Minnesota Health care News December 2013

Ear infectionsEric T. Becken, MD

Health information privacyMorgan Vanderburg

PneumoniaSara Erickson, MD

FREEYour Guide to Consumer Information

December 2013 • Volume 11 Number 12December 2013 • Volume 11 Number 12

Get involved today and learn how to implement

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by visiting FuelUpToPlay60.com

© 2012 National Dairy Council®. Fuel Up is a service mark of National Dairy Council. Fuel Up To Play 60 and the Fuel Up To Play 60 logo are trademarks and service marks of the National Football League. © 2012 NFL Properties LLC. All NFL-related trademarks are trademarks of the National Football League.

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FMD120000_FUTP_advertorial_Minnesota.indd 1 11/8/12 4:36 PM

CONTENTS

www.mppub.com

December 2013 • Volume 11 Number 12

Publisher Mike Starnes | [email protected]

senior editor Donna Ahrens | [email protected]

AssociAte editor Janet Cass | [email protected]

AssistAnt editor Andrea Peterson | [email protected]

Art director Alice Savitski | [email protected]

office AdministrAtor Amanda Marlow | [email protected]

Account executive Iain Kane | [email protected]

December 2013 Minnesota HealtH care news 3

Minnesota Heath Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email [email protected]. We welcome the submission of manuscripts and letters for possible publication. All views are opinions expressed by authors of published articles are solely those of the authors and do publications. 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 within written permission of the publisher. Annual subscriptions (12 copies) are $36.00/ Individual copies are $4.00.

4NewS

7 PeoPle

8 PerSPeCtIve

10 10 QueStIoNS

12 eAr, NoSe, AND throAt ear infections By Eric T. Becken, MD

14 reSeArChClinical trialsBy Harold Kaiser, MD

16 tAKe CAre health information privacy By Morgan Vanderburg

18 CAleNDAr

20 INSurANCe Private insurance exchanges By Linda Heuer, MBA, RPA

22 CAregIvINgNew sick-leave lawBy Rep. Rick Hansen

24 PulMoNologyPneumoniaBy Sara Erickson, MD

26 CoMPleMeNtAry MeDICINe Nature’s health benefits By Jean Larson, PhD, CTRS,

HTR

28 rAre DISeASe Alpha-gal allergy By Nancy L. Ott, MD

Tamiko Morgan, MD

Metropolitan Health Plan

Jason A. Mehling, MD, MHA

Consulting Radiologists, Ltd.

Background and focus: Post-acute care is becoming an increasingly important compo-nent of health care delivery. It is also becoming increasingly community-based. Medical advances are dramatically expanding the range of access to these services and, at the same time, creating a larger number of problems provid-ing them. Choppy access to electronic medical records and ensuing medication manage-ment complications, as well as problems with care team coordination, can impede the goal of improving outcomes while lowering costs.

Objectives: We will discuss the evolution of post-acute care

and illustrate the dynamic potential it holds. From the hospital to the physician to skilled nursing, rehab, and home care, we will present perspectives from across the care continuum. We will investigate com-munication problems between care team members and present poten-tial solutions. We will examine how elements of health care reform like ACOs and insurance exchanges can drive both improvement in and higher utilization of post-acute care. We will discuss the tools that are necessary for post-acute care to reach its full potential.

MINNESOTA HEALTH CARE ROUNDTABLE

Please mail, call in, or fax your registration by 4/7/2014

Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601.

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MNsure Receives Additional Federal FundingThe U.S. Department of Hu-man Services (DHS) awarded a $41 million grant on Oct. 24 to MNsure, Minnesota’s online health insurance exchange. Jenni Bowring-McDonough, MNsure spokesperson, said that MNsure expected to receive the award. Funding will be used for infor-mation technology infrastruc-ture, security training, system improvements, and ongoing oper-ations through 2014, according to a MNsure statement.

The original state applica-tion in August requested $45 million. Bowring-McDonough said the $4 million reduction was due to cutbacks in the federal Centers for Medicare & Medicaid Services budget.

Funds from a previous grant will be used to cover the $4 million difference between the request and the award, an official said after the exchange’s gov-erning board reviewed its $76.3

million budget for 2014. The Oc-tober award brings total federal funding for MNsure development and operations to about $155 million.

Allina Fires Employee For Privacy BreachA medical assistant at the Allina Health Inver Grove Heights Clinic has been fired for accessing more than 3,800 patients’ medical re-cords without authorization.

Allina initiated an investiga-tion after another employee at the clinic complained about the medical assistant accessing what appeared to be unauthorized records. Once the breach was confirmed, the health system re-leased a statement saying, “Allina Health determined that this em-ployee had accessed the records of patients between February 2010 and September 2013 without authorization. This employee had access to demographic informa-tion, clinical information, health insurance information, and the last four digits of social security

numbers.”

David Kanihan, Allina spokes-man, said, “We did not determine a motive. We do believe that it is highly unlikely she did this for financial gain or identity theft.” The incident has been reported to the U.S. Department of Health and Human Services, as required by law.

Allina mailed letters to notify patients whose records were accessed in the incident and has set up a call center to answer questions. In addition, Allina is offering affected patients no-cost identity-monitoring services to ensure they do not experience any consequences of the breach. Officials say they are evaluating their policies on patient privacy and reviewing computer security programs to help prevent future incidents.

“We have zero tolerance for unnecessary and unauthorized access to patient information,” said Penny Wheeler, MD, presi-dent and chief clinical officer at Allina. “This standard applies to all employees, including medical personnel.”

Optum Admits Partial Fault for Federal Exchange ProblemsMinnetonka-based UnitedHealth’s Optum unit, a subsidiary of UnitedHealth Group, has acknowledged partial responsibility for problems in the initial performance of the federal health exchange website. A four-hour congressional hearing of the House Energy and Commerce Committee was held Oct. 24 to bring together the site’s principal contractors (Optum, CGI Feder-al Inc., Serco Inc., and Equifax Work Solutions) to account for the role each played in the devel-opment and launch of the system.

Optum acquired Quality Software Services, Inc. (QSSI) in 2012, and the federal government has since paid QSSI $85 million to construct two key components of the $500 million health-care exchange website.

Andrew Slavitt, Optum vice president, said at the hearing that QSSI successfully delivered a data services hub that verifies

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consumer information by sending queries to several government databases. Slavitt also acknowl-edged that the technology was “overwhelmed” by thousands of people attempting to register simultaneously after the site launched. He testified that a pos-sible cause of the performance problems “was a late decision [by the government] requiring consumers to register for an account before they could browse for insurance products.” Both he and CGI vice president Cheryl Campbell said that the two weeks the government spent testing the system as a whole just before the launch date was a significantly shorter time frame than other projects of comparable size and complexity. When asked what would have been the industry standard, Slavitt said, “Months would have been nice.”

QSSI increased the capacity of its registration and access tool within a few weeks after the launch, and it is now operating as expected, Slavitt noted at the hearing.

According to officials, mem-bers of both parties expressed concern that the contractors all seemed strangely satisfied with their performance in the produc-tion of the site that has been the source of heated debate due to its serious technological glitches.

Complaints About Humana Prompt Investigation RequestMinnesota Attorney General Lori Swanson is asking for a federal investigation into business prac-tices of Humana, one of the na-tion’s largest Medicare insurers. According to officials, complaints have been filed against the com-pany by consumers and medical providers across the state during the last couple of years. Com-plaints allege improper denial of coverage, overcharging for copay-ments, failure to follow appropri-ate appeals processes, and failure to disclose which providers are in-network. “One thing we’ve seen is Humana denying coverage for things that Medicare would clearly cover,” Swanson says.

On Oct. 18, Swanson sent a letter to the federal administrator for the Centers for Medicare & Medicaid Services (CMS), which regulates private Medicare in-

surers, requesting that CMS look into the 27 affidavits. “Whether it’s a $50 copay or a $5,000 med-ical bill, it matters. We just want them to hold true to what they promise people,” Swanson says.

Humana, based in Louisville, Ky., provides coverage to more than 100,000 seniors across Min-nesota. This state has the highest rate of Medicare beneficiaries enrolled in a Medicare Advantage plan: 49 percent compared to 28.8 percent of beneficiaries in the U.S. According to officials, Humana covers 17 percent of this market in Minnesota.

In a statement regarding the allegations, Humana officials said, “Humana has not been noti-fied of this matter by the Minne-sota Attorney General’s Office or by CMS. We take these matters very seriously and are working to identify the facts.” The statement added that its Medicare Advan-tage plans have received a quality rating of four-and-a-half stars on a five-star scale.

Swanson wrote that she is asking the CMS to conduct the investigation because the state has no authority to enforce Medi-care Advantage plan rules. This request is the most serious action that can be taken.

Lawmakers Request Review of Board of NursingState legislators are seeking an audit of the Minnesota Board of Nursing and a legislative hearing to review its actions. Sen. Kathy Sheran (DFL–Mankato), chair-woman of the Senate Health, Human Services, and Housing Committee, said last week, “We need to determine … that the process of reviewing complaints creates an outcome that assures public safety to the best of our ability.”

The request for an inves-tigation comes after the Star Tribune reported on a review of more than 1,000 disciplinary actions taken by the board since 2010. The newspaper found that nurse misconduct that could end careers in other states had been overlooked in several cases. It reported that the board licensed more than 260 nurses who had


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news to page 6

records of unsafe practice, some of which resulted in patient harm or death. Since then, the Star Tri-bune has reported that in an ad-ditional 23 cases, a nurse accused of patient harm was allowed to continue practicing.

“If there are gaps in the disci-plinary process, we want to know about it and improve upon it if we can,” Shirley Brekken, executive director of the Minnesota Board of Nursing said in a statement. “The board is always looking at its processes from a variety of perspectives, not only efficiencies, but effectiveness.”

Sheran met with Brekken in mid-October, and said she came away with concerns that the board may not have the necessary resources to deal with the num-ber of complaints filed. Sheran also voiced concerns that board members and staff could require training to assert their responsi-bility to protect the public.

Rep. Tina Liebling (DFL–Rochester), chair of the House Health and Human Services com-mittee, joined Sheran in planning

to request that Brekken testify at a joint-committee hearing and that the legislative auditor exam-ine the Minnesota Board of Nurs-ing, along with other professional licensing boards that employ a similar disciplinary approach. “I expect there will be a number of findings and suggestions for change,” Sheran said.

A spokesman for Gov. Mark Dayton said, “pursuing a review is an appropriate next step and one that the governor strongly supports.”

HCMC Opens New Pediatric Intensive Care UnitHennepin County Medical Center (HCMC) has opened a new, nine-bed pediatric intensive care unit (PICU).

Rooms in the 5,500-square-foot unit contain couches that fold out into double beds for parents who want to stay over-night with their children, and monitors that display real-time medical data, including lab re-

sults. Wraparound windows were installed in each room so patients can stay connected to the natural rhythms of the day. This is espe-cially important for children with traumatic brain injuries, accord-ing to Andrew Kiragu, MD, PICU medical director.

The expansion was planned as HCMC identified a growing need for more space for pediatric trau-ma and critical care services.

Blue Cross, Sanford Health Announce BlueConnect

Blue Cross Blue Shield of Minnesota and Sanford Health have announced their partner-ship in offering BlueConnect, a new health plan available wherev-er Sanford Health has a presence within the Blue Cross coverage area. Consumers and employers in 26 counties in western Minne-sota and select border counties in North Dakota, South Dakota, and Iowa will have access to the health plan.

BlueConnect will offer care through 30 hospitals, 308 clinics, and 1,300 physicians, and will provide access to Sanford Health Centers of Excellence such as Sanford Cancer and the Roger Maris Cancer Center, Sanford Children’s, Sanford Heart, and Sanford Orthopedics and Sports Medicine.

The plan is available for enrollment through MNsure and traditional channels outside the exchange, and coverage will begin January 2014.

Editor’s noteAfter the article on flexible spending accounts in the No-vember 2013 issue of Minnesota Health Care News went to press (“Flexible spending account$, Use it or lose it!” by Linda Heuer, MBA, RPA), the IRS announced a modification to these accounts’ use-or-lose provision to allow a carryover of up to $500 to the next plan year. The ways to use up FSAs that the article describes have not changed.


news from page 5

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Ellen Abeln, MD, board-certified in radiology, has been inducted as

a fellow into the american college of radiology. she is medical director

of the Breast center of suburban imaging, coon rapids, and is on staff

at Unity and Mercy hospitals. abeln earned her medical degree from the

University of Minnesota. Both her residency in diagnostic radiology and

fellowship in cross-sectional imaging were served at the cleveland clinic.

Sanjay Chaudhary, MBBS, board-certified in internal medicine and

nephrology, has joined the critical care team at es-

sentia Health–st. Mary’s Medical center in Duluth.

He earned his medical degree from the B.P. Koirala

institute of Health sciences in Dharan, nepal; served

a residency in internal medicine at creighton Univer-

sity Medical center, omaha; and completed fellow-

ships in nephrology and critical care medicine at the

Mayo Graduate school of Medicine, rochester.

Nancy Hutchison, MD, physical medicine and

rehabilitation (PMr) specialist

and medical director of cancer

rehabilitation and survivorship for the Virginia

Piper cancer institute and courage Kenny re-

habilitation institute, Minneapolis, has received

the Minnesota nonprofit Breast cancer aware-

ness association’s annual award for outstanding

contribution to the breast cancer community. she

completed medical school at wake Forest Univers-

ity, winston-salem, n.c., and PMr residency at the

University of Minnesota.

Steven Hecht, PhD, co-director of the University of Minnesota trans-

disciplinary tobacco Use research center (ttUrc), received the fifth

annual award for excellence in cancer Prevention research in novem-

ber, presented jointly by the american association for cancer research

and the cancer research and Prevention Foundation. Hecht, whose doc-

torate in organic chemistry was earned at the Massachusetts institute of

technology, was honored for more than 30 years of research on tobacco

and its link to cancer. in addition to his ttUrc duties, he heads the

carcinogenesis and chemoprevention Program at the univers-

ity’s Masonic cancer center and is a member of the medicinal chemistry

graduate department.

James Kirkland, MD, PhD, director of the robert and arlene Kogod

center on aging at the Mayo clinic in rochester, testified on oct.

29 before the U.s. senate special committee on aging. the points he

stressed included the need to maintain a pipeline of emerging treatments.

Mayo’s center on aging has initiated a nationwide geroscience network

in collaboration with 10 other centers studying aging; the network re-

cently received funding from the national institute on aging.

David Rothenberger, MD, has assumed the role of head of the

University of Minnesota Department of surgery. Board-certified in

colon and rectal surgery and in general surgery, he

graduated from tufts University school of Medi-

cine, Boston; completed a general surgery residency

at st. Paul-ramsey (now regions) Hospital; and

completed a fellowship in colon and rectal surgery at

the University of Minnesota. Previously, he held the

John P. Delaney chair of clinical surgical oncology

at the University of Minnesota, where he had been

the deputy chairman of the department of surgery

since 2006.

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In 2006, new federal health care legislation was passed that allowed adults with disabilities receiving Medical Assistance to enroll in a Special Needs Basic Care

(SNBC) health plan. This recognition of the need to pro-vide comprehensive, multidisciplinary care for adults with disabilities prompted Metropolitan Health Plan (MHP), a nonprofit state health maintenance organization, to create its own SNBC program. This program is Corner-stone Solutions, which is offered in partnership with the Hennepin County Human Services and Public Health Department.

What it does“Cornerstone” is defined as something that is essential, indispensable, or basic: the chief foundation on which something is constructed or developed. Cornerstone Solu-tions provides integrated health care services to certified disabled adults, making it easier for them to find and receive the care they need. We do this by providing mem-bers with one primary point of contact—a care guide––to help them access the physical, mental/behavioral, and social service support they need.

How it worksUpon enrollment, every Cornerstone Solutions member is assigned a care guide who helps the member identify his or her needs. The care guide meets with the member within the first 30 days to complete a thorough health risk assessment and develop a care plan. This plan is patient-centered, designed to meet the individual needs of the member.

Care guides also help members navigate service delivery systems, which often can be very complex. In addition, they connect members with benefits and resources; ensure members understand their health plan; communicate with doctors and others involved in members’ care; assist mem-bers with paperwork deadlines and eligibility; and serve as advocates and problem-solvers. The use of care guides is central to providing seamless delivery of care.

Care guides receive special training that focuses on working with people with disabilities, and they are also experienced in working with culturally and economically diverse populations. In addition to care guides, members have 24/7 access to nurses through HealthConnection, a nurse phone line.

Members of the plan are entitled to some additional benefits, such as a free YMCA membership, and transpor-tation to and from medical and dental appointments.

ResultsDental health is a major focus for MHP. Many members are unaware of the potential consequences that can

result from neglecting oral health care, which is why care guides spend time educating members on the dental ben-efits available to them, as well as why receiving preventive and diagnostic oral health care on a regular basis is so important.

A care guide reported that, “One individual in particular was embarrassed to bring up his need for the dentist, but filling out [MHP’s dental] questionnaire encouraged him

to express his concerns. As a result, he is getting new partials … He told me there are not enough words in Webster’s dictionary to express how happy he is about his new teeth.”

In addition to individual success stories such as this one, MHP has seen improvement in a number of other areas, including:

• The percent of MHP members who kept a follow-up visit for a mental health need in-creased from 52 percent to 67 percent between 2009 and 2011.

• MHP members’ colorectal cancer screening rates rose by approximately 27 percent from 2011 to 2012.

• Members’ breast cancer screening rates rose approximately 8 percent from 2011 to 2012. Breast cancer screening rates among MHP members are 12 percent above the Minnesota average.

EligibilitySince its inception in 2008 with 50 members, Cornerstone Solutions has expanded, currently serving close to 3,000 members. Members must be age 18 to 64, residents of Hennepin County, certified disabled by Social Security or the State Medical Review Team (SMRT), and either eligible for both Medicare and Medical Assistance (MA) or eligi-ble only for MA.

Cornerstone Solutions members include those with physi-cal, mental, and behavioral disabilities. Generally defined as physical or mental impairments that substantially limit one or more major life activities, disabilities may or may not be noticeable. Some “invisible” disabilities include developmental/cognitive disabilities, depression, autism, epilepsy, and traumatic brain injury.

Supporting individual effortsMHP recognizes the special challenges of its disabled members, and remains committed to helping them overcome these obstacles and function at their highest capacity.

Cornerstone Solutions

Dr. Morgan serves as medical director of

MHP. Morgan is board-certified in pediatrics,

with additional training in health care administration,

integrative medicine, and health coaching. She has 12 years of clinical

experience with Hennepin County Medical Center’s Department of Pediatrics

and has served as an associate professor at the University of Minnesota.

She is also an active community advocate for eliminating health care

disparities.

For more information about Cornerstone

Solutions or to refer someone to the program, contact (888) 562-8000

PE RSPEc t ivE

Metropolitan Health Plan (MHP)

Tamiko Morgan, MD

The use of care guides is central to providing seamless

delivery of care.

Comprehensive health care for adults with disabilities


(www.cornerstone-solutions.org).

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Interventional radiology (IR) is a fairly new specialty. What is its history? The earliest known vascular X-ray occurred in 1896, when a physician injected X-ray dye into the hand of a cadaver. This basic procedure is used today and is called angiography. The X-ray it produces is a picture of blood vessels, called an angiogram. During the 1950s–1990s, radiologists around the country developed ways to perform procedures using X-ray guidance to minimize pain and risk to the patient. In the early 1950s, a Swedish radiologist published a method of safely accessing hollow organs and blood vessels by using a needle-and-wire technique. This procedure can be used to drain fluid from infected organs and vessels, to introduce catheters into the body, and to perform angiography. Interventional angiography was born in 1964, when a U.S. radiologist dilated an artery in an elderly woman’s leg. Around the same time in Minnesota, Dr. Kurt Amplatz advanced the field by inventing new interventional

devices and techniques. In 1977, the first successful use of coronary angioplasty was performed in a live human. In the 1980s, chemoemboli-zation was introduced. This technique destroys tumor tissue by injecting tumor-killing medicine through a catheter directly into a blood vessel that feeds the tumor.

IR is used to diagnose and treat many different parts of the body. Please give us some examples of how it works.Interventional radiology is used for ailments from the top of the head to the tips of the toes. Carotid and cerebral angiography treat such ailments as cerebral aneurysm, which occurs when weakness in the wall of a blood vessel supplying the brain with blood and oxygen causes the vessel to dilate. Dilation can burst the vessel and cause a stroke. IR can also treat the opposite condition, carotid stenosis (which is a narrowing of one of these arteries), by angioplasty (surgical repair of a blood vessel) and stenting. A stent is a small tube that is inserted into a previously blocked vessel to keep it open.

IR doctors place catheters in patients who need long-term intravenous access in order to receive dialysis, chemotherapy, or chronic adminis-tration of medication. In addition, interventional radiologists perform image-guided biopsies of tissue in areas where densely packed nerves and vessels could make surgical biopsy comparatively risky. If biopsied tissue is found to be cancerous, some patients may undergo embolization or ablation of the cancer. Embolization introduces material into the small blood vessels that nourish the cancer. This cuts off the blood supply and starves the cancer. We also treat vein-related conditions in the lower extremities, including varicose veins and deep venous thrombosis. We can use catheters to open clotted veins, or to close painful varicose veins.

How do interventional radiologists collaborate with other medical specialties? We collaborate

with multiple other medical specialists. For example, at Abbott Northwestern Hospital we are present at many of the tumor conferences to help guide in the treatment of cancer. We collaborate with urologists in the treatment and removal of kidney stones. We collaborate with our surgical colleagues with the embolization of tumors prior to tumor removal to help minimize blood loss, or the drainage of a gallbladder in a patient that is too sick for surgical removal of the gallbladder. We join with our vascular surgery partners in the treatment of abdominal aortic aneurysms.

What does the future hold for IR? Medical devices used in IR continue to become smaller, safer, and easier to use. Catheter-based drug- and radiation-delivery devices have evolved consider-ably since the introduction of chemoembolization

10 Q U EST I O NS

Jason A. Mehling, MD, MHADr. Mehling practices interventional radiology at multiple Twin Cities locations of Consulting Radiologists, Ltd.

Interventional Radiology

in the early 1980s. Catheter-delivered and balloon-mounted stents and stent grafts have become the treatment of choice over open surgical procedures in most parts of the body. IR is the most rapidly changing field in medicine, and new application of old techniques is leading to new and improved minimally invasive treatments.

Has this field changed the survival rate for any medical conditions? One area in which IR has improved both morbidity and mortality is interventional oncology. No longer does every tumor need to be surgically removed. Through minimally invasive techniques, we can destroy a tumor with a needle or deliver high doses of chemotherapy or radiation through a catheter directly to the tumor’s vascular supply. This requires an incision only one to two millimeters in length. Most of these procedures are performed on an outpatient basis, saving patients time and money and reducing risk of infection and length of hospital stay.

IR involves exciting scientific advances that may lead both to inherent dangers and unrealistic expectations. What can you tell us about this? No procedure is risk-free. Any procedure performed on a patient, whether minimally invasive or not, can have complications. Not every patient is a candidate for a minimally invasive procedure, or any procedure at all. It is always important to set reason-able expectations for treatment, and to discuss all risks, benefits, and alternatives to each procedure.

What kinds of medications are used in IR? One of the most exciting recent advancements in IR is in the area of catheter-delivered medication, used for treatment of many tumors. Drug- or radiation-coat-ed beads, barely visible to the human eye, are injected directly into the blood supply of a tumor via a catheter inserted through the skin and into a blood vessel that feeds the tumor. We use fluoroscopy—radiographic

images—and catheters to guide us to the tumor. Other catheter-injected devices, such as bland embolization material or metal coils, can be used to treat such ailments as uterine fibroids or to embolize tumors in blood vessels in order to decrease blood supply before surgical removal.

Please share an example of IR making an immediate, signifi-cant health care improvement. Patients who arrive at the hospital with overwhelming, body-wide infection often are too sick to undergo an operation, but need life-saving intervention. IR allows us to drain infected fluid from the kidney, gallbladder, or abdomen by inserting a needle into the fluid through the skin, guided by radiographic imaging. In some patients, this minimally invasive procedure eliminates the need for surgical intervention. Other specialists then manage the cause of the infection.

Can IR treat medical conditions in utero? There are a few insti-tutions in this country that perform fetal image-guided surgery for rare procedures such as amniotic shunts and fetal blood sampling. Weare often involved in procedures related to bleeding immediately after surgery, especially in high-risk patients. We can insert balloons into the blood vessels supplying the uterus and inflate them just after a baby is delivered, to decrease bleeding after delivery.

What are the most important things that people can do to keep from needing your services? Many ailments we treat result from other medical conditions or risk factors. Controlling vascular risk factors such as hypertension, cholesterol, diabetes, smoking, and obesity can prevent vascular disease. Taking basic preventive measures to help reduce the risk of cancer also helps.

December 2013 MINNesOTA HeAlTH CARe NeWs 11

Ear pain is a common cause of concern for parents of infants and young children, although it can also appear in adults. Often, the diagnosis is acute otitis media (AOM), or a

middle ear infection. This frequently accompanies a common cold or other infection because an upper respiratory infection makes the

Eustachian tube swell, which prevents normal drainage of fluid from the middle ear. When this happens, fluid becomes trapped, forming a breeding ground for viruses and bacteria and leading to AOM.

SymptomsThe symptoms of AOM overlap those of many childhood illnesses as well as upper respiratory infections in adults. Adults and older children may complain of sudden ear pain associated with a fever. Infants and young children may demonstrate ear pain by pulling or rubbing their ears, crying, or changing sleep and behavior patterns. Unfortunately, none of these symptoms are specific for AOM, as they frequently accompany fever, nasal congestion, and even con-junctivitis (commonly known as pink eye). This means that only an experienced clinician who examines the child or adult can make a diagnosis of AOM.

When to go to the doctorOften, parents have difficulty deciding when to seek medical attention for a sick child or themselves. The following are general guidelines for children and adults who have symptoms consistent with a possible ear infection. These do not replace personalized medical guidance and caregivers should not hesitate to contact their physician with specific questions or concerns.

Contact your doctor if you or your child have:

•Fever greater than 102°

•Symptoms lasting longer than 48 hours

•Redness or bulging behind the ear

•Drainage from the ear

•Dizziness, confusion, or decreased levels of consciousness

•Severe ear pain

DiagnosisThe diagnosis of AOM can be made only by a health care profes-sional. Accurate diagnosis sometimes requires removal of earwax

12 MInnESOTA HEAlTH CARE nEWS December 2013

E a r , N osE , a N d th roat

Ear infectionsWhen to see the doctor

By Eric T. Becken, MD

Do you have trouble using the telephone dueto hearing loss, speech or physical disability?

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

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

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to offer a clear view of the eardrum. Additional tests, including pressure testing known as tympanometry, can be helpful but will not yield a diagnosis. A definitive diagnosis can be made only by visual inspection of the eardrum by an experienced clinician.

TreatmentHistorically, all patients with AOM received antibiotic treatment. Recently published guidelines suggest a more nuanced approach (Pediatrics 2013). Often, the appropriate treatment is not to use antibiotics because viruses, which do not respond to antibiotics, cause many episodes of AOM.

If a health care provider determines that antibiotics are necessary, standard first-line treatment will be amoxicillin, amox-icillin-clavulanate (Augmentin), or cefdinir. Alternative antibiotics should be considered if the child still has symptoms after 72 hours of treatment. Treatment decisions are based, in part, on the age of the patient and the severity and duration of symptoms. A general guideline is that all children under six months of age should receive antibiotics while older children and adults should receive antibiotics only if they have severe symptoms or symptoms that last longer than 48 hours.

Reduce painAlthough treatment of AOM is based on the age of the patient and the severity and duration of symptoms, some aspects of treatment are consistent across age groups. Whether or not antibiotics are prescribed, acetaminophen (Tylenol) and ibuprofen (Advil) are the first-line agents for pain control. These medications will also assist with fever reduction. Eardrops that contain local anesthetics are an option but don’t offer significantly more pain reduction than oral medications. Homeopathic and naturopathic treatments such as warm oil or garlic eardrops are reportedly beneficial for pain control and even reduction of infection, but there are no scientific studies that corroborate this. Additionally, there is no evidence that chiro-practic care or allergy management treats acute AOM episodes or decreases the risk of AOM.

Reduce risk However, there are ways to reduce the risk of developing not only AOM but other diseases as well:

Vaccines can help decrease the likelihood of acquiring an infection. The pneumococcal vaccine prevents specific bacterial infections, which are among the most common causes of AOM. Annual influenza vaccines decrease the rate of influenza infections that lead to AOM in many children and some adults.

Breastfeeding. Children that are breastfed for at least six months have fewer episodes of AOM during early childhood. This is be-cause antibodies critical to the immune system are transferred from mother to child in the breast milk.

Avoid tobacco smoke. Exposure to tobacco smoke leads to an increased rate of AOM. This is due to Eustachian tube dysfunction caused by the smoke.

Ear tubes Although episodes of AOM often disappear spontaneously or with antibiotics, some children have infections that are resistant to oral antibiotics. Others develop AOM repeatedly or have fluid in their

middle ear that does not go away. Repeated ear infections or persistent fluid may require placement of pressure-equalizing (PE) tubes.

Three or more infections in six months, four or more infections in a year, or middle ear fluid that is present for more than three months

merits referral to an ear, nose, and throat physician for consideration of PE tubes. If tubes do not solve the problem, other interventions are available.

Seek helpAcute otitis media is common and rarely life threatening. However, it can be extremely painful and can lead to hearing loss, chronic ear problems, and impaired speech development. Evaluation by a primary care provider or an ear, nose, and throat physician is appropriate for anyone with concerns regarding ear infections.

Eric T. Becken, MD, is a board-certified ear, nose, and throat specialist prac-ticing with Midwest Ear, Nose and Throat Specialists at its Eagan, Maplewood, St. Paul, and Woodbury locations.

December 2013 MInnESOTA HEAlTH CARE nEWS 13

Acute otitis media (AOM), or a middle ear infection … frequently accompanies a common cold or

other infection.

Many of you may have seen an advertisement for a Clinical Trial, or Clinical Research Study, in the newspaper, on TV, or on social media and may be considering volun-

teering to participate. Before you start, there are several important points to consider.

What are they?

Clinical trials are research studies that are a necessary part of the process a drug or medical device goes through before approval. This article explains the process of determining if a new medication is effective and safe.

The need for clinical trials is large because more than half the U.S. population takes some kind of prescription medication. More than 90 percent of the population reports taking over-the-counter medication on a regular basis. The medications that people use require extensive and expensive research, development, and clinical testing. By the time a drug is approved by the federal Food and Drug Administration (FDA), approximately $1.2 billion has been invested in it (this includes the cost of compounds that fail to be approved). The approval process may take up to 15 years and only about one of 10,000 drugs gets approved. A new medication usually begins in the laboratory. After being tested in the laboratory and in animal studies, the most promising experimental treatments are moved into clinical trials. Drugs are tested to establish that they are safe and effective.

Process

Clinical trials are organized into four phases.

Phase I

Researchers test an experimental drug in 20–80 healthy volunteers to evaluate its safety, to determine a safe dosage range, and to identify side effects.

Phase II

The experimental drug is tested in 100–300 people who actually have the condition the drug is designed to treat. This phase is to determine safety and effectiveness.

Phase III

Researchers test the experimental drug in large groups of people (1,000–3,000) to confirm effectiveness, monitor side effects,

14 MinneSoTA HeAlTH CARe newS December 2013

Rese a Rc h

Should you participate?

By Harold Kaiser, MD

Clinical trials

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

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compare the drug to commonly used treatments, and collect infor-mation that will allow the experimental drug or treatment to be used safely.

Phase IV

Researchers test the drug in volunteers after it has been approved and is on the market. The goal of this phase is to gather additional information about the drug’s risks, benefits, and optimal use.

A clinical research study is conducted according to a plan known as a protocol.

The protocol is designed to safeguard the participants’ health and to answer specific research questions.

A protocol describes:

• who is eligible to participate in the trial

•Details about tests, procedures, medications, and dosages

A clinical research study is led by a principal investigator (PI), usually a physician. Members of the Pi’s research team regularly monitor participants’ health to assess the progress of the study.

Oversight

each clinical trial in the United States must be approved and mon-itored by an institutional Review Board (iRB). This board is an independent committee that consists of physicians, statisticians, and members of the community. The iRB ensures that clinical trials are ethical and that risks are minimal and are worth any potential bene-fits. The iRB must also ensure that the rights of a research volunteer are not violated.

every volunteer (research subject) who consents to participate in a research study has the right to receive:

• information about the nature and purpose of the trial

•An explanation of the procedures to be followed in the clinical trial, and any drug or device to be used

•A description of any attendant discomforts and risks reason-ably to be expected from the clinical trial

•An explanation of any benefits to the subject reasonably to be expected from the clinical trial, if applicable

•A disclosure of any appropriate alternative procedures, drugs, or devices that might be advantageous to the subject, and their relative risks and benefits

• information about medical treatment, if any, that is avail-able to the subject if complications should arise during or after the trial as a result of the trial

•An opportunity to ask any questions concerning the clinical trial or the procedures involved

•A copy of a signed and dated written consent form

Deciding to give consent to participate is free of intervention of any element of force, fraud, deceit, duress, coercion, or undue influence on the subject’s decision.

in addition, anyone who consents to participate in a clinical trial can withdraw at any time and end his or her participation in the trial without any repercussions.

Federal regulation also requires all institutions in the United States that conduct or support biomedical research involving peo-ple to have an iRB initially approve and periodically review the research.

Informed consent

informed consent is the process of providing potential participants with the key facts about a clinical trial before they decide whether to participate. The informed consent document includes details about the study, such as its purpose, duration, required procedures, and whom to contact for further information. This document also

December 2013 MinneSoTA HeAlTH CARe newS 15

Clinical trials to page 34

For more information• www.ClinicalTrials.gov provides the public with information about current

clinical research studies. This includes a summary of each study’s protocol, including its purpose, recruitment status, and eligibility criteria. Study locations and specific contact information are listed to assist with enroll-ment. ClinicalTrials.gov is a free service of the National Institutes of Health, developed by the National Library of Medicine.

• TheCenterforInformationandStudyonClinicalResearchParticipation(CISCRP). (617) 725-2750, Toll-free: (877) MED-HERO Fax: (617) 725-2753, www.ciscrp.org

• www.centerwatch.com helps people access clinical trials.

• ClinicalResearchInstitute(CRI) lists clinical trials seeking volunteers in the Twin Cities metro area. (612) 333-2200 x 5, www.CRIminnesota.com

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Ta k e C a re

Requirements governing the privacy of health information have changed drastically over the past 20 years. Prior to the enactment of the federal Health Insurance Portability and Accountability

Act of 1996 (HIPAA), few federal rules existed to protect the privacy of health information. Consequently, health care providers and insurers often committed privacy breaches with few repercussions. In explaining the need and purpose for federal privacy protections, the drafters of the HIPAA regulations cited these examples of privacy breaches:

• A Michigan-based health system accidentally posted the medical records of thousands of patients on the Internet.

• A Utah-based pharmaceutical benefits management firm used patient data to solicit business for its owner, a drugstore.

• Health insurance claims forms of thousands of patients blew out of a

truck on its way to a recycling center in East Hartford, Conn.

• A patient in a Boston-area hospital discovered that her medical record had been read by more than 200 of the hospital’s employees, most of whom had no legitimate reason to do so.

In an attempt to prevent these types of breaches, HIPAA regulations created specific rules that govern the sharing of health information by health care organizations. These federal privacy regulations also grant individuals specific rights related to their health information, including the right to be notified when a breach of their health information occurs.

Who is regulated?These privacy requirements apply to “covered entities” under HIPAA. Covered entities include most health care providers, health plans, and health

information privacy

16 MInnEsoTA HEAlTH CARE nEws December 2013

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Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older.

Services• Outreach service and consultation with family or concerned persons• Evaluation and assessment for chemical dependency and/or mental health

issues completed by qualified professionals• Volunteer support for older adults who are chemically dependent• Support from peer volunteer counselors for older adults with mental health issues

ProgramsOlder Adult Chemical Dependency Primary Treatment ProgramA comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

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care clearinghouses. Certain requirements also apply to “business associ-ates.” This term includes contractors, subcontractors, and other outside persons or entities that perform a service on behalf of the covered entity but are not part of the covered entity’s workforce. Common examples of business associates include law firms and language interpretation services that have access to the covered entity’s health information. some of the protections and rights provided by HIPAA are explained below.

Consumer protection under HIPAA

Right to accessBefore HIPAA, many states failed to pass legislation that provided individ-uals with a right to view a copy of their medical record. Individuals now have the right to obtain and inspect a copy of their health information, which the covered entity must produce within 30 days of a request. In addition, covered entities are generally required to provide a copy of the medical record in electronic format if requested by an individual. Viewing an electronic copy is already available in many cases, as many health care providers offer online account options not only to view medical records, but also to schedule appointments, fill prescriptions, and make payments.

Right to request an amendment Individuals have the right to request an amendment of their health infor-mation if they believe that information is inaccurate or incomplete. If the covered entity denies the request, it must provide a written basis for the denial to the individual and also allow the individual to submit a statement of disagreement for inclusion in the medical record. If the covered entity

accepts the request, it must amend the information within 60 days. It also must provide an amended version of the health information to persons identified by the individuals or to persons that the covered entity knows might rely on the information to the individual’s detriment.

For example, let’s say a hospital physician sends clinical documentation about a patient to the doctor who referred the patient. The patient requests a copy of her medical records and sees that the clinical documentation con-tains an error. she submits an amendment request to the hospital to change content in the clinical documentation because it states she had surgery on her left knee but, in reality, she had surgery on her right knee. The hospital physician is obligated to 1) change the note because it is inaccurate and 2) send an updated note to the referring doctor. This is because, if the referring doctor relies on the inaccurate information, it could result in harm to the patient.

AuthorizationsThe HIPAA Privacy Rule generally requires covered entities to obtain written permission from individuals for uses of health informa-tion that are not directly related to treatment or payment. For example, a covered entity needs written authorization to share an

individual’s health information with a life insurance company or employer. The content of the authorization form must provide a specific description of the health information affected and the recipient of the information. Individuals should read any authorization form closely before signing. The covered entity cannot refuse or condition treatment, payment, or eligibility of benefits based on whether the individual signs the authorization.

December 2013 MInnEsoTA HEAlTH CARE nEws 17

Individuals now have the right to obtain and inspect a copy of

their health information.

December Calendar

7Food Allergy Resource FairThe Food Allergy Support Group of Minneso-

ta presents this resource fair, featuring allergy-friendly foods and products, allergy safety information, and doctors who will be available to answer questions. Free, no registration required. Visit www.foodallergysupportmn.org for more information.Saturday, Dec. 7, 9 a.m.–12 p.m., Eisenhower Community Center, 1001 Hwy 7, Hopkins

10 Digestion Without the DramaVital Life Chiropractic hosts this free

wellness workshop to help uncover hidden reasons for digestive difficulties and transform your digestive system into a powerful, efficient machine. If you restrict your diet to avoid heartburn, gas, or constipation and worry about not knowing what’s in every dish at hol-iday parties, this course may be for you. Visit vitallife.eventbrite.com or call (651) 757-5096 to register. Tuesday, Dec. 10, 6:30–7:30 p.m., Vital Life Chiropractic, 3470 Washington Dr., Ste. 108, Eagan

11 Ovarian Cancer Survivor GroupThe Teal Survivors Support Group, hosted

by the Minnesota Ovarian Cancer Alliance, is for women who are long-term ovarian cancer survivors or those who have experienced a recurrence. Join others on the same recovery journey for support and strength. Free. Please RSVP to Judy at (612) 203-3456. Wednesday, Dec. 11, 6–7:30 p.m., Minnesota Ovarian Cancer Alliance, 4604 Chicago Ave., Minneapolis

12 Young Widowed Support GroupPark Nicollet grief counselors facilitate this

drop-in support group for men and women of any age that have experienced the death of a spouse, partner, or fiancé. Come meet others who understand to gain insight and understand-ing. For more information, call (952) 993-0594. Thursday, Dec. 12, 6:30–8 p.m., Park Nicollet Methodist Hospice, 700 5th St. S., Hopkins

17Substance Abuse/Mental Health SupportRamsey County Human Services hosts

this free, weekly support group for individuals affected by substance abuse and/or mental health issues. Professional counselors are on staff to facilitate the discussion. Join others who can relate and support you on your journey. To sign up, call Bob at (651) 266-3528. Tuesday, Dec. 17, 1:30–2:30 p.m., 402 University Ave. E., 1st Floor Conference Room, St. Paul

18 Lou Gehrig’s Disease Caregiver Support Group

The ALS Association Minnesota/North Dakota/South Dakota Chapter presents this monthly support group for family members and care-givers of individuals affected by Lou Gehrig’s Disease. RSVP required. Please contact Jennifer at (888) 672-0484 or [email protected]. Wednesday, Dec. 18, 7–8 p.m., Union Plaza Building, 333 N. Washington Ave., Ste. 105, Minneapolis

18 Look Good, Feel Better Mercy Hospital offers this free program

in collaboration with the American Cancer Society. Join a licensed cosmetologist who teaches people with cancer ways to enhance their appearance and self-image during chemotherapy and radiation treatments. Get advice on dealing with hair loss and dry skin, and receive a free makeup kit. Registration required. Call (800) 227-2345 to sign up or for more information. Wednesday, Dec. 18, 6:30–8 p.m., Mercy Hospital Cancer Resource Center, 4050 Coon Rapids Blvd. NW, Coon Rapids

21 OCD Support Group OCD Twin Cities hosts this semimonthly

support group for individuals affected by obsessive compulsive disorder (OCD) and related disorders. Come meet with others who understand, learn how to maximize your treatment, and connect with resources you may not have known about. For more information, contact Burt at (612) 722-1504 or [email protected]. Saturday, Dec. 21, 11 a.m.–1 p.m., St. Louis Park Community Center, Room 215, 6300 Walker St., St. Louis Park

For many, the holiday season is one of celebration and reconnecting with loved ones. But the additional responsibilities, travel, and potential financial burdens, compounded by sleeping and exercising less and changes in alcohol and food consumption habits, can be a recipe for feeling overwhelmed.

Self-care is an important part of planning for the holiday season. It is imperative to keep realistic expectations for yourself and to not take on too much. Learn to say, “No” when necessary. Plan ahead as best you can, while staying open to the idea that things may not go exactly as planned. Set a budget for gift and food shopping, and stick to it.

Keeping your body in balance physically can play a significant role in how you handle stress as well. Treat yourself, but avoid overindulgence in sugary foods and alcohol, and keep healthy meals and snacks a part of your routine. Take some “alone time” when you need it. Spending 10 to 15 minutes in a quiet space will allow you to mentally slow down and renew your inner calm.

16 Guided Relaxation/Yoga Session HealthEast Ways to Wellness

offers this relaxing yoga session, The Gift of Silence, to help you decompress from holiday season stress and slow down to be present in each moment. Free, but registration is required and space is limited. Call (651) 232-1926 to sign up. Monday, Dec. 16, 12:15–1 p.m., Woodwinds Health Campus, 1925 Woodwinds Dr., Woodbury

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

Managing Holiday Stress


Right to request restrictionsIn certain situations, covered entities are not required to obtain the in-dividual’s authorization to share health information. Examples include disclosures of health information for treatment or payment purposes. Even though an authorization is not needed, individuals may still submit a request to restrict or limit the sharing of health information in these cir-cumstances. For example, an individual may submit a request that asks the covered entity not to share information with his/her health care providers at other organizations.

Although covered entities are required to consider these requests, they are also free to deny these requests at their discretion. Recent amendments to the HIPAA regulations require health care providers to agree to an individual’s request to restrict disclosure of his/her health information to a health plan. The restriction request, however, must pertain solely to an item or service for which the health care provider has been paid out-of-pocket and in full. For example, if a patient personally pays for a lab test and requests that the resulting lab report not be shared with his/her health plan, the provider must agree to this request in most cases.

Right to request confidential communicationsIndividuals may request that a covered entity communicate with them at al-ternative locations or by alternative means. For example, an individual who does not want his family members to know about a certain treatment may request that his provider send all communication regarding this treatment to his place of employment. As another option, the individual may request that the information is sent in a sealed envelope instead of a postcard format. The covered entity must accommodate reasonable requests for confidential communications.

Notice of privacy practicesNearly all covered entities are required to provide a notice of privacy practices. This notice must describe how the covered entity may use or share an individual’s health information. It also describes an individual’s rights related to health information and, more importantly, how an individual may exercise these rights.

Another helpful feature of the notice is that it must incorporate any state privacy laws that are more stringent than federal privacy law. Many states have passed heightened requirements for health information, which often relate to information that could be considered sensitive, such as that relating to mental illness, genetic information, communicable diseases, and HIV/AIDS.

Privacy breach protections and notifications

Individuals who feel their health information privacy has been breached can:

1. Notify their covered entity via the procedure described in the covered entity’s notice of privacy practices. Once someone engages this process, the covered entity must investigate the breach allegation and notify the person if a breach occurred. The covered entity must also impose sanc-tions on employees who violate HIPAA or privacy-related employment policies.

2. Contact their State Attorney General Office (www.ag.state.mn.us) or the federal Office for Civil Rights (www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html).

Morgan Vanderburg works as a privacy analyst for the Mayo Clinic in Rochester. The information in this article does not necessarily reflect the views of Mayo Clinic.

December 2013 MINNESOTA HEAlTH CARE NEwS 19

i nsu r a n c e

What is a private insurance exchange? A private insurance exchange is a website that functions as a mar-ketplace where individuals comparison-shop for medical insurance. While that description also applies to the State of Minnesota’s public insurance exchange, MNsure, and to exchanges sponsored by other states or the federal government, there are differences between public and private exchanges. Before we compare the two types, let’s first understand private exchanges.

While public exchanges and some private exchanges offer only medical insurance, other private exchanges may also offer dental, vision, and life insurance, as well as pretax accounts such as flexible spending accounts (FSAs) and health savings accounts (HSAs).

Some private exchanges have individual health insurance prod-ucts and offer multiple insurance carriers, while others offer group health insurance plans from one insurance carrier.

Health insurance options available on a private exchange may consist of different plans from one insurance company. Or, a private exchange may consist of plans from multiple insurers. Some private exchanges are linked to public exchanges where employees can find and apply for health insurance and, if they qualify, obtain subsidies to help lower the cost of buying coverage on public exchanges.

Private vs. public exchangesPrivate exchanges differ from a public exchange such as MNsure in the following ways:

•Public exchanges only offer health insurance. Private exchanges can offer other insurance products besides health insurance, including home insurance, auto insurance, and pretax accounts such as FSAs.

•Private exchanges can be customized websites that offer all benefits sponsored by the employer, as well as other insur- ances not sponsored by the employer.

•A private exchange’s support team of licensed insurance agents can help visitors to the exchange understand and enroll in all the products and services available on the exchange. This differs from MNsure, whose navigators help visitors choose among only health insurance plans.

How to use private exchangesUsing a private exchange is quite easy, much like using an

online travel site such as Travelocity or Expedia. Simply enter basic demographic information on the private exchange website, and the website will list the options available to you and the cost of those options. Beginning in 2014, the cost of individual health insurance premiums will be based on a limited number of criteria: age, geo-

Private insurance exchanges

How they benefit youBy Linda Heuer, MBA, RPA

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graphic location, family size, and whether someone is a smoker or a nonsmoker.

Because the exchange is a marketplace, employees are offered multiple plans. Different plans have different features, such as vary-ing deductible amounts, copays, and networks.

save money using a private exchangeThe following are ways in which a private exchange saves employees money.

•For some small companies, individual health insurance premium rates can be lower than group rates.

•Since a private exchange sells a high volume of products, individual rates for insurance products such as home, auto, and life insurance can be very competitive.

•Employees can choose a higher deductible plan that has a cor-responding lower insurance premium than a lower deductible plan option.

•By enrolling in pretax accounts such as FSAs or HSAs to com-plement the health plan selected, employees can save money by using pretax dollars to pay for qualifying health expenses.

everyone benefitsWho benefits from private exchanges? Everyone.

The key benefit to employees of using a private exchange to select health insurance is the freedom to choose the plan that is best for them and their family instead of being limited to choosing from among plans that their employer offers. No matter if you are single or have a family, whether you’re healthy or suffering from chronic health conditions, a private insurance exchange offers options that meet everyone’s needs. consider these examples:

•A healthy employee without dependents uses his employer’s private exchange and is given $4,000 by the employer to spend on insurance through a Defined contribution Plan. Because the employee is rarely sick, eats healthily, exercises frequently, and only visits the doctor for an annual checkup, he selects a high-deductible health insurance plan. This plan costs less than $4,000, so he puts the remaining money into a health savings account (HSA). The HSA allows him to save up un-used health insurance money each year and use it either pretax for health expenses, if needed, or save it for health expenses upon retirement.

•A less healthy employee without dependents also has been given $4,000 by his employer to use on his company’s private exchange. This employee is often at the doctor’s office for checkups, at specialists for treatments, and at the chiro- practor to get realigned. This less healthy employee visits the private exchange and selects a health insurance plan that will cover his many appointments. He also puts some of his employer-contributed money into a flexible savings account (FSA) so that he can pay for doctor visits and chiropractic appointments with tax-free dollars. (Money put into an FSA is tax-free.)

•An employee with healthy dependents has been given $4,000 by her company for health insurance. She and her dependents are typically quite healthy. Therefore, the employee chooses an insurance plan that will cover all of her family’s routine medical expenses like checkups and prescriptions, plus emer-gencies, just in case an emergency occurs.

•An employee who has chronically ill dependents has been given $4,000 for health insurance by her employer. She frequently takes her dependents to the doctor or urgent care and spends a great deal of money on over-the-counter and prescription medications. She chooses a plan that helps cover all these expenses. in addition, she puts $2,500 of her own money into an FSA so she can use the FSA’s tax-free dollars to pay for out-of-pocket health care bills.

No matter whether you or your dependents are healthy or are dealing with chronic health problems, there is a plan on private ex-changes for you. For those unsure about which plan to select, there is a customer support team on each private exchange that can help you make a selection that’s right for you.

Linda Heuer, MBa, rPa, is a principal with the accounting firm Eide Bailly LLP in its Minneapolis office and is the company’s director of employee benefits. She consults on health care reform, defined contribution health plans, private insurance exchanges, flexible benefit plans, COBRA, health reimbursements, health savings accounts, VEBA, and qualified transportation plans.

December 2013 MiNNESOTA HEAlTH cArE NEWS 21

C a reg iv i n g

On Aug. 1, the new Family Sick Leave Law passed by the Minnesota Legislature during the 2013 legislative session went into effect. This law allows employees who have

accumulated sick leave to use their leave to provide care to family members. Accrued sick time can be used to care for a child of any

age (including stepchildren or foster children), a spouse, sibling, parent, grandparent, or stepparent.

This represents a major health care change that has the immedi-ate, practical effect of improving people’s lives.

The need A man profiled on Minnesota Public Radio told how his employer wouldn’t let him use sick leave to visit his father, who had suffered a stroke. He was quoted in the story as saying, “At the very end I just finally said, ‘Well, I learned that next time I’ll just tell you [the employer] I have a cold because that’s how simple it would’ve been for me to use a huge bank of time I’ve accumulated.’ I’ve been [employed by the same employer] 22 years. I had to just take the day without pay.”

When workers are faced with family caregiving that interferes with their work schedules, those without paid leave or who can only use sick time for themselves often have to cut their work hours or leave their jobs. Obviously, this hurts them, their families, and their income and retirement security. It also hurts our broader economy.

A 2011 MetLife report found that an average woman would lose nearly $143,000 in wages due to dropping out of the labor force to assume adult caregiving responsibilities. The report factors in wages lost while not working as well as lower wages after returning to the workforce, since a hiatus for caregiving often results in out-of-date or otherwise diminished skills. Factor in lost pension or Social Security benefits, and the loss nearly doubles.

This isn’t good for workers, families, or businesses. A change was long overdue.

History The bill was first proposed in 2009 but was vetoed by then-Gov. Tim Pawlenty. It was re-introduced during the 2012–2013 legislative session and passed with broad bipartisan support, receiving 99 of 134 votes in the House and 41 of 67 votes in the Senate. In today’s polarized politics, it was noteworthy that this bill received strong

22 MInneSOTA HeALTH cARe neWS December 2013

Help for Minnesota

familiesBy Rep. Rick Hansen

New sick-leave law

support from members on both sides of the aisle. This was the first major change since the state added dependent children to the sick-leave law 20 years ago.

Eleven states and the District of Columbia have their own family leave laws beyond the federal Family Medical Leave Act. California and New Jersey are the only states to offer paid family leave, while Oregon, Vermont, Washington, and Wisconsin have laws similar to Minnesota’s that allow employees to use accrued sick time (or other paid time off) to care for family.

Who is affected? The law affects an estimated one-third of employees in the state because employers are increasingly combining sick leave, vacation, and holidays under “paid time off.” Because this paid time off can generally be used at an employee’s discretion, it already allows employees who have it to care for sick family members. Including, as is becoming increasingly common, to care for a sick parent. A recent report by AARP states that nationwide, nearly two-thirds of workers age 45–74 are responsible for caring for an adult relative. As the nation’s and Minnesota’s populations become older, and as baby boomers continue to age and retire—the “silver tsunami” demo-graphic—more and more Minnesotans will face this situation.

BenefitsEnacting the Family Sick Leave Law gives Minnesota workers peace of mind that they will be able to take time off to help a sick relative without losing income. By offering a way to use their sick time to care for family, we can help Minnesotans remain in the workforce and continue as family caregivers. That peace of mind and practical support is important, especially in a still-recovering economy.

In addition, this law can lessen the need for more expensive, outside care. If a family can care for an aging parent outside a nur-sing home, taxpayers and the state save in Medicare, Medicaid, and nursing home costs. The average cost of a private room in a Minne-sota nursing home is $205 per day—more than $6,000 per month. Average assisted living costs in the state exceed $3,300 per month.

LimitationsHowever, it is important to note that we are not solving every prob-lem with this law. It does not require employers to offer sick time to employees; it merely expands the use of sick time already available. In addition, employers are allowed to limit the amount of sick time that an employee may use to care for non-offspring relatives to 160 hours during a 12-month period. There is no limit to the number of accrued hours that an employee may use to care for children.

This law applies only to businesses with more than 20 em-ployees. If you have exhausted all accrued sick leave but still need time off to care for a family member, you can take unpaid time off through the Family Medical Leave Act. Then, if you accrue more sick time, or a new calendar year begins (restarting the 160-hour limit), you again can use your sick time to care for family members.

With a changing workforce, we face an even greater issue.

Many workers, both in Minnesota and across the nation, receive no sick time or paid time off at all. People working as contractors or

low-wage workers lack sick leave and/or paid time off. In fact, the United States is the only nation in the industrialized world that doesn’t require employers to offer paid sick leave. That is an incredi-ble and sad fact.

For more informationIt’s clear that this is a major issue and that we have a moral, societal, and economic obligation to address it. Often these changes in leave laws result in slow societal change because people aren’t aware of the options available to them. The Department of Labor and Industry is conducting outreach to inform the public of this law, but please help spread the word.

If you have additional questions about this law, contact me at [email protected] or (651) 296-6828. You also can find more information by visiting the Department of Labor and Industry website (www.doli.state.mn.us ) or by contacting the Labor Stan-dards Unit ([email protected]) at (651) 284-5070 or (800) 342-5354.

Rick Hansen (DFL–South St. Paul), is the state representative for District 52A and was the chief author of the expanded sick-leave law.

December 2013 MINNESOTA HEALTH CARE NEWS 23

Nationwide, nearly two-thirds of workers age 45–74 are responsible for

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This time of year brings festive gatherings, an increase in the number of people in close proximity with one another—and an increase in the number of people diagnosed with pneu-

monia. Pneumonia is an infection in the lung that is most commonly caused by bacteria, although viruses and fungi can also cause it. This infection produces inflammation in the lung, which causes air sacs (alveoli) inside the lung to become filled with fluid or pus. It is this accumulation of material in the alveoli that leads to symptoms.

24 MInnesoTa HealTH care news December 2013

Pu l mo n o lo gy

PneumoniaPrevention and prompt

response are keyBy Sara Erickson, MD

SymptomsThe most common symptoms of pneumonia are cough, production of mucus (i.e., sputum or phlegm), fever, chills, shaking, shortness of breath, rapid breathing, and chest discomfort. symptoms can range in severity. Mild, or so-called “walking” pneumonia, typically al-lows someone to carry on with daily activities despite feeling subpar. However, symptoms also can become life threatening and require treatment in an intensive care unit. severe pneumonia can kill people quickly because they drown in the fluid flooding their lungs.

DiagnosisIf you are coughing, whether or not you’re coughing up thick yellow or green sputum, and you also have a fever or shortness of breath, it is very important that you promptly seek medical care to be evalu-ated for pneumonia. If you suspect you have it, it’s always best to be seen by a health care provider soon after symptoms appear because pneumonia can progress quickly.

To diagnose pneumonia, your doctor will ask about your symp-toms and your medical history. In addition, he or she will examine you and listen to you breathe because abnormal lung sounds can in-dicate that you have pneumonia. In addition, your doctor likely will order a chest X-ray to confirm the diagnosis of pneumonia. other tests that can help confirm the diagnosis are a blood test—if it shows a high white blood cell count, that’s an indicator of infection—and a sputum culture to detect any bacteria growing in the lungs.

TreatmentPneumonia typically is treated with an antibiotic medication, which kills bacteria. (Viral and fungal pneumonia are treated with differ-ent medication.) Typically, patients treated with an antibiotic will start to feel better within three to five days after beginning to take it. even if you feel better before you have finished taking all of the antibiotic prescribed, it is very important to complete the full course of medication prescribed, exactly as the directions specify. If you don’t finish the antibiotic, the pneumonia may recur—some bacteria may remain alive and then be resistant to future treatment.

Fever-reducing medications like ibuprofen or acetaminophen are used in combination with antibiotics. Your doctor may advise you

In the next issue...

•Antibiotic resistance

•New back pain treatment

•Dual Medicaid/ Medicare-eligible beneficiaries

to rest for the first few days after you’ve been diagnosed, although you may feel tired for several weeks after the diagnosis. Health care providers schedule a follow-up appointment to take place one month after someone has been diagnosed with pneumonia, to make sure symptoms have gone away. at that time, the provider will take another chest X-ray to make sure all the pneumonia is gone.

Risksalthough anyone can develop pneumonia, children under age 2 and people over age 65 have the highest risk of developing a severe case of it. This is because these age groups tend to have immune systems least capable of fighting off infection. other risk factors for developing pneumonia are smoking, alcohol abuse, and having certain medical conditions, including diabetes, heart failure, chronic obstructive pulmonary disease (coPD), or au-toimmune disease. Taking immunosuppressive medication, such as chemotherapy or long-term steroid therapy, also increases a person’s risk of developing this condition.

PreventionThe best ways to prevent pneumonia are to:

1. Get a flu shot every fall. Bacterial pneumonia that develops in someone weakened by the flu can be very severe.

2. Get the pneumonia vaccine, called a pneumococcal vacci-nation. This is especially important for people in high-risk

categories. This vaccine protects against one specific bacteria, streptococcus pneumoniae, one of the deadliest bacteria known to cause pneumonia. It is recommended that everyone over the age of 65 get the pneumococcal vaccine.

3. Quit smoking and avoid secondhand smoke. cigarette smoke makes the lungs more susceptible to pneumonia.

4. Practice excellent hand hygiene. Frequently washing your hands or using hand sanitizer is an excellent way to prevent the spread of germs that can cause pneumonia.

Seek treatment promptlyPneumonia is contagious and can be fatal; according to the Mayo clinic, pneumonia kills more than 60,000 people in the United

states annually. ask your doctor if you or your child should receive the pneumonia vaccine; maintain excellent hygiene practices to limit the spread of disease, including covering your snee- zes and coughs and cleaning hands frequently; and see your health care provider without delay

if you develop a cough, cough up yellow or green mucus, and have fever, chills, shortness of breath, and chest discomfort.

Sara Erickson, mD, is a board-certified pulmonologist and practices with Lakeview Hospital, Stillwater.

December 2013 MInnesoTa HealTH care news 25

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Digging in rich black soil, seeing the first sprouts emerge from a garden, or walking through a canopied forest just plain feels good. There are sound scientific reasons for that,

as research has started discovering during the fairly recent past. Here’s what is currently known about some of the ways that expo-sure to nature contributes to enhanced health.

Early evidence

Hospital patients recovering from surgery had shorter hospital stays and took fewer painkillers if their rooms provided a view of nature than if their rooms looked out onto a brick wall, reported a landmark study by health-care design researcher Roger Ulrich, PhD, at the Center for Health Systems and Design at Texas A&M University (Science 1984). A study published in the medical journal Chest (2003) reported that adult patients in a procedure room noted improved pain control when they viewed a nature scene and heard recorded nature sounds. And viewing underwater nature scenes reduced the anxiety, fatigue, and distress reported by breast cancer patients undergoing chemotherapy, according to another study pub-lished the same year (CyberPsychology and Behavior Journal 2003).

Reduced stress

Validation of these findings has been obtained from measuring objective indicators of stress physiology such as brain wave activity, muscle tension, and levels of cortisol, which is a hormone produced by the body in response to stress.

Ulrich, now a professor of architecture at the Center for Health-care Building Research at Chalmers University of Technology in Sweden, reported that brain waves in adults who were viewing pho-tographs of nature showed elevated alpha wave activity, compared with adults who viewed photographs of a built urban environment. Elevated alpha wave activity is associated with relaxed wakefulness and decreased anxiety. Nature’s calming effect was detected by another study that recorded oxygen use in the brain of people who spent 20 minutes of contemplation in either a forest setting or an urban, non-forested one. Oxygen uptake and brain activity of the people exposed to the natural environment were characteristic of a state of relaxation (Biopsychosocial Medicine 2012).

Muscle tension in people who viewed nature scenes, compared with that in people who viewed an urban built environment, was lower after watching a video that had been shown to elevate the stress response (Journal of Environmental Psychology 2010).

26 MiNNESOTA HEAlTH CARE NEwS December 2013

Com plem e nta ry m e d i C i n e

Grow healthyBy Jean Larson, PhD, CTRS, HTR

Nature’s health benefits

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lower levels of cortisol were reported in adults after they performed mental activities in a hardwood forest than in those who had performed the same activities in an indoor classroom (Journal of Medical Entomology 2004).

Enhanced immune function

while physiologic indicators of stress can decrease after exposure to nature, indicators of immune response can increase, according to research reported in 2011 (interna-tional Journal of immunopathology and Pharmacology). Subjects who visited a forested area, but not a non-forested urban environment, were found to have enhanced activity of their natural killer (NK) cells. These cells provide a rapid response to cells infected with a virus and also attack tumor cells. in addition, the same individuals had higher levels of anticancer proteins within their NK cells. Both effects continued to be observed when tested 30 days after exposure to the forested area.

Improved cognition

Research has shown that cognitive benefits gained by working with plants include improvements in concentration, ability to remember, and ability to pay attention. working with plants may ameliorate clinical depression as well, suggests research reported in the Journal of Advanced Nursing (2010). After participating in a 12-week program of therapeutic horticulture, 50 percent of the depressed pa-tients studied showed a clinically relevant decline in their scores on a depression-measuring test. This reduction in depression continued to be in effect when measured three months after the program ended.

Multiple studies have found that cognitive malfunctioning in children diagnosed with attention deficit hyperactivity disorder (ADHD) improves upon exposure to nature, reported Biopsycho-social Medicine in 2012. One study found that performance on concentration-requiring tasks was higher after the children tested had spent time in a natural wooded area, compared to a built urban area. Another study suggested that children with ADHD showed milder symptoms when engaged in activities in an outdoor environment than when engaged in the same activities in an indoor, windowless play area.

Mortality

Not only can interacting with the natural environment reduce stress and improve both immune and cognitive functioning, it may also help equalize health inequalities associated with lower socioeconomic status (Biopsychosocial Medicine 2012). That was the conclu-sion of researchers who found that people who had low income but high levels of residential green space had mortality rates comparable to people of higher socioeconomic status. in contrast, people who had low income but little residential green space had higher mortality rates than their wealthier counterparts.

Applications

The idea that exposure to nature can heal has given rise to such adjunctive therapies as therapeutic horticulture and therapeutic landscape design. Therapeutic landscape design, as mentioned at the start of this article, has been shown to produce measurable, positive health effects.

Therapeutic horticulture uses plants and plant-related activities to promote health and wellness. Gardening, for example, provides an opportunity to create and control the environment. This sense of control creates a sense of empowerment and self-esteem, which aids healing. Gardening also affords a sense of purpose and achievement, which can support people dealing with depression or other mental health concerns.

The risk of developing a mental health disorder may actually increase as someone spends more time in front

of a screen (Developmental Psychology 2008, Journal of Environ-mental Psychology 2009). Time spent in nature thus can mediate against such health problems, both by getting someone away from

December 2013 MiNNESOTA HEAlTH CARE NEwS 27

Nature’s health benefits to page 32

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Alpha-gal

A l le rg i es

the number of people in the western world who have food allergies has been increasing during the past few decades. one of these allergies has only recently been recognized,

and that is an allergy to a component of red meat called galac-tose-alpha-1,3-galactose, or “alpha-gal.” to better understand this reaction, it’s helpful to understand food allergies in general.

Risk factorscertain factors predispose an individual to develop certain food allergies. children who have eczema as a baby have an increased risk of hypersensitivity (allergy) to certain foods. someone who is allergic to pollen is more likely to be allergic to raw fruits and

Diagnosing a rare diseaseBy Nancy L. Ott, MD

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A food allergy reaction can range from mild

skin rashes and an itchy mouth to anaphylaxis, a life-threatening reaction.

vegetables. latex allergy predis poses someone to be hypersensitive to the uncommon food allergens avocado, banana, and chestnut. occupational allergens are often substances that are at a high concentration in someone’s work environment and cause reactions in people who inhale or touch them instead of ingesting them. an example is so-called “baker’s asthma,” which is a hypersensitivity to flour.

CausesMost allergic reactions to foods are first noted in young children, with a select group of foods causing almost 95 percent of these reactions. these foods are milk, egg, peanut, soy, wheat, peanuts, and tree nuts. if an allergy develops in older children and adults, it tends to be to fresh fruit and vegetables, peanuts, tree nuts, fish, or other seafood.

any food can cause an allergic reaction, although protein is usually the culprit. this reaction also can be caused by carbohydrate attached to protein. when carbohydrate is attached to protein it’s called glycoprotein. a food allergy reaction can range from mild skin rashes and an itchy mouth to anaphylaxis, a life-threatening reaction.

anaphylaxis occurs immediately or up to two hours after ingest-ing an allergen (the substance to which someone is allergic). symp-toms can include flushed skin, hives, swelling, vomiting, diarrhea, difficulty breathing, loss of consciousness, and shock. in order for someone experiencing anaphylaxis to survive, treatment must begin

very soon after exposure to the allergen. the only treatment that will save a life is injecting the person with epinephrine.

the following real-life case illustrates how a food allergy can be associated with geographic, medical, and lifestyle factors. it also shows how the cause of the patient’s life-threatening reaction became clear only when all of these factors were taken into account. this case history has been modified to protect the patient’s identity.

Pieces of the puzzleWho? What? a 60-year-old man living in Minnesota had four epi-sodes of anaphylaxis. During the first three episodes of anaphylaxis, the patient showed up at an emergency room with itchy red hives all


alpha-gal allergy to page 30

Any food can cause an

allergic reaction.

over his skin, difficulty breathing, nausea, and vomiting. epinephrine was given immediately, which made his symptoms go away. the fourth episode occurred while he was on a hunting trip in a remote location; he self-injected epinephrine with an epiPen, which relieved the symptoms. an hour later he arrived at a hospital, where his symptoms did not reoccur.

Where? When? the first episode occurred while he was chopping wood during a vacation in Virginia, where he grew up. on two of the four occasions he experienced anaphylaxis, he had eaten fish one to two hours before symptoms appeared. But the other two allergic reactions occurred in the middle of the night, when he had not eaten for six to eight hours.

Medical factors. the patient’s primary care provider tested the patient’s blood to see if the man was allergic to fish. the test was negative. the patient reported that he had not been stung by a bee, wasp, or hornet, which could have explained the anaphylaxis. nor was he taking cancer medication, antibiotics, or blood pressure medication, which also could have caused his reaction. He had taken ibuprofen for knee pain two hours before one of the anaphylactic episodes but had tolerated ibuprofen after the reactions. He had

exercised two hours before two of the episodes. His past medical history indicated that he had mild hay fever, which he self-treated with over-the-counter antihistamines as needed. He had no cancer, asth-ma, heart problems, or gastrointestinal problems.

He said that he had been allergic to ticks when he lived in Virginia but not while living in Min-nesota. starting during his teen years in Virginia, he would develop hives around the site of a tick bite and they would itch severely for several days. However, he had never had a tickborne infection, such as lyme disease.

Geography, lifestyle the patient’s lifestyle history revealed that he had recently retired from work as a park ranger. He

now was spending more time visiting his relatives in Virginia; while there, he and they often visited a cabin where he had spent a lot of time as a boy. this is where he was when his first anaphylactic episode occurred.

Fitting the pieces togetherthe new england Journal of Medicine reported in 2008 that a carbohydrate called galactose-alpha-1,3-galactose (alpha-gal) was causing anaphylaxis in patients who shared several things in common. First, these patients lived in the same part of the country,


alpha-gal allergy from page 29

Call to get help with: Planning for long-term care Remaining independent in your community Arranging for in-home services Getting help from state agencies Becoming involved in your community

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p with

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which included Virginia, Missouri, and tennessee. second, they were being treated with a cancer drug, cetuximab, which contained alpha-gal.

the third commonality among these patients? in addition to experiencing an allergic reaction shortly after their cancer drug was administered, these patients experienced a delayed allergic reaction hours after they ate red meat, such as beef, pork, or lamb.

red meat contains alpha-gal.

the reason for the delay in allergic reaction, unlike the faster onset of symptoms after administration of the cancer drug, is that alpha-gal in meat is attached to protein. the delayed reaction occurred because the ingested alpha-gal had to go through the intestines in order for digestion to release the alpha-gal from the pro-tein. at that point, the patients’ bodies recognized it as an allergen and responded with anaphylaxis. Furthermore, these patients also had allergic reactions to the lone star tick, which is endemic in their region of the United states. a blood test was developed to detect allergy to alpha-gal.

The final puzzle piecethis test was performed on the patient’s blood and confirmed his allergy to alpha-gal.

after further history-taking, he remembered having eaten steak or hamburger each day he experienced an anaphylactic reaction. the days his episodes occurred within two to four hours of eating beef were the days he was working vigorously (chopping wood, clearing

brush) or had taken ibuprofen, both of which are known to enhance an allergic reaction such as anaphylaxis and may have hastened onset of the reaction.

although this patient lived in Minnesota where the lone star tick has not been found—yet—and although he was not taking the cancer drug that has been associated with this allergy, he did spend time in Virginia and had a history of allergic reactions to tick bites.

Lesson learnedthis case illustrates the importance of a thorough medical history. although the patient had told his story to multiple providers during the course of two years, none of them had made the connection be-tween the patient’s time spent in a state known to contain the lone star tick (Virginia), his long history of tick bite reactions, and his red meat consumption the day of the reactions. all factors pointed to alpha-gal.

if you or your family members vacation or have lived in the region of the country known to contain the lone star tick and have had hives or reactions to tick bites, be aware of this unusual allergy. check the centers for Disease control and Prevention website for states that have the lone star tick (www.cdc.gov/ticks/maps/lone_star_tick.html). Keep in mind that climate change may cause this tick to extend into additional states over time.

Nancy L. Ott, MD, is board-certified in pediatrics and in adult and pediatric allergy and immunology. She is a senior associate consultant at the Mayo Clinic Children’s Center, Rochester.

Qualifies forFSA/HSA spending

Indicators of stress can decrease after

exposure to nature.

sitting in front of a screen and by inducing calming, nature-related physiologic effects.

Do it yourself

Of all the do-it-yourself projects you may be undertaking at this time of year, inte-grating nature into your daily life may be the simplest.

Even during a Minnesota winter, most people are able to:

1. Take nature breaks. Look out into nature and allow your mind to relax. You likely will feel refreshed and be ready for the next task with a renewed sense of energy.

2. If at all possible, get outdoors! Take a walk or sit in nature each day. While you’re outside, turn off your mobile devices and appreciate nature.

3. If you cannot get outside, purchase an app for your smart-phone and relax to healing images of nature. This can be a way for people with allergies to plants or soil to access nature’s benefits.

Nature’s health benefits from page 27

4. Bring nature into your office or home by hanging a nature picture, installing one as the wallpaper on your computer screen, or by bringing in a plant. Consider plants that have aromatic impacts, such as rosemary (said to enhance memory) or lavender (said to enhance relaxation).

5. Head outside the lights of the city and gaze into the night sky to feel connected to the rest of the universe.

6. Feel happier and healthier during the long days of winter by getting outside. Bundle up and go for a walk, visit a local skating rink, rent skis or snowshoes at a park, or sled down the neighborhood big hill.

7. Use greenery to create a table arrangement to lift your spirits.

8. Visit a local conservatory or arboretum.

Jean Larson, PhD, CTRS, HTR, is the manager of Nature-Based Therapeutic Services at the Minnesota Landscape Arboretum, Chaska, which, among other goals, seeks to integrate self-care into health care. Larson is also an assistant professor of nature-based therapeutic studies at the University of Minnesota.

32 MINNEsOTa HEaLTH CarE NEWs December 2013

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1. Have you or a member of your family ever received post-acute care(ongoing care provided in any form after discharge from a hospital)?

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November Survey results ...

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited.

For more information, please visit www.mnhcca.org. We are pleased to present the results of the November survey.

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around

SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS 33

“A way for you to make a difference”

Join now.

SM

Welcome to your opportunity to be heard indebates and discussions that shape the futureof health care policy. There is no cost to joinand all you need to become a member isaccess to the Internet.

Members receive a free monthly electronicnewsletter and the opportunity to participatein consumer opinion surveys.

www.mnhcca.org

Health Care ConsumerAssociation

Minnesota

MHCN0813_pg33:MHCN March07 Gray 2P-ES 9/3/13 10:40 AM Page 1


explains risks and potential benefits. The participant then decides whether to sign the document. A potential research volunteer may also take the informed consent document home to discuss with family members or his or her doctor. Informed consent is not a contract. Volunteers are free to withdraw from the study completely or to refuse particular treatments or tests at any time.

The study is conducted according to the protocol. The number of visits the participant makes to the research site and the proce-dures that are conducted at each visit will vary depending on the protocol. Procedures may include providing information about the par-ticipant’s medical history and current and past medication use, having an electrocardiogram (ECG) performed, having laboratory tests performed, etc. Often, research volunteers are required to complete a daily diary to record their symptoms, their use of medication, and their medical progress.

Risks and benefits

Potential risks of participating in a clinical trial may include:

•Side effects

•The treatment being studied may not be effective

•The possibility that you are taking a placebo, which is an

inactive substance that will not affect your health

•Participation may be time-consuming

Potential benefits of participation may include:

•Learning more about your disease or condition and obtain-ing early access to new medications

•Free, study-related exams and testing; free, study-related medication; and parking reimbursement

•Compensation for time and travel

Offering hope

If you are considering participating in a clinical trial, be informed. Explore your motivation for participating, consider the potential risks and benefits of partic-

ipation, and decide whether a clinical research study is good for you.

Clinical trials offer hope for many people and an opportunity to help researchers find better treatments for others in the future.

Harold Kaiser, MD, is a board-certified allergist with Allergy & Asthma Specialists, PA, in Maple Grove, Minneapolis, and Plymouth. He is also a clinical professor of medicine at the University of Minnesota medical school and conducts clinical trials with Clinical Research Institute, Inc., Minneapolis.

December 2013 MInnESOTA HEALTH CArE nEwS 34

More than half the U.S. population takes some kind of prescription medication.

Clinical trials from page 15

Elizabeth Klodas, M.D.,F.A.S.C.C is a preventive

cardiologist. She isthe founding Editor inChief of CardioSmart

for the AmericanCollege of Cardiologywww.cardiosmart.org,

a published authorand medical editor for

webMD. She is a memberof several national

committees on improvingcardiac health and afrequent lecturer on

the topic.

Preventive Cardiology Consultants isfounded on the fundamental belief thatmuch of heart disease can be avoidedin the vast majority of patients, andsignificantly delayed in the rest, by prudentmodification of risk factors and attainablelifestyle measures.

We are dedicated to creating a true part-nership between doctor and patient workingtogether to maximize heart health. Wespend time getting to know each patientindividually, learning about their lives andlifestyles before customizing treatmentprograms to maximize their health.

Whether you have experienced any typeof cardiac event, are at risk for one, or

are interested in learning how to preventone, we can design a set of just-for-yousolutions.

Among the services we provide

• One-on-one consultations withcardiologists

• In-depth evaluation of nutrition andlifestyle factors

• Advanced and routine blood analysis

• Cardiac imaging including (as required)stress testing, stress echocardiography,stress nuclear imaging, coronary calciumscreening, CT coronary angiography

• Vascular screening

• Dietary counseling/Exercise prescriptions

Now accepting new patients

A unique perspective on cardiac care

To schedule an appointment or to learn more about becominga patient, please contact:

Preventive Cardiology Consultants6545 France Avenue, Suite 125, Edina, MN 55435

phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

Important Patient Information

This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you.

WARNING

During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body.

What is Victoza® used for?

• Victoza®isaglucagon-like-peptide-1(GLP-1)receptoragonistusedtoimprovebloodsugar(glucose)controlinadultswithtype2diabetesmellitus,whenusedwithadietandexerciseprogram.

• Victoza®shouldnotbeusedasthefirstchoiceofmedicinefortreatingdiabetes.

• Victoza®hasnotbeenstudiedinenoughpeoplewithahistoryofpancreatitis(inflammationofthepancreas).Therefore,itshouldbeusedwithcareinthesepatients.

• Victoza®isnotforuseinpeoplewithtype1diabetesmellitusorpeoplewithdiabeticketoacidosis.

• ItisnotknownifVictoza®issafeandeffectivewhenusedwithinsulin.

Who should not use Victoza®?

• Victoza®shouldnotbeusedinpeoplewithapersonalorfamilyhistoryofMTCorinpatientswithMEN2.

What is the most important information I should know about Victoza®?

• Inanimalstudies,Victoza®causedthyroidtumors.Theeffectsinhumansareunknown.PeoplewhouseVictoza®shouldbecounseledontheriskofMTCandsymptomsofthyroidcancer.

• Inclinicaltrials,thereweremorecasesofpancreatitisinpeopletreatedwithVictoza®comparedtopeopletreatedwithotherdiabetesdrugs.Ifpancreatitisissuspected,Victoza®andotherpotentiallysuspectdrugsshouldbediscontinued.Victoza®shouldnotberestartedifpancreatitisisconfirmed.Victoza®shouldbeusedwithcautioninpeoplewithahistoryofpancreatitis.

• Seriouslowbloodsugar(hypoglycemia)mayoccurwhenVictoza®isusedwithotherdiabetesmedicationscalledsulfonylureas.Thisriskcanbereducedbyloweringthedoseofthesulfonylurea.

• Victoza®maycausenausea,vomiting,ordiarrhealeadingtothelossoffluids(dehydration).Dehydrationmaycausekidneyfailure.Thiscanhappeninpeoplewhomayhaveneverhadkidneyproblemsbefore.Drinkingplentyoffluidsmayreduceyourchanceofdehydration.

• Likeallotherdiabetesmedications,Victoza®hasnotbeenshowntodecreasetheriskoflargebloodvesseldisease(i.e.heartattacksandstrokes).

What are the side effects of Victoza®?

• Tellyourhealthcareproviderifyougetalumporswellinginyourneck,hoarseness,troubleswallowing,orshortnessofbreathwhiletakingVictoza®.Thesemaybesymptomsofthyroidcancer.

• Themostcommonsideeffects,reportedinatleast5%ofpeopletreatedwithVictoza®andoccurringmorecommonlythanpeopletreatedwithaplacebo(anon-activeinjectionusedtostudydrugsinclinicaltrials)areheadache,nausea,anddiarrhea.

• Immunesystemrelatedreactions,includinghives,weremorecommoninpeopletreatedwithVictoza®(0.8%)comparedtopeopletreatedwithotherdiabetesdrugs(0.4%)inclinicaltrials.

• Thislistingofsideeffectsisnotcomplete.YourhealthcareprofessionalcandiscusswithyouamorecompletelistofsideeffectsthatmayoccurwhenusingVictoza®.

What should I know about taking Victoza® with other medications?

• Victoza®slowsemptyingofyourstomach.Thismayimpacthowyourbodyabsorbsotherdrugsthataretakenbymouthatthesametime.

Can Victoza® be used in children?

• Victoza®hasnotbeenstudiedinpeoplebelow18yearsofage.

Can Victoza® be used in people with kidney or liver problems?

• Victoza®shouldbeusedwithcautioninthesetypesofpeople.

Still have questions?

Thisisonlyasummaryofimportantinformation.Askyourdoctorformorecompleteproductinformation,or

• call1-877-4VICTOZA(1-877-484-2869)

• visitvictoza.com

Victoza® is a registered trademark of Novo Nordisk A/S.

DateofIssue:May2011Version3

©2011NovoNordisk140517-R3June2011

Victoza® helped me take my blood sugar down…

Model is used for illustrative purposes only.

and changed how I manage my type 2 diabetes.Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells.

While not a weight-loss product, Victoza® may help you lose some weight.

And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

If you’re ready for a change, talk to your doctor about Victoza® today.

FOR TYPE 2 DIABETES

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily

Indications and Usage:Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children.

Important Safety Information:In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer.Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis.Before using Victoza®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration.The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies.

Please see Brief Summary of Important Patient Information on next page.

If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW.You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088.Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

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Minnesota Health care News December 2013