Minnesota Health care News September 2011

September 2011 • Volume 9 Number 8

Imaging servicesCally Vinz

Medicaldecision-makingVictor Montori, MD

Sleep medicineJason Cornelius, MD

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A philosophy of caring is good. A history of it is better.Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity.

That’s not just something we say. As the nation’s largest not-for-profit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

To learn more about our communities in Minnesota, call 1-888-GSS-CARE.

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Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), MinnesotaMedical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), MinnesotaBusiness Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options forMainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA),Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans.

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

SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS 3

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PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

ASSOCIATE EDITOR Mary Scarbrough Hunt [email protected]

ASSISTANT EDITOR Scott Wooldridge [email protected]

ART DIRECTOR Elaine Sarkela [email protected]

OFFICE ADMINISTRATOR Juline Birgersson [email protected]

ACCOUNT EXECUTIVE John Berg [email protected]

ACCOUNT EXECUTIVE Sharon Brauer [email protected]

ACCOUNT EXECUTIVE Iain Kane [email protected]

www.mppub.com

SEPTEMBER 2011 • Volume 9 Number 8

CARDIOLOGYTreating little heartsas they growBy Francis X. Moga, MD

BACK PAINSpine-related painBy Daniel Hanson, MD

ARCHITECTUREDesign with dignityBy Alanna Carter, Assoc.AIA, LEED-AP

CALENDARSuicide prevention

HEALTH CAREROUNDTABLEThe wellness revolution

ORTHOPEDICSAnkle injuriesBy Sumner McAllister, MD

FEATUREShrinking thehealth care footprintBy Victor M. Montori, MD, MSc

7 PERSPECTIVE

10 QUESTIONS

6 PEOPLE

NEWS4C O N T E N T S

Jason Cornelius, MD

Minneapolis Clinicof Neurology

Shannon R. Bruce

Horses HelpingHumans

RADIOLOGYEnsuring theright medical imagingBy Cally Vinz

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� Check enclosed � Bill me � Credit card (Visa,Mastercard, American Express, or Discover)

Please mail, call in or fax your registration by 10/06/2011

MINNESOTA HEALTH CARE ROUNDTABLEMINNESOTA HEALTH CARE ROUNDTABLE

Background and focus:Created as part of nationalhealth care reform, accountablecare organizations (ACOs) arenow part of every health carepolicy discussion. As defined bythe 111th Congress, ACOs areorganizations that include physi-cians, hospitals, and otherhealth care organizations withthe legal structure to receiveand distribute payments toparticipating physicians andhospitals to provide care coordi-nation, invest in infrastructureand redesign care processes,and reward high-quality andefficient services.

Exactly what this means isunclear, and a confusing array

of levels and qualifications for ACOs has been proposed. With 2012 as astart date for Medicare reimbursement through ACOs, Congress is develop-ing firm definitions at this time. Some say ACOs turn physicians into insur-ance companies; others say they are a way for physicians to take a leader-ship role in fixing a broken system. As health care organizations race tojoin, create, or redefine themselves as ACOs, they all face more questionsthan answers.

Objectives: We will review the history, goals, and rationale behind theACO model. We will review the latest federal guidelines defining what anACO can be. We will discuss how the ACO will affect health insurancecompanies, employers, and the pharmaceutical industry. We will illustratewhat must not be allowed to happen if the model is expected to succeed.We will examine who decides if ACOs are successful and how those deci-sions will be made. We will explore why so many people, representing verydifferent perspectives on health care, are opposed to the idea and whatcan be done for it to achieve its best potential.

Panelists include:

� Michael Ainslie, MD, Pediatric Endocrinology, Park Nicollet Clinic� Dave Moen, MD, President, Fairview Physician Associates� Jennifer Sorensen, Executive Director, Minnesota Home Care Association� Vernon Weckwerth, PhD, University of Minnesota School of PublicHealth, Health Policy and Management

T H I R T Y - S I X T H S E S S I O N

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Accountable CareOrganizations

Accountable to Whom?

Report Ranks StatesFor Obesity RatesMinnesota ranks as the 32ndmost obese state in the country,according to an annual report onobesity in the United States.

“F as in Fat: How ObesityThreatens America’s Future 2010”was released byTrust for Amer-ica’s Health (TFAH) and the RobertWood Johnson Foundation. Itfound that adult obesity ratesincreased in 28 states last year,including Minnesota, with obesityrates dropping only in the Districtof Columbia. Officials say theobesity epidemic has troublingracial, regional, and income dis-parities. For example, 10 of the 11states with the highest obesityrates were in the South, withMississippi having the highestrates for all adults (33.8 percent)for the sixth year in a row.

“Obesity is one of thebiggest public health challengesthe country has ever faced, andtroubling disparities exist basedon race, ethnicity, region, andincome,” said Jeffrey Levi, PhD,

executive director ofTFAH. “Thisreport shows that the country hastaken bold steps to address theobesity crisis in recent years, butthe nation's response has yet tofully match the magnitude of theproblem. Millions of Americansstill face barriers—like the highcost of healthy foods and lack ofaccess to safe places to be physi-cally active—that make healthychoices challenging.”

The report says Minnesotacould do more to address theobesity epidemic by taking stepssuch as setting nutritional stan-dards for school meals or forfood sold in schools throughvending machines.The state alsolacks requirements for body massindex screenings of children andadolescents or other forms ofweight-related assessments inschools.

HMOs Saw RecordProfits in 2010Despite a troubled economy andrising health care costs, HMOs inMinnesota saw their most prof-

itable year ever in 2010, a newreport from health care researchconsultant Allan Baumgartenshows.

The record profits were aresult of strong margins on bothgovernment and private plans,the report says. In addition,health plan enrollment grew forthe second consecutive year.

The new report, part of thetwice-yearly analysis on hospi-tals and health plans in Minne-sota provided by Baumgarten,focuses on HMO plans inMinnesota, and finds that HMOsand county Medicaid plans inMinnesota had a net income of$264 million, or 3.6 percent ofoperating revenues of $7.3 bil-lion.The report found a netincome from operations of $194million plus investment incomeof $69.8 million. Baumgartennotes that in the past 15 years,HMOs in Minnesota had posteda 3 percent margin only once.

The data show the healthinsurance companies overall hadstrong results. Blue Cross andBlue Shield of Minnesota had a

net income after taxes of $100million, and its Blue Plus planhad a profit margin of 6.9 percentin 2010. Medica Insurance com-pany had a net income of $44million. And HealthPartners’health plans showed a 3.7 per-cent margin for 2010.

As in past years, health plansshowed good profits on stategovernment plans, the reportsays. “In 2010, state public pro-grams (Medical Assistance andMinnesotaCare are the largest)accounted for about 46 percent ofrevenues but 78 percent of healthplan profits.

Minnesota health plansimproved their net income onMedicaid plans (not includinginvestment income) from $119.5million in 2009 to $170 million in2010,” the report says. “On aver-age, HMOs collected $77 more inpremiums from the state permember per month than theypaid out in medical expenses.Losses on MinnesotaCare offsetpart of that profit.”

N E W S

4 MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

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The equipment includes amplified (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment.

To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663,(888) 206-6555 TTY.

Eligibility requirements do apply.

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Federal Program toCover Pre-existingConditionsA new federal program to pro-vide health insurance for peoplewith pre-existing conditionsrecently lowered its premiums inMinnesota.The Pre-ExistingCondition Insurance Plan (PCIP)was created as part of theAffordable Care Act (ACA) andwas designed as a bridge forpeople with pre-existing condi-tions until broader health insur-ance coverage is available in2014. At that time, under the ACAtimeline, pre-existing conditionswill no longer disqualify peoplefrom being eligible for insurancecoverage.

In Minnesota, premium ratesfor PCIP were recently lowered38 percent, part of a nationwidemove by the U.S. Department ofHealth and Human Services toattract more enrollees for theplan. HHS officials say Minneso-tans enrolled in PCIP will haveaccess to a provider network thatincludes 22,264 doctors, 1,120pharmacies, and 129 hospitalsthroughout the state.

Federal officials say PCIPprovides access to health carecoverage for many Americanswho have been locked out of thecurrent system. “With PCIP, you’llbe insured for a wide range ofbenefits, including primary andspecialty physicians’ services,hospital care, and prescriptiondrugs,” says Jackie Garner, theConsortium Administrator forIndiana at the Centers for Medi-care & Medicaid Services. “Youwon’t be charged a higher premi-um because of your medical con-dition and your eligibility isn’tbased on your income.”

In Minnesota, the premiumsfor PCIP now range from $174 to$307 per month. Deductibles varyfrom $1,000 to $3,000, and arange of copays also apply forclinic visits and prescriptiondrugs. Officials note the programdoes not have lifetime caps onwhat the plan will pay out forenrollees.

Since 1976, Minnesota hashad a state program called theMinnesota Comprehensive HealthAssociation (MCHA), which wasalso created to provide insurancefor people who could not pur-chase it on the private market dueto preexisting conditions. MCHA’spremiums vary widely based onwhat deductible is chosen, but ingeneral range from $200 to$1,000 per month.The plan alsorequires some copays.

DHS Reports RiseIn Abuse ofSynthetic DrugsA new report on drug trends intheTwin Cities finds a rising levelof abuse of synthetic drugs.Thetwice-yearly report tracks druguse in the metro area by using arange of sources.

The report, issued by theMinnesota Department of HumanServices (DHS), finds that syn-thetic drugs are sold online andin head shops as incense, bathsalts, or “research” chemicals,but actually are designed andmanufactured for human con-sumption.The drugs—which canbe purchased legally—are soughtfor their psychoactive effects thatmimic the effect of illegal partydrugs, the report says.

The DHS report says that useof synthetic drugs can produceincreased heart rate, delusions,agitation, and extreme paranoia.Carol Falkowski, drug abuse strat-egy officer for DHS and author ofthe report, says that while it’s dif-ficult to determine the actual rateof use of synthetic drugs, thenumbers appear to be increasing.

“These are no longer rare,isolated incidents. A pattern ofuse is emerging with syntheticdrugs,” she said. “Young peopleare attracted to them because theeffects are extreme and glamor-ized and they can be purchasedonline. Many young people thinkthat if something is purchased onthe Internet, it is somehow safe.Nothing could be further fromthe truth.”


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Stefano M Sinicropi M.D. (spine surgeon), Glenn R. Buttermann M.D.(spine surgeon), Louis C. Saeger M.D. (interventional pain physician),Daniel W. Hanson M.D. (spine surgeon), Stephen T. Knuff D.O.(interventional pain physician), Thomas V. Rieser M.D. (spinesurgeon) Seated - Mark A. Janiga M.D. (interventional painphysician), Mark K. Yamaguchi (interventional pain physician)

Blue Cross and Blue Shield of Minnesota has named Zachary Meyer

as its vice president of wellness and prevention. Meyer previously

was executive vice president and general manager at Ceridian Health

and Productivity Solutions and has held positions at Mayo Clinic,

CIGNA Behavioral Health, Allina Hospitals and Clinics, and North

Memorial Medical Center. At Blue Cross, he will be responsible

for leading community and business strategies for wellness and

prevention.

Therese Zink, MD, of Zumbrota, was recognized June 28 at the

Minnesota Rural Health Conference in Duluth for her outstanding

contributions to rural health care. Zink received the Minnesota Rural

Health Hero award for promoting rural health in Minnesota and

across the county. She is a member of the University of Minnesota

faculty, a published author, and a family physician in Zumbrota. As a

faculty member at the University of Minnesota Medical School, Zink

teaches medical students in the Rural Physician Action Program. Zink

also edited an anthology of stories, poems, and essays about rural

health care today, which she shared with rural medical school pro-

grams across the U.S. In Zumbrota, she started a Violence Prevention

Committee to raise awareness about family violence and better coor-

dinate efforts among the police, community members, and mental

health and health care providers; helped create a

fund to help families in need of short-term assis-

tance; and is partnering with a nonprofit to pro-

vide preventive care and fluoride washes to

school-age children in the local school system.

The Minnesota Academy of Family Physi-

cians (MAFP) has selected Anthony Lussenhop,

MD, of Alexandria, as its 2011 Family Physician

of theYear.The award is presented annually to a

family physician who represents the highest ideals

of the specialty of family medicine, including caring, comprehensive

medical service, community involvement, and service as a role

model. Lussenhop has practiced at the Alexandria Clinic for almost

15 years and also serves as the clinic’s medical director. He attended

medical school at the University of Minnesota and did his residency

at the Duluth Family Medicine Residency Program.The award was

presented to Lussenhop during the MAFP All-Member Celebration in

April. MAPF awards were also presented to Jeremy Springer, MD, U

of M/Methodist Family Medicine Residency Program (Teacher of the

Year); Kolawole Okuyemi, MD, MPH (Researcher of theYear); Sara

Oberhelman, MD, Mayo Family Medicine Residency Program

(Resident of theYear); Lindsey Chmielewski (Medical Student Award

for Contributions to Family Medicine); and Jeff Schiff, MD, MBA,

medical director/Health Care Programs, Minnesota Department of

Human Services (President’s Award).

Gov. Mark Dayton appointed the following area residents to state

boards, commissions, and councils effective June 30. Nancy Diener

of Duluth was appointed to the Commission of Deaf, Deaf Blind, and

Hard of Hearing. Chandra Mehrotra of Duluth and NancyTuders of

Grand Rapids were appointed to the Board of Examiners for Nursing

Home Administrators. LaTina Else Siers and Chris Henley, both of

Duluth, were appointed to the Board of Psychology. Amy Behning of

Duluth and Marmie Jotter of Hibbing were appointed to the State

Advisory Council on Mental Health.

P E O P L E

AnthonyLussenhop, MD


Shannon R. BruceHorses Helping Humans

Shannon R. Bruceis the founder ofHorses HelpingHumans, an

equine-assistedlearning programfor domestic

violence survivors.She also developeda 16-hour, equine-assisted pilot

therapy programat the University ofMinnesota EquineCenter in St. Paul.Bruce is a domes-tic violence spe-cialist, a formersupport groupfacilitator forSVABW, and a

former crisis linecounselor for theDomestic Abuse

Project inMinneapolis.

unique form of therapy called equine-assisted psychotherapy (EAP) is beingused more and more by psychotherapists

to help victims of domestic violence, as well asthose suffering from post-traumatic stress disor-der (PTSD), eating disorders, attachment disorderand other behavioral issues, substance abuse,anxiety, depression, and even autism. Similarly,equine-assisted learning (EAL) has been used innon-therapy environments, such as leadershipcourses. In both EAP and EAL, the focus is on theclient learning through experience.

Equine-assisted intervention is gaining respectfrom mental health practitioners worldwidebecause they can measure the effectiveness inclinical outcomes and because the model providesa quick way to assess a client through observinghis or her interaction with the horse. Numerousarticles have been written in professional journalsabout horses being used to help individuals over-come fear, guilt, anger, and feelings of inferiority,helping them to learn self-confidence, self-reliance, and assertiveness. EAP and EAL havebeen used to help ex-soldiers with PTSD learnresiliency skills; to help trau-ma survivors, at-risk youth,addicts, criminal offenders,families, and couples, andeven to teach leadershipskills to corporate groups.

The nonprofit organization called the EquineAssisted Growth & Learning Association(EAGALA) provides EAP/EAL training and certifica-tion programs for mental health professionals andequine specialists in the U.S. Certification must berenewed every two years. EAGALA is affiliatedwith many professional mental health organiza-tions in the U.S., including the American Psychol-ogical Association.

How it works

Horses make ideal therapy partners for severalreasons: because of their size and strength,because they are prey animals, and because flightis their instinctual response to danger.

Horses are acutely aware, perceptive, and sensi-tive to body language and non-verbal communica-tion cues; they respond very accurately to theinternal emotional states of those around them.

Participants never actually mount a horse; riding isnot the therapeutic element or the goal. Rather,participants interact on the ground while accom-plishing tasks such as taking the horse through anobstacle course, playing a game, or solving a puz-zle. Accomplishing individual tasks is not the goal,however; what is important is the experience dur-ing the process. What distinguishes the EAGALA

model from other models is that it is experiential:Clients are allowed to discover connections them-selves about their relationships. No external voiceor force will tell the client what to do; she mustrely on herself. In the process, the client learnshow empowering this feels. Participants frequent-ly have profound insights into problems becausethe human-horse interaction helps the client“mentalize,” i.e., mentally and verbally reach con-clusions about one’s own thinking and behavior.This provides a sense of ownership and responsi-bility for one’s own actions and choices, defeatingthe feeling of powerlessness.

“Horses Helping Humans” in Minnesota

Here in Minnesota, the nonprofit organizationSouthern Valley Alliance for Battered Women(SVABW) sponsors and refers clients to a TwinCities organization called “Horses HelpingHumans“ (HHH), founded in 2009 and one of sev-eral EAGALA-certified programs in Minnesota.Abuse victims can receive up to four half-days oftherapy cost-free, made possible through SVABW

sponsorship, private dona-tions, and professionalsdonating their services. TheHHH program consists ofground exercises in thehorse arena as well as class-es where clients learn torecognize “red flags” inrelationships, how to tell if a

person is trustworthy, how to develop confidence,become assertive, and how to use “narrative ther-apy” to help their children overcome past trauma.Learning is done in groups of eight, one group perweek. Sessions last for four hours twice weekly fortwo weeks.

Often by the time survivors reach HHH, they havespent years living with an abuser and havelearned to become ”invisible” in order to avoidabuse.While interacting with a horse, clients learnto rely solely on themselves, discovering hiddenstrengths—often for the first time in their lives.One woman recently shared tearfully that the actof merely placing a halter around the horse’s headgave her a glimpse of how confidence feels.Another client, while using an unsuccessful stra-tegy to accomplish a task with the horse, wasreminded of how often she had tried an ineffectivecoping mechanism to avoid abuse, only to face theabuse again and again.

Through the unique process known as equine-assisted therapy, domestic violence survivors andothers learn to confidently face and overcomechallenges, manage anger and other emotions,and trust their instincts as they interact in theworld.

Horses Helping HumansEquine-assisted therapy

P E R S P E C T I V E

A

Equine-assistedintervention is gaining

respect from mental healthpractitioners worldwide.


Dr. Cornelius is a board-certified neurologist and sleep specialist practicing with theMinneapolis Clinic of Neurology at their Golden Valley and Maple Grove locations.He is also associate medical director of the North Memorial Sleep Health Centers inRobbinsdale and Maple Grove.

What is “sleep medicine”? Sleep medicine is a specialty dedicated to the diagnosisand management of sleep disorders, which affect more than 70 million people in the U.S.There are more than 80 different conditions recognized by the International Classificationof Sleep Disorders. We have become increasingly aware of the important consequences thatsleep disturbance has on quality of life and overall health.

What special training is required to become a sleep medicine doctor?The practice of sleep medicine is multidisciplinary, so its specialists come from a varietyof medical training/degree backgrounds including neurology, pulmonology, psychiatry,pediatrics, and otolaryngology. In order to be recognized by the American Board of SleepMedicine, providers must pass a certification exam in addition to either satisfying practiceexperience requirements or completing a 12-month fellowship program.

What are some common reasons to see a sleep medicine doctor? The mostcommon complaints are difficulty falling asleep or staying asleep, feeling excessively sleepyduring the day, and trouble maintaining a regular sleep/wake cycle (usually due to shiftwork). The underlying problem can range from mild to life-threatening. People becomeconcerned when they experience poor memory/concentration, low motivation, irritability,and/or inappropriate dozing—particularly drowsiness when driving. Patients or their bedpartners may also recognize characteristic features of disorders like obstructive sleep apnea,restless legs syndrome, and narcolepsy.

What causes obstructive sleep apnea? What are the signs and symptoms?Obstructive sleep apnea (OSA) is caused by a collapse or a narrowing of the upper airway.Normal physiologic changes that take place during sleep can promote OSA in patients withsusceptible anatomic features like a large tongue base or extra fatty tissue around the neck.Snoring and pauses in breathing during sleep are clues that the upper airway is narrowed.OSA often leads to daytime sleepiness because sleep at night is fragmented when the brain iswoken due to upper airway narrowing. OSA also contributes to a number of serious healthproblems like high blood pressure, diabetes, heart attack, and stroke.

Are there any new advances in the treatment of obstructive sleep apnea?Continuous positive airway pressure (CPAP) remains the first-line therapy for OSA. Un-fortunately, a significant percentage of patients become noncompliant with CPAP. A promis-ing alternative is an upper airway stimulation device. It is implanted like a pacemaker andstimulates a nerve activating muscles that move the tongue forward to prevent collapse ofthe upper airway during sleep. The patient can activate the device at bedtime using a hand-held programmer. The North Memorial Sleep Health Centers in Robbinsdale and in MapleGrove are participating in a study to prove that the device is safe and effective.

What kind of metrics and devices are typically used in an overnight sleepstudy? An overnight sleep study, or “polysomnogram,” involves sleeping overnight in a


Jason Cornelius, MD

1 0 Q U E S T I O N S

Photo credit: Bruce Silcox

&

laboratory designed like a hotel room. Small electrodes are attachedto your head, face, and legs to record brain waves, eye movements,and muscle activity. Flexible bands are placed around your chest andabdomen to measure breathing. A technician places a clip on yourfinger to detect blood oxygen levels, activates video recording and amicrophone to record snoring, then places a sensor under your noseto measure air flow/pressure. Most people are comfortable with theequipment. Your sleep is monitored remotely from another room.

What should people know about over-the-counter (OTC)and prescription sleep medications? Your health care pro-vider may recommend OTC or prescription sleep aids after carefulconsideration of such things as your age, current medications, andother medical conditions. You should review potential side effectsand start treatment in a familiar setting until you know how you willrespond. Prescription sleep aids are typically used for one to twoweeks while the patient makes sleep habit and behavior changes.They are usually not recommended for long-term use, except underthe direction of a sleep specialist.

What can you tell us about insomnia? “Insomnia” refers tothe inability to fall asleep or stay asleep despite adequate sleepingconditions, resulting in impaired daytime function. Ten to 30 percentof the general population experience some form of insomnia. Stress,depression, anxiety, too much caffeine, smoking, chronic pain, undi-agnosed sleep disorders, or poor sleep habits can all contribute.

Insomnia is usually temporary but can develop into a chronic disor-der. Although medication can be useful for short-term management,sleep specialists will focus on detailed sleep hygiene and behaviormodifications.

What is restless legs syndrome (RLS)? RLS involves a strongurge to move the legs (or arms), predominantly in the evening hoursduring periods of inactivity. Moving or stretching reduce symptoms,but RLS can still impact one’s ability to fall or stay asleep. The condi-tion can be worse in pregnancy or iron-deficiency. Some patients alsohave jerking of their limbs while sleeping. This condition is known asPeriodic Limb Movement Disorder (PLMD). Regular exercise andavoiding stimulants like caffeine or nicotine can help reduce RLS orPLMD symptoms, but medication may still be required.

What should people do to maintain proper sleephygiene? Allow sufficient time in your schedule for sleep—mostpeople need 7 to 8 hours. Think about how your daily activitiesaffect sleep: Limit caffeine intake after noon; don’t smoke close tobedtime; avoid alcohol or heavy meals several hours before bed; andget regular exercise. Establish a routine that includes an hour of quietrelaxation before going to bed. Your bedroom should be dark, quiet,and kept at a cool temperature. Use the bedroom only for sleep (andsex)—not studying, paying bills, using a computer, or discussingproblems. Finally, try to get up at the same time each morning, andavoid napping.


Good sleep hygiene means doing everything one canto ensure a proper night’s rest.

SPINE SURGEONS

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

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

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

NON-SURGIC AL SPINE C ARE

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

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

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

esearch has shown that complex problems like

back and neck pain are best treated by centers

of excellence that specialize in spine. Consequently, in

2010, Summit Orthopedics created Summit Spinecare

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

6,500 spine center space in Woodbury.

Summit Spinecare combines the expertise of three

non-surgical spine specialists, three fellowship-trained

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

and an injection suite — all under one roof.

We’ve also invested in patient education with an

on-line spine encyclopedia at www.SummitSpinecare.

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

36-page Home Remedy Book with exercises that relieve

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

for you to provide as a resource to your patients.

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

sufferer no longer has to drive around town anymore.

Now isn’t that a welcome relief?

At last, a spine center with everything under 1 roof

R

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

651.738.BACKwww.SummitSpinecare.com

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Patients with medical questions rely on physicians to suggestthe best course of action. In some cases, it is appropriate touse high-technology diagnostic imaging (HTDI) procedures

such as magnetic resonance imaging (MRI), computer tomogra-phy (CT), positron emission tomography (PET), and nuclearcardiology tests. However, while incredible technologicaladvances in HTDI are helping to ensure more accurate diag-noses, the steep increase in the number of tests ordered hasnot corresponded proportionately to improved patient out-comes. Potential overuse of such tests can expose patientsto unnecessary radiation, delay diagnosis, and contributeto rising health care costs.

Through a collaboration of medical groups, healthplans, and the Minnesota Department of Human Ser-vices, the Institute for Clinical Systems Improvement(ICSI)—a nonprofit, independent organization inMinnesota—developed a patient-oriented, cost-effectiveapproach to ordering HTDI scans that enables patientsand physicians to discuss medical imaging options basedon evidence and consistent standards of practice.

Before developing this “decision-support” model, ICSIcoordinated a three-year study in which 4,500 providers in five

Minnesota medical groups ordered more than one million HTDIscans. Providers included Allina Medical Clinic, Essentia Health,

Fairview Health Services, HealthPartners Medical Group, and ParkNicollet Health Services. The study showed that using an evidence-based,

decision-support option increased the likelihood of appropriate imaging,improved the diagnostic quality of scans ordered, and ensured that patients got

the right test in a timely manner. In November 2010, ICSI made thistool available to all medical groups and hospital-based clinics inMinnesota—the first time a common set of criteria has been adoptedby many medical groups on a statewide level.

Strengthening the provider/patient relationship

Prior to implementation of this new option, if a patient complainedof a nagging headache, the physician might have thought an MRI waswarranted. Before the test could be ordered, however, the physicianwould need to contact a radiology benefits management (RBM) firm todetermine if the scan would be covered by the patient’s insurance plan.The call might take only a few minutes, but approval could sometimestake a day, and if coverage was denied, the physician would need todetermine if there was an alternate diagnostic test.

With the ICSI solution, the physician enters a patient’s symptomsinto the decision-support software, along with the scan selected. Thedecision-support tool then rates the diagnostic value of the imagingscan selected. Scores of 7, 8, and 9 are shown in green, indicatingscan types that are highly warranted for the condition. Moderate rat-ings of 4, 5, and 6 are shown in yellow, while low scores of 1, 2, and3 are shown in red, signifying that a test may not be indicated for thesymptoms. When this happens, the software suggests better optionsbased on criteria from the American College of Radiology.

Now when a patient complains of a persistent headache, patientand physician can see together what is most appropriate and sharein the decision-making. Because many Minnesota health plans acceptthe decision support tool’s criteria for selecting appropriate scans,most physicians do not need prior approval from an RBM firm.

R A D I O L O G Y

Ensuring theright medical

imagingImproving accessto care

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Helping physicianshelp the patient

Physicians already using decisionsupport say it’s reassuring to knowthat other health care providersdeveloped the criteria used in thesoftware.

Allina Medical Clinic DistrictDirector Phil Hoversten, MD, said,“Quality is defined by a wholegroup of constituents, not by indi-vidual doctors or clinics. Theamount of information in the com-puter makes using the decision-support tool far superior to callingan RBM. Plus, the tool’s simple drop-down menu and immediateresponse are very convenient.”

“Physicians are committed to using the latest scientific knowl-edge to make good decisions,” said Kevin Larsen, MD, chief med-ical informatics officer and associate medical director at HennepinCounty Medical Center (HCMC). “This tool supports physicians inthat effort. Physicians cannot always keep up with all of the changesin today’s medical environment,” said Larsen. “If we see a medicalsituation we don’t encounter often, this is a way to bring us up-to-date, patient-specific information with the latest evidence telling uswhat the right test might be.”

“The average length of time for a new technique or businesspractice to become established is about seven years,” said RossChambers, MD, of Fairview Medical Group in Milaca, Minn. “Foryears, a doctor may have ordered an MRI for headache, but ifsomething were to change in the field of neurology, it might takeseven years for that doctor to change. We now can educateproviders at the time they order a test. This can impact practicesvery quickly.”

“We have integrated the RadPort software (part of the decision-making tool) in our electronic healthrecord,” said Chip Truwit, MD, chiefof radiology at HCMC. “This is not atrivial matter. It lessens both patientfrustration and physician time to haveeverything coordinated.” Health careorganizations can also access thedecision-support criteria via the Web,making this option available to alltypes of clinics.

Avoiding unnecessary radiation

Physicians are also concerned aboutexposing a patient to unnecessary radia-tion if a CT scan is inappropriatelyordered. In a majority of cases, the diag-nostic potential of a CT scan outweighsthe risk, but a 2007 New England

Journal of Medicine article reported that exposure to too much radia-tion, especially in children, is estimated to contribute to 1.5 percentto 2 percent of cancer deaths in the United States each year.

“Radiation exposure concerns us greatly as radiologists,” saidTruwit. “We want to make sure patients are not exposed needlessly.

With this tool, we are more likelyto get the right test done the firsttime.”

PPrroovviiddiinngg vvaalluuee

“We don’t want to perform thewrong test,” Truwit said. “Somephysicians might order a CT with-out contrast solution to evaluate formetastatic disease. Unless a patienthas large metastatic lesions, we arenot going to see them on the regularCT scan or characterize them well.

The decision-support tool has algorithms that have looked at posi-tive and negative exams given the history of the patient. We try notto do a study that isn’t going to have a high likelihood of a yield.”

Since November 2010, this has become a statewide initiative,the objective being to standardize HTDI ordering and base it on evi-dence. This is the first time a common set of criteria have beenadopted by many medical groups statewide.

“Patients are very sophisticated now,” said Truwit. “In this elec-tronic era, they know an awful lot about their conditions. This toolenables us to engage them in their care in a new way. It’s better forthem, better for physicians, and better for the health system. It hasno downside.”

Cally Vinz is vice president of clinical products and strategic initiatives atICSI, headquartered in Bloomington, Minn.


This example shows that a chest CT would provide marginalvalue for the patient. Based on evidence, the decision-supporttool is recommending an MR.

Radiationexposure

concerns usgreatly as

radiologists.


With up to 500 operationsper year, Children’sHospitals and Clinics

of Minnesota performs the mostpediatric cardiac procedures inMinnesota. Alongside thesesurgeries, Children’s also conductsa growing number of adult surgicalprocedures. Adults who were bornwith heart defects and wereoperated on as childrenrequire lifelong care fortheir condition—by doctorsspecially suited for their once-tiny hearts.

Background

The idea of performing heartsurgeries on adults at a chil-dren’s hospital may seem odd,but at Children’s Hospitals andClinics of Minnesota, it’s becom-ing more and more common. Thisphenomenon is partly due to the suc-cess we have had in treating majorheart issues in children. Twenty or 30years ago, many children with heartdefects didn’t live long. But today,

medical practices and techniques haveadvanced so that even infants with majorheart defects are living longer and healthi-er lives. As a result, we regularly seepatients well into their 20s and beyond.

Early successes

One example of the long-term relation-ships we now have with our heart patientsis the story of Nick Zerwas. Nick wasborn with a condition called tricuspidatresia; his heart had three chambersinstead of four and he needed surgery

days after he was born. This was in 1980, well before most heartdefects could be detected in utero, so his parents had taken himhome from the hospital before they realized anything was wrong.When Nick started turning blue, he was rushed to Children’s, wherehe was diagnosed and operated on. Nick endured nine more open-heart surgeries. When he was first diagnosed, he was not expectedto live past his seventh birthday. Today, Nick is 30, married, andstill receives care from our cardiovascular staff.

This trend of treating adult patients in pediatric facilities is nolonger a surprise to those in the medical community. According tothe journal Circulation, the number of adults in the U.S. with con-genital heart defects is estimated at upward of 1 million—meaningthat there are nearly 1 million people with heart defects who willcontinue to need specialized care.

Amy Wynia is another example. Now in her late 30s, married,with two children, Amy has endured heart surgery three times: onceimmediately after her birth in 1973, and again at ages 5 and 15.The last two surgeries took place at Children’s.

She was born with tetralogy of Fallot, sometime called “bluebaby” syndrome, a defect that is a combination of four heart abnor-malities and results in a lack of oxygen in the blood. Her first sur-gery took place when she was less than 24 hours old. The cardiacsurgeon created a connection between the aorta and the artery tothe lung, providing more blood flow and thus improving her color.Amy’s physicians knew she would need more surgeries later on. Asshe grew, so too would the strain on her heart.

By the time she was five, Amy’s heart needed a more completerepair. Surgeons closed the hole between the two lower chambers of

C A R D I O L O G Y

Treatinglittle heartsas they grow

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Pediatriccardiac care continues

into adulthood

Francis X. Moga, MD

her heart, removed the additional mus-cle tissue obstructing blood flow to herlungs, opened the pulmonary valve, andclosed the surgical connection of the lungartery and aorta created when Amy wasa newborn.

By age 15, Amy’s heart had againoutgrown its previous repairs, so surgeonsplaced a valve to stop the backflow ofblood from her lungs. As she grew, wefollowed her closely, especially during hertwo pregnancies, and helped her make thetransition from her teenage years intomotherhood. Amy continues to see us forregular check-ups.

Pediatric specialists for adult hearts

When a child is diagnosed with a congenital heartdefect, it is a bitter pill for a family to swallow.Thankfully, the outcomes for that child’s survivaland the chance of living a full life are much greatertoday than they were decades ago.

Today, more than 95 percent of congenitalheart defects can be detected in utero, most com-monly at 18–20 weeks of gestation. This early diag-nosis vastly improves a child’s chances of survival.

One of the great success stories in the last fewdecades is the surgical repair of hypoplastic left heart syndrome(HLHS). HLHS is a complex and rare heart condition in which thechambers and arteries on the left side of the heart are small andunderdeveloped, with valves that don’t work properly. Prior to themid-1980s, HLHS was a fatal diagnosis, but in 1985, surgeons atChildren’s became the first in the Upper Midwest to perform thethree-part surgery required to treat HLHS. Today, Children’s is aleader in HLHS treatment, with one of the highest success rates inthe country.

Patients like Eric Carlson are alive today because of these live-saving procedures. Eric was diagnosed with HLHS while still in thewomb. Six days after he was born, we performed the first of threesurgeries he would need to repair his heart. The national survivalrate following the first stage of surgery is approximately 82 percent,but the survival rate at Children’s over the past three years has beennearly 100 percent.

Before his third birthday, Eric had two more operations thatwere required to completely repair his heart. He is now an activesecond-grader who enjoys riding his bike and playing with his twoolder brothers.

Eric, and others like him, will still need to see a specialistthroughout his life, but because of the HLHS procedure and ever-improving outcomes, children who would otherwise not survive areliving well into their adult years. The doctors best suited to treattheir hearts are the ones who have been treating them since thebeginning.

This trend of intermingling child and adult cardiac specialtieshas led many pediatric cardiac surgeons to seek extra training inadult care, and adult cardiac surgeons to seek extra training inpediatrics. This training is steadily becoming standard, and many

of our cardiologists and surgeonsconsult with older patients andtheir care teams in adult facilities.

Improving treatment

When it comes to treating heartdefects and the many surgeriesthey require, numbers matter. AtChildren’s, we’ve performed morethan 11,000 pediatric heart sur-geries since our program’s incep-tion in 1973; we are the largest

provider of pediatric cardiovascular services inthe region. In April 2010, we opened a new car-diovascular center at our Minneapolis hospital,which features a state-of-the-art operating roomand around-the-clock access to cardiac special-ists. The new facilities are helping us improvetreatment of children and adults with heartdefects, helping them live fuller, richer lives wellinto their 30s, 40s, and beyond.Francis X. Moga, MD, is a pediatric cardiothoracic

surgeon at Children's Hospitals and Clinics of

Minnesota, located in Minneapolis.


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Talking about spine-related pain can seemconfusing due to the variety of symptomsinvolved and because of other, pre-existing

conditions. There are also a number of care optionsthe patient may take: conservative (exercise or physi-

cal therapy), interventional(e.g., injections), and surgi-cal—all of which have a placein treating spine-related pain.Spine care professionals have

long emphasized the need for anindividual to develop strong“core” muscles around thespine and pelvis in order toimprove spine health. Somepopular exercise activitiessuch as Pilates, yoga, andkettle bells focus onstrengthening andstretching the musclesand ligaments around thecore. Only 20 to 30 min-utes a day is enough timefor a full set of exercisesand enough time to streng-then the spine. Developing anexercise program that can beadhered to and practiced four

or five times per week is probably the most impor-tant thing a person can do to maintain a healthyback. Other areas of spine health include goodnutrition, adequate fluid intake, and enough rest.

Many websites feature core-stabilizing exercisesthat are helpful, but getting expert advice and atten-tion from a trained health care professional—a physi-cal therapist, athletic trainer, or chiropractor, forexample—is often very helpful when beginning acore-strengthening program.

Causes of spine injuries

We can injure our spines in many ways.Often the process of aging itselfbrings arthritis, which is causedby the disks in the spine (thecushions between the vertebrae)becoming dehydrated. Thismakes them more susceptibleto degenerative conditionsthat can cause pain. So it’simportant to drink enoughwater each day. Pain can belocalized to the back and neckbut can also cause “referred”pain, pain that radiates into thearms or legs.

B A C K P A I N

Spine-relatedpainCauses andtreatment options

By Daniel Hanson, MD

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The most common cause of back and neck painis muscle strain. This happens when a person lifts some-

thing improperly and does not have a sufficientlystrong core. Pain caused by muscle strain is routinely

treated with a brief period of rest and over-the-counter anti-inflammatory medicine. Occasion-ally, stronger pain medications are needed, suchas muscle relaxants. Pain radiating into the arm

or leg is more concerning. It is often due tonerve compression, which is often associatedwith an area of numbness or muscle weak-ness. When this occurs, seeing your pri-mary care physician or spine specialist isoften recommended. Many nonsurgicaloptions still exist, but an MRI or CT mye-logram (an MRI or CT using contrast dye)is needed eventually to diagnose the sourceof the nerve compression and to focus non-surgical treatment on that nerve or area.

Types of back pain

Some of the most common causes of back painin children are scoliosis (curvature of the spine)

and pars fractures—also known as spondylolysis—commonly due to sports-related injuries. (Spondylo-

lysis means that stress on the fifth lumbar vertebra hasfractured it, weakening the spine so that it cannotmaintain its proper position and starts to shift out of

place.) In adults, the most common cause of back pain is diskherniation in the lower back and neck. The disk is a flat, round struc-ture that separates the vertebrae in the spine. In disk herniation, thedisk’s central portion “herniates,” or slips into the spinal canal, put-ting pressure on a nerve root which then causes pain. As we age,additional problems such as spinal stenosis (arthritic bone spurs thatnarrow the spinal canal) can become more common. This can oftenprevent an older person from standing or walking for a long periods.

Spine-related pain treatment options

While various minimally invasive surgical treatments are available,there are more conservative, nonsurgical measures that can be triedfirst, such as bracing, core-strengthening exercises, and/or injections.The most important thing one can do to prevent back pain is todevelop a weekly exercise routine.

Another helpful intervention involves a diagnostic and/or thera-peutic injection in the spine. Epidural steroid injections are commonlyused to treat cervical and lumbar-mediated arm and leg pain. Ineither of these conditions, a nerve in the neck or lower back is com-pressed. Common causes of nerve compression are disk herniation,spinal stenosis (arthritic bone spurs), balance instability, and narrow-ing of the nerve foramen. The foramen is a natural opening or cavityin a human body, usually one through which blood vessels and nervespass through bone. In addition, inflammatory reactions can occuraround the nerve.

Many studies have been performed that show the therapeuticbenefit of injections. Steroid drugs help because they stop inflamma-tion, breaking the cycle of pain and contributing to stabilization ofthe nerve membrane. There are several types of epidural steroid injec-tions, including caudal, interlaminar, and transforaminal. Of these

three types of injections, transforaminal—or selective nerve root—injections allow the steroid to be concentrated in the area of nervecompression. They are also performed to confirm or diagnose thesource of painful symptoms. Confirmation of the source of pain leadsto significantly better surgical results.

Other types of injections to treat back and neck pain includefacet injections and medial branch blocks. The term “facet” refersto the facet joint, the small stabilizing joint between each vertebra.The nerves in the facet joint are called “medial branches”; “block”means to numb the pain. If the pain is at the facet or medial branch,a procedure called a medial branch rhizotomy (deadening the nerve ina facet) can be performed, which will provide two to 18 months ofpain relief.

When nonsurgical treatments fail, then surgery may be recom-mended. The physician will determine the scope of treatment optionsbased on the patient’s diagnosis and diagnostic imaging to determinethe source of compression or degenerative changes. Technologicaladvances are being made all the time, resulting in improved surgicaloutcomes. Examples include minimally invasive approaches andmotion preservation technologies such as cervical and lumbar diskreplacements. Sometimes a spinal fusion is recommended.

The combination of conservative care (adapting a healthy life-style), diagnostic/therapeutic interventional therapies, and surgeryprovide most patients with a successful outcome in managing theirback, arm, and leg pain.

Daniel Hanson, MD, is a board-certified spine surgeon with Midwest SpineInstitute and a member of the American Academy of Orthopedic Surgeonsand the Norwegian American Orthopedic Society. He is also medical directorof orthopedics at Unity Hospital in Fridley.


Cateringby Seward Co-op

At a conference onaging, a speakerasked the audience,

“If you could take only oneitem with you to a nursinghome, what would it be?”As the room rang with sto-ries of pocket watches, loveletters, and photo albums, Irealized that these items repre-sented different symbols for thesame possession: family.

Since that conference, the focusof my architectural design insenior care communities hasbeen to create an environ-ment that supports residents,their loved ones, and theproviders who care forthem. Every room in a carecenter offers an opportunityto contribute to the autono-my, dignity, and independ-ence of residents. As we age,even though our day-to-daytasks change and our lives stoprevolving around careers, thereremains the desire and need for

family, a need to feel connected to others, and a needto feel valued.

To create an environment that supports eachsenior’s whole self, I felt that, as a designer, Imust first walk in his or her shoes. And that’sexactly what I did.

Experiencinglong-term careIn order to betterunderstand the chal-lenges that residentsface in a skilledcare center, I askeda client if I couldspend 24 hours asa resident in her

care center, a building devel-oped in the 1960s as a model medical institu-

tion. I was admitted in the morning and given a stroke diagnosis,along with an associated care plan. The right side of my body wasimmobilized, and I was in a wheelchair. Being in a wheelchair helpedme to see firsthand obstacles associated with the inability to move onmy own.

My main focus was identifying physical challenges posed by thebuilding’s design, but I quickly found myself preoccupied with anemotional struggle. As I made my way to the dining room, lifts andmedical carts cluttered the hallways due to a lack of storage, makingit very difficult for me to navigate down the narrow corridors.Because of the clutter in the corridors, I was not able to access thehandrails along the wall to pull myself down the corridor. Transitionstrips located between the carpet and hard surfaces presented anoth-er challenge. The height differential made it very difficult for me toget my wheelchair through the doorway into the dining room. Aftera couple of failed attempts, my 32-year-old independent spirit wasbroken and I found it easier to depend on the staff to transport me.

When I finally made it to the central dining room, I wanted toget to know my tablemates. Unfortunately, the capacity of this din-ing room was 70 people. Since there was a fixed food schedule, all70 residents were eating while the staff pushed squeaky metal cartsaround the room and tried to coax residents to finish their meals.I could not even hear myself think, let alone the question a womansitting beside me asked. Given that mealtimes are traditionally atime of socializing and connecting, this was a lost opportunity.

The physical design challenges were considerable, but thebiggest lesson I learned was that, though the structures that com-pose a setting are important, the greatest opportunity to positively

A R C H I T E C T U R E

There’s a huge difference inthe kind of home care youcan receive from someonewho really understands whatyour life is like as a senior,especially your concerns anddesire for independence.

Our loving, caring, compassionateseniors are there to help. We offer all theservices you need to stay in your own home, living independently.

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Call us today. Like getting a little help from your friendsTM.If you’re interested in becoming a provider we would like to hear from you too.Minneapolis Area: 763-694-0165 • St. Paul Area: 651-274-4285

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D E S I G N with dignityLessons from 24 hours ina senior care center

By Alanna Carter, Assoc. AIA, LEED-AP


affect a resident’s life lies with the caregivers.Not long after I arrived, my morning cup of coffee kicked in,

and I needed help going to the bathroom. I pulled the cord and theassistant came, helped get me onto the lift, and began unbuttoningmy pants. I’m sure that this was a completely insignificant task forthe assistant, but for me it was an awakening to awareness of howlittle dignity is left for residents of a care center, and how little self-care they are able—or allowed—to do themselves. When stripped ofdignity and the ability to care for one’s self, or contribute meaning-fully to life, it is understandable how the will to live can fade.

After my experience in a care center designed under the medicalmodel, I promised myself that I would no longer design nursinghomes this way, but I would focus on supporting the individual’sneeds and desires. This is culture change. Further, it is not only thedesign of the physical building that provides this support, but alsothe way in which care is delivered. The goal of the culture changemodel is to transform nursing homes into comfortable environmentsthat support dignity, self-determination, and a sense of home. Themodel develops places where residents are supported in being asindependent as possible, and visitors are comfortable spending theday with loved ones.

“Back to basics” designHow do you design for this environment? It’s simple: Go back tothe basics. At the core of culture change is home. Homes are associ-ated with independence. Care centers operating under the culturechange model strive to be as close to home as possible while stillproviding state-of-the-art care. Here are some strategies used toachieve this.

Flexible wake-up schedules. No longer is there a fixed, one-schedule-fits-all mindset. Residents wake up on their own instead ofhaving the staff wake everyone on a pre-determined schedule. Notonly does this give residents more self-determination and independ-

ence, but they are also morerested throughout the day.Thus, they tend to participatein more activities, interactsocially with peers and staff,and have a better appetite.

Open dining plan.Another change is toreplace central diningareas with servingkitchens and attached

dining rooms that serve the 10 to 20 resi-dents of a “household.” Similar to the flexible wake-up time,

open dining permits residents to eat on their own schedule. Servingkitchens in each household allow staff members to double as short-order breakfast cooks, so residents can have a warm breakfast oftheir choosing, regardless of what time they get up. This supportsgreater connection between residents and staff, as residents can sitat the counter and talk with providers while watching breakfastbeing made.

Improved resident/staff interaction. Better interaction betweenstaff and residents is an important aspect of the culture changemodel. In the past, the nurses’ station was a central desk. Staff

SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS 17Design with dignity to page 19

13 Emerging Research on Spinal Cord InjuryKenny Grad School is an education seriesfor people with a spinal cord injury andtheir families. We will explore how tolocate clinical trials and determine whetherthe research is of interest. Information alsowill be provided on how to best find andevaluate research findings. Free, but regis-tration is required; call 612-863-7306.Tuesday, Sept. 13, 6:30–8 p.m., SisterKenny Rehabilitation Institute, 800 E.28th St., Minneapolis

14 Joint Replacement: What’s New?Is it Right for Me?Attend this seminar for the latest informa-tion in joint replacement. Experts in ortho-pedic medicine share their knowledge soyou can make smart health care decisions.To register, call 952-806-5696.Wednesday, Sept. 14, 7–8 p.m., TRIAOrthopaedic Center, 8100 Northland Dr.,2nd Floor, Bloomington

15 4th Annual David A. RothenbergerLectureAttend this presentation and hear Dr.William R. Brody, former president ofJohns Hopkins University and provost ofthe University of Minnesota’s AcademicHealth Center, speak about the toughissues facing today’s academic healthcenters. Presented by the University ofMinnesota Medical School, this event isfree and open to the public.Thursday, Sept. 15, 4–5 p.m., MayoAuditorium, 420 Delaware St. S.E.,Minneapolis

19 Infant CPRDo you care for an infant? This class pro-vides basic cardiopulmonary resuscitationinstruction for parents or child caregivers.Certification is not given with this class.Please register by calling 651-480-4440.Monday, Sept. 19, 7–9 p.m., ReginaMedical Center, 1175 Nininger Rd.,Family Birthing Center, 1st FloorClassroom, Hastings

21 Aging Eye ForumEye specialists from Phillips Eye Institutewill discuss glaucoma, cataracts, intraocu-lar lens implants, macular degeneration,low vision, and retinopathy. Refreshmentswill be served. Free, but seating is avail-able. Registration is required. Please callBeth at 612-775-8964.Wednesday, Sept. 21, 6–8 p.m., PhillipsEye Institute, 2215 Park Ave. (enter doorson 710 E. 24th St.), Minneapolis

22 Interstitial Cystitis (IC) EducationIC is also known as painful bladder syn-drome. This quarterly session offers womenan opportunity to learn more about IC andvisit with other women dealing with theseissues. Each meeting has a special guestspeaker. Free, but registration is requested;call 952-993-0377.Thursday, Sept. 22, 6:30–8 p.m., ParkNicollet Stilts Bldg., 6700 Excelsior Blvd.,St. Louis Park

28 Young Parkinson’s/Movement DisorderSupport GroupThis support group is designed for peoplewith Young Parkinson’s Disease/MovementDisorder and their families. This is a greatplace to share questions, concerns, or feel-ings with other individuals living withParkinson’s. If you have any questions,contact Tanya Rand at 651-232-2258.Wednesday, Sept. 28, 6–7:30 p.m.,Bethesda Hospital, 559 Capitol Blvd.,B-Level Conference Rm., St. Paul

Send us your news:We welcome your input. If you have an event youwould like to submit for our calendar, please sendyour submission to MPP/Calendar, 2812 E. 26thSt., Minneapolis, MN 55406. Fax submissions to612-728-8601 or e-mail them to [email protected]. Please note: We cannot guaranteethat all submissions will be used. CME, CE, andsymposium listings will not be published.

America's leadingsource of health

information online

Suicide Prevention WeekSeptember 2–8

Suicide takes the lives of nearly 30,000Americans every year. Research has consis-tently shown a strong link between suicideand depression, with 90 percent of the peo-ple who die by suicide having an existingmental illness or substance abuse problem atthe time of their death. It is not only youngadults and adults who are at risk; childrenand the elderly also can suffer from majordepression.Most suicidal people do not want to die;they want the pain to stop. The impulse toend it all, however overpowering, does notlast forever. Your willingness to talk aboutdepression and suicide with a friend, familymember, or co-worker can be the first stepin getting help and preventing a suicide.Watch for these warning signs:• Ideation (thinking, talking, or wishing

about suicide)• Substance use or abuse (increased use or

change in substance)• Purposelessness (no sense of purpose or

belonging)• Anger• Trapped (feeling like there is no way out)• Hopelessness (there is nothing to live for,

no hope or optimism)• Withdrawal (from family, friends, work,

school, activities, hobbies)• Anxiety (restlessness, irritability, agitation)• Recklessness (high risk-taking behavior)• Dramatic changes in moodIf you or a friend is in immediate danger,call 911. If you or a friend is in crisis, callthe National Suicide Prevention Hotline at1-800-273-8255. For additional suicide pre-vention and depression information, visitSuicide Awareness Voices of Education(SAVE) at www.save.org.

27 Suicide GriefSupport GroupThis support group is for adults and highschool students who have experienced adeath by suicide. Family and friends arewelcome to attend. Advance registration isrequired; call 952-758-4431.Tuesday, Sept. 27, Mayo Clinic HealthSystem (Queen of Peace), 301 2nd St. N.E.,New Prague Locate additional Minnesotasupport groups at www.save.org.

September Calendar


spent most of their time in thisfixed location, leavingthe area to check onresidents when a prob-lem arose. Centralizednursing keeps providersand residents separate;culture change stressesdecentralized nursing. Inthe new model, staff andresidents work, live, andsocialize together. Chartingand other tasks take place on a comfortable couch in a householdliving room instead of at a desk chair behind a behemoth nurse sta-tion. In addition, staff are available to one another at all times viatext messaging and phone calls, making overhead paging obsolete.

Accommodation of visitors. Another important element indesign is catering to visiting family and friends. The culture changemodel takes steps to ensure that visitors are comfortable spendingtime in the facility. For example, the smells of ammonia and imagesof stained carpets have cast a dark shadow in the minds of manyindividuals. Now there are carpet tiles that can be quickly and easilyreplaced when soiled, and products that eliminate ammonia fromfibers to reduce the acrid smell. In addition, many facilities nowoffer wireless Internet connection and have coffee shops and giftshops that residents and their guests will appreciate.

Creating a home-likeatmosphereDesigning for a home-like environ-ment is a key concept in a senior liv-ing center layout. In older facilities,everything is shared—even the bed-rooms. In contrast, the culturechange model includes public, semi-private, and private places.Mirroring the familiar idea of liv-ing in a house, a facility is sepa-

rated into smaller cottages, each housing 12 to 20residents. This arrangement supports improved care for residents inmany ways:

• There is a better staff-to-resident ratio, allowing for efficient, morepersonalized care.

• The family-oriented environment encourages stronger social bondsamong the residents.

• Residents have more privacy because they are sharing their imme-diate living space with only a handful of others, rather than with40 to 80 people on a large, impersonal ward.

The culture change model notes the importance of normal socialpatterning and designs in a hierarchical household system. Forexample, when residents walk into their cottage, they enter a lobbyarea that brings to mind a household porch or foyer. This is a com-mon area where residents can meet and greet visitors, staff, andother residents, but need not feel obligated to allow them passagefurther into their home.

Next in the layout are the kitchen, dining room, and livingroom spaces. They serve as semi-private spaces where residents inthe household can come and go as they please and visit with fam-ily and friends.

In the back of the cottage are the bedrooms. Each residenthas his or her own room, offering complete privacy. Residents candecorate their rooms as they wish. This is an area where residentscan spend uninterrupted quality time with their family and friends.

My research as a resident within a nursing home was invalu-able, resulting in a whole new perspective with regard to designingsenior communities. Adopting the culture change model is a positivestep toward offering seniors the dignity, independence, and overallenvironment that they deserve. For people who cannot safely stay intheir own homes, designers can best support them emotionally andphysically by creating a positive, home-like environment.

After all, home is where the heart is.

Alanna Carter, Assoc. AIA, LEED-AP, isdirector of senior environments atMohagen/Hansen Architectural Group andthe founder and current president of SageMinnesota (Society for the Advancementsof Gerontological Environments).

Design with dignity from page 17

Leg Pain StudyDo your legs hurt when you walk?Does it go away when you rest?

Or, have you been diagnosed with PAD?You may have claudication, caused by lack

of blood supply to the leg musclesThe University of Minnesota is seeking volunteers

to take part in an exercise-training program,funded by the National Institutes of Health

To see if you qualify,contact the

EXERT Research Team at

612-624-7614or email [email protected] visit EXERTstudy.org

EXERTstudy.org


The goal of the culture change model isto transform nursing homes into comfort-able environments that support dignity,self-determination, and a sense of home.

MR. CHRISTENSON: How do you definewellness?

DR. LAWSON:Wellness is really about fullyembodied health from a holistic standpoint.All the perspectives—mental, emotional,physical, environmental, relational—need tobe involved. If you are just talking aboutwellness from a physical standpoint, you aremissing three-fourths of the boat. The secondpart of it is that wellness does not excludedisease or disability or injuries. Many, manypeople who are suffering from some kind ofdiagnosis or injury can still pursue theirhighest level of wellness and well-being forthemselves—that is important. The thirdthing is that it is not a set place that any ofus are ever going to arrive at. It is a movingtarget, an ongoing evolution, and a commit-ment to a conscious participation in a well-lived life.

DR. RADCLIFFE: As someone who sees patientsevery day, I see wellness as a balance. It is away to meet people where they are, withtheir experience, their heredity, their labora-tory tests, and their resources, and then find-ing out what they are willing to do and howwe can make a difference in their lives.

MS. SARGENT: Health is about individualstruly understanding what is happening intheir lives and developing a path and aplan to best achieve wellness at it relatesto what they are experiencing. Expanded tothe employer, it is the same thing. Everyemployer needs to have an understanding ofwhere they are and where they want to beand customize that plan for wellness fortheir organization.

MR. CHRISTENSON: Bill, how do you distinguishbetween wellness and preventive medicine?

DR. LITCHY: Some people confuse preventiveservices and preventive medicine and well-ness. Preventive services are those things weprovide—at first-dollar coverage—to peopleto make sure they do not have or are not sus-ceptible to certain diseases. Preventive careis about how you maintain health and some-times even restore health. Wellness to me is aphilosophy. All of those things go together. Asallopathic physicians, we have been taught tocure disease. We should be thinking abouthow we restore health.

MR. CHRISTENSON: Tom, what do you see asthe generator of this wellness revolution?

MR. HENKE: One big piece is that the finan-

cials of health care have changed dramati-cally. The plan designs offered to consumersthrough employers have radically changedover the last five or six years. Now the major-ity of consumers have high-deductible plans—or if they do not have a high-deductibleplan, they have much more personal ac-countability for the amount they spend inhealth care. With that, they have decidedthey spend too much. One of the drivers hereis the consumer saying, “If this is going tocost me a lot, what could I do to avoid that?”

The other part that put this in a super-charged position is that the government pay-ment model changed to encourage account-able care organizations and to make rewardsor payment to the care providers. It is muchmore beneficial for a care provider to get up-stream and work on wellness to avoid thecost that will follow patients who are out ofcompliance or not at their optimal wellnessstate. Also, in the past, employers and healthplans did not know what things had a goodreturn on investment (ROI) in terms of well-ness. We all knew that we should eat right,exercise, should not smoke or drink. But howdo we best influence consumers to do thatinexpensively, efficiently? The data is finallycoming in.

MR. CHRISTENSON: Not so long ago, healthcare insurance had no deductibles, no copays—it covered everything. Now—with copays, de-ductibles, et cetera—people are beginning toask: Do I pay $20 or $30 to go to a physicianwhen I can go to a wellness practitioner andpay the same amount for a whole-service visit?

MR. HENKE: There has been a trend to cover-ing less traditional or nontraditional practi-tioners over the last 15 years. One piece tothis is that some employers are taking a veryaggressive approach, using biometric screen-ing—cholesterol levels, body mass index,weight measurement. It’s a first step in con-necting to whether an individual is doing thework he or she needs to do. Employers aredriving that because it comes back to cost.An overweight patient is much more likelyto have additional health care costs, and em-ployers just cannot afford it anymore.

DR. LAWSON: Cost is by no means the onlydriver for consumer behavior. Twenty yearsago, American consumers were spendingsignificantly more out-of-pocket dollars tosee complementary and alternative (CA)medicine providers. There were more visitsto CA providers than to primary careproviders in the United States at that time—and that was before those economic changeswith payment policies and stuff with thirdparties. There has also been a growing grass-roots hunger from the American populationto the effect that “this is not enough, wewant more.”

DR. ZEIGLER: If you look at public policy on anational level as well as a local level, it isturning itself upside down—and with goodreason. We are a country that per capita paysjust about the most in dollars per person buthas overall outcomes that are only moderateor worse. Looking at Third World countriesin comparison to our own, we do not havemuch to brag about. We are a rich nation.We have generally a high standard of living.We have access to a lot of care, yet we tendnot to change our health care behaviors. Sohow do we effect change in a society that isvery much oriented to the here and now? Itcomes down to creating value-based systemsthat consumers are willing to purchase. Weare seeing, as Karen said, consumers movingto other areas of health care because of itscost effectiveness, because of their prefer-ences, because of their outcomes. We need totake a step back and look at how we design

About the RoundtableMinnesota Physician Publishing’s

35th Minnesota Health Care Roundtableexamined wellness as the centerpieceof a changing focus in health care.Seven panelists and our moderatormet on April 28 to discuss this topic.The next roundtable, on Oct. 13, willexplore the role of accountable careorganizations in health care reform.

M I N N E S O T A H E A L T H C A R E R O U N D T A B L E

The WellnessRevolution

A changing focus in health care


A B O U T T H E PA N E L I S T S


Julia Halberg, MD, MPH, MS, is vice president of global healthservices and chief medical officer of General Mills. Halberg earned hermedical degree from the University of Connecticut. She received a mas-ter’s degree in biology/ecology and a master’s of public health degree inepidemiology from the University of Minnesota. She is board-certified inoccupational medicine. Halberg has published extensively on several

topics, including shift work and blood pressure. At the University of Minnesota, she is anadjunct assistant professor in the department of environmental and occupational health.Halberg serves on the Occupational Medical Residency and the Midwest Center for Occupa-tional Health and Safety (MCOHS) advisory boards.

Tom Henke, MBA, is president and CEO of QuickCheck Health.Henke’s 25 years in health insurance include 15 years of executiveexperience with Medica Health Plans as chief innovation officer, seniorvice president and general manager of commercial markets, and vicepresident of sales and account management. In these roles, Henke hadoverall responsibility for Medica’s largest segment, representing 1 mil-lion members and more than $2 billion of revenue. He successfully launched many newproducts in many new markets and delivered market-leading growth. Henke has an MBA infinance from the University of St. Thomas.

Karen Lawson, MD, is an assistant professor in the Department ofFamily Medicine and Community Health at the University of MinnesotaMedical School and director of health coaching at the university’s Centerfor Spirituality and Healing. She is board-certified in both family medi-cine and integrative and holistic medicine, and was a founding diplomatof the American Board of Integrative Holistic Medicine. Lawson is the

co-leader and initiator of the National Team for Standards, Certification, and Research forProfessional Health and Wellness Coaches. At the university, Lawson is active in undergradu-ate and graduate medical education, and in the center’s graduate program.

William Litchy, MD, is chief medical officer of MMSI, the Mayo Clinichealth plan administrator. With graduate degrees from Saint Louis Uni-versity (MS, Anatomy), the University of Minnesota Medical School, andthe Mayo Graduate School of Medicine (Neurology), Litchy initiallyjoined the Mayo Clinic staff in 1982 and currently is a consultant in neu-rology. He also is the chair of Mayo Health Plan Operations Committee,which is responsible for the oversight of Mayo Clinic employee health plans. With MMSI andthe health plan, he has been involved in the development of wellness and care managementprograms for Mayo Clinic employees as well as other commercial and government-basedcompanies.

Noël Radcliffe, MD, is a family medicine physician at Edina SportsHealth & Wellness, PA. Within her practice, she includes alternative,holistic, and spiritual care. A board-certified, active member of the Amer-ican Holistic Medical Association, she began pursuing this area of interestwhen constraints of the managed-care system threatened the values ofmedicine she felt were important, namely caring and compassion. Rad-

cliffe lectures locally and nationally on topics such as consciousness and healing, depression,and forgiveness. She received her MD from the University of Wisconsin Medical School, withspecialty training in family medicine at Hennepin County Medical Center.

Jennifer A. Sargent, MS, is vice president of corporate wellness formyHealthCheck. Prior to joining Life Time and myHealthCheck, Sargentwas senior vice president of sales for U.S. Preventive Medicine. Hercareer also includes time at Matria Healthcare as vice president of salesand at Medica Health Plans as fitness program manager, as well as man-aging health enhancement programs for 3M and the University of NorthDakota. A graduate of the University of Minnesota Duluth, Sargent has a master’s of science inkinesiology and is pursuing her MBA at the Carlson School of Management.

Mark T. Zeigler, DC, a graduate of Northwestern College of Chiro-practic, was named president of Northwestern Health Sciences Universityin 2006. Prior to that, he was in private practice for 26 years in Sturgis,S.D., and was the city’s mayor from 2001 to 2006. Under his leadership,Northwestern completed a major 2008 campus expansion; attained a10-year re-accreditation; established clinical education partnerships with

the University of Minnesota, the Mayo Clinic, and HealthPartners; and founded the Center forHealth Care Policy and Innovation. Zeigler is vice president of the Associ-ation of Chiropractic Colleges and is on the board of the Minnesota Cam-pus Compact and Foundation for Chiropractic Progress.

Robert Christenson has 40 years of experience in health care policyand consulting. He helps solo and small-group practitioners build a fullpractice of ideal clients and improve their net revenue. B

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these systems and address thoseobvious shifts in what consumersare doing today.

DR. RADCLIFFE: From the perspectiveof the consumer, there are a couplethings that drive this strong interestin wellness. One is the change in ourconsciousness and awareness of howwe see health and wellness. I see itas being driven by the availability ofinformation from other traditions—Eastern philosophy and how otherpeople are living their lives and howthey are thinking about theirhealth—and also from access to theInternet. Suddenly you are awarethat there are all these other options.

DR. LITCHY:With regard to ROI, thereare issues that are very difficult toaddress. People struggle to find ROIin a variety of programs, whether itis health and wellness programs, dis-ease management programs, what-ever. But one issue that we alwayshave to keep in mind is that it is notjust the health care dollar that isbeing spent. It is—for employers—the absenteeism and presenteeismthat is well beyond the dollars theyspend for health care.

DR. HALBERG: At General Mills, wehave not been measuring absen-teeism/presenteeism, but seeingthe loyalty and the morale that leadto increased productivity. Ourdepartment of global health is aboutadvocacy and helping employeesunderstand their health and improveon it. We look at loyalty and morale—and thereby productivity.

MR. CHRISTENSON: While new possi-bilities for cross-disciplinary partner-ships are clear, much of the progress isstymied by the reimbursement system.What are the major causes of thisproblem?

DR. RADCLIFFE:We have been stuck inthe idea that we need to have a cer-tain type and quantity of studies thatprove efficacy. Though science is im-portant, we need to be able to take abigger-picture look. For instance,menopause. A patient has meno-pausal symptoms and can’t take hor-mones, so she wants a differentsolution. I have had really good luckhaving people do Chinese medicineand acupuncture. Knowing thatthere is a good response, I can referher to get a treatment that may bebeneficial for her. We need moredata that shows that it is beneficial.I am looking for that as I try to findout where I can send people to doother alternatives.

I also think that a lot of times

when we send people for alternativetreatments, we are also empoweringthem and they are making otherchanges that then impact otherareas of their health. When we sendpeople for Chinese medicine andacupuncture, they don’t need to stayon it for the rest of their lives. Wecreate a change, and they are in-structed in some health-changinglifestyle techniques that also play arole. There is a bigger picture to nothaving just science.

DR. ZEIGLER: Our third-party payersystem has historically reimbursedfor disease management versushealth promotion. Now there is atrend by third-party payers to lookat how can we save dollars and movepatient populations to providers whogive care with the best evidence andthe best cost-efficiency that im-proves patient satisfaction. Take low-back pain, for instance. I am awareof some third-party payers who aretrying to move those patients toproviders who they know are goingto prevent low-back surgeries ormore expensive procedures that aregoing to drive up the cost. Secondly,as you look at the movement towardmedical homes and the encourage-ment to bundle payments, it doesnot matter when you have a collabo-ration of providers in the medicalneighborhood, so to speak. It isabout getting the patient as well asyou possibly can in order to save themost dollars. It is a driver we aregoing to see being explored inMinnesota and across the countryover the next two to three years.

MR. CHRISTENSON: Why havehealth plans been hesitant to get intowellness?

MR. HENKE: It is important to notethat I don’t speak for a health plan atthe moment, but have in the past.One piece of it is the way in whichall systems are paid. Right now theyare paid dominantly in this marketby transactions. So every time some-thing is done, a payment is made.That is starting to evolve withaccountable care organizations(ACOs). In that world, we havecoaching that is intangible—it’s verydifficult to code exactly what conver-sation just occurred. That coachingtime was pressed down as all thecare delivery systems went to pro-duction models that required fasterand faster visits. One statistic I findfascinating: There is a recent RANDstudy that showed that the 10 mostcommon things done in the retail



clinic—Minute Clinic or Target Clinic—rep-resent 10 percent of its revenue. Those same10 things also represent 18 percent of all pri-mary care visits and 12 percent of all emer-gency room visits. In a world where we arespending enormous resources, $25 billionspent in clinics and emergency rooms forthings that can be done in a Minute Clinic isnot an efficient use of human capital. So youhave a large, clogged-up health system. Wehave insurers that are paying the way they’vealways paid and, because of that, every por-tion is optimized in their piece. It does notallow for new thought processes.

Since 1975, health plans, at least inMinnesota, all have covered preventive medi-cine and they have covered large numbers ofwellness services, but they are not alwayswell known. The nursing coach lines havebeen in place. We have also had chiropracticservices that have been covered for manyyears in the local health plans. Acupuncturehas been covered for quite a while. It isevolving, but to a great degree consumers didnot know what they could use within thehealth plans.

MR. CHRISTENSON: How well do third-party payers reimburse chiropractors?

DR. ZEIGLER: The chiropractic pro-fession, by and large, is covered by

all third-party payers. It’s not the cov-erage, really—it’s how you drive patients tothe right providers. In South Dakota theyjust had a legislative war on copays. The in-surance industry, in particular Blue Shield,raised copays for a chiropractic visit to morethan $50; for medical providers, it remained$15. So they introduced a bill in the Legisla-ture saying that you cannot discriminate co-pays for the same services. It passed both theHouse and the Senate, but was vetoed by thegovernor. Both chambers overrode his veto.In the industry today it is all about eliminat-ing barriers and getting the patient to theright provider. What we need to do in the fu-ture is watch the General Mills and the LifeTimes, as purchasers of health care designsystems that will be value-based. They willlook at leveraging and driving consumersand their employees to areas that ultimatelysave money. It will be business, not the pub-lic arena, that will change the way healthcare is going to go.

MR. CHRISTENSON: What is the role of integra-tive health care and integrative medicine inhelping to advance this wellness revolution?

DR. LAWSON: The two big pieces of integra-tive health care are that it takes a holistic

perspective to get us looking at all the com-ponents and all the perspectives of a personor a family or the system, and that it is opento and available to the best therapeutic inter-ventions and resources that are available forthat person’s situation and resources—whether those are things that may be per-ceived as conventional or things that havebeen outside the mainstream. Prior to the’90s, we had alternative medicine—peoplewere doing [either] that or this. Then we hadcomplementary medicine. People were doingboth things, but often they were not commu-nicating between providers or telling onedoc what the other was doing. With integra-tive health care, if you are, for example, anoncology patient, you may be receivingchemotherapy and seeing a naturopath forsupplements and an acupuncturist for acu-puncture. As you are doing that, everybodyknows about everything. What that can bringto this movement has always been, tosome extent, about wellness and well-being. It has always been about opti-mizing a way of living and the abilityto live and do as one wants. A philos-ophy and focus that that movementhas held for 25 to 30 years is nowmoving into the mainstream.

MR. CHRISTENSON: Much of integra-tive care is happening in a teamenvironment. If we lookat medical homes,who should beincluded on theteam that isworking withthe patient?

DR. HALBERG:You have to beopen and inclu-sive. I use the integrative approach with ouremployees when I see someone who is nothealing. They have been diagnosed, theyhave a condition and it is being medicallytreated, but their mind is not there. We arevery fortunate to have high-quality integra-tive care in the Twin Cities. The holistic ap-proach is what we need to look at with themedical home as well. Rather than sayingwho should be included, I think most peopleshould be and you can pick from them all.

DR. ZEIGLER: It depends on the condition andthe situation. Certainly in a number of envi-ronments there are providers who excel be-cause of their experiences and their training.The collaboration of providers takes into ac-count patient preferences, the best evidence

that exists for the condition, and the clinicalexperience. At our institution we have achiropractic program, an acupuncture andoriental medicine program, and a massagetherapy program. We concentrate on thewhole person and try to deliver care withnatural components and in a natural setting.We understand that there is a fit for allproviders and a need for different deliverysystems. That is why we seek out models ofcare that are integrated—whether it be withour Woodwinds Clinic in HealthEast, withour students at Abbott Northwestern, withour massage therapy students at RegionsHospital, with our chiropractor program atMethodist. We work with the Center for Spir-ituality and Healing. We put these youngstudents together in an integrative settingand they go through diagnosis, the processof developing treatment plans, and then theyallow patients to decide which route of care

they would like to take.

MR. CHRISTENSON: One of the most interestinginnovations has been a new team membercalled a health coach.

DR. LAWSON: For years we called it the miss-ing provider. When you see an MD or a chi-ropractor or a naturopath, that providersays, “This is what you need to do.” Out inthe parking lot, you ask yourself, “How am Igoing to do that in my life? What do I starton first? What are my barriers?” There wasnot a professional to help people navigatethat. It’s the health coach or the health andwellness coach; the definition is still evolv-ing. A national team is working on settingthe standards for this. Team members havedefined certified health and wellness coachesas “professionals from diverse backgrounds

M I N N E S O T A H E A L T H C A R E R O U N D T A B L E sponsored by

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There comes apoint where per-sonal accountabilityhas to step in.Tom Henke, MBA



in education that work with individualsand/or groups, in a client-centered process,to facilitate and empower a client to achieveself-determined goals related to health andwellness. Successful coaching occurs whencoaches apply clearly defined knowledge andskills so that the clients mobilize their owninternal strengths and external resources forsustainable life change.” The movement iscoming from everywhere—fitness, recre-ation, wellness, mainstream medicine, psy-chology, behavior change, and everything inbetween.

MR. CHRISTENSON: What type of training andoversight should be given to a health coach?

DR. LAWSON:We are still working on that,but there is agreement that it is not a week-end class. This is not something that justanybody should be able to write on their

business card. It will probably settle out be-tween 130 and 150 hours of education in ad-dition to a bachelor’s degree. There will needto be a requirement for four to six months ofclinical supervision. There will be a nationalboard-certification testing process that willidentify knowledge in areas around lifestyleand lifestyle medicine.

MR. CHRISTENSON: Should there be a processto certify wellness programs?

DR. HALBERG: I am a little nervous about that.The more certifications you require, themore barriers you put up. Wellness programsneed to be individualized; one size does notfit all. I think certification would take awayinnovation, as well as putting up barriers.

DR. LITCHY: I am also concerned about certifi-

cation of a program when we still are tryingto define what everything really means. As itmatures, there may be a time in the future,but I don't think the time is now. Programcertification would more likely hinderprogress at this time, because certification ingeneral does that.

MR. CHRISTENSON: When did you begin yourwellness programs at Mayo, Bill?

DR. LITCHY: There has been a long history inthe wellness programs we offer commercialclients, starting with health assessments andidentifying how you can use them and thengoing into providing information throughwebsites, books, and a variety of things.Mayo has a whole series of books, even oneon complementary medicine. Now there is astrong move to approach all these thingsfrom multimodalities. Each person learns

differently, each person will work differ-ently. If you have only one tool to usewith people, you will lose a lot of them.

MR. HENKE: As Karen mentioned, con-sumers have been paying for thingsoutside the health care insuranceworld all along, and we are not tak-ing advantage of that. Winningmodels will win—period. Rightnow, even on the insurance-

covered things, a typical de-ductible is between $1,000

and $3,000. That meanssomething on the order of

50 percent or more of allpatients will not reach

their out-of-pocketmaximum. So, inessence, they havezero coverage forthe current sys-

tem. That means that anything that is notcovered by insurance is on an equal footingwith covered things because it is 100 percentpaid by consumers. The question is whetherthe world really is ready for this—and Iwould suggest it is. Then I would suggest wefocus on adding value directly to the con-sumer. If it is there, employers will pay for it,insurers will pay for it. If it is not there, itwon’t be paid for. It is about getting con-sumers what they need.

DR. ZEIGLER: It goes deeper than just thehealth care system. Wellness needs to be partof our public policy. We have to take a standon how we feed our children in school, howwe promote good food, how we promotehealthy living. It is changing perspectives ofconsumers and changing behaviors. Look athow we buy our food, how we cook it, how

we prepare it. Look at tobacco use and howwe continue to abuse alcohol in certainsocioeconomic areas. Obesity still tends to beone of the largest problems within the UnitedStates. Look at cardiovascular disease anddiabetes. The debate really is a public policydebate.

DR. HALBERG: I would take it one step furtherfrom a business standpoint, and say healthand wellness have to be part of strategicvision for companies to be successful goingforward. We have a senior leadership believ-ing in that and that helps a lot to make amore open environment where we work.

DR. LITCHY: Until senior leadership takes therole of wanting it and talking about it, it justdoes not happen. When we work with newcompanies, that is the biggest thing we em-phasize. The stronger a company’s seniorleadership, the more successful wellnessprograms are. That’s simply the way it is.

MS. SARGENT: One of the biggest reasons wehave seen employer wellness programs fail isbecause they don’t change their culture. Theywill put a wellness program in place, theymay have a health risk assessment, dosome biometric screening—buttheir cultural aspect does notchange. They are still serving un-healthy foods and they do not havean environment that is conducive forpeople to exercise and manage stress. It doesnot become a part of what they do as an or-ganization. It is more than just putting a pro-gram in place and hoping that it works. Youhave to have it be a part of your strategy andchange your organization, your culture, andwho you are.

MR. CHRISTENSON: Many chronic conditionsare linked to unhealthy lifestyle choices. Whatare some examples of how our society encour-ages people to make the wrong choices?

MS. SARGENT:We have a society of conven-ience and a little bit of entitlement. We as asociety have this “I want it and I want it nowand I should have it now” kind of feeling—because we have such high-stress, busylives and unhealthy things are convenient.Because healthy behaviors are much lessconvenient, it makes it easier to choose theunhealthy over the healthy.

DR. RADCLIFFE: One thing that concerns meis advertising. How many ads [like this] dowe see: “If you have the symptoms, see yourdoctor”? There is no empowerment, and verylittle public health information out there.

DR. ZEIGLER: I read an article about a study atthe University of North Carolina–Greens-


MinnesotaPhysicianPublishing, Inc.

People come to thetable with not justlabs, but with theirwhole historyand experiences.Noël Radcliffe, MD




M

boro. Two economists studied WalmartSupercenter openings in almost 1,600 loca-tions nationwide. They demonstrated over10 years, from 1996 to 2005, that when aWalmart Supercenter enters a county, onaverage the residents of that county gainabout a pound and a half and the county’sobesity rate goes up by about two percentagepoints. So, fundamentally, our society is try-ing to make choices for us. It comes back toconsumers making healthy decisions. It isthe obligation of our educational institutionsto talk to our future providers about chang-ing behaviors, shifting consumer choices thatconsumers are making, and providing good,sound information that can change thosebehaviors.

MR. HENKE: The alignment centers in healthcare are very, very difficult to put in place.Let me use this silly example. If I am notdriving with my seatbelt on, I can get ar-rested. But my brother-in-law can get on hismotorcycle without a helmet. That is a verysimple example of an odd choice for societyto make. Health plans struggle with notbeing able to say they won’t cover a statin if

you haven’t stopped eating fats. Wecan’t do that. There comes a pointwhere personal accountability hasto step in. I would suggest that,

rather than complain about the sys-tem and society, we just go after the tar-

geted areas and win in those markets wherethere is interest. Rather than mandate thateveryone has to eat right, let’s reward thepeople who are eating right. We are going tohave to break down some of the insuranceregulations to have that flow-through to theconsumer. Right now consumers do not getrate cuts for following the right practices—even if they are following doctors’ orders.

DR. HALBERG:With regard to responsibility, Ivetoed a requirement that you had to fill outa health questionnaire before using our fit-ness center. I could not see instituting an-other barrier for liability purposes. Peopleask what small employers can do. There areso many things you can do, even at smallcompanies: Join with the American Heart As-sociation, American Cancer Society, Ameri-can Diabetes Association. They have walksand runs all the time. You can buy T-shirtsand get your people involved. To feel goodabout ourselves and to feel healthy, we needto engage. Volunteering is one way.

MR. CHRISTENSON: If a significant portion ofwellness involves making healthy choices, whatare some examples of successful programs?

DR. LAWSON: One of the most groundbreak-ing is Dean Ornish’s work with reversingheart disease. He put together a multidimen-sional team approach that was not usinghigh-cost interventions. Many, many practi-tioners said, “You are never going to get peo-ple to eat that way, to exercise, to do groupsupport.” And now it is reimbursed byMedicare because the cost of reversing heartdisease by a lifestyle-change program at$5,000 per year versus a typical quadruplebypass, which starts and goes up from about$30,000 a year—with similar morbidity/mortality outcomes—is pretty significant.

MR. CHRISTENSON: Jennifer, when you werewith U.S. Preventive Medicine, what were someof their successful programs?

MS. SARGENT: Partnering with employerssucceeded when employers understoodthat you have to take the program pasteducation to intervention. As an in-dustry, we have done the educationpiece pretty well. But we have not hadprograms in place to intervene.The successful programsare where the employertook charge of theprogram and said,“We need to domore. We need to in-stitute walking pro-grams and we needto have a fitnesscenter. We need tohave fruits and veg-etables available toour people,” andthen incorporatedthe whole family. Kids are a big part in mak-ing a wellness program successful.

DR. HALBERG:We trademarked a real-timehealth risk assessment. Our Health Numbergives people a snapshot in time of theirhealth status. Then there are health coachesto educate, motivate, and help them chooseone thing to move forward with. We use ink-dated fingersticks to do fasting glucose andlipids. We record weight and blood pressure.And we ask six objective questions. We cate-gorize scores on a scale of zero to 100. It’s alldone anonymously. Everyone gets their ownHealth Number. Then we project what theirpeers are doing. It’s a healthy competition,totally confidential, but it motivates them totake the next step.

MR. HENKE: The employer is an importantcenterpoint for a lot of change, but it is notthe only place. People spend half their time

at home, so reaching out just to the employeris not enough. Some successes I have seenare where the stakeholder—whether a gov-ernment agency, employer, a vendor—takes awhat’s-in-it-for-me approach and aligns itand meets with immediate response. If youare an employer who wants employees to be-have differently, you have to have a carrot ora stick, and it will absolutely make a differ-ence. If you put either rewards or penaltiesin, you will see dramatic change in participa-tion. If you do it incorrectly, you can makepeople pretty unhappy as well.

DR. LAWSON:While behaviors are criticaland they are often the easiest thing to meas-ure, belief change is a huge piece of this. Too

often we minimize the impact and empower-ment of learning to think of your life differ-ently, working your life differently ineverything from reducing pain to improvingquality of life. A lot of people, when they askabout health coaching, really focus on behav-ior. We need to be thinking broader thanthat.

MR. CHRISTENSON: What are some incentivesthat will make these programs successful?

MS. SARGENT: There are a lot of ways you cando incentives—and you can take a stick andpaint it orange and call it a carrot. More andmore employers are moving away from thetraditional carrot approach—I am going topay my employee $300 because maybe theydid a few things over the course of a year—to more of an outcome-based incentive pro-gram design. This is where you look at keyindicators and tell people, “If you don’t reachcertain goals, you are going to pay more.”

d.

It will be business—not the public arena—that will change theway health care isgoing to go.

Mark T. Zeigler, DC



Maybe that’s a long-term strategy; it’s notthat you have to get to these goals tomorrow.

DR. ZEIGLER: Tom and Jennifer are right.Incentives can create tremendous shifts inbehavior. They are taking nontraditional ap-proaches to create those levers and using re-lationships as a driver in changing behavior.In other words, it is not just the fact that Iam going to drop $100 into your HSA or Iam going to reduce your annual health cover-age by $200 if you meet these markers, but itis creating these communities of partici-pants. You create obligations of one on an-other: If you don't meet your marker, you areletting down your friend, your coworker onthe team. So I will get up at 6:30 a.m. be-

cause if I don’t, I am going to let down myteam. Would I get up at 6:30 on my own?No. It is this obligation they are creating toincentivize behavior changes.

DR. LITCHY:We spend a lot of time talkingabout how we are going to help the em-ployee, but many of our employees are mar-ried and have children. Our cost for thedependents and children is more than theemployee costs. We are challenged on howwe can engage the other members of thefamily.

DR. HALBERG:We have a healthy night out wesponsor for the community at the schoolswith parents, grandparents, and providers.We introduce fun ways of looking at nutri-tion, exercise—not just for our families butthe whole community. Recently we joinedwith American Harvest: For employees whoneeded to lose weight, for every pound ofweight they pledged to lose, we would give a

pound of food to the local food bank. Thattie to the community was a great motivationfor our employees.

MR. HENKE: One thing that is happening is aretailization of health care. Consumers aremuch more involved in their own decisions—good or bad—than ever before. One examplewe are working on now at QuickCheckHealth is the question of how to monitor pre-diabetics. If someone is prediabetic, it is op-timal to measure their A1c up to two times ayear to see if it is progressing. In a perfectworld, we would have a physician spendingtime with the patient twice a year doing thatwork. That is optimal. However, to have aprediabetic come in for an A1c check mightmean two visits because the health system isnot organized to do the test first and followwith the doctor immediately thereafter. It isorganized to see the doctor, then go get yourtests, and then you won’t have your scoreuntil you come back. That needs to be re-designed.

A second piece is that it costs $200 to$300 for a typical office visit with some labs.

So now we’re saying we are going tospend $400 a year on the 25 percent of

all adults in America who are pre-diabetic. That is a huge in-

crease in health care costsacross the board. Duringa single year, only a por-tion of those will migrateupward towards dia-betes. How do we ad-dress that? An exampleof what I would con-

sider a disruptive innova-tion is a rapid test that could be sent to thehome. The patient might have a $10 gift cardfor completing the rapid test. The patientcannot see the score until the doctor seesthe score. If we could move to a world wherethat is the approach to health care ratherthan centralizing everything at the clinic,consumers win, doctors can spend less timeon patients that don’t need to be there andmore time with those who do, and the sys-tem can win.

MR. CHRISTENSON: How have medical doctorsbegun to incorporate wellness more into theirpractice?

DR. RADCLIFFE: It comes on many levels. Thefirst is personal, how we chose to live ourlives and model for patients. How do we asemployers take care of our employees? Butalso wellness in the office: We take moretime. We want to talk to patients, to look notjust at their labs or their family history, but

to understand the barriers to them living ahealthier life. Are they caring for a sickmother? Are their kids having issues thattake up a lot of their time? Is their workplaceunsupportive? What are the issues and howcan you help them so that they have the timeand energy to focus some of their energy onthemselves and their wellness? The patients Isee fall into two groups. The first group feelshelpless. How many people do we know whowould save hundreds of dollars if they quitsmoking and still they don't quit smoking? Itisn’t about money. They do not feel like theycan do it. Part of that holistic approach isunderstanding that people come to the tablenot just with labs, but with their whole his-tory and experiences. In my clinic we spenda little extra time talking about those aspectsversus just looking at their labs.

DR. ZEIGLER: I was in private practice in Stur-gis, S.D., for 26 years. When I entered prac-tice in the late ’70s, I put an ad in the localnewspaper talking about my approach to thewhole person—body, mind, and spirit—andabout eating healthy, having an active life-style, and taking care of ourselves. I remem-ber getting chastised by my medicalcounterparts. In today’s environ-ment, open up any magazine, anynewspaper and look at how theads are talking about health care.There is a remarkable generationalshift. What excites us now in education isthat we have an opportunity to build on thatand break down the barriers to create betteroutcomes.

MR. CHRISTENSON: Bill, is there a growingnumber of holistic practitioners at Mayo?

DR. LITCHY: Yes. They have formed a sectionof interactive medicine. The philosophy atMayo has always been that the patient comesfirst. Generally, the approach has been totreat the whole patient, although we as allo-pathic physicians have been constrained byour training.

DR. HALBERG: I could not agree more that weare restrained by our training. I am oldenough to say it was always about disease—we never did prevention. It was always whatkind of technology or pharmacology you aregoing to use to get the person better. It is anawakening for those of us who are older toembrace these different treatments.

MR. HENKE: But there always is this issue ofcompensation. Who is going to pay for it?

DR. LAWSON: The restraints fascinate me.Yes, your payment plan covers acupuncture,but it has to come with a referral and the



Kids are a bigpart in makinga wellnessprogramsuccessful.Jennifer A.Sargent, MS



referral specifically has to be from your pri-mary care provider. Then I have to provide apitch with research documents to my pri-mary care provider to get them to write thereferral. Or we will cover massage, but onlyif it is for a diagnosis. If I go preventivelyonce a month, then I don’t get a diagnosis.

DR. ZEIGLER: I practiced in an environmentthat was defined by patient prefer-

ence. They could come to me forlow-back pain or they could goacross the street to the osteopathor MD. Now Optum Health—

which has tens of thousands ofchiropractors, physical therapists, and occu-pational therapists as part of their network—has developed a paradigm for low-back painbecause of what they know through theirdata. They are going to shift many of theirenrollees to chiropractors because they knowthe cost savings, the cost efficiency, and thepatient satisfaction. Would they have donethat 10 to 15 years ago? No. But because ofthe numbers they have, they know exactlythe dollar amount they are going to save ifthey can get it to a certain provider before itgoes to a specialist and on to probable sur-gery. Like it or not, that drives a lot of deci-sions—good [ones], most of the time.

MR. CHRISTENSON: What are the most impor-tant things employers need to evaluate whenthey look at the myriad wellness programsavailable to them?

DR. HALBERG:We always like to look atoutcomes measurements, of course. Is theprogram going to engage people, sustain be-haviors, and how is it going to go moving for-ward? There are a lot of good programs outthere. There is no one-size-fits-all, whetherit’s nutrition or getting moving. The pro-grams also have to have management sup-

port. We have talked about senior leader-ship, which is key, but we also found outthat middle management has to kick in

too or it will not be successful.

MR. CHRISTENSON: Bill, how do you marketyour programs to employers?

DR. LITCHY: The brand opens a door, butdoes not close the deal. We are cog-

nizant that some of the things wedo simply will not work with

some organizations. We wantto make sure there is a

match. Sometimes it does not match, not be-cause we have a program that is not good orthe company is not a good company. Therecan be different philosophies. You also haveto be able to demonstrate that you can suc-ceed at what you do. Outcomes are criticaland that magic word “data” is essential.Sometimes it is hard to get the data youneed. You may not be able to show the ROI,but you can show the engagement.

MS. SARGENT: I will echo some things thathave been said. Not every program is goingto fit every employer. The program and com-pany need to be flexible and nimble to meetthe needs of the employer and build a strat-egy around it, not just put a program or aproduct in place. It also needs to offer a vari-ety of modalities for people to engage. It can-not just be telephonic. There needs to be aphysical way for people to engage, whetherat the worksite or in other ways. One key isfinding a wellness program that will inte-grate with other programs you provide.Employers may have disease manage-ment with a carrier and they may havean employee assistance program andthey may have case management andthen a wellness program. How does it allfit? How do we not confuse memberswith somebody calling from thiscompany and somebodycalling from anothercompany for the samething? We need part-ners that are willingto sit together onthe client’s behalf tointegrate the solu-tions for a seam-less memberexperience.

DR. HALBERG: One other point is to get a localchampion. If you can get one or two employ-ees to really engage people, that local cham-pion will help determine success.

MR. CHRISTENSON: What are some of thebroader environmental and cultural aspectsthat affect the general health and wellness ofemployee populations?

MS. SARGENT: There are a number of things—smoking policies, food served in the cafete-ria, lots of little up to big things that cultur-ally and environmentally can impact health.Are you willing to do the tough thing tochange your culture and deal with theimpact?

MR. CHRISTENSON: What obstacles inhibit com-panies from investing in wellness programs?

DR. LITCHY:Money—simply that and whetherpeople are willing to realize that it is an in-vestment in their organization. To be veryfrank, there are organizations where the in-vestment really is not of value. If they have aturnover of 150 percent a year, I can see whythey would choose not to invest in their pop-ulation. If you have turnover of 2 percent ayear—Mayo, for example—there is a big in-centive to take care of the population.

MR. HENKE: It is all about how the seniormanagement culture sees health care. Whenthey see a 10 percent renewal increase forhealth care and they are looking at cuttingbenefits, there is not an appetite for addingthings that cost money unless they are ab-solutely proven to have a result.

DR. ZEIGLER:We got a Blue Shield grant toapply for a wellness program. It was a god-


M

Let’s make this anevolution versus revolution.

Julia Hallberg, MD, MPH, MS

Belief changeis a huge pieceof this.

Karen Lawson, MD



send because it gave us the green light toimplement a change. It did change the workenvironment, and you have to have the sup-port of senior management to do that. Andyou have to allow these things to evolve. Thereturn on investment came quicker than weexpected. Within two years we had premiumdrops in our overall insurance that we allcollectively shared.

MR. CHRISTENSON: What are some of thefactors that inhibit wellness programs frombeing effective?

DR. RADCLIFFE: Patients often do not feel sup-ported in their workplace. Without that, it isvery hard for them to implement any change.Understanding how your workplace is stress-ful or unhealthy is critical to being able tohelp people commit to these programs.

MR. HENKE: The data is really compelling onthis. If there is one thing you can do, it isabout the senior management engagementand the champions. If you do not have thelocal champion, it just won’t work.

MS. SARGENT: There is a lot of research goingon right now about intrinsic versus extrinsicmotivation. The program has to have a com-ponent of working with the individual to findout what is going to intrinsically motivatethem to make the change. That is the hardthing to do.

DR. HALBERG:We combined health andsafety; our safety managers were also ourhealth managers. Often, people say, “I’m notsure I want my employer asking me aboutmy health—that is very personal to me.” Butfrom a safety perspective, it is all about be-havior change. What do I have to do to be

the safest I can be? Zero lost time, zeroinjury, win/win. Pair the health and safetyduality and they can incorporate it easierinto their everyday lives.

MR. CHRISTENSON: What role should healthinsurance companies play in keeping the well-ness momentum going?

DR. RADCLIFFE: I would like to see them offerincentives to employers to clean up theirworkplace. Maybe they would have to dosome kind of analysis, but in the long runI think it would be a healthier workplaceand healthier employees.

MR. CHRISTENSON: There are lots of wellnessprograms where there are no medical practition-ers involved at all. What issues are posed byhow these establishments archive patient data?

DR. RADCLIFFE: Having at one time practicedas a medical professional in an environmentthat was set up for what you are describing,there is not often educational expectation ofthings such as even basic rules of HIPAA.Certainly those wellness centers are very fo-cused on client empowerment and the clientbeing responsible for his or her own issues,challenges, and medical information. Butthere needs to be a certain level of safetytriage awareness, because clients don'talways understand what the level of knowl-edge is at the different places. I have seenthose issues coming up more and more inthe last five years as coaching has reallytaken off and we are getting a lot more part-nerships among fitness facilities, communityhealth places, and medical facilities.

DR. LITCHY: On the other hand, it is critical tobe able to integrate the data from all the dif-

ferent areas from which people are seek-ing wellness, so that we can do the

evaluations that are essential to con-tinued improvement. The struggle ishow to obtain the data legallythrough HIPAA and how we cantransfer that data among groups.

Because, unfortunately, a field inone person’s data set is notthe same field in anotherdata set. We are workingright now in a consortiumof several major medicalcenters around the coun-try and trying to figureout how we can put theidentified data togetherin a single database. Weare now at 18 monthsof very rigorous work

and are still challenged.

MR. CHRISTENSON: We have come to our finalquestion of the afternoon: How do we win thewellness revolution?

DR. RADCLIFFE: I would like us just to makesome steps forward. One thing that standsout is the need to personalize any type ofwellness plan. I love the idea that it startsfrom the top, but how do we do that? Howdo we actually get owners and senior man-agers involved in championing it? I think itwill happen on its own because they them-selves will be facing their own health issues.I think that will come.

DR. LITCHY: Fifteen years ago we were wor-ried about how we were going to take care ofthe high-dollar-cost people in the plan. Thenwe went on to say, “Let’s take care of every-one.” Now we’re talking about the high-costpeople again. We talked about wellness awhile ago and then forgot about it. We arenow bringing it back again.

MS. SARGENT: In order to win and not lose—or however you want to frame that—youneed to have some common vision andcollaboration among the key stake-holders: carriers, providers, em-ployers all starting to move in thesame direction with some sort ofcommon vision.

DR. ZEIGLER:We do know that the con-sumer is purchasing health care differentlytoday than they did 10 years ago. They arespending their own dollars to purchase carethe way they want to see it. I believe we needto listen to how consumers want to see theirhealth care and use health care education toour advantage to shift those populations intodifferent behaviors and different systems.

MR. HENKE: If we focus exclusively on theconsumer, focus exactly on what their prob-lems are and what they need, and we don’tworry about the other stakeholders—whogets paid, who wins, who loses—that is howwe are going to win.

DR. LAWSON: As long as we have the mindsetthat there is a barrier, something to over-come—if there is a loser and a winner—wewill continue to flail.

MR. CHRISTENSON: The last word, Julia, isyours.

DR. HALBERG: Slow and steady, let’s make anevolution versus revolution.



The stronger acompany’s seniorleadership, the moresuccessful wellnessprograms are.

WilliamLitchy, MD



Lateral ankle sprain

By far the most common ankle injury is a lateralankle sprain, on the outer side of the ankle. Sprainsrepresent a stretching or tearing of the bands offibers, called ligaments, that connect bone to bone.According to the American Academy of Ortho-paedic Surgeons (AAOS), every day about 25,000people sprain their ankle. About 90 percent of theseinvolve the ligaments on the outer side of the ankle.Most sprains heal with time and protection fromfurther overuse or injury, along with proper rehabil-itation of the injury. Rehabilitation helps decreasepain and swelling; restore range of motion, strengthand flexibility; and prevent chronic problems. Be-sides ice and nonsteroidal anti-inflammatory drugs(NSAIDs), physical therapy techniques such as ultra-sound and electrical stimulation may help reducepain and swelling. Balance and strength trainingmay help prevent reinjury or chronic joint weakness.Proper initial care and rehabilitation of an anklesprain may greatly reduce the need for surgery.

Applying the PRICE (protection, rest, ice, compres-sion, and elevation) acronym is advised for anklesprains, and ankle splinting or other orthopedicdevices may be helpful for more significant sprains.Certain patients and significant ankle sprains maystill require surgical attention to improve recoveryand future level of activity or performance.

Medial ankle sprain

Spraining the deltoid ligaments on the inner aspect(medial) of the ankle is rare due to the strength ofthese ligaments and the bony structures of the anklejoint. Spraining a deltoid ligament, called a medialankle sprain, often ties to other injuries like a frac-tured fibula, tendon tears, nerve injuries, or frac-tures of other ankle bones. X-rays are often recom-mended with moderate to severe medial and lateralsprains to help identify the particular bone injuries.With no fracture, treating a medial sprain mirrorsthat for a lateral sprain, but recovery may takemuch longer.

Ankle injuriesTreatment advances speedreturn to active lifestyle

By Sumner McAllister, MD

O R T H O P E D I C S

Each year, foot andankle problemssend Americans

on millions of clinicvisits, according to theNational Center forHealth Statistics. Ankleinjuries affect people ofall ages, regardless ofwhether or not they arephysically active. Thisarticle describes commonreasons patients seekcare for ankle injuries,treatment choices, andadvances in care.

WHO’S A BIGGER BASEBALLFAN, YOU OR ME?You’ll find that people with Down syndromehave a passion for knowledge and learningthat can rival anyone you’ve met before.To learn more about the rewards of knowing orraising someone with Down syndrome, contactyour local Down syndrome organization.Or visit www.dsamn.org today.

©2007 NationalDown SyndromeCongress

It is the mission of the Down Syndrome Association ofMinnesota to provide information, resources and support toindividuals with Down syndrome, their families and theircommunities. We offer a wide range of services, programs andmaterials at no charge. If you are interested in receiving oneof our information packets for new or expectant parents,please email [email protected] or

For more information please call:

(651) 603-0720 • (800) 511-3696

Extensor tendonitis

Patients with general pain on the top of theirfoot, along with pain when the extensor tendonsare stretched, may have extensor tendonitis. Thetibialis anterior tendon is most often irritated inathletes who run, hike, ski, or bike. To help prevent recur-rence, patients should wear properly fitting shoes and nottie laces too tight. Orthotics such as pads in the front ofthe shoe can relieve pressure. While the pain can be signif-icant—and often mimics that of a stress frac-ture—rest, not surgery, is needed. Regularlystretching the calf muscles and strengthen-ing the extensor muscles also reduce thelikelihood of reinjury.

Fractures

About 15 percent of ankle injuries involvebreaking a bone. As part of the exam, clinicians should ask patientsabout any previous ankle trauma, whether they heard a sound like a“pop” when the injury occurred, and about weight-bearing ability.The inability to bear weight immediately after an injury or at the timeof an x-ray, along with specific locations of bone tenderness, indicateincreased risk of a fracture and further justify obtaining x-rays.

To make patients comfortable following a fracture requires painmanagement and appropriate immobilization of the ankle. In cases ofserious ankle fractures or very unstable injuries, patients are oftenreferred to an orthopedist.

Achilles tendonitis

Tendons connect muscles to bone and allow motion. Tendonitis is anirritation of the tendon through overuse or injury. The Achilles ten-don connects the large calf muscles to the heel and is frequently irri-tated by certain activities, such as running or jumping, or in poorlyconditioned individuals who increase the intensity of their activity tooquickly. The pain of Achilles tendonitis is usually just above the heeland is worse in the morning or with exercise. Proper stretching, con-ditioning, and exercise are the best practices to prevent irritation.

Among many options to treat Achilles tendonitis are a period ofrest or decreased activity, proper stretching, ice applications, NSAIDs,good shoe selection, and certain shoe inserts such as a heel wedge orlift. Achilles tendonitis generally does not require surgery, though acomplete tear usually heals faster with surgery. Steroid injections totreat Achilles tendon problems should be avoided as they can increasethe risk of a tendon tearing completely. Preventing injuries involvesmaintaining flexibility in the ankle joint, including regularly stretch-ing the Achilles tendon, and orthotics to support the foot and correctbalance or rotation problems through the foot and ankle.

Chronic ankle instability

Patients with chronic ankle instability feel like the outer side of theirankle often “gives way” when they are walking, exercising, or simplystanding. Weakened ligaments cause the instability, which can devel-op after multiple ankle sprains, especially following a sprain that didnot heal sufficiently.

X-rays, CT scans, or magnetic resonance imaging scans may beused in diagnosis. The patient’s activity level also guides treatment.Nonsurgical options range from use of NSAIDs to manage pain andinflammation to physical therapy and use of an ankle brace for sup-

port. Surgery to repair or reconstruct damagedligaments and, in some cases, to perform othersoft tissue or bone procedures, is needed formore serious injuries or in cases not respondingto other courses of treatment.

Arthritis in the ankle

While not an ankle injury, arthritis in the ankle canresult from a previous ankle injury. Patients with “anklearthritis” have worn out the cartilage and bone of thetibiotalar joint, typically due to one or more factors

such as being overweight, having a genetic tendency for arthri-tis, prior injuries to the ankle and foot, and more. Most patients findpain relief with changes in footwear, such as cushioned inserts or“rocker-bottom” soles, and by limiting high-impact activities. Besidesmedications like NSAIDs for inflammation and pain, braces or insertsand cortisone injections may be helpful. Certain patients with anklearthritis may benefit from orthopedic evaluation when other treat-ments have not adequately controlled the pain or returned the patientto an acceptable level of activity. Surgical options, ranging fromminimally invasive techniques to ankle replacements, are advancing,allowing patients more range of motion, less pain, and higher levelsof functioning.

Ankle injuries to page 34

Proper initial care and rehabilitationof an ankle sprain may greatly reducethe need for surgery.


In the next issue...

• Pre-diabetes

• Sexual health

• Preventing falls


As the nation struggles with the costs of an oppressively largehealth care footprint, many patients with chronic conditionsface a health care footprint of their own that is ever-growing

and never-ending. Beyond the expense, the burden of illness—symp-toms, disability, and avoidance of activities to prevent symptoms—can significantly reduce patients’ independence, quality of life, andability to care for loved ones and pursue goals and dreams.

For the chronically ill, the goal often is not a cure, but rathercontrolling the condition and reducing the risk of long-term compli-cations. There has been an explosion in chronic conditions, due inpart to aging of the population; improvements in survival of previ-ously lethal conditions; and, increasingly, defining conditions basedon risk. Examples include diabetes (defined as blood sugar levelsabove which patients are at high risk of vision impairment or loss),hypertension (blood pressure levels above which treatment reducesthe risk of stroke), and dyslipidemia (LDL cholesterol levels abovewhich treatment reduces the risk of damage to the heart). As a result,many patients, particularly older ones, have multiple chronic condi-tions. Many of these people are fundamentally healthy—they havefew symptoms and experience little illness—but receive a largeamount of health care: Medicare patients with five or more chronicconditions account for almost 70 percent of health care expenditure.For them, the fundamental problem is not the burden of illness, butthe burden of treatment.

To understand the role of treatmentas a burden, we have to understand whatmodern health care requires of patients. Mostof the recommended care comes from guidelinesthat focus on a single condition. These guidelinesrequire tests to diagnose, prognosticate, monitor, and trig-ger referrals and treatment; indicate measures to ascertainthe quality of care performed; and propose treatments, dictat-ing the outcomes that need to be achieved. These guidelines areproblematic for a number of reasons:

• The research on which they are based is often corrupt. Consider, forexample, reports of selective publication of studies favorable toantidepressants, with suppression of those not so favorable.

• The guidelines’ writers are often specialists with narrow expertiseand important financial relationships with corporations that standto profit from adherence to the recommendations.

• The recommendations fail to account for patient context—includingwhat other conditions and treatments they have and take, but alsopatient circumstances.

Attention to these circumstances has been minimal. To bring thisinto focus, let’s consider the case of John, a fictional patient whoresembles an increasing number of my own patients.

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John is a 55-year-old accountant, husband, and father of two. He hasdiabetes, for which he takes metformin and glipizide; abnormal bloodlipid levels, for which he takes a statin; and high blood pressure, forwhich beta blockers were recently added to his diuretic because hisoffice readings were above goal. After this addition, John experiencesdizziness when he stands up. His weight seems parked at 238 pounds.He also has depression and chronic low back pain, as well as somenerve pain in both feet.

To achieve guideline targets for patients with type 2 diabetes,John’s primary care clinician refers him for evaluation by specialistsin podiatry, dietetics, diabetes education, and endocrinology. Johnmust take time off work for each of these appointments. He emergeswith advice to cut back on carbohydrates, fats, salt, and calories; totake his pills regularly; to check his blood sugars twice per day; toexercise; and to check his feet daily. John feels no one paid muchattention to his back difficulties when advising exercise. Because ofback stiffness and abdominal obesity, he will have to ask his wife totake a look at his feet regularly. Meanwhile, his complaints of painand difficulty sleeping remain largely unaddressed.

One reason John doesn’t sleep well is the situation at work. Heused to be one of three accountants; through downsizing, he is nowthe only accountant. He takes work home regularly, feels pressure toperform, and is noting that the numbers are not adding up. He wor-

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SHRINKING the health care footprintA call for minimally disruptive medicineBy Victor M. Montori, MD, MSc

ries that the company may be going under—and with it his job, hishealth insurance, his ability to pay his debt, and his mortgage. Butmortgage payments are not the main concern about his home situa-tion. A few months ago, seeking refuge from an abusive husband,John’s daughter returned home, bringing with her two beautifulgranddaughters. John’s daughter is drinking heavily.

As John sits in his La-Z-Boy reviewing all these concerns, he opens a letter from his primary care physician. Working in a pay-

for-performance environment,she must report diabetes out-comes for her patients. In herletter, she says that, because of John’s failure to achieve diabetic care goals, she will no longer treat him and hemust find a new primary careclinician.

John’s “failure” to achievediabetes goals despite hisphysician’s efforts is usually

interpreted as John “not taking personal responsibility” or being“noncompliant.” Much of what has been written about not followingphysician’s advice or taking medicines as recommended, often callednonadherence, suggests that John’s nonadherence is intentional. Thisis often related to beliefs about disease (e.g., If I do not have symp-toms, I must not be sick) and treatment (e.g., If I take these medi-cines, they will harm me) that are not correct and that lead patientsto opt out of some aspect of the treatment program. Solutions to theproblem of intentional nonadherence therefore require doctors tolearn about their patients’ beliefs, educate patients about the condi-tion and treatments, present them with options, invite them to partic-ipate in shared decision-making, and provide tools (such as pillboxes) to help them implement the agreed-upon plan of action.

The burden of treatment

But intentional nonadherence is only part of the story. The problemwith John’s adherence to therapy, visits, tests, diet, exercise, etc., isthat these tasks do not fit into his life. His physician, instead of work-ing with John to create a program that fits into his life, has chosen tointensify therapy. She expected the endocrinologist to start John onan injectable agent to reduce his blood sugars. A greater emphasis onself-management, she thought, would make John check his sugarstwo or more times per day. Indeed, a study reveals that on averagepatients with diabetes spend 48 minutes per day taking care of theirdiabetes—but still frequently miss recommended activities. An esti-mate of how much diabetes patients ought to be doing places thesedemands at 122 minutes per day.

This type of nonadherence reflects treatment burden, a situationin which the treatment workload exceeds the patient’s capacity to

take on the work of being a patient. Treatment burden couldresult from reductions in patient capacity (through pain,

depression, isolation, illness burden), from increasingtreatment workload, or both, especially for patientswith multiple chronic conditions. Poorly coordinated,disease-focused care can result in treatment intensifi-cation for each condition, with each demanding itsown lifestyle changes, tests, monitoring requirements,

treatments, and visits—resulting in large, inefficient increases in treat-ment burden.

The solution to this form of nonadherence requires that the focusof care shift from caring for each condition to the care of the patientas a whole person. In particular, clinicians and patient must worktogether to take stock of the patient’s capacity and workload.

Patients’ capacity comes from their ability to enlist family,friends, coworkers, and others in the work of being a patient; theirresilience in the face of illness; their general literacy, and, in particu-lar, their health literacy; their quality of life; and their capacity totake care of family, recreation, and work. These are not measuredrou tinely in medical practice. Nor do we know how effective patients are at conveying—and clinicians at eliciting—a sense of the patient’sever-changing capacity to do patient work.

Treatment workload may be easier to assess. But even the bestrecords will not note all the recommendations and advice thatpatients accumulate from different health professionals, or howpatients perceive all these actions.

Principles of minimally disruptive medicine

To improve outcomes for patients with multiple chronic conditionsby reducing nonadherence, clinicians and patients must work togetherto lower the burden of treatment, i.e., to optimize the balancebetween workload and capacity. In pursuit of this goal, our researchgroup, in collaboration with others, is working to develop a measureof treatment burden that patients can report.

To reduce treatment burden, minimally disruptive medicinerequires that clinicians take an unusual step: Stop guideline-mandated


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Shrinking the health care footprint to page 32

For Medicare patientswith five or morechronic conditions, the fundamental prob-lem is not the burdenof illness, but the burden of treatment.

interventions. Consider, for example, patient monitoring of bloodsugar levels. According to the American Diabetes Association Stan-dards of Care for 2011, this practice is of benefit, albeit small, forpatients with type 2 diabetes who take insulin—to improve the safetyof this treatment—and for patients who want to see the impact ofchanges in their lifestyle or treatment on sugar levels. For patientslike John, routine self-monitoring significantly increases the workloadand will not produce a big enough benefit to justify it.

John’s situation would require that his clinician help him identifyhis goals and prioritize the available treatments according to theirability to achieve those goals. This will require John’s doctor to stategoals in ways that John can “own”: We should not discuss LDL cho-lesterol, HbA1c, or bone density. Rather, the focus should be on theeffect of treatment on the outcomes that are important to John: livingindependently, being able to care for loved ones, being able to liveunhindered by complications of the diseases or treatments, and avoid-ing premature death.

Our research group reported in the Journal of the AmericanMedical Association in 2010 that only 1 in 20 diabetes trials re por-ted the effect of treatments on patient-important outcomes. We need more of this research. For example, it has been clear since2008 that tight control of blood sugars is unlikely to favorably affectJohn’s quality of life, lifespan, or risk of most diabetes complications.We need more research of this type to help John’s physician an swer important questions: What treatments would help Johnaccomplish his goals? What other treatments are less likely to helpand could be discontinued or delayed until John is able to do them?

Changing the practice of medicine

The agenda of minimally disruptive medicine calls for judicious use ofevidence-based interventions that are consistent with the patient’scontext, values, and preferences. However, the medicine being prac-ticed today is the medicine of overtesting and overtreatment in pur-suit of disease-centered outcomes that will get clinicians bonuses inpay-for-performance schemes. These costly practices contribute tohealth care inflation and to the well-being of the health care industry.Everyone appears to benefit—except patients like John.

Minimally disruptive medicine thus requires clinicians to skillful-ly determine a patient’s context and to engage him or her in a sharedapproach to designing a treatment program. This form of personal-ized medicine seeks to optimize the treatment workload, enhancepatient capacity, and reduce the burden of illness and the burden oftreatment, all while pursuing the patient’s goals for care and life.

Patient participation is essential to minimally disruptive medicine.Furthermore, patients will need to push political levers to swing thependulum back from disease-centered systems that pit cliniciansagainst patients who “fail” to achieve quality metrics. Minimally dis-ruptive medicine will move us closer to realigning the goalsof doctor and patient, improve adherence to effective ther-apy, and allow patients to receive care that is for andabout them. Everything else will follow—including asmaller health care footprint.

Victor M. Montori, MD, MSc, is a professor of medicine in theDepartment of Medicine and director of health care deliveryresearch for the Knowledge and Evaluation Research Unit inthe Department of Health Sciences Research at the MayoClinic, Rochester.

Shrinking the health care footprint from page 31


Health Care ConsumerAssociation

Minnesota

Each month members of the Minnesota HealthCare Consumer Association are invited toparticipate in a survey that measures opinionsabout topics that affect our health caredelivery system. There is no charge to jointhe association, and everyone is invited.For more information, please visitwww.mnhcca.org. We are pleased to presentthe results of the August survey.

Per

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8073.9%

26.1%

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Disagree Strongly

disagree

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10

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30

40

50

17.4%

47.8%

19.6%

15.2%

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2. I felt the information received at discharge wasclear and easy to understand.

1. I, or a member of my immediate family,have spent at least one night in a hospital inthe last 5 years.

Per

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5

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17.4%

37.0%

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5. I felt the care delivered after discharge wasadequately coordinated.

4. I was allowed to participate in decisions aboutwhere care would be continued after discharge.

Per

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Disagree Strongly

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15.2%

54.3%

21.7%

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3. I felt the attending physician knew about theinformation given at discharge.

August survey results...

“A way for you to make a difference”

Join now.

SM

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

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

www.mnhcca.org

Health Care ConsumerAssociation

Minnesota


Heel fractures

Sixty percent of tarsal fractures involve the calcaneus, also knownas the heel. Heel bone fractures are often severe and disabling, pre-venting many daily activities and most sports. Beyond confirmingthe fracture by x-ray, CT scans show the severity and other possibleinjuries, and help determine the most effective treatment plan. A castor an immobilization device is used if the broken bones have not beendisplaced. Otherwise, surgery helps restores the normal position ofthe bone pieces and speeds healing.

The AAOS notes that research for improving outcomes hasfocused on three areas: smaller incisions for fixing the fracture; defin-ing which treatment method works best for which type of fractureand which type of patient—for example, smokers or people withdiabetes; and inventing better plates and screws.

Treatment advances

According to the National Institute of Arthritis and Musculoskeletaland Skin Diseases, advances in diagnosing and treating injuries to theankle and foot include:

Arthroscopy. The biggest advance is using arthroscopy to viewjoint problems without major surgery. Tiny incisions mean lesstrauma, swelling, and scar tissue than with conventional surgery, aswell as decreased hospitalization and rehabilitation. Because injuriesoften are addressed earlier, success is more likely.

Tissue engineering. Unlike other tissues, injured joint cartilage

does not heal on its own. Techniques such as transplanting one’s ownhealthy cartilage or cells to improve healing are used today for smallcartilage defects. Questions remain about the usefulness and cost ofthis treatment.

Targeted pain relief. New pain-killing, medicated patches andgels can be applied directly to an injury site rather than be taken sys-temically, thereby limiting some of the potential side effects.

Treatments on the horizon

According to the institute, future developments likely will include:

• Technical advances and new imaging methods for improved diagno-sis and treatment

• Improved rehabilitation techniques that may reduce the need forsurgery

• Treatment improvements based on the role of nutrition in healing

• Musculoskeletal tissue engineering

Most of the ankle injuries we see in our 24-hour urgent care areminor and heal relatively quickly with proper instructions and treat-ments begun promptly after the injury occurs. It’s good to know,however, that advances in the care of ankle and foot injuries arebeing made in a wide area of diagnostic and therapeutic options,enabling people to resume healthy and active lifestyles more quicklyand completely.

Sumner McAllister, MD, practices family medicine at Apple Valley MedicalClinic.

Ankle injuries from page 29


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