Health care infomation for Minnesota doctors Cover: Diagnostic errors by Phillip M. Kibort, MD, MBA Something to build on by H. Theodore Grindal, JD and Nate Mussell, JD Minnesota Healthcare Roundtable - Accountable Care Organizations Professional Update: Orthopedics
Patient safety’s next frontier By Phillip M. Kibort, MD, MBA I t all started with Julia. About seven years ago, a 16-year-old girl who had some mild depression, but otherwise was per- fectly healthy, began having back pain. The urine analysis was normal. When the pain began radiating to her right upper quadrant, she then was evaluated with multiple tests. Her liver function tests were slightly ele- vated, her BUN/creatinine normal, her white count elevated with a lymphocytosis, a SED rate and CRP both elevated, amylase and lipase normal, and electrolytes normal. A CAT scan of her abdomen revealed a very abnormal-looking and contracted-appearing gall bladder. Her primary physician focused in on the gall bladder, as did the consultants in hematology/oncology, gastroenterology, infectious disease, and surgery. Everyone thought it was most likely the gall bladder that was causing her pain and elevated LFTs. An ERCP revealed no stones in her biliary tract but an abnormal-looking gall bladder. The patient then went to surgery for a cholecystectomy; it was a successful surgery. She was then transferred from recovery room to her hospital room on the medical/surgical floors. Within hours, she bled to death. What happened was that Julia’s doctors got caught in the trap of confirmation bias: They all went down the same road and no one challenged anybody else’s thinking. It turned out that Julia had Epstein-Barr virus hepatitis and was slowly ERRORS to page 10 PRSRT STD U.S. POSTAGE PAID Detriot Lakes, MN Permit No. 2655 Volume XXV, No. 10 January 2012 Something to build on A 2012 legislative preview By H. Theodore Grindal, JD, and Nate Mussell, JD L egislators and Gov. Mark Dayton got an early Christmas present in December when the November state fiscal forecast showed an unexpected $830 million surplus. Coming on the heels of the longest government shutdown in the state’s history and partisan tension that rose to heights not seen in the past, the surplus could help bring about a quick session as legislators look to the fall with every seat up again for reelection. However, a num- ber of issues are still hanging over the Legislature, even with a short ses- sion. How and if any of these issues get resolved over the next three months is anyone’s guess, particularly in an election year. Surplus is only the beginning By all accounts, the 2012 legislative session is likely to be a short session PREVIEW to page 14 The Independent Medical Business Newspaper IN THIS ISSUE: Minnesota Health Care Roundtable Page 20 Diagnostic errors
Transcript
Patient safety’s next frontierBy Phillip M. Kibort, MD, MBA
It all started with Julia. About seven yearsago, a 16-year-old girl who had somemild depression, but otherwise was per-
fectly healthy, began having back pain. Theurine analysis was normal. When the painbegan radiating to her right upper quadrant,she then was evaluated with multiple tests.Her liver function tests were slightly ele-vated, her BUN/creatinine normal, her whitecount elevated with a lymphocytosis, a SEDrate and CRP both elevated, amylase andlipase normal, and electrolytes normal. ACAT scan of her abdomen revealed a veryabnormal-looking and contracted-appearinggall bladder. Her primary physician focusedin on the gall bladder, as did the consultants
in hematology/oncology, gastroenterology,infectious disease, and surgery. Everyonethought it was most likely the gall bladderthat was causing her pain and elevated LFTs.An ERCP revealed no stones in her biliarytract but an abnormal-looking gall bladder.
The patient then went to surgery for acholecystectomy; it was a successful surgery.She was then transferred from recoveryroom to her hospital room on themedical/surgical floors.
Within hours, she bled todeath.
What happened was thatJulia’s doctors got caught in thetrap of confirmation bias: Theyall went down the same roadand no one challenged anybodyelse’s thinking. It turned outthat Julia had Epstein-Barrvirus hepatitis and was slowly
ERRORS to page 10
PRSRTSTDU.S.POSTAGE
PAIDDetriotLakes,MNPermitNo.2655
Volume XXV, No. 10
January 2012
Somethingto build onA 2012 legislativepreview
By H. Theodore Grindal, JD,and Nate Mussell, JD
Legislators and Gov. MarkDayton got an early Christmaspresent in December when
the November state fiscal forecastshowed an unexpected $830 millionsurplus. Coming on the heels of thelongest government shutdown in thestate’s history and partisan tensionthat rose to heights not seen in thepast, the surplus could help bringabout a quick session as legislatorslook to the fall with every seat upagain for reelection. However, a num-ber of issues are still hanging overthe Legislature, even with a short ses-sion. How and if any of these issuesget resolved over the next threemonths is anyone’s guess, particularlyin an election year.
Surplus is only the beginning
By all accounts, the 2012 legislativesession is likely to be a short session
PREVIEW to page 14
The Independent Medical Business Newspaper
IN THIS ISSUE:Minnesota Health Care Roundtable Page 20
Diagnostic errors
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CAPSULES 4
MEDICUS 7
INTERVIEW 8
BEHAVIORAL HEALTHAutism update 16By George Realmuto, MD,and Israel Sokeye, MD
OPHTHALMOLOGYOpening eyes tonew options 28By Y. Ralph Chu, MD
MEDICINE AND THE ARTSBeyond decoration 30By Megan Hatch
PROFESSIONAL UPDATE:Orthopedics 32By Steven W. Meisterling, MD
DEPARTMENTS
C O N T E N T S JANUARY 2012 Volume XXV, No. 10
JANUARY 2011 MINNESOTA PHYSICIAN 3
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Diagnostic errors 1Patients safety’s next frontierBy Phillip M. Kibort, MD, MBA
Something to build on 1A 2012 legislative previewBy H. Theodore Grindal, JD,and Nate Mussell, JD
Minnesota Health Care Roundtable 20Accountable Care Organizations
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The cost of research, bothfailed and successful, is reflected in product pricing. Currentfederal guidelines allow generic equivalents marketplace accessbased on the patent date, not the release date, of a product. Thisconsiderably narrows the window in which costs of advances maybe recovered. A further complicating dynamic involves the payers.Physician reimbursement policies sometimes reward utilizinglower-cost “proven” products and cast those prescribing higher-cost products as “over-utilizers,” placing them in lower-tieredcategories of reimbursement and patient access.
Objectives: We will discuss the issues that guide the earlyadoption of new pharmaceutical therapies and how they relate tomedical devices. We will examine the role of pharmacy benefitmanagement in dealing with the costs of specialty pharmacy. Wewill explore whether it is penny-wise but pound-foolish to restrictaccess to new therapies and what level of communication withinthe industry is necessary to address these problems. With the babyboomers reaching retirement age, more people than ever will betaking prescription medications. As new products come down thedevelopment pipeline, costs and benefits will continue to esca-late. We will provide specific examples of how specialty phar-macy is at the forefront of the battle to control the cost of care.
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Fairview, ZipnosisPartner to OfferOnline ServicesFairview Health Services hasannounced it will provide anonline care service in partner-ship with St. Paul-basedZipnosis.
Officials say the services willcover a number of conditions,including cold and flu symp-toms, sinus infections, acne,seasonal allergies, yeast infec-tions, and tobacco cessation.More serious conditions will bereferred to a Fairview clinic.
With the move, Fairviewjoins other health organizationslike HealthPartners and BlueCross and Blue Shield ofMinnesota, which have also setup online health care services.
“Together, Fairview andZipnosis are making high-qualityhealth care convenient andaffordable for consumers,”says Terry Martinson, FairviewMedical Group executive region-al medical director. “Whenpatients need care for specificconditions, we are just a clickaway.”
Hennepin HealthSystem Acquires HFAHennepin Health System (HHS)and Hennepin Faculty Associ-ates (HFA) have finalized a dealthat merged the physician prac-tice with the health system thatruns Hennepin County MedicalCenter (HCMC) and its affili-ated clinics.
On Nov. 29, the HennepinCounty board, which ownsHHS, voted to approve themerger, which dissolves HFAand makes its members employ-ees of the health system. Thechange became official Jan. 1.
Officials say the move inte-grates two organizations thatalready had a close relationship.“It is in the interest of HCMCand the physicians who providecare to operate as a singleorganization, rather than sepa-rate entities, in order to bestserve patients in these newmodels of care delivery,” saysDavid Jones, HHS chair.
The move might also beseen as another example of howindependent physician practicesno longer are practical in
today’s health care environ-ment. Many practices, both inthe metro area and in GreaterMinnesota, have been absorbedby larger health systems asregulatory and market changesmake independent practicemore difficult to sustain. Andthe new arrangement has a his-torical precedent: HCMC physi-cians were directly employed bythe hospital before the creationof HFA in 1984.
“As health care reformtakes shape, state and federalhealth care programs across thenation are being redesigned toshift the financial risks of car-ing for patients to the peopleand entities that are providingthe care,” says Lawrence Massa,Minnesota Hospital Associationpresident and CEO. “To surviveeconomically, providers mustfind ways to increase efficiencyand contain costs. Integrateddelivery systems offer one wayto achieve these financial goalswhile preserving the quality ofpatient care.”
Officials say that becauseHFA is a nonprofit corporation,no direct payment is involved
in the merger. The group’sassets, including facilities usedfor clinical care, administration,and parking, will be transferredto HHS. Officials add that HFAhas no outstanding debt. TheMinneapolis Medical ResearchFoundation, currently ownedby HFA, will become a nonprof-it subsidiary of HHS.
Health RankingsShow Rise inChronic DiseasesA new United Health Founda-tion report on the nation’shealth raises alarms about therise in rates of chronic diseasessuch as obesity and diabetes,saying that the increase in suchconditions is undermining thecountry’s health.
The annual America’sHealth Rankings has consistent-ly gotten attention for its grad-ing of individual states’ healthstatus, but it also presents anoverall snapshot of the nation’shealth, and foundation officialssay they are concerned abouttrends shown by recent data.
Providing care at multiple modern clinics in Minnesota and Wisconsin
A 2011 trip to the remote mountainous region of Central Honduras, Central America, provided hope and healing for many children and a rewarding experience for Dr. William and Lauren Schneider and their daughters, Nikolett and Hannah.
The Holy Family Surgery Center opened in 2009 to serve orphaned and abandoned children who have no other way of a�ording medical care. Dr. Schneider and a volunteer team had the opportunity to examine 200 and perform surgeries on 58 children, involving ACL reconstruction and the repair of many neglected fractures.
Improving the lives of patients, supporting, serving…
Pictured (l-r) are Lauren and Dr. William Schneider and their daughters Nikolett and Hannah. The family spent time caring for orphans and patients in Central Honduras.
t multiple modere aviding carorP innesota and n clinics in Mtiple moder onsiniscWnesota and
JANUARY 2012 MINNESOTA PHYSICIAN 5
The report says areas ofimprovement, such as improvedsmoking cessation, reduced hos-pitalizations, and a decline incardiovascular deaths are offsetby increasing rates of obesity,diabetes, and the number ofchildren in poverty.
Officials with United HealthFoundation say that in responseto the trends, the group willlaunch a campaign called “TakeAction for Change,” that will usesocial media such as Facebookto encourage individuals tomake health-promoting deci-sions. The campaign is cospon-sored by the foundation, theAmerican Cancer Society,Campaign for Tobacco-FreeKids, and YMCA.
The rankings find Minne-sota as the sixth-healthiest statein the nation. The rankingmarks three years in a row thestate has finished sixth, whichis also the lowest grade Minne-sota has received. Minnesotawas ranked No. 1 in the nationfor seven of the report’s 21years. It was ranked in the topfive every year until 2009.
The United Health Foun-dation report says Minnesota’sstrengths are its low rates ofdeaths from cardiovasculardisease, its low rate of unin-sured residents, and the state’shigh rate of high school gradua-tion. Challenges include a highincidence of infectious disease,low per-capita public healthfunding, and a high prevalenceof binge drinking.
The report also findsthat obesity in Minnesota hasincreased from 17.4 percentto 25.4 percent of the adultpopulation, and that diabetesincreased from 4.9 percent to6.7 percent of the populationin this state.
Luke Benedict, MD, anendocrinologist at AllinaHospitals and Clinics and aboard member of the AmericanDiabetes Association–Minne-sota, says the United HealthFoundation report confirmswhat health experts have beenseeing for some time. “We’vebeen trumpeting this for years,that there’s a huge problemwith obesity. It is a true epi-demic and this report echoesthat,” he says. “Minnesota isdoing better than a lot of other
states, but we’re still followingthe same general trend—we’regetting heavier.”
MHA Gets GrantFor Patient SafetyThe Minnesota Hospital Asso-ciation (MHA) is part of a$218 million effort to preventinjuries and complications athospitals across the country.
The Partnership forPatients initiative recentlyannounced that 26 hospitalsystems and organizationswill work together as hospitalengagement networks toimprove patient safety. The net-works will develop collaborativeefforts to train hospital staffand provide support and techni-cal assistance to hospitals toimprove patient safety andpromote quality improvementgoals. The efforts will be moni-tored by the Centers of Medi-care & Medicaid Services(CMS) to ensure that the pro-gram’s goals are being met.
Officials at the U.S. Depart-ment of Health and HumanServices (HHS) say the Partner-ship for Patients consists ofmore than 6,500 members,which include hospitals, pro-viders, consumer groups,employers, and unions. Amongthe goals of the initiative is atarget of reducing the numberof hospital-acquired conditionsby 40 percent and reducing hos-pital readmissions by 20 per-cent by 2014.
MHA officials say thefederal funds will allow thegroup to add three staff mem-bers to its patient safety team,to provide members with train-ing and technical assistanceto address hospital-acquiredconditions, readmissions, andsafety-culture issues.
According to MHA com-munications director JanHennings, the new partnershipswill ensure that Minnesota hos-pitals will continue to be at theforefront of delivering high-quality care. “We in Minnesotahave always had a very goodworking relationship with part-ners such as Stratis Health andICSI [Institute for ClinicalSystems Improvement]. This
CAPSULES to page 6
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grant is going to help us reallysolidify and build upon thosepartnerships,” she says. “We’reextremely excited about it and Ithink that Minnesota is in goodshape to use that grant moneyto the fullest.”
Medtronic to Pay$23.5 Million inKickback CaseThe U.S. Department of Justiceannounced last week thatMinneapolis-based Medtronicwould pay $23.5 million to set-tle accusations that it paid kick-backs to physicians for usingthe company’s medical devices.The case follows several othersin which medical device manu-facturers have paid large settle-ments in recent years.
The Justice Departmentsays Medtronic paid physiciansthrough post-market studiesand device registries to implantMedtronic pacemakers anddefibrillators in patients onMedicare and Medicaid insur-ance plans. The cases in ques-
tion involved data and informa-tion about Medtronic devices,collected by physicians partici-pating in the studies or reg-istries, for which Medtronicpaid a fee ranging from $1,000to $2,000 per patient. Justiceofficials say the Medtronicpayments were a way of solicit-ing physicians to switch fromcompetitors products toMedtronic devices.
“Medicare and Medicaidbeneficiaries depend on theirphysicians to make decisionsbased on sound medical judg-ment, especially when they arechoosing which pacemaker ordefibrillator to implant,” saysB. Todd Jones, U.S. Attorneyfor the District of Minnesota.“Medical device manufacturersmust not be permitted to useimproper payments to cloudthat judgment.”
For its part, Medtronicsays the settlement does notindicate the company did any-thing improper or unlawful.“Medtronic is happy to havethis investigation behind us, sowe can continue designing andexecuting clinical trials that
generate evidence to improvepatient care, outcomes, and costeffectiveness,” says MarshallStanton, MD, vice presidentof clinical research and reim-bursement for the Cardiac andVascular Group at Medtronic.
MDH Grants Go toCommunity HealthThe Minnesota Department ofHealth (MDH) will give grantstotaling $11.3 million to com-munities throughout Minnesotafor health improvement efforts.The grants are part of theStatewide Health ImprovementProgram (SHIP), which wascreated by the Legislature aspart of health reforms passedin 2008.
The grant programs willcover 51 counties, four cities,and one tribal government overthe next 18 months, officialssay. That is down from the firstround of grants, which coveredall 87 counties and nine tribalgovernments. MDH officialsnote that funding for SHIP wasreduced in the 2011 legislativesession, resulting in fewer
grantees this year.“To improve health in
Minnesota, we have to thinkin terms of prevention, notjust treatment,” says EdwardEhlinger, MD, Minnesota Com-missioner of Health. “In Minne-sota and nationally, the twomain causes of chronic diseaseand premature death are obes-ity, caused by poor nutritionand insufficient physical activi-ty, and commercial tobaccouse. We must do somethingto address these problems asindividuals, as communities,and as a state.”
The recent rise in obesitylevels in Minnesota, pairedwith data that show anti-smok-ing efforts have become lesseffective, is part of a nationaltrend of an increase in chronicdisease and unhealthy habits.“Not only do chronic diseasesreduce the quality of life andlife expectancy for Minnesotans,but the costs of treating themcreate a substantial burdenfor our health care system,”Ehlinger says.
Capsules from page 5
www.cmecourses.umn.edu2012 CME Courses(All courses in the Twin Cities unless noted)
SPRING COURSESUrology for Primary CareMarch 15, 2012
Lillehei SymposiumApril 5-6, 2012
Cardiac ArrhythmiasApril 13, 2012
Integrated Care Conference: IntegratingBehavioral Health into the Health Care HomeApril 13, 2012
Intensive Care Unit (ICU) Team TrainingApril 23-25, 2012
North Central Chapter Infectious DiseasesSociety of America (NCCIDSA) AnnualMeetingApril 28, 2012
Care Across the Continuum: ATrauma & Critical Care ConferenceMay 11, 2012
Global Health TrainingMay 14-28, 2012
Advanced Pediatric DermatologyMay 18, 2012
Bariatric Education ConferenceMay 23-24, 2012
Workshops in Clinical HypnosisMay 31-June 2, 2012
Topics & Advances in PediatricsJune 7-8, 2012
FALL COURSESPsychiatry ReviewSeptember 2012
National Pediatric Hypnosis TrainingInstitute (NPHTI)September 20-22, 2012
Twin Cities Sports MedicineOctober 5-6, 2012
Practical DermatologyOctober 2012
ONLINE COURSES (CME credit available)For more information:www.cme.umn.edu/online
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Twin Cities Orthopedics has added five neworthopedic surgeons to its medical staff. JasonBarry, MD, is a sports medicine fellowship-trained orthopedic surgeon who specializes intotal joints, fracture care, and general orthope-dics. His special interests include ACL recon-struction and arthroscopy of the shoulder,knee, and hip. He willsee patients at the CoonRapids, Fridley, and
Shoreview locations. Scott Holthusen, MD,is a fellowship-trained foot and ankle specialistfrom the University of Washington/HarborviewMedical School. He will see patients at theChaska and Waconia locations. Allan Hunt,
MD, specializes in sportsmedicine and treats ath-letes of all ages. His areas of expertise includearthroscopic shoulder reconstruction and adultshoulder, knee, and hip reconstruction. He willsee patients at the Edina and Plymouth loca-tions. Daniel Marek, MD, is a fellowshiptrained hand surgeon from the University ofWashington who treatsconditions of the hand,
wrist, and elbow in both adults and children.He will see patients at the Chaska, Glencoe,and Waconia locations. Corey Wulf, MD,specializes in sports medicine, multiligamentknee reconstruction, cartilage transplant, andgeneral orthopedics. He will see patients at theEdina and Eden Prairie locations.
Brian D. Patty, MD,vice president and chief medical informaticsofficer for HealthEast Care System, hasreceived a national award from the Associationof Medical Directors of Information Systems(AMDIS). The 2011 AMDIS awards saluteexcellence and outstanding achievement inapplied medical informatics, honoring individ-uals and organizations that have successfullyapplied information systems and computer
technology into the practice of medicine. Patty was honored as astrong advocate for the effective use of health care IT and innova-tion to improve quality, safety, and efficiency. AMDIS is a nonprofitorganization representing more than 2,000 physician health-careinformation technology leaders.
Ben Bache-Wiig, MD, has been named vice president of med-ical affairs for Abbott Northwestern Hospital. Bache-Wiig, who isboard-certified in internal medicine, most recently was presidentof North Clinic PA, a multispecialty clinic with more than 50 physi-cians. He also served on the board of trustees of North MemorialHospital and is a board member of Medica Health Plan. Bache-Wiigsucceeds Robert Wieland, MD, who is now executive vice presidentof Allina’s Ambulatory Services.
James Mohn, MD, has joined St. Luke’s Cardiology Associatesin Duluth. Mohn received his medical degree from the Universityof Minnesota Medical School and completed his internship andresidency in internal medicine at Hennepin County Medical Center.He completed his fellowship as chief cardiology fellow at theUniversity of Iowa Hospitals and Clinics in Iowa City and com-pleted his fellowship in interventional cardiology at the U of M.Previous to this position, Mohn was a clinical instructor at theUniversity of Minnesota Medical School and a hospitalist atHennepin County Medical Center’s Division of Cardiology.
M E D I C U S
Jason Barry, MD
Allan Hunt, MD
Scott Holthusen, MD
Daniel Marek, MD
Corey Wulf, MD
JANUARY 2012 MINNESOTA PHYSICIAN 7
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� Could you tell us a little about the work that youdo with the Medical Technology Caucus?
As co-chair of the House Medical TechnologyCaucus, I’m a passionate advocate for protectingand defending and helping what is not only aMinnesota success story, but an American successstory. The work of the committee is not only aboutthe jobs that are created by these device companiesor in this industry but really about helping to savelives and improving lives.
There are approximately 60 to 70 membersright now that are members of the caucus, fromvarious areas of the country that represent similarecosystems or corridors where medical technologyis strong and vibrant. There aren’t many voices inCongress that care about this issue, and that’s whyI’ve taken a leadership role and talk about why it’sso important. We have periodic meetings with leg-islative and congressional staff, and with the FDA,to loop them in.
With the caucus, I canhelp educate Congress aboutthe medical device industry. Ialways tell people that, inaddition to being the Land of10,000 Lakes, Minnesota isthe land of 400 medical tech-nology companies that pro-vide 35,000 jobs.
� What are some of thebiggest issues that yourcaucus has been looking at recently?
There are really two issues that are front and cen-ter right now that are impacting the industry oractually threatening the medical device community.
No.1 is the upcoming medical device tax. I callit the medical innovation tax. It’s the tax that startsin a little over a year and was part of the newhealth care reform law, the Affordable Care Act(ACA). More than 220 cosponsors—that’s morethan half the Congress—have signed legislation torepeal that tax before it actually goes into effect.
This $20 billion medical innovation tax is anill-conceived tax on innovation that could reduceaccess to life-saving technologies for Americans.We think it’s a very wrong-headed approach.Studies have shown it’s going to have a 10 percentreduction of the workforce in the industry, with43,000 jobs lost nationwide. That does not evencount the supply chain or ecosystem with indirectjobs that would be affected.
The other issue, quite honestly, is the inconsis-tent and unpredictable and less-transparent ap-proach from the FDA toward the medical deviceindustry. The approval process for medical devicesis badly in need of reform. It’s just become a lotmore difficult for doctors working with new tech-nologies and the entrepreneurs and engineersdeveloping these products that are life-saving andlife-improving to gain approval of these devices
and bring them to market.We’ve seen the approval process become a
much longer time frame, and primarily it’s becausethe goalposts get moved on these companies dur-ing that process. It is a real issue now, where a lotof the medical technology start-ups are no longerstarting in Minnesota or the United States. Theinvestment has traveled to Europe or even Braziland China now, where the clinical trials might bedone in Europe, for instance, because those coun-tries have a much more streamlined regulatoryprocess. So that’s the other issue—working bipar-tisan and bicamerally on what is the best way tostreamline and modernize the FDA, so that it’sconsistent and predictable.
� There has been bipartisan support for a lot ofthe issues in the caucus. How are you reachingconsensus on some of these issues?
These are issues that are not Republican issues orDemocratic issues. They’reAmerican issues, affecting allof our constituents. The wayI’ve been successful is, num-ber one, just building rela-tionships with my colleagueson these issues. Things areworking in Washington,especially in this area. It’sstill slow and frustratingbecause you have to getmomentum, and you have to
convince a larger number of folks. But we are mak-ing progress. The best opportunities come frombeing results-oriented and solution-oriented.
� What do Minnesota medical device manufac-turers tell you they are most concerned aboutwhen it comes to government regulations?
In terms of the regulatory situation, what I hearabout most often is having the goalposts moved inthe middle of the process. This isn’t about cuttingregulations. The industry wants consistent regula-tions, but it wants a relevant process. We’re hopingto create a gold standard that is streamlined andeffective.
Part of the frustration is getting the FDA tounderstand why this is central to keeping jobs herein Minnesota and the United States. One of theproblems we’ve seen is that questions get askedduring the FDA approval process that do not applyto the product itself. There are also issues with thedisparity between what we call “FDA time” andreal time when it comes to tracking medical deviceapprovals.
This has a real impact on jobs. In Minnesotawe have a number of small employers who want tobecome the next Medtronic but they’re not yetprofitable, and the fact is that we’re making itmore difficult for them to grow here. The regulato-ry issues are definitely on their minds, and of
Rep. Eric PaulsenU.S. House of Representatives
Rep. Eric Paulsen is atwo-term member ofthe U.S. House of
Representatives fromMinnesota’s third
congressional district.Paulsen sits on theHouse Committee onWays and Means and isa founder and co-chairof the House MedicalTechnology Caucus.
Paulsen has been activein working on issuessuch as reformingthe medical device
regulatory process andhas called for repealingthe medical devicetax that was part ofthe Affordable CareAct. In addition,Paulsen is co-chairof the CongressionalWellness Caucus,which works topromote wellness
and preventive healthprograms among
businesses in Minnesotaand across the nation.
Defending a Minnesota success story
8 MINNESOTA PHYSICIAN JANUARY 2012
I N T E R V I E W
In addition to being theLand of 10,000 Lakes,Minnesota is the land
of 400 medical technologycompanies that provide
35,000 jobs.
course, the medical device tax on the hori-zon is also a concern.
Congress has the oversight capability tofocus attention on the FDA and we’re work-ing with the energy and commerce commit-tee to find ideas on how to modernize andstreamline the regulatory process. I’m theauthor of one bill to allow more third-partyreview processes, and there is languageabout keeping a more consistent time clockduring the process. This legislation hasbipartisan support; the goal in the House isthat we’re really working on trying to havethese ideas rolled together as one packageearly next year.
� When it comes to the ACA, if bothpolitical parties agree health care hassignificant problems, why does consider-ing the solutions generate so little bipar-tisan support?
Health care reform was needed, but I reallydid not agree with how it was done. Whenthe bill was being debated, I argued that thebill was flawed because it did not addressthe issue of health care costs. There was alot of emphasis on access but costs were notaddressed, and those costs are still rising.I think the ACA is going to collapse of itsown weight.
The truth is there is, and was, a lot ofbipartisan support for some ideas such asliability reform, risk pools for small busi-
nesses, not excluding people for preexistingconditions, and insuring younger adults.But we needed a 90-page bill, not a 2,000-page bill.
We do need a more consumer-drivenapproach to health care. We need new mod-els where consumers know what health carecosts are, because some of these are hidden.We should look at health savings accounts.With HSAs, costs come down as consumersare paying attention to where they aredirecting their dollars. We can bend the costcurve by doing things in different ways sothat we are reimbursing providers for thingslike disease management and prevention.
One of my other responsibilities here isthat I am co-chair of the congressionalWellness Caucus. There are real opportuni-ties in that area: for example, sharing suc-cess stories from companies that are provid-ing wellness programs for employees.
� How do you see health care issuesfactoring into the coming elections?
Health care premiums have been a pocket-book issue for individuals and families andsmall businesses alike. The issue is not goingto go away. We in Congress need to be pay-ing attention to that. That’s why I’m reallytrying to champion some of Minnesota’s suc-cesses, whether it’s in medical technology orwith wellness initiatives, and educate mycolleagues about how we can replicate and
share these stories and save money as partof the federal health care reform efforts.
This sort of one-size-fits-all approachthat was done a year and a half ago was thewrong direction, and then the public lashedout in the last election. But Congress isgoing to be forced to deal with this becauseof the cost issue going forward, just from asustainability standpoint. It’s going to weighin during the election. My constituents arelooking for thoughtful, results-oriented,solution-oriented approaches to some diffi-cult issues and challenges.
� What would you like physicians inMinnesota to know about how they canmake a difference in federal health carepolicy issues?
I would like physicians to know that I’malways in a listen-and-learn mode. The realstories, the real anecdotes from the experi-ence level that they have, are very meaning-ful to me. I do talk to quite a few physiciansand doctors on a regular basis, and it meansa lot more to me when I share stories withmy colleagues, or when I’m speaking at atown meeting and I’m sharing these typesof real-world experiences, instead of juststatistics and numbers.
I keep an open door, because that ishow I’m going to be able to even betterrepresent my district and my constituentsin Minnesota.
JANUARY 2012 MINNESOTA PHYSICIAN 9
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going into DIC (disseminatedintravascular coagulation); bythe time this was noticed, it wastoo late.
Every day, in every country,patients are diagnosed with con-ditions they don’t have, or theirtrue condition is missed. ButJulia was the turning point in
my career as a chief medicalofficer, leading me to becomepassionate about how we makedecisions in medicine and inmanagement.
Defining diagnostic errors
A diagnostic error occurs whena correct diagnosis is uninten-tionally delayed (e.g., if anotherdiagnosis is made first) whensufficient information is avail-
able or when the correct diagno-sis is completely missed. Thank-fully, not all diagnostic errorslead to harm.
Diagnostic errors constitutemore than 17 percent of all med-ical adverse events. In 1999,patient safety expert LucianLeape, MD, estimated that40,000 to 80,000 deaths occur
each year because of misdiag-noses. However, diagnosticerrors tend to go unrecognizedand underreported, and we livewith an underdeveloped sciencein trying to figure them out. Theroot causes of diagnostic errorsare difficult to study, as errorstend to be defined only in hind-sight and it’s impossible toreconstruct mental processeswith complete accuracy. It is
natural for us to attempt to sep-arate errors into those due toknowledge deficits versus thoseresulting from thinking errors,but both factors likely con-tribute.
Another difficulty is thatmore than 10,000 specific ill-nesses have been identified andare diagnosable. The more casesyou see that are in the primarycare arena, the higher the uncer-tainty about your diagnoses;the more specialized you are,the more you have a little un-certainty removed.
Normal accident theoryholds that accidents are in-evitable in complex and tightlycoupled systems—like medicine.Physicians apply imperfectknowledge and lab data that aretypically nonspecific and incom-plete, working in a dynamic situ-ation, to somehow make senseout of a case presentation. Aseries of interdependent deci-sions and/or actions are oftenrequired to reach a goal; the sit-uation changes over time, some-times very rapidly; goals shift orare redefined; and decisions thatclinicians make change thedynamics, resulting in new chal-lenges to resolve.
Given the complexities ofcaring for patients, what can wedo to reduce the incidence ofdiagnostic errors? There are twoways of approaching the ques-tion: systems issues and cogni-tion issues.
Systems issues
In the case of medicine, thesystem issues that cause us tomake diagnostic errors include:(1) breakdowns in delivery offunctions, such as the follow-upof an abnormal or critical lab orimaging result, (2) productivitypressures, (3) discontinuouscare, (4) handoff problems, (5)poor standardization processesand policies, (6) poor communi-cation, and (7) lack of essential,patient-relevant information.
Clinicians do their workwhile embedded in a complexmilieu of people, artifacts, pro-cedures, and organizations. Allof these factors can contributeto or detract from diagnosticperformance. Even well-trainedindividuals are at risk of makingserious errors while working in
a poorly designed system.
Cognitive issues
Research has shown that defi-ciencies of medical judgment,rather than deficiencies in med-ical knowledge, lead to morediagnostic errors in clinical set-tings. Cognitive psychology isthe study of how we reason, howwe formulate judgments andmake diagnostic decisions basedon data gathering, data synthe-sis, and data verification, eachof which may be prone to error.
Diagnostic errors thus arisefrom failure in systems and fail-ure in cognition. The cognitiveerrors can result from failures inheuristics and from biases.
Heuristics are intuitive(“common sense”) judgmentsbased on experience-based tech-niques for problem-solving andlearning—efficient methods toget to an answer. Humans areevolutionarily hardwired to useheuristics in decision-making;and, in fact, decisions based onheuristics are correct 80 percentto 85 percent of the time. Theproblem is, our experience-based intuition is not infallible.The novice needs more experi-ence to use heuristics well, andthe expert tends to use this typeof reasoning wisely, but in theprocess sometimes forgets to bemore analytic-minded in reach-ing a decision.
In addition to heuristics,our decision-making can beaffected by numerous biases,in the form of:• Overconfidence• Premature closure/anchoring• Availability bias• Base-rate neglect bias• Representativeness bias• Confirmation bias• Commission bias• “Satisficing”
Overconfidence bias. Thefirst and most important biasis overconfidence: believingyou have more ability than youreally do. Generally it is consid-ered a weakness and sign of vul-nerability for clinicians toappear unsure or to discloseuncertainty to patients. Further-more, as physicians get olderand more experienced, theirconfidence increases, oftenresulting in a decreasing felt
Errors from cover
10 MINNESOTA PHYSICIAN JANUARY 2012ERRORS to page 13
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need for updating their knowl-edge. This reinforcing overconfi-dence cycle is the nail in the cof-fin of robust learning that wouldallow clinicians to improve diag-nostic problem-solving overtime.
Premature closure oranchoring bias describes thetendency to stop too soon andnot order critical tests or gathercritical information. Or it canresult in deciding that the pa-tient’s current problem is relatedto the first thing you’ve diag-nosed. These biases lead us tojump to a conclusion and neg-lect to do a broader search forother possibilities.
Availability bias is the ten-dency to judge a diagnosis asmore likely if it is more easilyretrievable from your memory;that last patient you saw hadmeasles, so this one must haveit as well. All of us give morecredence to recent events.
Base-rate neglect bias isthe tendency to ignore the truerate of disease and pursue rarebut more exotic diagnoses.When you hear hoof beats, youthink of horses, but how oftendo you want to go to zebras?
Representativeness bias isthe tendency to be guided byprototypical features of diseaseand miss atypical variances.What we often forget is thatclassic features of a diseaseoccur only about a third of thetime. (Not all heart attacks comein with classic chest pain, jawpain, and pain radiating downthe left arm.) When we get a testresult, we may forget to keep thefalse positives and negative ratesin mind.
Confirmation bias is ourtendency to seek only data thatconfirm rather than refute ourhypothesis. Remember Julia’scase, in which everyone wentdown the same road of thought.We tend to give more credenceand legitimacy to data that sup-port our diagnosis—and ignoredata that don’t.
Commission bias reflectsour need to do something ratherthan just stand there. We feelbetter when we do something,even when it may be wrong. Butsometimes it is better not to act
right away. Sometimes it’s betterto “go to the balcony” to overseethings before acting.
“Satisficing.” This bias,which combines the verbs“satisfy” and “suffice,” involvesintentionally making a subopti-mal decision in order to satisfycompeting demands. Whenresources are limited, peoplechoose a “good enough” solutionthat partially satisfies multiplegoals. In medicine, satisficingbias is seen when clinicalencounters are constrained bytime and uncertain or absentdata and clinicians juggle multi-ple problems, prioritizing someover others.
Other factors
Other important factors influ-encing decision-making aredecision fatigue and lack offeedback.
Decision fatigue. Whenyou have to make more andmore decisions during the day,you become fatigued. Your deci-sion-making ability drops signif-icantly; in fact, you tend not tomake decisions or to delay themas the day goes on, though thatmay cause more problems. Howmany of you, when taking call atnight covering for others, havedelayed a decision, hoping to letyour colleague make it (recallingthe resident mantra, “Keep ’emalive to 8:05.”)?
Lack of feedback is a hugeproblem in medicine. We allknow that learning and feedbackare inseparable. But in medi-cine, the reality is that some-body else may hear, down theline, what the diagnosis was orwhat the lab test was—and youmay never get the feedback youneed to learn whether your diag-nosis was right or wrong.
Can we become “debiased”?
Aiming to produce completelyunbiased decisions is a fool’serrand, as many biases are pre-conscious and cannot be over-come by simply willing ourselvesto ignore them, any more thanwe can will ourselves to be taller.So, what can we do to reducebias in medical decision-makingon the individual, system, andcolleague/mentor levels?
On an individual level,we can:
• Be aware of our base rates.• Consider whether data aretruly relevant rather than justsalient.
• Seek reasons why decisionsmay be wrong and entertainalternative hypotheses.
• Ask questions that would dis-prove rather than confirm thecurrent hypothesis, keeping inmind we are wrong more oftenthan we think.
On a system level, we canask:• How can we control systems tobe better?
• How can we train people to doa better job?
• How can we use informationtechnology better?
With regard to systemsimprovements, for example, wecan begin measuring categoriesof errors, as we have in otherareas of patient safety, by meas-uring harm rather than just themisdiagnosis. We can also try tobuild workflow computer-basedtools such as web-based diagno-sis decision-support systems.Unfortunately, computer-basedclinical decision-support systems
have not proven to work effec-tively yet, because they are notfully coupled with the electronicmedical record.
On a practice/hospital/colleague/mentor level:• Remind your partners, stu-dents, and colleagues thatwhile “the simplest explana-tion tends to be the best”(according to Occam’s Razorprinciple), it is not always thebest. Encourage learners tofind clinical data that don’t fitthe provisional diagnosis, andto always ask why if we can’texplain the diagnosis.
• Encourage learners to slowdown. Help them understandthat unless the clinical situa-tion is a true emergency, tak-ing a little time may help youavoid biases.
• Acknowledge our mistakes. Noone is infallible, and we needto teach future generationsthat they, like us, will makemistakes.
• Use scenario planning as amethodology to help decreaseerrors and keep in mind whatother diagnoses should be
Errors from page 10
JANUARY 2012 MINNESOTA PHYSICIAN 13
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given the election year, redis-tricting, and a general desireto limit the time spent at theCapitol following the long andarduous 2011 session and subse-quent special session. Theprospect of an unexpected statesurplus also changes the sessiondynamics as legislators wrangleover the easier, but still con-tentious, question of where themoney goes, should any be leftover after the required paybacksto the state’s cash-flow accountand budget reserve. One of thekey factors contributing tothe surplus was a significantdecrease in health and humanservices spending, largely attrib-uted to lower than expectedenrollment in the state’s MedicalAssistance (MA) program.
With the surplus in hand,expect any supplemental budgetdiscussions to turn to the ques-tion of repaying the K–12 educa-tion shift, an issue that neitherRepublicans nor Democratswant to own heading into anelection year. Proposals willmost certainly be brought for-ward to repay the shift in the
current year, but those couldcome at the expense of an effortto make further cuts in the bud-get. Either way, the previouslyanticipated stalemate and parti-san fighting over even a smallbudget deficit will be avoided, atleast for one year.
There are considerable ques-tions about what, if anything,will be moved forward regardinghealth care policy in the 2012session. Committee leaders inboth bodies began puttingtogether their 2012 agendas inNovember and December inhopes of moving quickly comeJanuary to get in and out of ses-sion in a 10-week time frame.Leadership in both bodies puttogether a legislative packagethey are calling Reform 2.0.While the reforms are largelycentered on streamlining gov-ernment functions, there may bea few health policy initiativesthat emerge, including potentialreforms to the current claimsdata reporting performed byhealth plans in the state.
With the exception of theReform 2.0 package, and apotential partisan fight over a
health insurance exchange, thelegislative agenda remains aquestion mark. Republican lead-ership will likely move forward afew ballot question initiatives,but given the contentious elec-tion year ahead, it’s reasonableto expect significant politicalgamesmanship.
Getting a head starton the Legislature
The Dayton administrationwasted no time this fall waitingfor the legislative session tobegin, taking a hands-on ap-proach to a number of signifi-cant MA reform initiatives.Going back to last session, therehas been increased focus onwhere the almost $4 billionfunding the state’s MedicalAssistance program was beingspent, particularly in managedcare programs. Last year, thegovernor announced early on hisdesire to move toward a compet-itive bid pilot program for MAmanaged care, starting with apilot project in the Twin Citiesseven-county metro area. InOctober, Gov. Dayton andDepartment of Human ServicesCommissioner Lucinda Jessonannounced the results of thecompetitive bid, awarding con-tracts to HealthPartners andUCare for the Twin Cities’ man-aged-care population.
The competitive bid pilot,which was included in the 2011HHS budget, is projected to gen-erate savings of about $175 mil-lion. However, there are still sig-nificant questions about whetherthose savings will be achievedthrough greater efficiencies inmanaging that population orwhether the savings will beobtained solely through furtherreductions in provider reim-bursement. The latter resultwould have an even greaterimpact on already razor-thinpayment rates for the state’spublic programs.
Politics and thehealth insurance exchange
One of the more public debateslikely to take place in the 2012session is the discussion overwhether legislation is requiredfor a state-run health insuranceexchange. Under the federalAccountable Care Act (ACA),states are required to have in
place, by Jan. 1, 2014, the frame-work for a state health insuranceexchange, or states will beforced to use the federal insur-ance exchange.
The tension between theRepublican legislative majoritiesand the Dayton administrationonly intensified over the fallmonths as the governor movedforward on implementing ahealth insurance exchange. Inlate October, Gov. Dayton issuedan executive order establishing aHealth Insurance Exchange TaskForce through the Departmentof Commerce to begin imple-menting a state-based insuranceexchange.
The insurance exchangeissue became a political hot but-ton last session for Republicanleadership in the House andSenate, as a number of caucusmembers opposed moving for-ward on an exchange out ofopposition to federal health carereform. Rep. Steve Gottwalt(R–St. Cloud), chair of theHealth and Human ServicesPolicy Committee, went so far asto propose a bill implementingthe exchange. In an interestingtwist, the insurance exchangebill was scheduled for a hearingon the same day as another billauthored by Gottwalt that calledfor a ban on the use of statefunds to implement any provi-sions of the ACA.
Opposition to the healthinsurance exchange concept maybe even greater in the Senate,where Sen. David Hann (R–EdenPrairie), chairman of the SenateHealth and Human Service Pol-icy and Finance Committee, hastaken a strong position opposingthe exchange. In spite of theiropposition, Republican legisla-tors will likely find themselves ina difficult catch-22 should theymove forward with efforts tothwart implementation of astate-run exchange. Without astate insurance exchange, theywould be forced to accept onerun by the federal government,a position even more perilousgiven Republicans’ disdain forfederally run health care.
A question of constitutionality
One of the questions hangingover legislators’ heads in the2012 session is how the U.S.Supreme Court will rule on the
14 MINNESOTA PHYSICIAN JANUARY 2012
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Accountable Care Act’s constitu-tionality. The ACA continues togenerate significant politicalopposition, largely from manyfirst-term Republican Senate andHouse members. Although theSupreme Court is not scheduledto reach a decision until after thelegislative session ends, the merethreat of an “unconstitutional”ruling could put the brakes onmany of the ACA programs thatthe state would otherwise beginimplementing beginning in 2013,including the aforementionedhealth insurance exchange.
The Supreme Court’s deci-sion could also have a signifi-cant impact on the future of thestate’s Medical Assistance pro-gram. In the Supreme Court’sannouncement that it wouldhear the ACA case, the courtchose to address not only thequestion of the individual man-date, but also the question ofwhether Medicaid expansionwas constitutional as well.However the court rules, thedecision will again be front andcenter in campaign season nextfall, in both Minnesota and therest of the country.
What district are you in?
If fights over budget and policyweren’t enough already, theuncertainty surrounding theredistricting process and whatthe new legislative boundarieswill look like will certainly shapethe 2012 legislative session. As aresult of the Legislature and thegovernor failing to come to anagreement on a redistrictingplan, the task once again wasput into the hands of the courts.
Over the fall months, a five-judge redistricting panel tookinput from around the statefrom the public and other inter-ested stakeholders to assist inthe process of drawing new leg-islative and congressional dis-tricts. The judicial panel willrelease the newly drawn lines onFeb. 21, a full two weeks afterthe local caucuses are scheduled.The timing puts legislators andcandidates in a precarious posi-tion as they begin recruitinglocal delegates without actuallyknowing whether any of thosedelegates will be in their newlydrawn districts.
The 2010 census data cer-tainly provided details regarding
population growth that haveproved controversial in the redis-tricting debate. Significantgrowth areas included theInterstate 94 corridor and largeportions of Scott and Carvercounties. As an example, Rep.Michael Beard’s current districtin Shakopee saw such significantpopulation increases over thelast 10 years that his currentHouse district has the popula-tion of a Senate district.
On the other side of theequation, the core cities ofMinneapolis and St. Paul sawpopulation reductions over thepast 10 years, potentially forcingthe boundaries on some of thesedistricts out into the inner-ringsuburbs. Democrats have longargued that the interests of corecity residents often vary signifi-cantly from those of suburbanresidents and that every effortshould be made to ensure thatcommunities of interest are notdivided. Nevertheless, the redis-tricting process is sure to onceagain leave some pleased andothers not so much, as a newpolitical reality takes shape inFebruary. The urgency to end the
session early and allow legisla-tors to get back to their districtsand begin a long campaign sea-son will be in full swing once thenew district maps are released.
What can my practice do?
The best way to ensure that yourpractice’s or clinic’s opinions areheard is to reach out to yourstate senator or state representa-tive. The state’s website at www.leg.state.mn.us lists contactinformation for all members ofthe Minnesota House and Senateand provides up-to-date informa-tion on legislation, as well asdescriptions of all bills intro-duced during the legislative ses-sion. You can call Senate Infor-mation at 651-296-0504 or HouseInformation at 651-296-2146 formore information. Contact infor-mation for the governor’s officecan be obtained throughwww.governor.state.mn.us.
H. Theodore Grindal, JD, and NateMussell, JD, are with the Minneapolis lawfirm of Lockridge Grindal Nauen PLLP. Theyprovide government relations services forhealth care providers.
JANUARY 2012 MINNESOTA PHYSICIAN 15
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B E H A V I O R A L H E A L T H
Parents are often shockedand scared when they aretold their youngster has
autism. The word “grief” hardlyconveys the gut-wrenchingreevaluation of their hopes anddreams for their child as theysoldier forward to find services.
The primary care provider(PCP) will be an importantresource to parents as they seekto navigate the highly complexmental health and disabilityservices systems in education,health, mental health, and spe-cialized services, includingoccupational therapy andbehavioral interventions. PCPsare sensitive to and knowledge-able about the developmentaldelays of language and recipro-cal interaction and the narrowrange of interest and behaviorsthat are the hallmarks of thisdisorder. They are knowledge-able consultants to the familyon clinical care choices.
In the past decade, agroundswell of interest inautism has led to an increase infederal and private research toexplore new ways of examining
and modifying autism. Thisenormous scientific investmentand resultant array of informa-tion about autism have created arole for primary care physiciansthat goes beyond screening andreferral. For example, medicalworkups that include sophisti-cated genetic testing and phar-macological treatments maysoon become standards for pri-mary care.
This report highlights someof the newest information aboutautism that may be important toprimary care physicians in theirrole as educators of parents,selectors of laboratory tests,providers of medically basedtreatments, and referrers tomedical subspecialists for spe-cific medical interventions.
Etiology
The identification of autism andthe spectrum of deficits associ-ated with this neurodevelopmentdisorder is improving as high-tech diagnostic assessments areemployed. While the etiology ofautism is complex, researchstudies increasingly suggest thatinteractions among the physicalenvironment (infections, toxins),genes, and in utero insults resultin disordered central nervoussystem cytoarchitecture, leadingto profound deficits in higher-level cortical functioning anddevastating consequences tosocial, language, and imagina-tive abilities.
Genetic studies. Some ofthe most recent genetic studies,rather than looking for specific
alleles associated with the dis-order, take a broader view. Forexample, a recent study detecteda significant increase in copynumber variations (CNVs) inautism. Like Fragile X disorder,in which a small portion of theX chromosome is expanded by arepetition of three base pairs(CGG), in autism there are mul-tiple sites within the genomewhere these copy numberrepeats may be found. One studyshowed that about 38 percent ofchildren diagnosed with autismspectrum disorder (ASD) had asignificant increase in theseCNVs and 7.4 percent had path-ogenic CNVs. This subgroup ofthe larger population of individ-uals with autism presented withmultiple congenital abnormali-ties and dysmorphism. This spe-cific type of genetic abnormali-ties (CNVs) in autism supportsthe disorder’s association withFragile X, which represents thelargest single genetic disorderwith an outcome consistent withautism.
Technological advances ingenetic sequencing, microarrayanalysis, and exome sequencing
Autism updateAn expanded role
for primary care providers
By George Realmuto, MD and Israel Sokeye, MD
16 MINNESOTA PHYSICIAN JANUARY 2012
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may more rapidly identify genet-ic abnormalities contributing tothe expression of the disorder.These advances will be availableto primary care physicians with-in the next few years.
Neuroimaging studies.Other avenues for exploring theetiology of autism include neu-roimaging studies. While thestudies have not yet produced aneuro-anatomical signature,they have shown anomaliesaffecting different areas of thebrain (brain stem, cerebellum,limbic system, and associationcortex) of children with ASD.Beyond the specific structures,highly sophisticated neuroimag-ing studies that can follow nervetracks support the notion of dis-ruption in the functional con-nectivity among these structuresduring the childhood phase ofbrain development in ASD.
Neurochemical studies.Neurochemical studies haveinvestigated the well-known roleof serotonin, epinephrine, andnorepinephrine in messagingthrough the brain. New informa-tion has added more weight toan old hypothesis about the role
of oxytocin in autism. Oxytocin’swell-known role in birthing andorgasm has been extended toinclude its ability to enhancesocial reciprocity and bonding.These very socially advancedcapacities are deficient inautism, consistent with newinformation that suggestschanges in oxytocin neurotrans-mission in autism. Oxytocin wasone of the first hormones syn-thesized, and ongoing clinicaltrials are investigating its poten-tial to alter behavior in individu-als with autism.
Parental factors influenc-ing risk. New information sug-gests that age of conception mayinfluence the risk for autism.While mother’s age is not associ-ated with increased risk, fathersolder than 35 years of age con-ferred greater risk, and that risk
increased as father’s ageincreased. This information maybe of special interest to familiesconsidering additional childrenwho already have an affectedchild, as the father’s age is anadditional risk to an alreadyincreased risk signaled by theproband. Other family planningissues have come to light in con-nection with studies demonstrat-ing increased risk due to shortintervals between pregnancies.In addition, recent studies haveshown that mothers taking anti-depressants (SSRIs) in the yearprior to their delivery have atwofold increased risk of havingchildren with ASD, with a higherrisk if these SSRIs were takenduring their first trimester.
Epidemiology research.Epidemiology studies in Irelandhave shown that the number of
immigrant children beingreferred for services with diag-nosis of ASD has dramaticallyincreased, predominantly inchildren born to immigrantsfrom sub-Saharan Africa. Thiscorrelates with the increase inincidence in the same popula-tion in Minnesota. The reason(s)for this increase in incidence areunclear, and more studies areneeded to further investigate thisresult.
Finally, the relationshipbetween immunizations andautism continues to be a com-mon question. Multiple studies,including a definitive investiga-tion by the Institute of Medicine,have found no association and,further, have uncovered scien-tific fraud in the study that pur-ported to find a relationship.
In summary, the prevailingview is that autism is caused bya pathophysiologic process aris-ing from the interaction of anearly environmental insult and agenetic predisposition. There-fore, it is strongly recommendedthat all children with autism/ASDs be considered for clinical
JANUARY 2012 MINNESOTA PHYSICIAN 17
AUTISM to page 18
The enormous scientific investmentand resultant array of information
about autism have created a role forprimary care physicians that goes
beyond screening and referral.
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genetic evaluation and genetictesting so that families can becounseled regarding recurrencerisk, prognosis, and associatedmedical comorbidities.
Treatment ofautistic spectrum disorders
Management of autism symp-toms can be divided into threemain approaches: parental edu-cation, behavioral therapy, andpharmacotherapy. The latter twoare discussed below.
Behavioral therapy.Multiple treatment options havebeen suggested, with differingdegrees of evidence, for individ-uals with ASD. It appears thatwith only a primitive view of eti-ology, theory-based approacheshave missed the mark. A recentmeta-analytic review of behav-ioral and medical interventionsfound that medication had avery limited place in overallmanagement of core symptomsbut could be useful for irritabi-lity and, perhaps, perseverativebehaviors. The same review sug-gested that while a variety ofbehavioral programs, such as
applied behavioral analysis, areuseful for some children, ques-tions remain about for whom,for how long, at what intensity,and at what age these highlyresource-intensive interventionsare appropriate. More researchneeds to be done on this topic tofurther determine the most suit-able patient population that willbenefit from applied behavioralanalysis intervention.
To date there are no medicaltreatments that affect the coresymptoms of the disorder. Someof the newest approaches arereviewed here.
Pharmacotherapy. Priorto initiating medications onindividuals with ASD, it isessential to get a thorough med-ical evaluation, as evidence ismounting that medical disor-ders have a significant effect onbehaviors, level of functioning,
and response to educationaltherapies. Since no medicationsare autism-symptom-specific,medication therapy should beselected with a specific behav-ioral target in mind. Clinicaland research literature canguide effective intervention forbehavioral problems such asaggression, self-injurious behav-ior, agitation, hyperactivity, anx-iety, poor sleep, and repetitive orstereotypic behaviors that inter-fere with learning and socialinteractions. Many physiciansin primary care have experiencewith challenging behaviors fromtheir management of other men-tal health disorders—for exam-ple, treatment of hyperactivityin ADHD children or physio-logical tension in children withseparation disorder—that maybe transferable in treating thesephenomena in children withautism.
ADHD is an often recog-nized comorbidity with ASD.Reluctance to treat these symp-toms separately has been rootedin the concern that stimulantmedication treatment for ADHDwould cause or exacerbateseizures. Nonetheless, there isa high rate of ADHD-autismcomorbidity, and recent findingssuggest that psychostimulanttreatment combining extended-release methylphenidate (MPH)in the a.m. with immediate-release MPH in the p.m. areassociated with significant be-havioral improvements in multi-ple settings. Perhaps more to thepoint was the finding that therewas very little evidence for be-havioral deterioration at higherdoses.
A study supported by theNational Institutes of Healthidentified risperidone (Risper-dal) and, through randomizedclinical trials, aripiprazole(Abilify) for treatment of irri-tability associated with autisticdisorder. Both atypical neurolep-tics were found to be effectivefor these associated symptomsat low doses and are FDA-
18 MINNESOTA PHYSICIAN JANUARY 2012
Autism from page 17 Since no medications areautism-symptom-specific, medication
therapy should be selected with a specificbehavioral target in mind.
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approved for that indication.While management of this prob-lem may be significant for fami-ly and child functioning, thesemedications are not withoutvery concerning side effects.Current research is looking atgenetic predictions of atypicalneuroleptic medication-inducedmetabolic syndrome in autism.In adults, previous data suggestthat differential risk for obesityand antipsychotic-inducedweight gain is influenced bycommon variants in the dopa-mine D2 receptor (DRD2), theserotonin 2C receptor (HTR2C),and the central cannabinoidreceptor gene 1 (CNR1). Arecent study shows that in chil-dren with autism, the variancepredicted by CNR1 was modest(9.1 percent), suggesting thatother pathways and gene vari-ants may be important. Ongoingefforts include additional sam-ples and variants to replicateand expand these analyses.
The latest effort to translateetiology into intervention isbased on a premise that abnor-malities in the GABA neuro-transmitter system may underlie
the abnormal cytoarchitecture,both because it is a major troph-ic stimulus in embryonic devel-opment and because it mayaccount for the sensory abnor-malities noted in childhood andbeyond. One study that exploitsthis theory is a 12-week, double-blind, randomized, placebo-con-trolled study of N-Acetylcysteine(NAC) in 24 children withautism. Subjects randomized toNAC were initiated at 900 mgdaily and finally titrated up to2700 mg per day. Compared toplacebo, NAC resulted in signifi-cant improvements in AberrantBehavioral Checklist (ABC)total (p=0.007), ABC irritability(p<0.001), ABC stereotypysubscale (p=0.019), and Repeti-tive Behavioral Scale (RBS)(p=0.027). This preliminary trialhas supported the utility of NACin reducing irritability as wellas repetitive and stereotypedbehaviors, which are among thecore symptoms of autism.
Other studies have exploredmecamylamine, a nicotine-receptor-active agent in treatingcore autism symptoms. This the-ory-driven project is based on
postmortem findings of nicotinicreceptor aberrations. Althoughmecamylamine appears safe forchildren with autism, data didnot suggest a benefit.
Extending the recentadvances in understanding theepigenetic abnormalities inFragile X syndrome (FXS) toautism may provide an interest-ing intervention direction. Arecent double-blind, placebo-controlled crossover trial explor-ing the safety and efficacy ofarbaclofen, a GABA-B agonist,in FXS showed significantimprovement on the ABC-Lethargy/Social Withdrawalscale. Also, clinicians and par-ents reported that subjects weremore socially engaged and morecommunicative. Due to the asso-ciation of FXS with autism,Arbaclofen shows promise fortreating behavioral symptoms inFXS and, possibly, for treatingcore social deficits in autism.
Primary care physiciansmay have an additional role inautism management as more ofthe health-related disabilities ofautism come to light. For exam-ple, it has recently been reported
that boys with ASD havedecreased bone cortical thick-ness. The question has beenraised about dietary intakes thatwould result in this outcome. Itwas found that ASD childrenconsumed less than 68, 60, 60,and 57 percent of DRI for calci-um, magnesium, vitamin D, andvitamin K, respectively. There-fore, it is critical to monitorbone-health nutrient intake ofchildren with ASD. Some nutri-ent insufficiencies, perhapsVitamin D, also may have impli-cations for brain function.
A critical role for primary care
Though much work needs tobe done to further understand,prevent, modify, and manageautism, one thing is clear:Primary care physicians willcontinue to play a critical rolein the identification, diagnosis,education, care management,and possible referral ofautism/ASD cases.
George Realmuto, MD, is a professorof psychiatry at the University of Minne-sota. Israel Sokeye, MD, is a child andadolescent psychiatry fellow at theUniversity of Minnesota.
JANUARY 2012 MINNESOTA PHYSICIAN 19
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MR. CHRISTENSON: What is an ACO?
DR. MOEN: ACO is a legislative constructthat enables change in health care. The wayI view it, it enables us to begin to balanceindividual health and population health ap-propriately in a system and drive accounta-bility to both.
DR. WECKWERTH: An ACO is a formless col-laborative entity intending joint accounta-bility for measurable quality improvementsand to reduce rates of health care spending.
MR. WATSON: It’s the latest way to bend thecost curve.
MR. CHRISTENSON: What is a shared savingspayment program? What does it mean?
DR. MOEN: It’s a mechanism to allow adifferent style or type of contracting thatrewards or allows alignment of incentivesfor managing cost care, not just producingvolume of services.
DR. THORSON: The intent of the shared sav-ings program is to say, how do we reducethe waste and maintain the quality andallow for more efficient utilization of bothlimited resources and dollars? Is it reallygoing to transition the payment from beinghospital-centric to more outpatient-centric?
MR. WATSON: It makes the assumptionthat there will be savings. The savingssupposedly come from the elimination ofepisodic independent activities, and there-fore you’re pooling something, and there-fore it should cost less in the aggregate.That’s the assumption. Whether or not it’strue, I don’t know.
DR. AINSLIE: One of the problems is, theregulations from CMS have an after-the-fact payment. You don’t even know whatpatients are in your ACO, so you don’t knowwho you’re taking care of and how you’retaking care of them, and it will be decidedafter-the-fact by CMS who can arbitrarilysay, you did a good job and we’ll pay youthat money, or no, you’re getting nothing.It’s all controlled by CMS.
MS. SORENSEN: I would also like to add thatit is still considered voluntary. So patientswill be passively enrolled into an ACO,which they may or may not be familiarwith, or be forced based on demographicsor where they live. If they choose to opt out,the ACO group may or may not know thatpatient has opted out.
MR. CHRISTENSON: What is critically importantfor doctors to know about ACOs?
DR. AINSLIE: I define an ACO as an HMOwithout the money. They are trying to savemoney, and that is the bottom line. It’s notto improve patient care, it’s not to improvephysicians’ well-being. It’s for CMS to savemoney. I tell physicians that if they go intoit, they certainly have a right to do so and aright to compete and a right to see whetherthis might work. What bothers me morethan anything else is that if they do, theirpatients are going to automatically be in-cluded, and they have no say in the process.
DR. KLODAS: The overwhelming thing thatwe need to come to terms with is how rap-idly everything is changing. The way I prac-tice medicine now may not be tenable infive years because these types of forces aremaking it almost impossible. I like to spendtime with my patients, and have a practicestyle that is more preventative. We’re goingto have a very difficult time existing inde-pendently. I think the thing that independ-ent practitioners need to think about is away to smartly consolidate within this mar-ketplace. As far as specialists go, frankly, a
lot of specialists are now part of ACO-typesystems. They’re very affiliated with hospi-tals. Already, most cardiology practices inthis environment here are owned. Theyalready belong to systems.
DR. THORSON: ACO is a technical changethat has been made to try to drive culturalchange at the delivery of health care. I thinkit is trying to get physicians to realize thatthe way we provide care needs to change. Idon’t think there’s any question that we can’tcontinue to do what we’ve been doing andhave a health care system that will stayafloat. The government is trying to do atechnical change to force cultural changewithin clinics. And cultural change is hard.Technical change is a lot easier. The thingwe talk about all the time is how we have tochange the culture of how we deliver care.This is an awkward time because we’re try-ing to change culture before payment hasbeen changed. It’s taking a very big leap offaith.
DR. KLODAS: I think that a big thing notbeing addressed is that, as a society, we’regetting sicker. No amount of this piddlingwith the way we pay for health care reallyaddresses some unbelievable statistics thatwe haven’t faced up to. I’m a cardiologist,so I know cardiovascular care. The currentexpenditure every year for cardiovascularcare in this country, just care, is $270 billiona year. In 2030, on the current trajectory, it’sexpected to reach $810 billion a year. That’sa stimulus package thrown at a disease yearafter year that is unsustainable. That’s a pub-lic health issue. It’s not necessarily how wepay for this. The ACO is projected to save $5billion over the next eight years. That’s theCBO [Congressional Budget Office] esti-mate. That’s nothing in this giant pool of aproblem. I totally agree with you. We need torefocus on how we truly deliver care, howwe can truly impact this cost curve, becauseI don’t think this is going to do it.
MR. CHRISTENSON: Vern, what are the bestthings we can say about ACOs?
DR. WECKWERTH: The intents are very good.We are going to improve population health,and that’s to be done because everyone issupposed to have a personal health planthat will be intervened by the particularhealth care specialty most appropriate for it.Secondly, it’s therefore going to benefit indi-viduals, and if individuals are benefited, the
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
Accountable CareOrganizationsAccountable to Whom?
About the RoundtableMinnesota Physician Publishing’s
36th Minnesota Health Care Roundtableexamined the topic of accountable careorganizations. Seven panelists and ourmoderator met on Oct. 13, 2011, to
discuss this issue. The next roundtable,on April 19, will explore the subject ofspecialty pharmacy and its role incontrolling the cost of health care.
A B O U T T H E PA N E L I S T S
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
Michael Ainslie, MD, is a pediatrician and a pediatric endocrinologistwith Park Nicollet Clinic, where he has practiced since 1977. He served asthe chair of the Board of Trustees of the Minnesota Medical Association.He has served on Park Nicollet committees for salary and bonus, systemsresearch, risk management, ethics, and recruitment. He was chief of pedi-atrics at Methodist Hospital from 1992 to 1998 and served on the Admin-
istration Committee for Methodist Hospital.
David Moen, MD, is president of the Fairview Physician Associates(FPA) provider network (affiliated with Fairview Health Service), an inte-grated health system of more than 20,000 employees and 3,000 physi-cians. As FPA president, Moen leads the development of Fairview HealthNetwork, an integrated multispecialty provider network. He and his teamdeveloped a team-based primary care model—the Medical HomeModel—that is now deployed across 41 primary care clinics. Moen also is chief medical officerof NetClinic, a Web-based interactive health portal for clinicians to deliver virtual care topatients. Moen earned his medical degree from the University of Wisconsin and completed hisresidency in family medicine at the University of Minnesota.
Elizabeth Klodas, MD, FACC, is a board-certified cardiologist withmore than 15 years of experience treating patients with heart disease.Klodas completed fellowships at both the Mayo Clinic and Johns HopkinsUniversity. She specializes in noninvasive cardiac imaging, including stresstesting, echocardiography, nuclear, CT, and MRI imaging. Klodas foundedPreventive Cardiology Consultants and sees patients at her independent
practice in Edina. She has led several patient education initiatives at the American Collegeof Cardiology (ACC) and spearheaded the formation of ACC’s patient education website,www.cardiosmart.org. Klodas is a medical editor for webMD, and also serves as director of theHeart Disease Prevention Program at General Mills.
Jennifer Sorensen, MEd, is executive director of the MinnesotaHomeCare Association (MHCA), which represents 250 members, includingbusiness affiliates and providers. Prior to joining the MHCA, Sorensonworked for the Mesa County (Colo.) Department of Human Services, over-seeing programs including the Area Agency on Aging, Adult Protectionservices, Adult Resource for Care and Help, Community Services BlockGrants, and Medicaid home and community-based services programs. She had a significantrole in the collaborative development and implementation of programming for seniors, CareTransitions programming, and the regional Medicaid Accountable Care Organization. Sorensonhas a master’s in education (guidance and counseling) from North Dakota State University.
David Thorson, MD, is a board-certified family physician who practicesat Family HealthServices Minnesota PA in St. Paul. He received his medicaldegree from the University of Minnesota Medical School, Minneapolis, andhas a Certificate of Added Qualifications in sports medicine. He currently ischairman of the Minnesota Medical Association Board of Trustees. In addi-tion, Thorson has served as chair of Family HealthServices Minnesota’s
Neuromusculoskeletal Services Clinical Practice Committee, and as team physician for the St.Paul Saints baseball team, U.S. Ski Team, U.S. Freestyle Team, Mahtomedi High School, and theTwin Cities Marathon. He is a former president of the Minnesota Academy of Family Physicians.
Jonathan Watson, MA, has worked with the Minnesota Association ofCommunity Health Centers (MNACHC) since 1996, and currently serves asassociate director and director of public policy. MNACHC represents 17community health centers in Minnesota that serve more than 190,000patients in medically underserved communities. Prior to joining MNACHC,Watson was a budget and policy analyst for the Wisconsin Department ofHealth & Family Services. He has also served on a number of statewide committees and taskforces. Watson has a BA in economics from St. Olaf College in Northfield, Minn., and a master’sdegree in public and international affairs from the University of Pittsburgh.
Vernon Weckwerth, PhD, is a retired professor at the University ofMinnesota, where, over a career of more than 50 years, he held jointappointments and taught in the School of Public Health, Medical School,School of Nursing, College of Pharmacy, Carlson School of Management,and Humphrey Institute. He earned his master’s and PhD in biostatisticsat the U of M. His research specialties include effects of variables on
health service delivery, design of research, inductive methods, and distance executive educa-tion. Weckwerth is director emeritus of the U of M’s ISP Off-Site Executive Study Programs inHealthcare Administration. He also serves on the editorial board of theJournal of Health Administrative Education.
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.
JANUARY 2012 MINNESOTA PHYSICIAN 21
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group is. There will no longer beseparate episodic care. The carethat’s appropriate for the individualat that point in time takes the judg-ment of more than just a single dis-cipline. If the ACO can pull it off, ifwe change the practitioner’s view ofwhat collaboration means, then thiswill work. It isn’t clear to me whatthe incentives for collaboration are.
MR. WATSON: They elevate primarycare in our health care system upon the front end. I’m looking at ourmember community health centers,safety net clinics working togethernow among themselves and alsolooking to partner with mentalhealth providers and with hospitalson a more formalized basis. I thinkwith that communication and col-laboration, it’s what we’ve been say-ing we have to do for the last 30years, and we’ve never done it. Ithink it is forcing some of thosediscussions.
MS. SORENSEN: It’s an opportunityfor clients and patients to be servedon a continuum of care versus afragmented piece of care that wecurrently deal with. All of our sys-tems are required to speak to eachother, yet we don’t. Patients get losttime and time again. We need totalk to the other players across thetable because this is part of thewhole care plan, and yours is nomore important than the otherplayer.
DR. MOEN: There might be anopportunity to decrease the numberof regulations. If you could actuallyget into a population system thathad a better goal and focused on anoutcome, maybe you wouldn’t needsome of the governors we have inplace today. I think there’s an oppor-tunity to reduce clinical variation,and there’s good research thatdemonstrates that a tremendousamount of the cost of health care isdue to clinical variation, variationin decision making, variation in thetypes of things that people do forcertain conditions. Some of thatvariability is hard to manage, butthere’s really good evidence that alot of variation in today’s systemisn’t justified. There isn’t a greatreason why Medicare costs so muchmore in New York than it does inMinneapolis or Davenport. Howlong are we going to pretend thatit’s about how much we pay nursesinstead of facing the fact that it’sabout the variability and the prac-tice and the incentives that are inplace?
MR. CHRISTENSON: What are thethree worst things about ACOs?
DR. AINSLIE: The biggest problemis that it’s another command-and-control mechanism that will beimposed on physicians and willcause them to consolidate. I feelsorry for the primary care docs whoare single practitioners in this state.They’re going to have to work withother people in other organizations.While it may cut down on individ-ual variability, that’s fine, but mostof the progress in medicine hasbeen from people who are thinkingoutside the box, not inside the box,and this program and others willjust make someone say, well, we’vegot to practice this way, or yourcomputer tells me I’ve got to do thisX, Y, and Z, and I’ll do that. It maytell me to have good diabetes con-trol, since I take care of kids withdiabetes. I can’t have anybody withan A1c over 8, for example, andevery year it’ll be screwed down to 7or 6. Well, what’s my first response?Get rid of the patients who are 12sand 14s because they’re screwing upmy average? That’s not good patientcare. I do much more for a 12 or 13,I feel, than for a 7 or 8, but thatskews my statistics, and so I won’tlike it if I’m paid on the basis of myA1c. The basic problem with ACOsis, it gets between the patient andthe physician, and we’re not orient-ing ourselves to where the realproblem lies—in the physician-patient interaction.
DR. KLODAS: The biggest thing to methat is amazing about this reformis that it completely leaves out thelinchpin for success, which is thepatient. There is no accountabilityon the part of the patient. You cando everything right, you can followevery single guideline, you can pro-vide all the education, all the med-ications, everything—but ultimately,if that patient walks out of the doorand doesn’t follow your advice,you’re the one who’s penalized, notthe patient. None of this can suc-ceed if patients are not accountable.I’m not saying it’s their fault, butthey have to be part of the solution.
MR. WATSON: There are reallythree kinds of problems we need toovercome with the ACOs. The firstis the start-up cost, for nonprofitsespecially. You have to look at ITsystems. You have to look at gover-nance of your ACO. All sorts ofchanges to your practice in thatsense that do cost money whileyou’re still trying to survive finan-
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
cially. Second, a lot of these ACOs that havebeen talked about and proposed are largelybased on urban, highly integrated systems.How does this play in greater Minnesota? Idon’t know. I see a lot of problems with that,given the different geographic distances be-tween providers and small population base.That’s a problem for some of our health cen-ters. Lastly, it’s silent on mental health anddental/oral health issues. In my book, that’sall part of someone’s health, and these ACOsare driven a lot just on the medical side. In-corporating more of those provisions wouldbeef up the ACO model.
DR. THORSON: Part of the problem withACOs has been talked about earlier, whichis the expected transform before paymentchanges. The one thing that we forget inMinnesota is we have a different perspective.[Mayo Clinic health care policy expert] DougWood has said that if everybody else in thecountry practiced medicine like it’s practicedin Minnesota, there would be $13 trillionsaved over 10 years. So we look and say, geewhiz, an ACO doesn’t necessarily work wellin some areas because we have a jaded per-
spective. We need to realize that theweakness in the ACOs is they'retreating Minnesota like the rest ofthe country. If you start talking tothem about shared savings, they’re
going to start me out with where I amright now and have this be my baseline andmeasure me where I’m going to be in threeyears. I’d be better off waiting a year and get-ting a lot worse at what I do, because it’sgoing to be hard to do a lot better in someareas than we are currently doing. There areother parts of the country that are so far be-hind where we are in Minnesota that theirability to change is dramatically different.
MR. CHRISTENSON: Another issue that fre-quently comes up when ACOs are addressed isthat it puts the physician in the insurance busi-ness. How is that possible?
DR. AINSLIE: ACOs are defined that way;that’s what they do. You don’t want to cometo me for your insurance needs. We haveprofessionals out there who do it a lot betterthan I do and know it a lot better. What in-surance should do is to insure risk. We’vegotten so far away from that definition thatnow we’re talking about insurance coveringfirst-dollar things, and should it cover thisor that or the other thing, without any ap-preciable looking at the risk and the cost ofit. We’re trying to control those costs by thismechanism. And again, for those of you in
practice in a large group like mine—Fairview and others—we can absorb someof those losses. Those of you out in Virginia,Minnesota, can’t do that. You have onecatastrophe and you’re out of business.
DR. KLODAS: There is some data about thefact that it doesn’t work. The demonstrationprojects were done with very large systemsin an attempt to demonstrate how well thiswas going to all turn out—and this wasdone with Geisinger Clinic, very integratedsystems. On average, they spent $1.7 millionthe first year just getting their organizationsup to speed, so they had funding or had thewherewithal to put that type of resource in.Well, in the first year, eight of 10 of thoseparticipants didn’t get any savings. They gotno return. The second year, it was only sixout of 10. In the last year of the three years,only half had received any return on theirinvestment. This is a big and expensive un-dertaking, and the way the savings werebeing calculated, I’m not sure it’sgoing to work for a lot of people.
MS. SORENSEN: I would also say,here in Minnesota, we are theHMO capital. We have large HMOsthat are integrated into our sys-tems currently. You throw in anACO concept, and then how doesthe HMO fit in within the physician-ACO realm? I think that’sgoing to convolute our pay-ment structure. The wayit is, reimbursement is-sues and individualizedcontracts that outsideproviders currently havewith certain HMOs, suchas in the home healthfield, all of our providersend up having to do or signup every year with one of the plans to makesure that they can see patients that arewithin that HMO realm. Now you’re bring-ing in a larger HMO system and this ACOpiece.
MR. CHRISTENSON: Do you see things withinthis ACO program that actually provide incen-tives for the withholding of care for financialgain?
DR. THORSON: I’ve heard that criticism.I personally do not see that. I think that ifwe look at the relationships we have withpatients, shared decision-making that weare going to be doing, it’s the shared deci-sion-making that’s going to influence thecost of care. When you sit down and talk to
people about the science of the care you’reproposing, the rationale for it, and havethem participate in that decision, peopleoften make the choice that is least expen-sive, not most expensive. I kind of joke[that] I have a biology degree and philoso-phy degree: I use my biology rarely and myphilosophy every day in clinic, because itreally is working on that shared decision-making and how you inform patients andreach that collaborative relationship oflooking at how you deliver care.
DR. MOEN: A question like that almostassumes that people are getting the carethey want today. We overtreat people andkill them every day because of our system.That’s the reality. There’s almost an inherentbelief that today’s system is ethical becausepeople choose what they want. There’s anassumption that people are actually choos-ing to be in the ICU at age 87, intubated,
just having a CABG [coronary arterybypass graft surgery], knowing
what they were actually head-ing into. There’s great evi-dence that shows that we doa horrible job of engaging
people in understanding what they justsigned up for.
MR. WATSON: We’re trying to withhold careunder ACO, the care that happens unneces-sarily in the emergency room or in a hospi-tal that doesn’t need to occur. That’s kind ofthe intent of the ACO. So it depends on howyou frame that question: Is it necessary careor is it ineffective and should not have hap-pened in the first place? That’s why I thinkI’m somewhat in support of the ACO modelin terms of elevating that primary care andavoiding those costs, ER visits, and the like.
MR. CHRISTENSON: The establishment andoperation of ACOs would necessarily involvethe creation of financial arrangements between
22 MINNESOTA PHYSICIAN JANUARY 2012
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Patients will bepassively enrolledinto an ACO.Jennifer Sorensen, MEd
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physicians and other entities that would other-wise be prohibited by current laws. How doyou respond to this conundrum?
DR. MOEN: That’s an issue that we’re dis-cussing with the government almost everyday. There are a number of things that needto change. Some of those rules were put ineffect because of the abuse of the fee-for-ser-vice system. It’s fascinating that as we startto change incentives, some of those regula-tions don’t make sense because they are reg-ulating something that’s no longer an issue.The question will be, what raft of new regu-lations will we have if this keeps going,which I’m sure it will. I also think that asphysicians, we tend to—and I’m a victim ofthis—think either/or. We have to be perfectbefore we start. We have to have the answerbefore we do anything. We’ve got to get outof that mindset. This is an iterative process.An ACO is perhaps the beginning of a differ-ent system, but there’s a lot of work to be
done around regulation, payment, the waycare is provided. We have to continue totransform over time. I think what I see is asense or recognition that the time has comefor us to change gears.
DR. THORSON: As an independent single-specialty group, there is no way that wecould do an ACO without violating Starkregulations. The same thing came up threeor four years ago. How many of you wereinvolved in the baskets of care stuff thathappened in the state of Minnesota? Thatwas going to violate the same type of Stark[regulations], and we have to be able tothink outside the box. I think we have to—itsounds hard—trust that the government is
going to do those waivers as they say theyare, because they would shoot themselves inthe foot if they didn’t. We have to realizethat transforming care is what this is about.We have to get critical mass so that the of-fices can afford to change how they do care.It’s not going to happen with 18 percentMedicare alone. This has to happen acrossthe board. It has to happen with third-partypayers. We have to recognize that thischange has to happen. You have to embraceit and say, we can’t continue to do whatwe’re doing.
DR. WECKWERTH: The irony is that nobodysaid collusion wasn’t effective. It’s just thatcollusion, by our terms, is what we didn’twant to do at that point in time. Now, underACO, collusion is good because it will arriveat the intent—only we won’t then call it col-lusion. So here’s the irony. When you wereon it for yourself, that was bad. Now ifyou’re on it being together, that’s good.
MR. CHRISTENSON:Can we adjust for riskin these shared servicesprograms? Is there away to do that?
MR. WATSON: We dohave to adjust forrisk. This is No. 1Aon my list of things
for ACOs. Thirty percent of our pa-tients who use a community health
center don’t speak English.Seventy percent are not
white. We have Somali immi-grant clinics in the Cedar-River-side neighborhood. This is ahuge issue for us. The stateright now is doing some riskadjustment on some their re-porting, and it only looks at
insurance status, which is unfortunate. Weneed to expand that to nonclinical issues—homelessness, poverty, English as your firstlanguage—all those sorts of variables fit intothe patients we see every day and under-stand why they have troubles negotiatingthe system as it exists today. Again, this isprobably the biggest issue for us in termsof risk adjustment, and getting to do itrequires resources. I understand why theState of Minnesota only does it on insur-ance status at this point, because they don’thave the resources to go beyond that. Thereis a pretty heavy cost to doing this correctly.
DR. MOEN: There is potential for some ofour partners, such as academic health cen-
ters, being penalized for caring for someof the most ill patients where there’s a tonof cost and there’s work that needs to bedone, but the current risk stratificationmodel doesn’t do a good job of characteriz-ing that risk.
MS. SORENSEN: You can do all the riskadjustment in the world, and at the end ofthe day you might not have met the mark.You could have spent all the time, all the re-sources, and invested a lot of dollars intorisk adjustment and planning for the future,but we’re dealing with human beings.Human beings are not the square pegs thatfit into a square hole. They are individuals,and they ebb and flow, and they changeevery day. We can’t set a perfect model to fiteverybody.
MR. CHRISTENSON: How will components ofour health-care delivery system that are notphysician groups be affected by ACOs?
MS. SORENSEN: That is a very intricate piecethat is missing in total care. How do we carefor people in their homes at the time oftheir need? It’s completely wiped off themap in regard to this. We have all ofthese programs about reducingrehospitalization, transitions ofcare, and all of those things, butevery time it’s discussed, homecare is an afterthought. Maybe weshould have pulled the home care agenciesin to see how that would fit? They’ve hadMr. Smith for the last six years. We probablycould have gotten some great informationon how that family works. What are the so-cial networks? What are the other ways thatthis patient can be served other than from amedical need and more from a holistic careneed. A lot of my providers that are withinmy network don’t get paid for that, but theydo it because it is in the best interest of thepatient and their client.
DR. AINSLIE: I think one of the basic philo-sophic problems we’re having is we’re mov-ing from an acute care model, which is afee-for-service model, to a chronic caremodel which has no model at this point.When you want to innovate or try some-thing different such as keeping the patientin their home—probably much better than ahospital bed, I would suspect— there’s noreimbursement for that. They’re just kind ofleft out of equation. Unfortunately, I thinkCMS and some of the others that are put-ting down these regs for the ACOs are stillin the acute care model. They want to con-trol cost because the acute care model is
JANUARY 2012 MINNESOTA PHYSICIAN 23
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You don’t evenknow what patientsare in your ACO.Michael Ainslie, MD
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going way up, and those of us in the chroniccare model are getting nothing.
MS. SORENSEN: As you know, home care isthe smallest slice of the pie but the one that
keeps getting cut the most. There arealways concerns about fraudulentuse and those types of things, andyet we are on the hook for face-to-face visits with CMS. It’s the
physician we’re supposed to be com-municating with, and it’s the physician whoneeds to sign off on the paperwork, but it’sthe home care agency that gets nailed forthe refusal of payment. That to me is a dys-functional piece of the system, and I don’tknow how to fix that right now until westart communicating.
DR. MOEN: You have to have parts of thecontinuum that become part of the modeland are rewarded for being part of themodel. Home care, in my view, has beentremendously underutilized appropriately.In my background as an emergency physi-cian, there were tons of people I could havesent home every day, but we didn’t get paidto do that so we put them in the hospital. Ithink there’s an opportunity, if we take it onand really try to serve a population, to de-velop different relationships with home careand other agencies such as the CourageCenter, other kinds of community resourcesthat absolutely are critical but today are notengaged in ways that are sustainable, andalso they’re not leveraging all that theycould offer potentially. They’re very con-strained because of today’s payment andregulatory models, and hopefully, as we
move forward, will become unconstrainedas we begin to really look at what’s optimalin the continuum.
DR. KLODAS: One of the things that I’mreally struck by in the definition andthe goal for ACOs: It is reliant onbringing stuff together and makingit bigger. Sometimes makingthings bigger isn’t necessarilybetter. I think this push sets upfor too-big-to-fail systemswhere you get so large and itcosts so much, but it can’t goout of business because ittakes care of our entire com-
munity. Now that system holds a commu-nity or an area hostage, and you just have tokeep feeding it. Sometimes bringing thingstogether is not more efficient.
DR. THORSON: The limitation with that bythe federal regulations saying, you can onlybelong to one ACO—that’s why that part hasto change. In a population area as an inde-pendent group, it would be to my benefit toparticipate in multiple ACOs because mychoices will be better and broader, andmy patients live in a big area. Ouronly choice, again, is to be our ownACO to prevent the problem of say-ing we can only belong to one, whichwill drive the alignment that willeventually prevent the groups fromstaying independent.
MR. CHRISTENSON: What are thepros and cons of patientsbeing assigned or attrib-uted to an ACO by CMS?
DR. WECKWERTH: CMScan’t even explain it. Itshould be pretty clear.They will tell youwhere you go. That’sstep 1. As only firstchildren do, that’s theway the world runs,and of course the backside of that is that nobody will be happy be-cause who among you ever wanted the eldersibling to tell you what to do? That’s what Iexpect will happen. They’ll just do it.
MR. WATSON: It’s based on claims for physi-
cians. It completely ignores other nursepractitioners or physician assistants, andthat’s really the model the communityhealth centers use a lot in terms of expand-ing access to care. It pretty much ignoresthose provider types in making that deci-sion. That’s problematic from our end aswell.
MS. SORENSEN: The assignment processbeing at a CMS level is so far removed fromthe actual patient. It’s kind of like reading apiece of paper and making a complete judg-ment on an individual and saying, I thinkyou need to go to Dr. A’s group versus Dr. C’sgroup. They don’t even know the patient;they’ve never seen the patient. It’s so arbi-trary and not patient-centered.
DR. THORSON: I think that attribution ofpatients is a struggle no matter who’s tryingto do the attribution, if it’s the third-partypayers, the government. They look at wherethe visits occurred, where more than 50 per-cent of the dollars were spent. When you’rea primary care doctor and you generate veryfew dollars taking care of a chronic diseasepatient, when they go in to have a very ex-pensive procedure, that throws things off.
MS. SORENSEN: This comes down to a fun-damental piece of patient choice as well. Aswe live in a society of individual choices andbeing thoroughly informed of our choices,
what are the ramifications of an ACO thatdoesn’t show or explain someone’s choices?It’s easy enough to get an attorney and thensue the ACO because they weren’t providedthe information and given patient choice or
There comes a pointwhere personalaccountability hasto step in.Jonathan Watson, MA
I would love to see a transitionto measurements aroundwell-being. Dave Moen, MD
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directive on their options. You come intoanother layer of care called case manage-ment in regard to making sure that every-body has their options laid out for themprior to being engaged into a program.
DR. KLODAS: Patients may not know thatthey’re in an ACO, but they actually retainthe right to go see other specialists that maynot be part of the ACO. That can completelythrow off the whole reason behind the ex-periment.
MR. CHRISTENSON: In effect, a patient couldbe assigned to an ACO and never see any doc-tors within that ACO and get all their care else-where. But the effect that’s going to have on theshared savings program for that ACO will bemanifested, is that right?
DR. MOEN: Not necessarily. The attributionmodel is defined by where primary caretakes place, and if the majority of it takesplace within a certain system, then costs areattributed to that system. There are going tobe a lot of people that aren’t attributed atall. There are going to be a number of peo-ple who change their attribution based onwho they’ve decided to go see.
DR. WECKWERTH: Assignment and attribu-tion are totally different things. I never sawthat assignment was something that wasgoing to be done beforehand. Attribution isjust an analytic way of taking a look to see
where people have been, to use that as oneof many sets of multivariables for analysis.Assignment has nothing to do with whereyou are told to go. You can go wherever youwant, show up, and if you’re in the rightbucket you’ll be analyzed over there. If
you’re in another bucket, you’ll be analyzedthere.
MR. CHRISTENSON: How should CMS addresshigh-risk patients affecting utilization within anACO?
DR. WECKWERTH: That’s where the attribu-tion comes in. You have those patientswhom you then analyze and see what madethem high use. And then you figure outwhich variables are associated with that andwhat then became high risk. I think we’rerunning under the assumption that there’sgoing to be a risk model, a multivariate one,by which you assign some kind of cumula-tive score and therefore you allocate it todifferent ACOs. Nobody said that was goingto happen. It may, but it certainly isn’t in theworks right now.
DR. AINSLIE: I’m sorry, but why would wehave preexisting conditions? Why would wehave people being dropped out of healthplans when they’ve hit certain things? It’sbecause of the business model. The actuar-ies have figured out when to drop people offand how to make price products based onthat information. The uninsured problem isdue to the way health plans operate, the waythey use analytics, and the fact that overall,the cost of care is not sustainable.
The powers that be certainly like toblame the physicians for this cost overrun.There were about 42 to 45 million unin-sured in 1965 before Medicare started, andtoday there are exactly about the same.Even places that tried to go from 94 per-cent to between 96 percent and 98 percentinsured have had a tremendous cost in-crease to get that few percentages, inMassachusetts. I think that we can go toa different model and have insurance dowhat it’s supposed to do, which is to in-sure risk, and move to a different modelwhere patients have control of some of
that first-dollar coverage that theynow enjoy without any thought ofcost. What happens in economicswhen costs go to zero? Demandgoes to infinity, and that’s whatwe’re seeing.
DR. WECKWERTH: I think he useda critical term. We were talkingabout the insurance, the risk. When
you have first-dollar coverage, you no longerhave insurance. You have prepayment. Itisn’t insurance; people are talking about pre-payment. If, in fact, the events will occurwith virtual certainty, that’s a prepayment ofthe service; that’s not insurance. For insur-
ance to exist, it has to have a risk. If wedon’t have a risk, then we aren’t talkingabout insurance. Really, prepayment is whatgoes on.
MR. CHRISTENSON: What are the benchmarksof quality that are going to be measured in theACO and determining shared savings?
DR. AINSLIE: As with many things in medi-cine, they will measure what they can meas-ure. I will be measured on my hemoglobinA1c values because you can measure that. Iwon’t be measured on how many carbs theytake in a day, whether they take the appro-priate insulin, all that. The idea is that ifyour A1c is good then you must be doing allthe other stuff very well. That may be a fal-lacious argument and not be good qualitycare. The problem is, what’s your bench-mark? I guess I’m going to have to have aterrible benchmark for the next three yearsbefore I get into it, because then I’ll lookgreat when I improve all that. That’s terriblemedicine. We’re measuring something thatwe can measure, but it has no sense in howwe apply it. If the quality measurements aredone correctly, they certainly can be, butphysicians haven’t been involved inthat much, and I think we need tolook at that and how CMS comesup with these benchmarks.
MS. SORENSEN: I think the otherthing is, too, currently as it’s set up, thereare 65 quality measures. You’re going tohave to have a quality improvement team,which is another layer of managementwithin your own organization just to be ableto gather the data. I can’t even imagine thetime that it’s going to take, one, to capturethat data, and two, to get your patients tofill out the questionnaires that are required.And then how does it all fit within this mag-ical formula that none of us really knowyet?
DR. WECKWERTH: This isn’t 65 things thatyou’re running out and doing that you aren’tdoing now. They, in fact, are supposedlythings that come because of the summary ofcare provision that is done.
DR. MOEN: I would argue that the measure-ment actually reinforces the model of sick-ness. I would love to see a transition tomeasurements around well-being, which Ithink speak much more to the social con-nections people have in their lives, their fi-nancial stability, how they feel about theirlives, the quality of their lives. The paradigmneeds to shift, and I think it could be simpli-
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There is noaccountabilityon the part ofthe patient.Elizabeth Klodas,MD, FACC
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26 MINNESOTA PHYSICIAN JANUARY 2012
fied as well if we engage patients in definingwell-being. I think it would help orient thesystem toward a more holistic view of whatactually constitutes health.
DR. KLODAS: If we look at our communitynow, whatever we’re doing, and I don’t carehow you measure it, it’s not working. We aregetting sicker and sicker, and no matter howmuch money we’re throwing at this, it’s notworking. This is beyond what an ACO cando. This is an entire community effortwhere you have food manufacturers whoare stepping back and saying, wow, maybewe shouldn’t make so much of that, and youhave communities getting together and say-ing, wow, we should probably build somemore walking parks, and companies gettingtogether and saying, hey, you know, maybewe should be giving people time during theday to go for a walk and do something.
MR. CHRISTENSON: Who do you see beingwinners and losers when accountable careorganizations are fully operational? Who arethe winners going to be?
DR. THORSON: My hope is the patients arethe winners. I’m not sure that’s been
proven yet, but that’s what myhope is, that the patients are thewinners. I think if you talkabout, in the health care profes-
sions, who are the winners and thelosers, I think outpatient delivery of healthcare is going to be the winner. And I thinkthe inpatient model of health care deliveredthrough hospitalizations and emergencyrooms will be the loser.
DR. AINSLIE: I think the winners are going tobe the CMS, because they rigged the system,and they will benefit from it primarily be-cause that’s what they want. The losers, I’mafraid, are going to be the physicians andpatients, especially in areas where we’realready doing a lot of this. As we’ve said, inMinnesota, we’re up on the ladder and I’mafraid that we’ll be judged. They’re going tolook at the rate of change, of improvement.It’s going to look awful for Minnesota be-cause we’re already pretty good. A place likeTexas or Louisiana is going to look wonder-ful because they have a long way to go. Idon’t think large groups or small groups orthe whole state of Minnesota is going tocome out [well] in this no matter how weset up an ACO.
MR. WATSON: Highly integrated systemsthat exist now, that can understand the rulesof the game as they’re entering the game,
are going to be big winners. Small, inde-pendent, autonomous practices that arejust trying to feel their way right now aregoing to be at a disadvantage. I see hospitalspotentially being losers. Empty beds don’ttranslate to revenue. I see greater Minnesotapotentially being a loser. I think who’s onthe bubble, not a winner or a loser, arehealth plans. I really don’t see what the roleof the health plan is exactly under an ACOmodel. I don’t know if they’re kind of back-room support or will transition to some-thing else, but I think they’re on the bubble.
DR. KLODAS: The winners are going to beadministrators and compliance officers. Ithink this is going to have an awful lot ofrules and regulations and new layers ofbureaucracy that are going to employ anawful lot of people who will be doingan awful lot of paperwork. The los-ers are ultimately, at least in thenear term and probably in most ofmy lifetime, are the taxpayers. Ihonestly don’t think this addressestrue cost of care. The costs are be-cause our population is chang-ing, we’re getting older,the rates of diabetesand obesity are unbe-lievable. You can’tsqueeze money out ofa system when every-body’s sick.
DR. MOEN: I hope mykids are winners inthat they inherit asociety that is actuallysustainable. I wouldhope that we would alltake the long-term view that this isn’t somuch about accountable care organizationsas it is about facing the things that we’reall alluding to. That is, we’ve got a publichealth problem that is unmanageable, and ahealth care system isn’t an adequate way toaddress much of what we’re talking about.If we don’t do this well, our whole society isat risk. We’re looking much different, and Idon’t think in very positive ways. If I worryabout one thing when I go home and go tobed at night, it is what kind of world we’releaving for our children.
MR. CHRISTENSON: How will allied healthprofessionals be affected by this?
DR. MOEN: They’re critical parts of thesystem. If we look at chiropractors andacupuncturists, which today are called
complementary medicine providers, there’sgood evidence that in some corridors thoseprofessions provide value. The trick is, howdo you begin to define that value, and thenhow do you connect in ways that are mean-ingful to those groups of providers and pro-fessionals to help improve the health of apopulation. It starts with looking at the roleof nursing and the changes that need tohappen and the leadership we need out ofthe nursing community to actually drive toa different model. It starts with the chiro-practic profession being honest with itselfabout some of the things that have gone onin that profession.
MR. CHRISTENSON: How do you see healthplans being affected by ACOs? Are they win-
ners, are they losers, or neutral?
DR. AINSLIE: Obviously, patients will need in-surance, and obviously even the largest ACOin the state is going to need reinsurance forcatastrophic risk, so they will provide thatinsurance—I’m sure, happily—at a cost. Itwill probably help them to some extent inthe short term and perhaps in the long termalso. What happened in the HMO model isthat they were first developed by physicians,as you know, and pretty quickly morphedinto health insurance models and consoli-dated and so on, and physicians lost controland lost their shirts.
MR. WATSON: I think, quickly, health planscould potentially do a lot of the backroomclaims processing. There seem to be a lot ofanalytics that need to occur in the ACOmethodology. We talked about the 65 meas-
The irony is thatnobody saidcollusion wasn’teffective.Vernon Weckwerth, PhD
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ures, you know, you need some sort of back-room office support for that. Secondly,health plans, I think, do a good job of set-ting up networks in terms of specialists. Ifyou do set up your own ACO, your own pri-mary care doctor, you’re going to need yournetwork, and I think health plans can pro-vide that expertise in terms of establishingthose networks.
DR. THORSON: I think that this past legisla-tion has been more insurance reform thanreally health care reform. I think the insur-ance industry is somewhat vulnerable. Ithink you could imagine a world whereaccountable care organizations are bigenough and cover enough patients that theycan market directly to business. They canmarket directly to communities and bypass
insurance plans. The nature of insuranceplans may well change from being insur-ance companies to become analytical com-panies where they will be administeringstuff but not insuring risk. But to be honest,the insurance people haven’t been insuringrisk, they’ve been trying to minimize riskand make money. I mean that somewhatseriously. They don’t pool risk anymore.They try to identify people who are highrisk and exclude them. I think that’s wherethings are going to have to change.
MR. CHRISTENSON: What are legitimategrounds for abandoning this whole ACOconcept as a failed effort?
MS. SORENSEN: At the end of the day, if wecan’t all work together or all our commoninterests aren’t on the table and we’re will-ing to give in a little across the board, we’re
not going to be very successful with thisprocess. Also, I think probably one of thebiggest things that keeps resonating in ouranswers is that there’s no patient incentivefor participation, and I think we really needto be looking at this through this develop-mental process. What is the incentive forthe patient to participate in this?
MR. WATSON: We need to have the ability tocommunicate across different systems anddifferent care venues. I think the one aspectwhere you could pull the plug legitimately isif we have massive market consolidationthat actually leads to higher prices andhigher premiums. Then I think it’s clearlytime to pull the plug.
MR. CHRISTENSON: What will ACOs need todo in order to succeed in fulfilling the “triple
aim” of better care for individuals, better healthfor populations, and reducing per capita costs?
MR. WATSON: What they need to do isprevent folks from falling through thecracks. When they do fall through thecracks, identify them and case man-age, whatever the terminology, care-coordinate their life. We need theinteroperability, we need the flexi-bility, and we also need the properrisk adjustments. Those are mythree big goals for an ACO to besuccessful.
DR. THORSON: We need to have patientengagement. We can’t do this just as physi-cians or health-care delivery systems forcingit onto patients. We have to change the pay-ment structure that allows for a wide varietyof care delivery to happen on an outpatientbasis and realize that we have a changingstate of health of our population. We have tofigure out how we’re going to fund the ill-ness load that is going forward in a way thatallows us to care for them as well.
DR. KLODAS: I don’t think this is goingto work, or anything is going to work, un-less patients have skin in the game. I don’tknow what that looks like, I don’t have aformula, but they have to be part of thesolution. It has to be real, and they have tobe accountable.
DR. AINSLIE: We need to teach ACOs how towalk on water because that’s what they’llhave to do in order to succeed. My guess isthat they won’t, and we’ll be onto the nextiteration. And you heard it here first: It’sgoing to be a nice euphemism for “twoweeks to live” because CMS has realizedthat they spend half of their money or moreon the last two weeks of a patient’s life. Ifwe can figure out what two weeks those areand do something about it, we’ll be all set.What the ACO has done is go in a retrospec-tive payment model and a quality modelthat they set up and judge and pay for, andguess what, they’re going to do that for thelast two weeks of someone’s life also. Youwill or won’t be paid for taking care ofsomebody with a terminal illness or otherproblems.
DR. WECKWERTH: Public health has had theanswer the whole time. We know in publichealth what to do. We know good and wellthat population is where the action is.In terms of individuals, they have to beaccountable. The accountable party is theindividual. That’s what it ought to be. Weknow what to eat, what not to eat,what to do, what not to do, every-thing else. I don’t know how we’regoing to get people to do it thatway, but the public health princi-ples are there. The individual accounta-bility has to be there, and that may soundstrange from an academic. Finally, we knowthat 95 percent of the health status of any-body, by every analysis that’s ever beendone, has nothing to do with the medicalhospital establishment. That only accountsfor about four percent of health status. Therest is diet. Of course, the most importantthing is choosing your ancestors, so that’swhat I think we should work on most. Whatare we going to do? Public health: Followwhat we know, do it for yourself, don’tblame somebody else, don’t pass it off.
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We have to realize that transform-ing care is what this is about.David Thorson, MD
toconjunctivitis sicca) and itsburdens, including blurredvision, itchiness, redness, for-eign body sensation, and overallirritation. About four out of 10Americans (37 percent) experi-ence symptoms of dry eye syn-drome on a regular basis. Butbecause the symptoms canmimic other syndromes, chronicdry eye often goes undiagnosed,which can lead to serious ocularcomplications, including eyeinflammation, infection, andeven scarring on the surface ofthe cornea.
Traditionally, the mostcommon treatments for dryeye syndrome have included lidhygiene, artificial tears, cyclo-sporine drops, steroid drops,nonsteroidal drops, topical andsystemic antibiotics, vitamins,and lid shampoos. Punctalocclusion can also be used topreserve tear output on theocular surface.
A recent development,intense pulsed light (IPL) treat-ment, has expanded the treat-
ment options available, and isdiscussed below.
Causes and mechanisms ofdry eye syndrome
The natural aging process canexacerbate dry eye; in fact, a
majority of people over the ageof 65 experience some symp-toms of dry eye. Women aremore likely to develop dry eyebecause of hormonal changes
during pregnancy and meno-pause. Medications can also beto blame; antihistamines, bloodpressure medications, and anti-depressants can reduce theamount of tears the eyes pro-duce.
External factors such asexposure to smoke, wind, anddry climates can also increasethe risk of dry eye, as can cer-tain procedures (e.g., refractiveeye surgeries, LASIK) and evenlong-term use of contact lenses.
In the past, chronic dry eyewas defined as a problem involv-ing insufficient tear production,but research has altered thisunderstanding. Today, ophthal-mologists classify dry eye as anocular surface disease becausewe have found that manypatients with adequate tear pro-duction are also suffering fromdry eye. The real culprit can bepoor-quality tear film on the sur-face of the eye. This tear film ismade up of proteins and elec-trolytes that help minimize thesymptoms of chronic dry eye.But when those components areunbalanced, dry eye can result.This is why many patients withdry eye don’t find relief fromover-the-counter artificial tearsolutions such as eye drops.
The meibomian glands,located at the base of the lasheson both the upper and lowereyelids, are an important com-ponent of tear balance becausethey secrete a fine layer of oilthat keeps the water element oftears from evaporating, whichcontributes to dry eye. The mei-bomian glands can become
abnormal with age or becauseof certain conditions, such asocular rosacea. Then, insteadof producing the necessarysmooth, olive oil-like secretions,the glands produce thick secre-tions with the consistency ofbutter or toothpaste. The oilysecretions get stuck, resultingin a deficient tear film and tearproduction and leading to dryeye syndrome.
Over the last several years,ophthalmologists have discov-ered that low-grade inflamma-tion on the surface of the eyecan also damage the ocularsurface and lead to decreasedtear production. While Restasis,the only FDA-approved topicalcyclosporine, is prescribed toreduce inflammation andprompt the natural productionof tears, its integration intotreatment plans has not solvedthe problem of abnormal meibo-mian gland secretion.
Development of IPL treatmentfor dry eye
In 2003, ophthalmologistsbegan noticing that patientswith chronic dry eye who hadreceived intense pulsed light(IPL) therapy as a dermatologictreatment for rosacea were expe-riencing a reduction in their dryeye symptoms.
Ophthalmologist RolandoToyos, MD, of Memphis, Tenn.,was the first to quantify therelationship between IPL andchronic dry eye in several clini-cal studies. Toyos has said thathe discovered this potential useof intense pulsed light by acci-dent after opening an aestheticsclinic in his practice in 2002.He had been using IPL forpatients with rosacea and acne.In an interview, Toyos recalledthat “my rosacea patients whohad the IPL treatment wouldreturn with their skin lookingmuch better—but some alsomentioned that their eyes feltbetter. On examination, theireyes really were better, eventhough the IPL treatment wasn’tdone directly on the glands.”
In 2005, Toyos received aresearch grant from the Amer-ican Society of Cataract andRefractive Surgery to study theprocedure. He discovered thatIPL can eliminate the symptomsof dry eye for patients who have
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Because intense pulsed light therapyoriginally was intended for dermatologicaltreatments, IPL treatment for dry eye may
offer patients additional skin benefits.
struggled for years with theuncomfortable condition. Toyos’research showed that the IPLtreatment gently stimulated themeibomian glands, improvingthe quality of secretions, andsuccessfully decreasing the pres-ence of dry eye.
Over the past decade, Toyoshas refined the IPL technologyto achieve optimum results inpatients with dry eye syndrome.For example, the IPL machineused for treatment of dry eyeuses lower energy settings thansimilar machines used for der-matological procedures. Thereis less energy variability on theIPL machine, to protect dry eyepatients while still ensuring theefficacy of the procedure.
IPL for dry eye is an off-label use of IPL, which is FDA-approved for dermatological use.Currently, about 15 clinics inthe U.S. are participating in thetreatment regimens for dry-eyepatients.
IPL treatment
IPL is a simple outpatient treat-ment. The first step includescleansing the patient’s face and
placing shields on both eyes toprotect the lids and lashes. Acooling gel is then applied to theeye area and surrounding skin.Next, the IPL hand piece ispassed across the skin, allowingthe pulse of energy to heat themeibomian glands (see photo).The treatment also seals the deli-cate blood vessels at the lid.
The complete proceduretypically lasts less than 15 min-utes and is painless. Patientsneed two to four treatments,separated by a month betweentreatments. Studies show anincrease in tear function afterthe fourth or fifth treatment.
Since I began offering IPL thera-py in 2011, many of my patientshave reported noticeable reliefin as few as two or three treat-ments. The number of treat-ments needed depends on theseverity of the patient’s dry eyecondition. Once the glands stabi-lize, patients may need mainte-nance therapy at least once ayear.
Because intense pulsed lighttherapy originally was intendedfor dermatological treatments,IPL treatment for dry eye mayoffer patients additional skinbenefits. For example, IPL helpsto develop collagen, lighten dark
spots, and tighten and plumpskin.
Although side effects andcomplications are rare, theyinclude but are not limited tobruising, swelling, purpura, andblistering. Caution is advised forpatients with a history of herpessimplex near the treatment area.Contraindications also includesun exposure two to four weeksprior to treatment, active infec-tions, compromised immunesystem, coagulation disorders,photosensitivity or allergy, useof aspirin/anticoagulants, preg-nancy, moles, and tattoos.
Dry eye syndrome is acommon ophthalmic conditionthat can have deleterious effectson patients’ quality of life. Thepotential of intense pulsed lighttechnology to treat this condi-tion is an exciting developmentfor patients and ophthalmolo-gists alike.
Y. Ralph Chu, MD, is medical directorand founder of Chu Vision Institute inBloomington and is an adjunct associateprofessor of ophthalmology at theUniversity of Minnesota Medical School,Minneapolis.
JANUARY 2012 MINNESOTA PHYSICIAN 29
Dr. Chu performs IPL procedure on a patient with dry eye.
As an oncologist, DavidKing, MD, talks withmany cancer patients in
his office at the Virginia PiperCancer Institute on the UnityHospital campus in Fridley. Theconversations typically start withtreatment protocols and whatpatients can expect. But theconversation often takes anotherturn when patients ask aboutthe impressive artwork hangingon the wall.
The abstract acrylic paint-ing, which covers the entire wallabove the doctor’s desk, lookslike it could be a sea or a forest.King explains that it’s called“Reflections on Gunflint Lake”and that he bought it at theannual Art-A-Whirl that’s heldeach spring in northeast Minne-apolis. Coincidentally, the artist,Peggy Thompson, is also a chap-lain at Unity Hospital.
Focusing on the paintingmight seem like a nice diversionfrom the difficult talk about can-cer treatment. In fact, it’s not anaccident but rather the result ofa purposeful program at AllinaHospitals & Clinics to infuse the
power of art—both visual artand music—in the healingprocess.
King observes that the artsoften help optimize a patient’scondition to better tolerate the
many side effects of chemother-apy and radiation. “The placeboeffect is an example of how themind can be a powerful force inthe healing process. Healingdoes not just happen on a physi-cal level; the arts help engagepatients in the healing processon a psychological, emotional,and mental level,” he says.
Allina is part of a nationaltrend in health care facilities toimplement arts programs as acore strategy to alleviate painand to improve care and patientsatisfaction. About 50 percent of
hospitals in the U.S. have artsprograms, according to theCenter for Health Design, inConcord, Calif. Allina developeda healing arts policy two yearsago for its 11 hospitals andnearly 100 clinics.
Allina’s healing arts programis modeled on an initiativebegun seven years ago at thePenny George Institute forHealth and Healing, which isbased at Abbott NorthwesternHospital in Minneapolis. Thevision was to use patient andpublic areas at the PennyGeorge Institute as exhibitspaces for local artists. Newexhibits of original art areinstalled monthly, with relatedinteractive arts programmingopen to patients, staff, and com-munity members.
Choy Leow, director ofAllina design and construction,developed a healing arts policythat embraces nature as a pri-mary subject and emphasizesregional artists. The exhibits arepart of what has grown to bethe largest hospital-based inte-grative medicine program in thenation. Unlike alternative medi-cine, which is typically used inplace of conventional medicine,the Penny George Institute’sintegrative services are offeredin conjunction with traditionalWestern medicine for both inpa-tient and outpatient care.
Pain relief
Last year, Allina published thefirst study showing that nontra-
ditional therapies relieve painamong a broad cross-section ofhospitalized patients by as muchas 50 percent. Results of thestudy were published in theMarch 5, 2010, issue of theJournal of Patient Safety. Thestudy included 1837 cardiovas-cular, medical, surgical, ortho-pedics, spine, rehabilitation,oncology, and women’s healthpatients at Abbott Northwestern.The treatments included non-pharmaceutical services: musicand art therapy and mind-bodytherapies designed to elicit therelaxation response, includingacupuncture, massage therapy,and healing touch. The studyexpands on earlier studies thatfocused on the effectiveness ofintegrative therapies in manag-ing pain in cancer or surgicalpatients.
“Western medicine is highlyskilled at treating illness and dis-ease with procedures,” says LoriKnutson, RN, BSN, HN-BC,executive director of the PennyGeorge Institute. “Effectivehealth care acknowledges thedifference between curing andhealing and the therapeuticproperties of the creativeprocess.”
Positive distraction andsymptom management
Historically, environmentaldesign in health care hasfocused on trying to minimizenegative factors in the environ-ment such as noise, light, andthe risk of infection. In the pastfew decades, however, the focushas changed to how hospitalscan create and reinforce positiveexperiences. Designers have rec-ognized that environmental fac-tors can also provide a positivedistraction, allowing patients toshift attention away from nega-tive factors in the health careenvironment and toward morerestorative aspects from the non-medical world.
A 2006 review of scientificliterature published in theJournal of Perinatology exam-ined the role of positive distrac-tion as a means of mitigatingstress for patients and caregiversin neonatal intensive care units.The review found that the envi-ronmental variables that aremost commonly known to con-
Beyond decorationThe power of art in healing
By Megan Hatch
30 MINNESOTA PHYSICIAN JANUARY 2012
www.mankato-clinic.com
Urgent CareMankato Clinic is looking for exceptional Physicians,Physician Assistants and Nurse Practitioners to workin our busy Urgent Care Department. Customer serviceskills and the very best patient care are essential for theseprofessionals who are the first point of contact for somepatients.You will work with a team of highly skilled supportstaff in an efficient, fast-paced environment.
There are full-time and casual shift opportunities available.Hours are weekdays 8 a.m.–8 p.m., Saturdays 8 a.m.–5 p.m., andSundays noon–5 p.m. Care is provided in three locations, two full-serviceurgent care/occupational medicine facilities and one express serviceclinic located in Mankato’s shopping mall.
Providers in full-time positions will enjoy an excellent benefits packageincluding generous CME expense and time-off allowances; 401(k) profitsharing plan; EAP; employee discounts and more.
Apply online at www.mankato-clinic.com, or contact Dennis Davito,Director of Provider Services at [email protected];Phone: 507-389-8654; Fax: 507-625-4353; Mankato Clinic, 1230 E. MainSt., Mankato, MN 56001. Mankato Clinic is an Affirmative Action/EqualOpportunity employer.
Research has shown that in addition toimproving patient outcomes, visual art
can increase patient satisfaction.
tribute to positive distraction arevisual art, access to nature, andmusic.
Results of a study publishedin the March 2003 issue of themedical journal Chest showedthat adult patients in a proce-dure room reported better paincontrol when they were exposedto a nature scene and heardnature sounds broadcast fromthe ceiling. A 1992 study pub-lished in the Journal of BurnCare & Rehabilitation foundthat using murals as a thera-peutic distraction resulted ina significant decrease in painintensity, pain quality, and anxi-ety reported by burn patients.In a 2003 study published inCyberPsychology and BehaviorJournal, breast cancer patientsreported reduced anxiety,fatigue, and distress duringchemotherapy when the patientswere exposed to virtual realityintervention displaying under-water scenes.
Patient and staff satisfaction
Healing arts programs in healthcare are also gaining favor as away to improve patient satisfac-
tion. The Centers forMedicare & MedicaidServices (CMS) haspublished patientsatisfaction scoressince 2008. In2012, CMS will upthe ante by basingMedicare reim-bursement in part onpatient satisfactionscores.
Research has alsoshown that in addition toimproving patient outcomes,visual art can increase patientsatisfaction. A 2002 study of sixdifferent hospitals owned byIntermountain Health Care inUtah sought to determine theextent to which environmentalsources played a role in overallpatient satisfaction. Nearly 400patients were interviewed bytelephone shortly after hospitaldischarge and were asked ques-tions about their level of satis-faction with six environmentalaspects of the hospital.
Those surveyed reportedthat inside the patient rooms,interior design—including visualart—was the most satisfying
feature. Outside the patientrooms, hospital interior design—again, including visual art—was second only to maintenanceas an environmental source ofpatient satisfaction.
Researchers noted thatwhen former patients were talk-ing about their hospital rooms,they often commented on theartwork. While patients andthe public are the primary rea-sons many hospitals have artsprograms, 55 percent of theprograms surveyed by theCenter for Health Design alsofocus on using the arts to reduce
stress and burnout among staffmembers, a significant problemin health care. The visual artscan facilitate cultural compe-tence as well: Artwork from dif-ferent cultures can sensitizeproviders, contribute to aninclusive environment, and serveas a form of cross-cultural com-munication.
As the role of art in healthcare evolves from art as decora-tion to art as a core componentof healing environments, a grow-ing body of research is expectedto firmly establish evidence-based design and provide a sci-entific basis for healing art as anecessary part of medicine.
Megan Hatch is clinic manager and artsprogram coordinator at Allina's PennyGeorge Institute of Health and Healing inMinneapolis.
JANUARY 2012 MINNESOTA PHYSICIAN 31
Mandala by Richard Bonk at thePenny George Institute for Healthand Healing at Unity Hospital.Cancer patients make mandalasat George Institute art classescalled Power Shields.
Boynton Health Service
Welcome to Boynton Health ServicePsychiatrist
(612) 624-1444
and 174055
A Diverse and Vital Health Service
P R O F E S S I O N A L U P D A T E : O R T H O P E D I C S
With spring comes thestart of baseball sea-son—and, for thou-
sands of athletes, from youthbaseball organizations throughprofessional leagues—the prom-ise of a winning season or thehope for personal achievementon the field. Unfortunately,along with that promise andhope come increasingly familiarreports of pitchers lost to throw-ing-arm injuries, often requiringsurgical reconstruction (includ-ing the well-known TommyJohn surgery that cost formerMinnesota Twins’ reliever JoeNathan a season).
The anterior band of theulnar collateral ligament (UCL)is the primary static restraint tovalgus force in the elbow from30 to 120 degrees of flexion.This ligament courses fromthe medial epicondyle of thehumerus to the sublime tubercleof the ulna along the medialaspect of the elbow. In the over-head throwing motion, valgustorque across the elbow canexceed the ultimate tensilestrength of the UCL, resulting intears of the ligament and signifi-
cant elbow injury in the over-head athlete. This injury hasbecome commonplace in colle-giate and professional baseballpitchers and often requires sur-gical reconstruction. Thesetypes of elbow injuries are alsobecoming more common inyounger baseball players. UCLtears can also occur, though lesscommonly, in athletes involvedin other overhead sports such astennis, football, gymnastics, andjavelin throwing. This articlefocuses on the symptoms andrisk factors associated with UCLinjuries, as well as the diagnosis,prevention, and treatment ofthese injuries.
Symptoms
Overhead athletes with injuriesto the ulnar collateral ligamentwill present to their coach,
trainer, physical therapist, ordoctor with a variety of symp-toms. Some will develop symp-toms from chronic overuse andattenuation of the ulnar colla-teral ligament, while others willreport with more acute painfrom a single event.
Athletes with chronic over-use injuries will typically presentwith elbow pain, neurologicsymptoms, and/or complaintsrelated to decreased perform-ance. These injuries are oftenpartial tears of the UCL. Thepain is usually located aboutthe medial aspect of the elbowat the site of the ulnar collateralligament. Pain is most com-monly experienced during theacceleration phase of the throw-ing motion and often occurs fol-lowing a game or performance.
Neurologic symptoms con-
sistent with ulnar neuritis orcubital tunnel syndrome areoften associated with UCLinjuries. These symptomsinclude numbness and tinglinglocated about the ulnar one anda half digits or pain about theulnar nerve within the cubitaltunnel. Loss of athletic perform-ance is often experienced as adecrease in throwing velocityand accuracy as well as a pitch-er’s lost ability to effectivelythrow and control his or herusual variety of pitches.
Acute injuries are oftenthe end result of chronic UCLtears. These events are frequent-ly preceded by complaints relat-ed to chronic overuse as out-lined above. The acute injury isheralded by sudden and oftensevere medial elbow pain duringthe throwing motion. Pitchersoften report feeling or evenhearing a “pop.” Ulnar nerveirritation is also common at thetime of injury.
Risk factors and prevention
Overhead athletes of all ages areat risk for UCL injury. Those at
A pitch for preventionUlnar collateral ligament injuries areon the increase in younger athletes
By Steven W. Meisterling, MD
32 MINNESOTA PHYSICIAN JANUARY 2012
UCL INJURY to page 34
Urgent Care
We have part-time and on-call positions available at a variety of Twin Cities’ metro areaHealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicineand internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.
For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link toview our Urgent Care opportunities.For more information, pleasecontact [email protected] or call Diane at: 952-883-5453; toll-free:1-800-472-4695 x3. EOE
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Family PracticeUrgent Care
NEW POSITIONS:
Dynamic, independent 3 location, single-specialtypractice in northwest Minneapolis suburbs is seekingadditional associates for its Rogers site and has Full Time/Part Time shifts in the Crystal and Rogers Urgent Care.
Two BC/BE Orthopaedic Surgeonswanted to join four orthopaedic sur-geons at Sanford Bemidji OrthopaedicsClinic in Bemidji, Minnesota. Part ofan 85-physician, multi-specialty grouppractice and 118 bed acute care hospi-tal. 1:6 call anticipated. Competitivecompensation/benefits package, paidmalpractice, relocation assistance andmore. Sanford Health of NorthernMinnesota has 1,450+employees andis part of Sanford Health system basedin Fargo, ND and Sioux Falls, SD.
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Freedom to Careand Freedom to Thrivewith Allina Hospitals & Clinics
We make a di�erence in the lives of our patients,our sta�, and our communities. Physicians can focuson patient care and can professionally thrive in Allina,and the result is the quality of care for which we areknown. We are based in Minneapolis, and havecomprehensive services throughout Minnesotaand in western Wisconsin. Become a part of theAllina team, joined together with a commonpurpose and uncommon caring.
Rice Memorial Hospital has an out-standing opportunity for the rightperson to serve as its Chief MedicalOfficer (CMO).Reporting directly to the CEO, thissenior executive will be responsible forleading the medical staff in the plan-ning, facilitating and implementing ofprograms to enhance physician effec-tiveness, quality of practice, clinicalintegration and patient satisfaction.The CMO will be line administrator forphysician services within the Emergency Department and is expectedto provide direct patient care at least four shifts per month in theEmergency Room.The position requires an MD or DO with a license to practice medicinein the State of Minnesota; as well as a minimum of seven years ofclinical experience and at least two years of physician leadershipexperience. An MBA or Masters degree in public health is desirable.Located in the lakes region two hours west of the Twin Cities, RiceMemorial Hospital is the state’s largest municipal hospital, providinga vast array of services to the residents of west central Minnesota,including high-tech diagnostics, rehabilitation, long-term care, DME,mental health, dialysis, radiation oncology and hospice. Rice recentlycompleted a $52 million building and renovation project.
Chief Medical OfficerCandidates submit a coverletter and resume to:Michael Schramm, CEORice Memorial Hospital301 SW Becker AvenueWillmar, MN 56201
Rice provides a competi-tive salary and generousbenefit package. To learnmore see our website atwww.ricehospital.com
particular risk include baseballpitchers and catchers, especiallythose that play both positions.Professional pitchers that throwat a higher velocity may haveadditional risk for UCL injury.Recently, research has focusedon identifying risk factors in aneffort to prevent injury inyounger athletes.
Adolescent athletes havebegun focusing on a singlesport and/or a single position atyounger ages. This early sportsspecialization has been impli-cated as a factor in the rise inadolescent athletic overuseinjuries. The true risk of seriousinjuries to youth overhead ath-letes is unknown, and the riskfactors leading to these injuriesare unproven, though severalrisk factors have been associat-ed with significant elbow injury.The factors with the strongestassociations with injury areoveruse and fatigue. Overuseand fatigue can occur on adaily, seasonal, or annual basis.Also associated with adolescentelbow injuries are increasedweight and height; number of
pitches thrown during a season,game, or week; satisfaction withperformance; and playing out-side of the athlete’s primaryleague. High pitch velocity andparticipation in showcases arealso associated with increasedrisk for injury. Other risk fac-tors include participation in asingle sport year round, throw-ing at maximum velocity for aradar gun, and improper throw-ing mechanics.
The consequences of throw-ing breaking pitches and curveballs at the youth level are un-known. Debate and controversycontinue to surround this sub-ject. Since the 1970s, sportsmedicine experts have warnedthat prepubescent athletesshould not throw curve ballsbecause of increased risk ofelbow injuries. There has beenlittle clinical data to support thiswarning to date. In fact, biome-chanical data has shown that athrowing a curve ball may createless elbow varus moment com-pared to a fastball. Nonetheless,throwing curve balls prior toskeletal maturity continues to beconsidered a risk factor for
elbow injuries by most sportsmedicine experts.
Injury prevention hasbecome an important focuswithin the sports medicine com-munity. Proper warm-up andstretching exercises shouldoccur prior to any athletic acti-vity. Overuse and fatigue shouldbe avoided. USA Baseball haspublished recommendationsin an effort to reduce the riskof injury and maximize theyounger player’s ability to per-form and advance to higher lev-els. These recommendationsinclude limiting pitch countsand discouraging excessivethrowing for the young athlete.Throwing curve balls is also dis-couraged. Early development ofproper mechanics is empha-sized, and coaches and parentsshould listen and react appropri-ately to an athlete when he orshe complains of pain. The spe-cific recommendations are avail-able at www.usabaseball.com.
Diagnosis
The diagnosis of UCL injury ismade with a careful history andclinical examination as well as
appropriate imaging studies.Concomitant pathology mustalso be identified. The examinermust be careful to identify thestatus of the UCL when focusingon other elbow pathology, asloss of elbow stability due toUCL insufficiency can lead toother pathology.
Important points in the his-tory include asking about thosesymptoms mentioned above.The athlete should also be ques-tioned about his or her seasonalsituation and career goals anddesire to continue to compete inoverhead athletics. The physicalexam should evaluate upperextremity strength and range ofmotion, neurovascular status,and swelling, and specific pointsof tenderness should be identi-fied. Elbow stability can be eval-uated by placing a valgus stressabout the elbow. This test willelicit pain by subjecting theinjured UCL to stretch.
Standard elbow radiographsare an important part of elbowevaluation. Anterior to posteriorvalgus stress x-rays may demon-strate increased medial joint
34 MINNESOTA PHYSICIAN JANUARY 2012
UCL INJURY to page 36
UCL injury from page 32
www.olmstedmedicalcenter.org
Olmsted Medical Center,a 150-clinician multi-specialty
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The Rochester communityprovides numerous cultural,educational, and recreational
Opportunities to fit your lifeFairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Shape your practice to fit your life as a part of our nationally recognized, patient-centered, evidence-based care team.
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If you would like to learn more about thisfantastic opportunity, please contact Hazelden’sPhysician Recruiter, Kierstin Justinger, [email protected] or at 651-213-4266or apply online at hazelden.org/jobs
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St. Cloud VAHealth Care System
is accepting applications for thefollowing full or part-time positions:
US Citizenship required or candidates must have properauthorization to work in the US.
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space opening and are helpful inidentified medial laxity and UCLinjury. MRI arthrogram is theradiographic gold standard toidentify a UCL tear; it is thestudy of choice to verify thediagnosis and can help identifyother pathology.
Treatment
The treatment for UCL injuriesdepends on many factors,including the extent of UCLtearing, patient desires andathletic goals, seasonal timing,and response to prior treat-ments. Nonoperative treatmentis a good option for partial UCLtears, though often UCL recon-struction is required in orderfor an athlete to return to com-petition.
Nonoperative programsinclude a period of “active rest”and should be initiated immedi-ately upon injury to the UCL.This period lasts from two to sixweeks depending on the severityof the tear. During this time ofrehab, the athlete should refrainfrom all throwing activities andany other activities that recreate
the patient’s pain. Core strength-ening as well as a shoulder andelbow rehab program shouldbe instituted during this time.Patients are encouraged to be asactive as possible, provided suchactivities do not elicit elbowpain. An interval throwing pro-gram is initiated after the activerest period and proper mechan-ics are emphasized. Return toplay is allowed provided thepatient remains asymptomatic.
Surgery is the preferredtreatment for athletes who havea complete UCL tear and wish tocontinue to compete in overheadactivities. Surgery is also indi-cated for those who have a par-tial tear and have failed torespond to a nonoperative pro-gram. Ulnar collateral recon-struction (Tommy John recon-struction) is the treatment ofchoice for most UCL injuriesrequiring surgery. This surgeryis done via a medial elbow inci-sion to expose the injured UCL.The ulnar nerve is identifiedwithin the operative field andmust be carefully managed. Ananterior subcutaneous ulnarnerve transposition is often per-
formed, depending on preopera-tive symptoms and surgeon pref-erence. The UCL is then identi-fied and drill holes are placed atthe site of UCL attachment atboth the ulna and the humerus.Next, the native UCL is repairedprior to graft placement. Graftselection is a matter of availabil-ity and surgeon preference. Themost common grafts used arethe palmaris longus and thegracillis tendons. The graft ispassed through the bone tunnelsand overlies the repaired liga-ment. Finally, the graft is appro-priately tensioned and securedwith the elbow at 30 degrees offlexion.
Postoperatively, the elbow issplinted for one to two weeksbefore initiation of elbow rangeof motion. Full range of motionis expected at six weeks. Shoul-der and core strengthening arean important aspect of rehaband these exercises are begunsoon after surgery. Overheadthrowing is not permitted untilfour months after surgery, atwhich time an interval throwingprogram is initiated. Expectedreturn to play for a baseball
pitcher is approximately oneyear following surgery, thoughoverhead athletes with lessdemanding positions may returnto play several months earlier.
Goals: Reducing UCL injuries,improving treatment
Injuries to the UCL are commonin overhead athletes, with base-ball pitchers at greatest risk forthis injury. Recently, efforts havebeen made to identify risk fac-tors and prevention strategies toprevent elbow injuries, particu-larly in adolescent athletes.
Many patients with partialUCL tears can be successfullytreated conservatively. UCLreconstruction is a good optionfor athletes who do not respondto nonoperative care or thosewith complete UCL tears. Futureresearch efforts will continue inan effort to decrease the inci-dence of this injury as well as toimprove treatment options.
Steven W. Meisterling, MD, is anorthopedic surgeon and fellowship-trainedsports medicine physician in practice withSt. Croix Orthopaedics, PA.
36 MINNESOTA PHYSICIAN JANUARY 2012
UCL injury from page 34
Crookston, MN, a strong community of8,000, is located along the Red Lake Riverin the heart of the fertile Red River Valley.Altru Clinic—Crookston is a well-established,collegial medical group with 3 FamilyPractice Physicians, 3 Internists and 4Mid-Level Providers. We have an ongoingpartnership with RiverView Hospital inCrookston that is a 25-bed, critical-accesshospital connected to our clinic. Call is 1:10.
Roseau, MN, which is just 20 minutes frombeautiful Lake of the Woods, is a FamilyPractice clinic consisting of 6 Family PracticePhysicians and 3 Mid-Level Providers.The town of Roseau has over 2,500 residents.LifeCare Medical Center is a 25-bed, critical-access hospital just adjacent to our clinic.Our friendly community is safe andwelcoming. Call is 1:7.
Altru is a physician-led, not-for-profitintegrated health system that serves a referralpopulation of more than 225,000. More than180 physicians representing 44 specialtiesserve this population base. Altru HealthSystem provides competitive compensation,reviewed annually with specialty-specificindustry data, along with an extensivebenefits package including generous pensionand profit-sharing plans.
Family Medicine w/ OB Opportunitiesin 2 Wonderful Rural Locations
Altru Health System is seeking Family Practitioners to join our existingand thriving practices in Crookston,MN and Roseau,MN.
www.altru.org
JANUARY 2012 MINNESOTA PHYSICIAN 37
Lake Region Healthcare is located in a magnificent, rural, andfamily-friendly setting in Minnesota lakes country where we aimto be the state’s preeminent regional health care partner.
Our award winning patient care and uncommon medical special-ties set us apart from other regional health care groups. LakeRegion’s physicians and their families also enjoy an unmatchedquality of professional and personal life.
Current opportunities including competitive salary and benefitpackages available for BE/BC physicians are:
Practice Well.Live Well.
Lake Region Healthcare is an Equal Opportunity Employer. EOE
712 Cascade St. S., Fergus Falls, MN736-8000 • (800) 439-6424
For more information contactBarb Miller, Physician [email protected] • (218) 736-8227
www.lrhc.org
• Dermatologist• Family Medicine• General Surgery
• Hospitalist• Internal Medicine• Pediatrics
Physicians:• Let us do your scheduling& credentialing
• Paid Malpractice• Physician Friendly• Choose where andwhen you want to work
• Competitve Rates• Courteous Staff
Clients:• Prevent loss of revenue• BC/BE physicians• Competitive rates• Quality coverage• Malpractice coveragepaid by us
Affiliated Community Medical Centers is a physician owned multi-specialty group with 11 affiliate sites located in western andsouthwestern Minnesota. ACMC is the perfect match for healthcare providerswho are looking for an exceptional practice opportunity and a high quality of life.Current opportunities available for BE/BC physicians in the following specialties:
• ENT• Family Medicine• General Surgery• Geriatrician/• Outpatient Internal
Medicine
• Hospitalist• Infectious Disease• Internal Medicine• OB/GYN• Oncology• Orthopedic Surgery
thought about. In the crystalball method, for example,somebody gives you an idea oran answer, and you tell the per-son you have a crystal ball thatsays, “This is wrong.” You tellthem they must identify theflaws in their own thinking.
• Become a devil’s advocate orhave one when you aremaking a decision.Someone should alwaysbe assigned to say, “Thisdiagnosis [or decision]doesn’t make sense tome, because of these fac-tors” or “Why is mythinking wrong?”
The patient’s role
In addition, we need touse patients as partners in think-ing through and testing the diag-nostic hypotheses. Patients havean important role to play,whether in regard to the tempo-ral keys you are looking for,knowledge of whether or not thetreatments are working, or newdevelopments or perceptionsthat can help you reach a cor-
rect diagnosis.How can patients help you
avoid diagnostic errors?• Make sure they tell you thewhole story.
• Ask them to ask you three vitalquestions as you search foranswers: (1) Is there anythingin my medical history thatdoesn’t fit the hypothesis? (2)
What else could it possibly be?(3) Might more than one thingbe wrong?
Systems, cognition issuesare intertwined
Esssentially, what I’ve been talk-ing about is metacognition, or“thinking about thinking.”Decision-making must includethe ability to reflect upon ourown thinking process and to
critically review our own conclu-sions, assumptions, and beliefsabout a problem. Unfortunately,no matter how good we becomein understanding how we makediagnoses, it will be impossibleto eliminate all diagnosticerrors. Almost all doctors, eventhe best clinicians, make mis-takes because they take cogni-tive shortcuts or jump to conclu-
sions too soon.In addition, system improve-
ments degrade over time,and correcting one systemproblem may introducenew opportunities forerrors. (An example: Givingresidents less call to decreaseerrors but then having handoffsgo up, thereby increasingerrors.) Systems evolve in stepwith the evolution of health care
technology, so system “repairs”will always lag behind to someextent and will fall short ofachieving perfection.
The key lessons here arethat diagnostic errors will occur;they are caused by both systemand cognition causes; and wehave unavoidable biases thataffect our diagnostic process.Our ability to come up with
solutions requires an under-standing of how thinking errors
and system weaknesses areintertwined in contributingto diagnostic errors.
Our goal must be todecrease the likelihood of
the loss of more Julias.
Phillip M. Kibort, MD, MBA, is vicepresident of medical affairs and chiefmedical officer of Children’s Hospitals andClinics of Minnesota.
Errors from page 13
38 MINNESOTA PHYSICIAN JANUARY 2012
Our ability to come up with solutionsrequires an understanding of how thinking
errors and system weaknesses are intertwinedin contributing to diagnostic errors.
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