Minnesota Physician August 2018 by Minnesota Physician Publishing

MINNESOTA

AUGUST 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting Exploring new potential BY MICK HANNAFIN

ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims. Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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AUGUST 2018 MINNESOTA PHYSICIAN

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TH 50 SESSION AUGUST 2018

CONSOLIDATION IN HEALTH CARE

Volume XXXII, Number 5

COVER FEATURES Physician/employer direct contracting Exploring new potential

Examining cost and quality issues

CAR T-cell therapy Modifying cells to fight cancer

By Veronika Bachanova, MD, PhD

By Mick Hannafin

Thursday, November 1, 2018, 1-4 pm

DEPARTMENTS

The Gallery, Downtown Minneapolis Hilton and Towers 1101 Marquette Avenue South

CAPSULES

MEDICUS

HEALTH INFORMATION TECHNOLOGY 10 Reducing patient no-shows Hitching a ride By Chip Truwit, MD, FACR, and Chris Merritt

HEALTH INSURANCE Medicare Cost Plans

PATIENT RECORDS Health information exchange

Sharing EHRs across networks By Karen Soderberg, MS

MEDICAL EDUCATION An indigenous curriculum

Improving the quality of care By Melissa Lewis, PhD, and Jill Doerfler, PhD

Changes may affect your patients By Kelli Jo Greiner

PROFESSIONAL UPDATE: ONCOLOGY Cancer health disparities 16 Factors and potential remedies By Narjust Duma, MD

SPECIAL FOCUS: PHYSICIAN BURNOUT Measuring the burnout curve 18 Data-driven solutions By Rahul Koranne, MD, MBA, FACP, and Heather Britt, MPH, PhD

BACKGROUND AND FOCUS: Consolidation in health care threatens the viability of the system and is escalating at an alarming pace. Patients are left with fewer choices, both in terms of which doctor to see and in terms of treatment options, including medications, from the doctor they do see. Costs are often increased and quality often decreases when systems become too large. Demands to comply with increasing regulations leave many medical practices in a bind. How can they maintain independence without the infrastructure of a large system?

OBJECTIVES: We will examine the root causes of health care consolidation. We will illustrate what has worked and what has not. We will explore cases where FTC regulations are pushed to the limits and the threat to patients this poses. We will look at the larger continuum of care and how public health issues are impacted by consolidation. We will discuss state legislative initiatives that need to be in place and what must be done to keep patient well-being at the center of health care delivery.

Panelists include:

Sponsors include:

Bryan Dowd, PhD, Professor, Division of Health Policy and Management, University of Minnesota School of Public Health

Carris Health

Cindy Firkins Smith, MD,

Center for Diagnostic Imaging (CDI) Entira Family Clinics Minnesota Gastroenterology, PA

Co-CEO, Carris Health Timothy Hernandez, MD, Medical Director for Quality, Entira Family Clinics

University of Minnesota School of Public Health

Scott M. Jensen, MD, The wellbeing of the health care workforce 20

Senator, District 47, Minnesota Legislature

Practical tips for a stressful profession

Scott R. Ketover, MD, AGAF,

By Mary Jo Kreitzer, PhD, RN, FAAN

President and CEO, Minnesota Gastroenterology, PA Liz Quam, Executive Director, CDI Quality Institute

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; email mpp@mppub.com; phone 612.728.8600; fax 612.728.8601. 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 the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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Collaborative Developing Benchmarks for PostOperative Opioid Prescribing The MN Health Collaborative, a group of 14 health care systems, is currently developing an innovative approach to prescribing opioids for post-operative pain. The new approach addresses the unique needs of patients based on their health histories, current diagnoses, and required surgical and post-operative treatment needs. To combat potential problems of overprescribing, such as side effects and dependence for some individuals, surgeons within the collaborative have begun an effort that uses a specific, nuanced approach to post-surgical opioid prescription. It was developed in part as an answer to the lack of evidence-based guidelines for post-operative opioid use and is based on available literature, expert consensus, and community data relevant to the effort. The best practices and takeaways will be

shared with the health care community as the efforts progress. Some of the collaborative’s goals are to help reduce, and eventually eliminate, opioid overdose deaths, as well as provide better prevention and treatment practices for opioid addiction. These require a multi-pronged approach including stricter prescription guidelines, improved drug disposal, true care coordination, and stronger education and support for both patients and providers. The new approach to post-operative opioid prescription expands upon the State of Minnesota’s Department of Human Services newly released guidelines. “We believe this work will provide a clearer determination of the varying pain management needs required by different surgical procedures,” said Claire Neely, MD, chief medical officer for ICSI. “This effort will help support a significant need to develop more patient-centered prescription practices where opioids are concerned.”

Sanford Health to Merge With Good Samaritan Society The boards of directors for two nonprofit, Sioux Falls-based organizations, Sanford Health and Evangelical Lutheran Good Samaritan Society, have signed an affiliation agreement. Discussions of the merger began last year. Once complete, it would create a $6 billion company with 47,000 employees. There is no financial exchange in the merger. The Evangelical Lutheran Good Samaritan Society will become part of Sanford and its name will change to the Good Samaritan Society of Sanford Health. Its current president and chief executive officer, David Horazdovsky, will remain in charge of the organization. Sanford will keep its name. Leaders of the two organizations said in a news conference in Sioux Falls that it was a new way to work together to provide care for senior citizens who will be increasing in

numbers in the coming years as baby boomers age. Details on the merger are still being discussed. Sanford Health employs 28,000 people in South Dakota, North Dakota, and seven other states, with 44 hospitals and close to 300 clinics. Evangelical Lutheran Good Samaritan Society employs 19,000 staff and operates more than 200 senior care services facilities, including post-acute, skilled-nursing, hospice, assisted-living, rehabilitation, and home-health facilities, in 24 states. The goal is to bring the organizations together by Jan. 1, 2019, pending review from the Federal Trade Commission.

Communication Between Hospitals During Patient Transfers Improves Care and Mortality Rates A study from the University of Minnesota Medical School has shown that diagnostic discordance

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AUGUST 2018 MINNESOTA PHYSICIAN

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CAPSULES

commonly occurred during inter-hospital transfers and was associated with increased patient mortality. More than a million patients are transferred between hospitals annually in the U.S. It is a challenging process for hospitals and patients, and breakdowns in communication are common. The researchers studied data from more than 180,000 adult patients in five states over a three-year period and compared the chronic diagnosis before and after transfer as well as the impact that data sharing had on information transfer and patient outcomes. They also investigated whether health information exchange functionality adoption improved diagnostic discordance and inpatient mortality. They found that there is a lot of lost information, or changes in diagnosis, from the sending hospital to the receiving hospital—73 percent of patients gained a new diagnosis following transfer while 47 percent of patients lost a diagnosis, according to

electronic records. However, transfers where both hospitals participated in data sharing mechanisms such as a health information exchange were associated with a lower rate of information loss and lower mortality. “In this population—which is very high risk—the ability of two hospitals to talk to each other has the potential to improve patient safety, make care much more cost effective, and reduce mortality,” said Michael Usher, MD, PhD, assistant professor of medicine in the division of general internal medicine and author of the study. The full study is published in the Journal of General Internal Medicine.

Psychiatric Residential Treatment Facility for Children Opens in Duluth Northwood Children’s Services has opened Minnesota’s first psychiatric residential treatment facility that will meet the needs of children requiring inpatient psychiatric care.

AUGUST 2018 MINNESOTA PHYSICIAN

Until now, families in the area who required these services have had to travel to other states for care. The facility, located in Duluth, will provide inpatient mental health services in a non-hospital setting for up to 48 children. It will offer intensive medical services, full-time nursing, a higher staff-to-student ratio, intensive psychotherapy, and active treatment each day. To qualify for services, patients must be under the age of 21 and be referred by a mental health professional. The facility will also offer educational services in collaboration with the local school district and district of residence; recreational programming and access to exercise facilities to maintain healthy physical activity; access to other therapies including occupational therapy, recreational therapy, physical therapy, and speech therapy; and other services including health care, dietary, emergency physician, and medication monitoring. “We are excited to offer this important service to Minnesota

children,” said Dick Wolleat, CEO of Northwood Children’s Services. “It’s been long needed, and now maybe families won’t have to travel so far to get the right treatment for their child.” This is the first of three such facilities that are planned to open in Minnesota over the next two years. Eventually, these facilities will provide a total of 150 beds for children. The Hills Youth and Family Services announced in June that it will build a 60-bed facility in East Bethel, which is expected to open in late fall 2019. Clinicare Corporation plans to operate an approximately 40-bed program beginning this fall at a location outside of the metro area that has not yet been determined.

Anesthesia and Surgery Linked to Decline in Memory and Cognition In Older Adults New research from Mayo Clinic has shown that exposure to general anesthesia and surgery is associated

Patients with regenerative medicine questions?

Regenerative medicine focuses on the body’s natural ability to repair, replace, and regenerate damaged or aging tissues. At MINNESOTA REGENERATIVE MEDICINE (MRM), a specialty clinic of HOGUE CLINICS, autologous bio-cellular agents such as platelet-rich plasma (PRP), fat aspirate concentrate (FAC), and bone marrow aspirate concentrate (BMAC) are used to treat degenerative conditions. To ensure proper placement, ultrasound or fluoroscopy guidance is used when clinically indicated during regenerative medicine treatments.

Regenerative medicine treatment categories at MRM include: • Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine) • Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING • Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT

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CAPSULES

with a subtle decline in memory and thinking skills for adults over the age of 70. The decline found in brain function was low, but it could be meaningful for older adults with already low cognitive function or pre-existing mild cognitive impairment who are considering surgery with general anesthesia. The researchers say that for older adults with borderline cognitive reserve that is not yet clinically obvious, exposure to anesthesia and surgery may unmask underlying problems with memory and thinking. According to Mayo Clinic, the link between cognitive decline and surgery and anesthesia in older adults has been debated for many years. Animal studies have suggested that exposure to inhaled anesthetics may be related to brain changes linked to Alzheimer’s disease, however most studies in humans have not consistently shown an association. For this study, the researchers analyzed nearly 2,000 participants

in the Mayo Clinic Study of Aging, a long-term epidemiologic and population-based prospective study about cognitive changes related to aging. Participants in Olmsted County undergo cognitive assessments at roughly 15-month intervals. The participants were all 70 to 89 years of age at the time of enrollment in the study. Researchers analyzed whether exposure to surgery and anesthesia during the period 20 years prior to enrollment was associated with cognitive decline and whether exposure to anesthesia after study enrollment as an older adult was associated with a cognitive change. They found that decline after exposure to surgery and anesthesia was slightly accelerated beyond that associated with normative aging. “We need to be sure that patients considering surgery, and their families, are properly informed that the risk of cognitive dysfunction is possible,” said Juraj Sprung, MD, PhD, an anesthesiologist at

Mayo Clinic and senior author of the study. “In addition, alternative strategies should be discussed with patients before surgery is undertaken for those deemed to be at high risk. This study provides further reasons for clinicians to start performing routine preoperative cognitive evaluations of the elderly to further clarify an individual’s risk of exposure to surgery and anesthesia. This initiative has been endorsed by the American Geriatrics Society but was not widely put into clinical practice.” The study authors emphasized that it is not possible to determine whether anesthesia, surgery, or the underlying conditions necessitating surgery caused the decline in cognition.

Glacial Ridge Opens Starbuck Location, Expands Services

with radiology technologists, lab technicians, and nursing staff from its location in Glenwood, about eight miles away. Two medical doctors and two nurse practitioners will provide care. An expansion to its Glenwood hospital facility was completed in January to increase the number of patient rooms. In the past decade, the number of local and regional patients using the health system’s services has tripled and so has the number of physicians and advanced care providers. “With Starbuck being an important part of our market area, we want to provide more convenient services to patients in western Pope County,” said Kirk Stensrud, chief executive officer of Glacial Ridge. He added, “Opening a clinic in Starbuck is a long-term commitment that Glacial Ridge Health System is making to better serve all of our patients.”

Glacial Ridge Health System opened its Starbuck Medical Center in late June. The facility is staffed

V Autism and Obstructive sleep apnea are now approved conditions V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

• Severe and persistent muscle spasms, including those characteristic of MS

• Intractable Pain

• Obstructive sleep apnea

• Autism

• Post-Traumatic Stress Disorder

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS (651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

AUGUST 2018 MINNESOTA PHYSICIAN

MEDICUS

Kelly Han, MD, director of advanced congenital cardiac imaging at the Minneapolis Heart Institute and Children’s Heart Clinic at Children’s Minnesota, has received the first The Jon DeHaan Foundation Award for Innovation in Cardiology. Han is being recognized for her outstanding contributions to improving both safety and quality of imaging congenital heart disease in adults, children, and infants. She has also made significant contributions to treating and caring for adult women with congenital heart disease who either want to become pregnant or have become pregnant and have special considerations due to their impaired cardiac status. Han earned her medical degree at the University of Wisconsin Medical School. Jafar Golzarian, MD, director of the division of interventional radiology and vascular imaging at the University of Minnesota, has been selected to receive the 2018 Honorary Member of Chinese College of Interventionalists (CCI). It is the highest honor awarded by the society. Golzarian is also an active researcher specializing in interventional treatment of peripheral artery disease, abdominal aortic aneurysms, uterine fibroid embolization, hepatocellular carcinoma, prostate artery embolization, and varicocele embolization. He received his medical degree at the University of Brussels in Belgium. Kurt DeVine, MD, a family practice physician at CHI St. Gabriel’s Health in Little Falls, received the Bruce and Denise Rueben Courage Award from the Minnesota Hospital Association (MHA) for implementing a clinic-based model that monitors patients using narcotics for pain with the assistance of community partners, encouraging reduced prescribing among his colleagues through the use of CDC guidelines, and offering suboxone treatments in the community. Steven Mulder, MD, president and CEO of Hutchinson Health, received MHA’s Spirit of Advocacy Award for being a long-standing champion for patient safety, including being an early supporter of and helping to develop the state’s adverse health events reporting law. Both recipients earned their medical degrees at the University of Minnesota Medical School. Patrick Riedel, MD, a glaucoma surgical specialist with Minnesota Eye Consultants, has performed the first in-human procedure of a new device to treat glaucoma. Riedel implanted the Brown Glaucoma Implant in a patient on May 1, 2018, as part of an investigational clinical study. The device is designed to lower intraocular pressure (IOP) in glaucoma patients by shunting aqueous humor from the anterior chamber of the eye to the surface of the eye. Because there are no physiologic sources of outflow resistance, the device can be engineered to target an IOP that is low enough to halt the progression to blindness in a patient with glaucoma. The early feasibility study will enroll a total of 10 subjects at up to three centers; they will be followed for 24 months. Riedel earned his medical degree at the University of Minnesota Medical School.

Osmo Vänskä

Paul Jacobs

Emanuel Ax

Women of the Minnesota Chorale

Santtu-Matias Rouvali

Gil Shaham

Season Opening: Osmo Vänskä and Emanuel Ax Sep 21-22

Vänskä Conducts The Planets Sep 27-29

Celebrating Northrop's Restored Pipe Organ Oct 12-13 | Northrop Memorial Auditorium

Shaham Plays Prokofiev Oct 18-19

612-371-5656 / minnesotaorchestra.org Orchestra Hall / #mnorch PHOTOS Vänskä: Travis Anderson Photo. Other photo credits available online.

MINNESOTA PHYSICIAN AUGUST 2018

HEALTH INFORMATION TECHNOLOGY

Reducing patient no-shows Hitching a ride BY CHIP TRUWIT, MD, FACR, AND CHRIS MERRITT

edicaid spends $5 billion on non-emergency medical transportation (NEMT) every year, but 3.5 million patients still miss medical appointments. Patients who do not receive timely care may experience health crises that require expensive emergency department visits and potential inpatient admissions. Moreover, estimates show that no-show appointments cost U.S. health care systems $150 billion each year in lost revenue and unproductive staff time. The National Institutes of Health says that patient no-shows significantly affect not just care delivery, but also cost of care and resource planning. Patient access to reliable transportation represents one of the most persistent barriers to health care in the U.S. Published data report that lack of transportation is responsible for 25 percent of all medical appointment no-shows. This is particularly true for our under-served populations, whose health is significantly constrained by social determinants, including access to food, housing, employment, and transportation. For this population, transportation is effectively “medicine.” Paradoxically, this transportation barrier exists at a time when the number of transportation options is unprecedented. Traditional taxis, clinic shuttles, public transportation, and ride share services like Lyft and Uber provide ride options. Moreover, the sheer number of these ride services alone provides exceptional coverage. So, why do patients still miss appointments due to lack of reliable transportation?

Treating the symptoms If you think about it in terms of medical care, the system is treating the symptom of transportation, not the disease. There have been multiple ride options for quite some time, yet no-shows persist. Some heath systems offered an incremental change, replacing taxis with Lyft and Uber, although their process itself changed little. In fact, a JAMA publication earlier this year reported that such programs have had very little impact on no-shows. However, such programs and the JAMA publication both fail to acknowledge that it’s actually the process that impacts patient engagement and participation in ride programs, not necessarily the make and model of the vehicle. Upstream Health Innovations (Upstream) and its first commercial venture, Hitch Health, witnessed this first hand at Hennepin Healthcare and set out to uncover why this was happening. It’s important to understand the “why” before you provide a solution to a problem, particularly one that is influenced by social determinants of health. Upstream’s human-centered health care design team met with hundreds of patients, families, and health care professionals to understand the problem and uncover a solution. Medicaid patients told us they need to call their health plan three days in advance of an appointment to request transportation. They are often put

AUGUST 2018 MINNESOTA PHYSICIAN

on hold and can spend 30–45 minutes on the phone, wasting their time and mobile phone minutes just to get a ride to the doctor. The coordination of return rides home is equally painful for both the patient and the clinic staff, with long wait times that often exceed 2–3 hours.

Jump starting the system Patients told us they do not want to call to schedule a ride, be placed on hold, download an app, or provide a credit card for either the traditional or new ride service options offered to them. Collaborating with Upstream and Hennepin Healthcare, Hitch Health has developed human-centered design software to improve patient access to transportation and care. The proprietary technology software (patent pending) sits between an appointment system—tied to electronic health records (EHRs) or practice management systems (PMS)—and a ride service such as Lyft. Importantly, Hitch Health is agnostic to both the health record and the ride service (ride share or taxi). Patient appointment data flows electronically to Hitch Health, whose software filters the appointment data to determine which patients will receive a ride offer. Hitch Health then automatically sends patients a ride offer through basic SMS texts delivered to their cell phones. The process is completely automated and controlled by the patient. When the appointment is over and it’s time to go home, the patient simply texts “ready,” and a ride will pick them up within minutes. The software was designed with simplicity and security in mind. Because the software sits in between an appointment system and a ride service, it communicates directly with the patient, removing the middleman. Hitch Health obviates the need for a phone call, app, or credit card to access the transportation service. Front-line staff can also track the patient’s ride locations through a dashboard, which increases coordination, efficiency, and customer service. Thus, Hitch Health is quite different from other “startup” solutions that simply exchange taxis for Lyft and Uber services, yet maintain the current process of engaging call centers to schedule rides. Hitch Health is an innovative logistics solution that automates both the front and back ends, providing a human-centered experience and increasing patient satisfaction.

Driving up the numbers The results are drawing attention. Hitch Health began a pilot with Hennepin Healthcare, a large safety-net hospital in Minneapolis with more than 650,000 annual appointments and a relentlessly persistent 19 percent no-show rate. Hitch Health has been deployed at five Hennepin Healthcare clinics, and has provided more than 8,000 rides to Medicaid patients in the metro area. Remarkably, 80 percent of these patients had six or more missed appointments in the previous 12-month period. Data suggests a reduction in no-shows of greater than 8 percentage points in those clinics deploying Hitch Health. Patients are showing up to their appointments and reporting

high levels of satisfaction with the service. Hitch Health currently has a strong 9.7/10 net promotor score from 3,000 patients who have taken the voluntary text satisfaction survey. Hospitals and clinics also report satisfaction with the increased efficiencies and improved attendance, both of which present a very real and immediate impact on their bottom line.

increased patient experience scores, and positive revenue impact to the bottom lines of health systems. This data, coupled with independent medical and operational evaluations, will be included in a publication designed to demonstrate how significantly a proactive approach to transportation can impact patient access to care. Health care providers and payers have an opportunity to integrate this service into their population health, patient engagement, and community health strategies.

How much of an impact? A case study with one of Hitch Health’s new customers in California No-show appointments cost said that their 20 percent no-show rate had cost U.S. health care systems them about $3.2 million in revenue opportunity in $150 billion each year. 2017. If Hitch Health reduced these no-shows by just 2 percent, the clinic could realize an additional $320,000 in revenue. To help clients calculate their own financial incentives, Hitch Health has added a return on investment calculator to its website: www.hitchhealth.co. The initial success and automated approach of Hitch Health has produced a high volume of requests from health care systems across the country. The company has already inked agreements with three health systems in California and Minnesota, and implementation is in full swing with those customers. Additional agreements are pending in subsequent markets as the company embarks upon its national rollout. Hitch Health will have a years’ worth of data by mid-2018, which will enable it to evaluate specific outcomes, such as decreased no-show rates,

Summing up Hitch Health values human-centered design and understands that listening to patients provides the innovation and creative thinking to develop solutions that work for all constituents. Based on this approach, Hitch Health’s process is working for health care systems, patients, and communities.

Chip Truwit, MD, FACR, co-founder of Hitch Health, is chief of radiology at Hennepin Healthcare and chief innovation officer at Upstream Healthcare Innovations. He is an emeritus professor of radiology at the University of Minnesota.

Chris Merritt is vice president of sales and market development at Hitch Health.

Creating a Healthier Minnesota Juniper is helping rural and urban communities across Minnesota create a culture of health. Our evidence-based programs give your patients the tools they need to take manage their health in a way that works. Juniper programs offer group training to prevent escalation of disease, reduce hospital admissions, lower health care costs, and improve independence. Programs concentrate on: n

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To locate a Juniper program, or to start one through your clinic or in your community, please call us toll free at 1-855-215-2174 or email info@yourjuniper.org. To find our more about the Juniper program please visit: www.yourjuniper.org Innovations for Aging, LLC, a nonprofit subsidiary of Metropolitan Area Agency on Aging, is the managing partner for Juniper, providing management information systems, coordination, member services and support to our partner organizations.

MINNESOTA PHYSICIAN AUGUST 2018

3Physician/employer direct contracting from cover

health care landscape: health care professionals manage health care, while insurance companies manage health plans.

increase the deductible and/or out-of-pocket costs, introduce consumerdriven health plans so employees can “understand the cost of health care,” increase their risk within their plan by raising their own specific stop-loss deductible, and so on.

Many employers have been sold on the idea that, through disease management and care management, health plans can manage health risks and health care costs. While the health plans may have their hearts in the right place, more often than not, we see little meaningful engagement with the employees they are trying to reach.

The issue with many of these strategies is that they do not affect the root cause of increasing health care costs. That is, they focus on “fixed costs,” which only make up 15 to 20 percent of their whole plan costs, and they ignore the actual health conditions that are prevalent in their plan. Additionally, many of these strategies are short-term fixes. They may alleviate or mitigate costs for a short period, but many of these tactics actually lead to higher health care costs in the long run.

We did not make our employees better consumers by giving them a high deductible.

There is an alternative. By contracting directly with health care providers in their area, employers may be able to lower their costs while still providing effective coverage to their workers. Many of these models can also benefit health care providers who choose to “go direct” to contract with employers.

Understanding the health care landscape Oddly, many business owners and administrators are only just beginning to understand a simple explanation for our convoluted and misaligned

Employers have also been sold on the idea of discounts by their brokers and agents. These discounts were supposed to help compare one health plan’s acuity at provider negotiations over another. While discounts may have had a function at some point, the fact is that these discount claims can be very deceiving.

Leverage is everything when it comes to negotiations. The larger the patient base, the more disruption may be caused by a health system dropping out of a given health plan’s network. Therefore, if you are a “Goliath provider,” your discount arrangement is very different than the independent “David providers” of the world. Ergo, a health plan may state that they have, on average, great discounts, but what they cannot tell employers is the range of discount from one provider to another. Therein lies the key to an employer’s newfound interest in developing direct provider partnerships that bypass the insurance carrier for certain services.

Data drives continuous improvement

Find life worth living.

“Kaizen”—a business model that, according to Six Sigma, aims to eliminate waste in all systems of an organization through improving standardized activities and processes—may shed some light on this challenge. Most employers have considered the idea of eliminating waste and improving efficiency in their medical plan as out of reach. They simply did not have enough data or clarity to develop even the most rudimentary risk management programs for employee health. That changed as consultants introduced “Big Data.” Data analytic companies download claims data from the health plans with granularity and report back aggregate finds in a HIPAA-compliant manner.

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AUGUST 2018 MINNESOTA PHYSICIAN

What many are seeing from this analysis is that we did not make our employees better consumers by giving them a high deductible. At best, the employer shifted costs to the employee. At worst, they may have created their next batch of catastrophic health cases. It turns out that, as individuals, we did not want to pay for care or prescriptions, so many people simply stopped going to the doctor or skipped their prescriptions. Further, employers are beginning to see their disease burden as they track patterns of utilization (where people are going and for what types of services) and the costs for specific care episodes, such as joint replacements or colonoscopies. By applying Kaizen techniques to their health plans, employers are also beginning to entertain the idea that going direct to providers for health care has its advantages.

Collaboration drives change Very large national employers such as Amazon, Berkshire Hathaway, and JPMorgan Chase are overhauling their strategy to be more inclusive of

medical providers and develop alternative financing. In Minnesota, we also have a handful of early adopters that have been contracting directly with small and midsized independent providers for many different types of care. These models include: Onsite healthcare. We are seeing employers bringing health care to the worksite, building onsite clinics, and inviting in local practice providers to deliver care for a fixed annual cost. To make care more efficient, these onsite clinics also provide lab services and dispense medications.

the volatility in claims cost and the risk that the employee will make an uneducated decision to go to the most expensive location and provider. Centers of excellence, private networks, and value-based benefits. Employers are developing their own “centers of excellence” and tailored private networks based on both quality of care and total cost of care. By guiding their population to the right provider at the right price, with the best possible outcome, employers that employ this strategy see increased health care utilization while having lower health care costs.

Employers that employ this strategy see increased health care utilization while having lower health care costs.

Employers have also introduced other services alongside primary care, such as mental health services and physical and occupational therapy. These services take the place of the traditional feefor-service benefit for those with access, and leave the health plan in place for those without access. By doing so these employers gain multiple advantages. They keep their employees healthy and engaged, keep them at work rather than leaving to get care, and, in the case of physical therapy (PT) or occupational therapy (OT), see reductions in workers compensation claims. Offering PT onsite means that employees do not need to use paid time off (PTO) or their own money to get care, diminishing the need for the employee to embellish where and how an injury occurred. In either event, the care is free and they are not missing work, so they can be more honest than if their paycheck and checking account were at risk with a high deductible. Near-site partnerships. Where onsite clinics do not make sense for logistical reasons (it’s tough to invite spouses and kids into a foundry, for example), we see employers reaching out to local independent practice groups that, on average, offer lower costs than larger systems. The companies—in many cases, small and midsized self-insured employers—develop mutual behavioral economic strategies to guide employees and families to these independent practices. In return, these health care practices develop greater engagement through outreach and additional services to track and report health improvements back to the employer (again, in a HIPAA-compliant manner). Direct primary care and bundled pricing. Providers are responding by considering and implementing new financial arrangements with employers, such as direct primary care and bundled programs. By, in essence, capitating the cost of primary care into a per-employee, per-month cost, the provider gains cash flow and reduces the write-offs. The employer, assuming they can shift care to this provider with lower copayments or waiving the deductible, gains stability in the health plan financing. Since health claims are volatile based on the volume of care at any given time, entering into a fixed cost to reduce that volatility has its advantages. Bundled care programs are also gaining steam with employers. With the proper set of data and the right consulting support, employers can see the extreme variability in costs for identical services. If we look at the episode cost for a colonoscopy, we need to consider the cost for the gastroenterologist, anesthesiologist, and pathologist (if needed), as well as the cost of the facility charge. Once all are grouped together for a single date of service, the cost range may be as great as 400 percent, depending on the provider and the location of the facility. By negotiating with a single provider a reasonable price for an “all-in” charge that will not deviate, the employer reduces both

Further, they are enticing employees to participate and engage with the providers by implementing “value-based benefits.” To engage their population with certain conditions like diabetes, chronic obstructive pulmonary disease (COPD), or heart conditions with low cost/no cost supplies and medication, they see employees re-engage with the chosen provider and come back into compliance with evidenced-based care guidelines. With this newfound health compliance, the employer sees reduced health care risk, which, over both the short and long term, creates lower health care costs.

The impact to the employer Upon reviewing the claims data for utilization, health scores, and total Physician/employer direct contracting to page 384

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MINNESOTA PHYSICIAN AUGUST

3CAR T-cell therapy from cover

complete response. Yescarta yielded an overall response rate of 70 percent in similar patient populations.

CAR T-cell therapy has revolutionized cancer treatment and sets a precedent A legacy of innovation for cell therapies as “living drugs.” Immunotherapy treatments may one day Fifty years ago, a University of Minnesota care team led by Robert Good, supplement or even replace chemotherapy. In the MD, performed the world’s first successful future, CAR T-cell therapies could also eliminate the matched, related donor blood and marrow need for blood and marrow transplants, according transplant. Stem cell transplants have since to Heather Stefanski, MD, PhD, a pediatric blood become a standard of care for the treatment of and marrow transplant physician who helped lead blood cancers. Now, University of Minnesota Immunotherapy treatments may the study that brought Kymriah to market to treat Health physicians, in partnership with researchers one day supplement or even pediatric acute lymphoblastic leukemia. at the Masonic Cancer Center at the University of replace chemotherapy. Expanding alternatives Minnesota, are at the forefront of innovations and In May 2018, University of Minnesota Health breakthroughs in cellular immunotherapeutics. became certified to offer patients Yescarta for the One patient’s journey treatment of refractory or relapsed diffuse large Cancer survivor Colin Cooley was first diagnosed B-cell lymphoma. A few days later, Kymriah also with follicular non-Hodgkin lymphoma. Cooley’s journey began in 2014. received FDA approval for use in treating the same type of cancer. The two Treatment put the cancer into remission initially. Later, Cooley relapsed, and immunotherapy drugs target the same B-cell protein CD19 on B-cells, but his condition morphed into the more aggressive diffuse large B-cell lymphoma. there were some differences in manufacturing and biological activity. For most patients, CAR T-cell therapies bring hope and open a door to the potentially effective treatment after traditional strategies such as chemotherapy, radiation, or blood and marrow transplants failed. In a multicenter clinical trial of more than 100 adults with relapsed or refractory large B-cell lymphoma, the remission rate after treatment with Kymriah was about 60 percent. Roughly 40 percent of patients achieved a

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AUGUST 2018 MINNESOTA PHYSICIAN

He was treated with a standard chemotherapy approach, but it soon became apparent that his lymphoma was not responding. Cooley was told that his disease is hard to cure and he had only several months to live. His oncologist referred him to University of Minnesota Medical Center. Here, after weighing options, the patient was offered a chance to enroll in a CAR19-T cell clinical trial. In late October 2016, Cooley received

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Chemotherapy and then infusion of CAR-T cells back into the patient’s body

Patient

Extraction of white blood cells, including T cells (leukapheresis)

If you have a patient who may be a candidate, please call University of Minnesota Health’s Blood and Marrow Transplant and Cellular Therapies intake team at 612-273-2800. We will ask some initial questions to determine eligibility (age, type of disease, etc.) and set up a consult appointment with the appropriate team.

Other immunotherapy approaches

Destruction of cancer cells

Expansion of CAR-T cells

Engineering T cells A gene encoding a chimeric antigen receptor (CAR) is transferred into the patient’s T cells

Immunotherapy has now been established as the “fifth pillar” of cancer treatment. While CAR T-cell therapy has yielded some of the most promising results in clinical trials involving patients with advanced blood cancers, at the University of Minnesota we examine the efficacy of other adoptive cell transfer approaches. Natural Killer (NK) cells are among the most innovative strategies. We pioneered the clinical trials for acute myeloid leukemia, B-cell lymphoma, multiple myeloma, and ovarian Ca. While most research has focused on patients with blood cancers, cellular therapy may also yield results for patients with solid tumors. Veronika Bachanova, MD, PhD, is a hematologist/oncologist at University of Minnesota Health and an associate professor of medicine in the University’s Division of Hematology, Oncology and Transplantation. She specializes in

A simplified depiction of CAR T-cell therapy.

treatment of lymphoma and leukemia using stem cell transplantation and novel immune-therapeutics. Dr. Bachanova leads the adult CAR T-cell therapy program through University of Minnesota Health and in her practice manages

a short course of outpatient lymphodepleting chemotherapy followed by an infusion of his own, engineered CAR-T cells. While many people can experience harsh side effects, such as high fevers, sepsis-like picture, encephalopathy, aphasia, or temporary memory loss, Cooley’s only side effects throughout the treatment were mild fever, fatigue, and minor nausea. Yet, the CAR-T cells immediately began fighting his lymphoma. One month later, Cooley’s lymphoma was already retreating. He remains cancer-free a year and a half later.

patients treated with cellular therapies.

Guidelines University of Minnesota Health is certified to administer CAR T-cell therapy with Yescarta and Kymriah for all FDA-approved indications. Eligibility guidelines and referral information: Leukemia. Patients ages 25 years old or younger with refractory or relapsed acute lymphoblastic leukemia are eligible for Kymriah. Lymphoma. Patients ages 18 and older with relapsed or refractory aggressive B-cell lymphoma, including diffuse large B-cell lymphoma and transformed lymphoma, progressing after two or more lines of systemic therapy, are eligible for Kymriah and Yescarta. Patients with primary central nervous system lymphoma are not eligible for this therapy. Patients with primary mediastinal lymphoma are also eligible for treatment with Yescarta. Prior to the CAR T-cell therapy, each potential patient will be carefully evaluated for eligibility by a multi-disciplinary team at University of Minnesota Health. These therapies carry their own unique set of side effects. Most symptoms occur within the first few days after the infusion, and most resolve by day 28. Possible complications include high fevers, low blood pressure, headaches, and loss of appetite, among other issues. During studies, some patients also experienced neurological problems such as lethargy, confusion, encephalopathy, and memory problems. MINNESOTA PHYSICIAN AUGUST 2018

ONCOLOGY

Cancer health disparities Factors and potential remedies BY NARJUST DUMA, MD

ealth disparities is a term used to describe differences in access to health care or in disease occurrence and disabilities between racial, socio-economic, and/or geographically defined groups. While the term is often interpreted to mean racial or ethnic disparities, many dimensions of disparity exist in the United States. Race or ethnicity, sex, sexual orientation or identity, age, disability, socio-economic status, and geographic location all contribute to an individual’s ability to achieve good health. Our health is determined in part by access to social and economic opportunities, as well as the resources and supports available in our homes, neighborhoods, and communities. Differences in living conditions explain in part why some Americans are not as healthy as they could be and why some have shorter life spans. These factors, defined as social determinants of health, were included in population sciences in the 1990s and brought about a revolution in the science of health disparities. Viewing patients not as individuals, but as the result of environmental interactions and available resources, expanded our knowledge in the etiology of multiple malignancies most commonly seen in minorities and underserved communities.

Cancer health disparities are adverse differences between certain population groups in cancer measures such as incidence, prevalence, cancerrelated complications, deaths, screening rates, stage at diagnosis, prognosis, response to cancer therapies, and survivorship. Generally, patients from low socio-economic backgrounds—who may lack health insurance, or may have limited or no access to effective health care—often bear a greater burden of disease than the general U.S. population.

History of disparities in health Racial disparities in health and health care are widespread and well documented. The initial report highlighting national health disparities was released by the U.S. Department of Health and Human Services in 1983. This report suggested that, while the overall health of the nation was improving significantly, persistent disparities existed in communities of color. In the early 1990s, large epidemiologic studies, such as the Harvard Medical Practice Study, suggested that there was practice variability and substandard care experienced by people of color and those with low socioeconomic status. As a result of all these studies, the Indian Health Service was established in 1995 with the goal of improving the health of the Native American population in the U.S. Over the years, cancer health disparities issues have been raised, with some initiatives improving the cancer screening rates and treatment access for some communities, but we still lack an effective and permanent program at the federal level.

Effect in cancer survival Multiple studies have described worse survival rates among minority patients with cancer. Minority patients are more likely to be diagnosed when their cancer has reached advanced stages, and have limited access to care after diagnosis. Other mechanisms may also play a role in the disparities observed, from poor tolerance to chemotherapy to low response rates to standard cancer treatments. Complex and interrelated factors contribute to the observed differences in cancer-related deaths among racial, ethnic, and underserved groups. Factors such as neighborhood socio-economic status, sex, and marital status affect the survival of patients with cancer, even more so than the patient’s race or ethnicity. Above all these factors, cancer stage was most detrimental in respect to cancer-related survival, underscoring the importance of ageappropriate cancer screening.

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AUGUST 2018 MINNESOTA PHYSICIAN

Biological differences also play a role in cancer health disparities. African American women are more likely to be diagnosed with triple-negative breast cancer than people from other racial/ethnic groups. This subtype of breast cancer is associated with a worse survival rate compared to other breast cancer types. Advances in genetics are improving our understanding of these biological differences and how these contribute to cancer health disparities. Unfortunately, not all patients have access to genetic testing or next gene sequencing (NGS)— DNA sequencing technology that can determine a wide range of mutations in neoplastic tissue—further widening the gap between insured and uninsured patients. Testing the tumor tissue for genetic mutations can help guide initial treatments (targeted versus cytotoxic therapy)

and understand cancer progression after first- or second-line therapy, helping us to understand the unique cancer characteristics in each patient. We hope that, as the field of oncology moves to routine NGS, this new technology will be become easily accessible at rural and inner city hospitals and that federally funded health care plans will provide coverage for this revolutionary treatment approach, with targeted therapy being the end goal.

Improving cancer health disparities: challenges and opportunities Solutions to cancer health disparities frequently lie within communities themselves and through increased patient access to care. Improving cancer screening strategies will allow us to diagnose patients with cancer at earlier stages, when more treatment options are available. Several studies have shown that patients with low socio-economic status are more likely to receive suboptimal cancer care, lowering their chances to overcome the disease. Several factors have been attributed to this, from low insurance rates among minority populations to limited resources in inner city or rural hospitals where most patients receive care. All cancer patients deserve equal treatment, regardless of their background, income, or insurance status. But access to care is not the only contributor to cancer health disparities. Due to certain historical events, mistrust in the health care system is common among some populations—and often leads to delays in diagnosis and treatment. Improving diversity in the health care workforce could improve the mistrust issues experienced by minority groups and provide them with deeper understanding of their cultural beliefs and perceptions of health. There is more to minority health than one can learn in a textbook.

Environmental factors Health is the result of interactions between biological and environmental factors. Higher rates of tobacco use, alcohol use, and obesity among minority groups and populations with lower socio-economic status contribute to cancer health disparities as well. Health education is a powerful tool to overcome these challenges; several campaigns have helped communities adopt healthier behaviors, resulting in decreased numbers of cancer cases. Affordable care, patient navigation, and community engagement are examples of interventions that have helped reduce cancer health disparities across the nation.

Lack of representation of minorities, women, and the elderly in cancer research Cancer research has produced notable achievements over the past several decades, including the development of targeted therapies demonstrated as effective in clinical trials. Unfortunately, the majority of these clinical trials did not include minorities, women, and the elderly. The agents secured approval based on their effectiveness in trials involving primarily young non-Hispanic white patients, making it difficult for physicians to assess the tolerability and efficacy of these new agents in minority and elderly patients. The lack of comprehensive participation in clinical trials leaves several questions unanswered and makes it difficult for physicians and patients to assess which treatment options are best. Despite multiple efforts led by the National Cancer Institute, the recruitment of these subsets of patients remains low, based on a recent study Cancer health disparities to page 364

MANY FACES OF COMMUNITY HEALTH 13TH ANNUAL CONFERENCE

Thursday–Friday, October 25-26, 2018 • Hyatt Regency Bloomington, MN Join us for a two-day conference that explores ways to improve care and health equity in under-served populations and among those living in poverty. It brings information and resources on chronic disease prevention and care, public policy and health innovations to Minnesota’s health care community, with a focus on safety net providers. Keynote Speakers: Dr. Michael Westerhaus and Dr. Roli Dwivedi of the Social Medicine Consortium The Consortium is a collective of committed healthcare professionals, universities, and organizations fighting for health equity through education, training, service, and advocacy, with social medicine at its core. This session will address the ways that structural and societal barriers faced by patients can often cause healthcare professionals to feel overwhelmed and isolated. Members of the Consortium will share tools that help us to rediscover agency, purpose, and collective impact in our work. Continuing Education Stratis Health designates the 2018 Many Faces Conference for 10 hours (6 hours on Thursday and 4 hours on Friday) of AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Attendees are responsible for determining if this program meets the criteria for licensure or recertification for their discipline.

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

manyfacesconference.org

For more information: contact Shelby Maidl / shelby.maidl@mnachc.org / 612-253-4715 ext 10 MINNESOTA PHYSICIAN AUGUST 2018

SPECIAL FOCUS: PHYSICIAN BURNOUT

Measuring the burnout curve Data-driven solutions BY RAHUL KORANNE, MD, MBA, FACP, AND HEATHER BRITT, MPH, PHD

care for patients can be impacted. Clinicians experiencing burnout may be disruptive in workplaces.

larmed by the rising tide of burnout in health care, many U.S. clinicians, hospitals, and health systems now embrace the “Quadruple Aim,” which expands the Triple Aim by adding the wellbeing of health care workers. In a 2014 Mayo Clinic survey, 54.4 percent of respondents reported at least one symptom of burnout, up almost 9 percentage points from Mayo’s 2011 survey. If we witnessed this prevalence of a disease in our communities, we would declare a public health crisis and mount a response.

Collectively, these effects reshape the culture, finances, and outcomes of health care organizations. Ultimately, communities bear the impact of burned-out professionals.

Minnesota has done just that through a statewide collaborative that invites hospitals and health systems to create work environments where clinicians, along with their patients and families, can thrive.

Wide-ranging effects

The impact extends beyond individual clinicians. Health care workers who experience chronic stress and negativity at work or at home are more likely to reduce practice time or leave health care entirely, and are at increased risk for substance abuse and suicide. Clinical quality and experience of

Back and Neck Pain... Results That Matter

Our response and journey Two years ago, the Minnesota Hospital Association (MHA) launched a statewide, data-driven Quality Improvement action framework focused initially on burnout among physicians and advanced practice professionals (APPs). Our long-term goal is to understand and improve the experience of everyone working in health care. In 2016, the baseline year of the initiative, 56 health care sites/systems (representing 104 individual hospitals) participated in a survey of burnout in frontline clinicians working across the continuum of care, including both independent and employed clinicians, as well as individuals working fulltime and part-time. Forty-three percent of the 13,693 clinicians surveyed responded, allowing for reporting across the state and at the site/system level. CEOs and CMOs of sites/systems reviewed their own data to identify key areas for action in mitigating burnout. In 2017, MHA invited 19,350 physicians and APPs at 63 sites/systems (representing 113 individual hospitals and including both independent and employed physicians, as well as full-time and part-time clinicians) to participate in a follow-up survey, which yielded a 29 percent response rate. The quantitative and qualitative data from these surveys are now being used to drive change across individual sites/systems and to develop a statewide roadmap for reducing burnout.

Our findings Multidisciplinary Spine Care Team Active Care Plan Cognitive Behavioral Coaching Program Patient Education Series Outcome Measurement & Reporting

PDR Outcomes

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To date, the MHA health care burnout survey reveals that 51 percent of physician and APP respondents feel great stress because of their work. Thirty-four percent are emotionally exhausted, 17 percent suffer from depersonalization, and 37 percent are burned out (based on the Maslach Burnout Inventory). Interestingly, we found identical rates of burnout and emotional exhaustion across independent and employed clinicians, as well as full-time and part-time clinicians. What’s driving burnout? Thirty-six percent of Minnesota physicians and APPs disagree with the notion that they have enough time for what is important. Thirty percent disagree with the idea that they have control over how they work, and 28 percent disagree that resources are allocated fairly. Three-quarters report that they spend either excessive or moderately high time on electronic health records (EHRs). Despite this rising tide, 80 percent of Minnesota clinicians report being very engaged or engaged in their work. Only 8 percent report being disengaged in some way, and 76 percent are satisfied with their current job. Seventy percent state that their professional values are aligned with leaders, and 68 percent believe their organization is committed to quality. These high levels of engagement and satisfaction suggest an ongoing opportunity

mental health supports (especially around depression and anxiety) to frontline clinicians. Recognize clinicians as whole persons, along with their families and loved ones. At the practice level, hire clinician floats to cover predictable Asked to identify key factors that would enable them to thrive life events, promote clinician control of the work environment, maintain professionally, physicians and APPs prioritized work-life balance (65 percent), manageable practice sizes, and optimize team meaningful work (52 percent), high quality care (44 support. Promote part-time careers and job sharing percent), and control (41 percent). In partnership for those interested. Foster an environment that with Minnesota health care CMOs and CEOs, supports choice and flexibility in work and hours. efforts are underway to develop a statewide quality For individuals, systems can make self-care a part improvement roadmap focused on interventions of professional expectations and strive to preserve at the organizational level, practice level, and Clinicians experiencing burnout clinician “career fit,” with set-aside and protected may be disruptive in workplaces. individual level that can be translated nationwide. time for individually meaningful activities. Offer Approach to reducing burnout a self-care assessment and support systems to It is time to adjust the perception of burnout as a match needs, provide a safety net system for crisis personal problem. We propose a socio-ecological interventions, and engage in worksite evidenceaction framework, using survey data to ensure based health promotion. Other mechanisms, such that continued efforts to decrease burnout do not as financial management counseling, child and rest solely with individuals. To ensure shared accountability as they change elder care, and after-hours meals, can ensure that clinicians thrive. the work environment and experience, health systems should focus on the Emerging best practices organizational level, the practice level, and the individual level. Several participating health care systems are now adopting this data-driven To address burnout, systems need first to communicate about the quality improvement framework. Two examples: issue: offer a compelling and collective vision, include the wellbeing of One Minnesota health system launched a series of activities in 2016 staff alongside other quality indicators, assess the experience of work, based on their burnout data, employee wellness assessment data, and a and share those stories regularly. Second, health care organizations must empower leaders and frontline team members to confront the issue: develop Measuring the burnout curve to page 344 a multidisciplinary guiding coalition to advance the work, actively listen to the frontline, and build skills and make available resources and incentives for action. Third, empowered individuals and leaders must act: use improvement science to test interventions, refine approaches and celebrate wins, and continue to institutionalize successful approaches.

Interventions to decrease burnout We selected two areas of substantial concern for clinicians—EHRs and work-life balance—for deeper examination and early action. Examples of what some health care systems have considered, tried, and tested in these two areas: Electronic Health Records. Organizationally, hospitals and health systems should develop a guiding coalition/wellness committee with the EHR as a key priority, establishing organization-wide environments that support choice and flexibility in how and when the EHR is used. At the practice level, identify and redesign inefficient work, include physicians and other clinicians in the redesign of clinical process and flows, use efficient communication mechanisms to minimize email/in-basket time burden, and deeply examine the administrative work pushed through the EHR. For individuals, encourage peer support and mentoring opportunities for all clinicians. Tailor IT support for individuals, and, where it makes sense, consider adding scribes or other personnel. Work-Life Balance. From an organizational standpoint, recognize and appreciate the value of work-life balance. Organizations need open dialogue to understand this value, and then to tailor their interventions based on unique needs and organizational culture. Core leadership principles of fairness and inclusiveness, along with transparency and values alignment, foster an environment where everyone feels valued. Establish a guiding coalition/wellness committee with work-life balance as a key priority. Offer

Telephone Equipment Distribution (TED) Program

to stem the tide, bolster engagement and satisfaction, and positively affect clinicians, their patients, and their families.

Do you have patients with trouble using their 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 ted.program@state.mn.us mn.gov/dhs/ted-program 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 PHYSICIAN AUGUST 2018

SPECIAL FOCUS: PHYSICIAN BURNOUT

The wellbeing of the health care workforce Practical tips for a stressful profession BY MARY JO KREITZER, PHD, RN, FAAN

ncreasingly, the wellbeing of the health care workforce is viewed as being “at risk.” The incidence of stress, depression, burnout, and suicide has escalated significantly over the past decade. More than half of U.S. physicians report symptoms of burnout—a rate that is twice that among professionals in other fields. Over 400 physicians take their own lives annually. U.S. physicians have the highest suicide rate of any profession, even higher than that of personnel serving in the military. The issue of stress and burnout within medicine starts early. Medical students and residents have higher rates of burnout and depression than peers who are pursuing nonmedical careers. Stress and burnout is not limited to physicians. While the rate of burnout in other professions such as nursing is not as high as in medicine, it is still significant. Thirty-four percent of hospital nurses and 37 percent of nurses working in long-term care report burnout.

Contributing factors Burnout, a syndrome characterized by exhaustion, cynicism, and perceptions of reduced effectiveness, is the outcome of prolonged exposure

to stress. Contributors to burnout include organizational issues within many systems, including staffing, scheduling, low control over the pace of work and subsequent time constraints, high emotional intensity, lack of flexibility that leads to work/life imbalance, lack of access to resources, leadership, and unfavorable organizational culture. In a recent survey of 14,000 physicians, the four top primary causes of burnout included excessive bureaucratic tasks, spending too many hours at work, feeling like just a cog in a wheel, and the increased computerization of practice. A study conducted by the American Medical Association and Dartmouth-Hitchcock Health Care System found that for every hour of face-to-face time with patients, physicians spent nearly two additional hours on their electronic health record (EHR) and doing other clerical work. Another major issue contributing to stress and burnout is moral distress, which occurs when providers are unable to act according to their core values and perceived obligations due to internal and external constraints. In an interdisciplinary study focused on physicians, nurses, nurse technicians, and respiratory therapists working in ICU and step-down units, moral distress was found to be significantly associated with severe burnout. It takes a personal toll on clinicians when circumstances make it difficult to fulfill their ethical commitments and deliver the best possible care. “Physician-friendly” and “family-friendly” organizational settings seem to result in greater physician wellbeing, according to a study funded by the Agency for Healthcare Research and Quality (AHRQ) involving a national sample of 171,000 primary care doctors. Additionally, physicians fare better in organizations where they are not compensated for individual productivity, are not under time stress, have more control over clinical issues, and are able to balance family life with their work.

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The impact of burnout is both personal and professional. Burnout can undermine a health professional’s sense of purpose and contribute to broken relationships, alcohol and substance abuse, depression, and suicide. There is also evidence that burnout impacts patient care, as it is associated with lower quality of care, increased medication errors, and decreased patient satisfaction. Physicians’ reactions to work conditions, however, have not been found to be consistently directly associated with lower quality of patient care. According to an AHRQ-funded study, although physicians are affected by work conditions, their reactions do not translate into poorer quality care because the physicians act as buffers between the work environment and patient care. When lower quality care was seen, the investigators found it was the organization that burned doctors out that led to lower quality care, rather than the burned-out doctors themselves. Whether burnout directly or indirectly impacts patient care quality, it is very costly to organizations. Clinician burnout places a substantial strain on the health care system, which leads to losses in productivity, lower job satisfaction, and high turnover rates. It has been suggested that the Institute for Healthcare Improvement’s Triple Aim of health care—which focuses on

AUGUST 2018 MINNESOTA PHYSICIAN

improving the health of populations, improving the patient experience of care, and reducing the per-capita cost of care—be expanded to include a fourth aim: improving care team wellbeing. The Quadruple Aim acknowledges that it is difficult to achieve the aims of improving patient care without a healthy and engaged care team.

Lifestyle, Thoughts and Emotions, Purpose and Values, Relationships, and Intentions and Actions.

Food Matters for Health Professionals is a continuing education course focused on improving food and culinary literacy. Co-taught by a physician and chef/ culinary nutrition educator, this course covers the role of food, lifestyle, and cooking in preventive health and wellbeing. Topics include inflammation and anti-inflammatory diets, gut health and dysbiosis, sugar and metabolism, fats, nutrient absorption, brain health, and sustainable food systems. During each More than half of U.S. physicians report symptoms of burnout. session, participants learn basic cooking foundational techniques and cook and eat a meal as a class.

There are state and national efforts underway to advance strategies aimed at policy and practice changes at the work unit and organizational level. Examples of system change include care team redesign, the use of scribes, giving providers more flexibility in scheduling, and making changes in the EHR. A recent article in the New England Journal of Medicine acknowledges the importance of clinical care redesign efforts, but cautions that, even if these redesigns are effective, they may not address the fundamental question of how physicians can reclaim joy in the practice of medicine. This reflects a sentiment expressed by many that they feel disconnected from their sense of purpose and have lost touch with what gives them joy and meaning in their work.

Minnesota resources Beyond addressing system issues that contribute to burnout, it is also important to provide resources that promote resilience, self-care, and wellbeing. This may take the form of mindfulness or resilience training, or programs aimed at cultivating a healthy lifestyle that includes exercise, nutrition, sleep, and stress management. At the University of Minnesota’s Earl E. Bakken Center for Spirituality & Healing, we offer many programs that individuals can access directly; we also offer programs that can be embedded within health care organizations or systems. A few examples:

The center also offers many in-person mindfulness-based courses and retreats, as well as more than 60 academic courses.

Additional resources Another important resource is the national Action Collaborative on Clinician Wellbeing and Resilience (nam.edu/initiatives/clinicianresilience-and-well-being), coordinated by the National Academy of Medicine (formerly the Institute of Medicine) in collaboration with the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), a network of more than 55 core organizations, and a network of over 80 other organizations. The wellbeing of the health care workforce to page 324

Taking Charge of Your Health and Wellbeing provides online resources to develop a personal plan for health and wellbeing and explore healing practices. Individuals take an assessment based on the Center’s Wellbeing Model (click on “Assess your wellbeing” at www.takingcharge.csh.umn. edu). Users receive feedback and are guided to set goals and identify strategies to meet their goals. The website is accessed by millions of unique visitors from around the world. Undergraduate medical students at the University of Minnesota Medical School use the Wellbeing Model to plan student-led programs and activities aimed at improving self-care and wellbeing.

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Mindfulness at Work is a 6-week online course that teaches core mindfulness skills with specific application to workplace settings, including health care. In addition to learning mindfulness practices, participants explore topics such as presence, emotional regulation, resilience, cognitive flexibility, and communication. This course is a partially covered benefit for faculty and staff at the University of Minnesota and was deployed last year in 32 countries around the world, as well as within multiple health systems and organizations. Resilience and Wellbeing for Health Professionals is a 6-week online, highly interactive and experiential course. Topics addressed include: Why You Need Self-Care When Working in Health Care, Mindfulness and Wellbeing, Change, Where and Why Do You Get Stuck, Healthy

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HEALTH INSURANCE

Medicare Cost Plans Changes may affect your patients BY KELLI JO GREINER

mong the 2019 changes to Medicare is one that may affect a number of your patients: Medicare Cost Plans, a type of Medicare plan very popular in our state, will end in most Minnesota counties.

Minnesota has more than 1 million people on Medicare. It also has the largest number of people enrolled in a Cost Plan of any state, with more than 400,000 enrolled, including those beneficiaries enrolled in an employer group Cost Plan. For decades, hundreds of thousands of Minnesota Medicare beneficiaries have purchased and enrolled in Medicare Cost Plans. Considered “other Medicare plans,” Cost Plans are different than Medicare Advantage and Medigap. Cost Plan enrollees use a provider network to get the highest level of coverage, but, unlike Medicare Advantage plans, they maintain their Original Medicare Parts A and B for coverage when they are outside their provider network. This flexibility has made Cost Plans a very popular option with Minnesota’s snowbirds. A change in federal legislation requires that there cannot be Cost Plans in counties where there are two or more Medicare Advantage

plans with an enrollment number of 1,500 for rural and 5,000 for urban counties. Those beneficiaries affected will need to obtain other coverage. Some will be automatically enrolled into a Medicare Advantage Plan from the same insurer, while other enrollees must select and enroll in a Medicare Advantage Plan or Medigap Plan of their own choosing. Either way, their provider network could change and some enrollees will need to change providers in order to get coverage and payment from their new plan. There are 21 counties in Minnesota where Cost Plans will be still be allowed in 2019, and these enrollees will not need to make a change unless they want to enroll in a different option for 2019 based on drug coverage or provider participation. The counties where Cost Plan enrollment will still be permitted in 2019 are: Aitkin, Carlton, Cook, Goodhue, Itasca, Kanabec, Koochiching, Lake, Le Sueur, McLeod, Meeker, Mille Lacs, Pine, Pipestone, Rice, Rock, St. Louis, Sibley, Stevens, Traverse, and Yellow Medicine.

Cost Plan popularity Cost Plans have been extremely popular in Minnesota for a number of reasons. One reason is that enrollees don’t have to use Cost Plan HMO networks for covered services. Non-HMO plan providers can provide covered Part A and B services that Original Medicare reimburses. This option has been a big draw for Minnesota’s snowbirds.

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Another positive for Cost Plan beneficiaries is that they can enroll in a Part D plan through the Cost Plan or in a separate stand-alone prescription drug plan. And enrollees can enroll in or drop a Cost Plan at any time, not just during open enrollment, and return to Original Medicare. There is no health screening or underwriting permitted, but Cost Plans typically do not accept beneficiaries with end stage renal disease. mnpsychconsult.com

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Cost Plan enrollees’ options For those enrollees who lose their Cost Plans, there are many options. But most Cost Plan enrollees must act, or they will return to Original Medicare and be responsible for their Medicare Part A and B coinsurance and deductibles as a result. A smaller portion of Minnesota’s Cost Plan enrollees will be able to keep their Cost Plan in 2019, because they live in a county that does not have enough other options or meet other criteria, as determined by the Centers for Medicare & Medicaid Services (CMS). CMS will announce all eligible counties later this summer. Another group of Cost Plan enrollees will be auto-enrolled (known as deeming) into a Medicare Advantage plan offered by the same company that offers their Medicare Cost Plan. While this ensures they have coverage, these enrollees should make sure their doctor is a participating provider. They should also find out if their drugs are covered by their new plan and if their pharmacy participates in the Medicare Advantage plan as a preferred provider. In addition, they need to decide if they can afford the new plan. If

AUGUST 2018 MINNESOTA PHYSICIAN

they aren’t happy with the plan they’ve been deemed into, they can choose another plan with any insurance provider.

2. They should find out what plans are available in their county.

3. Enrollees who choose a Medicare Advantage plan need to find out if their provider participates with the Medicare Advantage plan, The remaining Cost Plan enrollees will need to either enroll in a Medicare which varies by county and ZIP code. Advantage plan that includes Medicare Part D coverage or purchase a Medicare supplement (Medigap) with a separate 4. They should ask if their prescription drugs Medicare prescription drug plan. If a Cost Plan will be covered by their new Medicare enrollee is already enrolled in a separate Medicare Advantage plan. prescription drug plan and purchases a Medigap 5. They should ask if their pharmacy plan, they can keep their Part D plan in 2019 as long participates with the Medicare Advantage as it is still offered. Nearly all Medicare Advantage Minnesota has more than 1 plan and if it is a preferred pharmacy. million people on Medicare. plans require their enrollees to also get their Part D 6. Next, they need to decide if they can afford coverage from their Medicare Advantage plan. the premium. If not, there are programs Because the sunset of Cost Plans in most counties available that can help them pay premiums, presents unusual circumstances, CMS will offer some deductibles, and copayments if they are special options to affected Cost Plan enrollees that within income guidelines. will not be available to other Medicare beneficiaries: 7. Lastly, if it’s relevant, they should find out what travel or out-of• Like all Medicare beneficiaries, affected Cost Plan enrollees will be network benefits their new plan provides. able to enroll in a Medicare Advantage Plan with Part D during regular Medicare Open Enrollment from Oct. 15–Dec. 7, 2018. They have also been granted extra time to enroll during a Special Enrollment Period from Dec. 8, 2018–Feb. 28, 2019. • Cost Plan enrollees can opt to purchase a Medigap policy without any health screening through March 4, 2019, and enroll in a separate Medicare Part D plan. • If a Cost Plan enrollee is not deemed and still does not act by Dec. 31, 2018, they will return to Original Medicare and will have to pay Medicare Part A and B deductibles and coinsurance as of Jan. 1, 2019. They will be able to enroll in a Medicare Advantage plan or Medigap after Jan. 1, 2019, but their coverage would not take effect until the first day of the month after they enrolled. For example, if an affected Cost Plan enrollee enrolls in a new plan on Jan. 17, 2019, their coverage would not take effect until Feb. 1, 2019. They would have to pay Medicare deductibles and coinsurance if they received health care services during all of January.

Changing providers If your patient enrolls in a Medicare Advantage plan in which you are not a participating provider, they may have to switch to another provider to get the maximum coverage from their new plan. With a Medicare Advantage plan, the only payer of services can be the plan, not Original Medicare. If your patient is enrolled in a Medicare Advantage plan with a Point of Service (POS) option, they can probably continue to see you, but will have higher out-of-pocket costs. If your patient purchases a Medicare supplement, they can continue to see you and get covered services as long as you participate in the Medicare program. If the patient lives in one of the unaffected counties and remains enrolled in their Cost Plan, nothing should change as long as you still are a participating provider with their Cost Plan.

Cost Plan timeline You can help your patients understand that they’ll likely need to do something with their Medicare plan, but that time is not right now. Minnesotans on Medicare can just remain enrolled in their Cost Plan and enjoy the summer. But this fall, they’ll need to make important decisions, Medicare Cost Plans to page 304

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Key messages for patients As you meet with patients, remind them that: 1. They should be sure to open and keep every piece of mail they receive from their Cost Plan.

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PATIENT RECORDS

Health information exchange Sharing EHRs across networks BY KAREN SODERBERG, MS

innesota has made great strides in ensuring that nearly all hospitals, clinics, local health departments, and nursing homes have electronic health records (EHR) systems. A strong EHR foundation with standardized health data has been a critical tool for health providers as they care for patients. However, while personal health information for most Minnesotans is currently stored in electronic systems, it is usually in systems managed independently by each of their physician’s health systems. Patients who see a variety of physicians from different organizations, including people with multiple or complex health conditions, do not have their health information easily available in a comprehensive way unless that information moves electronically between systems. This is referred to as health information exchange, or HIE. HIE allows health organizations to securely share information with each other using agreed-upon standards and according to patient preferences. Minnesota has made progress on HIE, but many gaps exist. Some health organizations can exchange with some others, but not with all others. Therefore, a patient’s care too often continues to be inefficient and fragmented when they need to visit multiple health systems. Without this basic flow of

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information, research has shown that patients are more likely to receive repeat exams and/or tests, need to repeatedly describe their situation to multiple care providers, deal with uncoordinated care, and face delays in care.

About health information exchange A recent HIE study conducted by the Minnesota Department of Health (MDH), available at www.health.state.mn.us/e-health/hie, identified three important conceptualizations for HIE that offer great opportunity to positively impact individual and community health. First is “foundational” HIE, which will be achieved when health providers at any hospital, clinic, or nursing home can query and receive Continuity of Care Documents (CCDs) from other providers the patient has seen. A CCD contains basic information, such as such as lab tests and results, medications, immunizations, and documentation of diagnosis and treatment. While it is not a complete picture of a patient’s health, the CCD provides the minimal set of information that should be able to be exchanged between organizations. Building upon that foundation, “robust” HIE can be used to coordinate and manage patient care by exchanging and consolidating information, allowing the care team to better address all of the factors that impact a person’s health and well-being. For example, care coordination for complex patients can be better managed with timely and consolidated information on all of the care a person receives, ensuring that providers have a complete picture of a person’s health care needs. One stakeholder emphasized that “[HIE] can shift the focus to prospective outreach rather than retroactive chart chasing.” Event alerting is another example of robust HIE, whereby a provider can receive an automated alert when a patient is admitted to, or discharged from, a hospital or emergency room from outside their organization. This simple event alert allows the care team to act promptly to address any underlying issues that caused the admission, such as medication adherence or lack of caregiver support. Looking more broadly toward community health, “optimal” HIE means that health data can be used to generate aggregated reports of the total population to better identify health disparities, evaluate program effectiveness, target interventions, and implement prevention programs. With optimal HIE, providers can be notified of public health alerts and outbreaks impacting their community and receive timely intervention information. Communities would also be able to better identify and address future health issues before they become epidemics, such as the current opioid epidemic. As one stakeholder said, “We can only imagine what we can do with integrated data. The ideas that can come up through the grassroots are amazing. As those ideas develop, the demand for new ways to do it will force vendors to move along more innovatively. I get excited thinking [about what’s possible] if we can bring to bear all the information we have to be put to use.”

How HIE is working in Minnesota In Minnesota, HIE happens in a variety of ways, using many different health information networks. The state’s approach to HIE has been a public utility/private sector hybrid intended to support a market-based strategy that relies on communities and the private sector to develop innovative

solutions. This approach has resulted in providers having the ability to choose among a wide range of HIE organizations, all offering different services and pricing structures. For a variety of reasons, the Minnesota HIE model has not evolved as anticipated and is not meeting all needs. There is a tremendous amount of HIE happening securely and with appropriate patient authorization, but it is not happening equitably across the state or across the care continuum.

Local needs and frustrations Because of these various networks and non-networks, Minnesota’s health organizations need to manage multiple connections and/or rely on inefficient manual workarounds to exchange some or all shared health information. These efforts require time and financial resources for legal agreements and technical connections. This inefficiency takes resources away from patient care and adds costs to the health care system.

Minnesota’s current HIE environment includes A patient’s care too often a confusing array of connected and disconnected Over time, many stakeholders have expressed continues to be inefficient networks. Health systems that use a common frustration with the HIE gaps in Minnesota. The and fragmented. EHR vendor have established connections to each Minnesota Health Care Financing Task Force’s other and often to one or more national networks, 2016 final report (www.tinyurl.com/mp-dhsbut may not be connected to health systems that report) identified HIE as necessary for value-based use other EHR vendors. For example, the Epic payment arrangements and other health reform EHR platform is used by many health systems in efforts to reach their full potential. Consumer Minnesota, and they can all share information with each other, but must use demand for information has evolved as technology has evolved, and MDH one-off connections or other workarounds to connect to hospitals, clinics, research has found that Minnesotans expect their information to move with nursing homes, or other types of organizations that do not use Epic. Some them as they navigate the health care system. As one stakeholder stated, organizations have connected to Minnesota’s certified health information “As a health care consumer I expect my providers to share information organizations (HIOs), and those HIOs are establishing connections with each to coordinate my care. I don’t want to have to tell my story to multiple other. In many cases, HIE is happening as peer-to-peer exchange. Nationally, providers.” Further, technology has evolved to ease implementation of HIE there are currently several HIE networks that are not all connected to each for providers across the care continuum. other, although there is a recognition by many national organizations that they need to cooperate and link their efforts to advance HIE. Health information exchange to page 294

MINNESOTA PHYSICIAN AUGUST 2018

MEDICAL EDUCATION

An indigenous curriculum Improving the quality of care BY MELISSA LEWIS, PHD, AND JILL DOERFLER, PHD

n September 2013, the University of Minnesota Medical School–Duluth (UMMSD) launched a groundbreaking indigenous health curriculum to help its medical students understand indigenous patients. The mandatory curriculum consists of seven hours of lectures given to all first-year medical students. This is the first mandatory indigenous health curriculum in the U.S., and it exposes all students to the history, culture, and health beliefs of indigenous people. Other universities, including the University of Washington School of Medicine and the University of Hawaii John A. Burns School of Medicine, only offer elective courses in indigenous health. Many of UMMSD’s graduating medical students will go on to practice in Greater Minnesota, where they will encounter American Indian patients. Indigenous people have the largest health inequities in the U.S. and the highest rates of illness. This training will reduce bias and discrimination, improve patient care, and dispel myths about indigenous health beliefs. When medical students are taught an accurate history of American Indians, and understand their beliefs and modern-day lives, they can rely on

this information to guide their medical interactions and recommendations and reduce bias. Providers who work successfully with indigenous patients recognize that understanding the local community, incorporating indigenous health practices into their practice, and implementing culturally appropriate interpersonal behavior is key to providing effective health care.

The role of AIS UMMSD has worked with the American Indian Studies (AIS) faculty at the Duluth campus to assist with teaching and to prepare the curriculum’s content, which strives to debunk common stereotypes about American Indians that still persist. As recently as five years ago, medical schools often brought in guest speakers who, while well meaning, would reduce the differences between indigenous and non-indigenous populations to a short checklist that included instructions to avoid direct eye contact— because American Indians consider it to be rude or aggressive, and to use a soft rather than a firm handshake. While students who attended these lectures probably felt confident that they understood their American Indian patients, in reality, they did not. No population should be reduced to such simplistic characterizations. AIS faculty take care to represent the diversity present in local and federally recognized Native nations in their lectures. Students are also encouraged to research local indigenous populations once they are employed as physicians.

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From its inception in 1972, the mission of UMMSD has been to “be a national leader in improving healthcare access outcomes in rural Minnesota and American Indian/Alaskan Native (AI/AN) communities.” About 44 percent of UMMSD’s graduating physicians practice in communities with populations under 25,000, where they serve large numbers of indigenous patients. Since 1987, when the Center of American Indian and Minority Health was established to recruit, retain, and graduate more indigenous medical students, UMMSD has trained over 100 American Indian and Alaskan Native physicians. With this three-decade commitment to indigenous health, it made sense for the Duluth campus to work to reduce bias and health disparities. Indigenous community members mainly receive primary care from physicians outside of their tribal community who have little understanding of their history, culture, or health beliefs. Research has shown that indigenous people receive better care from health care providers who have received training in indigenous care, history, culture, and contemporary issues, or who are themselves American Indian.

American Indian care issues Students strive to treat American Indian patients appropriately, but often unknowingly rely on false and damaging information that they inadvertently picked up from the popular media and their early education. The vast majority of elementary and high school history and civics textbooks lack any mention of indigenous people after 1900. Compounding this issue today, there is little media coverage that effectively conveys the diversity and complexity of the contemporary lives of indigenous people, who

AUGUST 2018 MINNESOTA PHYSICIAN

are routinely portrayed as alcoholic, unintelligent, poor, and lazy. These unconscious biases can creep into medical visits, resulting in poorer care. As a result, indigenous patients receive many questions about alcohol and drug use, questionable parenting, and family planning.

as well as the importance of reclaiming and revitalizing these activities to continue traditions and to exercise treaty rights. They also learn about the value of the Ojibwe language and the importance of contemporary efforts to increase the number of people who speak Ojibwe.

Indigenous people experience numerous Indian Health Service. This lecture challenges during clinic and hospital visits. For familiarizes students with the health system example, a recent study showed that American for tribal citizens, including its mission, goals, Indian patients feel they are treated poorly, face operations, and history. unfair biases, are treated dismissively, and find Medical racism, unconscious bias, and that their provider often trivializes their medical Indigenous people have the indigenous identity. This lecture covers the problems. The study’s first author, Dr. Goodman, largest health inequities in the U.S. history of the complex legal and political status of believes that the root cause of this stems from a lack American Indians and the impacts of colonialism. of education in medical schools. She further notes In addition, students are introduced to the that courses in medical school on indigenous health intersection of race, medical care, and research, are often electives or presented in a stand-alone including the medicalization of race starting lecture that concentrates only on the statistics of with slavery in the U.S. and moving to modern disease prevalence and health status. Often, these statistics don’t contextualize day medical terms that confer racism, such as blood quantum, a pseudothe social, political, and historical determinants, all of which lead to unfair scientific measurement of how much of an individual’s blood/ancestry is and misleading stereotypes that can influence clinical practice and ultimately from a particular nation; race; DNA; and the thrifty gene theory, which shape indigenous people’s health care experiences and health status. states that fatter individuals, including indigenous people, carry “thrifty genes” that purportedly allow them to survive better during times of food Deciding on the curriculum’s content scarcity. Unethical medical research and forced sterilization are also covered, Once the administration and course directors approved offering an along with the implications of racial, medical, and indigenous identity. indigenous health curriculum, our collective group of stakeholders had to decide what to include. So, we held a retreat for students, faculty, and community members as a way to gather input on the proposed curriculum. We held the retreat at a zero-carbon footprint building on campus, had a traditional healer open the proceedings, heard songs from a visiting professor who came from a local tribal community, and had the food prepared by a local Anishinaabe caterer. It was important to create an atmosphere that reflected the beliefs and protocols of indigenous people. This provided a comfortable environment for all guests and showed non-indigenous participants what a typical indigenous meeting was like. The final curriculum was comprised of seven hours of new lectures with many in-depth topics to help students treat indigenous patients with respect and understand their culture within a medical setting: A brief history of Native people. This lecture defines key terminology and describes the tribal nations in the U.S. and Minnesota. Important policy eras in American Indian history are discussed, including the removal era, assimilation policies, boarding school era, and termination era. Students learn how these policies have negatively affected local communities in areas such as health, education, and self-determination. Sovereignty and politics. This is an introduction to the unique political status of American Indian nations and people. Students learn about how and why this unique political status came to be and what it means today, including defining treaty relations with the federal government, trust obligations of the federal government, or a citizen’s treaty rights. Students learn about the local treaties of Ojibwe nations as well as the importance of those treaties for all Americans. Culture, spirituality, and resilience. This lecture is meant to familiarize students with the basic premises of indigenous and Ojibwespecific culture. Students learn about the common activities of Ojibwe people by season, including harvesting wild rice, hunting, and harvesting maple sap. They learn about the history and purpose of these activities,

An indigenous curriculum to page 284

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3An indigenous curriculum from page 27

their curricula to include community input, indigenous content specific to their area, and regional and tribal input.

Patient-centered care and reducing bias. This final lecture is meant to give students practical techniques to reduce bias and discrimination during medical encounters. Medical school faculty members provide content related to the health status and disparities of indigenous people. Students are taught skills of self-critique, including cultural humility and reflexivity.

Outcomes and next steps

Conclusion

American Indian studies faculty have enjoyed the opportunity to teach medical students, and have found them to be interested, engaged, and willing to discuss the challenges and difficulties of serving American Indian patients. The students can immediately see how they will apply the knowledge learned in the Students are introduced to indigenous curriculum in their career. Faculty also the intersection of race, noted that Native medical students make strong medical care, and research. connections between their personal experiences and the diversity of experiences of Native people.

The indigenous health lectures have been well received by medical students. Two years of evaluation have shown that medical students learned important information about American Indian health, history, and belief systems. In addition, students retained this knowledge six months after the lectures were delivered, and there was an increase in the students’ cultural empathy. Some students have expressed interest in receiving more advanced training, which would involve engaged relationships with community members and patients, research projects that would allow them to delve into indigenous health literature further, and increased training on patient-provider relationshipbuilding techniques.

Melissa Lewis, PhD, is an assistant professor in the Department of Family Medicine at the Missouri University School of Medicine.

Jill Doerfler, PhD, is an associate professor in the American Indian Studies Department at the University of Minnesota–Duluth.

It is important to note that, while these broad topics around indigenous history, culture, and health are important for all health professionals to learn during their training, this would require other medical schools to modify

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1. Expand exchange of CCDs to support care transitions between organizations that use Epic and those that do not.

Minnesota is not alone in struggling to achieve statewide HIE, and 2. Expand event alerting (for admission, discharge, and transfer) to models are evolving around the country in response to technological support effective care coordination. changes and funding challenges. Many states are 3. Identify, prioritize, and scope needs for ongoing moving toward hybrid models and moving away connected networks and HIE services with from either solely government-led or solely private the goal of optimal HIE. sector-led HIE. Few states have implemented the more visionary Minnesota HIE goals of robust and Input from providers and the public optimal HIE, focusing primarily on connecting The task force was appointed by the Commissioner The Minnesota HIE model has clinics and hospitals without considering the value of Health in May 2018 and has begun meeting. not evolved as anticipated. of connecting across the care continuum. The activities of the HIE Task Force are open to the public, and MDH encourages interested parties Moving forward to engage with this process (see www.health.state. MDH’s HIE study sought to identify and address mn.us/e-health/hie/taskforce). Much work still what needs to happen for Minnesota to achieve needs to be done to achieve these HIE goals, and its HIE goals. Key overarching themes are that your clinical expertise will help ensure that the Minnesota needs to establish and communicate a compelling and path forward supports your workflows, clinical care, and improved forward-thinking statewide goal for HIE, develop a plan to achieve this patient outcomes. goal, and address existing legal barriers that inhibit foundational and robust HIE. Karen Soderberg, MS, manages the e-health research program at the As a result of that study, the Minnesota e-Health Initiative has launched Minnesota Department of Health. She would like to acknowledge contributions to an HIE Task Force to move Minnesota in the direction of connecting HIE this article from team members of the department’s Office of Health Information networks to provide essential HIE services statewide. Building on existing Technology: Jennifer Fritz, Marty LaVenture, Anne Schloegel, and Melinda assets, including the various networks and technologies already in place, the task force will develop implementation plans to: Hanson. For additional information, contact mn.ehealth@state.mn.us.

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MINNESOTA PHYSICIAN AUGUST

3Medicare Cost Plans from page 23 so they have coverage that meets their needs for 2019. Important dates to share with patients: August 2018: Medicare and insurers send letters to let affected enrollees know about changes to their Medicare coverage. Oct. 1, 2018: Medicare.gov’s Plan Finder Tool lists available Medicare plan information, but enrollment is not yet open. Oct. 15–Dec. 7, 2018: Open Enrollment for Medicare Advantage and Medicare Part D plans for all beneficiaries. Dec. 8, 2018–Feb. 28, 2019: Special Enrollment Period for Cost Plan enrollees affected by changes. Nov. 2, 2018–March 4, 2019: Medigap and Medicare SELECT guaranteed issue rights for Cost Plan enrollees affected by changes. Jan. 1–March 31, 2019: Medicare Advantage enrollment period for all Medicare Advantage enrollees (new for 2019).

Help for your patients with Cost Plans Multiple resources can help Medicare patients navigate these changes to Cost Plans and other Medicare-related concerns. The best place to start is to encourage your patients to call their insurance provider and find out if they have a Cost Plan. Their Cost Plan company will also be able to help them figure out their options once things begin happening in the fall.

The Senior LinkAge Line, a service of the Minnesota Board on Aging and Minnesota’s Area Agencies on Aging, provides objective, unbiased information and assistance regarding Medicare and Medicare plan options. Your patients can call them at 1-800-333-2433 or visit www.seniorlinkageline.com for a live chat with a specialist. The Senior LinkAge Line is Minnesota’s federally designated State Health Insurance Assistance Program (SHIP) and has a mandate to provide help with Medicare issues. Computer savvy patients can visit www.Medicare.gov beginning Oct. 1, 2018, to view 2019 plan options on the Medicare Plan Finder. While they won’t be able to enroll until Open Enrollment begins on Oct. 15, they can review and compare their options. When they do enroll, their new plan will take effect Jan. 1, 2019. Each October, the Minnesota Board on Aging publishes its comprehensive Minnesota-focused Medicare guide, called Health Care Choices for Minnesotans on Medicare. This annual publication is full of helpful Medicare information, including all Medicare plan options available to Minnesota Medicare beneficiaries. You can get a free copy by calling the Senior LinkAge Line at 1-800-333-2433, or view it online at www. mnhealthcarechoices.com. Kelli Jo Greiner is a health care policy analyst with the Minnesota Board on Aging.

Providing (and Protecting) High Quality, Cost-Effective Patient Care The Minnesota Ambulatory Surgery Center Association (MNASCA) is a statewide, non-profit trade association OUR MISSION MNASCA is dedicated to promoting quality, value-driven outpatient surgical care. We are committed to ensuring that surgery centers continue to thrive as a distinct model for the delivery of safe, affordable and advanced surgical services to Minnesota’s health care consumers. OUR MEMBERS Our 42 certified member ASCs provide a full range of surgical services. MNASCA supports members through advocacy, outreach, communication, and supporting legislation that lowers the cost of care and increases the quality of health care outcomes. OUR MEMBERSHIP MNASCA offers a variety of membership levels, including individual/nurse membership, associate membership (for our non-ASC supporters), and full facility membership.

Join us for our Annual Conference (venue pending) Thursday, October 11 & Friday, October 12, 2018 Additional details will be posted at www.mnasca.org 30

AUGUST 2018 MINNESOTA PHYSICIAN

For questions about MNASCA, our annual conference, or memberships, please contact Rachel Stuckey at rstuckey@messerlikramer.com.

MINNESOTA PHYSICIAN AUGUST 2018

3The wellbeing of the health care workforce from page 21

Additional tips

Steps to address the wellbeing of the health care workforce: The collaborative has three goals: improve baseline understanding • Understand the issue of stress and burnout within your organization. of challenges to clinician wellbeing; raise the visibility of clinician stress Listen to clinicians and staff, conduct focus groups, and collect data and burnout; and elevate evidence-based, on stress, burnout, resilience, and wellbeing so multidisciplinary solutions that will improve that you can benchmark your organization and patient care by caring for the caregiver. In measure change over time. a recent editorial describing the role of the • Implement interventions targeted at the work collaborative, Victor Dzau, MD, et al, noted that unit and system level to address issues that the consequences of burnout are unacceptable by U.S. physicians have the highest contribute to stress and burnout. any standard and that we have an urgent, shared suicide rate of any profession. • Offer resources within your organization that professional responsibility to respond and to promote self-care, resiliency, and wellbeing of develop solutions. clinicians and staff. Last April, I co-chaired a workshop 160 hosted First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main • Invest in leadership development. by the National Academy of MedicineProviders Global of Business Communication Solutions – www.laserwave.net • Recognize that culture change is complex and Forum on Innovation in Health Professional takes time. Education. The workshop was titled “A Systems Approach to Alleviating

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Sioux Falls VA HEALTH CARE SYSTEM

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

with a Mankato Clinic Career

The VAHCS is currently recruiting for the following positions:

Cardiologist Endocrinologist Neurologist PACT Physiatrist

Psychiatrist Psychologist Pulmonologist Women Health Director

Emergency Medicine (part-time) ENT (part-time) Gastroenterologist (part-time) Urologist (part-time)

apply online at www.USAJOBS.gov

Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

(605) 333-6852 ·

www.siouxfalls.va.gov

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Apply online at www.mankatoclinic.com

Regional Medical Director MINNEAPOLIS, MN HealthPartners Medical Group, based in Minneapolis, Minnesota, is actively recruiting a Regional Medical Director (RMD) to oversee our urgent care services and our in-house primary care physician float pool. The RMD will coordinate and oversee the clinical, operational and financial performance of all HealthPartners Urgent Care clinics. RMDs will partner across the care group to provide a consistent care model and experience for patients. The RMD will report directly to the senior Medical Director, Primary Care. To accomplish the intended outcomes, the RMD must maintain effective working relationships with patients, leadership, clinician and staff colleagues across the care group. Requirements: • Effective in leading physicians and advanced practice clinicians, including coaching, team building and development. • Effective, efficient and articulate communication skills; ability to effectively cooperate, collaborate and communicate with all disciplines and levels of professionals within a large multi-specialty organization • Actively participate in care group initiatives to achieve desired outcomes • M.D. or D.O. degree and current Minnesota medical license, or ability to obtain a Minnesota medical license • Two years of leadership and management experience. Preferred candidates will have five years’ experience as a practicing physician, with experience in ambulatory care settings. • Board certification in Family Medicine or Internal Medicine/Pediatrics is required. HealthPartners offers a competitive salary and benefits package and a commitment to providing exceptional patient-centered care. For more information, please contact diane.m.collins@healthpartners.com or call Diane at 952-883-5453, or 800-472-4695 x3. Apply online at healthpartners.com/careers, Job ID# 48701. EOE

MINNESOTA PHYSICIAN AUGUST 2018

3Measuring the burnout curve from page 19 commitment by the organization’s physician wellness committee/employee wellness committee. All individuals were trained in change management, and leaders received special training to be strong supporters and enablers of change. The system’s intranet now allows clinicians to submit suggested changes to the organization and its EHR, with acknowledgement sent within 48 hours. To ease clinic stressors, scribes were added for some clinicians, along with additional clinic nurses. Clinicians received one-on-one coaching about coding, EHR entry quality, and overall quality goals. Social events for staff and their families offered an opportunity for focused conversation about important topics like burnout. Between 2016 and 2017, this health care system significantly reduced the burnout level of its clinicians and improved in key areas needing to be addressed, as measured through MHA survey data. A second health care system has explicitly focused on burnout across clinicians using a 10-step process: 1) The organization actively engages in the state’s annual survey of burnout. 2) The chief medical officer actively led the design of the survey and how it is administered. 3) The health system tailors its survey invitation, and carefully curates its list of active clinicians. 4) The leadership team thoughtfully reviews data and presents it across regions. 5) The organization partners with MHA to deeply understand the results. 6) Data are reviewed at regional clinician meetings. 7) Each regional and leadership team seeks feedback on specific improvements. 8) Burnout strategy teams are organized in each region, and a resiliency leader has been named for the organization. 9) Burnout is stressed as one of the health

system’s top organizational priorities. 10) Leaders commit to keep this issue at the forefront. Between 2016 and 2017, this organization witnessed a substantial improvement in clinician reports of values alignment with leaders, a significant driver of burnout in our trend data.

Good news Emotional exhaustion, depersonalization, and overall burnout are lower in Minnesota than across U.S. physicians. Targeted strategies by participating organizations have resulted in an increase in the alignment of professional values with leaders. Stress among clinicians is also showing a downward trend over time. Increasingly, health care systems across Minnesota identify burnout as an important issue to address. Work-life balance, meaningful work, high quality care, and control are important for clinicians to thrive. Advanced practice professionals appear to be experiencing lower burnout than physicians.

Not-so-good news Most clinicians spend moderately high or excessive time on the EHR, a challenge that is worsening over time. Almost one-third of clinicians report they do not have enough time, control, or resources to do their jobs. Burnout is highest among those in family medicine, internal medicine, med-peds, general surgery, and emergency medicine. Stress is high in these practice areas, as well as in obstetrics/gynecology and pediatrics. Anesthesiology is the most recent specialty to appear at risk. Millennials and baby boomers have lower stress levels than Generation X clinicians. Burnout follows a similar pattern. And Generation X and boomer clinicians are much more likely to report excessive time on the electronic health record than millennials.

Looking ahead

We’ve helped businesses successfully reach physicians for over 30 years. Created as a marketing vehicle, our original research and editorial content is required industry reading. Advertising in Minnesota Physician is one of the most cost-effective methods of communicating with doctors in Minnesota.

The rise in clinician burnout suggests a public health crisis, and this phenomenon appears to be a near-universal problem across health care. Like hand hygiene or infections, clinician burnout may be best tackled at a population level, rather than relying upon individuals or health systems to do this work alone. Leaders across our state are working to address clinician burnout just as they would other quality issues—using a systematic and data-driven continuous quality improvement approach of formulating hypotheses, collecting data, testing interventions, and spreading those best practices that show the most improvement. Enabling this approach at a statewide level allows for numerous stakeholders and health systems to engage in an action framework that can produce real and sustainable change, with all parties learning and working together rather than competing. Bending the burnout curve may prove to be one of our industry’s greatest challenges. If we solve this challenge, we can improve the lives of health care staff, and ultimately the lives of the patients, families, and communities they serve. Rahul Koranne, MD, MBA, FACP, is chief medical officer at the Minnesota Hospital Association (MHA).

Heather Britt, MPH, PhD, is senior director of health care burnout research at MHA.

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AUGUST 2018 MINNESOTA PHYSICIAN

The MHA would like to recognize and thank the frontline clinicians, CEOs, and CMOs of health care systems who are leading and participating in the statewide action framework described in this article.

A Place To Be Your Best.

Urgent Care Physicians HEAL. TEACH. LEAD.

Dr. Julie Benson, MN Academy Family Physician of the Year

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service

POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic)

• An updated competitive salary and benefits package, including paid malpractice

• Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE

Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Nephrology • Cardiologist • Internal Medicine/Family Practice • Urologist • Psychiatrist • Tele-ICU (Las Vegas, NV)

Ely VA Clinic

Hibbing VA Clinic

Current opportunities include:

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

•

www.minneapolis.va.gov MINNESOTA PHYSICIAN AUGUST 2018

3Cancer health disparities from page 17

Possible explanations for low palliative care and pain management utilization in minorities include differences in cultural attitudes toward end-of life-care, decision-making, and opioid use, as well as limited access to or understanding of the benefits of palliative services and hospice due to language barriers, immigration and insurance status, and lack of palliative care services offered at inner city or rural hospitals.

that reviewed the representation of minorities and women in oncology clinical trials over the past 14 years. This lack of representation has also been observed in clinical trials that target malignancies more commonly seen in minorities, such as multiple myeloma. Our recent study reported that only 8.6 percent of trial participants were African American, despite the fact that this population represented more than 20 percent of prevalent cases. Low clinical trial Achieving health equity requires enrollment of minority and elderly patients is likely valuing everyone equally. multifactorial, including causes such as health literacy, mistrust in the medical system, lack of access to participating centers, cultural or religious beliefs, and fear of side effects. Collaboration between investigators, the National Cancer Institute, the pharmaceutical industry, and the community is necessary to ensure access to clinical trials for all patients.

Future directions

While some factors associated with cancer health disparities are unmodifiable, including age, sex, and tumor characteristics, a larger number of factors can be modified to improve the survival of minorities and underserved populations with cancer. Achieving health equity requires valuing everyone equally, with focused and ongoing societal efforts to improve patients’ health education and access to care. One single intervention will not fix the problem, but if communities and physicians work together, we will be closer to eliminating disparities in cancer health.

Pain and palliative care services/end-of-life care Minority patients face multiple barriers to medical care or early referrals to pain and palliative care services. These include cultural beliefs and practices, language barriers, and financial limitations. Multiple studies have also suggested that minority patients are less likely to receive referral to pain and palliative care services during their cancer journey. In addition, lower utilization of hospice services has been reported. We need to focus attention on why these cancer health disparities persist after diagnosis and treatment.

Narjust Duma, MD, is a hematologist and oncologist Fellow at Mayo Clinic, Rochester. In addition to her dedication to her patients as a provider, Dr. Duma is committed to her research and advocacy in diversity and inclusion, as well as to her research on underrepresented patient populations in clinical trials and how it affects the treatment of cancer patients. She was recognized as the 2018 resident of the year by the National Hispanic Medical Association.

Carris Health is the perfect match “I found the perfect match with Carris Health.” Dr. Cindy Smith, Co-CEO & President of Carris Health

Carris Health is a multi-specialty health network located in west central and southwest Minnesota. Carris Health is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/ BC physicians in the following specialties: • Dermatology • ENT • Family Medicine • Gastroenterology • Geriatrician • Hospitalist

• Internal Medicine • Nephrology • Neurology • OB/GYN • Oncology • Orthopedic Surgery

• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urology

Loan repayment assistance available.

FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | Shana.Zahrbock@carrishealth.com | (320) 231-6353 | acmc.com We are pleased to introduce Carris Health, a new entity launched in January to deliver high quality health care to West Central and Southwest Minnesota. Carris Health is a partnership between ACMC Health, Rice Memorial Hospital and CentraCare Health. This partnership allows us to reach beyond our individual capabilities to combine the talent and skills of all three organizations. Visit www.carrishealth.com for more information.

AUGUST 2018 MINNESOTA PHYSICIAN

Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

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

• Physician (Care In the Community/ Integrative Whole Health) • Physician (Hospice & Palliative Care)

• Physician Psychiatrist (Mental Health)

• Physician (Hematology/Oncology) Part-Time • Physician (Pulmonologist) Part-Time • Physician (IM/FP) St. Cloud MN

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

PRACTICE WHERE BEAUTY SURROUNDS YOU

Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.

WORK-LIFE BALANCE: • Competitive salary • Significant starting & residency bonuses • 4-day work weeks • 51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190

• Physician (IM/FP) Brainerd MN

• Physician (IM/FP) Montevideo MN

• Associate Chief of Staff/ Education (Office of the Director)

• Associate Chief of Staff Primary & Specialty Ambulatory Medicine

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:

Visit www.USAJobs.gov or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

MINNESOTA PHYSICIAN AUGUST 2018

3Physician/employer direct contracting from page 13 costs, we see these companies winning the battle against rapidly increasing health plan costs. For two employers with onsite clinics, a robust well-being platform, onsite PT, value-based benefits, alternative home care, and near-site clinic arrangements, the cost avoidance of actual claims against trend over a 10-year period has been in the range of $4 million to $7 million. Other employers that have engaged with a local independent primary care provider to help them manage the health of their population have seen lower costs savings—approximately 3 to 5 percent over a three-year period—but they have purchased as much as 55 percent more office visits over the same period.

The impact to the provider What has been seen as the curse of independent providers may turn out to be their best sales pitch. If you are an independent provider, you likely

AUGUST 2018 MINNESOTA PHYSICIAN

Direct employer contracting allows you to use this to your advantage. Your local employer would very much like to understand what they are paying for and how they can lower their costs (and if you can offer great outcomes and a better patient experience, you have checked off all three needs for an employer).

A handful of early adopters have been contracting directly with small and midsized independent providers.

For all of these employers that have scuttled the conventional strategies in favor of rebuilding the health of the population, the ultimate payoff is in healthier, more engaged, and more productive employees, as each of these studies show a radical reduction in voluntary turnover and improved profitability.

suffer from what I termed the “David syndrome,” meaning that you get paid a fraction of what large “Goliath” systems are paid to provide the same services and, often, the same health outcomes.

For those employers offering value-based benefits or waiving copayments and deductibles if employees use you, there is a very nice ripple effect: You are getting paid 100 percent of your fee from the employer and do not have to chase down employees/ patients for late fees, which reduces your write-offs.

The options discussed in this article are merely options, not legal advice. There is no “one size fits all” solution. Each plan is unique, so employers should work with their insurance broker to set up a program that fits their needs. For independent health care providers, these models may offer an attractive alternative. Should you have questions regarding this model or are in need of further information, please contact our offices at 952-945-0200. Mick Hannafin is a consultant at Associated Benefits and Risk Consulting.

STAY FOCUSED AMONG THE DISTRACTIONS.

Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E  A N A LY T I C S  R I S K M A N A G E M E N T  E D U C A T I O N

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is for innovation. Celebrating 50 years of blood and marrow transplant leadership University of Minnesota Health physicians have been successfully translating groundbreaking therapies from the lab to patients around the globe. A tradition of cross-disciplinary collaboration and expertise has led to boundary-pushing developments like FDA-approved CAR T-cell therapies, creating more positive outcomes for both pediatric and adult patients.

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