or other measures just haven’t taken off yet. It took us a while to come up with the PHQ 9 as our general measure for depression in patients. It’s kind of accepted in Minnesota now and Minnesota Community Measurement uses it. Maybe PAM has the potential to do that, or maybe there’s another measure. There has to be something that’s simple to establish in

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patients that’s pretty universal and gets taught to those of us in the clinical field.

to motivate patients. So what is our reward system?

behavior inside a system, rather than from within, is probably not the best way to do it.

DR. VAN ZYL YORK: We have a problem reliably measuring motivation. A key difference between it and an Apgar score is that the Apgar measures health status. When you’re measuring motivation, you’re measuring potential. You’re also trying to determine what someone would be willing to do in the future. Anytime you ask people the hypothetical question, “Would you be willing to do this?” the correlation with what they actually do is generally pretty low, and it’s situational. Motivation is only part of successful behavior change or maintenance. Also, when you’re looking at people who may be motivated, they are at different points in their life, different points in the social structure. All that is hard to reflect in a number.

DR. VAN ZYL YORK: One of the key questions is, how does that affect that trust relationship that patients have with providers or that people have with their employer? If you feel that your employer is just out to have you pay more of the money and them pay less and not keep the bargain that was made when you were employed, that may be motivating in some respects. But is it, over the long haul, going to decrease motivation when we look at incentives for performance or for maintenance of health?

DR. NERSESIAN: I agree. We make a distinction between intrinsic and extrinsic motivators. An extrinsic motivator might be that my 30th reunion is coming up and I want to fit in a dress I wore in high school. Or my employer is giving $20 a month so that I can join the health plan subsidizing my gym, so I will do that. I don’t think those things are bad because sometimes, that’s the hook that you get into a patient. But we’re looking for longterm, lifelong change, and I don’t think you get that with fitting in your dress for the reunion, because when the reunion’s over you’re back to square one. This is what we, as physicians, were not trained in during medical school. I’d say, “Why don’t you stop smoking? You don’t want to get lung cancer, do you?” But how many 20year-olds are thinking about lung cancer? They’re thinking, “When I’m 70, I’m going to die from something.” I wouldn’t think to ask them, “When you play softball, wouldn’t you like to have a little more speed running around the bases or a little better agility?” And they think, “Gee, I never thought

DR. KLODAS: Motivation varies second to second. So I don’t know how you could possibly quantify it and enter it in a chart as a number. MR. STARNES: Who should be involved in determining what factors go into a measure of patient engagement?

MR. STARNES: Should employers be involved in this type of work at all? DR. FISCHER: It would be really helpful for employers to have the same message that physicians and insurance companies give to patients. Having health as a company value is important too. I’ve had patients that are losing weight because the company has decided that it, as a whole, is going to lose 1,000 pounds

DR. VALDIVIA: Developing a score will require a tremendous amount of input from the academic community. Think about what we’ve learned about things that are simpler to measure, like blood pressure; we just recently changed the limits on blood pressure for diabetes. We are learning more and more about how to use even those measures that have been around for many years, like blood pressure. We are a long way from being able to understand patient engagement. DR. VAN ZYL YORK: I wonder whether that is necessarily putting money in the right place. I think we need to do a lot more research about what sort of factors, programs, services, what sort of environment, help people move in directions that are in their best interest. We need to understand some of those things before we can measure them. Using something like the patient activation measure in looking at the outcome of some of those programs may be helpful, but it’s multidimensional. We’re going to have to look at this in a more complex way because humans are complex organisms. What characteristics make something work for one person and not for another? DR. FISCHER: What is the reward system for the patient? That’s what we have to look at. Financial reward might be part of it, but I don’t think that’s the thing that’s really going

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We work a lot with family dynamics to improve patient engagement. Laura Gandrud, MD

and now employees are walking at lunch and exchanging healthy recipes. I don’t know that they would have done that on their own, but as a group, they’re willing to participate. DR. KLODAS: The big advantage of an employer is the ability to create a village. It’s your family for eight hours of every day, five days a week. That’s your support system, and the company can choose what foods are in the cafeteria and what activities are promoted at break time. It’s a huge opportunity. MR. STARNES: Remembering the work that went into developing utilization review and how that went into best practice guidelines, could we apply any of that to patient engagement? DR. VALDIVIA: Absolutely. There were important lessons learned. One of them is that trying to apply rules from the outside to control

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about that.” That’s intrinsic motivation. MR. STARNES: How can technology be used to facilitate patient engagement? DR. NERSESIAN: The top-selling apps in this country have to do with calorie counts, exercise, weight loss, and fitness kinds of things. There are apps used to manage arthritis with a picture of a guy on the screen. You touch those places that hurt this morning, what hurt tonight, and at the end of the month, you show it to your rheumatologist and your rheumatologist has a good idea where most of your aches and pains were. There are fairly simple apps that could be used to help people keep track of their exercise and eating. DR. GANDRUD: There have been different meter designs for patients with diabetes,

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M I N N E S O T A particularly children, which give the patient the ability to use a video game if they test their blood sugar at the appropriate time. This links rewards or the removal of rewards to behaviors that you want to encourage. Technology could be used in that way. DR. MILLS: Email is a very effective way of maintaining a connection with patients, especially when following up after an office visit. There are some concerns around the security of email, so the next natural step is to use secure messaging via a designated HIPAA-compliant communications portal. Encouraging patients to track specific health metrics via phone or online is a great way of making them active participants in ongoing management of conditions. It also allows us as physicians to get a greater and more tangible insight into how well their condition is being managed and what impact it is having on their day-to-day life. MR. STARNES: Do we run into issues when people don’t have access to technology? DR. VAN ZYL YORK: We run into that a lot, particularly when you’re trying to lead people to reliable health information as opposed to less reliable health informa-

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MR. STARNES: How can clinic patient portals help?

MR. STARNES: What is the best role that a health plan can play in patient engagement?

DR. MILLS: They certainly have a role, but we should not see them as a panacea for patient engagement. A well-designed portal can help individuals track certain elements of their health and can be an excellent conduit to establish an ongoing dialog between physician and patient outside the office environment. In addition, the data an individual patient can provide can also help a physician better manage their health issues to drive better outcomes.

DR. FISCHER: It would be really nice to see all the stakeholders get together on a task force and collaboratively work together on how to share this information. It seems like different pods are trying to come up with information and they’re not sharing it, or it’s not the same information, and that leads to more patient confusion and more cost.

DR. NERSESIAN: My patients have MyChart on Epic so they can see the results of their tests. A lot of these technologies will work if they get down to the personal level. If you’re a heart failure patient, your scale can notify your doctor if you gain more than two pounds in a day. In this country within a couple years, everyone’s going to have a smartphone. Blood pressure cuffs were developed that plug into an Apple iPhone. The FDA went to Apple and said, we’re going to regulate

An engaged patient has a better quality of life. Elizabeth Klodas, MD

tion. We’ve done some partnership work with public libraries by telling people that they can access information there. But we need to not overestimate the availability of technological means although I think that’s going to change. We’ll be seeing more and more availability of those sorts of things. When we talk in some of our workshops about medication management and ask, how do you remember to take your medication on time, the one that always comes up—and is when you see a lot of light bulbs go on—is using your cell phone to set an alarm to remind you when it’s time to take medication or do something else. DR. MILLS: The telephone is a great tool for checking in with patients, making sure they understand instructions or that they’re not experiencing any undue side effects from medications.

MINNESOTA

this as a medical device, and the last thing Apple wants is regulation from the Food and Drug Administration, so they backed off from it. DR. VAN ZYL YORK: Evaluation is key. Some weight loss apps do work for some people or may work for a period of time. But we need to seriously consider what is cost-effective and who it’s effective for. There is some great informational work being done by the CDC, the Text4baby Project for expectant mothers. The CDC sends moms texts on a regular basis with health information and reminders. That has been shown to be fairly effective in having people follow through on needed health behaviors. We need to not assume that all of these will work, and to determine the best way to design them.

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DR. NERSESIAN: It may sound inflammatory, but I think health plans can do a lot more. I think they support wellness in theory more than they do in practice. There are some good things that have been done, like promotion to get to the gym. Some plans have health coaches over the phone, but to me they’re so far removed from the patient and the patient’s doctor and providers that it’s not optimal. Some of it comes across as window dressing. Whether it’s the employer or the health plan, there is some conflict of interest or at least dual interest. They want to keep more of their money and the employer wants you to be healthy so you don’t miss work, and that’s okay. I would just like to see a win/win situation or maybe a win/win/win situation. There are certain interventions that benefit the health plan, that benefit your employer, and also benefit you, and a case must be made for that. If it looks like it’s purely in the interest of the employer or the health plan or just the patient, the other parties won’t buy into it. DR. KLODAS: Health plans are critical. They have all the data. They know where you live, they know what drugs you take, they know where you got them filled, they know how often you got them filled, they know how much you weigh, they know where you work. I mean, they know everything about you. That’s a little scary, but it’s also a tremendous opportunity to influence behavior, and health plans can be very creative. Humana has this program called Humana Vitality that’s a partnership between Humana and Wal-Mart. If a person goes with their Humana Vitality card and they buy apples, they get points on their Vitality card and those points can be used for stuff. If they buy Cheetos, nothing happens. DR. VALDIVIA: That’s a great example of incentivising behavior without interfering in on-the-ground activities. How are they going to reward us for focusing on population health and managing and engaging patients? The other is changing benefit models; in one of the European countries, you can sign up

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AUGUST 2013 MINNESOTA HEALTH CARE NEWS

M I N N E S O T A for a health plan for 10 years. Suddenly, the dynamic changes. There’s a different incentive, both for the provider and for the insurance company, to put resources into different segments of the population that today they have no interest in doing from a business standpoint. DR. VAN ZYL YORK: One of the key points in terms of that short-term vs. long-term view is a message from health plans that they’re trying to help you do things that are going to be in your long-term best interest in terms of your health. That’s what shapes cultural norms; it is no longer a cultural norm that everybody smokes. It will soon cease to be a cultural norm that we eat some of those things that we shouldn’t be eating, or that we don’t walk every day or that our employer doesn’t provide the opportunity to walk on company grounds. That shapes outcomes for everybody, regardless of which health plan you’re with and whether you switch plans every three years. As those norms impinge on people, it has a positive outcome. MR. STARNES: How could these initiatives be coordinated? DR. KLODAS: There are so many things we could try to improve about people’s lives, but maybe the thing to coordinate around is prediabetes. Pick something that everybody agrees is what we’re going to engage around at the payer level, at the employer level, at the care level. Pick one problem and address it in a coordinated fashion. Otherwise you get stuck with multiple inputs about all these different diseases. It’s overwhelming, and when you’re overwhelmed, you give up. DR. MILLS: The ideal scenario would be a completely coordinated approach. A first step along this road would be sharing of data from employer and health plan initiatives so that it is accessible to providers to help them proactively manage their populations. To do this we are going to have to move from “closed” systems to ones with APIs (Application Programming Interfaces) that will allow patients to easily share and connect appropriate data. MR. STARNES: How are we going to finance increased patient engagement? DR. FISCHER: That’s the toughest question we have here today. Currently, I think everybody in the health care chain is going to have to bear some of the cost. I like Liz’s idea of being creative with it, because that’s what can actually move progress.

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R O U N D T A B L E

DR. VALDIVIA: This is a great question because the system is going to respond to this as a key input and change on that basis. I think you break the question down into, is this new money or is this existing money? We’re learning we’re not tolerating the nearly $3 trillion spent on health care in this country, so it’s probably not new money going to the system. So if it’s not new money, then it’s existing money. The next question is, is it short-term repayment, or are we going to say, well gosh, we’re going to have a windfall in 50 years so let’s invest the money now and we’ll repay ourselves in the future. I don’t think that’s going to work. I think somewhere we’re going to have shift money to support this, and it’s going to have to pay off in the short term. Our only way to get there is to change the payment model away from feefor-service to something that we can use to invest in these short-term activities and be repaid for them.

financial incentives to do the right thing, the truth is that if a patient-centric approach to care is to be universally adopted, there needs to be a reason for physicians to get involved. DR. NERSESIAN: Can state and federal reform issues help? I don’t think we wait for government or wait for a lot of dollars. Honestly, as a pediatrician, how hard can I promote breast-feeding if a nursing mother doesn’t have a place to go and pump? Most of my moms were back to work in a month. How many women stayed out more than a month when they had their babies? Six weeks at most. Otherwise, you’re probably out of a job. And yet, how many places have a good place to pump at work and a refrigerator to store the pumped milk? Low-key stuff. I think we’re the solution. MR. STARNES: How could existing stakeholders work together to create this funding? DR. VALDIVIA: Big challenges exist today because of the way we finance health

We are a long way from being able to understand patient engagement. Tomás Valdivia, MD

DR. MILLS: There are two elements to financing improved patient engagement. The first is the purchase of systems that facilitate the process. A technological solution that sits alongside the electronic health record and facilitates patient data capture and out-ofoffice communication, although not absolutely necessary, is desirable if one is serious about making a step change in patient engagement and participation in decisionmaking. If CMS and other payers are serious about improving outcomes through better engagement, then it would seem appropriate to subsidize or have some financing options available for the purchase of such systems. The second is providing financial incentives, or a mechanism by which engagement activities can be billed for, so that physicians can be remunerated for the extra time they may need to spend in new activities. Although in the ideal world we shouldn’t need

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care. One of the challenges from a financial standpoint is the plan sponsor, whether it’s the employer or whether that’s the health plan that doesn’t have an incentive to invest in people that are well today. That’s one of the big disconnects in the system that doesn’t allow us to fund these kinds of activities. Sometimes there are windfalls like the tobacco suit. We’re able to invest those kinds of dollars, but those don’t come along very often. Another disconnect is the payment model that rewards us for doing things today. It’s not a health system, it’s a disease cottage industry, and we’re paid that way and it’s creating that problem. Until we address the fundamental issue of what’s shaping us, and that is how we get paid, that’s a disconnect as well. I’m sorry to bring more problems than solutions to the table, but I think fundamentally, until we address our financing model of paying a year at a time as opposed to over a

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MINNESOTA HEALTH CARE NEWS AUGUST 2013

M I N N E S O T A longer time frame, and, ultimately, the way we fund our delivery system in global payment versions versus fee-for-service, we’ll have a difficult time paying for these things. DR.GANDRUD: I’m in agreement. DR. VAN ZYL YORK: One of the key pieces in looking at that payment system is that our payment system now is organized primarily around doctors and hospitals, and we need a payment system that looks at the broader health care services that are provided. Those broader services currently do not have adequate financial support, so we don’t use those services, and they could make a difference. We have the illusion that doing this is somehow going to save us money. I’m not sure it will. DR. KLODAS: What are we paying for? I don’t know that we know exactly what it is that we’re going to buy with any money that we throw at this. What’s the outcome? If the outcome is people buying oranges, well, people are going to bear that cost. There

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a Cheetos-like snack that happens to be made out of pinto beans. It’s just as portable and it’s flavored with less salt. Have you made a seismic change in care? No. But you’ve stopped maybe 100,000 people from eating Cheetos that day. Wow. That’s a huge thing if you look at it from a population perspective. If you make a sandwich with 100 fewer milligrams of sodium? This is where Subway and companies can be part of the solution. One hundred milligrams of sodium is nothing from an individual perspective, but Subway has 30 million individual unique customers a week. How many truckloads of salt is that across a population? It’s huge. So there are things that can be done for which there’s just a tremendous amount of opportunity. DR. VALDIVIA: Private enterprise has to play a role. We don’t have as much capital as we used to. We used to have the luxury of fat, juicy margins; what we did with those margins was to fund more da Vinci machines and maybe

Data show that an engaged patient has better outcomes and at a lower cost. Vivi-Ann Fischer, DC

might be some points or something, but I guess I’m not sure. MR. STARNES: Is there is a role that private enterprise can play in funding patient engagement? DR. KLODAS: Private enterprise can make advice more actionable. We spend a lot of time educating people, we spend a lot of time making them feel really bad about their blood tests—and then they go home and try to do something and it fails, because ultimately they go home and back to the environment where they were failing before, and they don’t know what to do. There’s a huge gap between knowing and doing. There’s tremendous opportunity for that gap to be filled by individuals or companies that see something that could actually help, is not tremendously expensive, and is maybe a shift in spend. Instead of buying Cheetos, you buy

MINNESOTA

some Gamma Knives and other things with that capital. I don’t know that we’re going to have the same luxury of excess capital. I don’t think we have any choice but to partner with private enterprise to get some of this stuff done. Technology is one of the easiest and simplest examples, like apps to diagnose skin diseases. Technology is here and it’s going to happen, so I would suggest you get engaged and partner with organizations and private enterprise because they’re going to do this whether we want it or not. So let’s guide it and get involved in it. MR. STARNES: How will we know that patient engagement is working? DR. GANDRUD: Quality of life measures, quality of care, efficiency of care, cost of care— all those measures would be helpful in defining our success. DR. MILLS: We will know because our patients will be more satisfied, the health-related out-

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comes of our patients will improve, and the cost of delivering care will not be rising at the rate it has over the last decade. DR. VALDIVIA: We must understand what’s effective and what isn’t. It’s going to take an extraordinary amount of research to understand how this all works and what role it plays. DR. VAN ZYL YORK: Knowing whether patient engagement is working or not requires asking the patient. There were comments made earlier about the information that advertisers and companies have about us as consumers. We can have some of that sort of information about people as health care consumers and across the whole spectrum of health care activities. We have to be willing to ask the questions to figure out what are the right questions. Just because you have data doesn’t necessarily mean that you have information. How do they relate? A lot of those are research questions about what it is that makes a difference. Ultimately, there is a sense of “you either know it’s there or you don’t” when you ask a patient how their health care system is working for them, if they are getting what they need, and how they are feeling about it. If you’re asking them in a safe environment where there is nothing at risk for them, I think we can learn a lot of information. But we have to be willing to explore, to ask questions, and to do the necessary research. DR. FISCHER: We’re going to know that patient engagement is working when we see an increase in healthy behavior as reported at the annual physicals, a reduction in diabetes, and a reduction in diabetes relapse rates. I’m hoping that we will be able to stop some of these disease processes earlier, when people are 10 to 20 years old, and not wait until they’re 60 and then try to change their cardiac problems. DR. NERSESIAN: When the average person thinks, “What I can do for my own lifestyle to enhance my health, and how can I work with others, make use of community resources, make use of people with expertise and form those partnerships?”; when employers and government and health payers are all together—we may not agree on everything but when we agree on a lot of very basic facts—then we will have reached the point where this will be successful. DR. KLODAS: My measure is pretty simple, but aspirational: that the colors on the CDC map of obesity start to reverse.

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AUGUST 2013 MINNESOTA HEALTH CARE NEWS

TA K E C A R E

Choosing wisely Is that medical test or procedure really necessary? By Tim Hernandez, MD, Kris Soegaard, and Howard Epstein, MD, FHM

Telephone Equipment Distribution (TED) Program

ost people aren’t comfortable questioning their doctor’s recommendation when it comes to tests and procedures. We’ve been conditioned to “follow doctor’s orders” and, quite frankly, the majority of patients don’t have the benefit of a medical degree to back them up. But now, there is nationwide access to information designed to help patients discuss tests and procedures that are frequently prescribed, but may not be necessary and may even be harmful. This information is available through Choosing Wisely, a national campaign developed by the American Board of Internal Medicine (ABIM) Foundation. Three Minnesota health care organization—the Minnesota Health Action Group

Do you have trouble using the telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud

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

MINNESOTA HEALTH CARE NEWS AUGUST 2013

(The Action Group), the Institute for Clinical Systems Improvement (ICSI), and the Minnesota Medical Association (MMA)—have joined forces to support Choosing Wisely. Since the campaign was publicly announced in April 2012, 26 medical specialty societies representing more than 725,000 physicians have each identified five tests and procedures that may be overused or unnecessary for that specialty. Participating medical societies and their lists of tests and procedures can be found at www.ChoosingWisely.org. How it works Choosing Wisely provides information and guidance for both patients and physicians about: • Specific tests or procedures that are often overused and, if performed unnecessarily, may cause harm • The potential danger to the patient when health care services are performed unnecessarily • Tips to help patients ask their doctors the right questions during the process of diagnosing an individual health care need • Tips for physicians to help communicate with patients about tests and procedures, why a procedure or test might not be recommended, and its potential side effects The ABIM Foundation partnered with Consumer Reports to develop easy-tounderstand information about these tests and procedures that helps patients and physicians understand when a conversation about appropriate use may be needed. In Minnesota, The Action Group and ICSI received a joint grant from the ABIM Foundation to collaborate to support the Choosing Wisely campaign. The MMA received a separate grant from the ABIM Foundation to generate physician awareness about the campaign and establish a network of clinics interested in implementing recommendations. In partnership with the Guthrie Theater, the MMA will develop communication-skills training for physicians to improve conversations with patients about appropriate care.

Overuse of health care services is a leading cause of rising U.S. health care costs.

unnecessary, it may be harmful. Two examples are nuclear imaging for coronary disease and the general use of CT scans. Both procedures are associated with significant radiation exposure. In fact, many experts agree that patients are exposed to excess radiation through procedures like non-indicated CT scans and nuclear imaging with stress test. In one study, as many as 34 percent of CT scans were associated with incidental findings. Such findings often lead to further studies or procedures, as well as anxiety for patients. Some studies estimate as many as one-fifth of all nuclear cardiac scans are positive when the patient has no obstructive coronary disease. The consequence is often an angiogram that may lead to potentially more significant complications and great expense. Choosing Wisely in Minnesota As a regional collaborative, The Action Group and ICSI led the process to identify the targeted tests and procedures that will be the initial focus for Choosing Wisely in Minnesota. Working with stakeholders that included The Action Group, ICSI, physicians, employer purchasers, and consumers, 11 tests and procedures related to the medical situations listed below were identified as potentially unnecessary or even harmful. 1. Imaging for low back pain within the first few weeks after onset of pain, unless certain “red flags” are present 2. CT scans during immediate evaluation of minor head injuries 3. Imaging for uncomplicated headache 4. Elective, non-medically indicated inductions of labor or cesarean delivery before 39 weeks’ gestation Choosing wisely to page 34

In the next issue..

Why it’s necessary

Overuse of health care services is a leading cause of rising U.S. health care costs. While some health care utilization is driven by our aging population, the Institute of Medicine—an independent, nonprofit organization that works outside of government to provide unbiased advice to decision-makers and the public—estimates as much as 30 percent of health care spending is wasted on unnecessary services, excessive administrative costs, fraud, and other problems. The largest problem is unnecessary services. Also referred to as clinical waste, this accounted for an estimated $5.8 billion of the $37.7 billion spent on health care services in Minnesota in 2010. Many patients believe that more care equals better care. However, that is not necessarily true. More care may not only be

• Erectile dysfunction • Flu shots • Health insurance exchanges AUGUST 2013 MINNESOTA HEALTH CARE NEWS

INSURANCE

Affording long-term care

hile most elderly individuals prefer to live at home, a significant number of Minnesota seniors will need a higher level of care than can be provided in their homes by community supports or by family members. They will need long-term care, which is typically provided in senior housing developments, assisted living centers, and nursing homes.

Start planning for it now. By Michele Kimball

According to the state Department of Human Services (DHS), approximately 11 percent of Minnesotans younger than 84 require long-term care at some point. That percentage grows to 55 percent for those above 85 years of age. And this care is not cheap.

Elder and Advocacy Services I am passionate about being an advocate for the elderly and disabled, including in maltreatment, injury and wrongful death claims.

Other services include: • nursing home litigation • health care agent appointments • elder abuse and neglect • elder mediation • nursing home resident rights • estate planning • speaker

Please contact: Suzanne M. Scheller, Esq. Scheller Legal Solutions LLC 6312 113th Place North Champlin, MN 55316

763.647.0042 suzy@schellerlegalsolutions.com

www.schellerlegalsolutions.com 30

MINNESOTA HEALTH CARE NEWS AUGUST 2013

Costs

Getting a handle on long-term costs is critical.

Senior housing developments, assisted living centers, and nursing homes often require down payments that cost tens of thousands of dollars and cost as much as a mortgage payment each year the care is used. DHS studies have shown that the average annual cost of long-term care in 2012 was $67,000 for nursing home care; $40,000 for care provided in an assisted living facility; and $20,000 for home health care. Not having a long-term care plan in place before you need it can lead to serious financial consequences. Without careful planning these costs can quickly eat through a family’s retirement savings and could leave some dependent on public Medical Assistance programs to pay for their care after their personal assets have all been spent. This is why it is critical to start planning for your long-term care right away, whether you’re in your 60s, 50s, 40s or even younger. In fact, starting when you’re younger and before you have a chronic disease will help you purchase such insurance less expensively. Doing careful research on what type of care settings fit your lifestyle and wishes, how much those facilities cost, and how you can adjust your retirement planning to ensure that you have funds will help ensure you are prepared. Creating your own plan also gives you the peace of mind of knowing that you will have control over where you’ll spend the last years of your retirement and what type of care you’ll receive. Careful planning also ensures that your long-term care costs don’t eliminate your ability to pass along some assets to your children and grandchildren.

• Find out if your employer offers insurance that you can purchase to cover long-term care and talk to your insurance agent or financial planner about planning for longterm care needs. • Determine if you are able and willing to save on your own to pay for long-term care with personal income and savings.

Getting a handle on long-term costs is critical to the financial future of not just individual Minnesotans but our state as well. By the year 2030, Minnesota’s over-65 population will double—and if a significant number of tomorrow’s seniors don’t have adequate plans in place for long-term care, the state budget will end up picking up progressively more of the costs. That may sound appealing, but the downside is that seniors receiving state-provided care will not have as much control over what type of facility they may eventually live in, where the facility is located, or whether or not they have a private room. State-provided care would also take funds away from other state needs. Other private financial options for covering long-term care Retirement income, savings, and investments. This is how most people who are not on Medicaid pay for long-term care. These resources could include Social Security, pensions, 401(k) plans, IRAs, stocks, bonds, and annuities. AARP’s long-term care cost calculator (www.aarp.org/longtermcarecosts) tracks the annual percentAffording long-term care to page 32

Own your future Last year, the State of Minnesota and Lt. Governor Yvonne Prettner Solon launched a statewide campaign called “Own Your Future” to encourage Minnesotans to think about and plan for their long-term care needs (mn.gov/ownyourfuture). The timing for this statewide education campaign couldn’t be better as our state’s senior population is surging at the same time that people’s understanding of longterm care, how much it costs, and how to afford it lags far behind. In 2012 the Department of Health and Human Services (DHS) surveyed 2,400 individuals at the Minnesota State Fair and found that 27 percent had no idea how they would The Own Your Future pay for their long-term care needs. Luckily for these individuals, the website has Own Your Future website has some first steps to take when considering some first steps to take. your personal plan. • Assess your long-term care risk and learn how much long-term care costs in your community.

• Determine what changes you may need to make to your home in order to live there longer—installing grab bars in the bathroom, for example—or if a house more suited to older residents, like a one-level, would be more appropriate. • Talk to friends or relatives who currently provide caregiving for a loved one. You can learn a lot from talking to people who have direct experience. AUGUST 2013 MINNESOTA HEALTH CARE NEWS

Affording long-term care from page 31

receive, and access to your personal health information. Discuss this with your life insurance agent.

age increase for specific services and can help you determine how much money you need today and the typical rate of increase Resources in investments you need to cover future AARP offers a resource guide Studies have shown costs. to help individuals prepare Continuing-care retirement that the average for their future long-term care communities (CCRCs). These needs. To order a printed copy annual cost communities provide a continuof the resource guide, of long-term care um of care, all in one location. call (888) OUR-AARP/(888) Seniors can transition from in 2012 was 687-2277) or TTY (877) 434independent living to assisted 7598. $67,000 for living to nursing care, all in the Contact the One Stop nursing home care. same building complex. In some Shop at (800) 333-2433 or cases, this approach can be a more ecovisit www.MinnesotaHelp.info for personnomical approach than other options. alized, objective assistance in understandHowever, before joining such a community ing all your long-term care options. The it is important to consult with a trusted financial or One Stop Shop does not sell, market, or endorse any insurlegal adviser to be confident that the community will be ance product, lender, or planning service. financially viable for a long time and that you understand For information on long-term care insurance in all the costs involved. Minnesota, contact the Minnesota Department of Life insurance. Depending on your policy, you may be Commerce Consumer Response Team at (651) 296-2488 able to borrow or withdraw money while keeping the polior (800) 657-3602 (outside the metro area) or email cy. Many policies also allow people with terminal illnesses to access www.Consumer.protection@state.mn.us. some of their death benefits early. But itâ&#x20AC;&#x2122;s important to understand how your decision could affect your taxes, any public assistance you Michele Kimball is the director of the Minnesota chapter of AARP.

Minnesota

Health Care Consumer July survey results ... Association

26.67%

16.67% 33.33%

No opinion

Disagree

6.67%

10.0% 6.67% 3.33% Strongly agree

Agree

No opinion

Disagree

5. I am concerned that fixed health care prices could lead to excluding patients that do not fit a profitable profile.

40.0%

46.67%

40 30

26.67%

16.67%

6.67%

3.33% Agree

15 10

Strongly disagree

No opinion

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS AUGUST 2013

Strongly agree

Agree

No opinion

Disagree

26.67%

25 20.0%

20 15 10

10.0% 3.33%

3.33% 0

Percentage of total responses

16.67%

Strongly agree

25 20

15 10

Agree

33.33%

0.0% Strongly agree

if I knew the costs of care in advance.

Percentage of total responses

40.0% 40.0%

Percentage of total responses

43.33%

4. I could better utilize my health insurance coverage

40.0%

advance how much it was going to cost.

3. I am concerned that fixed prices for medical services may affect quality of care.

2. I would be more likely to seek care if I knew in

1. I support current initiatives that offer medical services for a fixed price.

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the July survey.

Strongly disagree

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? AUGUST 2013 MINNESOTA HEALTH CARE NEWS

Choosing wisely from page 29

5. Elective, non-medically indicated inductions of labor before 41 weeks gestation, unless certain aspects of maternal health support induction 6. Routine prescription of antibiotics for mild-to-moderate sinusitis unless symptoms last for seven or more days or symptoms worsen after initial improvement

Patient information is downloadable at ConsumerHealthChoices.org, including select materials in Spanish. Materials include fact sheets and articles about when specific tests and procedures are truly necessary, when they can cause harm to a patient, how they contribute to excess spending, and alternative tests/procedures. There is also general information about how to be a more informed patient.

7. Repeat colonoscopy sooner than every five years for patients who have one or two small polyps, without high-grade dysplasia, completely removed via high-quality colonoscopy 8. Feeding tubes in patients who have advanced dementia; instead, offer oral-assisted feeding 9. Recommending more than a single dose of palliative radiation for an uncomplicated bone metastasis 10. Stenting coronary artery blockages that are not directly causing an acute heart attack 11. Routine preoperative testing for low-risk surgeries without a clinical indication Choosing Wisely has the potential to truly drive change in care delivery by: • Encouraging physicians to take a good, hard look at the care they deliver on a daily basis, in order to ensure the safety of their patients by avoiding unnecessary procedures and tests

• Educating patients and physicians about the identified areas of overuse and how both patients and physicians can affect the quality and safety of health care

• Giving employers and individual patients access to information about health conditions and appropriate health care services, and guiding them on how to begin this conversation with their physician and what questions to ask To learn more about this initiative, visit ChoosingWisely.org or ConsumerHealthChoices.org. We encourage you to use these materials to prepare for your next doctor visit. If your doctor recommends one of these tests or procedures, you can feel confident about asking the right questions. Not only could you directly improve the care you receive and your ultimate health outcomes, you could save valuable health care dollars. Tim Hernandez, MD, is board-certified in family medicine; practices with Entira Family Clinics, located in the east metro; and is Entira’s medical director for quality improvement. Kris Soegaard is COO of the Minnesota Health Action Group. Howard Epstein MD, FHM, is board-certified in internal medicine and is an internal medicine hospitalist and palliative care physician at Regions Hospital, St. Paul. He is also chief health systems officer at the Institute for Clinical Systems Improvement (ICSI), Bloomington.

Now accepting new patients

A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures.

Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.

We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health. Whether you have experienced any type of cardiac event, are at risk for one, or

are interested in learning how to prevent one, we can design a set of just-for-you solutions. Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions

To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

MINNESOTA HEALTH CARE NEWS AUGUST 2013

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