Minnesota Physician November 2013

One team, one billComprehensive care for knee surgery

By Owen R. O’Neill, MD

Physician-owned practices are adapting to the challenges of health care reform that stress the provision of high-quality care at lower cost with improved patient satisfaction. Twin Cities Orthopedics, a large physi-

cian-owned practice that has been in business for over 60 years, set out to further explore ways to innovate and lead in the evolving health care delivery system that would do just that. The resulting TCO Excel Surgery & Recovery Program, which offers a bundled price for knee replacement surgery, has

Screening for risky substance use to page 12

One team, one bill to page 10

Vo lume x x V i i , N o. 8N ove mb e r 2013

Screening for risky substance use Clinics implement a new model in primary care

By Pam Pietruszewski, MA

During the past five years, more than 80 Minnesota primary care clinics have implemented the DIAMOND

program (Depression Improvement Across Minnesota, Offering a New Direction) to treat patients with depression. In 2011, the Insti-tute for Clinical Systems Improvement (ICSI), in partnership with the Pittsburgh Regional Health Initiative and the Wisconsin Collabo-rative for Healthcare Quality, received a $3.5 million grant from the Agency for Healthcare Research and Quality. The goals of the grant were to combine the evidence-based “Screen-ing, Brief Intervention and Referral to Treat-ment” (SBIRT) program with the DIAMOND program to screen patients for risky alcohol or drug use, as well. As part of the grant, all three partners helped primary care clinics in their states to train clinic staff, build patient and community awareness of the underserved conditions, develop patient registries to track patients progress, and support sustainability for the model.

During the past two years, ICSI has helped 34 primary care clinics in Minnesota im-

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our ad-dress is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email [email protected]. We welcome the submission of manuscripts and letters for pos-sible publication. All views are opinions expressed by authors of published articles are solely those of the authors and do not neccessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publications. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business or other professional advice and counsel. No part of the publication may be reprinted or reproduced within written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

November 2013 • Volume XXVII, No. 8

Features

Departments

SpecIal focuS: RuRal health

Crossing the shaky bridge 20By Terry J. Hill, MPA, and Eric Shell, CPA, MBA

Southern Prairie 22 Community CareBy Keith Halleland, JD, and Mary Fischer, MSW

Community health 24 needs assessmentBy Colleen Spike, RN, and Mary Hildebrandt, PHN

Teleradiology 26By Nihar Shah, MD

co Nte NtS

capSuleS 4

MedIcuS 7

INteRVIew 8 Jeffrey Tucker, EFPMIntegrity Health Network, LLC

ModelS of caRe 16Turning health programming inside out By Emily Karlen, MPT

ophthalMology 18Keratoconus By Sumitra S. Khandelwal, MD, and Sherman W. Reeves, MD, MPH

phySIcal MedIcINe/ 30 RehabIlItatIoN Cognition and cancer By Nancy Hutchison, MD, and Mary V. Radomski, PhD, OTR/L

letteRS 38 By Thomas C. Votel, MD

oNe teaM, oNe bIll 1Comprehensive care for knee surgeryBy Owen R. O’Neill, MD

ScReeNINg foR RISky 1 SubStaNce uSeClinics inplement a new model in primary careBy Pam Pietruszewski, MA

November 2013 MINNESOTA PhySIcIAN 3

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

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

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

MINNESOTA HEALTH CARE ROUNDTABLE

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

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

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Post-acute careFixing cracks in the systemThursday, April 17, 20141:00–4:00 PM, Symphony Ballroom

Downtown Minneapolis Hilton and Towers

FORTy-FIRST SESSION

Allina, Children’s Mother Baby Center ExpandsAllina Health and Children’s Hospitals and Clinics of Minne-sota has announced an expan-sion of the Mother Baby Center with a 50,000-square-foot addition at Coon Rapids-based Mercy Hospital. The two- story addition will incorporate a single-story clinic that is part of the current complex.

According to Allina officials, plans for the addition include two operating rooms, 13 labor/delivery/recovery rooms, eight special care nursery rooms, 19 postpartum rooms, and a sky-way that will connect to Mercy Hospital operating rooms.

The Coon Rapids City Coun-cil approved the site plan at a meeting on Oct. 1. Construction is scheduled to begin in Decem-ber and will be completed in late March or early April 2015, according to Jennifer Olson, executive director and vice pres-ident of operations at Mother

Baby Clinical Service Line of Children’s Hospitals and Clinics of Minnesota.

Minnesota Hospital Association Gets Safety FundingThe U.S. Centers for Medicare & Medicaid Services (CMS) has awarded the Minnesota Hospital Association (MHA) Hospital Engagement Network (HEN) $4.5 million. It is one of six hospital engagement net-works to be selected to develop and share new strategies and outcomes with hospitals across the nation after competing in the federal Partnership for Patients program.

The U.S. Department of Health and Human Services created the Partnership for Patients program in 2011 to im-prove health care quality, safety, and affordability with specific goals to decrease preventable hospital-acquired conditions by 40 percent and hospital 30-day

readmissions by 20 percent.

MHA HEN and the other networks will use this funding to develop advances for severe sepsis and septic shock, clos-tridium difficile (C. diff), and iatrogeneic delirium. They will also focus on increasing the safety of workers and hospital culture and reducing the num-ber of hospital-acquired condi-tions and readmissions.

U of M, Harvard Unite Against Diabetic Kidney DiseaseThe National Institutes of Health has awarded the Univer-sity of Minnesota and Harvard University $24.3 million to study a potential treatment for kidney disease in patients who have type 1 diabetes. The universities will partner on the five-year clinical trial, which is a part of the Preventing Early Renal Function Loss in Diabe-tes (PERL) consortium.

Researchers will evaluate

the possible benefits of allopuri-nol, an FDA-approved drug that can lower uric acid, in reduc-ing kidney function loss. Past studies from the Joslin Diabetes Center and other sources have linked high levels of uric acid to an increased risk of kidney complications in people with diabetes.

The trial will be led by Michael Mauer, MD, professor of pediatrics and medicine at the University of Minnesota Medical School, and Alessan-dro Doria, MD, PhD, MPH, associate professor of medicine at Harvard Medical School and associate professor in the Department of Epidemiology at the Harvard School of Public Health. Luiza Caramori, MD, MSc, PhD, assistant professor of medicine and pediatrics at the University of Minnesota Medical School, will direct the study.

“Data indicates that moder-ately high serum uric acid levels predispose to diabetic kidney disease. However, we don’t know whether this is due to uric acid itself or to something else

4 MINNESOTA PHySICIAN November 2013

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that goes together with it. That’s why this study is important—to determine if uric acid is the culprit or not,” says Doria.

An estimated 500 patients with type 1 diabetes and a high-er risk of losing kidney func-tion will take part in the trial. For three years, half will take allopurinol, while the other half take a placebo. Research will be done at institutes in the PERL consortium, including the University of Minnesota. Participant recruitment could begin as early as this October, officials say.

“If we see a benefit of allo-purinol on slowing progression of diabetic kidney disease, this will become a standard addi-tion to the treatment of diabetic kidney complications, espe-cially given that allopurinol is relatively inexpensive and safe,” says Caramori.

Results of Sentinel Node Surgery Study Reported in JAMAA procedure called sentinel lymph node surgery can iden-tify if cancer remains in the lymph nodes of patients with node-positive breast cancer after chemotherapy, according to results of a study conducted through the American College of Surgeons Oncology Group.

The majority of breast cancer patients whose disease has spread to their lymph nodes have surgery to remove most of the lymph nodes in their armpit area after chemotherapy to determine if cancer is still present. Sentinel lymph node surgery is less invasive, remov-ing only a few lymph nodes that are the most likely to contain cancer. This lessens the chanc-es of surgical complications like numbness and arm swelling, according to Judy Boughey, MD, a breast surgeon at Mayo Clinic.

“Since treatment with chemotherapy before surgery can eliminate cancer in the lymph nodes in some patients, we were interested in evalu-ating whether sentinel lymph node surgery could success-fully identify whether cancer remained in the lymph nodes after chemotherapy,” says Boughey.

Researchers studied 756 women with node-positive breast cancer who had under-gone chemotherapy treatment. Of these, 637 had both axil-lary and sentinel lymph node surgeries. The new, less invasive option accurately determined the presence of cancer in 91 percent of women in the study, including 255 with node-neg-ative breast cancer and 382 with continuing node-positive disease.

The study had a false nega-tive rate of 12.6 percent, which was substantially lower when dual tracers, blue dye, and radiolabeled colloid were used to identify sentinel lymph nodes. When two or more sentinel lymph nodes were removed, the rate dropped below 10 percent. Full results of the study were published online in the Oct. 9 issue of JAMA.

Mankato Nurses, Mayo Reach AgreementAfter five months of negotia-tions, 470 nurses represent-ed by the Minnesota Nurses Association (MNA) at Mayo Health Systems Clinic agreed to a new three-year contract at the Mankato hospital, averting a possible strike. Changes in contract terms address quality of care for patients and give nurses more input on staffing levels, schedules, and workload without fear of retaliation, MNA officials say.

An MNA statement said the nurses were working to gain the power to make bed-side decisions about patient care, stop patient intake when patient volumes were getting to a point they weren’t com-fortable with, and review the hospital’s staffing models under the acuity-based care system it is moving to. They also wanted training for the charge nurses whose job it is to assess patients in the acuity system. The issues gained community attention at meetings, public events, and an informational picket outside the hospital on Sept. 17.

“We’ve got the words that will guide hospital practices toward safe staffing, but we still need a commitment from Mayo

November 2013 MINNESOTA PHySICIAN 5Capsules to page 6

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•Developing strategies to leverage exciting new opportunities: Accountable Care Organizations, MedicalHome,BasketsofCare

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Our Independent physicians keep hometown healthcare where it belongs.

“The time they save me meeting reporting requirements allows me to spend

more time with patients.”– Christopher Wenner, MD, Clinic Owner

Integrity Health Network member, Cold Spring

Mankato before we can all rest easy that all patients are being properly cared for,” said Chad Weiler, RN, co-chair of the bar-gaining unit and member of the MNA negotiations committee.

“We look forward to the pos-itive, professional, and solution- based input from our nurses and all our staff members, as we work in the best interest of our patients, their families, the communities we serve and the sustainability of our organiza-tion,” said Ryannon Frederick, RN, chief nursing officer for Mayo Clinic Health System in southwest Minnesota.

New Cleaning Method Comes to FairviewFairview Southdale Hospital will soon become one of the first hospitals in Minnesota to use cleaning robots that emit ultraviolet (UV) light rays to disinfect patients’ rooms and bathrooms, operating rooms,

and staff locker rooms. On Oct. 9, the Edina hospital joined more than 100 hospitals in the U.S. that are already using the new cleaning technology.

The robots, which cost $80,000 each, use pulsed xenon UV light that is 25,000 times more powerful than the sun to eliminate harmful bacteria, bacteria spores, viruses, and fungi on all surfaces in a room and in the air. “We will still do our complete, hands-on clean-ing routine,” says Courtney Nel-son, director of environmental services at Fairview Southdale. “But this additional step will allow us to reach places that are very challenging to disinfect manually, such as the ceiling.”

Here’s how it works: After standard cleaning procedures are complete, a portable robot is brought into the room, posi-tioned on one side of the bed, and set to begin the automated cleaning sequence. Once com-plete, the process is repeated on the other side of the bed and in the bathroom. The total cleaning time for one room is 15 minutes. Because the robots

use UV light rays, there is no chemical residue.

According to officials, the technology is effective against even the most threatening pathogens, including Clostridi-um difficile (C. diff), norovirus, influenza, and staph bacteria, including methicillin-resistant staphylococcus aureus (MRSA).

Use of the robot necessitates caution, however, as people cannot be in the room while the machine is operating. Hospi-tals place warning signs on the doors of rooms while they are being cleaned, and a motion sensor on the robot will auto-matically disable the machine if anyone enters the room.

Regions Hospital Reduces Unneeded Blood TransfusionsRegions Hospital recently announced that a technology they have used since 2011 has reduced blood transfusions by about 14 percent, or 94 units

per month. The hospital’s pathology department devel-oped and implemented the decision-support tool for its electronic medical record in partnership with the American Red Cross to improve appropri-ate use of red blood cells based on the latest evidence-based clinical guidelines.

The program reduced the hemoglobin trigger, the point at which doctors begin a trans-fusion, to levels below 7 g/dl. When transfusions are needed, they are initiated at cautious levels of about one unit at a time.

According to a 2012 analysis of blood use at 464 hospitals, more than 802,000 units of blood and $165 million in costs could be saved annually if every hospital in the U.S. adopted these evidence-based best practices.


Capsules from page 5

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Yun Shin Chun, MD

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Medicus

Yun Shin Chun, MD, FACS, has joined Allina Health’s Virginia Piper Cancer Institute, Minneapolis, as a staff surgeon and medical director of hepato-pancreato-biliary programs. Previously a staff surgeon and assistant professor at Fox Chase Cancer Center, Philadelphia, she graduated from New York Medical College, received general surgery training at Mayo Clinic, and completed a surgical oncology fellowship at M.D. Anderson

Cancer Center, Houston.

Sanjay Chaudhary, MD, has joined the Critical Care department at Essentia Health–St. Mary’s Medical Center, Duluth. Board-certified in internal medicine and nephrology, he earned a medical degree from B.P. Koirala Institute of Health Sciences in Dharan, Nepal, and served a residency in internal medicine at Creighton University Medical Center, Omaha.

He completed fellowships in nephrology and critical care medicine at Mayo Clinic. Swati Prasad, MD, a hospitalist, has also joined Essentia Health–St. Mary’s Medical Center, Duluth. She graduated from Nepal Medical College, Kathmandu, and served an internal medicine residency at Creighton University Medical Center, Omaha.

David Rothenberger, MD, assumed the role of head of the University of Minnesota Department

of Surgery in October. He graduated from Tufts University School of Medicine, Boston; completed a general surgery residency at St. Paul–Ramsey Hospital; and completed a fellowship in colon and rectal surgery at the University of Minnesota. Previously, he held the John P. Delaney Chair of Clinical Surgical Oncology at the University of Minnesota, where he had been the deputy chairman of the department of surgery since 2006. Joseph Westermeyer, MD, PhD, has received the R. Brinkley Smithers Distinguished Scientist Award from the American Society of Addiction Medicine. Chief of psychiatry services at Minneapolis Veterans Administration Health Care System and a professor of psychiatry at the University of Minnesota, Westermeyer completed medical school and psychiatry residency at the University of Minnesota.

Imran Khawaja, MD, has been named medical director of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center (HCMC). He earned a medical degree from King Edward Medical University,

Lahore, Pakistan; completed a psychiatry residency at New York Medical College, Valhalla, N.Y.; and completed a sleep medicine fellowship at Mayo Clinic. Previously, Khawaja practiced psychiatry and sleep medicine at the Minneapolis Veteran’s Administration Medical Center. Christine Tompkins, MD, has joined HCMC’s pediatrics department. She graduated from the University of Nebraska Medical Center, Omaha; completed a pediatrics residency at

the University of Connecticut, Farmington; and completed a pediatrics fellowship at Brown University, Providence, R.I. James Wetmore, MD, has joined HCMC’s nephrology department. He graduated from University of Texas Southwestern Medical School, Dallas; completed an internal medicine residency at University of Alabama, Birmingham; and served a nephrology fellowship at University of California, San Francisco.

November 2013 MINNESOTA PHYSICIAN 7

Please tell us about the background and mission of Integrity Health Network.

We are a merger (2010) of two long-standing names in the health care marketplace: North-star Physicians Network (formed in 1985) and Northland Medical Associates (formed in 1979). Our mission is to provide an innovative model of care inspired by and centered on our patients. We believe in providing a balanced marketplace through competition.

What are some of the biggest challenges you face?

We face state and federal health reform that favors—in fact, seems to force—consolidation in the marketplace, creating fewer and fewer huge corporate health care systems and reducing com-petition in the marketplace. The ramifications of this include the possibility of losses of innova-tion, increased costs due to decreased competi-tion, and a loss of choices for care.

What does “independent practice” mean?

Independent practice, by our definition, is any provider or facility that has the desire to remain independent of the large corporate health care systems and exercise a degree of control over their own future. It means that decisions are made in the exam room, not the boardroom.

Simply stated, independent practice means that one or more physicians have decided to practice the way medicine has traditionally been practiced—that is, unconstrained by the demands of a larger organization, which would otherwise employ the physician and/or providers. Though each practice may work in collaboration with other medical entities, decision-making, especially as it pertains to patient treatment and referrals to other physicians, is not dictated by a large corporate organization. The result is that independent practitioners often have much greater latitude in terms of treatment and refer-ral options than do employed physicians. This can be particularly important in cases where a corporate administrator insists on referrals to a financially productive but professionally substandard physician within a closed system. It means the freedom to always focus on what is best for patients.

What are the best improvements the Integrity Health Network model can bring to health care delivery?

We bring collaboration and an unrelenting pur-suit of quality. This means not bought-and-paid-for quality like some systems are content doing through expensive magazine ads, but actual patient-centered quality focused on better care and higher patient satisfaction.

What are some of the differences between health care delivery in the outstate areas vs. the metro area?

In the metro area you generally have various specialties within a much smaller radius than in outstate or rural areas, where we rely on tele-medicine and shared recruitment of specialties to try to fill community health needs.

What is your opinion of state govern-ment’s role in rural health care policy?

Policy and legislation, beginning in 2007–2008, have heavily favored large systems; small orga-nizations and independent practices have been faced with many challenges in response to this. Any government role in health care delivery should be kept at a supportive and advisory level. There is no question that health care has its share of challenges, but legislating improve-ment has not been the best answer. Instead of getting help in understanding the problems and then support in resolving them from within, health care has been handed a book of rules and restrictions that are in some cases unclear, and has been told, “Figure this out and make it work,” with the not-so-subtle undertone of “or else we’ll do it for you.” Sadly, this has extended even higher, to the federal level, as well.

How will MNsure (the state’s online health exchange) affect health care delivery in greater Minnesota?

Anecdotally, we are hearing about employee hours being cut and the need for patients to take on more jobs to make ends meet. We are also seeing large payers focus on narrow networks and signing with only one or two large health systems and leaving other providers out. We are looking at the very real possibility of loss of com-mercial insurance enrollees and a substantial in-

8 MINNeSOTA PhySIcIAN November 2013

IntervIew

Jeffrey Tucker, EFPM

Integrity Health Network, LLC

Jeffrey Tucker has worked in health care administration for nearly 25 years. he has been

ceO and president of Integrity health Network since 2010. his experience has included health plan negotiations and

contract administration, man-agement, budgeting and finan-cial management, investment

management, quality improve-ment and pay-for-performance programs, care coordination

oversight, marketing, and out-reach. In his work in develop-

ing clinic and hospital net-works, Tucker has also focused on electronic health records, e-clinics, e-commerce, elec-

tronic prescribing, and finding ways technology can facili-

tate greater communication: between physicians, between physicians and hospitals, and

between providers and patients.

Upholding the independent practice

flux of medical assistance patients. This places stress on the limited resources available in the smaller communities and possibly will not cover the costs of providing care to the expanded population.

Large health systems are absorbing more and more rural clinics and hospitals into their organizations. What impact do you see this having on the cost and quality of care in rural areas?

Large systems are focused on market share rather than patient care. Large health systems enter rural communities and acquire small physician practices. This leads to fewer choices for patients, both in the primary care setting and the specialty care setting, as large systems refer to physicians they employ. As the large health systems gain market share, it leads to increased rates for consum-ers, insurance companies, and government payers because the large health system has great leverage with the payers. It is hard to negotiate with the only game in town.

Large systems also tend to lose focus on the individual commu-nities they serve. Often, patient care decisions are dictated from a management team at the system headquarters 100 miles away; it is presumed that all clinics and hospitals are the same. clinics and hospitals should focus on the needs of their communities; not every community has the same challenges.

The best improvement potential and cost management occur at the independent provider level. Physicians who have a vested interest in their own practices have incentives at both the health outcome and the cost outcome levels. Improvement in both is best achieved with a change of culture, not a change of owner-ship. These physicians are not only able to apply change more

readily, but they also are usually more willing to do so.

The impact we have seen has been a transition of the acquired hospital into a triage point for shipping patients to the parent organization’s city-based hospital. Among the clinics themselves, once acquired, we have seen hemorrhaging in the departure of the providers (seeming to run across the age spectrum) who were long-time members of the community.

Where do you see the future of rural medicine in Minnesota going?

Until recently it appeared the future of rural medicine was being usurped by large health systems where physicians were being re-placed by mid-levels and community hospitals were being acquired for use as triage points before shipment to a metro area for care. We’re seeing a backlash in communities against this model as they realize they want and deserve care—and a voice—in their own community. We are returning to the days when providers actu-ally looked at putting up their own shingle and practicing how and where they wanted. The number of calls we have received in this regard has been substantially higher in the past six months than in the previous couple of years.

So the trend for larger systems to purchase rural clinics has led to dissatisfaction on the part of providers in those clinics, with the loss of autonomy in both clinical practice and administrative philosophy. Alternatively, there has been some success in integrat-ing rural clinics with local, community hospitals. Perhaps a more palatable option for the independent providers who own their prac-tices, both specialty and primary care, is to work in closer collabo-ration with local hospitals, but retain independence.

November 2013 MINNeSOTA PhySIcIAN 9

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exceeded all expectations— and points the way toward the future of health care delivery.

In June 2012, TCO launched a pilot for the Excel program. As of September 2013, the program had served 35 patients. The comprehensive program cares for patients having an out-patient total knee replacement, from pre-surgery through re-covery post-surgery, all for one price. What sets the program apart from other approaches are two key components: com-prehensive care and bundled payment.

Integrated, comprehensive care

A unique aspect of the Excel program is the comprehensive, all-inclusive nature of the care. Patients are supervised by a complete medical team—a sur-geon, an internal medicine phy-sician, and an orthopedic nurse

practitioner—with a shared goal of providing seamless, coordi-nated care.

The Excel program is de-signed for young, healthy and active individuals who don’t have other serious medical issues that might require a hospital stay. We estimate that about 30 percent of all total

knee arthroplasty patients would be candidates for the program. (Patients requiring a higher level of care, such as a cardiology consult, would not be candidates for the Excel program.) After a patient is accepted into the program, a consulting nurse practitioner guides him or her through the

entire experience, from the initial surgical consultation through aftercare in one of the program’s specially designed orthopedic recovery suites.

Currently, surgery takes place at Twin Cities Orthope-dics’ Crosstown Surgery Center. Four hours following surgery, the patient is transported in

a medi-van to nearby York Gardens in Edina. There, the patient is taken to a private recovery suite equipped with many of the amenities of home, such as a flat-screen TV and a kitchenette. Caregivers and family are encouraged to visit at any time of day and are also welcomed to stay with the pa-tient. Patients in the orthopedic recovery suites have 24-hour medical care; the surgeon, internal medicine physician, and program nurse practitioner make daily rounds. In addition, continuous care is provided by subspecialty trained orthopedic nurses and the rehabilitation facility is within steps of their suite.

“Our goal with Excel is for the patient to anticipate every single step,” says Justi-na Lehman-Lane, DNP, who oversees the program. “We want our patients to know what is coming next.” She ensures that every patient has her cellphone number, adding, “We’re like the small-town clinic.”

The recovery suites are another innovative aspect of the Excel program. Though some surgical centers across the country outsource recov-ery to hotels, a hotel room can feel almost as impersonal as a hospital, and certainly doesn’t meet the sanitary qualifications or the on-site medical rehabil-itation that the Excel program offers.

Troy Simonson, CEO of Twin

Cities Orthopedics, notes that this model allows the practice to “control what the nursing staff is doing at York Gardens, how the pre-operation teach-ing is done, how prepared the patients are coming in to it, and how the physical therapy is going to be done. All of the nurses and therapists have been

trained by us, and we designed the clinical pathways they follow. They spend time in the surgery center so they understand the entire patient experience. Every-one is on the same team.”

Sharelle Peterson, an athlete and knee replacement patient, says the Excel program was far more comforting and inviting than a hospital stay. “Being part of the Excel program, I was able to stay in a place where I didn’t feel sick. I was there because I was recovering. The environment was much more comfortable than the hospital, and I received assistance when I needed it much quicker than my hospital experiences in the past. I also saw my surgeon every day.”

The financial model

The bundled, all-inclusive price package for the Excel program also sets it apart from alterna-tives. In contrast to the tradi-tional financial model, where a patient may receive eight to ten bills for a knee surgery, patients in the Excel program receive a single bill. And that one single bill covers the entire facility cost and health care team—sur-geon, care team, and internal medicine doctors—that pro-vides support, education, and care throughout the process.

The bill also includes sur-gery and recovery costs, and as many physical therapy sessions as needed. The use of the dedi-cated orthopedic recovery suite, rather than in-hospital recovery, has reduced costs—by up to 50 percent in some cases—while elevating the patient experience. A traditional knee replacement

10 MINNESOTA PhYSICIAN November 2013

What sets the program apart are two key components: comprehensive care and

bundled payment.

One team, one bill from cover

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One team, one bill to page 37

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November 2013 Minnesota Physician 11

plement this integrated, care manager model (elements of DIAMOND plus SBIRT). Since these clinics had extensive experience with DIAMOND, a key focus of the grant work in Minnesota was to determine the impact of adding substance use to the care model.

Interest in the SBIRT program

SBIRT is an early intervention designed to provide screening, brief behavior change interven-tions using motivational inter-viewing, and referral to formal addiction treatment when needed. Clinics added SBIRT for several reasons:

• Minnesota ranks sixth na-tionally for binge drinking.

• Risky alcohol and drug use are among the top four contributors to chronic diseases.

• Care managers see a high incidence of risky sub-stance use in patients with depression.

• Many of the clinics already had established a care management-based model. A DIAMOND care team is composed of the pri-mary care physician; a care manager who reg- ularly contacts the patient and coordinates their care; and a consulting psychia-trist who works with the care manager and recom-mends changes for patients not improving.

• Clinics wanted to de-termine how handling multiple behavioral health conditions would affect patient care and care man-ager productivity.

“The main benefit of screen-ing for risky substance behav-iors is to prevent patients from getting chronic illnesses such as cardiovascular disease, can-

cer, and diabetes,” said Mark Bixby, MD, North Memorial Health Care. “Through earlier identification, we can change a patient’s behavior before he or she becomes seriously ill.”

For Kristin Somers, MD, a psychiatrist at Mayo Clinic, combining elements of SBIRT

and DIAMOND fit with Mayo’s desire to be innovative in integrating behavioral health into primary care. “Adding this component enhances our health care home and makes our clinic unique,” she said.

Implementation

With the integrated model, patients typically are screened before they see their physician. The PHQ-9 (Patient Health Questionnaire—nine questions) is used to identify depression, while the Alcohol Use Disorders Identification Test (AUDIT) or Drug Abuse Screening Test (DAST-10) is used to screen for alcohol or drug use.

If a patient is positive for one or more of these conditions, the primary care physician is informed. He or she recom-mends the appropriate care plan and introduces the patient to a care manager, who typical-ly has a background in nursing, social work, psychology, or as certified medical assistants. The care manager becomes the patient’s primary contact for education, care coordination, and follow-up.

The care manager provides routine follow-up to repeat the PHQ-9 and enters the patient’s data each time into a registry. Using the registry, the consult-ing psychiatrist and the care manager review a patient’s progress each week. If a patient is not improving, the psychi-atrist might recommend a change to treatment. The care manager relays the recom-mendation to the primary care physician, who has ultimate

responsibility for the care plan. Roughly 30 percent of patients with depression receiving this type of care are in remission by six months.

Screening for substance use indicates if a patient is at low, medium, or high risk. Most receive a brief intervention in

which the care manager edu-cates the patient on the health risks and uses motivational interviewing to help the patient set goals for behavioral change. If a patient has possible abuse or dependence issues, he or she is referred to additional resources.

Changing roles and workflow

“Adding screening for substance use increased the work for our DIAMOND care managers,” said Mary Lou Oman, RN, psy-chiatric nurse consultant, who helps to oversee 15 care manag-ers for Entira Family Clinics.

Although care managers find their caseloads need to be decreased in order to address multiple conditions, physicians support the additional screen-ing, and management for sub-stance misuse. “Our traditional care has almost been hyphen-ated by the requirements of time,” said Jeffrey Virant, MD, Stillwater Medical Group. “We acknowledge that an illness has stolen the patient’s motivation and hope, and yet we give them a pill and say, ‘Call us in four weeks.’ We lose a lot of patients at that point. Now, I rely on my care manager to help the patient put one foot in front of the other. This is really valuable.”

Challenges and lessons learned

There are challenges to imple-menting the integrated model, but participating clinics are learning how to address them


Clinics indicated that the factors making depression care successful in primary care also

apply to risky substance use treatment.

Screening for risky substance use from cover

Screening for risky substance use to page 36


Victoza® is a registered trademark of Novo Nordisk A/S.© 2013 Novo Nordisk All rights reserved. 0513-00015590-1 June 2013

Indications and UsageVictoza® (liraglutide [rDNA origin] injection) is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.Because of the uncertain relevance of the rodent thyroid C-cell tumor fi ndings to humans, prescribe Victoza® only to patients for whom the potential benefi ts are considered to outweigh the potential risk. Victoza® is not recommended as fi rst-line therapy for patients who have inadequate glycemic control on diet and exercise.Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis has been observed in patients treated with Victoza®. Victoza® has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at increased risk for pancreatitis while using Victoza®. Other antidiabetic therapies should be considered 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.Victoza® has not been studied in combination with prandial insulin.

Important Safety InformationLiraglutide causes dose-dependent and treatment-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 fi ndings 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.Do not use in patients with a prior serious hypersensitivity reaction to Victoza® (liraglutide [rDNA origin] injection) or to any of the product components.Postmarketing reports, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis. Discontinue promptly if pancreatitis is suspected. Do not restart if pancreatitis is confi rmed. Consider other antidiabetic therapies in patients with a history of pancreatitis.When Victoza® is used with an insulin secretagogue (e.g. a sulfonylurea) or insulin serious hypoglycemia can occur. Consider lowering the dose of the insulin secretagogue or insulin to reduce the risk of hypoglycemia.Renal impairment has been reported postmarketing, usually in association with nausea, vomiting, diarrhea, or dehydration which may sometimes require hemodialysis. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment.Serious hypersensitivity reactions (e.g. anaphylaxis and angioedema) have been reported during postmarketing use of Victoza®. If symptoms of hypersensitivity reactions occur, patients must stop taking Victoza® and seek medical advice promptly.There have been no studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.The most common adverse reactions, reported in ≥5% of patients treated with Victoza® and more commonly than in patients treated with placebo, are headache, nausea, diarrhea, dyspepsia, constipation and anti-liraglutide antibody formation. Immunogenicity-related events, including urticaria, were more common among Victoza®-treated patients (0.8%) than among comparator-treated patients (0.4%) in clinical trials.Victoza® has not been studied in type 2 diabetes patients below 18 years of age and is not recommended for use in pediatric patients.There is limited data in patients with renal or hepatic impairment.

Please see brief summary of Prescribing Information on adjacent page.

* Victoza® 1.2 mg and 1.8 mg when used alone or in combination with OADs. † Victoza® is not indicated for the management of obesity, and weight change was a secondary end point in clinical trials.

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14 Minnesota Physician November 2013

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

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-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 carci-noma (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 glycemic 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. Based on spon-taneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis has been observed in patients treated with Victoza®. Victoza® has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at increased risk for pancreatitis while using Victoza®. Other antidiabetic therapies should be considered 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 prandial insulin has not been studied.CONTRAINDICATIONS: Do not use in patients with a personal or family history of medullary thyroid car-cinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Do not use in patients with a prior serious hypersensitivity reaction to Victoza® or to any of the product components.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 rele-vant 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 receiving 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. In the clinical trials, there have been 6 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 2 cases in comparator-treated patients (1.3 vs. 1.0 cases per 1000 patient-years). One 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. Five of the six Victoza®-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One Victoza® and one non-Victoza®-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 refer-ence 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 frequently 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 consistent 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 calcitonin <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, calci-tonin 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 ultra-sound 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 evaluation. 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. Pancreati-tis: Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis, has been observed in patients treated with Victoza®. After initiation of Victoza®, observe patients carefully for signs and symp-toms 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 sus-pected, Victoza® should promptly be discontinued and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Consider antidia-betic therapies other than Victoza® in patients with a history of pancreatitis. In clinical trials of Victoza®, there have been 13 cases of pancreatitis among Victoza®-treated patients and 1 case in a compara-tor (glimepiride) treated patient (2.7 vs. 0.5 cases per 1000 patient-years). Nine of the 13 cases with Victoza® were reported as acute pancreatitis and four were reported as chronic pancreatitis. In one case in a Victoza®-treated patient, pancreatitis, with necrosis, was observed and led to death; however clinical causal-

ity could not be established. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) or insulin may have an increased risk of hypoglycemia. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea (or other concomitantly administered insulin secretagogues) or insulin 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. 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. Some of the reported events occurred in patients receiving one or more medications 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 caus-ative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Hypersensitivity Reactions: There have been postmarketing reports of serious hyper-sensitivity reactions (e.g., anaphylactic reactions and angioedema) in patients treated with Victoza®. If a hypersensitivity reaction occurs, the patient should discontinue Victoza® and other suspect medications and promptly seek medical advice. Angioedema has also been reported with other GLP-1 receptor agonists. Use caution in a patient with a history of angioedema with another GLP-1 receptor agonist because it is unknown whether such patients will be predisposed to angioedema with Victoza®. Macrovascular Outcomes: There have been no clinical studies establishing conclusive 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 com-pared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® has been evaluated in 8 clinical trials: A double-blind 52-week monotherapy trial com-pared Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, and glimepiride 8 mg daily; A double-blind 26 week add-on to metformin trial compared Victoza® 0.6 mg once-daily, Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, placebo, and glimepiride 4 mg once-daily; A double-blind 26 week add-on to glimepiride trial compared Victoza® 0.6 mg daily, Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, placebo, and rosiglitazone 4 mg once-daily; A 26 week add-on to metformin + glimepiride trial, compared double-blind Victoza® 1.8 mg once-daily, double-blind placebo, and open-label insulin glargine once-daily; A double-blind 26-week add-on to metformin + rosiglitazone trial compared Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily and placebo; An open-label 26-week add-on to metformin and/or sulfonylurea trial compared Victoza® 1.8 mg once-daily and exenatide 10 mcg twice-daily; An open-label 26-week add-on to metformin trial compared Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, and sitagliptin 100 mg once-daily; An open-label 26-week trial compared insulin detemir as add-on to Victoza® 1.8 mg + met-formin to continued treatment with Victoza® + metformin alone. 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 double-blind 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. In these five trials, 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. Common adverse reactions: Tables 1, 2, 3 and 4 summarize common adverse reactions (hypoglycemia is discussed separately) reported in seven of the eight controlled trials of 26 weeks duration or longer. Most of these adverse reactions were gastrointestinal in nature. In the five double-blind clinical trials of 26 weeks duration or longer, gastrointestinal adverse reactions were reported in 41% of Victoza®-treated patients and were dose-related. Gastrointestinal adverse reactions occurred in 17% of comparator-treated patients. Common adverse reactions that occurred at a higher incidence among Victoza®-treated patients included nausea, vomiting, diarrhea, dyspepsia and constipation. In the five double-blind and three open-label clinical trials of 26 weeks duration or longer, the percentage of patients who reported nausea declined over time. In the five double-blind trials approximately 13% of Victoza®-treated patients and 2% of comparator-treated patients reported nausea during the first 2 weeks of treatment. In the 26-week open-label trial comparing Victoza® to exenatide, both in combination with metformin and/or sulfonylurea, gastrointestinal adverse reactions were reported at a similar incidence in the Victoza® and exenatide treatment groups (Table 3). In the 26-week open-label trial comparing Victoza® 1.2 mg, Victoza® 1.8 mg and sitagliptin 100 mg, all in combination with metformin, gastrointestinal adverse reactions were reported at a higher incidence with Victoza® than sitagliptin (Table 4). In the remaining 26-week trial, all patients received Victoza® 1.8 mg + metformin during a 12-week run-in period. During the run-in period, 167 patients (17% of enrolled total) withdrew from the trial: 76 (46% of withdrawals) of these patients doing so because of gastrointestinal adverse reactions and 15 (9% of withdrawals) doing so due to other adverse events. Only those patients who completed the run-in period with inadequate glycemic control were randomized to 26 weeks of add-on therapy with insulin detemir or continued, unchanged treatment with Victoza® 1.8 mg + metformin. During this randomized 26-week period, diarrhea was the only adverse reaction reported in ≥5% of patients treated with Victoza® 1.8 mg + metformin + insulin detemir (11.7%) and greater than in patients treated with Victoza® 1.8 mg and metformin alone (6.9%).Table 1: Adverse reactions reported in ≥5% of Victoza®-treated patients in a 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248Adverse Reaction (%) (%)Nausea 28.4 8.5Diarrhea 17.1 8.9Vomiting 10.9 3.6Constipation 9.9 4.8Headache 9.1 9.3

Table 2: Adverse reactions 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 Reaction (%) (%) (%)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 Reaction (%) (%) (%)Nausea 7.5 1.8 2.6Diarrhea 7.2 1.8 2.2

VICU3X1334_ISI_Update_A_Size_Ad_BS_r6.indd 1 5/31/13 12:48 PM


Constipation 5.3 0.9 1.7Dyspepsia 5.2 0.9 2.6

Add-on to Metformin + GlimepirideVictoza® 1.8 + Metformin

+ Glimepiride N = 230Placebo + Metformin + Glimepiride N = 114

Glargine + Metformin + Glimepiride N = 232

Adverse Reaction (%) (%) (%)Nausea 13.9 3.5 1.3Diarrhea 10.0 5.3 1.3Headache 9.6 7.9 5.6Dyspepsia 6.5 0.9 1.7Vomiting 6.5 3.5 0.4

Add-on to Metformin + RosiglitazoneAll Victoza® + Metformin +

Rosiglitazone N = 355Placebo + Metformin + Rosiglitazone

N = 175Adverse Reaction (%) (%)Nausea 34.6 8.6Diarrhea 14.1 6.3Vomiting 12.4 2.9Headache 8.2 4.6Constipation 5.1 1.1

Table 3: Adverse Reactions reported in ≥5% of Victoza®-treated patients in a 26-Week Open-Label Trial versus Exenatide

Victoza® 1.8 mg once daily + metformin and/or sulfonylurea

N = 235

Exenatide 10 mcg twice daily + metformin and/or sulfonylurea

N = 232Adverse Reaction (%) (%)Nausea 25.5 28.0Diarrhea 12.3 12.1Headache 8.9 10.3Dyspepsia 8.9 4.7Vomiting 6.0 9.9Constipation 5.1 2.6

Table 4: Adverse Reactions in ≥5% of Victoza®-treated patients in a 26-Week Open-Label Trial versus Sitagliptin

All Victoza® + metformin N = 439

Sitagliptin 100 mg/day + metformin N = 219

Adverse Reaction (%) (%)Nausea 23.9 4.6Headache 10.3 10.0Diarrhea 9.3 4.6Vomiting 8.7 4.1

Immunogenicity: Consistent with the potentially immunogenic properties of protein and peptide pharma-ceuticals, patients treated with Victoza® may develop anti-liraglutide antibodies. Approximately 50-70% of Victoza®-treated patients in the five double-blind clinical trials of 26 weeks duration or longer were tested for the presence of anti-liraglutide antibodies at the end of treatment. Low titers (concentrations not requiring dilution of serum) of anti-liraglutide antibodies were detected in 8.6% of these Victoza®-treated patients. Sampling was not performed uniformly across all patients in the clinical trials, and this may have resulted in an underestimate of the actual percentage of patients who developed antibodies. Cross-reacting anti-liraglutide antibodies to native glucagon-like peptide-1 (GLP-1) occurred in 6.9% of the Victoza®-treated patients in the double-blind 52-week monotherapy trial and in 4.8% of the Victoza®-treated patients in the double-blind 26-week add-on combination therapy trials. These cross-reacting antibodies were not tested for neutralizing effect against native GLP-1, and thus the potential for clinically significant neutralization of native GLP-1 was not assessed. Antibodies that had a neutralizing effect on liraglutide in an in vitro assay occurred in 2.3% of the Victoza®-treated patients in the double-blind 52-week monotherapy trial and in 1.0% of the Victoza®-treated patients in the double-blind 26-week add-on combination therapy trials. Among Victoza®-treated patients who developed anti-liraglutide antibodies, the most common category of adverse events was that of infections, which occurred among 40% of these patients compared to 36%, 34% and 35% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. The specific infections which occurred with greater frequency among Victoza®-treated anti-body-positive patients were primarily nonserious upper respiratory tract infections, which occurred among 11% of Victoza®-treated antibody-positive patients; and among 7%, 7% and 5% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. Among Victoza®-treated antibody-negative patients, the most common category of adverse events was that of gastrointestinal events, which occurred in 43%, 18% and 19% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. Antibody formation was not associated with reduced efficacy of Victoza® when comparing mean HbA1c of all antibody-positive and all antibody-negative patients. However, the 3 patients with the highest titers of anti-liraglutide antibodies had no reduction in HbA1c with Victoza® treatment. In the five double-blind clinical trials of Victoza®, events from a composite of adverse events potentially related to immunogenicity (e.g. urticaria, angioedema) occurred among 0.8% of Victoza®-treated patients and among 0.4% of comparator-treated patients. Urticaria accounted for approximately one-half of the events in this composite for Victoza®-treated patients. Patients who developed anti-liraglutide antibodies were not more likely to develop events from the immunogenicity events composite than were patients who did not develop anti-liraglutide antibodies. Injection site reactions: Injection site reactions (e.g., injection site rash, erythema) were reported in approximately 2% of Victoza®-treated patients in the five double-blind clinical trials of at least 26 weeks duration. Less than 0.2% of Victoza®-treated patients discontinued due to injection site reactions. Papillary thyroid carcinoma: In clinical trials of Victoza®, there were 7 reported cases of papillary thyroid carcinoma in patients treated with Victoza® and 1 case in a comparator-treated patient (1.5 vs. 0.5 cases per 1000 patient-years). Most of these papillary thyroid carcinomas were <1 cm in greatest diameter and were diagnosed in surgical pathology specimens after thyroidectomy prompted by findings on protocol-specified screening with serum calcitonin or thyroid ultrasound. Hypoglycemia: In the eight clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 11 Victoza®-treated patients (2.3 cases per 1000 patient-years) and in two exenatide-treated patients. Of these 11 Victoza®-treated patients, six patients were concomitantly using metformin and a sulfonylurea, one was concomitantly using a sulfonylurea, two were concomitantly using metformin (blood glucose values were 65 and 94 mg/dL) and two were using Victoza® as monotherapy (one of these patients was undergoing an intravenous glucose tolerance test and the other was receiving insulin as treat-ment during a hospital stay). For these two patients on Victoza® monotherapy, the insulin treatment was the likely explanation for the hypoglycemia. In the 26-week open-label trial comparing Victoza® to sitagliptin,

the incidence of hypoglycemic events defined as symptoms accompanied by a fingerstick glucose <56 mg/dL was comparable among the treatment groups (approximately 5%).Table 5: Incidence (%) and Rate (episodes/patient year) of Hypoglycemia in the 52-Week Monotherapy Trial and in the 26-Week Combination Therapy Trials

Victoza® Treatment Active Comparator Placebo ComparatorMonotherapy Victoza® (N = 497) Glimepiride (N = 248) NonePatient not able to self−treat

0 0 —

Patient able to self−treat 9.7 (0.24) 25.0 (1.66) —Not classified 1.2 (0.03) 2.4 (0.04) —Add-on to Metformin Victoza® + Metformin

(N = 724)Glimepiride +

Metformin (N = 242)

Placebo + Metformin (N = 121)

Patient not able to self−treat

0.1 (0.001) 0 0

Patient able to self−treat 3.6 (0.05) 22.3 (0.87) 2.5 (0.06)Add-on to Victoza® + Metformin

Insulin detemir + Victoza® + Metformin

(N = 163)

Continued Victoza® + Metformin alone

(N = 158*)

None


0 0 —

Patient able to self−treat 9.2 (0.29) 1.3 (0.03) —Add-on to Glimepiride

Victoza® + Glimepiride (N = 695)

Rosiglitazone + Glimepiride (N = 231)

Placebo + Glimepiride (N = 114)


0.1 (0.003) 0 0

Patient able to self−treat 7.5 (0.38) 4.3 (0.12) 2.6 (0.17)Not classified 0.9 (0.05) 0.9 (0.02) 0Add-on to Metformin + Rosiglitazone

Victoza® + Metformin + Rosiglitazone

(N = 355)

None

Placebo + Metformin + Rosiglitazone

(N = 175)Patient not able to self−treat

0 — 0

Patient able to self−treat 7.9 (0.49) — 4.6 (0.15)Not classified 0.6 (0.01) — 1.1 (0.03)Add-on to Metformin + Glimepiride

Victoza® + Metformin + Glimepiride

(N = 230)

Insulin glargine + Metformin +

Glimepiride (N = 232)

Placebo + Metformin + Glimepiride

(N = 114)Patient not able to self−treat

2.2 (0.06) 0 0

Patient able to self−treat 27.4 (1.16) 28.9 (1.29) 16.7 (0.95)Not classified 0 1.7 (0.04) 0

*One patient is an outlier and was excluded due to 25 hypoglycemic episodes that the patient was able to self-treat. This patient had a history of frequent hypoglycemia prior to the study.In a pooled analysis of clinical trials, the incidence rate (per 1,000 patient-years) for malignant neoplasms (based on investigator-reported events, medical history, pathology reports, and surgical reports from both blinded and open-label study periods) was 10.9 for Victoza®, 6.3 for placebo, and 7.2 for active comparator. After excluding papillary thyroid carcinoma events [see Adverse Reactions], no particular cancer cell type predominated. Seven malignant neoplasm events were reported beyond 1 year of exposure to study medica-tion, six events among Victoza®-treated patients (4 colon, 1 prostate and 1 nasopharyngeal), no events with placebo and one event with active comparator (colon). Causality has not been established. Laboratory Tests: In the five clinical trials of at least 26 weeks duration, mildly elevated serum bilirubin concentrations (elevations to no more than twice the upper limit of the reference range) occurred in 4.0% of Victoza®-treated patients, 2.1% of placebo-treated patients and 3.5% of active-comparator-treated patients. This finding was not accompanied by abnormalities in other liver tests. The significance of this isolated finding is unknown. Vital signs: Victoza® did not have adverse effects on blood pressure. Mean increases from baseline in heart rate of 2 to 3 beats per minute have been observed with Victoza® compared to placebo. The long-term clinical effects of the increase in pulse rate have not been established. Post-Marketing Experience: The following additional adverse reactions have been reported during post-approval use of Victoza®. Because these events are reported voluntarily from a population of uncertain size, it is gener-ally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure: Dehydration resulting from nausea, vomiting and diarrhea; Increased serum creatinine, acute renal failure or worsening of chronic renal failure, sometimes requiring hemodialysis; Angioedema and anaphylactic reactions; Allergic reactions: rash and pruritus; Acute pancreatitis, hemorrhagic and necrotizing pancreatitis sometimes resulting in death.OVERDOSAGE: Overdoses have been reported in clinical trials and post-marketing use of Victoza®. Effects have included severe nausea and severe vomiting. In the event of overdosage, appropriate supportive treat-ment should be initiated according to the patient’s clinical signs and symptoms.More detailed information is available upon request. For information about Victoza® contact: Novo Nordisk Inc., 800 Scudders Mill Road, Plainsboro, NJ 08536, 1−877-484-2869Date of Issue: April 16, 2013 Version: 6Manufactured by: Novo Nordisk A/S, DK-2880 Bagsvaerd, DenmarkVictoza® is covered by US Patent Nos. 6,268,343, 6,458,924, 7,235,627, 8,114,833 and other patents pending. Victoza® Pen is covered by US Patent Nos. 6,004,297, RE 43,834, RE 41,956 and other patents pending.© 2010-2013 Novo Nordisk 0513-00015681-1 5/2013

VICU3X1334_ISI_Update_A_Size_Ad_BS_r6.indd 2 5/31/13 12:48 PM

The health care landscape is changing, and the need to deliver greater value in

health care has never been more urgent. To deliver greater value, our clinical programming needs to evolve from the provider- and patient-centric models of the past and present, respectively, to a population-centric approach. Such an approach delivers high-er value care by making a given population’s values the corner-stone of medical care programs.

This article discusses key factors contributing to the current state of health care delivery; a proposed evolution in care delivery; an orthopedic population-centric quality ini-tiative; and how physicians can accelerate the evolution to pop-ulation-centric programming in their practices.

Barriers to advancing health care deliveryFour key factors contribute to the current barriers to improv-

ing health care delivery.

Unsustainable cost increases. According to CMS’ “National Health Expenditures Projections 2011–2021” report, total health care spending in the United States is expected to consume nearly 20 percent of our economy, or $4.8 trillion, by 2021, up from $2.6 trillion in 2010. Although the rate of increase has slowed in the past decade, it continues to be well above the rate of inflation. If the price of a dozen eggs in 1945

had climbed at the same rate as health care costs, today those eggs would cost $55.

Care resourced for revenue rather than value. In the quest for higher revenues, traditional fee-for-service reimbursement rewards both excessive and costly treatments. As an ex-ample, in 2009 Health Affairs journal reported that increases in medical practices’ ownership of MRI equipment are related to higher use of both MRIs and surgeries for people with low back pain (LBP). Additionally, specialist compensation often reflects the potential of a partic-ular specialty to drive revenue; consequently, more providers are drawn into the high reve-nue–producing specialties.

It is not surprising that back pain patients and their primary care providers often report hav-ing reasonable access to spine surgeons (whose average annual compensation is $688,503, according to the American Medical Group Association), but very limited access to psychol-ogists (annual compensation of $68,640, according to the U.S. Bureau of Labor). Imbalances such as these do not meet the needs of the LBP population. Only 1 percent to 2 percent of people seeking medical care for LBP will have surgery, accord-ing to the American Academy of Orthopedic Surgeons, but up to 77 percent of people with chronic LBP also have a psy-chiatric diagnosis (excluding somatoform pain disorder), according to Spine journal.

Inconsistent application of evidence-based best-practice medicine. Over the past decade, Health Affairs reports, just

over 50 percent of American and European medical practi-tioners followed care guidelines. Individuals will vary in clinical presentation, but evidence sup-ports improved outcomes when guidelines are followed.

Outdated expectations. Communities expect health care providers to deliver better health. In the latter half of the 20th century, this expectation was reasonable; physicians had conquered top causes of death such as pneumonia, tubercu-losis, and diarrhea. However, since the late 1990s, at least 60 percent of all deaths are due to poor lifestyle choices, such as inactivity, poor diet, and smok-ing. When individual behaviors account for such a high percent-age of our health, it is unrea-sonable to expect that health care providers alone will restore complete health. For that, we must look to the individual, with the support of the commu-nity, in partnership with health care providers.

Evolution in care deliverySince doing “more of the same” will not lead to delivering higher value care, and some current health-care program strategies will not deliver higher value quickly enough, Fair-view’s system-wide orthopedic programming has evolved to a population-centric approach. In delivering quality programming through this lens, many of our initiatives have been able to simultaneously deliver higher quality of care and better popu-lation health while also reduc-ing the cost to the community.

Many providers have already moved beyond the provider- centric care model and into delivering patient-centric care. They acknowledge that pro-viding access to health care requires extended evening and weekend office hours, and that some patients may want their care delivered in a retail store rather than a clinic.

Population-centric program-ming requires us to look beyond the care we deliver to individ-ual patients and consider new avenues for improving health


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in a population. For example, seeing an opportunity to im-prove the health of its employee population, Fairview Physician Associates provided additional refrigerators so that employees could store healthy lunches rather than rely on the nearby fast-food restaurants.

Financial goals also must shift in order to deliver higher value care. Past care models, based on fee-for-service reim-bursement, would often focus financial goals on generating revenue (e.g., How many sur-geries would have to be done in order hit a certain revenue target?). Following this mod-el, spine surgeries were often financial drivers for hospitals. This approach, illustrated by the funnel in Figure 1, shows that to increase the health system’s sur-gical volume to 600 procedures would require a market share of 300,000 people.

As reimbursement tight-ened over the years, health care systems began to focus more on reducing “costs,” defined as the

health care system’s resources needed to deliver a service (e.g., How can we reduce length of stay for hospital patients billed under a particular diagnosis-related group [DRG]?).

Population-centric pro-gramming looks at financial opportunity from a different perspective. We invert the fun-nel, and add other information that reflects the patient’s and community’s values (see Fig. 2). For example, knowing that conservative care often provides

comparable outcomes for many people with low back pain, the health system sees financial opportunity by noting the num-ber of people with chronic low back pain and aiming to more quickly and effectively manage their symptoms, with the goal of preventing disability and any clinically inappropriate surger-ies. This approach adds higher value care through improving quality outcomes and reducing cost. In population-centric pro-gramming, “cost” is defined as the community’s resources con-sumed when a service is deliv-ered. It considers indirect costs, like lost work days, in addition to the community’s direct costs.

In addition to redefining cost, population-centric care requires redefining quality. Many existing care models de-fine quality by safety or process measures that serve to meet regulatory needs. In popula-tion-centric programming, quality is measured by the population’s values. For many patients, safe care is assumed; the fundamental value of the

care lies in being able to return to the lives they had before becom-ing ill or injured. In health care, short- and long-term function-al out-comes or

quality of life indexes often best capture these values. Table 1, on page 28, illustrates this evolu-tion toward population-centric health care delivery.

A population-based program in action In its programming for the hip and knee replacement popula-tion, Fairview sought feedback from key community stakehold-ers and orthopedic experts. For this population, pain manage-ment is critical both for patient satisfaction and for progres-

sion of recovery. When pain is poorly managed, the health care delivered is of lower value, with lower community satisfaction and higher costs.

Many surgeons and nurs-es from both the clinic and hospital perioperative teams commented that they can easily identify patients preoperatively who will not respond well to the standard pain management in-terventions following these pro-cedures. Bringing together the

clinic and hospital teams, we created a new service, Preop-erative Pain Consults (POPCs), for patients at the University of Minnesota Medical Center. This service allowed surgeons to re-fer patients at high risk for poor postoperative pain management to Fairview Pain Management Center for a consult two weeks prior to surgery. The consult results in a pain management plan to be initiated in recovery and then maintained by an inpatient pain specialist during

November 2013 MINNESOTA PHySICIAN 17

Figure 1. Low-back surgery funnel of the past.

Low Back Cost Funnel:

300,000People

100,000with LBP

57,000Chronic

LBP

36,000Seeking Care

600Surgeries

Figure 2. Low-back-pain population funnel.

Low Back Population Funnel:

600Surgeries

2,400Hospitalized

3,000Completely

Disabled

4,000WorkComp

36,000Seeking Care

53,000Work

Limited

57,000Chronic

LBP

100,000withLBP

300,000People

Turning health programming inside out to page 28

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Keratoconus is one of the most common causes of full-thickness cor-

neal transplants in the United States. Keratoconus is a non-inflammatory ectatic disorder of the cornea characterized by a slowly progressive loss of corneal strength, with thinning and warpage of the cornea into a cone-like shape (see Fig. 1). This coning and thinning of the cornea causes high levels of ir-regular astigmatism to develop, often complicated by central corneal scarring. Historical-ly, there has been no cure for keratoconus. Instead, treatment has focused on rehabilitation of vision, typically with specially fitted hard contact lenses. One of five patients with keratoco-nus would progress to such severity of disease that corneal transplantation was required to restore sight.

Within the past decade, a new corneal treatment has rev-olutionized the care of kerato-conus and other corneal ectatic

disorders. Corneal crosslinking (CXL), developed by researchers at the University of Dresden, Germany, is the first therapy shown to halt the progression of this disease and even to im-

prove vision. In this treatment, riboflavin is applied topically on the eye and is absorbed by the

cornea. Ultraviolet light is then used to excite the riboflavin, releasing oxygen free radicals and causing increased covalent bonds to form between corneal collagen fibers.

Results from multiple clini-cal trials across the U.S. and in other countries have shown that the resulting increase in corneal strength gained by crosslinking can halt the disease and possi-bly make corneal transplanta-tion unnecessary.

Corneal ectasia

Corneal ectasia is a broad term encompassing several diseas-es that cause thinning and steepening of the cornea. The most common corneal ectatic disorders include keratoconus, pellucid marginal degeneration, and ectasia after LASIK. All of these disorders, which may represent a spectrum of the same disease, result in warpage of the corneal shape and induce irregular astigmatism. Irregular astigmatism results in high lev-els of visual blur and is not cor-rectable with spectacles or soft contact lenses, which can only correct astigmatism that is reg-ular and symmetric. Thus, these patients often require specially fitted hard contact lenses such as gas-permeable contact lenses and scleral contact lenses.

Ectatic disorders of the cor-nea, such as keratoconus, are typically progressive conditions and bilateral in nature, though the two eyes may be affected

asymmetrically. Heredity plays some role in acquisition of the disease, though its development appears to be multifactorial and poorly understood. Multiple as- sociations with other diseas-es exist, the most common of which is atopy. Atopic patients, who often suffer from concur-rent allergic conjunctivitis, may precipitate or worsen underly-ing corneal ectatic tendencies by frequent eye rubbing.

Two concerning issues in keratoconus are the progression of the disease and the patient population. The onset of the dis-ease occurs in young patients, sometimes in the early teenage years. Patients are usually diagnosed only when their vision can no longer be fully corrected with glasses, prompt-ing more complete ophthalmic evaluation and imaging of the corneal shape. The disease pro-gression typically follows one of two courses: either a rapid progression to severe levels of visual impairment or a more in-dolent course, where functional vision is retained throughout life. Most progression occurs when patients are in their 20s and 30s, and tends to slow and stabilize when they are in their 40s and 50s as some aging- related crosslinking of the cor-neal fibers occurs.

In patients with severe ectasia or keratoconus-related corneal scarring, full-thick-ness corneal transplantation by penetrating keratoplasty (PK) may be required for visual rehabilitation. Though PK is potentially sight-saving, visual recovery from this procedure can take up to a year or more and often still requires the use of hard contact lenses for best vision. Furthermore, significant morbidity can occur from the surgery, including cataract, glaucoma, and rejection epi-sodes of the transplanted tissue. Such an arduous postoperative process can cause significant hardship in the young patient population, limiting employ-ment and recreation during this time frame. Additionally, the five-year survival rate of a corneal graft in the setting of keratoconus is 80 percent. Thus,

18 MInnESOTA PHySICIAn November 2013

OphthalmOlOgy

Keratoconus Corneal collagen-crosslinking

advances treatment

By Sumitra S. Khandelwal, MD, and Sherman W. Reeves, MD, MPH

Corneal crosslinking, developed by researchers at the University of Dresden, Germany, is the first therapy shown to halt the progression of

this disease and even to improve vision.

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most young corneal transplant patients can expect multiple transplant surgeries in their lifetime. Finally, patients with transplanted eyes face a lifetime of possible complications such as infection due to immunosup-pression related to chronic use of topical steroid drops; graft rejection; and potentially dev-astating graft dehiscence from even mild trauma to the eye.

Corneal crosslinking

Corneal crosslinking (CXL) was first reported in the 1990s at the University of Dresden. The initial efficacy and safety of crosslinking with riboflavin and UV light was demonstrat-ed in rabbit and porcine eyes. Encouragingly, these models also showed that the therapy was not toxic to other parts of the eye, so long as the cornea was of a certain minimal initial thickness.

Since the publication of the initial work, multiple human studies have echoed these results. Randomized controlled trials in keratoconus patients have shown stabilization and even improvement in the corneal shape in treated eyes compared to non-treated eyes, which continued to have ectatic progression. Long-term studies have also shown that improve-ment in the corneal shape may even continue for several years after the initial crosslinking treatment.

The introduction of crosslinking to the arma-mentarium of keratoconus treatment has also spurred investigation into combining crosslinking with other corneal therapies. One such therapy combines crosslinking with the placement of Intacs intra-corneal ring segments. The Intacs device has shown effica-cy in helping to reshape highly irregular corneas to which hard contact lenses can no longer be fitted. When combined with crosslinking, the Intacs proce-dure may result in even greater flattening of the central cornea in keratoconus, increasing corneal stability in comparison with the Intacs procedure alone.

In addition, there is ongoing investigation into combining laservision correction therapy, such as topography-guided photorefractive keratecto-my, with crosslinking in eyes manifesting early keratoco-nus. Though keratoconus has previously been an absolute contraindication to laser vision correction, the corneal stabili-ty gained by crosslinking may allow these eyes to be treated with advanced excimer laser ablations. The combination of these therapies may neutralize the irregular astigmatism of keratoconus, potentially restor-ing vision without the use of hard contact lenses.

Early detection

The advent of corneal collagen-crosslinking has made early diagnosis of keratoconus even more important, given that a therapy is now available to stop further ectatic progression. Corneal imaging technology has also advanced rapidly in the last decade, allowing earlier detection of corneal ectasia, though the initial change in a patient’s vision is still the usual precipitat-ing event for further medical in-vestigation of corneal shape.

Corneal topography is the primary method of assessing the stage and severity of keratoconus; it provides a topo- graphic map of the cornea that shows areas of relative steep-ness or flatness compared to normal. Corneal tomographic

imaging gives additional infor-mation about regional corneal thickness abnormalities, and has been extremely useful in conjunction with topography for detecting early corneal ectatic change (see Fig. 2, on page 29). Both of these corneal imaging modalities are also used to follow keratoconic corneas after crosslinking treatment, and often show improvement in the topography weeks or months before the patient realizes any

vision im-provement.

The ability of tomogra-phy and topography

to help diagnose keratoconus at a very early stage may allow patients who have minimal keratoconus symptoms but are at high risk for progression, earlier access to crosslinking and, therefore, to avoid future ectasia-related comorbidities.

Figure 1. The photograph shows bulging of the cornea, consistent with keratoconus. Photo courtesy of David Hardten MD.

Keratoconus to page 29

A new corneal treatment has revolutionized the care of keratoconus

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Federal health care re-form, passed in March 2010, has brought sweep-

ing changes to the american health care industry. Medicaid expansion, health insurance exchanges, accountable care or-ganizations, health information exchanges, and a host of other initiatives have either been introduced already or will be rolled out in the next few years.

as a result of this market- based transition from pay for volume to pay for value, health care providers must provide better care and better popula-tion health, at a lower cost to patients, third-party payers, and the broader U.s. economy. the formula, based on the institute for health improve-ment’s triple aim, is: Better Quality + improved Population health = Value.

this massive system change is putting intense pressure on rural hospitals and clinics to adapt to the new environment

or risk becoming obsolete.

to survive in the current (volume-based payment) system while preparing to do well in the future (value-based pay-ment) system, rural hospitals

and critical access hospitals (cahs) will need to cross the

shaky bridge from the past era of health care to a future era fraught with uncertainty and challenges. charging across the bridge too quickly might result in a tragic fall, possibly even

organizational death; neglect-ing to prepare to cross safely, taking steps that are too tenta-tive, or staying in place until it is too late to move forward may prove equally disastrous.

this article looks at the im-pact of health reform on rural health providers, as well as what providers can do now to prepare for the new health care reform models and value based reimbursement—and to take the first step across that shaky bridge.

ACOs and rural providers

among the most important factors driving health reform is the rapid expansion of ac-countable care organizations (acos) across the country. the emergence and growth of acos is a direct result of the deteri-oration of the fee-for-service-based payment system. More than 300 acos may have been certified by Medicare by the end of 2013, with many similar models emerging from state Medicaid programs and private insurance providers. the polit-ical reform has already led to market reform momentum that will not be deterred by politi-cal elections or federal policy changes.

the acos developed to date have been fairly evenly divided between those that are hospital led, and those led by physician groups. the aco requirement for at least 5,000 Medicare patients has resulted in most acos serving urban areas, but they have steadily expanded into rural areas. a new national rural hospital aco is currently under development, but only a handful of certified rural acos have emerged to date.

in June 2013, more than 4 million Medicare beneficia-ries, or about 11 percent of the total Medicare fee-for-service beneficiaries, were receiving health care through acos, and the number was expected to in-crease rapidly. the aco model is heavily based on primary care coordination, medical homes, and patient-centered care coordination, with chronic illness management, preven-tion, and wellness as other notable features.

the expansion of acos will have significant implications for all providers. Value-based purchasing programs, for example, will shift payments from low-performing hospitals to high-performing hospitals. acute care hospitals with high-er than expected risk-adjusted readmission rates will receive reduced Medicare payments for every discharge. Physician payments will also be modified, based on performance against quality and cost indicators.

the future value of rural hospitals lies partially in their relationships with local primary care physicians, and par-tially in the hospitals demon- strating high efficiency and quality. in this regard, they must achieve and publicly report high-quality outcomes and must closely monitor and actively pursue quality goals. they will also be challenged to coordinate care effectively and achieve high patient-satisfac-tion scores.

Recent studies have demon-strated that critical access hos-pitals provide care to Medicare beneficiaries at a cost slightly lower than their urban coun-

Special focuS: RuRal health

Crossing the shaky bridge

The challenge for rural hospitals in a value-based future

By Terry J. Hill, MPA, and Eric Shell, CPA, MBA

This system change is putting intense pressure on rural hospitals and clinics to adapt to the new environment or risk becoming obsolete.

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terparts. cahs also have the financial advantage of receiving cost-based reimbursement and may also have access to feder-al, state, and private grants. in contrast to the historic incen-tives to bring rural patients into large hospitals for treatment, we expect that large health systems and acos, in search of cost savings and value, will eventually try to drive low-acu-ity patients and other business to cahs. this will be good news for rural provider. But in the short term, rural hospitals must meet numerous challeng-es that will severely test their resiliency. these include:

• Recruiting and retaining the primary care physi-cians (PcPs) needed to serve the growing num-ber of people with health insurance in rural com-munities. though medical school enrollment has increased overall recently, the number of primary care residencies has not grown proportionately, and PcP salaries will in-crease with the increasing demand.

• Participation in health information exchanges and patient databases will require health informa-tion technology that is often not available in rural areas. Rural hospitals and clinics trail their urban counterparts in electronic health record adoption, and ongoing costs of and access to needed technical expertise have become significant rural issues.

• Rural hospital gover-nance and leadership must become aware of the transformative changes taking place in the health care industry, and must begin to position their organizations to adapt to the changing marketplace. achieving and document-ing health care value won’t be accomplished overnight, and a journey of a thousand miles must begin with the first steps of expanding awareness.

• it seems clear that acos may be only an early mod-el in the U.s. health in-dustry’s evolution to more comprehensive, risk-based population health man-agement. in other words, providers of the future will be financially incentivized to keep large groups of people healthy, manage

their chronic illnesses, and coordinate their medi-cal care, increasingly in home-based settings. this will require greater collab-oration with other types of community health provid-ers and engaging the local community in self-care and disease prevention initiatives. Rural provid-ers should begin now to learn about population health management and, in preparation for becom-ing community wellness centers, consider initiating wellness programs for their own employees.

Launching initiatives to meet coming changes

the evolution of the american health-care payment system will occur in phases, and rural providers should prepare ac- cordingly, bearing in mind that form will follow function, which will follow finance. the four types of rural provider initiatives described below can be implemented in stages, designed to correspond with anticipated policy changes.

the first initiative involves optimizing operating efficien-cies, patient safety and quality. this is something any hospital or any medical clinic can focus on immediately. We define effi-ciency as:

• appropriate patient vol-umes meeting the service area needs

• Revenue-cycle manage-

ment excellence

• expenses managed aggressively

• Physician practices man-aged effectively

• effective organizational design

• increasingly lean finan-cial, clinical, and opera-

tional processes

the second initiative deals with primary care alignment. this is based on the assumption that revenue streams of the future will primarily be tied to primary care providers, which often comprise a majority of the rural hospital health-care delivery network. thus, small and rural hospitals, through

alignment with their physi-cians, will have extraordinary value relative to costs. there-fore, it is important that rural hospital and rural physician leaders begin to discuss future partnerships and collaborative initiatives, and, when practical, work through formal agree-ments and shared leadership.

the third recommended ini-tiative calls for rationalizing the local health-services network. Rural health providers need to explore a wide range of affilia-tion options, ranging from net-work relationships, to interde-pendence models, to full asset ownership models. this also includes identifying the number of providers needed in a service area based on population, and then calculating the impact of integrated regional health-care systems. Under the aca, rural hospitals are allowed to par-ticipate in more than one aco, although rural physicians are

Rural hospitals must achieve and publicly report high-quality outcomes and closely

monitor and pursue quality goals.

Crossing the shaky bridge to page 34

shared vision innovative design

Engan associatEsarchitectsinterior designers

Mayo clinic healthSyStem – Springfield

Springfield, Minnesota

800-650-0860 www.engan.com

In 2010, the Minnesota Legislature authorized the Department of Human

Services (DHS) to approve alter-native payment/health care de-livery projects for the Minnesota Medicaid population, using “al-ternative and innovative health care delivery systems organized by providers” (now known as the HCDS [Heath Care Delivery System] demonstration project). In 2013, DHS moved forward with its first set of HCDS pilot projects, focusing on the follow-ing primary goals:

• Encourage providers to innovate in order to deliver higher value care to Medic-aid enrollees

• Support robust primary care and care coordination

• Test payment models that increase provider account-ability

• Create alignment with similar initiatives across payers

The common elements of any

HCDS pilot project for Minneso-ta Medicaid, through a contract with DHS, include:

• The provision of the full scope of primary care services and enhanced care coordination

• Engagement of patients and families in their care

• Impact upon the quali-ty and total cost of care (TCOC) through new mod-els and strategies

• Development of more meaningful community partnerships

• Gain sharing with provid-ers, otherwise known as shared savings or pay-for-performance bonuses

What this amounts to is a historic and unique opportunity for providers in Minnesota to work with DHS in serving the Medicaid population through new ACO-like structures (a provider-owned HCDS) and val-ue-based reimbursement (gain sharing or pay-for-performance bonuses). The plan is that DHS and each pertinent HCDS would first establish a TCOC projected number on an annual basis for a certain population (e.g., $100 million for 10,000 people, aka “attributed lives”), and then attempt to reduce the TCOC number, and thereafter “split the savings” that had been created.

Clearly, any of these new HCDS models would have to promote enhanced care coordi-nation and disease prevention in order to succeed. Promotion of patient and family engagement, along with new, creative com-munity relationships, embrac-ing areas like mental health services, would be important. Exactly how that might work, however, is to be left to the inge-nuity of each HCDS.

Evolution of a new model of care delivery

In 2006, a group of 12 counties in southwestern Minnesota, now known as Southern Prai-rie Community Care (SPCC), had begun discussing how they might help improve the delivery and cost of care to the Medicaid population in their counties.

With the launch of the HCDS demonstration project though DHS, SPCC began to seriously explore designing a HCDS mod-

el in order to contract with the state under the HCDS demon-stration project. Through a joint powers board formed in early 2012, SPCC decided to proceed with a formal HCDS planning process. They estimated that the HCDS would likely serve around 30,000 Medicaid enrollees in the counties involved: Chippewa, Cottonwood, Jackson, Kandi-yohi, Lincoln, Lyon, Murray, Nobles, Redwood, Rock, Swift, and Yellow Medicine.

SPCC sees itself as the first rural Accountable Community for Health in Minnesota and the nation. What that means to us is that SPCC exists for the purpose of improving the health of the counties’ Medicaid recipients, with the particular focus of reducing the impact of chron-ic diseases and mental health illnesses. This will be done through a public/private part-nership, creating a new health system and day-to-day plan for how the public health and social service agencies can work more productively and efficiently with the medical sector on specific health improvement initiatives, as well as enhanced primary care, preventive health, and mental health services. We have embraced the notion that the quality of care delivered can be improved at the same time, and that patients and families will be more satisfied with the care and services they receive. We also believe these changes will eventually benefit all the people in our region, and not just the Medicaid population.

Planning a cutting-edge project

In 2013, SPCC responded to the second round of requests for proposals coming from DHS to establish an HCDS pilot site. In June 2014, SPCC was awarded the opportunity to contract for such a pilot, with a projected start date of Jan. 1, 2014. As this goes to publication, the contract between SPCC and DHS is still being finalized, and the work toward implementation of the pilot project is in full swing in the SPCC counties, involving each and every provider in the region.


Southern Prairie Community Care

Improving costs and delivering higher value care in southwestern Minnesota

By Keith Halleland, JD, and Mary Fischer, MSW

22 MINNESOTA PHYSICIAN November 2013

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During the two-year plan-ning process, SPCC focused on the following key innovations for its HCDS pilot:

Development of a care model that would include reliance on a “health care home” for each Medicaid enrollee, serving as the focal point for a new and improved level of care coordi-nation for both physical and mental ailments.

Inclusion of all medical and community providers in the service area with respect to both care delivery and shared savings/pay-for-performance bonuses, meaning that medi-cal services and mental health services providers would all be engaged in care delivery and enhanced care coordination within SPCC.

Chronic disease manage-ment and care coordination techniques that would result in higher quality care to the re-gion, also leading to short- and long-term cost savings. While there are short-term savings that can be achieved through enhanced care coordination (e.g., fewer emergency room vis-its) the longer term goals include such things as reducing the level of diabetes in the region, a true population health objective.

A health information exchange that would allow all the electronic medical record systems being employed by pro-viders in the region to “roll up” into one shared medical data ex-change, combining all pertinent medical and financial informa-tion needed to provide higher quality and more efficient care in “real time,” available at the fingertips of the providers in a user-friendly, focused, and consolidated manner. Without complete and adequate real-time medical data available at the provider level, enhanced care coordination and the reduction of chronic diseases is simply not possible, as a true picture of the “health” of the patient is piecemeal and inadequate rather than comprehensive and accurate.

An enhanced focus on men-tal health problems and better care coordination for those

suffering from a severe mental illness. Our preliminary data show that failure to adequate-ly address and coordinate the needs of those suffering from a combination of mental and physical illnesses is one of the biggest areas of potential cost savings and quality improve-ment. Unfortunately, in today’s world, coordination of these services typically is insufficient to truly improve outcomes.

A shared savings formula that was unique to the makeup of providers in the region and tied directly to “who can make a difference.” The idea here is that those providers with adequate influence over patient care should be rewarded for improv-ing cost and quality outcomes, rather than simply for another procedure.

The creation of a South-ern Prairie Center for Com-munity Health Improvement (SPCCHI), creating a public/private partnership to establish health improvement goals for the region on an ongoing basis, with pertinent medical data readily available from the health information exchange, along with a governance structure that brings all key providers to the table for medical decisions required for the success of SPCC. In particular, this orga-nization will be the place where the medical providers will meet to discuss health improvement strategies for the region, with access to necessary data and the support services of SPCC.

Engagement of all public health and social service agen-cies in the region. SPCC believes that an important part of its success will lie in the redesign of public health and social ser-vices connected to the Medicaid population, to better coordinate the entire range of services pro-vided, including housing, food, medical, transportation, and other services. This total-cost-of-services (TCOS) approach

looks at better quality care and services coordination, aimed at reducing costs across the spectrum.

Collaboration is key

These key design elements of SPCC demonstrate the hard work and thoughtful planning in its development. All those in-volved are eager to see this new version of population health and the creation of a true Account-able Community for Health in southwestern Minnesota, a rural area where people believe that collaboration is the key to getting better results.

Along the way, many ob-servers have asked how much of this SPCC effort is tied to the Affordable Care Act, and wheth-er the health plans in Minnesota

support our efforts or intend to fight against us. First, this is a Minnesota effort, backed by both DHS and MDH. Minnesota has been a lead innovator in the Medicaid world for decades. The HCDS demonstration and the Accountable Communi-ties for Health agenda being explored and fostered by both DHS and MDH are really part of a local and national trend of working directly with providers on a local level, in shaping the enhanced delivery of care and creating greater efficiency of costs. Innovations like those now available with electronic data and enhanced care coor-dination techniques are also key to seeing these new models become a success.

Keith Halleland, JD, is a founder of Halleland Habicht, a combined law and consulting firm in Minneapolis, where he focuses on regulatory com-pliance, business transactions, and health care policy. mary Fischer, mSW, is executive director of South-ern Prairie Community Care.

November 2013 MINNESOTA PHYSICIAN 23

Improving the health of the counties’ Medicaid recipients, with the particular focus

of reducing the impact of chronic diseases and mental health illnesses.

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The 2012 statewide health assessment from the Minnesota Department

of Health (MDH) has noted that “health starts long before illness is manifest; it begins in homes and schools, in jobs and workplaces, and in communi-ties” (“The Health of Minnesota: Statewide Health Assessment,” MDH, April 2012). Now, as part of national legislation, an opportunity exists for the health care organizations, government agencies, and community mem-bers to join forces and strength-en the health care system at the local level.

The Affordable Care Act (ACA) requires all nonprofit tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) once every three years. The CHNA must include 1) a description of the community served by the hos-pital; 2) the process and meth-odology used in the assessment, the data sources, and other information used to identify

community health needs; 3) input from those representing the broad interest of the com-munity; 4) a prioritized process to identify community health needs; and 5) an implemen-

tation strategy to address the identified health needs.

The results of the CHNA and ongoing strategy to address the

identified needs must be made widely available to the public on the hospital’s website, and a hard copy must be available on-site until the hospital’s two subsequent CHNAs are adopted

(potentially up to six years). Any public input on the CHNA must be documented and taken into consideration in the implemen-tation of the existing CHNA or addressed in the subsequent CHNA.

Rural CHNA and a planning pilot

In May 2012, Stratis Health, with support from the Minneso-ta Department of Health Office of Rural Health and Primary Care, invited two hospitals to join in an initiative to engage key community stakeholders across the continuum of care in a community-based process to improve health care in rural areas. (Stratis Health is Minne-sota’s Medicare quality improve-ment organization, or QIO.)

River’s Edge Hospital & Clinic, working in collaboration with Nicollet County Public Health, was chosen as one of the two hospitals and communities to participate in this unique project. In addition to identi-fying priority health needs in Nicollet County, the initiative was designed to build sustain-able capacity for community engagement, assessment, and planning. The community and care providers are then better equipped to use their communi-

ty’s strengths, assets, and resources to meet their identi-fied priority health needs.

Identifying priorities

The Nicollet County Commu-nity Health Assessment Team met for the first time in Octo-ber 2012. The team’s objectives were to develop a vision of a healthy community; establish a common understanding of the current health of the commu-nity; and identify opportunities to make the vision a reality in Nicollet County. The team’s vision for a healthy communi-ty in Nicollet County included affordable and accessible health care; affordable but healthy food sources (fresh fruits and vegetables are often more expensive); access to exercise; programs and trails for the community; and public safety.

In reviewing the commu-nity health profile for Nicollet County, the multidisciplinary health assessment team used several surveys, state and county data sources, and public health indicators to identify gaps in care and services within Nicollet County (see sidebar on page 25 for data sources). As the team analyzed the data, com-mon themes and priority needs emerged, including awareness of and access to care; healthy teens and young adults; mental health; aging in place; transpor-tation; healthy kids; and health and wellness. The team voted on these top priority areas and chose two to focus on within the CHNA and planning pilot: (1) mental health and (2) healthy teens and young adults.

Gaps in care coordination topped the list for needed men-tal health services in Nicollet County. For the healthy teens and young adults theme, the identified top priorities for Nicollet County included bul-lying, binge drinking, hunger, and the availability of youth activities.

To address the county’s needs in these areas, two multidisciplinary task forces were formed to:

• Create a common vision among the members of the



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Healthy Teens & young Adults and the Mental Health Task Forces

• Seek broad representation on both task forces

• Establish goals and objectives for the two task forces

• Build capacity using local resources and assets

• Identify existing gaps

• Determine measurable baseline data and establish benchmarks

• Develop a community-wide strategy to address the identified needs over the next three years

• Implement the plan

• Monitor the data and ad-just the plan

Mental health task force

Provision of mental health services is a national crisis, with many facets and gaps in care coordination. At first, this priority need seemed almost too big to deal with on a local level. However, as the Nicollet Coun-ty Mental Health Task Force continued to meet, it became apparent that there were gaps in care the task force could attempt to bridge.

The task force met and identified the populations in need and those receiving mental health services within the coun-ty. The group acknowledged that a large number of people in the community who are living with mental health concerns are unable, unwilling, or unsure of where to seek services. Further, the discussions revealed that

even in the multidisciplinary task force (made up of social services, hospital professional staff, psychologists, law enforce-ment, educators, public health, and state-operated services), not all members were aware of the available resources. Therefore, one of the group’s first tasks was to identify the available resourc-es to meet the needs of our patients and clients.

The second area of con-cern centered on education. The Nicollet County Mental Health Task Force is exploring a program called Mental Health First Aid (MHFA). MHFA is an early intervention program that educates community members, first responders, doctors, nurs-es, clergy, and outreach workers on how to identify, understand, and respond to people showing signs of mental illness or sub-stance abuse, and, ultimately, to connect them with appropriate care resources.

Healthy teens/young adults

Supporting the health and well-being of teens and young adults was another area that seemed overwhelming for a small, local task force. At the initial meeting, the group looked at the areas of youth activities, bullying, binge drink-ing, and hunger. Ultimately, the task force decided to support youth activities initiatives that are already moving forward in the community.

In its discussions, the group recognized that there are opportunities for youth to be involved with organized sports, but few places where they can participate in life-long exercise

activities with little or no cost. It was particularly striking that the “tweens”—middle-school-age adolescents—had few places to go that were safe and encourage healthy activity.

The task force learned that two youth activities initiatives were under way in St. Peter. One is a multi-use recreational trail. Three individuals have established a plan for this trail and are currently meeting with leaders of the community for approval. The task force has met with them to find out how we can support their efforts.

The other initiative is a skateboard path. This initia-tive has a plan, but will need funding and support from the community. Here, the task force will focus on gaining grassroots support from local groups and community members.

A journey toward improved community health

The CHNA is a journey that can

seem never-ending and full of surprises. However, the bench-mark data collection done for the CHNA has provided measurable insight into where gaps in care and services exist—and has given us real hope of improving life for people in our community. Having input from a broad base of community stakeholders is invaluable in that it adds layers of understanding and focus on areas of concern.

River’s Edge Hospital & Clin-ic and Nicollet County Public Health are just beginning this journey, but we are not in it alone. A good cross section of people from the community has joined forces with us in making Nicollet County a healthy and safe place to live.

Colleen Spike, rN, is the CEO of River’s Edge Hospital & Clinic in St. Peter. mary Hildebrandt, PHN, is the director of Nicollet County Public Health.

•MinnesotaStudentCountyTableshttps://education.state.mn.us/MDE/StuSuc/SafeSch/MNStudentSurvey/

•CountyHealthRankings&Roadmapswww.countyhealthrankings.org

•NicolletCountyDataBookSouthwest/SouthCentralHealthSurveywww.wilderresearch.org

•AtlasofMinnesota/USCensusBureauforRuralPolicy&Developmentwww.ruralmn.org/atlas-online/

•MinnesotaDepartmentofHealthCenterforHealthStatisticswww.health.mn.us/index.html

Data resources for Community Health Needs Assessment

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Healthcare Planning and Design

Ophthalmology - Essentia Health

High-tech imaging and subspecialty interpre-tation are no longer

exclusive to metropolitan areas. Patients do not have to be transported via ambulance or helicopter to gain access to MRI and CT scans. Early interven-tion for trauma cases can be started immediately, right in the patient’s own local hospital. Advanced cancer staging exams with PET or MRI can be per-formed locally.

Often, community-owned rural hospitals are making the investment in high-tech equip-ment. They are just as commit-ted as their metro counterparts to practicing the high standards of patient care that comes with performing these exams at their facilities.

But it’s not all about the machines. Having the equip-ment is only part of the equa-tion. Providing optimal care is also about obtaining the most information possible from the imaging exam. This happens

when a subspecialty radiologist specifically trained and focused in that area interprets the study. Subspecialty interpretation of medical imaging is the standard of care in major metropolitan centers—and is becoming so in rural areas as well.

Developing a partnership

Mature teleradiology solutions are making subspecialty in-terpretation the norm in rural communities. Access to breast radiologists, neuroradiologists, or oncology-focused radiolo-gists, for example, is now readily available in rural settings when

partnered with the right radiol-ogy group. In some instances, a local general radiologist works in conjunction with a subspe-cialty group.

Moreover, working with a radiology group using teleradiol-ogy need not be an impersonal partnership. While there are some national radiology groups so large that it may be difficult to form relationships between local physicians and radiolo-gists, there are other options. Most metropolitan mid- and large-sized radiology groups offer various levels of service to nearby rural communities. Partnering with a nearby group allows local physicians to work with a smaller pool of specialty radiologists that are available for phone consultations at any time. Better working relation-ships and communication can be developed, improving the care of patients and professional satisfaction of both referring physicians and radiologists.

On-site coverage bolsters teleradiology

Working with an in-state ra-diology group also allows for a combination of on-site care and teleradiology. Despite the advances in teleradiology, some exams/procedures require the on-site presence of a radiolo-gist. For example, image-guided biopsies, abscess drainage, ar-thrograms, and pain injections require the physical presence of a radiologist.

While there may be alter-natives to some of these proce-dures, rural communities can better serve their patients and provide a broader range of ser-vices if their radiology partner-ship provides on-site coverage. Most radiology groups based in nearby cities typically provide

some form of scheduled on-site coverage for such procedures.

For example, several subspe-cialty radiologists from Sub-urban Radiologic Consultants (SRC) travel weekly to hospitals and clinics in western Minne-sota, giving patients in rural communities direct access to these physicians. This means that a woman who has a breast lump or a suspicious finding on her screening mammogram can undergo an evaluation and same-day biopsy performed by a breast radiologist, who gives the results directly to the patient.

On-site coverage also helps justify acquisition of more advanced equipment at larger facilities in rural Minnesota, which can then serve as a more convenient referral site for smaller regional clinics and hos-pitals. Rice Memorial Hospital, in Willmar, recently installed a state-of-the-art interventional radiology suite. This invest-ment serves patients not only in Willmar but also in many of the surrounding cities. SRC interventional radiologists use the new suite to provide focused cancer therapy such as tumor cryoablation or chemoemboli-zation and vascular procedures such as dialysis fistula mainte-nance or angioplasty.

Leveraging radiology resources

Radiology groups can leverage resources at their own imag-ing facilities for their partners. Radiology groups often em-ploy numerous technologists, information technology staff, medical records staff, nurses, and other health professionals with specific and valuable skill sets. These individuals can collaborate with staff at partner hospitals and clinics to improve imaging services. For example, lead technologists from SRC’s Twin Cities-based outpatient imaging facilities, Suburban Imaging, make site visits to partner rural clinics and hos-pitals. They may assist with training or deployment of new equipment. Alternatively, tech-nologists from partner sites may spend time at a Suburban Imag-ing facility to learn a new exam 26 MInnESOTA PHySICIAn November 2013


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or to gain additional experience. Each site’s needs will vary based on local expertise, so a radiology group with broad experience and flexibility will be of value to rural partners.

The benefits of collabo-rating with a larger regional group naturally expand to other supporting areas. For example, subspecialty radiology groups may provide their rural part-ners with assistance in meeting imaging accreditation require-ments as well as navigating the accreditation process. As part of ever-changing over-sight and billing requirements, both outpatient and hospital imaging facilities are seeking accreditation of their various imaging modalities. While this is becoming more and more necessary to receive payment for services, it is also important in building confidence with patients and health care provid-ers. SRC’s outpatient imaging centers are all accredited by the American College of Radiology

and other accrediting agencies. SRC leverages the team involved in obtaining this accreditation to its rural partners, usually without cost. Most of our rural partners have already received accreditation in one or more modalities or are in the process of doing so.

Benefits in cost, quality, care

The right radiology partnership can benefit in many other ways that are often overlooked. Rural facilities should be able to rely on their radiology group to provide assistance with quality control, continuous improve-ment projects, scanning pro-tocols updates, radiation dose management, and more. When not on-site, subspecialty radiol-ogists are able to participate in tumor conferences and offer case consultations via video and audio conferencing. Addition-ally, continuing education and enrichment programs can be broadcast from the metro area to physicians and staff in rural

communities. For example, a presentation by national breast imaging expert Louise Mill-er, RTRM, was hosted at The Breast Center of Suburban Im-aging in Coon Rapids (a north-ern suburb of Minneapolis) and video-conferenced to mammog-raphy technologists in western Minnesota this past summer.

Beyond imaging exam interpretation and leveraging resources, mid-size to large radiology groups can help their partners reduce their costs related to technology. Purchas-ing and maintaining radiology information management sys-tems (RIS) and the software and hardware to store and retrieve images (PACS) is expensive and complex. Often it is more effi-cient to outsource this work to a radiology service provider. Costs are typically lower with this ap-proach, as multiple smaller sites can leverage the same econo-mies of scale available to large groups. Information technology costs to maintain these systems

24/7 also can be mitigated. Rural departments can stay focused on providing excellent patient care instead of manag-ing software and hardware.

Providing state-of-the-art patient care is at the core of partnerships between rural medical facilities and well- established mid-size to large regional radiology groups. These radiology practices provide direct access to subspecialty radiologists, leverage years of experience managing successful imaging facilities, and provide cost-effective technology solu-tions to achieve this goal. As high-tech imaging continues to advance, and the complex-ion of health care changes, an in-state radiology group makes an ideal partner for long-term success.

Nihar Shah, mD, is medical director of the Greater Minnesota Partnerships for Suburban Radiologic Consultants, North Group. He subspecializes in body and breast imaging.

November 2013 MInnESOTA PHySICIAn 27

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the remaining hospital stay. In addition, the pain specialists provide direction on how the patients can safely taper off their opioids.

In fewer than four months, the program grew to include additional orthopedic and neu-rologic populations; in less than a year, it was targeted to be available for all patients having elective inpatient surgeries on the campus. Although our ini-tial focus was patient-centric—aiming foremost to improve the comfort of these patients—we quickly expanded to a more population-centric perspective. We understood that this work potentially could address the problem of opioid misuse and

abuse in larger populations. Knowing that about 70 per-cent of the surgeons educated at the University of Minnesota remain in the state to practice, we committed to providing our orthopedic residents additional training in perioperative opioid management.

After a year, the hip and knee replacement population demonstrated a length of stay (LOS) of 1.35 days, less than the LOS for a clinically similar peer group that did not receive POPCs. The POPC patients were able to advance their inpatient physical therapy sooner com-pared to the other group, and they expressed great satisfaction with their pain management

and overall experience. The cost savings in delivering care to this population were significant; a system-wide integration would save $5.83 million and return nearly 2,500 more workdays to the community and 5,000 days to patients at home.

Although all of the care entities already were delivering care well individually and as entity-based teams, the health system was able to achieve dramatic, sustained improve-ments at a lower cost through a population-centric approach to this type of surgery.

Accelerating your care model evolutionChange is challenging. Popula-tion-centric programming turns a lot of previously held truths for quality programming inside out. Throughout our journey in driving quality improvement, we have found the most success in using the following tactics:

1. Seek win-win opportu-nities. In the case of the POPCs, we began the ser-vice at a site where we had a highly interested physi-cian and where the need for revamping site-wide pain management had recently been identified.

2. Always have a way to objectify program results. It is difficult to secure sustained resources with-out supportive data that extend beyond anecdotes.

3. Use the data. Even if the data do not conclusively determine a direction, they can drive a discus-sion, tell a story, and help you better understand your population. Use sto-ries to build and maintain momentum, especially for those delivering the care.

4. Do not AIM for what is BEST; DO what is BETTER. Population-

centric programming involves a large number of stakeholders, and rarely will everyone agree on a “best” course of action. However, people often can agree on what will yield a better result than the current state. Incremental progress is still progress.

5. Work from values held in common. Overwhelm-ingly, care providers care foremost about the people they serve. When work-ing across many entities, focus on improving the quality of care and the patient experience rath-er than focusing on any financial goal.

6. Bring your grit. The value of imagination and per-sistence cannot be under-estimated in population- centric programming.

Providing better health at a lower total cost to the commu-nity requires health systems to move out of their provider silos and roles, and even beyond multidisciplinary teams, and look at ways to partner with various community entities. A strong, system-level commit-ment to population health will help erode the most challenging barriers to population-centric programming: silo thinking, misaligned incentives, com-peting priorities, and fear of change.

By moving beyond tradition-al health care delivery, we can bring higher value health to our communities and the popula-tions we serve.

Emily Karlen, MPT, is senior project management consultant for orthope-dics at Fairview Health Services and has been recognized regionally for innovations in health care delivery.

28 MInnESOTA PHySICIAn NovEMbEr 2013

Table 1. Summary of the evolution toward population-centric health care delivery.

Past Present Future

Delivery focus Provider-centric: FIX the patient Patient-centric: CURE the patient Population-centric: COLLABORATE with the patient and community to deliver better HEALTH to the patient

Accountable parties Individuals/silo entities Multidisciplinary teams Individuals with the support of community entities in partnership with health care providers

Financial focus Revenue Reduce “cost” (direct costs to deliver care) to increase profit margins Reduce cost (direct and indirect costs) to community

Quality metrics Safety Safety + process measures Safety + process measures + functional outcomes

Turning health programming inside out from page 17

Applicants can apply online atwww.USAJOBS.gov

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Primary Care(Family Practice orInternal Medicine)

Psychiatrist

Hospitalist

Endocrinology

Emergency Medicine

Pulmonologist

FDA approval of CXL

CXL has now been per-formed in Europe and elsewhere in the world for more than a decade, but it is still not FDA-approved in the U.S. However, sev-eral ongoing clinical trials in the U.S. allow patients access to crosslinking treatment. Our ophthal-mology group has done clinical trial work in several previous crosslinking studies and is currently part of the CXLUSA study group (www.cxlusa.com). This surgeon investigator study group is allowed to treat keratoconus, post-LASIK ectasia, and similar ectatic corneal problems, and to perform treatments combining crosslinking therapy with other corneal surgeries.

A promising treatment

Keratoconus is a rare but potentially devastating ectactic disease of the cor-nea, frequently resulting in vision loss from irregular astigmatism and corneal scarring.

While traditional therapy for keratoconus and other similar ectatic disorders has been limited to hard contact lenses and corneal transplantation, corneal collagen-crosslinking now offers an avenue to slow or halt the progression of the disease and to limit the development of further keratoconus complica-tions.

Sumitra S. Khandelwal, MD, and Sherman W. Reeves, MD, MPH, practice oph-thalmology at Minnesota Eye Consultants.

Figure 2. Pentacam topography of a patient with keratoconus. In this imaging, warmer colors indicate steepening, with most patients having a range of blue and green.

The bottom left picture shows an area of steepening, which is notably more yellow and orange than the rest of the topography.

Keratoconus from page 19

NoveMbeR 2013 MInnESOTA PHySICIAn 29

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Patients frequently re-port cognitive problems during cancer treatment,

especially with chemotherapy. Typical complaints are forget-fulness, word-finding difficulty, trouble concentrating, difficulty multitasking, mental fatigue and inefficiency with previously easy tasks, inability to follow the flow of a conversation, and get-ting lost in previously familiar locations.

It is not entirely clear why some patients have cognitive changes with cancer treatment and others don’t. Cognitive dif-ficulties during and after cancer treatment can also be related to anxiety, pain, insomnia, electrolyte imbalances, medica-tions, cancer or paraneoplastic effects of the central nervous system, and hormonal changes. But these factors alone do not account for the familiar pattern of cognitive changes reported by cancer patients who have no underlying medical reason for cognitive change.

A growing body of research has led to the conclusion that “chemobrain” is real. Chemo-brain is now called mild cogni-tive impairment (MCI) of cancer treatment, reflecting the multi-factorial nature of the problem. However, there is strong evi-dence that the pattern of decline in verbal and visual spatial ability is primarily attributable to chemotherapy and remains as a measurable impairment over time.

A recent meta-analysis of the problem showed that the deficits remain for over six months after completion of chemotherapy

(Jim, H et al., 2012, J Clin Oncol 30:1–12). Alterations of cerebral white matter on MRI have been detected in patients with cogni-tive changes after chemothera-py compared to healthy age-matched controls. (Depres, S et al., 2011, J Clin Oncol 29:1–8).

The National Comprehen-sive Cancer Network (NCCN) has recently published clinical practice guidelines for Cancer Survivorship (v 1.2013. nccn.org). Cognitive function is one of the eight major areas for screening and treatment for cancer survivors.

A review of the science be-

hind cancer-related MCI con-cluded that about 25 percent of cancer survivors have MCI and that interventions for treating the condition are beneficial (Ah-les TA et al., 2012, J Clin Oncol 30:3675–3686).

Chicken or egg?One difficulty confronting the clinician in treating the cancer survivor reporting distress and/or cognitive difficulty is the chicken-or-egg phenomenon. The awareness of acute cogni-tive decline is anxiety produc-ing, leading to distractibility and more cognitive difficulty. Lack of familiarity with MCI by medical providers, family, and friends may contribute to feelings of isolation, fear, loss of control, and hopelessness. A re-cent study showed that patients who developed cognitive prob-lems related to cancer treatment had higher distress scores (Ploos van Amstel, FK, 2013, Support Care Cancer 21:2107–2115). When cognitive treatment does not alleviate distress, or when

Physical medicine/Rehabilitation

Cognition and cancer

Finding focus after chemotherapy

By Nancy Hutchison, MD, and Mary V. Radomski, PhD, OTR/L

30 MINNeSOTA PHySICIAN November 2013

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there is significant evidence for clinical depression, a referral to a mental health professional is indicated in addition to cogni-tive remediation therapies.

RehabilitationAfter ruling out medical and neurologic causes of cognitive decline, the clinician should re-fer the patient to a rehabilitation professional (usually an occu-pational or speech therapist) to provide the patient with cogni-tive therapy. Medications have little benefit for patients with

MCI unless there are coexisting medical or psychiatric condi-tions. Modafinil has been stud-ied and has shown some limited promise. However, most patients do not want or need medication; and medication cannot address the social, psychological, and practical aspects of daily living with MCI that are part of the re-habilitation professional’s treat-ment. Financial and side effect concerns are additional negative factors with medications.

These rehabilitation ap-proaches appear to minimize

problems associated with chemobrain:

• Learning new cognitive strategies. Patients work with a cognitive thera-pist to implement “work-arounds” (e.g., using note-taking strategies, planning techniques, timers, and smart tech-nology) that help improve their performance on daily activities.

• Engaging in physical ex-ercise. even light exercise or physical activity that

uses skeletal muscles and expends energy has benefit for cognition in cancer sur-vivors (Fitzpatrick, T et al., 2012, J Psychosoc Oncol 30:5, 556–572).

• Performing brain-training exercises. Patients perform commercially available computer-based exercises (such as Lumosity and PositScience) that chal-lenge speed of processing, memory, and concentra-

November 2013 MINNeSOTA PHySICIAN 31

Problem in daily life Central cognitive issue Cognitive strategies that mrs. r. learned and implemented

Absentmindedness: Forgetting where she parked her car; forget-ting what she intended to do from moment to moment; making errors during meal preparation

Poor encoding: Mrs. R. often had so much on her mind that she did not focus her attention long enough to encode new information.

Pausing: Mrs. R. learned to recognize when her thoughts were racing and to stop and to take mental inventory of what she was doing, feeling, thinking.

Avoiding multitasking: Mrs. R. found that she could greatly reduce errors during meal preparation if she focused on the task at hand rather than trying to do two or three other chores at the same time.

Jotting notes: Mrs. R. realized that she was most prone to absentmindedness when fatigued. On such occasions, she simply jotted notes on a small notepad regarding parking locations or “to do” items that came to mind.

Disorganization: Being unable to begin an unstructured activity; easily overwhelmed and quickly quitting activity

Fatigue: Mrs. R. typically started to sort her photographs after dinner; fatigue interfered with her concentration and problem-solving.

Pacing: Mrs. R. found that she could successfully complete repetitive household tasks (like folding laun-dry) during her low-energy times of the day and started reserving complex tasks (like her photography project) for peak energy times of her day or week.

Means-ends analysis: Mrs. R. found that she could not only complete but also enjoy her photography project if she separated planning from doing. She broke the project into smaller steps and kept a written list of those steps, tackling them one at a time.

Cognition and cancer to page 32

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Opportunities for full-time and part-time staff Physicians are available in the following positions:•Gastroenterologist•Emergency Department•Hematology/Oncology• Internist, w/Women’s Health Experience•Compensation and Pension•General Internal Medicine (Minneapolis)•General Internal Medicine (Rice Lake/Hayward, WI Outpatient Clinic)•General Internal Medicine (Chippewa Falls, WI Outpatient Clinic)

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tion. While the impact of brain training on daily life activities remains unclear, these activities are safe and often enjoyable and show promise in terms of before-and-after effects on cognitive testing.

Chemobrain case studyThe following case example illustrates how all of the above approaches are used to address chemobrain.

After ruling out brain me-tastases, Mrs. R.’s physician referred her to occupational therapy when she described persistent problems with forget-fulness and distractibility that began during her chemotherapy for breast cancer. For example, in the past month, Mrs. R. lost her car in the mall parking lot; made errors when preparing easy, familiar meals for her family; couldn’t figure out how to organize photographs for her daughter’s graduation party;

and was increasingly withdrawn at work for fear of being unable to remember words, names, or express herself. Furthermore, it was evident that Mrs. R. suf-fered from poor sleep, fatigue, and disrupted daily routines. Mrs. R. was most anxious to “fix” the problem so that she could minimize the burden on her husband and daughters and, ultimately, gain enough confi-dence and stamina to return to work full time.

The occupational therapist recommended four weekly outpatient visits at which they would explore new strategies for more effectively accomplishing activities that mattered most to Mrs. R. each session focused on 1) understanding the central cognitive issue that disrupted performance; 2) training in new cognitive strategies or approach-es; and 3) problem solving regarding implementation of these strategies specific to Mrs. R.’s daily activities. The occu-pational therapist hypothesized that alternate approaches would

decrease Mrs. R.’s experience of failure and distress, and im-prove her everyday performance and sense of competence.

The table on page 31 pro-vides examples of strategies that proved effective in addressing some of Mrs. R.’s primary con-cerns. The examples link daily life problems, cognitive issues, and strategies.

Concurrent with her outpa-tient occupational therapy, Mrs. R. implemented a physical and cognitive fitness regimen. She started and adhered to a daily walking schedule and spent time each day on the computer playing games that challenged her memory and concentration.

At the time she discontin-ued occupational therapy one month later, Mrs. R. described substantial improvements in her cognitive functioning. Mrs. R.’s improvements at home seemed to buoy her confidence at work. She reported that many of the strategies that had proved help-ful at home were also helping her at work. While she still did

not see herself as “100 percent,” Mrs. R. was less anxious about her performance and reported that she felt better able to cope with her remaining, intermittent cognitive concerns.

Chemobrain is realCognitive impairment in cancer survivors is a real phenomenon that has a negative impact in the domains of vocational, social, and emotional health. Rehabil-itation strategies provided by cognitive therapists (occupation-al therapists and speech lan-guage pathologists) are benefi-cial in improving function and quality of life. Therapy is usually only a few sessions, but provides significant benefits for cancer survivors with this condition.

Nancy Hutchison, mD, a board- certified physiatrist, is medical director for cancer rehabilitation and survivorship at Courage Kenny RehabiIi-tation Institute and the Virginia Piper Cancer Institute in Minneapolis. mary v. radomski, PhD, oTr/L, is a clinical scientist at Courage Kenny Research Center.

32 MINNeSOTA PHySICIAN November 2013

Cognition and cancer from page 31

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

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

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

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

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The MVAHCS, affiliated with the University of Minnesota, is seeking a Spinal Cord Injury and Disorders BE/BC physician/physiatrist. Duties

include providing interdisciplinary care for acute and chronic SCI/D Veterans in the inpatient and outpatient setting. Staff has on-site access to medical and surgical specialties, advanced

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Minneapolis VA Health Care SystemPhysician/Physiatrist

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.

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the fourth recommended initiative is to develop popula-tion-based payment strategies to correspond to the anticipated payment and implementation phases. these would be:

• Developing self-insurance strategies for integrat-ed delivery systems and self-insured employers

• Developing commercial payer strategies

• Developing Medicare strategies

• Developing Medicaid strategies

these strategies will un-doubtedly require access to advanced business and finan-cial expertise that is fully aware of anticipated reimbursement policies and changes. of special note is the growth of commu-nity care organizations (ccos),

which establish a new “mar-ket” for insurers and providers to come together to manage health care expenditures for a defined population. in the new models, hospital beds, once considered revenue genera-tors, will rapidly become cost

centers. health education, care coordination, telehealth, and a variety of other prevention and chronic illness services will be, for the first time, generators of revenue for both hospitals and physicians. For example, keep-ing a patient in his or her rural home with telemedicine cover-age, rather than in a hospital bed, will prove financially ad-

vantageous. the ultimate goal will soon become managing the health of large populations, at lower costs, with higher quality outcomes.

Charting a new course

Rural hospitals and rural

physicians have historically dealt with the acute challeng-es related to serving an older, sicker, poorer, and geographi-cally isolated population. With fewer providers per capita, with limited technology and exper-tise, and with the cards usually stacked against them, these providers have often served heroically in rural communities

across the country.

the current environment, driven by health care reform and market realities, now offers a new set of challenges. Many rural health care providers have not yet considered either the magnitude of the changes or the required strategies to appropriately address the trans-formational change.

crossing the shaky bridge from one era to the next will not be easy, but rural providers have much to offer in terms of value. they should begin now to increase their awareness, calculate their assets, and begin to chart a course into the future.

Terry J. Hill, mPA, is executive director of the National Rural Health Resource Center, based in Duluth. eric Shell, CPA, mbA, is a principal at health consulting firm Stroudwater Associates.

Health education, care coordination, telehealth, and other services will be, for the

first time, generators of revenue for both hospitals and physicians.

Crossing the shaky bridge from page 21

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

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Screening for risky substance use from page 12

over time.

Getting honest answers. “Many patients think heavy drinking and even some drug use is normal,” said Bixby. “so some view screening for alco-hol or drug use as invasive and inappropriate.”

“Patients are not always truthful,” added somers. “they try to minimize their actual substance use. it is viewed as a social activity, not a health problem like depression.”

training in motivational interviewing helps care manag-ers better align with patients as collaborators. this helps remove judgment and strengthens pa-tient self-efficacy. nancy Mun-son, Rn, integrated Behavioral health care, Mayo clinic, said, “Making patients aware of the medical complications resulting from binge drinking makes it easier for them to buy into some behavioral change.”

“When we create a comfort-able environment, we are more likely to get accurate answers,” said Rebecca Godfrey, care co-ordinator, north Memorial. “it is not what we say, but how we say it.” Folding the alcohol and other drug screenings into over-all patient health assessments also helps to destigmatize the discussion of risky substance use for north Memorial.

in smaller communities, clinic staff and patients may know each other, making it uncomfortable for both parties to discuss the issue. however, a number of clinics noted that pa-tients are more open than they originally thought to talk about their substance use. others are relieved that someone is finally talking about the issue because they didn’t know how to bring it up.

Accessing outside resources. “Knowing what external resources are available for patients with substance use issues is very important for

those requiring more than a brief intervention,” said Greta humphrey, care coordinator, north Memorial. entira de-veloped a list of resources and invited leaders of various orga-nizations to share information on their programs.

Gaining buy-in from psy-chiatrists. “Psychiatrists may initially worry about losing work or possible liability issues if they consult with a care man-ager in primary care instead of performing direct patient care,” said sawyer. “the reality is that there haven’t been prob-lems. the results speak for themselves.”

Support for a care management approach

clinics indicated that the fac-tors making depression care successful in primary care also apply to risky substance use treatment. these include:

• obtaining senior manage-ment commitment

• Finding a strong clinic champion

• having a registry to moni-tor patient progress

• sharing early success sto-ries to validate the model

• helping staff feel good about the care they provide

• hiring care managers who work well in a team, have compassion for patients with behavioral health conditions, and are skilled in motivational interviewing

Outcomes and measurement

to date, Minnesota clinics have screened roughly 26,000 patients for risky substance use. three percent were eligible for a brief intervention and, of those, 40 percent completed the inter-vention. at follow-up, 80 percent of these patients reported a decrease in binge drinking days (men consuming five or more drinks and women consuming four or more drinks in about two hours).

clinics are seeing successes. tianna harrell, care coordi-nator, north Memorial health

care, helped a patient with possible alcohol abuse access a treatment program for teens, and the young woman gradu-ated from the program. “she invited me to the ceremony and said she doesn’t know what she would have done if she hadn’t gotten into the program,” said harrell.

at entira, angela Rivas, care manager, remembers a patient who acknowledged us-ing heroin. “he had been using for two years and had hooked his girlfriend,” said Rivas. “he hadn’t told his parents or his doctor. in fact, his doctor was shocked when he found out. We sent this patient to treatment, and he’s doing phenomenally well.”

“Down the road, i hope we have more outcome data,” said tim hernandez, MD, entira. “Referral to treatment makes it difficult to know patient out-comes because of confidentiality. Long-term studies have to be done to determine the ben-efits of keeping patients from moving from abuse to addic-tion. if we can start to see that this works upstream, that would be huge.”

The bottom line

While outcomes are still being gathered about how the evi-dence-based sBiRt model was implemented, current partic-ipants support the program. “the staff has embraced this work, and we are seeing prog-ress,” said Bixby.

hernandez noted that the further integration of behavioral health into primary care “is coming whether we want it or not. clinics should figure out their process.”

“screening for risky sub-stance use has been incredibly valuable,” said Virant. “When we’re dealing with behavioral health issues, alcohol and drug use can often be major comor-bidities. in retrospect, not to have acknowledged that would have been foolish. We have the first new tool in a long time that’s proven to work.”

Pam Pietruszewski, mA, ICSI direc-tor, leads the SBIRT initiative at ICSI.

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St. Cloud/Sartell, MN

We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an out-patient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.

Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefi t package, paid malpractice and a commitment to providing exceptional patient-centered care.

Apply online at healthpartners.jobs orcontact [email protected]. Call Diane at 952-883-5453; toll-free:800-472-4695 x3. EOE

healthpartners.com© 2013 NAS(Media: delete copyright notice)

MN Physician4" x 5.25"4-color

Please contact or fax CV to:

Joel Sagedahl, M.D.5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

www.NWFPC.com

Join the top ranked clinic

in the Twin CitiesA leading national consumermagazine recently recognizedour clinic for providing the bestcare in the Twin Cities based on quality and cost. We are currently seeking new physicianassociates in the areas of:

• Family Practice

• Urgent Care

We are independent physician-owned and operated primaryclinic with three locations in theNW Minneapolis suburbs. Work-ing here you will be part of anaward winning team with partner-ship opportunities in just 2 years. We offer competitive salary andbenefits. Please call to learn howyou can contribute to our innova-tive new approaches to improvinghealth care delivery.

surgery could cost roughly $40,000, while that same pro-cedure with a stay in the excel recovery retreat almost cuts the cost in half to $21,000.

We have found that the $21,000 “sticker price” is about 30 percent less than what in-surance companies in the twin cities pay for a typical knee re-placement. By using on-site staff and resources, tco has taken much of the guesswork out of the costs of the procedure and recovery time. the excel team provides all the before and after care, handles the lab work and the medications, and performs the surgery at their outpatient surgery center. the cost savings is substantial no matter who is footing the bill, patient or insur-ance provider.

of the all-inclusive price, simonson says, “Patients love it. there are no surprises, we give full disclosure on the price, and they’re only dealing with us as

far as the billing goes, not hear-ing from six or seven different entities.”

since the nation’s computer-ized health care billing system is built around a fee-for-service model, insurers are working to accommodate tco’s bundled-payment approach. currently, healthPartners and Medica are participating insur-ers. Going forward, tco plans to continue negotiating with other insurers and payers.

this financial model of bun-dled payment could be applied to any procedure that is elec-tive and has a clear start and end point. as a specialty, knee surgery is ideal for bundled payment, but this model is also applicable to other specialties, such as gastroenterology (e.g., for colonoscopy).

Taking on risk

tco is a physician-owned prac-tice and takes on the majority of the risk of covering the knee

replacement procedure. the ex-cel program stresses a pre-oper-ative comprehensive educational session with the patient and caregiver. in addi-tion, best practice protocols for the program have been devel-oped and established by the physicians and their care team to ensure that the highest qual-ity of care is delivered through-out the care continuum. these factors contribute to patients and caregivers feeling confident and prepared, which in turn has resulted in improved recovery and extremely high patient satis-faction.

Opportunities for growth

hip and knee replacement pa-tients are trending for younger people. today’s active lifestyles, every day athletics, and daily workouts are taking a toll on people, even in their 40s. these active patients need to get back to work and their lifestyle in short order. With the excel program, they can recover in a

private, nicely appointed suite; start therapy immediately; and recover faster.

additionally, the program greatly simplifies the health-care billing process and pro-vides one transparent price for the entire continuum of care.

With the success of the excel program, tco is planning to expand the program to other tco locations across the metro. While tco is initiating the program with knee replacement patients, we will soon expand excel to include all of our major procedures that would benefit by a stay in our recovery retreat. this includes shoulder, ankle, and hip surgeries.

“We’ve designed excel to provide a tremendous patient experience and high quality care,” says simonson. “it’s where health care should go.”

owen r. o’Neill, mD, is a board-certified orthopedic surgeon and a physician in the Excel Outpa-tient Surgery and Recovery Program at Twin Cities Orthopedics.

One team, one bill from page 10

To the editor:

Regarding the article “CSI Minnesota” by Lindsey

Thomas, MD (Minnesota Physician, September 2013): I enjoyed this well-written article regarding forensic medicine. Your readers may appreciate some background on the struggle to bring forensic medicine to its current unquestioned acceptance in our community.

My exposure to this inter- esting field was serendipitous. In 1956, I was settling comfortably into the general practice of medicine in St. Paul and Roseville. The coroner of Ramsey County, who lived in that area, stopped by one day to ask me to be a deputy coroner. In those days a body could not be moved until there was a pronouncement of death. That would be my job for my area.

A short time after I started, the coroner died. A new coroner was appointed who was an attor- ney as well as a physician. It seemed ideal, but he soon became ill and died. The deputy investigator for the coroner’s office was a friend of my family, and called

me to ask if I might cover the office, part time, until the next election.

The coroner’s office was in the Ramsey County Court-house, and there was a morgue on Hill Street just across the street from Nina Clifford’s famous brothel. The morgue was in an old brothel of lesser fame, owned by Hattie Daniels.

My first visit to the morgue was a horrible incident. A young man had taken his life and I was called to come make the pro-nouncement. I arrived just about the time the young man’s father had arrived. It was July, and it was hot. The morgue had a walk-in cooler that could hold four bodies. There were four more wrapped in sheets placed on the floor. The young man’s body was on the marble autopsy table. Suction tubes for autopsies were hanging from a coat hanger overhead and running to an exposed toilet in a small bath-room. The father asked if I could move his son’s body to some other place for his mother to see. I was arranging this when the mother arrived. This horrible scene was embedded in my mind and I

vowed to change the process.

With the help of some friends, I formed a citizens’ committee to petition the County Commissioners to build a new facility. The St. Paul Pioneer Press was helpful in showing the public this awful place. We built a new, state-of-the-art coroner’s office and morgue facility on the Nina Clifford property.

This activity kept me in the office longer than I had planned, and required that I run for elec-tion to complete the process. That was an experience. My wife was angry because I almost lost to a popular used-car salesman. At the time, you did not have to be a physician to be a coroner.

I was successful in writing up a bill requiring that the coroner be a physician in Minnesota. Sen. Joe O’Neill and Sen. Nick Cole-man nursed it through the legis-lature.

We were performing about 400 autopsies a year. I used the pathologists from Ancker Hos-pital (now Regions Hospital) and pathology residents from Jesse Edwards’ (a famous cardiovascular pathologist)

program at Charles T. Miller Hospital and St. Luke’s Hospital (now merged to become United Hospital).

I was hoping to leave the office as soon as possible. John Coe, a forensic pathologist at Hennepin County General Hos-pital (now Hennepin County Medical Center), had a young forensic pathologist resident who was ready to leave the program. It was a real opportunity for us to get a qualified person for the Ramsey County Coroner’s Office. I made the proposal to the county commissioners, but they did not accept it.

John Coe and I formed the Minnesota Coroner and Medical Examiners Association. I was its first president, and John was the second. We held some excellent conventions and brought needed attention to this neglected office. Ramsey County and Hennepin County are now served by com-petent forensic pathologists, as evidenced by Lindsey Thomas, MD. Excellent article.

—Thomas C. Votel, MD (retired) St. Paul, Minn.

38 MINNESOTA PHYSICIAN NoVeMber 2013

Letters

Bach’s Brandenburg ConcertosDEC 12 Temple Israel, Minneapolis 7:00pmDEC 13 St. Philip the Deacon, Plymouth 7:00pmDEC 14 Saint Paul’s UCC, Saint Paul 7:00pmDEC 15 Trinity Lutheran Church, Stillwater 3:00pm

Continuing our annual holiday tradition, the SPCO presents Bach’s most cherished set of orchestral works, the Brandenburg Concertos. These cornerstones of the Baroque literature have been praised by generations of music lovers for their profound inventiveness and dazzling instrumental virtuosity.

Handel’s MessiahDEC 20 Basilica of Saint Mary, Minneapolis 8:00pmDEC 21 Basilica of Saint Mary, Minneapolis 1:00pm

Celebrate the holidays with one of classical music’s most beloved traditions as rising young British maestro Jonathan Cohen conducts Handel’s Messiah. A cherished holiday custom since its premiere in 1742, this is sure to be a wonderful musical experience for the whole family and a highlight of the Twin Cities holiday season.

order online thespco.orgphone 651.291.1144

MNPhysician_Oct.indd 1 10/10/2013 12:31:15 PM

Cathy Mooney (608)[email protected]/MedCareers

EOE/AA/LEP

A landscape of opportunities

PhysiciansGundersen Health System, based in LaCrosse, Wis., offers you the opportunity to practice cutting-edge medicine. But we also believe that medicine is about people and that’s why our medical outcomes are among the nation’s best (gundluth.org/accomplishments).

Currently seeking physicians for the following:

We are a physician-led health system,where teaching and research are possible with competitive salary, benefits, CME and loan forgiveness.

• Endocrinology• Dermatology• Family Medicine• Movement Disorder Neurology• Outpatient Internal Medicine• Pulmonary Critical Care

At MMIC, we believe patients get the best care when their doctors feel calm and confi dent. So we put our energy into creating risk solutions designed to eliminate worry. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care.

To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.

Relax.Discover solutions thatput you at ease.

MnPhy POMM.indd 2 4/15/2013 1:22:58 PM

Documents

Minnesota Physician November 2013