Minnesota Physician October 2011

The world used to bemuch simpler, or atleast it seems that way

to many of us who practicedhealth care in the ‘70s and‘80s. The prevailing paternalis-tic attitude that permeated thehealth care system at thattime meant that patientswould enter our facilities seeking an expertopinion, be given a definitive diagnosis, andsent on their way. The assumption on bothsides was that the wisdom and expertiseimparted at the clinic or hospital visitwould be passively transferred, pending thenext acute intervention of our patient withthe health care system.

Today, we physicians are confrontedwith an explosion of new technology,increasingly complex interventions, and an

evolving focus on the need forlongitudinal support of healthissues, requiring increasedinvolvement of our patients.While we may use differentterms—engagement, involve-ment, empowerment, activa-tion—in our discussions, all ofthem speak to

the need to have active partici-pation from patients and, inmany cases, their family andother caregivers. But while weoften have a clear understand-ing as citizens of our role aswe interact with mechanics,lawyers, or financial advisers,the roles and responsibilitiesof physicians and patients

ENGAGEMENT to page 10 PRSRTSTDU.S.POSTAGE

PAIDDetriotLakes,MNPermitNo.2655

Volume XXV, No. 7

October 2011

PaymentincentivesNext-generation modelswill emphasizetotal cost of care

By Ann Robinow

Changes in health care pay-ment incentives are slowlycreeping into physician

consciousness, though many physi-cians are still oblivious, in denial, orbelieve we’ve been here before andthis, too, shall pass.

Is a change in payment incen-tives for real this time? Right nowand for the foreseeable future, thismarket is in transition, creating con-tradictory messages to the healthcare delivery system. For physicianstrying to navigate between the oldworld (fee-for-service) and newworld (total cost of care) of pay-ments, it’s a challenging time.

Why should physicians careabout preparing for changes in incen-tives? Two reasons: First, it matters to

your patients. Second, itmatters to you.

Premium and cost-sharing affordability is agrowing problem forpatients. Physicians are

PAYMENT to page 12

The Independent Medical Business Newspaper

IN THIS ISSUE:Health care

reformPage 20

Terms of engagementCo-creatingour future

with patientsBy Gary

Oftedahl, MD

Official CMS Industry Resources for the ICD-10 Transitionwww.cms.gov/ICD10

Version 5010 Deadline:

JAN 1st, 2012

ICD-10 Deadline: OCT 1st, 2013

Are yo

u

read

y?

CAPSULES 4

MEDICUS 7

INTERVIEW 8

PAIN MEDICINEPrinciples ofpain management 14By Cory J. Ingram, MD

PRACTICE MANAGEMENTTransformingbilling practices 28By Brian Kueppers andNels Peterson

PATIENT PERSPECTIVEShared decision-making 30By John Malan

PRACTICE MANAGEMENTThe pre-visit interview 34By Thomas Rieser, MD

DEPARTMENTS

SPECIAL FOCUS: HEALTH CARE REFORM

C O N T E N T S OCTOBER 2011 Volume XXV, No. 7

MINNESOTA PHYSICIAN 3

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Ouraddress is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601;e-mail [email protected]. We welcome the submission of manuscripts and letters for possible pub-lication. All views and opinions expressed by authors of published articles are solely those of theauthors and do not necessarily represent or express the views of Minnesota PhysicianPublishing, Inc., or this publication. The contents herein are believed accurate but arenot intended to replace legal, tax, business or other professional advice and counsel. Nopart of this publication may be reprinted or reproduced without written permission ofthe publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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TheIndependentMedicalBusinessNewspaper

Terms of engagement 1Co-creating our future with patientsBy Gary Oftedahl, MD

Payment incentives 1Next-generation models willemphasize cost of careBy Ann Robinow

FEATURES

www.mppub.com

Vijay Eyunni,MD, MPHMinnesotaOccupational Health

Changes ahead 20By Sarah Duniway, JD, andGregory A. Larson, JD

Immigrant accessto health care 22By Jessie Kemmick Pintor, MPH,and Lynn A. Blewett, PhD

Getting off the escalator 24By Mary Ellen Wells, FACHE

Making headwayin mental health 26By Sue Abderholden, MPH

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OCTOBER 2011

4 MINNESOTA PHYSICIAN OCTOBER 2011

DHS NamesKerber As NewInspector GeneralThe Minnesota Department ofHuman Services (DHS) hasannounced it will coordinateits fraud prevention and recov-ery efforts under the Office ofInspector General (OIG), simi-lar to models used by the U.S.Department of Health andHuman Services and 16 otherstates.

Officials say the reorganiza-tion will improve DHS’ fraudprevention and recovery effortsand more effectively structurestaff who investigate and auditDHS programs. They add thatthe OIG model has traditionallyhad greater independence fromthe areas it monitors andstronger mechanisms to moni-tor and report abuse. In fightingfraud, the OIG will work closelywith the Office of the Minne-sota Attorney General and otheragencies who have a role incombating fraud and abuse.

“Fraud prevention andrecovery is a critical part of

what we do every day at DHS,”says DHS CommissionerLucinda Jesson. “Every dollar ofwaste and fraud is one less dol-lar that goes to the people weserve. All Minnesotans deserveto know that DHS takes its roleas stewards of its public dollarsseriously, and will not toleratethose that misuse them.”

Currently, fraud preventionand recovery efforts are locatedin the program areas they mon-itor. With the reorganization,such efforts will be consolidatedinto a single office and operateout of the office of the commis-sioner. This includes healthcare, child care, and food sup-port fraud detection and recov-ery efforts.

Jerry Kerber, current DHSlicensing director, will head theOIG office as Inspector General.

Shorter Hours forResidents NotHelping, Study FindsDespite a reduction in the hoursthat residents need to be onduty, many doctors in training

report feeling burnt-out, anational study from MayoClinic has found.

The report, published inthe Sept. 7 issue of the Journalof the American Medical Asso-ciation, surveyed more than16,000 residents in internalmedicine training programs, anumber representing 75 percentof internal medicine residentsin the U.S.

The study was overseen byMayo Clinic general internistand biostatistician Colin West,MD, PhD, co-director of theMayo Department of MedicineProgram on Physician Well-Being. It found that 51.5 per-cent of residents reportedburnout symptoms, 45.8 per-cent noted emotional exhaus-tion, and 28.9 percent had feel-ings of depersonalization.

A significant number of res-idents also reported a low qual-ity of life, the survey found. Ofthe responding residents, 14.8percent rated their quality oflife either as “bad as it couldbe” or “somewhat bad.” Onwork-life balance, 32.9 percentreported being somewhat or

very dissatisfied.“Physician well-being is

extremely important for thephysician, but also forpatients,” West says. The study’sauthors say that physicianburnout, depression, job dissat-isfaction, and low quality of lifecan harm patient care by con-tributing to major medical andmedication mistakes, poor carepractices, and patient dissatis-faction.

Residency programs haveattempted to reduce burnoutamong students by reducinghours, but the study did notfind the efforts thus far to beeffective.

West says the findings sug-gest more action needs to betaken to reduce stress on resi-dents. “We hope that now thatwe have established nationalnumbers for these distress vari-ables, we can perhaps focus lesseffort on documenting the prob-lem and turn greater attentionto how best to improve the situ-ation,” he says.

C A P S U L E S

SPINE SURGEONS

Paul D. Hartleben, M.D.Board-Certi�ed Orthopedic SurgeonFellowship-Trained Spine Surgeon

Bryan J. Lynn, M.D.Board-Certi�ed Orthopedic SurgeonFellowship-Trained Spine Surgeon

Nicholas J. Wills, M.D.Fellowship Trained Spine Surgeon

NON-SURGICAL SPINE C ARE

Tom Cesarz, M.D.Board-Certi�ed Physical MedicineFellowship-Trained in spine

John A. Dowdle, M.D.Board-Certi�ed Orthopedic Surgeon

Kristen M. Zeller, M.D.Board-Certi�ed Pain ManagementFellowship-Trained Pain Management

esearch has shown that complex problems like

back and neck pain are best treated by centers

of excellence that specialize in spine. Consequently, in

2010, Summit Orthopedics created Summit Spinecare

as a regional specialty center for spine, based in a new

6,500 spine center space in Woodbury.

Summit Spinecare combines the expertise of three

non-surgical spine specialists, three fellowship-trained

spine surgeons, spine-specialized therapists, X-ray, MRI

and an injection suite — all under one roof.

We’ve also invested in patient education with an

on-line spine encyclopedia at www.SummitSpinecare.

com. Also, as a free community service, we provide a

36-page Home Remedy Book with exercises that relieve

neck and back pain. Call us and we’ll send you 20 copies

for you to provide as a resource to your patients.

By having it all in one place, the back or neck pain

sufferer no longer has to drive around town anymore.

Now isn’t that a welcome relief?

At last, a spine center with everything under 1 roof

R

The spine specialty center of Summit Orthopedics2090 Woodwinds Drive, Woodbury, MN 55125Appointments & Referrals:

651.738.BACKwww.SummitSpinecare.com

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OCTOBER 2011 MINNESOTA PHYSICIAN 5

UCare Teams UpWith CaringBridgeMinneapolis-based UCare hasannounced it will begin work-ing with CaringBridge, anonline service that allows peo-ple with serious medical condi-tions to update friends andfamilies through a personalizedwebsite.

CaringBridge websites arefree and not only allow patientsand their families to get infor-mation out about health condi-tions, they provide a place forpeople to leave messages ofsupport. It also lessens someof the stress in clinical situa-tions, when in the past medicalstaff might have to help notifyloved ones.

According to Jeri Peters,clinical services director forUCare, the new partnership willallow CaringBridge officials totrain UCare support staff inhow to talk to patients duringdifficult health situations andhelp them explore variousoptions for informing othersor seeking support.

“It will be one moreresource for us when we havemembers who are challengedwith a very serious healthcondition,” Peters says.“CaringBridge removes someof the burden from primarycaregivers from communicatingwith a long list of individuals.It also helps ensure that accu-rate information and the sameinformation is given. And peo-ple don’t have the cost of all ofthose phone calls.”

With the announcement,UCare becomes the third insur-ance company to establish anofficial partnership withCaringBridge. Minnetonka-based Medica is another insur-ance partner with Caring-Bridge, and there is a long listof health systems and hospitalsthat work with the group inMinnesota as well.

Mayo Clinic,Altru AnnouncePartnershipMayo Clinic has announced anew relationship with AltruHealth System, based in GrandForks, N.D.

Rochester-based MayoClinic created the Mayo ClinicCare Network, of which Altru isthe founding member, to pro-vide Mayo expertise to clinicsnot owned by Mayo’s officialnetwork of facilities, the MayoClinic Health System.

“For many years, MayoClinic has enjoyed collaborativerelationships with hospitals,group practices, and providersaround the world. By develop-ing formal connections withhigh-quality, culturally alignedpractices, the Mayo Clinic CareNetwork takes these naturalcollaborations even further,”says David Hayes, MD, medicaldirector of the Mayo ClinicCare Network.

The two groups announcedin May that they would workmore closely together, and theSept. 14 announcement sig-naled that the Mayo brand willbe more prominent in westernMinnesota and North Dakota.Sioux Falls-based SanfordHealth has also been very activein the same market, acquiringor partnering with numerousfacilities in western Minnesota.

Minnesota BestAt Long-Term Care,Report SaysA new report lists Minnesotaas No. 1 in the U.S. for deliveryof long-term care services andsupport to state residents.

The report, Raising Expec-tations: A State Scorecard onLong-Term Services and Sup-ports for Older Adults, Peoplewith Physical Disabilities, andFamily Caregivers, was releasedby AARP, the CommonwealthFund, and the SCAN Foun-dation on Sept. 8. The analysisfinds wide variation in the qual-ity of services and supportdelivered to seniors and fami-lies. It examines four keyelements of long-term caredelivery performance: afford-ability and access, choice of set-ting and provider, quality of lifeand quality of care, and supportfor family caregivers.

Officials say that some ofthe long-term care indicatorswere measured in the study for

CAPSULES to page 6

C A P S U L E S


the first time. “This report willhelp states make and sustaintargeted improvements so thatpeople can live and age withdignity in their own homes andcommunities,” says SusanReinhard, AARP senior vicepresident for public policy.

Minnesota, Washington,and Oregon were found to bethe top three states in deliveringlong-term care services and sup-port. However, officials say,even the top states need to domore work to create higher-per-forming systems of services andsupport for seniors. “All statesneed to vastly improve in areasincluding home care, assistedliving, nursing home care, andsupport for family caregivers,and more efficiently spend thesubstantial funds they currentlyallocate to long-term servicesand support,” the groups say ina statement.

Officials say the reportshows the top-scoring stateshave policies that improveaccess to services and choices,such as providing alternatives

to nursing homes. Another posi-tive factor is establishing a sin-gle point of entry into the long-term care system. Finally, thehighest-scoring states haveimproved support for familycaregivers by offering legalprotections and other servicesthat address caregiver needs.

“This scorecard is a criticalfirst step toward creating amuch more person- and family-centered system of care thatdelivers services honoringeach individual’s dignity andchoices,” says Bruce Chernof,president and CEO of the SCANFoundation. “To fully realize thevision of a high-performing,long-term services and supportsystem, we must measure per-formance, track improvements,and create opportunities forstates to learn from each other.”

Minnesota ranked fourthnationally in affordability andaccess of long-term care servic-es and support, third in choiceof setting and providers, fourthin quality of life and quality ofcare, and fourth in support forfamily caregivers.

Vaccination NumbersUp for Teens, StateOfficials SayData from the Centers forDisease Control and Prevention(CDC) show that a greater num-ber of teens in Minnesota arereceiving recommended vacci-nations, state officials say.

However, officials withMinnesota Department ofHealth (MDH) say Minnesotacan do better, noting that therates of vaccination duringteen years are still not as highas they should be.

The CDC report shows thatimmunization rates for the rela-tively new tetanus-diphtheria-pertussis booster (Tdap) in-creased from 52 percent in 2009to 70.3 percent in 2010. In addi-tion, immunization with menin-gococcal vaccine, which pro-tects against a serious form ofmeningitis, increased from 43.9percent to 57.0 percent. And37.8 percent of adolescent girlshad completed the three-doseseries of human papilloma virus(HPV) vaccine, which prevents

cervical cancer, up from 27.0percent in the prior year.

“We’re pleased thatMinnesota continues to showimprovement in coverage ratesfor these important vaccines,”says Kristen Ehresmann,director of Infectious Disease,Epidemiology, Prevention andControl for the MinnesotaDepartment of Health (MDH).“We’re making progress, butthese results also tell us we stillhave much work to do beforewe can say our young peopleare sufficiently protected fromthese diseases.” Officials notethat Minnesota vaccinationrates for the diseases have risenat a pace that is similar tonational averages.

State health officials sayit’s important for teens to getthese vaccines because they areat an age of increased risk forthe diseases. Also, the standardadolescent health check-uprecommended at 11 or 12 yearsof age is a good time to receivethese vaccines from their reg-ular health care provider,officials add.

Capsules from page 5

Alan Johns, MD, MEd, has been appointed assistant dean formedical education and curriculum and assistant professor in theDepartment of Family and Community Medicine at the University ofMinnesota Medical School Duluth. Johns has taught clinical medi-cine at the University of Minnesota Medical School Duluth since1982. He has practiced internal medicine at SMDC Health System(now Essentia Health East) since 1981. He was a member of the firstclass of medical students who began their education on the Duluthcampus in 1972, graduating in 1976. He also was one of the first

American Indians to attend that medical school.He achieved his master’s degree in education in2009 from the University of Minnesota Duluth.

Respiratory Consultants welcomes two newproviders, Madhu Kannapiran, MD, and Kris-ten Hasson, MD, to their pulmonary, criticalcare and sleep medicine practice in Robbins-dale, Maple Grove, and Monticello. Kannapiranattended The Ohio State University College ofMedicine, completed his

internal medicine residency at Hennepin CountyMedical Center (HCMC), and completed his fel-lowship in pulmonary and critical care medicineat the University of Minnesota. Hasson attendedthe University of Wisconsin Medical School,completed her internal medicine residency atHCMC, and completed her fellowships in sleepmedicine as well as pulmonary and critical caremedicine at the University of Utah.

Junger Tang, MD, a board-certified neurologist, recently joinedthe Minneapolis Clinic of Neurology. He received his medical degreefrom Northwestern University in Evanston, Ill. He completed hisinternship, neurology residency, movement disorders fellowship, andmultiple sclerosis fellowship at the Mayo Clinic in Rochester. Tangis seeing patients at the Multiple Sclerosis Treatment and ResearchCenter at the Minneapolis Clinic of Neurology in Golden Valley andat the Minneapolis Clinic of Neurology’s Burnsville office.

P.J. Flynn, MD, has been elected to theexecutive committee of the Alliance for ClinicalTrials in Oncology. Flynn, who is board-certifiedin medical oncology and hematology, isMinnesota Oncology’s research director andprincipal investigator for Metro-MinnesotaCommunity Clinical Oncology Program. TheAlliance merges three National Cancer Instituteclinical trials cooperative group programs: Can-cer and Leukemia Group B, North Central Can-

cer Treatment Group, and American College of Surgeons OncologyGroup. The purpose of the group is to reduce the impact of cancer byuniting a broad community of scientists and clinicians from manydisciplines that are committed to discovering, validating, and dissem-inating effective strategies for the prevention and treatment of cancer.In addition, several researchers with Mayo Clinic in Rochester werenamed to leadership roles. Edith Perez, MD, was named Alliancevice-chair; Daniel Sargent, PhD, was named group statistician; JanBuckner, MD, was named director of cancer control, prevention, andhealth outcomes program; and Heidi Nelson, MD, was named direc-tor of the American College of Surgeons clinical research program.

Fredericus (Erik) van Kuijk, MD, PhD, has been appointedhead of the Department of Ophthalmology within the University ofMinnesota Medical School, where he began his duties on Oct. 1. VanKuijk earned both his MD and PhD (biochemistry) from the Univer-sity of Nijmegen, the Netherlands. He completed his internship, resi-dency, and fellowship at the University of Texas Medical Branch,Galveston, where he was a professor in the Department of Ophthal-mology and Visual Sciences until accepting the U of M appointment.Van Kuijk also completed an additional year of training in retinaldegenerative diseases at Moorfields Eye Hospital, London.

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P.J. Flynn, MD


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� What is occupational medicine?

In simple terms, occupational medicine is takingcare of employees. It’s a branch of medicine thataims to produce high quality medical care andinjury prevention for anyone who’s working.

Our goal is to advise both employees andemployers about how to keep workers safe at theworkplace and productive, and to take care of anyhealth issues that rise out of their employment.

� How does one become an occupationalmedicine physician?

It used to be you’d get people who are alreadyworking in other fields of medicine that are inter-ested in occupational medicine, and they wouldgravitate toward that field of medicine.

In the last 25 years therehas been an established resi-dency system for occupa-tional medicine physicians.They have a residency pro-gram just like any other sub-specialty. And they take theboards and become a certi-fied occupational medicinephysician.

� If someone gets hurt atwork, do they see anoccupational medicinedoctor, or their own doctor?

It’s kind of split right now. Under Minnesota law,they have the right to go see their own doctors.

On the other hand, employers also have con-tracts with occupational clinics, and the employercan ask employees—can’t force them, but can askthem—to go see the occupational medicine doctor.

And that’s where we come into play. Wehave contracts with employers, so when employeesget injured, they usually come to us because theyget good care and they get immediate care. If theycall their doctors, a lot of times they will say,“Come in next week.” Whereas occupation medi-cine providers are geared toward taking care ofemployees with a very aggressive approach, so wesee them right away.

� Do most of your patients come from largerbusinesses?

Not necessarily. We do have contracts with smallercompanies. A lot of times it just depends on thecompany. One of the things that employers aredoing is cost containment. Sometimes the compa-ny’s insurer will tell them, “Your costs are too high;you need to send to an occupational clinic if youhave an injury.” Or they will do some evaluationof your site to see what can be done to preventinjuries—or even before you hire, do pre-employ-ment screening to make sure you’re hiring the rightperson for the right job so they’re not getting hurt.

� How do occupational medicine physicians workwith other types of physicians?

Two ways: One, occupational medicine physicianswill work as consultants to primary care physi-cians. When a primary care physician does notknow what to do, or has done as much as he orshe can do and there are still issues, then they con-sult an occupational medicine physician.

The second way we interact with physicians isto send people to other specialties. An examplecould be, somebody got a twisted knee at workstepping off the ladder and has a torn meniscusand obviously needs surgery. I would send him toan orthopedic surgeon. If they’ve been exposed [tosomething and] have got a rash that’s not gettingbetter, I send them to a dermatologist to do some

allergy testing. So if it’s some-thing we can’t treat to a con-clusion, then we use othersubspecialists to resolve it.

� How are the costs ofoccupational medicineservices covered?

There are two ways. One iscalled employer-paid services.The employer pays directly.These services include aphysician exam or a drug testbefore hiring. Let’s say you’re

working under asbestos standards: you have to seethe doctor every couple years to have a chest x-ray.All that comes under this area. The employer pays.

Sometimes we do a fitness-for-duty exam if theemployer is not sure the employee can do the job.These exams are employer-paid.

The second one that is equally big is workers’compensation. That is when an employee getsinjured or ill at work, whether from exposure, afall, or any kind of injury—that is paid by workers’comp insurance.

They will submit a claim, just like anythingelse. It’s a fee-for-service type of thing, so if some-body gets hurt and I see them four times, wecharge the employer for four visits to the office andget paid for the office visits.

� Which type of payment is more common?

It’s a balance. I would say probably it used to bemore work comp—I’d say 60/40—because employ-ers were not doing much and people were gettinghurt more. Now, employers are doing more and theinjury rate is down. There’s been a 40 percent dropin the injury rate in the last 10 to 15 years. Peopleare not getting hurt as much as before; the employ-ers are doing a better job of prevention and a bet-ter job of hiring people qualified to do the jobphysically, so the injury rate is significantly down.

Right now I would say 40 to 45 percent isinjury care and maybe 50 to 55 percent employer-paid services.

Vijay Eyunni, MD, MPHMinnesota Occupational

Health

Vijay Eyunni, MD, MP, is aboard-certified occupa-tional medicine physician

with MinnesotaOccupational Health,one of the largestoccupational healthclinics in the state.He is also a staffphysician with

St. Paul-based SummitOrthopedics.

Eyunni received hismedical degree from

Kasturba Medical Collegein Manipul, India. Hereceived a master’s inpublic health degreefrom the University ofMinnesota. He currentlyis a team physician withthe Minnesota Twinsand the Minnesota

Swarm, a professionallacrosse team.

Keeping employees safe at the workplace


I N T E R V I E W

Employers are doingmore and the injuryrate is down. There’s

been a 40 percent dropin the injury rate in the

last 10 to 15 years.

� What made the difference?

Premium costs kept going up; businesseswere leaving the state because costs weregoing up, so the employers had to do some-thing to get their costs down.

Practices have changed. About 15 to 20years ago we used to see patients hurtingtheir backs and saying, “I don’t want to workfor a month,” and that was perfectly OK.

Those kinds of things don’t happen now.People stay right on top of it. The lost-timerate is down, the injury rate per thousand isdown. There is a lot of automation, so youdon’t see the repetitive work that you usedto see, so that has also created fewerinjuries. And there’s better education; a lotof companies have safety personnel.

We have a program called ergonomicevaluation; we go to companies and showemployees how to do proper lifting andproper bending, so they’re in better shape.It’s a combination of all these things thathas really decreased the injury rate.

� What are some of the services occupa-tional medicine provides that mostphysicians probably are unaware of?

I think the belief is that occupational physi-cians just take care of injuries. We do drugtesting, which is getting very big in the busi-ness community. Many companies are doingpre-hire drug testing.

Also, once they’re hired there is a lot oftesting done for any injuries or things likethat. We do ergonomics, evaluate the jobs,and recommend programs for companies.We also do a lot of pre-placement evalua-tions and we do what is called isokinetictesting. Especially for heavy industries, youwant to make sure the employee is able todo the job. Once people go through isokin-etic testing, the incident rate for injury goesdown significantly.

I think a lot of physicians are not awarethat we do a lot of regulatory exams, likeOSHA-mandated exams for people workingwith chemicals or asbestos or noise or con-fined spaces.

� What role does the wellness andprevention movement play?

One area where employers are still kind ofhesitant is wellness programs, where you goin and look at the population and work withthem on their blood pressure, diabetes, andcholesterol problems.

Because that falls under their privateinsurance, employers are not real excitedabout that. They don’t see the result imme-diately; it’s a long-term result, so employersare a little hesitant to spend up-front dollars.A lot of employers also have transientemployees and they don’t want to spend themoney on them because they’re gone in acouple of years.

The ergonomic programs, or where theyput the stretching programs in place, or dothe isokinetic testing—that’s getting busierbecause they’re seeing the results instantly.

� Is there ever a conflict between treatingthe patient and meeting the needs ofan employer?

First and foremost you want to take care ofthe employee. On the other hand, we have towork with the employer. If there is somelight duty, then the employee can go back towork instead of staying out for a week. Theycan answer phones or look at trainingvideos for a few days.

I think of it as a dual responsibility: youwant to take care of the patient, but on theother hand, you have some responsibility tothe employer. It’s a little bit like sports medi-cine. We want to be aggressive in our treat-ment and be right on top of it, but at thesame time want to give the best treatment sothey’re back on the job.

Going back to work is positive as longas it’s not aggravating the part that’s hurt.It’s better psychologically, and movement isgood. I think these are all medically positivethings.

So, sometimes you see that conflict. Butit’s very rare, because most employees knowthat what we’re trying to do is what’s bestfor them.


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have become somewhatblurred.

The work on healthcare homes over the pastfew years has clearly identi-fied the need for patientengagement and involve-ment as a critical element insuccessful implementation ofthe model. But as we continueto design and incorporate thesenew approaches into our deliv-ery of health care, it wouldbehoove us to consider exactlywhat “engagement” looks like inthe context of improving care.

Jessie Gruman, PhD,president of the Center forAdvancing Health (CFAH),defines patient engagement as“actions individuals must takeover time to obtain the greatestbenefit from the health careservices available to them.” Thisconcept of patient engagementaddresses the specific actionsour citizens/patients will haveto incorporate into their life-styles in attempting to maintaintheir health. Far from the acute,episodic practice of the past,the notion of patient engage-

ment in health care requirescomponents of physician-patient teamwork and patientparticipation unimaginable notso long ago.

Engagement andhealth care redesign

There are several reasons weneed to focus on the need forengagement as we continue ourwork in redesigning health care.

First, patients are beinggiven increasing responsibilityfor both finding and makinguse of the resources we in thehealth care system offer.Questions of how we providethat information to patients—and, at the same time, simplifythe effort required for them toobtain it—are important.

Second, the increasingdemands on our patients meanthat the disparity between those

who are engaged and involvedand those who aren’t engagedwill grow. The unintended con-sequences to those who are orbecome “unengaged” (e.g., dueto social and intellectual issues)will require significant atten-tion. It may lead to thesegroups suffering even more sig-nificant health issues due totheir inability to access careand participate with the termswe’ve identified supportingengagement.

Third, the 21st-centuryfocus on “patient-centered” careprovides an opportunity toinstitutionalize the elementsnecessary for successful patientengagement.

As we talk about developingengagement, there are at leasttwo overlying issues that weproviders need to consider.

To begin with, what arethe “rules of engagement”? Doour clinics and health care sys-tems clearly articulate to ourpatients, in a resource that isreadily accessible and under-standable, what we expect whenthey interface with us—whomto call for an appointment,when services are available,whom to call in the middle ofthe night, what to do with abilling concern, whom to seewhen their preferred provider isunavailable? I suspect manywould have difficulty in identi-fying such a resource documentthat would establish even thosebasic “rules.” More fundamen-tally, have these rules beendeveloped in consideration ofwhat our patients might need,or are they still designed for thebenefit of those of us workingwithin the health care setting?

A shift to patient-centeredcare, in an effort to driveengagement, will often require arewriting of the rules that haveheld us in good stead for years.Whereas in the past, theprovider has assumed thatmerely telling a patient whataction was necessary was suffi-cient, in today’s patient-cen-

tered world we will need to pro-vide specific actions that wouldbe helpful, framed against anunderstanding of the patient’svalues and resources. Ensuringthere will be access to the sys-tem when the patient needs it—not when it’s convenient for theprovider—will require a shift inour thinking about schedulesand availability.

But as we change the mod-els used to deliver health care,and even as we rewrite therules, we need to fundamentallybegin to identify and create theterms of engagement. It is inthis area that groups such asthe CFAH and other patientadvocacy groups have focusedmuch of their work. We aretalking about creating anunderstanding and agreementbetween the health care pro-vider and the patient/family thatlay out the roles and responsi-bilities for all, and that recog-nize the increasing need formutual interdependence—acknowledging that neither ofus alone can solve the problem;we need to work together. [Seethe Patient Perspective articleon page 30 for an example of anengaged patient working withphysicians as partners.]

Behavioral elements ofengagement

In a white paper published in2010, the Center for AdvancingHealth outlines 10 behaviorsthat will be needed at somepoint, in some combination, bycitizens during their experi-ences with the health care sys-tem. [The paper may be down-loaded from the CFAH website,www.cfah.org, by choosing“Supporting Patients’Engagement in Their Healthand Health Care” in the “RecentCFAH Publications” menu.]

In brief, patients must:1. Find safe, decent care2. Communicate with health

care professionals3. Organize their health care

Engagement from cover


A shift to patient-centered care …will often require a rewriting ofthe rules that have held us in

good stead for years.

4. Pay for health care5. Make good treatment deci-sions (elements of shareddecision-making)

6. Participate in treatment7. Promote health8. Get preventive care9. Plan for end of life10. Seek health knowledge

For all of these behaviors,there are lists of specific activi-ties that provide concrete exam-ples of how they might play outin practice.

This behavioral definitionof engagement has the potentialto address several critical areas.If we expect our patients tomeet these elements of engage-ment, it is imperative that weevaluate how we as organiza-tions provide the environmentthat supports this level ofinvolvement. Do we provide theresources that support thoseseeking to become involved andengaged, or is the complexity ofour system non-navigable to theaverage person? Beyond theavailability of educational mate-rials, sharing opportunities, andtechnical support, do we as cli-

nicians demonstrate behaviorsthat would support patientswho are actively participating inmaintaining their health?

Take, for example, patients’use of the Internet. How manyphysicians continue to expressfrustration, often manifestedby rolling eyes, body language,or terse comments, when con-fronted with a patient carryinga thick bundle of printed mat-erial from the Internet? Ratherthan consider what we might bemissing in meeting the needs ofour patients, we are critical ofthem for seeking informationfrom other sources. How wereact, the questions we ask, theinvitation we send throughmany different actions—allthese will be critical in support-ing the engagement we’reexpecting, and needing, in thenew world of health care.

There are atleast three types ofactivities that arecritical in patientengagement: shar-ing information,shared decision-making, and

responsibility for care. As weexpect our patients to movefrom the traditional, passiverole to becoming active, ques-tioning, participating partners,this behavior change will pres-ent a significant challenge tomany practitioners. In recogni-tion of that challenge, it is criti-cal that we in health care beginto think concretely and activelyabout our role in creating theenvironment that is essential inleading to engagement.

Reframing roles

We can argue philosophicallythe need for an empoweredpatient. But there is little debateabout the need to create anenvironment and a culture thatwill lead to the engagement ofour patient population inbecoming and staying healthy.The 10 behaviors cited by Dr.

Gruman are aframework for thediscussion. Theyallow us to consid-er what it is we’reasking of ourpatients, but alsowhat we will need

to create and provide withinour health care system—andacross the community—if we’reto successfully accomplish thevision of a healthy population.

So as we continue our workin reframing the health caresystem in which many of us re-side professionally, we need toaddress not only the roles wewill have in this new world ofhealth care, but also how wecan begin to move from whathas been a provider-centricmodel to one that focuses onthe patient.

Only by including patientsat many levels of our planningand, in effect, co-creating thatfuture, will we begin to under-stand what it will take on allsides to ensure that we have theengagement of everyone inachieving the healthy tomorrowwe all desire.

Gary Oftedahl, MD, is chief knowledgeofficer at the Institute for Clinical SystemsImprovement in Minneapolis.


better positioned to help thananyone else. That means consid-ering the value of care from theperspective of the patient. And,as provider payment incentivesevolve, and benefit and networkdesign changes develop, theefficacy of resource utilization(e.g., medication usage, outpa-tient visits, diagnostic testing,emergency room admissions)will increasingly affect howmuch physicians earn, theirmarket share, and their accessto patient populations.

Physicians usually don’tknow how they perform on costmeasures. Initiatives to makeboth patients and doctors awareof the cost of individual servicesand the total cost of caring forpatient populations are prolifer-ating. While the methodologiesvary, the intent is the same: toimprove care delivery whilemaximizing value.

Consumer informationabout unit costs and total carecosts is increasingly availablethrough plan websites andprovider data-sharing. Plans,public purchasers, and employ-

ers are coupling benefit designsthat create incentives for con-sumers to shop for better valuewith tools to support that effort.Together, these initiatives willaffect a critical mass of yourpatients.

Patients, plans look for value

Total cost of care (TCOC) is awidely used metric that tiespatients back to primary caregroupings and measures allcosts of providing care acrossthe full continuum of services.TCOC analyses consider the ill-ness attributes of patients usingrisk-adjustment tools, so theanalyses consider that sickerpatients require more resourcesto treat and healthier patientsrequire fewer resources.

Total cost of care can behigh because of primary careunit prices, the unit prices ofthe other providers involved ina patient’s care, and the relativenumber and intensity of ser-

vices used to manage similarlyill patient populations. Excep-tionally high unit prices (typi-cally achieved through success-ful plan negotiations) now havea direct, negative impact onpatients—an impact that will befelt by physicians and medicalpractices as well.

Some physicians will findthemselves on the outside look-ing in when plans feature “valuenetworks” or “tiered networks,”coupled with benefit or prem-ium incentives for using themost cost-effective providers.Health insurance exchanges, inwhich price-sensitive individualpurchasers see the full premiumvariation among plan choices,will further stimulate growth of“value network” products.

In addition, plans are shar-ing more performance data (al-though detailed data-sharing isstill very limited) and publicsites are making it easier toevaluate a physician’s perform-ance relative to his or her peers.Both the best and worst per-formers will need to understandhow they are doing in order tounderstand how to optimizetheir future positioning.

The dizzying array ofmethodologies used to measureperformance can be frustratingfor physicians. But the unifyingvision is to think about carefrom the perspective of patientvalue. In other words, how canphysicians help keep careaffordable overall and helppatients use their scarce healthcare dollars to buy the mosthealth possible?

Helping patients decideabout the value of health careservices will become an impor-tant role for physicians. Mostpatients are too overwhelmedor intimidated to ask questionsabout treatment recommenda-tions, but that doesn’t meanthey aren’t concerned. Forexample, patients need to knowwhether the tests or interven-tions recommended (which willcost them hundreds or thou-sands of dollars out of pocket)are the best use of their scarce

dollars, and they will want theirtrusted physicians to help themmake those decisions. (Visitcostsofcare.blogspot.com forsome compelling examples ofthese issues.)

Today, in the absence ofinformation about variation inprice/cost among different serv-ice site choices and with limitedinformation about comparativeeffectiveness, physicians aren’tparticularly well equipped for“the value conversation”—and,in many cases, even feel con-flicted about playing this role.Much of this information isalready transparent on healthplan websites geared to con-sumers, and plans are increas-ingly willing to share this infor-mation and will become moreso as providers request it.However, even when armedwith this information, mostphysicians will need to thinkthough how they discuss thisvalue issue with their patients.Framing it in terms of cost vs.benefit may be helpful, i.e.,“We could perform that imagingservice now, but based on whatwe already know, it won’tchange our treatment recom-mendations and could cost youas much as $XX.”

If physicians and theirteams can’t help their patientsmake good value decisions,patients will look elsewhere forinformation. When that hap-pens, physicians position them-selves poorly with respect totheir role as patient advocates,and trust may erode when thehigh cost or low yield of aphysician recommendationcomes into question throughanother party.

What to do?

How can physicians positionthemselves to deliver the mostvalue for patients? Here are afew suggestions:

Don’t fixate on themethodological details of cost-of-care metrics. Many physi-cians are frustrated by the lackof uniformity of analysesamong plans, the state, CMS,etc. But what really matters isthat these analyses are direc-tionally consistent and drive thesame incentives. Reducing re-admissions, ER visits, complica-tions, using the lowest-cost care


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Payment from cover Helping patients decide about the value ofhealth care services will become an

important role for physicians.

setting and generic drugs, etc.,will improve your performanceunder virtually every analysis.Stay focused on patient valueand the big picture, and youwill do well no matter what themethodological details.

Rethink your pricing posi-tion. After decades of clout-based negotiations, there arebig disparities in contractedrates within the same plannetworks. Negotiating a higherfee level may have been advan-tageous in the past, but now,above-market contract rates area barrier for patients. It’s timeto get competitive with yourpricing—especially for sched-uled and commodity-type serv-ices (lab, imaging, etc.).

Evaluate your practicestyle. Will you take phone calls,emails, or Web visits frompatients? Does every patientinquiry require an office visit?Can others on your team pro-vide certain services at lower orno cost to patients? Do yourequire a set of diagnosticsbefore even evaluating apatient? Do you pride yourselfon being “thorough,” as reflect-ed in the number of tests youorder? If your patients werepaying for every service them-selves and understood the yieldand treatment impact of yourrecommendations, would theythink they were getting enoughvalue? Are low-yield and false-positive tests driving yourpatients into a cascade of carethat isn’t really improving theirhealth status? In a market thatis defined by total cost of care,inefficient resource use drivesyour total cost of care up, mak-ing you unaffordable and inac-cessible to your patients.

Consider the price andpractice style of the physiciansand facilities where you sendpatients. When you send pa-tients to a high-priced doctor orfacility, it increases their finan-cial exposure and affects yourTCOC. If there is no compellingreason to use a more expensivesource, patients will appreciateyour consideration for their wal-lets, especially when it comes toroutine services like imaging,lab, and scheduled proceduressuch as a colonoscopy.

For patients attributed toyou or your practice (meaning

the data indicates that they aremost likely your patients), yourTCOC performance is directlyaffected by care provided tothat patient by others. This pay-ment incentive is intended tomake referring physiciansaware of the impact of theirpreferences in providers ofhealth services.

Are you sure that the high-priced and/or high-utilizingphysicians or facilities you sendpatients to are worth it in termsof better outcomes or patientexperience? Is it time to have aconversation with your col-leagues or facility leadershipabout how you can work to-gether to improve? If you losepatients because you aren’tdelivering enough value, theywill, too; and, conversely, ifothers in your practice aren’tdelivering value, that will affectyou as well.

Your prescribing patternshave a similar impact. Mostpatients have plan coverage thatmakes generics much moreaffordable to them. Prescribinggenerics whenever possible hasbenefits for physicians as well,because when the cost of pre-scription drugs is included inTCOC, optimizing generic druguse makes a significant differ-ence in performance metrics.

Manage your patient pop-ulation even when they aren’tsitting in your exam room. Doyour patients effectively “vapor-ize” when they leave your sight?It is critical to reach out to yourchronically ill patients to makesure they are getting the careand support they need toachieve the best outcomes. Yourpatients will appreciate that youare tracking them. And betteroutcomes reduce TCOC byavoiding admissions, readmis-sions, and complications.

Further, in TCOC models,because you achieve the bestperformance when chronicallyill patients are well managed,you will want to make sure thatthose patients are identified asyours. Most attribution modelslook back on 12 to 18 months ofclaims to evaluate wherepatients have received care, soyou need to make sure yourpatients are showing up in yourdata. Currently, that means theyhave been seen in your office.

(Future analytic methods likelywill evolve to enable tracking ofother types of patient interac-tions, such as phone calls andWeb visits.) If it is difficult forpatients to see you and they endup with another primary caresite or in the ER, that will workagainst you.

Accurately and fully codecomorbidities. There are twocompelling reasons to makesure you are accurately andcompletely coding for all rele-vant diagnoses for every patient.

First, quality of care isaffected. If you have lost trackof a significant comorbidity,you may not be completelymeeting the care needs of thatpatient. With busy schedules,it isn’t easy to keep track of pa-tient complexities, but goodcare requires it. Audits of cod-ing for comorbidities or chronicconditions typically reveal biggaps in diagnosis coding.

If that isn’t motivationenough, there’s also this: Eval-uation of physician perform-ance on TCOC considers howsick (or not sick) their patientsare. The information to perform

risk adjustment to reflect differ-ences in the illness burden ofpatient populations comes fromclaim data. If your ICD codingdoesn’t include a diagnosis codeduring a 12-month analytic per-iod, it won’t be considered inthe risk adjustment process andyour patients will look less sickin the performance analysis.And if your patients appear lesssick than they really are in yourperformance analysis, yourTCOC will appear higher than itreally is.

As payment incentivesevolve and change, it’s a confus-ing time and difficult transitionfor physicians. But the goodnews is that payment modelsare now being designed tocreate an environment in whichdoing the best thing for thepatient finally makes economicsense for everyone.

Ann Robinow is president of RobinowHealth Care Consulting. She has morethan 30 years of experience in healthfinancing, management, and policy, withan emphasis on innovative redesign ofhealth care markets and provider incen-tives for cost and quality performance.


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

Seriously ill and dyingpatients request that youand I care well for them—

and one mark of caring well ismanaging their pain well.

In my field, palliative medi-cine, managing pain is a corner-stone of treatment. People oftenattempt to explain palliativemedicine with academic prin-ciples and healing platitudes.But after practicing palliativemedicine for only a short while,I came to the conclusion thatpalliative medicine is simply amedically sound approach topain management. That realiza-tion led me to develop what Icall guiding principles that pro-vide a practical approach topain management specific toopioids (see sidebar 1). To illus-trate how these principles workin practice, this article brieflydescribes various scenariosinvolving pain management.

Note that the principles andscenarios in the article rest onthe assumption that the pa-tients being treated have opioid-responsive pain and no contra-indications to opioid use.

Introduction of opioids(guiding principles 1–3)

There are three guiding prin-ciples for the introduction ofopioids to patients with normalliver and kidney function.Guiding principle #1 is toaddress whether or not thepatient is opioid-naïve. If thepatient has not been on opioidsconsistently for three to sevendays, then the patient is opioid-naïve and may be started on ashort-acting opioid only, to beused as needed. (Long-actingopioids such as fentanyl patch,MS Contin, and OxyContin haveno role in an opioid-naïvepatient.)

The one exception to thisguiding principle comes intoplay for people with cognitiveimpairments, who are unableto report their pain accuratelyand in a timely manner. Apply-ing guiding principle #2 (“doseby mouth and by the clock”)in this scenario, we wouldprescribe a scheduled, low-dose, short-acting opioid,preferably by mouth, withclose monitoring.

When initiating opioid ther-apy, guiding principle #3 advis-es us to initiate a bowel regimewith sennas and Miralax tomanage constipation, the mostfrequent side effect associatedwith long-term opioid therapy.

Long-term management(guiding principles 4–10)

In patients successfully initiatedand responding to opioid ther-apy, careful titration of the opi-oids is often necessary. Guidingprinciple #4 reminds us that thetitration of a short-acting opioidshould be carried out in incre-ments of 50 percent to 100 per-cent, based on the patient’s painscore of less than or equal to 6,or greater than 6, respectively.

When patients are takingfrequent doses of short-actingopioids throughout the day andnight, it may be time to intro-duce a long-acting opioid. Guid-ing principle #5 advises thatwhen transitioning a patientfrom short-acting to long-actingopioids, the goal is to have thepatient on both a long-actingand a short-acting opioid. Thegoal is never to have a patienton a long-acting opioid only.

Following guiding principle#6 regarding morphine equiva-lents, we can transition ourpatient from frequent, short-acting opioids to long-actingopioids with minimal break-through dosing (i.e., as-needed

dosing to manage breakthroughpain). Breakthrough dosing islikely the most common errorwe see on palliative care rounds(followed closely by the lack ofuse of morphine equivalents).

As an example, our teamrecently saw a man with apathological fracture of his jaw;he was using multiple short-acting forms of opioids, equal-ing 54 mg of oral morphine aday. We recommended using a12 microgram-per-hour fentanylpatch, which is equal to 36 mgof oral morphine a day. Usingguiding principle #7, we thendetermined his breakthroughdosing. In this case, the break-through dose would be 10 per-cent to 15 percent of his totaldaily morphine equivalent,which is 3.6 mg to 5.4 mg oforal morphine for each dose.

Importantly, if an increaseis made in long-acting medica-tion, the breakthrough dosealso must be adjusted. The goalin managing the long-actingopioid is to ensure that thepatient has good pain controlwithout sedation. It is neverthe goal to increase the long-acting opioid so that the patientdoesn’t have to use a break-through dose.

The dose of long-actingopioid is likely correct if thepatient is using two to fourbreakthrough doses a day. Itwould be an unusual situationto schedule a short-acting opi-oid with long-acting opioids.Following guiding principle #8,when a patient is on a long-acting opioid and a short-actingopioid, it is often necessary toadd another medication as anadjuvant. For example, in thesituation of bone pain, it wouldbe reasonable to consider bis-phosphonates or steroids toreduce the pain and perhapsreduce the amount of opioidneeded.

Guiding principle #9applies to dose end failure—pain that occurs toward the endof the time frame in which amedication dose is intended tobe effective. One common sce-nario is a patient experiencingincreasing pain on the third dayof a fentanyl patch, or perhapsmidday pain when on MSContin or OxyContin. In thissituation, the clinical decision

Principles ofpain management

A practical approach totreatment with opioids

By Cory J. Ingram, MD


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would be to change the patchevery 48 hours or add anMS Contin or OxyContin in themiddle of the day.

Finally, guiding principle#10 draws attention to man-agement of incomplete cross-tolerance when switching apatient from one opioid toanother. The basis of this prin-ciple is that patients may expe-rience more effective analgesiafrom a lower rather than anequivalent dosage of anotheropioid. Practically, then, thedose of the new opioid needsto be 25 percent to 40 percentless than what the equivalentcalculation would suggest.

Parenteral opioids(guiding principles 11–17)

When managing opioids forpatients with serious, life-threatening illness, it is likelythat the need for parenteralopioid management will arise.One common type of erroroccurs when a patient onhigh-dose opioids is placed onstarting-dose, standard-order,patient-controlled analgesia(PCA), which would typically

be reserved for opioid-naïvepatients who require parenteralopioids.

In determining the parent-eral dosing morphine equiva-lents, guiding principle #6 must

be used. A walk-through exam-ple is given in sidebar 2.

When managing a PCA witha basal rate to provide continu-ous pain relief, it is importantto recognize that patients do

not immediately feel changes inthe basal rate. Guiding principle#12 reminds us that it takes atleast eight hours after a basalrate change for the patient to bein steady-state at the new dose.The clinical translation is thatbasal rate changes generallyshould be made no more oftenthan once every eight to 12hours. Orders with basal-rateranges for nurses to titrate leadto dose-stacking and an unclearpicture of what dose the patientis actually getting.

If a patient is in pain, therecommended way to titrate thepain is with the PCA. Accordingto guiding principle #13, thePCA dose can be increased by50 percent to 100 percent.Certainly, if a patient is havingpain and you are titrating thePCA over the course of an houror two, it is very possible for thePCA dose to be higher than thebasal rate. Your patient will becomfortable, and you may thenchange the basal rate after eval-uating the amount of drug usedin the last eight to 12 hours. Itwould now be time to increase


PAIN MANAGEMENT to page 16

Guiding principles to management of opioids

Introduction of opioids in patients with normal liver andkidney functionGP #1: Determine whether the patient is opioid-naïveGP #2: Dose by the mouth and by the clockGP #3: Initiate a bowel regimeLong-term management of opioidsGP #4: Titrate short-acting opioids in 50–100% incrementsGP #5: Transition to long-acting from short-acting opioidsGP #6: Determine morphine equivalentsGP #7: Determine breakthrough dosing (10–15%)GP #8: Add an adjuvant medicationGP #9: Deal with dose end failureGP #10: Manage incomplete cross-toleranceParenteral opioidsGP #11: Calculate PCA dose at 50–150% of basal rateGP #12: Confirm basal-rate steady state for 8 hoursGP #13: Titrate the PCA in increments of 50–100%GP #14: Limit basal rate increase to a maximum of 100%Special populationsGP #15: Choose the correct opioid for patients with renal and

hepatic failureGP #16: Permit dying patients to use PCAsGP #17: Titrate down at 50% to prevent withdrawal

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your basal rate, and guidingprinciple #14 will remind youthat you may not increase thebasal rate more than 100 per-cent. Set the new PCA doseaccording to guiding principle#11, in keeping with the newbasal rate.

Special populations

Guiding principle #15 remindsus of the importance of choos-ing the correct opioid whentreating patients with hepaticand renal failure. In renal fail-ure, the safest drugs are fen-tanyl and methadone; other

common choices, to be usedwith caution, are Dilaudid andoxycodone. Morphine andcodeine should be avoided inrenal failure. In hepatic failure,morphine, oxycodone, orDilaudid may be used withcaution, but methadone shouldbe avoided. Fentanyl is likelythe safest choice.

In caring for dying patients,all of the guiding principlesapply. Guiding principle #16permits the use of the PCAbutton by professional nursingstaff for dying patients exhibit-ing signs of suffering from painor dyspnea but are too ill topush the PCA button.

If titrating downward, or inthe event of loss of route forwhatever reason, Guiding prin-ciple #17 reminds us that pa-tients can withdraw from theiropioids. Typically, patients needat least 50 percent of their pre-vious opioid dose to preventwithdrawal. So if a deliriouspatient removes his fentanylpatch, you need to find a wayto replace at least 50 percentof his opioid needs.

Opioid managementguided by resources

Opioid management in allpatient populations requirescareful attention to the details

elucidated by these guidingprinciples. Regardless of ourexperience and knowledge,we should consider using anequivalents chart, a calculator,and a colleague to check ourwork when managing opioidmedications.

Cory J. Ingram, MD, is an assistantprofessor of family and palliative medicineat the Mayo Clinic College of Medicine inRochester, Minn., and is medical directorof palliative medicine at the Mayo ClinicHealth System in Mankato, Minn.


Pain management from page 15

Determining parenteral dosing morphine equivalents: an example

1. Calculate morphine equivalents: 120 mg x 2 = 240 mg po morphine daily (don’t include the breakthrough)2. Convert to iv drug of choice: Use Dilaudid (GP #6: determine morphine equivalents)

240 mg po morphine/24 [hrs?] x 1 mg po Dilaudid x 1 mg iv Dilaudid_ = 12 mg iv Dilaudid/24 hrs4 mg po morphine 5 mg po Dilaudid 0.5 mg iv Dilaudid/hr

3. Incomplete cross-tolerance: 0.4 mg iv Dilaudid/hr (GP #10, 25–40% reduction; this is only a 20% reduction)4. Choose the PCA dose: 0.2 mg iv Dilaudid q 15 min (GP #11: PCA dose 50–150% of basal rate)5. Choose the frequency: q 15 min6. Choose the lock out dose: Basal 0.4 mg/hr x 4 hrs = 1.6 mg in 4 hrs PCA: 0.2 mg x 2 hits/hr x 4 hrs = 1.6 mg in 4 hrs

I would choose 3.2 mg.

A 35-year-old man with advanced colon cancer is on 120 mg of MSContin BID with 6 mg of po Dilaudid for breakthrough pain. He hasused four doses of po Dilaudid in the last 24 hours. His pain has

been well controlled. He has lost his oral route, and you want totransition him to a PCA. To calculate the appropriate dosage, followthese steps:



Victoza® (liraglutide [rDNA origin] injection)Rx OnlyBRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treat-ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve gly-cemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied.CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiv-ing liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a compara-tor-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have sub-sequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most fre-quently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consis-tent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calci-tonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evalua-tion. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other poten-tially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medica-tions known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing con-clusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer.Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248Adverse Event Term (%) (%)Nausea 28.4 8.5Diarrhea 17.1 8.9Vomiting 10.9 3.6Constipation 9.9 4.8Upper Respiratory Tract Infection 9.5 5.6Headache 9.1 9.3Influenza 7.4 3.6Urinary Tract Infection 6.0 4.0Dizziness 5.8 5.2Sinusitis 5.6 6.0Nasopharyngitis 5.2 5.2Back Pain 5.0 4.4Hypertension 3.0 6.0

Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials

Add-on to Metformin TrialAll Victoza® +

Metformin N = 724Placebo +

Metformin N = 121Glimepiride +

Metformin N = 242Adverse Event Term (%) (%) (%)Nausea 15.2 4.1 3.3Diarrhea 10.9 4.1 3.7Headache 9.0 6.6 9.5Vomiting 6.5 0.8 0.4

Add-on to Glimepiride TrialAll Victoza® +

Glimepiride N = 695Placebo + Glimepiride

N = 114Rosiglitazone +

Glimepiride N = 231Adverse Event Term (%) (%) (%)Nausea 7.5 1.8 2.6Diarrhea 7.2 1.8 2.2


Victoza® (liraglutide [rDNA origin] injection)Rx OnlyBRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treat-ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve gly-cemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied.CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiv-ing liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a compara-tor-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have sub-sequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most fre-quently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consis-tent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calci-tonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evalua-tion. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other poten-tially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medica-tions known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing con-clusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer.Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248Adverse Event Term (%) (%)Nausea 28.4 8.5Diarrhea 17.1 8.9Vomiting 10.9 3.6Constipation 9.9 4.8Upper Respiratory Tract Infection 9.5 5.6Headache 9.1 9.3Influenza 7.4 3.6Urinary Tract Infection 6.0 4.0Dizziness 5.8 5.2Sinusitis 5.6 6.0Nasopharyngitis 5.2 5.2Back Pain 5.0 4.4Hypertension 3.0 6.0

Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials

Add-on to Metformin TrialAll Victoza® +

Metformin N = 724Placebo +

Metformin N = 121Glimepiride +

Metformin N = 242Adverse Event Term (%) (%) (%)Nausea 15.2 4.1 3.3Diarrhea 10.9 4.1 3.7Headache 9.0 6.6 9.5Vomiting 6.5 0.8 0.4

Add-on to Glimepiride TrialAll Victoza® +

Glimepiride N = 695Placebo + Glimepiride

N = 114Rosiglitazone +

Glimepiride N = 231Adverse Event Term (%) (%) (%)Nausea 7.5 1.8 2.6Diarrhea 7.2 1.8 2.2

Health law reform is likemajor highway con-struction: All the signs

point to something big happen-ing not far down the road, but itis often difficult to track whenit starts, know what you shoulddo to prepare for it, and, once itarrives, know the precise natureof the projects absorbing theattention of various knots ofgovernment workers (whetherhard-hatted or business-suited).If you are attempting to goabout your business, the onlyspecifics you are likely todemand can be summed upsimply: How does this affectme? If you are a provider oflong-term care services, thePatient Protection and Afford-able Care Act (ACA) includes apatchwork of provisions thatwill—or already do—affect you.

Many of the provisions areaimed at improving the integ-rity of the Medicare program.Others are intended to improvethe quality and efficiency ofcare offered and/or protectpatient populations served bylong-term care facilities. Thefollowing is a brief snapshot—taken at highway speed—of themost important changes.

Accountablecare organizations

Accountable care organizations(ACOs) are a new way forhealth care providers across thecare continuum to coordinatecare with each other, therebyreducing costs to the Medicaresystem. The ACO legislationincludes financial incentives forproviders to form ACOs and toshare in the savings created by

their coordinated efforts. Thedetails of how ACOs areformed, how they are to work,and how they will get paid arestill being formulated.

Although much of the pol-icy discussion about ACOs hasfocused on hospitals, long-termcare providers should be payingattention to this development,too. With their unique abilityto serve as an early-warningsystem to identify and addresspending health care issues forindividuals, as well as their crit-ical role in providing post-hospital acute care, long-termcare providers could play acritical role in an ACO and beinstrumental in the organiza-tion’s ability to create savingsfor Medicare, in addition toimproving health outcomesfor patients.

Elder Justice Act

The Elder Justice Act (EJA) wasenacted as part of the ACA andbecame effective on the date ofenactment, March 23, 2010.The EJA authorized a widerange of initiatives intended tocurb elder abuse, neglect, and

Changes aheadA road map for long-term care

By Sarah Duniway, JD, and Gregory A. Larson, JD


The Patient Protection

and Affordable Care Act

(ACA) was signed into

law just over 18 months

ago. This month’s special

focus articles survey the

changes that have already

occurred and that are

expected to occur as

national health reform

provisions take effect.

The articles examine

four different aspects of

health care: long-term

care, health care for

immigrants, the health

care workforce, and men-

tal health access and

treatment.

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exploitation in long-term carefacilities.

Self-reports of elder abuse.Particularly noteworthy is theEJA’s requirement for long-termcare facilities that annuallyreceive at least $10,000 in fed-eral funds to self-report in-stances of elder abuse. Thereporting requirement appliesto nursing facilities (NFs),skilled nursing facilities (SNFs),hospices that provide servicesin long-term care facilities, andintermediate care facilities forpeople with mental retardation,as well as to each individualwho is an owner, operator,employee, manager, agent, orcontractor of any such facility.The reports must be madeimmediately to the state surveyagency. “Immediately” isdefined to mean within twohours if the incident results inserious bodily harm, or within24 hours if the incident doesnot involve serious bodily harm.

Minnesota providers arealready familiar with the statelaw that requires reporting ofmaltreatment of vulnerableadults. However, not only doesthe EJA’s requirement apply toa broader class of reporters; italso imposes a stricter standard,with higher stakes. First, “anyreasonable suspicion” of abusemust be reported, which isarguably a lower threshold thanthe state law’s knowledge stan-dard. Second, significant finesmay be assessed on anyprovider that fails to report:from $200,000 to $300,000 perviolation. Finally, those who aresubject to the reporting require-ment may be excluded fromparticipation in federal healthcare programs for failing tomake a required report.

In a memorandum relatedto the EJA’s reporting require-ment, which was issued to statesurvey agencies in June, theCenters for Medicare &Medicaid Services (CMS) makesclear that it expects long-termcare facilities to “comply withthe law as it is plainly written,without any delay” occasionedby waiting for clarifying regulations. The CMS memorandumgoes on to outline long-termcare facilities’ responsibilitiesfor compliance with the EJA’s

requirements, including“required functions” and “advis-able functions.” Long-term carefacilities must:• Determine annually whetherthe facility received at least$10,000 in federal funds in thepreceding year, causing theEJA’s requirements to apply.

• Annually notify each coveredindividual of that individual’sreporting obligations (if thefacility determines it is subjectto the law).

• Conspicuously post a noticefor its employees specifyingthe employees’ rights, includ-ing the right to file a com-plaint against a facility thatretaliates against an employeefor making a report requiredby the EJA.

• Refrain from retaliatingagainst an individual wholawfully reports a reasonablesuspicion of abuse.The CMS memorandum

indicates that it is “advisable”for a facility to:• Coordinate with state andlocal law enforcement todetermine what actions areconsidered to be criminalconduct in the jurisdiction.

• Conduct a review of existingpolicies and procedures toensure adherence to existingCMS and state policies andprocedures for reporting inci-dents and complaints.

• Develop and maintain policiesand procedures to ensurecompliance with the EJA’snew requirements.

Increased enforcementahead. The EJA also providesfor funding of a number of ini-tiatives that create infrastruc-ture to combat elder abuse. TheSecretary of Health and HumanServices (HHS) is instructed todistribute $26 million in grantsthrough 2014 to establish foren-sics centers that will developforensic markers to determinewhen elder abuse, neglect, or

exploitation has occurred; pro-vide victim support and advoca-cy; and build capacity amonghealth care providers and lawenforcement officials to collectand examine forensic evidence.

The EJA authorizes anadditional $400 million ingrants through 2014 to supportthe efforts of state and localprotective services programsthat investigate reports ofabuse, neglect, and exploitationof elders, and $72.5 million inappropriations for state long-term care ombudsman grantsand training. The EJA alsoauthorizes the expenditure of$12 million each year through2014 to create a NationalTraining Institute to improvethe training of surveyors whoinvestigate allegations of elderabuse. This increased funding

signals a serious intent on thepart of government regulatorsto step up enforcement activi-ties regarding elder abuse.Long-term care facilities’ expo-sure to state and federal penal-ties in this area is almost cer-tain to increase. Accordingly,such facilities would be welladvised to conduct a thoroughreview of their existing policiesand procedures to ensure com-pliance with the EJA.

Nursing home transparencyand improvement

Public disclosure. The ACAalso includes a number of newdisclosure requirements forMedicare skilled nursing facili-ties and Medicaid nursing facili-ties, presumably in an effort toincrease public accountabilityof these facilities. Effective now,nursing home facilities mustdisclose to HHS the identity ofeach member of the governingbody; each officer, director,member, partner, trustee, ormanaging employee; and each“additional disclosable party”


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This increased funding signals aserious intent on the part of government

regulators to step up enforcement activitiesregarding elder abuse.


Immigrants and their chil-dren make up the fastest-growing group in the United

States, representing 12 percentof the population in 2009. Theproportion of Minnesota resi-dents that are immigrants hasincreased by 38 percent overthe past decade, and in 2009the foreign-born represented6.8 per-cent of the state’s popula-tion, or 360,000 residents.

Numerous federal policiesenacted over the past twodecades have had a significantimpact on immigrants’ accessto health care, and the 2010Patient Protection andAffordable Care Act (ACA) isno exception. This articlereviews the key provisions ofnational legislation pertainingto access to care for immigrants,highlighting the most recentprovisions of the ACA.

Immigrants in Minnesota

As shown in Figure 1, Minnesotais home to immigrants fromaround the world. Almost one-fifth of the state’s immigrantscome from Mexico (17 percent),

the largest single category ofimmigration, followed by immi-grants from Europe (13 per-cent). Africa is also a leadingsource of immigration, makingup 18 percent of the immigrantpopulation in the U.S. when allAfrican categories are combined(see sidebar.)

Legal immigrants can be inthe U.S. as either naturalizedcitizens or legal non-citizens.Non-citizens may be here eitherwith- or without authorization.In general, non-citizens aremore likely to be from young,working families: Over two-thirds of non-citizens in the U.S.and in Minnesota are in the 18to 44 age range; more than half

of non-citizens are married; andtwo-thirds reside in householdswith children present. Whilemost immigrants are working,non-citizens are much morelikely to have incomes below thepoverty level. Across the U.S.and within Minnesota, non-citizens are four times morelikely to be uninsured than theircitizen counterparts (U.S.Census Bureau, 2010).

Federal policies on immigrantaccess to coverage

Prior to 1996, legal immigrantsand their children were eligiblefor health coverage under theMedicaid program if they metstate-specific income- and asseteligibility criteria. Undocument-ed immigrants were not eligiblefor Medicaid or any other feder-ally funded public programs,and they remain ineligible tothis day. In 1996, PresidentClinton signed the IllegalImmigration and ImmigrantResponsibility Act and thePersonal Responsibility and WorkOpportunity Reconciliation Act(PRWORA), which restructuredthe U.S. welfare system and hada significant impact on legalimmigrants’ access to federallyfunded programs. Under thelegislation, legal immigrants losteligibility for all means-tested,federally funded programs—including Medicaid—for the firstfive years they were in the U.S.After 1996, states had to proac-tively enact their own legislationto cover undocumented immi-grants or legal immigrants sub-ject to the five-year ban, and fewstates opted to do so.

Policies constructed over thenext decade attempted to openup coverage for immigrant preg-nant women and children. TheState Children’s Health InsuranceProgram (CHIP) Unborn ChildAmendment of 2002 provided

states with the option of federalmatching funds to cover care forpregnant women regardless ofimmigration status. Once again,however, coverage would beextended only to states proac-tively pursuing (and passing)legislation to cover prenatal carefor these women, and care was“officially” provided or justifiedonly for the “unborn child”whose immigration status wasunknown—not the pregnantwoman herself.

Legislation passed in 2009—the Immigrant Children’s HealthImprovement Act—once againgave states the option to cover“legal” immigrant pregnantwomen and children currentlysubject to the five-year ban andto receive federal financialmatching payments to assistwith the cost of coverage. As ofJanuary 2011, six states hadopted to cover legal immigrantchildren, and 21 states includingMinnesota covered pregnantwomen during the five-yearwaiting period.

Finally, the ACA—signedinto law in March 2010—willincrease access to affordablehealth insurance for millions ofAmericans, but has specificallyexcluded many immigrants.Improved access to affordablecoverage, both public and pri-vate, will be facilitated throughthe implementation of federaland state health insurance ex-changes; Medicaid expansionsfor all persons under age 65with family incomes up to 138percent of the federal povertylevel (FPL); and an individualmandate that will require allU.S. citizens (and legal perma-nent residents) to purchasehealth insurance coverage in2014. Despite these far-reachingcoverage expansions, some 20million people will continue tobe uninsured, including a sub-stantial proportion (about 25percent of all uninsured adults)of the population due to theirimmigration status.

Under the ACA, legal immi-grants are, in most circum-stances, still subject to the five-year ban, and undocumentedimmigrants—regardless oflength of time in the U.S.—willremain ineligible for publicprogram coverage through

Immigrant access tohealth care

Fewer resources, less politicalwill to provide safety net service

By Jessie Kemmick Pintor, MPH, and Lynn A. Blewett, PhD


Read usonlinewherever you are!

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Medicaid or CHIP. Undocu-mented immigrants are alsospecifically prohibited from pur-chasing coverage in federal andstate insurance exchanges, asthe ACA requires that individu-als purchasing exchange-basedcoverage meet citizenship/legaleligibility requirements. Undocu-mented immigrants are exemptfrom the individual mandate,along with a small group ofindividuals including, for exam-ple, American Indians and thosewith financial hardship orreligious objections.

Significant barriersto access to care

Since 1996, significant restric-tions on access to public healthbenefits have been placed onboth legal- and non-legal immi-grants. The five-year ban onaccess to public health insur-ance coverage for all immigrantsthat exists today results in asignificant barrier to access toneeded care. The ACA has notaddressed the health care needsof immigrants under healthreform; in fact, non-legal immi-grants are specifically excludedfrom the individual mandateand the health insuranceexchanges.

States have had some flex-ibility in providing coverage forexcluded pregnant womenunder the reauthorization of theChildren’s Health InsuranceProgram, but few states haveopted for this specific and tar-geted expansion. Several states,including Illinois, New York, andMassachusetts, have pursuedstate-only funded children’shealth insurance programsfollowing a “Cover All Kids”strategy, with no federal finan-cial support. The expansionof state-sponsored children’sprograms is highly unlikelygiven the downturn in theeconomy, state budget deficits,and the growing political dividebetween the two governingpolitical parties.

So who will provide care toour immigrant population?Interestingly, while the U.S.explicitly restricts access to pri-vate and public health insurancecoverage for immigrants, bothlegal and non-legal, we impli-citly rely on our formal and

informal safety nets to providemedical care when it is needed.Hospitals that provide servicesto Medicare and Medicaidpatients must triage all patientsand admit those who are in anemergency situation, regardlessof legal status and health insur-ance coverage status. Thosewithout coverage often waituntil their situation has reacheda crisis state before seekingcare—often in the emergencyroom of a community hospitalor at the tax-supported localpublic hospital whose mission isto provide care to the poor andunderserved.

Community Health Centers(CHCs, also known as FederallyQualified Health Centers)—nonprofit clinics located inmedically underserved areas,both urban and rural—share amission of making comprehen-sive primary care accessible toanyone regardless of insurancestatus, immigrant status, or abil-ity to pay. The small but growingnetwork of 17 CHCs operating inover 70 locations in Minnesotahas played an essential role in

facilitating care for immigrants,providing basic primary care aslegal residents wait for the five-year ban to expire and as un-documented families get theirchildren the basic checkups andprimary care services needed inthe first years of life. In light ofthe growing restrictions underhealth reform, CHCs will playan even more pronounced rolein covering insurance gapsamong immigrants.

It’s a difficult time to betalking about doing more whenthere is less funding at both thestate and national levels, andless political will to provide thebasic safety-net services tothose in need. We are likely tosee lower state and federal taxrevenue, targeted to fewer andmore narrowly defined U.S.populations.

Jessie Kemmick Pintor, MPH, is adoctoral student and Lynn A. Blewett,PhD, a professor in the University ofMinnesota School of Public Health,Division of Health Policy andManagement.


Immigrant status among non-citizensin Minnesota (2009)

“Non-citizens” include legal immigrants, non-immigrants, and un-documented immigrants.• Legal immigrants are legal permanent residents (“green card”holders), asylees and refugees, and other immigrants with uniquesituations.

• Non-immigrants are individuals in the U.S. on a temporary tourist,student, or work visa.

• Undocumented immigrants* are people who (1) have entered thecountry without approval from immigration authorities, or (2) haveviolated the terms of a temporary admission (e.g., overstaying atourist/student visa without status adjustment*).

*It is estimated that of all undocumented immigrants currently in the U.S.,slightly more than half entered without approval, while others have overstayed atemporary visa.

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Central Americaand Caribbean 6%

Mexico 17%

OtherSouth America 6%

Laos 8%

Thailand/Vietnam 8%

India 6%

Somalia/Ethiopia 8%

Other Asia 15%

OtherAfrica 10%

Canada 5%

Europe 13%

Source: 2009 American Community Survey, U.S. Census Bureau.

FIGURE 1. Minnesota’s immigrants.


While giving talks onchange leadership, I’veoften referenced exer-

cises that help the audience real-ize the need to think outsidethe box. There’s a humorousYouTube vignette of two peopleon an escalator that stops unex-pectedly (go to YouTube andtype in “escalator fail”). Theirpanicked reactions, while overlydramatic, make incisive pointsregarding entrenched thinkingand what happens when we failto recognize the need to changeand find new solutions.

People who work in thehealth care industry are nostrangers to change—fromadvances in diagnostic technol-ogy and treatment options tonew reimbursement and regu-latory requirements. Over thepast 50 years, most health careorganizations have embracedincremental, system-sustaininginnovations that have requiredaccommodating the existingsystem rather than makingrevolutionary changes. ClaytonChristensen and MichaelOverdorf of the HarvardBusiness School have written

about “disruptive innovation”that creates transformationalchanges beyond the capabilitiesof existing systems. But theimpending changes due tohealth care reform, coupledwith large economic and dem-ographic shifts, portend an erathat has the potential to be verydisruptive.

Without question, there isa great deal of interplay betweenthe coming reforms and changesto the workforce. Whether ornot political forces undo theplanned reforms, most expertsagree that the long-predictedeconomic and demographicchanges that have begun willmandate a very different ap-proach to health care and the

health care workforce. There-fore, it’s imperative that physi-cians and other providers payattention to the coming needsand begin to address themaggressively.

What planned health carereforms are on the horizon?What demographic and econo-mic changes are coming? Andhow will the health care work-force need to adapt to succeedduring these disruptive times?In short, how can health care or-ganizations get off the escalator?

Key elements of health reform

Much has been written regard-ing the reforms that were en-acted in 2010 as part of thePatient Protection and Afford-able Care Act (ACA). The keyelements of the ACA addressthree main areas: cost (afford-ability), access (availability),and quality (appropriateness).Among the specific strategiesthat will affect providers are:• New payment mechanisms• A large increase in the numberof people with insurance cov-erage, along with improve-ments in coverage

• Greater emphasis on preven-tion and on care that is data-driven and based on bestpractices

First, as accountable careorganizations (ACOs) takeshape, providers will be expectedto develop population-basedmodels that span every aspectof care—from birth to death,prevention to episodic, acute tolong-term. Even in those com-munities where these modelsmay not be required (i.e., <5,000lives), it’s expected that many ofthe tenets of accountable carewill be implemented. Greateremphasis will be placed on pre-vention, chronic disease man-agement, and continuity of careas medical homes become a

necessity for successful prac-tices. Payment will move awayfrom volume-driven formulas;outcomes and population man-agement formulas will expand.

Second, 32 million morepeople will have access to healthinsurance. More people will beseeking care, putting greaterstrains on the already under-sized care structures.

Finally, health care is finallyentering the information age, ashospitals, insurance companies,and physicians adopt electronichealth records and decision sup-port systems. These will allowproviders to access patient infor-mation quickly, record patientconditions and treatments withgreater accuracy, and createdatabases that will help ensurethat best practices are followed.Pay-for-performance and mean-ingful use incentives will provideeven greater motivation foradopting EHRs and other high-tech systems.

While telemedicine applica-tions have been around foralmost 20 years, only recentlyhave we seen broader accept-ance of this type of caregiving.Store-and-forward techniqueshave been used in radiology anddermatology for years. Now, ad-vances in videoconferencing andmonitoring technology are spur-ring increased use and accep-tance of telemedicine. Also, asnetwork speeds improve, homeapplications will also grow, help-ing to extend prevention effortsand reduce unnecessary officeand hospital visits.

Changing demographicsand the workforce

Now, consider the followingdemographic changes:• The U.S. population is ex-pected to increase 13 percentby 2025, with greater ethnicand racial diversity.

• The aging of baby boomers isresulting in greater health careutilization. The first boomersturn 65 this yea; within 20years, more than 20 percent ofthe U.S. population will be 65or older. Of note, people overthe age of 65 use twice asmany physician resources asthose under 65.

• Chronic diseases and un-healthy behaviors are creating

Getting off theescalator

Health care reforms will require newworkforce strategies

Mary Ellen Wells, FACHE


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unprecedented utilizationdemands. By 2030, half thepopulation will have at leastone chronic condition. Thesepatients average at least twiceas many physician visits eachyear, compared to those with-out chronic conditions.According to the Centers forDisease Control and Preven-tion, more than one-third ofU.S. adults are obese, leadingto increases in chronic diseaseand disability and reducedproductivity.

• A significant portion of healthcare workers are entering theage of retirement. More than36 percent of registered nurseswill be between 50 and 64years old in 2015, and 25 per-cent of physicians are 60 orolder.

• Half of the current graduatesof physician training arewomen, many of whom areseeking better work/life bal-ance as they have and raisechildren. According to BrianDay, MD, president of theCanadian Medical Association,female doctors “will not workthe same hours or have thesame lifespan of contributionsto the medical system asmales.”

These changes, coupled withthe pending health care reforms,will have a tremendous impacton the American health careworkforce. Most notable is theshortage of caregivers. Prior topassage of the ACA, the Asso-ciation of American MedicalColleges projected a shortageof 124,000 physicians by 2025.Given increased coverage result-ing from the reform initiative,many believe there will be aneed for 155,000 physicians by2025. At the same time, theU.S. will be facing a shortageof more than 500,000 nurses.Though medical and nursingschool enrollments will increaseand more will be able to enterthe medical field thanks to loansand grants from the ACA, short-ages will remain.

Modified modelsof care delivery

The expected shortages ofproviders, in combination withthe increasing need for carecoordination and utilization

oversight, has led many groupsand systems to begin to modifytheir delivery models. For exam-ple, midlevel providers—nursepractitioners, certified registerednurse anesthetists, nurse mid-wives, and physician assistants—are taking on greater caseloadsand care coordination. Manyorganizations are developingmedical homes where physiciansprovide greater oversight andconsultation services rather thanconcentrating on treating indi-vidual patients.

There is still wide variationin the licensed scope of practicein every category of midlevelproviders. Acceptance of theexpanding role of these pro-viders also varies among physi-cians, so tensions often exist asdemonstration pilot projectsexpand and groups experimentto find the most effective sys-tems. It is clear, however, thatthe most successful groups willbe those that have learned howto best utilize each provider’sskills and abilities to the maxi-mum of his or her license.

Solo practitioners arealmost nonexistent in Minne-sota, and the number of inde-pendent practices has steadilydeclined. Many predict thatthere will be even further ero-sion of the independent groupsas they give way to systemsthrough employment or contrac-tual arrangements.

In addition, the site of carehas gradually changed over thepast 10 years, from heavily capi-talized hospitals to ambulatoryand other sites. Reform anddemographic changes will bringabout a new paradigm of care.Hospitals will no longer be thebastions of financial strengthand control that they are today.They are quickly becoming costcenters—the least favored accesspoint for the care people willseek throughout their lifetime.Hospital leaders are realizingthis and are struggling with thenew reality, where more admis-sions and expensive proceduresare not the desired outcomes.Clinics will take on importantroles in the integrated systems.

Senior care services areexpanding as well. Campuseswhere elders can move betweenindependent or assisted settings

through rehab or long-term carefacilities have become standardin most communities. Nursesand ancillary staff will need toshift away from the acute set-tings and into continuum-of-care facilities.

Drastic change is also occur-ring in administrative and sup-port positions in the health careworkforce. With the adoption ofelectronic health records, theneed for medical records andtranscription staff has declinedas IT staffs have expanded. Upto 50,000 more HIT workersmay be needed to implementEHRs in hospitals, clinics, andlong-term care facilities and tosatisfy criteria for meaningfuluse. And with greater emphasison outcomes and best practices,there is a great need for dataanalysts and decision supportspecialists in every area ofhealth care. The implementationof ACA-mandated insurance ex-changes will create new roles inthe insurance field and expandservices offered by businessesthat help individuals pick theirbest health-care insuranceoptions.

Adapt to survive and thrive

The many changes coming tothe health care workforce reflectboth the implementation ofhealth care reforms and thedemographic changes that arenow upon us. Several provisionsin the reform legislation willhelp address the shifts that areoccurring. However, physiciansand health care leaders will beexpected to make drastic, poten-tially disruptive changes in theway care is provided to managethe projected demands.

To paraphrase Darwin, it’snot the strongest or the smartestthat will survive; rather, it’s thosewho can adapt. Health care lead-ers will need to develop strate-gies to deal with health reform—or they’ll end up stuck on theescalator.

Mary Ellen Wells, FACHE, is vicepresident of client development atExperienced Resources, LLC, which placeshealth care leaders in interim roles andproject assignments. She has spent over30 years in various leadership positions atsome of Minnesota’s top health careorganizations, and is a fellow of theAmerican College of Healthcare Executives.


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The National Alliance onMental Illness (NAMI) haslong supported strong

health care reform legislationthat expands coverage to themillions of Americans who livewith a mental illness. It is hardto think of any other illness thathas faced such a long history ofdiscrimination under healthinsurance, ranging from beingunable to obtain insurance tohaving insurers refuse to covermental health treatment.

Three important pieces ofrecently enacted federal legisla-tion will begin to make someheadway in breaking down bar-riers and addressing discrimina-tory practices in mental healthcare: the Paul Wellstone andPete Domenici Mental HealthParity and Addiction Act(Wellstone-Domenici Parity Act);the Patient Protection andAffordable Care Act (ACA); andthe Health Care and EducationReconciliation Act of 2010.

Eligibility and access

The Paul Wellstone and PeteDomenici Mental Health Parityand Addiction Act will affect all

health plans, including self-insured plans. [A majority ofMinnesotans are covered underself-insured plans, to whichMinnesota’s parity law, passed in1995, did not apply.] It’s impor-

tant to note that the federal par-ity act still doesn’t require cover-age for mental health treatment;however, it does state that if aninsurer covers such treatment,

the insurer has to cover it in thesame way that it covers physicalhealth care. The act takes intoaccount financial limitations(copays, deductibles, and out-of-pocket limits), treatment limits

(number of visits, length ofstays), and nonquantified limits(prior authorization and medicalnecessity criteria). As the regula-tions are implemented, we ex-pect to see improved access formental health treatment.

The two health care lawsexpand eligibility for healthinsurance and thus will alsoincrease access to mental healthtreatment. Probably one of themost significant items is thesimplification of federal Medi-caid eligibility (called MedicalAssistance (MA) in Minnesota).In 2014, people with incomesbelow 133 percent of povertywill be able to qualify automati-cally for Medicaid. BecauseMinnesota had General Assis-tance Medical Care (GAMC) atthe time, our state was one of 11that could take advantage ofearly “opt-in” of Medicaid,allowing people who were onGAMC (incomes at 75 percentof the federal poverty level or$8,168) to be eligible for MA.There was quite a bit of a debateover this provision during the2011 legislative session, but inthe health and human servicesbill enacted during the specialsession, MA for people withoutdisabilities with very lowincomes remained in place.

Basing eligibility on incomerather than disability status

helps streamline enrollment andfosters earlier intervention. Theprocess for certifying that youhave a disability is a long andarduous, especially for peoplewith a mental illness. Findingand keeping the documentationand paperwork when you live inabject poverty and mostly onthe streets is nearly impossible.People who have a mental illnessare frequently denied benefits bySocial Security, often as many asthree times before they areapproved. For people with men-tal illnesses who end up in ourcriminal justice system, the earlyopt-in will make it far easier toconnect them with mentalhealth care services as soon asthey are released.

For young adults, perhapsexperiencing their first psychi-atric hospitalization, the earlyopt-in will enable them to accesstreatment in the communitywithout having to prove to theSocial Security Administrationthat they are so disabled by theirmental illness they cannot work.Now they will be able to qualifyfor MA, obtain care, and beginto work as part of their recovery.

Under the health reformlegislation, unmarried youngadults will be able to continue tobe covered under their parents’coverage until they are 26 yearsof age. [Minnesota has a lawproviding coverage up to 25 butit does not include self-insuredplans or state employees.] The18–26 age group is one of thelargest uninsured groups—andthese are key ages when mentalillness strikes. An increasingnumber of young adults withmental illnesses are attendingcollege—some part-time. Theirpart-time status has made itimpossible to be covered undertheir parents’ health plan; andpurchasing a single plan hasoften meant high deductibles,coverage of only generic medi-cations, and limited coverageof mental health treatment.Any reader with a recent collegeor high school graduate knowshow hard it is to find a job withhealth care coverage. Havingcoverage results in improvedaccess to appropriate and timelymental health treatment duringyears when there is a significantrisk of developing a mentalillness.

Making headwayin mental health

Breaking down barriers and addressingdiscriminatory practices

By Sue Abderholden, MPH


Under health care exchanges, all plans mustcover mental health services—which isa first—and they must be covered in the

same way as other health care conditions.

People with mental illnessesdie 25 years earlier than theirpeers—their life expectancy isthe same as that of people wholive in Bangladesh. Minnesotahas launched the “10 x 10” cam-paign to increase people’s lifeexpectancy by 10 years in 10years. Its efforts to promote in-tegrated care will be supportedby provisions in the ACAthrough grants for co-locatingprimary and specialty care incommunity-based mental healthsettings. Co-location offers anopportunity to provide coordi-nated care to individuals withmental illnesses and co-occur-ring primary care conditionsand chronic diseases.

The ACA established healthcare exchanges—a marketplaceto purchase health insurance.Under health care exchanges, allplans must cover mental healthservices—which is a first—andthey must be covered in thesame way as other health careconditions, as set forth in theWellstone-Domenici Parity Act.This will provide access to men-tal health care to individualsseeking single policies and thosewho work for small businesses.NAMI will be advocating for afull continuum of mental healthservices (in-home, day treat-ment, residential services, etc.)to be included in the essentialbenefit set.

The new law assures eligibil-ity for health coverage by pro-hibiting the practice of exclud-ing people with pre-existingconditions in all health plans.This went into effect right awayfor children under age 19, andwill expand to everyone else in2014. NAMI has learned ofpeople being denied coverage fornon-severe forms of anxiety anddepression—even if they hadnever been hospitalized. Forpeople with more serious formsof mental illness, having cover-age for treatment provides hopefor recovery. Using Minnesota’soption for people denied cover-age, the Minnesota Comprehen-sive Health Association, withits high deductibles, premiums,and copayments, was not feas-ible for many.

Preventive health services

The ACA requires that in the

future, all health plans will berequired to cover preventivehealth services—evidence-baseditems or services that have, ineffect, a rating of ‘A’ or ‘B’ in thecurrent recommendations of theU.S. Preventive Services TaskForce. This would includedepression screenings for adults,children, and adolescents.

More than 500 people die bysuicide in Minnesota every year,most as a result of untreatedmental illness, particularlydepression. Earlier interventionand access to effective treatmentcan help prevent these deaths.Depression often co-occurs withother health conditions, such ascancer (10 to 30 percent of peo-ple with cancer are found to beclinically depressed), heart dis-ease (depression is more preva-lent in heart patients than in thegeneral population, especially inyoung women with acute heartdisease), and diabetes. The ACAincludes funding for five-yeargrants to establish nationalcenters of excellence for treat-ment of depressive disorders.Additionally, there is funding tosupport education and researchon postpartum depression.

Minnesota has a severeshortage of mental healthprofessionals—especially fromdiverse communities, in ruralareas of our state, and in certaintypes of professionals (psychia-trists, clinical nurse specialists).This is particularly true for theprovision of children’s mentalhealth services. The new lawincludes funding for mental andhealth education and traininggrants and authorizes grants tocolleges and universities to sup-port the recruitment and educa-tion of students in social workprograms, interdisciplinary psy-chology training programs, andinternships or field placementprograms in child and adoles-cent mental health. There arealso grants available to statelicensed mental health organiza-

tions to train paraprofessionalchild and adolescent mentalhealth workers.

Several new opportunitiesto try new approaches underMedicaid are also included inthe ACA. These include anexpansion of home and commu-nity-based services for peoplewith disabilities (including thosewith a serious mental illness);alternatives to institutional levelof care; and coordinated care forpeople with multiple chronichealth conditions, includingserious mental illnesses. Minne-sota is looking at several of theseoptions as an alternative to morecostly institutional care and toprevent hospitalizations.

Much of the funding thatwas lost this year in Minnesota’slegislative session was grant

funding to counties to pay formental health care and treat-ment for people who were un-insured or underinsured (e.g.,through nonparity covered plansor high-deductible plans) andfor services not typically coveredby health plans. The more wecan move toward universal cov-erage and toward full coverageof mental health care and treat-ment, the less we will have torely on block grants to countiesand the less people will have to“wait in line” for care that theyneed.

NAMI is looking forward tothe implementation of many ofthe provisions of these three newlaws. The time of discriminatingagainst children and adults withmental illnesses is coming to anend. Accessing mental healthcare and treatment means thatpeople will be able to betterfunction in school, work, home,and the community.

Sue Abderholden, MPH, is the execu-tive director of NAMI Minnesota.


Effects of mental health reform on providers:

• Opportunities for earlier intervention• More integrated care, especially for comorbid diseases (e.g.,depression and diabetes/heart disease/cancer)

• Co-located primary care with specialty mental health care• Additional mental health professionals and paraprofessionals as aresult of training/education opportunities

• More home and community-based services for people with mentalillnesses

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

Most health careproviders are seeingan increase in the

number of self-pay patients.And if your practice is likemost, your level of accountsreceivable from self-paypatients is increasing fasterthan your revenue. Re-evaluat-ing your patient statement andbilling process can help im-prove both self-pay collectionsand patient satisfaction.

The traditional focus areasin health care billing—codingand compliance—are essentialbut insufficient when it comesto self-pay patients. There’s agreater need for clear and con-cise communication whetherin print or online. Self-paypatients demand administrativeease. Younger patients in parti-cular indicate they are willingto change providers to gainthat ease.

Consider these dramaticsurvey results released thisspring by Intuit Health:• 59 percent of Gen Y patients(i.e., those born between 1980and 1992) say they would

switch doctors for one withbetter online access.

• 41 percent of all patients donot have confidence that thebilled amount is correct.

• 28 percent of Gen Y patientsare unsure whether to paytheir doctor or the insurancecompany.

• 57 percent of patients havehad at least one medical billgo to a collection agency.

• 45 percent of patients waitmore than a month to paytheir doctor bill.The last statistic indicates

that health care providers have

an excellent opportunity toimprove their bottom line bytaking simple steps to improvethe clarity and accuracy of theirpatient statements.

Increasing the value of thepatient statement

Nurses, doctors, and adminis-trative professionals work hardto satisfy patients during a visit.Clear communication is a bigpart of the perceived serviceprovided in any in-personpatient interaction; just look atthe billboards along any metro-politan freeway and you can seehealth care providers emphasizetheir staff’s attentiveness topatient needs.

But what happens after thepatient leaves the facility? Forself-pay patients, the billingstatement becomes an impor-tant “after-care” communicationmechanism. The billing state-ment is an expression of thehealth care provider’s brand—for better or for worse. Consid-ering the Intuit Health surveyresults noted above, it seemsthat too often it’s “for worse,and the statement fails tostrengthen the provider’s brandand the patient’s experience.

The best statements notonly result in patient satisfac-tion through clear communica-tion, but also improve cash flowand decrease collections. It’simportant to realize that justlike good customer service

inside a provider’s facility, aclear and concise patient state-ment is beneficial for bothpatients and providers. So howdoes a health care provider setup the billing statement as avalue driver? Here are thebasics.

Be clear and bold. Brandyour statement. Patients cometo associate your brand char-acteristics—logo, type, colors,words—with their experiencesat your facility. Branding ex-presses who you are, so yourbrand should be consistenteverywhere. Remember thatpatients may visit more thanone facility or specialist. Pre-sent your logo and colors onthe statement exactly the sameway you do on all your mater-ials. Ensure that the brand isexpressed both in the body ofthe statement and on the tear-off stub.

Use legible, consistentfonts. Choose easy-to-readfonts and font sizes. APEX’sstatement design studio man-ager Joe Fyten recommendsthat organizations:• Use a sans serif typefacethroughout the statement(sans serif typefaces do notuse serifs, which are smalllines at the ends of characters;popular sans serif fontsinclude Helvetica, Arial, andGeneva).

• Limit serif fonts to messageareas (popular serif fontsinclude Times Roman,Palatino, and Garamond).

• Stay consistent with whateverfonts they choose.

• Never use more than twofonts within the statementdesign.

• Keep type sizes consistentwithin each area of the form.

• Use boldface type, larger type,or all capitals sparingly andonly for messages that needextra emphasis.Make sure patients don’t

have to search for their readingglasses to review the basicinformation. Enlarge the fontsizes of the account or guaran-tor number, amount due, state-ment due date, and remittanceaddress.

Be concise. State only whatis necessary. Self-pay patients

Transformingbilling practices

Billing design can improve self-paycollections and patient satisfaction

By Brian Kueppers and Nels Peterson


www.mankato-clinic.com

Mankato Clinic is looking for a full-time Nurse Practitioner or PhysicianAssistant to work in our Mapleton satellite 20+ hours/week, and rotatingweekday/every third weekend shifts in our Urgent Care Department.Qualifications include but are not limited to:

NP: Masters Degree in nursing encompassing specializedclassroom and experiential learning as a nurse practitionerOR grandfathered in as an NP if certified prior to 1995.Current licensure by the State of Minnesota and AdvancedPractice Certification by ANCC, ACNP, National Certifica-tion Board of Pediatric Nurse Practitioner and Nurses, orother certification agencies to practice as a registerednurse and Nurse Practitioner.

PA: Graduate of an approved Physician Assistant Program, Certificationby the NCCPA, and current Minnesota Registration with the State Boardof Medical Practice.

For both: Current authorization from the MN Board of Nursing/PhysicianAssistants to prescribe drugs and therapeutic devices; current Basic LifeSupport and Advanced Cardiac Life Support certifications; three years ofemployment experience preferred; effective interpersonal skills necessaryfor providing patient/family instruction and collaboration with health teammembers.

You will enjoy an excellent benefits package including generousCME expense and time-off allowance, 401(k) profit sharing plan; EAP;employee discounts; six paid holidays and more.

Apply online at www.mankato-clinic.com, or contact: Dennis Davito,Director of Provider Services, at [email protected]; Phone:

(507) 389-8654; Fax (507) 625-4353,Mankato Clinic, 1230 E. Main St.,Mankato, MN 56001. Mankato Clinic isan Affirmative Action/Equal OpportunityEmployer.

A billing statement should inform,not overwhelm.

are not experts in coding andcompliance. It’s better to pro-vide enough information to sat-isfy most patient’s informationalneeds than to overwhelm allpatients with data relevant foronly a few. Those few can call—and can receive quick and pre-cise answers when your officeor call center has ready accessto electronic patient billingdata. When patient supportrepresentatives have electronicaccess to the exact same docu-ment the patient is viewing,calls are likely to be shorterand more productive and willreinforce the provider’s commit-ment to offering a quality “after-care” experience.

Revise carefully. Consideragain the staggering surveyresults noted above—41 percentof patients believe their bill maybe inaccurate. A patient whoquestions a bill is much morelikely to be among the 57 per-cent of patients who keep a billoutstanding so long that it goesto a collection agency! Provid-ers typically get a strong finan-cial return on the modestinvestment of time it takes toget the statement design right.Once you have a draft design,ensure its accuracy in a rigor-ous proof-and-correctionprocess that involves runninga full month of statements.

In summary, a statementshould inform, not overwhelm.The provider’s brand should beprominent. Key informationshould be highlighted, and allaspects of the patient’s financialresponsibility should be crystalclear. Customer service repre-sentatives should have readyelectronic access to the exactdocument the patient receives.All of these can increase thevalue of the patient statementin both collections and one-callresolution when patients do callwith questions.

Online billing

Online billing is essential toyounger patients. Remember,59 percent of Gen Y patientssaid they would switch doctorsfor one with better onlineaccess. Your practice may haveinvested in software that allowspatients to access their medicaldata through an online portal.

It’s important also to ensureeasy online bill payment.

Ideally, online billing meanstwo things. First, patients areable to enroll in electronicstatements—which are moreconvenient for patients (and allbut demanded by youngerpatients)—and, furthermore,cost providers only about halfthe outlay for paper statements.Second, an ideal online billingsystem provides a portal forpatients to visit and makepayment.

The electronic statement.The primary guidance for elec-tronic statements is straightfor-ward: Your electronic statementshould exactly match your print-ed statement. You build yourbrand by clear and consistentcommunication. Your statementdesign (both printed and elec-tronic) should stress the avail-ability of online services, includ-ing bill payment. Consider usingQR (“quick response”) codesthat patients can photographwith their smart phones and betaken directly to the onlinebilling portal. All these aspectsof billing have the double bene-fit of making payment easier forpatients and lowering costs forproviders.

Electronic payments. Bynow, most people are familiarwith online payment portals,whether for utility companiesor online merchants. In addi-tion to offering a seamless cus-tomer experience, the onlinebilling portal should be fullybranded to feature your organi-zation. Patients should feel theyare interacting directly withtheir “own” provider and notwith an anonymous third party.Ideally, patients should have atleast three options for makingelectronic payment: via theonline billing portal, by phonewith a customer service repre-sentative, and by a one-timequick payment from a paperstatement.

Other considerations

Health care providers oftenuse third-party firms to helpachieve the financial andpatient-satisfaction benefits ofclear, effective billing. Whetherprinted or electronic statementsare processed in-house or by a

third party, it’s essential for thehealth care provider to main-tain direct access to the exactstatement sent to patients.

When customer servicepersonnel can review both pastand current statements, thecheck-in process can becomean opportunity for patients toresolve questions, thereby sav-ing call center resources later.When patients do call customerservice, calls are smoother andmore efficient when staff mem-bers can review current andpast statements.

Typically, patient statementsshould be archived for at least12 months. Some organizationsmay wish to maintain statementarchives for longer periods,matching the duration to med-ical records maintained underHIPAA requirements. By archiv-ing statements, providers canalso improve their ability totrack cash flows. Finance man-agers can view exactly whenpayments were received andaggregate statement and pay-ment data for more robustreporting.

When providers do elect towork with a third party for theprinting and distribution ofstatements, it’s essential to keepin mind the primary messageof this discussion: Patient state-ments and online payment por-tals should be branded commu-nication mechanisms designedto strengthen the bond betweenpatient and provider.

Technological transformation

The patient billing statementcan drive value for health careproviders and should not beoverlooked. In recent years,technology has transformed thebilling practices in industriesacross the board. Now, healthcare providers who put patientsatisfaction first can reducetheir own costs, improve serv-ice, and increase collectionsfrom self-pay patients.

Brian Kueppers is founder and CEOand Nels Peterson is a sales consultantfor Apex Print Technologies, based in St.Paul.


In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Central Lakes Medical Clinic, a 30-physician multispecialty group and Cuyuna Regional Medical Center, a critical access hospital offering superb new facilities with the latest medical technologies.Outdoor activities abound, and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and cultural activities.

Enhance your professional life in anenvironment that provides exciting practice opportunities in a beautiful Northwood’s setting.The Cuyuna Lakes region welcomes you.

CENTRALLAKES

MEDICAL CLINICP.A.

Contact: Todd Bymark, [email protected](866) 270-0043 / (218) 546-4322 | www.cuyunamed.org

We invite you to explore our opportunities in:

• Family Medicine • Internal Medicine• Emergency Room Medical Director

P A T I E N T P E R S P E C T I V E

In September 2009 I felt anache and pressure in mychest one evening as I walked

home from work. Over the nextcouple of weeks it recurred withmild exertion. At first I thoughtit might be indigestion or theremnants of a bad case of bron-chitis. When it didn’t go away,I went to see my primary caredoctor, who diagnosed my chestpain as angina caused by insuffi-cient oxygen to my heart, andsent me to a cardiologist.

A stress test and an EKGshowed that, not yet 60, I hadhad two nontransmural infarcts.I knew that an infarct was aheart attack, but I did not knowwhat nontransmural meant. Ilearned it means that the dam-age to the heart muscle did notgo all the way through the wallof the heart. “Mild” heartattacks, in other words.

Next I had an angiogramthat showed significant blockage(99 percent and 85 percent) intwo major arteries and lesserblockage (65 percent) in another.My cardiologist wanted to insertstents, but I had reservations,primarily because I know they

can close up again and, even ifthey worked perfectly, wouldrequire me to be on a bloodthinner for the rest of my life.He was not at all open to talkingabout alternatives. He startedme on Lipitor for my cholesterol

and lisinopril for my blood pres-sure. And that was it. If I wantedhis input or help, we’d be talkingstents.

Some years back, I had dis-covered I had borderline highblood pressure. I went to thebookstore (as my wife says I

always do when I’m scared) andlooked around. Dean Ornish’sbook “Dr. Ornish’s Programfor Reversing Heart Disease”caught my eye, and his holisticapproach, which involves a verylow-fat diet, exercise, and stress

management, was very muchto my liking. Unfortunately, Idid not take my conditionseriously enough to followthrough. Now that I had hada much sterner warning, I wentback to the book with renewedcommitment.

But my doctor said the dietwas too difficult, that I wouldn’tbe able to stay with it. He alsoimplied that—despite favorablereports in journals includingJAMA and Circulation, amongothers—he doubted Ornish’sclaim that adherence to the dietcould reverse blockage in thearteries. Then, demonstratingjust how little he understood ofwhat I was saying, the doctorsuggested that I was in denial.I disagreed vehemently, saying Ibelieved I could die at any min-ute. He looked at the angiogramand said, “No, I don’t think so.”Neither of the arteries withmajor blockage was the so-called widow-maker.

Seeking direction

The next two weeks were veryhard. My wife wanted me to dowhatever needed to be done asquickly as possible; if that meantgetting stents, then that’s what Ishould do. I, on the other hand,saw stents as a last-ditch meas-ure. One night it came to a head:We could not go on withoutsome sense of direction. Sud-denly we remembered that

a friend from church was mar-ried to a cardiologist. I calledher and she put her husband onthe phone. He spent the next30 minutes talking to me. Heprescribed metoprolol, a betablocker that lowers blood pres-sure and reduces the heart’smetabolic needs, and nitroglyc-erin, in case I experienced chestpain that didn’t go away, andtold me to call his office for anappointment. His compassionthat night was a godsend.

He gave me another stresstest. This time I did pretty well,with no angina. He reassuredme that my heart was stable andthat I could follow the Ornishprogram if I wished while stay-ing on the prescriptions, whichI was happy to do.

Differing views

Then something unexpectedhappened. Within a couple ofweeks of completing the stresstest without pain, I began tohave serious angina just walk-ing. My new cardiologist’s nursehad told me how to use thenitroglycerin: As soon as I feltchest pain, I was to rest andbreathe deeply for five minutes.If the pain did not stop, I wasto put a nitro tablet undermy tongue and wait five moreminutes.

If the pain continued, Iwas to do it again. If I got to thethird tablet, I was to go to theemergency room.

I never had to take the firsttablet, and because of that Inever thought to report thisdevelopment to my doctor. Overthe next two months I main-tained the Ornish diet, did yoga,meditated, and gradually beganexercising on a stationary bicy-cle, carefully maintaining mylevel of effort so that I experi-enced only mild angina thatquickly went away when Istopped to rest. Gradually, theamount of exercise I could tol-erate increased.

When I eventually told thecardiologist about all this, heseemed disappointed that I hadnot called. The reason, I ex-plained, was that I had read thatthe heart responds to angina bydeveloping new arteries, calledcollaterals, that grow around the

Shareddecision-making

Wary cardiologist, leery patient work it out

By John Malan


Sioux Falls VA Health Care System“A Hospital for Heroes”

Working with and for America’s Veterans is a privilege and we

pride ourselves on the quality of care we provide. In return for

your commitment to quality health care for our nation’s Veterans,

theVA offers an incomparable benefits package.They all come

together at the Sioux Falls VA Health Care System.

www.siouxfalls.va.gov

To be a part of our proud tradition, contact:

Human Resources Mgmt. ServiceP O Box 5046Sioux Falls SD 57117605-333-6852

• Orthopedic Surgeon

• Emergency Department Physician

• Chief of Primary Care

SHARED to page 32

My cardiologist wanted to insert stents,but I had reservations, primarily

because I know they can close up again.


Minneapolis VA Medical CenterMedical Director of Community-Based

Outpatient Clinics

The Minneapolis VA Medical Center (MVAMC), affiliated withthe University of Minnesota, is seeking a dynamic leader for theposition of Medical Director of the Community-Based OutpatientClinics (CBOCs).The Director supervises the clinical operationsand providers of 10 clinics throughout Minnesota andWisconsin,and oversees the development of several new clinics in bothmetropolitan and rural settings.We seek a physician with experi-ence in ambulatory medicine and administration who will pro-vide leadership and clinical duties for the CBOCs.The CBOCsprovide primary care, and mental health care onsite and throughtelemedicine to more than 20,000 veterans.This position wouldinclude an academic appointment at the University of Minnesota.Applicants must be board-certified in Internal Medicine andexperience working inVA facilities is preferred.Competitivesalary, possible recruitment incentive, and benefits with perform-ance pay.

Interested candidates should contact Don Rainwater,413-584-4040, ext. 2907, or [email protected].

Equal Opportunity Employer

Family PracticeUrgent Care

NEW POSITIONS:

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

• Partnership opportunity after 2 years

• Competitive salary with incentives

• Excellent benefits, 401k/employer paid pension

• Practice at one site/one hospital

• Physician-owned

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

1495 Highway 101 North, Plymouth, MN 55447763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

Live in the relaxed lake country of Mille Lacs and practice medicine where you will make a difference.

We’re looking for a Family Physician to join us atMille Lacs Health System in Onamia, Minnesota.

Loan forgiveness options may be available.

Contact: Fern Gershone: [email protected] Dr. Tom Bracken: [email protected]

7 FAMILY PHYSICIANS • 8 PAs • 1 GENERAL SURGEON • CRITICAL ACCESS HOSPITAL

ER STAFFED 24/7 • ATTACHED GERIATRIC UNIT & LTC FACILITY • 4 CLINICS

Caring for body, mind and spirit. Onamia, MN • mlhealth.org • 877 -535-3154

Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional part-time or full-time BC/BE

family medicine physicians to join our primary care team in Sartell,

MN. This is an out-patient only opportunity and does not include

labor and delivery or hospital call and rounding. Our current primary

care team includes family medicine, adult medicine, OB/GYN and

pediatrics. Previous electronic medical record experience is preferred

but not required. We use the Epic electronic medical record system

at all of our clinics and admitting hospitals.

Our HealthPartners Central Minnesota Clinics – Sartell moved

into a new primary care clinic in the summer 2010. We offer a

competitive salary, an excellent benefit package, a rewarding practice

and a commitment to providing exceptional patient-centered care.

St Cloud/Sartell, MN is located just one hour north of the Twin

Cities and offers a dynamic lifestyle in a growing community with a

traditional appeal.

For more information, please contact [email protected] or call Diane at 800-472-4695 x3. EOE

©

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

blockage into the area that is notgetting enough blood flow. Inshort, the heart heals itself.

He offered me a new pillthat would suppress anginaand allow me to be more active.I asked him if this would pre-vent my heart from knowing itneeded to develop collateralsand he said it would. Thus, tak-ing the medication would relievemy symptoms—but thwart theheart’s natural ability to healitself. No thanks, I said.

The central question

While my relationship with thiscardiologist was much moresupportive and open than withmy first cardiologist, we stillstruggled with a fundamentalquestion: Could I improve myheart’s health through lifestylechanges? Or was the best I couldhope for to manage the symp-toms of a sick heart by relyingon traditional medicine?

For me, the necessarychanges in my way of life werenot onerous. We had eaten alargely vegetarian diet for years.The biggest difference in the

Ornish diet was the limit onfats—only 27 grams per day, ofwhich only nine may be saturat-ed. I lost 20 pounds in the firstmonth or so and have never putit back on. Bill Clinton hasrecently done likewise, I hear.

I have a sweet tooth andI was afraid I would not beallowed to satisfy it, but thereare many recipes for low-fatdesserts that use fruit and othercomplex sugars that the dietallows. My other weakness is forthings salty and crunchy. I havehad to accept some loss there,though there are some crackerswith low fat and sodium that Ihave found are quite good whendipped in salsa.

My total cholesterol inJanuary 2010 was 108, wellwithin the desirable range. Wechecked it again in Decemberand it was still 108. The only

concern was that my HDL, the“good” cholesterol, was too low.I am addressing that withOmega 3 supplements. (Omega 3is a naturally occurring lipidthat increases HDL.)

A workable compromise—for now

I have hedged my bets by care-fully following my cardiologist’sinstructions, which his flexibilityhas enabled me to do withoutany major compromises. Sothings have gone well. I am exer-cising four or five times a weeknow and rarely experience anyangina. I continue to believe thatI might be farther along if I hada cardiologist who supported thecomplete Ornish program,which includes group sessions inwhich patients can talk witheach other and a caregiver abouttheir struggles and receive emo-

tional support and encourage-ment, as well as a greater will-ingness to discontinue medswhen it is safe to do so. I plan tovisit an Ornish-friendly cardiolo-gist in Chicago before year’s end.

I once had dinner with aman who told me he had heartdisease with at least one stent,as I recall. He had steak andpotatoes and ordered a side dishof gravy. Even the waitresslooked shocked. He said, “I’ma great believer in pills.” I dounderstand that doctors seemore of this kind of patientthan they do people like me—but I am, as it turns out, aperson like me.

I look forward to the daywhen doctors are trained andsupported in working withpatients who make a seriouseffort to be informed, who arewilling to make significantlifestyle changes, and who wantto be a full partner in theprocess of healing.

John Malan has a desk job in Springfield,Ill., where he is known to the local medicalcommunity as a well-read, engagedpatient with a strong desire to knowwhat’s going on and a strong will to live.


Shared from page 30 I have hedged my bets by carefullyfollowing my cardiologist’s instructions,

which his flexibility has enabled me to dowithout any major compromises.

Boynton Health Service

Welcome to Boynton Health ServicePsychiatrist

(612) 624-1444

and 174055

A Diverse and Vital Health Service


www.olmstedmedicalcenter.org

Olmsted Medical Center,a 150-clinician multi-specialty

clinic with 10 outlyingbranch clinics and a 61 bed

hospital, continues to experiencesignificant growth.

Olmsted Medical Centerprovides an excellent opportunityto practice quality medicine in a

family oriented atmosphere.

The Rochester communityprovides numerous cultural,educational, and recreational

opportunities.

Olmsted Medical Centeroffers a competitive salary

and comprehensivebenefit package.

Send CV to:

OlmstedMedical Center

Administration/Clinician Recruitment

1650 4th Street SE

Rochester, MN 55904

email: [email protected]

Phone: 507.529.6610

Fax: 507.529.6622

EOE

Opportunities availablein the following specialty:

Family MedicineRochester Northwest ClinicRochester Southeast Clinic

St.Charles Clinic

Internal MedicineSoutheast Clinic

Occupational MedicineSoutheast Clinic

DermatologySoutheast Clinic

Connecting your business to your market

Connecting your business to your market

By Robert Sweet, MD“I have prostate cancer

… and I want a robotic

prostatectomy ” This is

a common presenting“chief complaint” heard

nowadays in urologists’

offices across the state

and across the country

If you perform robotic prostatectomy, it

can be a plus in marketing your practice

If you don’t, you either try to convince your

patient that robotic prostatectomy isn’t all

it’s cracked up to be, or you refer him to

someone who does itTo date, removing th

aid of a robot isapplic

figure, given the rela-tively recent adoption

of the robot for use in

clinical applicationsThe rapid growth in

this field promisesto permanently alter

the way surgical proce-

dures—especially mini-

mally invasive surgeries—are perfo

and taughtThe curre

Volume XXI, No.7October 2007


B edside manner may be

viewed as a “soft” skill these

days, and advances in medi-

cine continue to heighten the

emphasis on clinical and technical

expertise But as medicine shifts its

focus to become more patient cen-

tered, patient experience is fast gain-

ing ground as a key measure of qual-

ity In 2004, for example, the U S

Medical Licensing Examination

added a national skills test on per-

sonal interaction and communica-

tion that medical students must pass

to be eligible for licensure And this

year, the National Committee for

Quality Assurance (NCQA) added

“shared decision-making” as one of

seven measures to assess patient

experienceShared decision-making involves

systematic interaction with

to arrive at an infbased o

Talk it outShared decision-making improves

the patient experienceBy Marcus Thygeson, MD,

and Karen Kraemer, RN, CMC

Lending ahandRobotic surgerymakes inroads into the

OR and beyond

Volume XXI, No.8November 2007


Bringing a newmedical deviceto marketThe challengesof picking a winnerBy Curt Miller

in Minnesota Physician

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Two BC/BE Orthopaedic Surgeonswanted to join four orthopaedic sur-geons at Sanford Bemidji OrthopaedicsClinic in Bemidji, Minnesota. Part ofan 85-physician, multi-specialty grouppractice and 118 bed acute care hospi-tal. 1:6 call anticipated. Competitivecompensation/benefits package, paidmalpractice, relocation assistance andmore. Sanford Health of NorthernMinnesota has 1,450+employees andis part of Sanford Health system basedin Fargo, ND and Sioux Falls, SD.

Bemidji, Minnesota, located in north-western Minnesota, is a beautifulresort community offering exceptionalschools, a state university, and year-round cultural activity as well as greataccess to the outdoors for year-roundrecreation activity. To learn moreabout this excellent practiceopportunity contact:

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

Here’s a familiar scenario;A new patient arrives atthe clinic to be seen for

an acute or worrisome condition(in my office, it would be relatedto back and/or neck pain). Uponchecking in, the patient is askedto fill out a written history beforeseeing the physician. Sometimesthe patient manages to do so;sometimes not. Even if thepatient has time to finish fillingout the form before the appoint-ment, he or she may neglect toinclude relevant informationor may provide inaccurate orincomplete information, especial-ly if the patient’s medical historyis complex.

The physician may havetime to glance through the his-tory before entering the room,but it will probably be only acursory review as he or she stepsinto the examining room. Val-uable time may be spent check-ing for accuracy and addingdetails that the patient may haveforgotten to include. Both thephysician and the patient feelrushed and frustrated, since theyboth want the same thing: tofind out what is wrong with the

patient and determine the bestcourse of treatment.

This scenario plays outevery day in medical clinics,from small family practices tomultispecialty facilities to sub-specialty groups. Every physi-cian would agree that there’sno substitute for an accurate,thorough patient history—andevery patient’s medical storyis unique. But patients andphysicians alike are dealingwith busy schedules and com-peting demands on their timeand attention.

In our practice, we havefound a solution to this dilemmaby developing a process inwhich an “interview historian”takes the patient’s history bytelephone several days prior to

the patient’s initial visit. Byimplementing this process, wehave been able to obtain com-plete and accurate informationfrom the patient, especially as itrelates to any condition or injurythat may have occurred as aresult of a motor vehicle acci-dent or a work-related accident,in addition to comprehensivedetail relative to the problemat hand.

We have found that thepre-visit interview enhances theusefulness of the patient history,reduces time spent reviewingand completing the history dur-ing the clinic visit, and increasespatients’ satisfaction with theirhealth care experience.

Managingcomplex information

Our practice began using whatwe called “personal historians”in the mid-1980s. The originalimpetus for the service was aneed to obtain detailed informa-tion for injury cases for whichthe details were often omittedduring a rushed or brief visit.Insurance companies for autoworkers’ compensation, andother professionals such asattorneys, were requesting spe-cific information so that accu-rate and fair decisions could behanded down.

This process eventuallyworked so well in acquiringvaluable information for injurycases that it was gradually incor-porated into the initial evalua-tion for all of our new patients.In its first incarnation, the pre-visit interview began with a tele-phone call to the patient, atwhich time the historian wouldrecord the patient’s history so itwould be available for thepatient’s initial visit with thephysician. Originally, the histor-

The pre-visitinterview

Understanding the patient’s story

By Thomas Rieser, MD


INTERVIEW to page 36

Boynton Health Service

Welcome to Boynton Health Service Medical Director

(612) 626-6738, [email protected]

173177

A Diverse and Vital Health Service


Minneapolis VA Medical CenterPrimary Care Provider

The Minneapolis VA Health Care System(MVAHCS) is seeking a Primary Care Provider.Applicants must be board-certified in internalmedicine.Clinical work involves taking care ofVeterans in the outpatient setting with optionsto do inpatient attending,working with internalmedicine residents.A faculty appointment inthe Department of Medicine at the Universityof Minnesota is possible.Competitive salaryand benefits with potential for a recruitmentincentive.

Send CV and application to:

Human Resources Management ServiceAttention: Brittany Buck

MVAHCSOne Veterans Drive

Minneapolis MN 55417or, email [email protected].

EEO Employer

Lake Region Healthcare is located in a magnificent, rural, andfamily-friendly setting in Minnesota lakes country where we aimto be the state’s preeminent regional health care partner.

Our award winning patient care and uncommon medical special-ties set us apart from other regional health care groups. LakeRegion’s physicians and their families also enjoy an unmatchedquality of professional and personal life.

Current opportunities including competitive salary and benefitpackages available for BE/BC physicians are:

Practice Well.Live Well.

Lake Region Healthcare is an Equal Opportunity Employer. EOE

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

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

www.lrhc.org

• Dermatologist• Family Medicine• General Surgery

• Hospitalist• Internal Medicine• Pediatrics

Urgent Care

We have part-time and on-call positions available at a variety of Twin Cities’ metro areaHealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicineand internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

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

©

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

The perfect match ofcareer and lifestyle.

Affiliated Community Medical Centers is a physician ownedmulti-specialty group with 11 affiliate sites located in westernand southwestern Minnesota. ACMC is the perfect match forhealthcare providers who are looking for an exceptional prac-tice opportunity and a high quality of life.Current opportuni-ties available for BE/BC physicians in the following specialties:

• Family Medicine

• General Surgery• Geriatrician/OutpatientInternal Medicine

• Hospitalist

• Infectious Disease

• Internal Medicine• Oncology

• OrthopedicSurgery

• Pain Management

• Psychiatry

• Pediatrics

• Pulmonary/Critical Care

• RadiationOncology

• Rheumatology

For additional information, please contact:

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

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

www.acmc.com

ian would type up the history,which would be added to theother paperwork in the patient’sfile. Today, the interview isrecorded and transcribed elec-tronically. In today’s health careenvironment, the historian typi-cally works from templates thatare used with electronic healthrecords.

Though the historian asksthe standard health historyquestions, a personal telephoneinterview allows the patient toexpand on and explain his or herparticular history. We are able toobtain information with moreaccuracy and depth as it relatesto the patient’s chief complaint,history of present illness, factorsthat make the problem betterand worse, past medical history,social history, review of systems,and medications. In addition tocompleting the standard historycomponents, the historians areable to more thoroughly recordthe patient’s story in a more per-sonal manner.

The pre-visit interview takesapproximately 30 to 60 minutes,depending upon the complexity

of the case. Over the years, wehave tweaked the process tokeep pace with improvements intechnology and practice man-agement including developmentof templates and electronichealth records. Currently, thehistorian initiates contact via aphone call, usually a few daysprior to the visit. At the time ofthe patient visit, a draft historyhas already been prepared andstored in the electronic healthrecord for the physician(s) toreview in detail with the patientduring the initial patient visit.

Our historians are medicaltranscriptionists who beginworking in our clinic environ-ment to learn the office process.They may perform daily tran-scription for our providers andthen begin to transition intoconducting telephone interviews.Once historians are fully trained,they usually work from theirhomes accessing our electronichealth record via our secure net-work. In order to best meet theavailability of our patients, theirwork hours vary accordingly. Westarted with one historian andnow employ four.

Because the new patientpre-visit interview is considereda part of the in-person new-patient visit, patients are notbilled separately for it. Althoughthis process is more costly toour practice (because we do notcharge separately for this visit),I feel the personal touch that itprovides results in a productthat is superior to the typicalsystem and makes new-patientvisits more efficient and com-fortable for the patient.

Improved patient,physician satisfaction

Patient satisfaction with thepatient pre-visit interviewprocess has been extremely high.Many patients have noted thatthis is the first time that some-one actually talked with themfor an extensive period of timeto listen to their story. We hearover and over again how gratefulthey are that they could have a“live“ conversation about theirhistory and upcoming visit.

The benefits to physiciansand other providers is that thepre-visit interview provides adeeper level of documentation

of the history, condition orinjury, timeliness, and past med-ical information—all of whichare extremely valuable in mak-ing an assessment regardingtreatment. The process also pro-vides for a first visit that engagesthe patient while we review therecorded history in an efficientmanner while verifying its accu-racy with the patient. Using thepre-visit interview streamlinesthe exam without compromisingquality. I believe that this pre-visit interview process can bevery helpful in any other med-ical specialty by providing aneffective, efficient, and meaning-ful use of time and resourcesfor both the patient and theprovider at each new-patientvisit.

Thomas Rieser, MD, is the foundingphysician at Minnesota’s Midwest SpineInstitute, an independent medical clinictreating spinal disease and disorders, andis involved in research on new techniquesand advances in spine care.


Interview from page 34

St. Cloud VA Health Care Systemis accepting applications for the following full or part-time positions:

• Internal Medicine(Alexandria, Brainerd,St. Cloud)

• Family Practice(Alexandria, Brainerd,St. Cloud)

• Psychiatrist (Brainerd,St. Cloud)

• ENT (St. Cloud)

• Geriatrician(Nursing Home—St. Cloud)

• Hematology/Oncology(St. Cloud)

• Neurology (St. Cloud)

• Dermatology (St. Cloud)

• Disability Examiner(IM or FP) (St. Cloud)

• Weekend MedicalOfficer of the Day(IM or FP) (fee for serviceappointment, St.Cloud)

• Medical Director-Extended Care & Rehab(IM or Geriatrics)(St. Cloud)

US Citizenship required or candidates must have proper authorizationto work in the US.

J-1 candidates are now being accepted for the Hematology/Oncology positions.

Physician applicants should be BC/BE. Applicant(s) selected for a position maybe eligible for an award up to the maximum limitation under the provision of theEducation Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including:

Sharon Schmitz ([email protected])4801 Veterans Drive, St. Cloud, MN 56303

Or fax: 320-255-6436 orTelephone: 320-252-1670, extension 6618

Favorable lifestyle26 days vacation

CME daysCompetitive salary

13 days sick leaveLiability insurance

Interested applicants can mail or email your CV to VAHCS

For more information, please contact: Kaitlin Osborn, Allina Physician Recruitment Toll-free: 1-800-248-4921 | Fax: 612-262-4163Email: [email protected]: allina.com/jobsEOE

10127 0811 ©2011 ALLINA HEALTH SYSTEM. ®A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM

Freedom to Careand Freedom to Thrivewith Allina Hospitals & Clinics

We make a di�erence in the lives of our patients,our sta�, and our communities. Physicians can focuson patient care and can professionally thrive in Allina,and the result is the quality of care for which we areknown. We are based in Minneapolis, and havecomprehensive services throughout Minnesotaand in western Wisconsin. Become a part of theAllina team, joined together with a commonpurpose and uncommon caring.


CardiologyDermatologyENTEmergency MedicineFamily MedicineGastroenterologyHospitalistsInternal MedicineNeurologyOccupational MedicineOncologyOrthopedic SurgeryPediatric SpecialtiesPsychiatryPulmonology (Sleep)RheumatologyUrology

Come home.Where organizational strength lies in the diversity of peoplewho call SANFORD HEALTH – home.

Sanford Health – Fargo Regionis redefining health care. Servingnorthwestern Minnesota andeastern North Dakota,we offerinnovative technology, support ofa multi-specialty organization, anddependable colleagues.

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Our employment model featurescompetitive salaries, a comprehensivebenefits package, paid malpracticeinsurance, and a generous relocationallowance.Contact:

Jean KellerPhysician RecruiterPhone: (701) [email protected]

Growing multi-specialty group practicein Northern Minnesota is looking fora BC/BE Family Practice Physician,Internal Medicine Physician,Emergency Room Physician,OB/GYN Physician, Urologist as well asan Orthopaedic Surgeon. Join an existinggroup practice and take over existingpractices from departing physicians. GrandItasca Clinic & Hospital in Grand Rapids,Minnesota has recently opened a new stateof the art clinic & hospital. Excellent salaryguarantee with outstanding incomepotential, full benefits and sign-on bonus.Community located in the beautifulnorthern Minnesota lakes area.

Contact: Gail Anderson(218) [email protected].

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Look for thefriendly doctorin a MN based

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Opportunities to fit your lifeFairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Shape your practice to fit your life as a part of our nationally recognized, patient-centered, evidence-based care team.

Whether your focus is work-life balance or participating in clinical quality initiatives, we have an opportunity that is right for you:

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

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(see definition below). Thedisclosure must also include adescription of the organization-al structure of each additionaldisclosable party to the facilityand the relationship of eachsuch additional disclosableparty to the facility and to oneanother.

The ACA defines “additionaldisclosable party” to mean anyperson or entity who exercisesoperational, financial, or mana-gerial control over all or a partof a facility, or provides finan-cial or cash management ser-vices to the facility; leases orsubleases property to the facil-ity, or owns a whole or partinterest of at least 5 percent ofthe value of the property; orprovides management or admi-nistrative services, managementor clinical consulting services,or accounting or financial ser-vices to the facility.

This definition, construedbroadly, could include not onlyindividuals and entities with anownership interest in or opera-tional control of a facility, but

also nearly any other person ororganization that contracts withthe SNF or NF to provide serv-ices or supplies—whether foodservice, housekeeping, account-ing, or pharmacy services.With this expanded scope ofdisclosure, there is potential for“additional disclosable par-ties”—even those without oper-ational control of the facility—to be named as parties in litiga-tion against a nursing facility,since the information willbecome public record and avail-able to plaintiffs’ counsel. Finalregulations, which may helpclarify this issue, are due by nolater than March 23, 2012.

Mandatory complianceprograms and qualityimprovement plans. The ACArequires nursing homes toestablish compliance and ethicsprograms. Compliance plansmust be effective in preventingand detecting criminal, civil,and administrative violationsand in promoting quality ofcare. Forthcoming regulationsfrom HHS may include a modelcompliance plan.

The ACA requires thatHHS publish regulations byDec. 31, 2011, that establishstandards relating to qualityassurance and performanceimprovement for nursinghomes. Within a year afterthese regulations are published,nursing homes will be requiredto submit to HHS their plansfor meeting the standards.

Incentives for home andcommunity-based services

Medicaid has traditionally paidfor long-term care services forlow-income Americans in insti-tutional settings such as nurs-ing homes. Effective October 1,2011, states will have the optionto offer home and community-based services and supports toMedicaid beneficiaries whowould otherwise require a levelof care offered in a hospital,nursing facility, or intermediatecare facility for the mentallyretarded (ICF/MR). States thatchoose this option (called theCommunity First Option) willbe eligible for a federal matchof an additional 6 percent for

reimbursable expenses in theprogram.

The ACA also removes bar-riers to home- and community-based services by allowingstates to provide more types ofsupport services (such as homehealth visits, adult day care,training in life skills, and dura-ble medical equipment) througha state Medicaid plan ratherthan through waivers. Minne-sota has been a leader in usingwaivers to provide home andcommunity-based services tothe elderly and disabled, so itwill be interesting to see howMinnesota takes advantage ofthis new funding opportunity.

Sarah Duniway, JD, and Gregory A.Larson, JD, are principals in the law firmof Gray Plant Mooty. They specialize inworking with nonprofit organizations andhealth care providers.


Changes from page 21

education that measurably improves patient care healthpartnersIME.com

Pediatric Conferences • Best Practices – Managing the Pediatric Patient in the Urgent Care Setting October 28, 2011• Pediatric Update: Beyond the Basics October 29, 2011

12th Annual Women’s Health Conference November 4, 2011Emergency Medicine and Trauma Update: Beyond the Golden Hour November 17, 2011Otolaryngology for Primary Care November 18, 201133rd Annual Cardiovascular Conference December 1-2, 2011Fundamental Critical Care Support February 23 - 24 and July 19-20, 2012Dermatology for Primary Care February 24, 201226th Annual Family Medicine Today March 8- 9, 201230th Annual OB/Gyn Update April 12-13, 2012The Mind of a Child: Psychiatric Challenges for Today’s Youth April 19, 2012

Psychiatry Update: Selected Topics for the Non-Psychiatrist April 20, 2012

continuing medical education

You wouldn’t give a 4-year-old a drink, so why would you give one to an unborn child?

As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy.

Share 049: Zero Alcohol For Nine Months.

www.mofas.org

You’re always there for them.

We’re always here for you.

We have defended and supported the individual needs of health professionals for more than 30 years. And nobody is more personally

committed to protecting you from the risks you face every day.

To learn more, call 800-328-5532 or visit MMICGroup.com

Protecting Your Peace of Mind

YoYY urMind

Documents

Minnesota Physician October 2011