July/August 2019 - Serving the Underserved

July/August 2019

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

SERVING THE

UNDERSERVED

In This Issue: • • • •

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Reaching out to the Underserved TCMS Celebration Engaging Future Physician Advocates Luminary of Twin Cities Medicine

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“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring underrepresented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota in the names of his parents, Drs. Charles and Susan, both pioneering graduates of the U of M Medical School, class of 1963.

As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters.

Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

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CONTENTS V O L U M E 2 1 , N O . 4 J U LY / A U G U S T 2 0 1 9

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Charles Bolles Bolles-Rogers Award Nominations IN THIS ISSUE

Serving the Underserved

By Thomas E. Kottke, MD

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PRESIDENT’S MESSAGE

“Dr. Watson will see you now”

By Ryan Greiner, MD

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TCMS IN ACTION

By Ruth Parriott, MSW, MPH, CEO Page 32

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SERVING THE UNDERSERVED

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Colleague Interview: A Conversation with Courtney Jordan Baechler, MD, MS

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Collaboration to Advance Quality Care in Underserved Populations

By Nicole Kapinos, DNP, RN

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SPONSORED CONTENT:

Prescribing Food: You Can’t be Healthy if You’re Hungry

By Carolyn Ogland, MD, FAAP Page 29

15

•

Putting Trust First: Family Independence Initiative

By Janayah Bagurusi

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•

Is it Time for Medicare for All?

By Lynn A. Blewett, MA, PhD

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•

SPONSORED CONTENT:

Addressing Food Insecurity in a Clinical Setting: A Case Study

By Nicole Bailey, MPH, Gina Houmann, MPH, RDN, LD, and Sarah Johnson, MBA, MPH, RDN, LD •

Accountable Health Communities: Going Beyond the Medical Diagnosis

By Eric B. Barth, MD

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•

SPONSORED CONTENT:

Serving Sexual and Gender Minorities in Health Care

By Carrie Link, MD

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•

Page 7

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Embracing Community-based Public Health Advocacy

By Lucas Zellmer

Environmental Health —Helping the Most Vulnerable Survive and Thrive in Times of Rapid Climate Change

By D. Eric Beck, MD, FACP In Memoriam Career Opportunities

32 Page 12 MetroDoctors

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Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

SERVING THE

UNDERSERVED

TCMS Annual Celebration: May 6, 2019

TCMS Celebrates First Fellowship Cohort

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July/August 2019

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LUMINARY OF TWIN CITIES MEDICINE

Steven Vincent, MD The Journal of the Twin Cities Medical Society

In This Issue: • Reaching out to the Underserved • TCMS Celebration • Engaging Future Physician Advocates • Luminary of Twin Cities Medicine

Despite Minnesota’s ranking as the 7th healthiest state in the nation, many residents are underserved. Read how the medical community is responding.

Articles begin on page 7.

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer

July/August Index to Advertisers

TCMS Officers

President: Ryan Greiner, MD President-Elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD

Children’s Hospital ......... Outside Back Cover Crutchfield Dermatology.....................................

Inside Front Cover

TCMS Executive Staff

Fairview Health Services .................................31

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com

HealthPartners....................................................14

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

Trish Greene, Administrative Specialist, Honoring Choices Minnesota (612) 362-3705; tgreene@metrodoctors.com

iCure

Lakeview Clinic .................................................31 MedCraft .............................................................23 North Memorial Health ..................................26 PNC Bank ...........................................................18

Annie Krapek, Program Manager, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com

PSP/LifeBridge ...................................................28

Amber Kerrigan, Project Coordinator, Physician Advocacy Network (612) 362-3706; akerrigan@metrodoctors.com

University of Minnesota Health ........................

Inside Back Cover

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

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Nominations are now open for the 2019 Charles Bolles Bolles-Rogers Award Criteria

Candidates for this “Physician of Excellence” award are nominated by their colleagues at Twin City area hospitals and/or clinics for achievement or leadership in medicine, contributions to clinical care, teaching and/or research.

This candidate is considered to be an outstanding physician by his or her peers.

The award is presented to the recipient by the Officers of the Twin Cities Medical Society Foundation at a medical staff meeting at the recipient’s hospital, clinic or other appropriate forum.

How to Nominate a Physician

The Chiefs of Staff of the Twin Cities area hospitals and Clinic Administrators/ Leadership submit nominations for the Charles Bolles Bolles-Rogers Award annually. The Twin Cities Medical Society Foundation Board of Directors has the honor of selecting the recipient. Download a nomination form at https:// www.metrodoctors.com/awards. Contact Nancy Bauer for more information: nbauer@metrodoctors.com; (612) 623-2893.

Nominations are due by July 31, 2019.

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MetroDoctors

The Journal of the Twin Cities Medical Society

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IN THIS ISSUE...

Serving the Underserved

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lthough Minnesota ranks among the healthiest states in the nation, the Twin Cities metro has the inglorious distinction of having the second worst rates of health and economic disparities in the country. Alongside the fortunate majority resides a large population of underserved individuals. Fortunately, our colleagues are taking action to promote their health and well-being and ease their suffering. This issue of MetroDoctors provides a sample of their activities.

To start the conversation, Dr. Courtney Jordan Baechler tells us she was drawn to Internal Medicine and Cardiology because of the opportunity to form life-long relationships with patients as they pursue health and well-being. She accepted the position of Assistant Commissioner, Minnesota Department of Health so that she could address upstream determinants like hunger, housing, and structural racism.

As medical students, I, along with many of my classmates, volunteered in free clinics. With their sophisticated care and informatics systems, the clinics of the Federally Qualified Health Center Urban Health Network (FUHN), are a far cry from those days. The article that they have given us attests to their creativity and innovativeness as they serve the metro’s underserved.

It is a truism that you can’t be healthy if you are hungry, and North Memorial Health is doing something about it with FOODRx. A pilot program with the Minnesota Department of Human Services, Second Harvest Heartland and other partners, FOODRx connects food insecure customers who have chronic health conditions with both food and basic needs resources in a clinic setting.

I rely heavily on my social network for information, and I’ll bet you do, too. I was fascinated to read about Wilder Foundation’s Family Independence Initiative, a program that uses the strengths and the power of social connections so that families in need can make changes for themselves. Simply getting them together to identify opportunities has increased family incomes, reduced needs for community services, and reduced poverty.

In the article that follows, Lynn Blewett, Professor of Health Policy at the University of Minnesota, School of Public Health, describes healthcare funding of the present and potential scenarios for the future. Although she doesn’t predict whether “Medicare for All” is in our future, she does observe that “when the CEO of

By Thomas E. Kottke, MD Member, MetroDoctors Editorial Board

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UnitedHealth starts a high-profile lobbying effort against Medicare for All, you know the clamoring [for a single payer] is hitting a nerve.” I suggest checking your pulse after reading her article.

Recognizing that multiple approaches to food insecurity are needed, HealthPartners has embarked on multiple efforts to both screen for food insecurity and make it easier for food shelf clients to make healthier choices. The health system partnered to co-found SuperShelf, a project that uses the principles of behavioral economics to promote healthy, appealing and culturally-appropriate foods.

It is probably true that all of us who provide clinical services could better promote the health of our patients by looking beyond ICD and CPT codable conditions. That’s exactly what Allina Health had in mind when they penned a cooperative agreement with the Centers for Medicare & Medicaid Services. When surveyed six months into the Accountable Health Communities trial, more than two-thirds of their team members agreed that the program improves patient experience.

Did you know, when responding to a 2002 survey, 4% of men and 11% of women reported that they participated in samesex sexual activity? That’s the statistic that M Health physician Carrie Link cites as she describes her career path to serve sexual minority patients at Smiley’s Clinic. She offers insights that are useful to all of us as providers of person-centerd care.

Community Health Workers (CHWs) improve care for patients with chronic care needs and have been found to be cost-effective members of the care team. As a Dr. Pete Dehnel Public Health Advocacy Fellow, medical student Lucas Zellmer advocated for their presence on the care team. He now gives us insight about what he learned by participating in this innovative program.

Since the beginning of his career our Luminary, Dr. Steven Vincent, has served the underserved in free clinics. His biography should inspire us all.

There is both a business case and a humanitarian case for addressing the medical and social needs of the underserved. It is my goal to convince you of that fact with this issue of MetroDoctors.

Let me know what you think.

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President’s Message

“Dr. Watson will see you now” RYAN GREINER, MD

H

ave you ever imagined what medicine is going to be like in 20 years — or 50? How about 100? How will we practice? What will be our focus? Who will be leading? I can imagine a time of competing healthcare brands like Google Health, Apple RX, or Microsoft Digi-health...

IBM’s Watson may become everyone’s doctor — and then what of us? Health care is changing in dramatic ways and accelerating rapidly. Patients are now healthcare consumers and approach the market as they would Amazon. They want to compare doctors, read reviews, and check prices — online. Large multinational technology companies are quickly accelerating their investment in understanding and disrupting the healthcare market. Can we remain relevant?

Stanford University recently trained an artificial intelligence (AI) algorithm to detect 14 different pathologies on X-ray. In 10 of 14, the AI program performed as well as the radiologist and in one case it outperformed the physicians. This built on research which showed AI algorithms can reliably detect stroke on imaging, and with increased speed and accuracy when compared to humans. Stories like this continue to proliferate. In 2017, JAMA published a study showing that deep learning algorithms were better able to detect metastatic breast cancer than a human radiologist under a time crunch. An AI diagnostic program at John Radcliffe Hospital in Oxford, England was more accurate than doctors at diagnosing heart disease. And then there is Watson. IBM’s deep learning tool was able to deliver actionable recommendations for oncology treatment within 10 minutes, based on a tumor’s genetic profile. The humans took 160 hours.

Computers don’t have bias. They are not affected by their emotions. They are not impacted by sleep deprivation and they can work 24/7 without a break. They can do complex statistical analyses in milliseconds.

They are reliable. “But wait,” you say, “we will always need surgeons!” Not so fast...Researchers at the Children’s National Health System and John Hopkins University recently turned loose a “robot” called the Smart Tissue Autonomous Robot (STAR) to independently perform open bowel surgery on unsuspecting pigs. The robot performed well, leaving the animals healthy and without complications. There is no question that robotics and AI are going to become more integral to our practice and will be performing more and more of the diagnostic reasoning and making evidence-based therapeutic recommendations. Like all other parts of our economy, the robots are coming.

We are a long, long way away from being replaced by robots, but these innovations should drive us to think about what is essential to the human component of medical practice. Maya Angelou once said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” Medical practice is about compassionate service — to our patients, our communities, and each other. Health systems on the cutting edge of healthcare consumerism understand that receiving medical care, at its most basic level, is about the emotional experience of receiving that care. Last time I checked, robots can’t provide that….

As long as we live that mission of “service” to our patients and communities, our significance as physicians will remain integral to health care. If we become transactional in the new world of healthcare consumerism and evolving technological innovation, we relegate ourselves to the “task” of medicine rather than the passion of the work. This edition of MetroDoctors highlights that mission of service and demonstrates how partnerships and activism can impact social determinants of health within our communities. It brings us upstream in the timeline of disease and illness to improve how people live, work, eat, and thrive. I encourage you to join us in this mission.

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TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

A Rousing Celebration!

The room was full and the conversation lively on May 6th as over 80 Twin Cities Medical Society members and friends gathered to celebrate the impact of our physician-led activities. Following a

social hour of libations and tasty bites from Surly, Board President Ryan Greiner, MD introduced dynamic speakers who brought to life four key TCMS initiatives. ACP coordinator Kerry Hjelmgren from Faribault/Owatonna exemplified the spirit of Honoring Choices as she shared the poignant effects of her work for both her community and her own family. Physician Advocacy Network leader Caleb Schultz, MD, godfather of the T21 movement in Minnesota, engaged the entire room in direct grassroots action by calling a legislator to support the statewide T21 bill. Medical student Diana Rubio thanked the TCMS Foundation and her physician mentor for support of her Dr. Pete Dehnel Public Health Advocacy Fellowship project MetroDoctors

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which resulted in over 25 medical students being trained in healthy food access and its role in community health.

It was my distinct pleasure to introduce enhanced services of the esteemed Physicians Serving Physicians (PSP) organization, which has helped over 1,000 physicians through recovery from substance use disorder and return to medical practice via confidential peer support. PSP now also provides general behavioral health assessment, clinical services, and on-line wellness resources to Minnesota physicians, residents, medical students and their immediate family members through its LifeBridge physician wellness program. All services are free of charge. Please explore the offerings at www.psp-mn.com. (See ad on page 28.)

The PSP expansion is made possible through its new Medical Advisor and an Executive Director. Mike Koopmeiners, MD is a Family Medicine physician who is also board certified in addiction medicine. He has a long history of volunteerism with PSP as a confidential peer mentor and helps lead the monthly PSP substance use recovery meetings. Mike is always looking for more physician volunteers to provide confidential peer support, both with substance use disorders and with the universal stressors of medical education and medical practice. He is available for individual or organizational consultation through PSP@metrodoctors.com or (612) 362-3747.

Executive Director Stephanie Malone, MPH joins PSP with a successful career of fundraising for growth within healthcare and public health

The Journal of the Twin Cities Medical Society

organizations such as CaringBridge and Children’s Hospital Foundation. She brings a passion for seeking solutions to the epidemic of physician burn-out, drop-out, and suicide. Stephanie is open to your ideas and can be reached at smalone@metrodoctors.com, or (651) 983-2625.

I owe my deepest gratitude to the TCMS Board of Directors and membership for providing generous support, advice, and enthusiasm for our mission during my first year at TCMS. With the energetic response to our first Annual Celebration, I have no doubt the next year will prove as inspiring.

Senior Physician Association Spring Gathering

Rev. Nancy Nord Bence, Executive Director of Protect Minnesota, was the featured speaker at the May 21, 2019 gathering of the Senior Physicians Association. Rev. Nord Bence spoke passionately about the efforts of Protect Minnesota’s Health Care Coalition to prevent gun violence, including the drafting of two pieces of legislation that were successfully passed by the House and several public rallies bringing attention to the incidence of gun violence.

Work will continue next year to secure Senate support for statewide legislation.

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Serving the Underserved

Colleague Interview: A Conversation with Courtney Jordan Baechler, MD, MS

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ourtney Jordan Baechler, MD, MS currently serves as Assistant Commissioner, Health Improvement, Minnesota Department of Health. Prior to this appointment she was Vice President, Penny George Institute for Health and Healing, Allina Health (2012-May 2018); Medical Director of Cardiac Prevention Services at United Health and Vascular Clinic in St. Paul (2011-2013) and Staff Cardiologist at the University of Minnesota, Department of Medicine (2010-2011). Dr. Baechler received her medical degree from the University of Minnesota Medical School, followed by an Internal Medicine Internship and Residency at the University of Minnesota Department of Medicine.

A Masters in Clinical Epidemiology from the University of Minnesota School of Public Health/Graduate School was completed while enrolled in the National Institute of Health Physician Scientist Program — Cardiology Fellowship/Graduate Degree in Public Health from the University of Minnesota Department of Cardiology/School of Public Health/ Graduate School.

What led you to pursue a career in medicine in general and cardiology in particular, and then give most of that up to become an assistant commissioner of health?

I was drawn to a career in Internal Medicine and Cardiology because of the opportunity to form life-long relationships with patients as they pursued health and well-being. I particularly enjoyed Cardiology because of the variety in the field. Not surprisingly, I love that depending on the study you cite, upwards of 85% of cardiac disease is preventable. I truly love primary prevention and the opportunities it has. That being said, it’s fascinating to unravel what goes into everything as people try to stay healthy — mental health, relationships, access, trauma, racism, poverty, etc. I also loved the “second chances” that Cardiology gives. We have some true medical miracles within Cardiology — stents, bypass, valves, Transcatheter Aortic Valve Replacements, heart transplants, defibrillators, you name it…we almost always have a way, if we are given the opportunity, to give people “another chance.” I think that’s an incredible time in the doctor/patient relationship where there is the opportunity to look at the role of lifestyle, medical management, etc. going forward to ensure the best outcomes for our patients. While I truly love the one-on-one (I’m continuing MetroDoctors

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to see patients in my new role as assistant commissioner), my interest in helping influence some of the challenges listed above at the state level has grown. I think there is a huge opportunity for physicians to provide leadership in helping the state address health (care) reform…we have gained significant knowledge throughout our training and in the exam room about some of the opportunities for improvement. I’m hopeful to shape that in positive ways for our state. Finally, when my daughter Sophia died unexpectedly in 2015, I found myself reflecting on how I spent my days. While I couldn’t change the death of my daughter, it was powerful to align some of my interests more broadly with my career. This opportunity to work upstream has made it easier for me to connect with Sophia on a spiritual level.

Who are/were your role models?

I have many role models throughout my training and career.

Tom Kottke, MD, MSPH really took me under his wing as I started my National Institute of Health Physician Scientist track.

I was excited to see a physician who was working on legislative and advocacy issues while maintaining his role as a cardiologist.

(Continued on page 8)

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Serving the Underserved Colleague Interview (Continued from page 7)

Dan Duprez, MD, PhD also served as a tremendous role model with his emphasis on prevention at the U of MN and allowing me to grow my skillset in that area. Finally, I had the incredible opportunity to meet Pekka Puska, MD who helped lead the North Karelia Project in Finland where they made significant strides in reducing heart disease mortality for the whole country.

I would describe him as 1/3 a physician, 1/3 a politician, and 1/3 a researcher….I realized from meeting him and seeing his work that in order to be effective at that level you needed respect and expertise in all of those areas.

What do you find most rewarding in your work as the Assistant Commissioner of Minnesota Department of Health (MDH)? Most frustrating?

I find the breadth of work at the MN Department of Health extremely fulfilling. We work on issues from homelessness, infant and maternal mortality, immunizations, health equity, clean air and water, family home visiting, opioids, suicide prevention, to chronic disease prevention and promotion. I love the opportunity to get at the root of what is causing so much of our chronic diseases. I also love the chance to be at the table and help shape these conversations with a clinical view. I get most frustrated at the speed of change; it seems things move quite slowly at the government level and we are challenged with the same issues many organizations face, particularly that the work is often subject to silos both within governmental agencies and outside. The legislative side can also be challenging. I’m surprised at how frequently health becomes a partisan issue. I believe as it relates to health, we have much more in common than different despite what popular politics makes us believe. However, I remain optimistic about what’s possible!

Please define/illustrate some key social and/or economic factors that impact health.

You have heard some of this from my responses above, but it’s crystal clear that health is hugely impacted by “social determinants.” This gets into these root causes: stable housing (a true home), poverty (economic opportunities), education, healthy environment, historical trauma, and racism.

How is MDH responding to the above issues?

A substantial amount of work on behalf of the agency went into changing the narrative on these issues and helping the state understand the impact of what shapes health or what costs and

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downstream impacts we see when we don’t adequately address the issues that create health. The 2017 MN Statewide Health Assessment did a wonderful job of framing all of this. For instance, when it comes to adults diagnosed with diabetes by educational attainment, 5.4% with a college degree have a diagnosis of diabetes compared to 11.1% diagnosis rate for those without a high school diploma. Inadequate prenatal care, defined as births without first trimester prenatal care, 29% of those without a high school diploma fall in this category compared to 13.6% with a high school diploma or more. Recognizing the importance of these social and economic drivers of health, we have worked collaboratively with a variety of agencies to help change these norms. MDH most importantly provides the voice of “health” as we work collaboratively with other agencies on solving the issues listed above.

As we work on solving the social determinants, we also work on effective solutions in real time. For instance, we do family home visiting in our child and family health division that allows public health individuals to meet with families who may be experiencing more of the challenges we indicated above. We help run our WIC (women, infants, and children) program for the state that allows for easier access to health care as well as supplementing nutrition and food services. MDH helps to keep our water and air safe for all in MN. It’s easy to take this for granted and unfortunately, the very individuals with challenging socioeconomics are the ones that are often most impacted by unsafe water and air. We work hard to avoid having something like Flint, MI in Minnesota. We have an entire Children’s cabinet dedicated to helping improve the well-being of our children in a systematic and efficient way.

On the other end, we have a regulatory body that is diligently working to keep our seniors safe as they transition through various phases in life. At the policy level, we work on areas like the Family Medical Leave Act (FMLA) for all Minnesota residents, tobacco policy, etc. These are just a very few highlights, but the majority of our work goes to collectively improving social determinants.

What key community engagement efforts are underway to address health equity?

We are grateful to Dr. Ed Ehlinger for raising our awareness of health equity. While MDH has been working for decades on addressing health equity, there are more clearly defined resources than previously and in a more targeted approach. Our health equity department started the Eliminating Health Disparities Initiative (EHDI). The EHDI program funds community initiatives that support closing the gap in the health status of populations of color and American Indians as compared to whites. EHDI was established by the MN State Legislature in 2001 to address the growing health disparities in our state (unfortunately despite being the 7th healthiest state, we are the second worst in the country in terms of our health disparities). We recognize that some of our work also has to start within the Department of Health. We started an MetroDoctors

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internal health equity advisory leadership team hub (I-HEALTH) where we convene an internal team of staff from all divisions who help streamline coordination and foster greater collaboration of health equity efforts within the agency. This allows us to have more equity in our grants (not just those through EHDI) and as we distribute $250 million in grants to the state annually, this internal work on equity increases our opportunity to have an impact externally. We have also created a Health Equity Advisory and Leadership (HEAL) council that allows a statewide advisory council comprised of leaders representative of communities most impacted by health inequities to have a larger voice and influence on our work. They provide guidance to MDH on how to advance health equity across the MDH system, policies, and programs.

What steps or changes can you suggest that an individual clinic or delivery system might undertake?

One of the biggest things I think an individual can do is start talking about these realities in health equity and asking some of these difficult questions…unfortunately, the data are getting worse, not better. One thing we have realized at MDH is the importance of racial equity and that health equity cannot be achieved without naming the impacts of structural racism and working toward racial equity. As physicians and clinicians, I appreciate our love for science…however, I’m afraid we are seeing the limitations of evidence-based medicine. If it were as simple as ensuring everyone had access to the same type of care, one size fits all, this would be a much easier problem to solve! But the reality is that recognizing the roots of inequities are tied to a legacy of historical trauma in communities is critical. That means there is a lot of distrust with traditional clinical care. However, that means there is the opportunity to solve health inequities in partnership with communities where much of the strength and resilience resides. Sometimes, the very best thing that we can do is to meet communities where they are and deeply listen to what they are asking for or how they feel we might help address their path to health and healing. At a local health system we did a pilot of looking at disparities with colon cancer screening. We found that often if the patient did a Fecal Occult Blood screening in the privacy of their home and it was positive, they were more likely to get a screening colonoscopy. While many of us would say this isn’t consistent with the latest evidence-based medicine, it ultimately gets us to the goal we are looking for even if it is a longer route there. With the disease burden we are seeing, heavy in mental health, substance abuse, and chronic disease, it begs for a different approach. I also think there is a huge opportunity to bring folks together through shared medical visits and have peers help lead the change while being facilitated by clinicians and ultimately giving folks more time to be successful in behavioral change. More than anything, I would say be courageous and speak up…many of your colleagues are thinking the same thing.

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What metrics are in place to measure success or failure of any given effort?

Metrics are the mainstay of what we do at MDH! We have begun a process for some time now where we crosscut nearly all our data from a racial and ethnic perspective to ensure the disparities are not lost in the larger population data. We have a tremendous amount of data collection on behalf of the state. From BRFSS (self-reported data), infant mortality, maternal mortality, chronic disease prevalence and mortality, homelessness, poverty, environmental health standards throughout the state, infectious disease prevalence and incidence, newborn screening, statewide quality reporting metrics (SQRMs)…if it’s out there, we are likely part of the collecting process. What we know is as it relates to health equity, we have a long way to go. Many of our metrics appear to be improving for our caucasian populations, but unfortunately, we are not seeing these same improvements in the other racial and ethnic groups.

What advice do you have for younger colleagues who are considering a career that combines clinical medicine and public health?

I bet I have a physician colleague reach out one-to-two times each week to discuss what I’m doing and how I got here. I have learned that having a medical degree opens up significant opportunities. We are fortunate that we have the opportunity to have a variety of career options. I have been grateful to be able to maintain a small clinical practice while still pursuing health at the state level. That was always a concern of mine and I would reassure younger colleagues that not only can you do both, but I believe we need leaders who have interests both in and outside the clinic. Not many people have the knowledge that we have gained on the inside of the clinic exam room or operating room and the tremendous opportunity that provides to help influence and support the health infrastructure that needs to be in place for our communities to thrive. I believe there is a great opportunity to better connect the community to the clinic, and physicians will be a big piece of that. There are great opportunities to get involved with local advocacy with MN chapters of the American Heart Association, Lung Association, Diabetes Association, etc. that can give you an idea of whether or not you like this type of work. Physician voices are powerful and impactful in helping to provide a voice in advocacy and legislative efforts. It is truly a privilege we have been given to work as physicians and it’s neat that there are so many productive ways to utilize our skills. I truly think of my journey into public health as just expanding my metaphorical doctor’s bag into the community.

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Serving the Underserved

Collaboration to Advance Quality Care in Underserved Populations

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he Federally Qualified Health Center Urban Health Network (FUHN) was established from the existing Neighborhood Health Care Network (NHCN) in 2012 and functions as a virtual Accountable Care Organization (ACO) that participates in Minnesota as an Integrated Health Partnership (IHP), and nationally as a Health Center Controlled Network (HCCN). FUHN was the first FQHC-only safety net Medicaid ACO in the nation. FUHN is comprised of 10 member organizations which are Federally Qualified Health Centers (FQHC) or FQHC look-alikes: • People’s Center Clinics & Services • Indian Health Board of Minneapolis • Native American Community Clinic • Neighborhood HealthSource • Open Cities Health Center • Southside Community Health Services • United Family Medicine • AXIS Medical Center • Community University Health Care Center (CUHCC) • Minnesota Community Care FUHN’s clinics have a long and proven commitment to serving their communities. The newest clinics participating in FUHN are AXIS Medical Center, which was founded in 2008 to serve the Somali and East African community with culturally and linguistically competent health care, and the Native American Community Clinic (NACC), which was founded in 2003 by three female physicians with many years of combined experience working in an FQHC setting and serving

By Nicole Kapinos, DNP, RN

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Native Americans. The oldest is United Family Medicine, which traces its history to serve community residents in need to the 1920s and its original predecessor organization, the Wilder Dispensary. The seven other organizations fall in between, having actively served their communities for decades.

Many of the network health centers were founded by neighborhood residents seeking to improve access to low-cost, quality health care. All FUHN clinics provide primary care and enabling services, are healthcare home certified, and work closely with many community partners such as county agencies, community mental health centers, racial and ethnic community organizations, and schools. This foundation of community members — both as planners and consumers of the services offered — is a continuing hallmark of the FQHCs. FUHN’s clinics are committed to advancing health equity, which means they believe people who experience the greatest disparities deserve not just the same level of access to mainstream healthcare services, but additional services and support so they can overcome the additional barriers and complexities they must face in order to be healthy and obtain the healthcare services they need.

Collectively, FUHN’s clinics serve over 111,000 patients. Of those, 91% represent diverse populations, 95% have incomes below 200% of the federal poverty level, and 41% are best served in language other than English. There are approximately 55,000 Medicaid/MN Care patients that are served at the FUHN clinics with 31,000+ of those patients attributed to the FUHN IHP/ACO. Communities

of color, immigrants and refugees served

by FQHCs experience a myriad of socio-economic, cultural, language, and other barriers to care; consequently, they bear a disproportionate burden of disease with higher rates of negative health outcomes. These realities result in a high burden upon the clinics to impact health disparities with positive outcomes.

In 2010, the Minnesota Legislature mandated the Minnesota Department of Human Services to develop a demonstration project for alternate healthcare delivery systems. The IHP program was born out of this legislation. FUHN clinic CEOs came together to join the IHP demonstration project because they recognized the opportunity to leverage their resources, foster collaboration with like-minded healthcare providers, improve the quality of care they offered their patients, and learn the new value-based payment landscape together. They also recognized that the healthcare environment was quickly changing around them, and they wanted to be active participants in payment reform. The CEOs realized that this was their opportunity to provide a voice for the underserved and shape the changes

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taking place around them rather than be shaped by those changes.

During the first IHP contract period (2013-2015), FUHN engaged a strategic partner to provide operational and data analytic support. FUHN also established monthly meetings with various stakeholders including clinical quality improvement, medical directors, and administration/ leadership. Population health management and care management strategies were developed based on the data analysis provided by the strategic partner. FUHN deployed these strategies in various ways including patient education, outreach to patients, and other care coordination activities. Because FUHN is comprised of 10 disparate clinics, strategies had to be tailored to meet the needs of different patient populations, different provider/ staff resource availability, and different organizational priorities. This was challenging work that resulted in a significant payoff in terms of decreased total cost of care and increased quality of care for the patients served by FUHN clinics. For example, from 2013 to 2016 Emergency Department visits were reduced by 23% and inpatient visits were reduced by 14%.

These and other improvements in care resulted in a 16-million-dollar reduction in costs for the Medicaid-attributed population (2013-2015). Due to FUHN being the nation’s first FQHC-led virtual ACO, the Commonwealth Fund and researchers from Dartmouth University studied FUHN and highlighted the following attributes as keys to its success: • committed leadership team focused around a singular purpose; • partnership with its strategic partner; • and the diversity of programs, services, and experiences among the 10 FQHCs. FUHN continued to innovate through its second and into its third IHP contract.

FUHN recognized early on that integrating clinical data from the electronic health record with the IHP claims data would allow the clinics to better target their efforts around population health management and care coordination. To that end, FUHN received a grant to support a health MetroDoctors

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information technology initiative around interoperability and health information exchange. FUHN is also the recipient of the Health Center Controlled Network grant through HRSA which allows FUHN to employ staff to provide strategic support, run the health information technology initiative and infrastructure, provide data analysis, population health management and quality initiatives.

the University of Minnesota Pharmacy Leadership Residency program which was funded by a grant from UCare. This grant allowed FUHN and the resident to design and implement a pilot program in which a clinical pharmacist and community health worker partnered to deliver comprehensive medication management services which also addressed the social determinants of health that may be preventing the patient

FUHN clinic CEOs came together to join the IHP demonstration project because they recognized the opportunity to leverage their resources, foster collaboration with like-minded healthcare providers, improve the quality of care they offered their patients, and learn the new value-based payment landscape together.

FUHN utilizes its clinical quality improvement group and chronic disease specific subgroups to develop programs and best practices to improve quality of care. For example, quality metrics indicated that the percentage of patients with hemoglobin A1c readings greater than 9 was increasing. Therefore, a diabetes subgroup was established to develop a care protocol for diabetes management that touched every area of care delivery. The group was comprised of quality staff, a medical director, certified diabetes educators, and nurses from many of the clinics. Evidence-based protocols and existing clinic resources were combined to create a FUHN level Diabetes protocol. The protocol was validated by the medical directors from all clinics. The diabetes subgroup then tracked a sample of patients at each clinic to see if the protocol resulted in the desired reduction in hemoglobin A1c values. It was successful and the clinics were polled about which resources they were lacking to fully implement the protocol. Most clinics cited a lack of clinical pharmacy resources. FUHN was able to provide a clinical pharmacy resource to two clinics through

The Journal of the Twin Cities Medical Society

from achieving optimal control of their hemoglobin A1c. Over 2018, FUHN clinics were able to reduce the number of patients with an A1c of greater than 9 by 7.0%.

FUHN clinics remain committed to advancing heath equity by continuous refinement and evolution of its processes and methods by utilizing its data analytics, clinical quality metrics and organizational priorities to target areas of improvement.

Nicole Kapinos, DNP, RN is the Director of Population Health/Quality Improvement at FUHN. She has over 10 years experience in health care as a registered nurse, operations manager, and clinical healthcare informaticist. Her current role blends all those experiences to provide support to FUHN clinics as they endeavor to improve population health, enhance patient experience, reduce costs and improve primary care access for the patients they serve. She holds a Bachelor of Science in Nursing from the University of Rhode Island and a Doctor of Nursing Practice in Nursing Informatics from the University of Minnesota. Nicole can be reached at: nkapinos@fuhn.org; (952) 288-4852.

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Sponsored Content

Prescribing Food: You Can’t be Healthy if You’re Hungry Contributed by Carolyn Ogland, MD, FAAP

In an effort to make health care more affordable while improving health, North Memorial Health is finding new partners to test new and innovative theories.

While assessing various social determinants of health, North Memorial Health identified food insecurity and diet as key contributors to many chronic conditions.

After considering a few different potential partnerships, we selected Second Harvest Heartland for a pilot program. Already equipped with research on ways to integrate food security into a healthcare setting, Second Harvest Heartland worked with each clinic to create a catered approach to addressing food insecurity.

More than a half million Minnesotans are food insecure. Two out of three Second Harvest Heartland clients are choosing between paying for food and paying for medicine or medical care. When our partnership began, Second Harvest Heartland

The Theory

The change theory is that by integrating food security into medical care, lower-income individuals will gain greater access to nutritious food and other basic-needs resources to ultimately improve health outcomes and satisfaction while saving medical costs for both providers and health plans. The FOODRx program is an innovative way to address hunger within the healthcare system and is a complement to North Memorial Health’s Collaborative Care Integrated Health Partnership with the Minnesota Department of Human Services.

The Program

Assessing for food insecurity is part of North Memorial Health’s routine customer screening process. FOODRx works with the clinic to identify customers who meet program requirements for participation,

Hungry people access the healthcare system more often than the general population.

had built the initial program outline for FOODRx and was seeking healthcare partners as a new channel to reach food insecure individuals along with information and data to measure the efficacy of the program.

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are food insecure and may benefit from the program.

FOODRx connects lower-income, food insecure individuals with chronic health conditions to food prescriptions that are tailored to their medical needs,

their specific cultural backgrounds and their preferences. Second Harvest Heartland provides support related to food assistance screening, food boxes and disease management education for at-risk populations with the ultimate goal of improving health while lowering the total costs of care for the population. Case studies demonstrate that adjusted annual health care costs are 121% higher for households with severe food insecurity, and food insecurity is a strong predictor of healthcare utilization, independent of other social determinants of health. By teaching customers how to eat and prepare foods that may improve their health, FOODRx helps customers gain a better understanding of their nutritional needs based upon their health status.

Qualifying, lower-income individuals with diabetes or cardiovascular disease can pick up FOODRx boxes once a month for six months. Food prescriptions are essentially boxes of food that are built by registered dietitians and contain roughly 25 meals each month. Designed to meet

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dietary and nutritional needs, the boxes contain healthy, shelf-stable food items like canned fruits and vegetables, whole grains and quality protein sources. For culture specific diets, the boxes are available in three different versions — traditional American, Somali and Hispanic. Each box also contains educational material including recipes that can be prepared using the contents inside. All recipes and educational materials are available in English, Somali and Spanish corresponding with the culturally-specific boxes.

Target Population

The program targets four conditions that are significant drivers of healthcare cost and can lead to use of preventable

More than a half million Minnesotans are food insecure. healthcare services like emergency care.

Specifically, FOODRx targets individuals who are food insecure and have diabetes, hypertension, ischemic heart disease or congestive heart failure. These conditions are particularly susceptive to poor outcomes or adverse events when there’s either food insecurity or dietary issues. And, they are areas being measured by Minnesota Community Measurement.

Most individuals eligible for FOODRx accept enrollment in the program. They are offered various location options to pick-up their monthly boxes, including their medical clinic, and connected with a dietitian to further enhance food preparation and shopping practices along with chronic disease education.

If transportation is an issue or the customer is not physically able to transport a food box, which can weigh up to 30 pounds, a North Memorial Health community paramedic volunteer has partnered with one of the clinics to deliver the box to their home. As an added enhancement, the community paramedic MetroDoctors

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team is trained to assess situations and build relationships quickly. So, while they’re delivering food boxes, paramedics identify potential in-home risk factors or other health issues on the spot. They share any pertinent in-home information with the care team and have occasionally even initiated an early intervention during the delivery.

The Rollout

After assessing where to pilot the program based on where the greatest needs were, North Memorial Health together with North Collaborative Care Network, found their affiliated clinics at the top of the list.

Broadway Clinic, North Clinic, Northwest Family Physicians and Stellis Health have been offering FOODRx to customers for about a year. North Memorial Health Clinics are being added into the program based on where the need is the greatest and will be phased in over the coming year.

We are measuring participation and customer experience. Ultimately, we plan to assess whether we improved customers’ health and prevented additional utilization or cost after customers complete the program. We’ll also conduct a longitudinal study to determine if we were able to truly change our customers’ dietary habits resulting in health improvement and cost

The Journal of the Twin Cities Medical Society

reduction. Initial FOODRx pilot projects have shown improved health outcomes, lower costs and fewer hospital visits.

Many of our providers question whether a six-month intervention is enough to rewire or hardwire healthier habits, especially with a population who have lived a lifetime of either poor access to food or lack of knowledge around what a healthy diet looks like. We’re looking at this closely and will determine if considering hunger as a health problem could be a critical component to providing successful value-based care.

Carolyn Ogland, MD, FAAP, is the Chief Medical Officer at North Memorial Health.

Additional contributions to this article were made by Jason Rusinak, Director of Payer Contracting, ACO and Network Management at North Memorial Health.

For nearly a decade, North Memorial Health has been on the leading edge of helping the Minnesota Department of Human Services develop, implement and assess innovative approaches to care and payment that result in higher quality and lower cost. By continuing to shape and structure pilot projects like FOODRx, North Memorial Health provides feedback and guidance along with a “boots on the ground” testing environment designed to ultimately improve population health and reduce costs.

North Memorial Health, along with the North Collaborative Care network of clinics were recently recognized by Second Harvest Heartland for their outstanding commitment to end hunger. The Hunger Hero Award recognizes their leadership and commitment to hunger relief by piloting the FOODRx program.

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KRISTEN KOPSKI, MD REGIONAL MEDICAL DIRECTOR

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,

Putting Trust First: Family Independence Initiative

F

or decades the social services sector has used a “gaps” model to offer support to people and communities. Government agencies, nonprofit organizations, and other providers identify needs within a region or demographic group and work to address those needs.

Through this model people receive an array of essential supports — food access, safe shelter, employment counseling, child care, and wellness services, just to name a few. For all the value and strengths of this model, it has a fundamental blind spot: When we approach social services strictly from a gaps perspective, we fail to recognize the strengths and the power of people to make change for themselves.

Social service providers are beginning to address this shortcoming with new models that emphasize people not as service recipients but as active participants.

The Family Independence Initiative (FII) is an example of an emerging movement to put power in the hands of families to lead their own change.

FII is a national effort to show that low-income families can improve their own financial and social well-being. Based on the principle that families are more successful when they lead their own change, the FII model has taken hold in communities across the country, including Boston, Oakland, Albuquerque, New Orleans, and Minneapolis-St. Paul. The Amherst H. Wilder Foundation partners with the national Family Independence Initiative to bring the approach to people in the Twin Cities who are working to lift themselves out of poverty.

By Janayah Bagurusi

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Big Data, Big Impact

How it Works

FII is not a direct service model. There is no curriculum or prescribed interventions.

Small cohorts of five to eight families meet monthly to share resources and support.

FII staff share information and enroll families, but otherwise take a backseat so cohort members can plan their own meetings and goals, including determining what they want and need.

Families own their solutions and support each other to achieve their goals. Such goals might include getting a raise, paying down debt, purchasing a home, or starting a small business. Members also take the lead in recruiting other families to join FII and start new cohorts. One recent FII Twin Cities participant had this to say about her experience: “I feel so positive, enlightened and optimistic about my future because of FII and my cohort group members. I’ve applied for a grant so that I can get supplies to start up my hair salon business. The business will help me gain financial independence and stability; that’s what I need for me and my kids to have a better self-sufficient life.”

The Journal of the Twin Cities Medical Society

There’s nothing new about neighbors coming together to support one another. What makes FII unique is its focus on using data to understand what works to help families reach and maintain stability.

Each family enrolled in FII tracks their progress through UpTogether, a national data system that connects FII families around the country. Families are responsible for entering their own monthly data and reviewing it themselves, which enables them to access and monitor their progress over time. Data tracking includes more than 200 points about families’ income and savings, health, education and skills, housing, resourcefulness, leadership, and networking with others. Families are provided laptops and earn cash incentives in exchange for entering their data and sharing information about their progress.

This data collected through UpTogether is used to track what works for families across the country to lift themselves out of poverty and achieve their goals.

This body of information helps policy makers, service providers, and the public at large understand the impact of investing in families directly.

The results speak for themselves. According to research by FII National, for those who participate over two years in other FII host cities across the country, families report increasing their annual income by 240% and their assets by 170%.

Fifty-five percent of families report a decrease in their use of public subsidies. At a local level, two families within FII Twin Cities started small businesses, resulting in (Continued on page 16)

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Serving the Underserved Family Independence Initiative (Continued from page 15)

an average annual supplemental income of $2,200. Other participants have paid off debt, purchased or repaired vehicles, and have enrolled in higher education. By building on their strengths and remaining accountable to each other, families are motivated to find solutions to the challenges they’re facing.

Access to Capital

UpTogether also connects FII families to flexible financial resources they can use to accelerate progress toward their goals. Through a pool of funds, families can access up to $2,400 over two years.

These funds can be used however participants see fit. A relatively small infusion of capital goes a long way in the hands of motivated families. On their website, FII National reports that from the 12 months before to the 12 months after drawing capital from the UpTogether Fund, total income increases by 19% on average, or by more than $5,500 a year while, at the same time, reliance on government

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entitlements and subsidies decreases by 42% or nearly $1,500. Families can also access other forms of financial support through UpTogether, including crowdfunding tools, credit-building resources, and lending circles.

From Credit to Initiative

In addition to making a difference in the lives of thousands of people across the country each year, the Family Independence Initiative is tackling one of the biggest systematic barriers that low-income families face — bad credit. In our current system, credit scores are easy to damage and difficult to repair. Families living paycheck to paycheck are more apt to experience momentary financial hardships, which can cause them to fall behind in paying bills or debt. This in turn lowers their credit score and limits their financial freedom. It can take years for families to rebuild their credit score after such an episode, making it even more difficult to get ahead financially.

FII offers an alternative. Rather than punishing families for low credit scores, FII National uses data from the UpTogether platform to reward families for the initiative they take to improve their own lives. In the “initiative score” system, families are awarded points for activities such as attending community workshops, increasing school attendance, and working to improve their health. Initiative scores are then used to determine the level of capital families can access through UpTogether.

The goal, as more and more FII participant families enter data that demonstrate the effectiveness of the initiative score system, is to influence traditional financial institutions to use a similar model so low-income families are better able to lift themselves up.

Beyond the Bills

Warriors — this group of mothers has organized community meetings, school events, and public awareness campaigns aimed at preventing bullying in local elementary schools.

Amidst all the statistics, nothing demonstrates the success of the Family Independence Initiative more than what families say about it. One Twin Cities participant put it succinctly: “I am grateful that a program like this exists. When I joined, I was feeling alone and unsure of what direction I should turn. I now feel that my path is clear and concise. I have accomplished a lot in a short period of time because of this program. I have actually found a job that I have been hoping for and I love it. I have found a church in which I truly feel like I belong. All thanks to FII.” Janayah Bagurusi is the Director of Family Supportive Housing Services at the Amherst H. Wilder Foundation. She has more than 20 years of professional nonprofit experience at the local and national level, values diversity and community engagement, and is committed to building the capacity of organizations to integrate their programming to achieve the greatest impact for individuals, families and youth. She has experience developing community-based programming around employment, wealth creation, leadership development, and personal growth.

She is skilled in coaching others to reach their personal and professional goals. Janayah holds a Bachelor of Arts Degree in Social Work from the University of St. Thomas and a Master’s of Public Affairs degree from the University of Minnesota’s Humphrey School of Public Affairs. Janayah can be reached at janayah.bagurusi@wilder.org.

Though FII is meant to support families as they work toward financial stability, the impact goes far beyond household income. When families come together and recognize their combined strength, entire communities benefit. One of the current FII Twin Cities cohorts has taken up the issue of bullying. Calling themselves LAW — Leaders, Advocates, MetroDoctors

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Is it Time for Medicare for All?

I

t’s an interesting time for US health policy. As Democratic candidates for the presidency clamor for Medicare for All, the Trump administration continues to claim they will introduce a new plan to replace the Affordable Care Act (ACA).

While it’s likely that nothing much will happen in the next few years to change the current system we have today, I am fairly confident in stating that the costs of our system will continue to increase and the burden of those costs will continue to be borne by US citizens and their families.

The US healthcare system has relied on a complex system of public and private health insurance with a now-shaky foundation of voluntary employer-sponsored insurance. In the time before American corporations faced global competition, when labor unions were still strong, and when we had a large manufacturing base, health benefits were a standard part of an employer benefit package. For those who were employed, good health insurance was generally part of the standard employment contract. Our circumstances have changed significantly, however, with the rise of a global economy, the decline of labor unions, and a transition to a more service-oriented workforce. Healthcare costs continue to grow, and there has been an erosion in employer-sponsored health insurance both in terms of coverage offered and in the amount of cost increases that employers are willing to bear.

The decline in employer-sponsored coverage started long before enactment

By Lynn A. Blewett, MA, PhD

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of the ACA in 2010 and the implementation of the Health Insurance Exchanges in 2014. Since 1999, employer-based coverage has declined from 67% to 58% in 2017 for the nonelderly US population.

Low-wage workers are even less likely to have employer-sponsored coverage (48%), requiring many workers to look to the expensive nongroup market for health insurance.

Even for those with employer-sponsored coverage, employers are pushing cost increases onto employees through increased cost sharing including high-deductible plans,1 large copayments, and limited provider networks. In 2017, 60% of Minnesota’s private-sector employees were covered by high-deductible plans, with an average deductible of $3,700 for a family plan. Employees are on the hook for increasing copayments which now average $30 per visit, with higher copayments for specialists and ED use.2 Unsurprisingly, almost a third (32%) of Minnesotans reported having trouble paying medical bills in 2016.

The Journal of the Twin Cities Medical Society

Our public healthcare programs, Medicare and Medicaid/CHIP (Children’s Health Insurance Program), once seen as supplements to a vital private health insurance market, are now more integral to the way people access health coverage.

As the employer-sponsored market has declined, more Minnesotans rely on coverage from safety net programs. The ACA was also responsive to the high rates of uninsurance — adding options for coverage through the expansion of the income eligibility for Medicaid, premium subsidies offered on MNsure (Minnesota’s state-based Health Insurance Exchange), and a revamped and federally subsidized MinnesotaCare program.

While many lament the possibility of Medicare for All (or any other type of government-run health system), government-subsidized health insurance is already playing a larger role than it has in the past. For Minnesotans who get subsidized coverage in 2019 (including the 125,425 on MNsure; 72,000 on MinnesotaCare; and 900,000 on Medicaid and 1 million on Medicare),3 the financial assistance provided by the federal and state programs is critical to getting and keeping health insurance coverage.

Our employer-sponsored health insurance system is supported through public dollars as well. Private sector employers received a tax exemption to the tune of $280 billion in income and payroll taxes in 2018,4 the largest single federal tax expenditure in the federal budget. This largely

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Is it Time for Medicare for All? (Continued from page 17)

hidden tax subsidy allows employers to contribute to the cost of an employee’s health insurance premium; 82% for single coverage and 71% for family coverage.5 The last group of people who pay full price for their coverage are those with incomes too high to qualify for subsidies or state programs and do not have access to employer-sponsored insurance. These people must purchase coverage on the nongroup market and face the actual high costs of health insurance coverage.

And yes, I understand that these new programs are buying people into an increasingly costly healthcare system. However, the mechanisms that other countries’ universal coverage systems use to control costs are difficult to envision in the US at this point in time. Other countries have employed price setting through all-payer fee schedules, primary care gatekeepers to limit access to costly specialists, global public budgets for hospitals or health systems, and strict price caps and product review of new technologies that must demonstrate added value, effectiveness, and efficiencies. Although there is increasing pressure for the government to do something, Congress has not even been able to pass legislation allowing the Medicare program to negotiate prices for costly prescription drugs. And I would argue that market-based solutions only go so far with the government contributing almost half of all healthcare spending along with limitations on the essentials of a market-based system (e.g., price transparency including information on negotiated discounts, adequate quality measures and reporting, and universal coverage).

I have no silver bullet, except to note that in order to control costs and increase coverage we are all going to have to give up something. For many that may be a choice of provider or increased cost sharing; for providers it may be a loss of income or working for a larger health system under a global budget or an all-payer fee schedule.

Many of these ideas are being tested in communities across the country and they MetroDoctors

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are likely part of our future in some form or another. Several states have introduced legislation to limit surprise billing for outof-network providers, other states have implemented their own individual health insurance mandate to bring everyone into the system. Massachusetts implemented limits on the overall rate of growth of healthcare spending to 3.1% (something Minnesota did in the early ’90s), and yet other states are adopting prescription price transparency laws. But the public sector cannot tackle cost containment on its own.

One thing we can do today, and must do at the state level, is to work toward universal coverage. We’ve seen that we can’t just rely on our private healthcare system to open its doors and let everyone in. In Minnesota, with an uninsurance rate of just 6.3% and many people already eligible for existing subsidized health insurance programs, funding for outreach and enrollment is essential. The next target is those who purchase coverage in the nongroup market without subsidy. A bipartisan bill to provide tax credits for those above the ACA income eligibility for premium tax credits was recently proposed by Minnesota legislators. This approach, along with a reinstatement of the individual mandate to bring everyone into the market, makes sense in order to achieve goals of coverage gains. Though universal coverage will not address the cost problems in health care, it’s a first step in moving toward a more comprehensive system.

Enacting a Universal Health Care system as a solution to affordable health care in the US used to be only whispered about among a few advocates and policy makers who championed the cause. But these murmurs are growing into a loud rumbling heard across the country. Medicare for All proposals are now a key issue of the 2020 presidential campaign and Congress has had its first hearings to discuss the pros and cons. And when the CEO of UnitedHealth (a for-profit company that announced a 22% increase in profits, earning nearly $3.5 billion in the first quarter of 2019) starts a high-profile lobbying effort against Medicare for All, you know the clamoring

The Journal of the Twin Cities Medical Society

is hitting a nerve.6 As more and more people confront the exorbitant cost burden associated with needed care, there will be pressure for change. Something is going to have to give — sooner or later. Let’s get started!

Lynn A. Blewett, PhD, is a professor in the University of Minnesota Division of Health Policy and Management and the director of the State Health Access Data Assistance Center (SHADAC). Dr. Blewett holds a PhD in Health Services Research, Policy and Administration from the University of Minnesota School of Public Health (1992), a Master’s in Public Affairs from the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota (1986), and a BA in psychology from the University of Wisconsin at Madison (1980). Her research interests include healthcare policy, access to care, disparities, Medicaid/CHIP, immigrant health, survey research, and international health systems. She can be reached at: (612) 626-4739, orblewe001@umn.edu.

(Endnotes) 1.

Defined as plans that meet the minimum deductible amount required for Health Savings Account eligibility ($1,300 for individual coverage and $2,600 for family coverage in 2017).

2.

State Health Access and Data Assistance Center (SHADAC). (October 2018). 50-State Fact Sheets: State-Level Trends in Employer-Sponsored Health Insurance (ESI), 2013-2017 [PDF file]. Retrieved from https://www.shadac. org/sites/default/files/ESI_Fact_Sheets_October2018/ALL_STATE_Oct18.pdf.

3.

Minnesota Department of Human Services (MN DHS). (2019). Managed care enrollment figures.

Retrieved from https://www.dhs.state.mn.us/ main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_141529.

4.

Urban Institute and Brookings Institution, Tax Policy Center (TPC). (2016). Key Elements of the US Tax System: How does the tax exclusion for employer-sponsored health insurance work?

Retrieved from https://www.taxpolicycenter. org/briefing-book/how-does-tax-exclusionemployer-sponsored-health-insurance-work.

5.

Merhar, C. (2018, November 8). What Percent of Health Insurance is Paid by Employers?

People Keep blog. Retrieved from https:// www.peoplekeep.com/blog/what-percent-ofhealth-insurance-is-paid-by-employers.

6.

Snowbeck, C. (2019, April 16). UnitedHealth CEO warns against Democrats’ push for single-payer health coverage. StarTribune.

Retrieved from http://www.startribune.com/ unitedhealth-group-profit-jumps/508636842/.

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Sponsored Content

Addressing Food Insecurity in a Clinical Setting: A Case Study Contributed by Nicole Bailey, MPH, Gina Houmann, MPH, RDN, LD, and Sarah Johnson, MBA, MPH, RDN, LD Nearly one in 10 Minnesota households currently struggle with food insecurity.

This resulted in 3,402,077 visits to food shelves in 2017 — the highest number of visits ever recorded. For seven consecutive years, there have been more than three million visits to food shelves in Minnesota, which suggests our state has reached a “new normal”.1 A survey of over 4,000 food shelf clients from across Minnesota shows that 77% of respondents rely on the food shelf at least once a month and 42% already use Supplemental Nutrition Assistance Program (SNAP),2 a federally-funded program that aids millions of low-income individuals and families who are experiencing food insecurity.3 Often, food insecurity is linked to poorer health. Data shows that two out of three food shelf clients report experiencing one or more chronic health issues, 43% report high blood pressure, 33% report high cholesterol and 28% report diabetes.2 Adding to the concern, households experiencing food insecurity experience annual healthcare costs $235 to $1,092 higher than their food-secure counterparts.4 While the Supplemental Nutrition Assistance Program (SNAP) may help mitigate the impact of food insecurity on health,5 there is much to do when it comes to improving availability of and access to healthy foods.

As part of its efforts to understand food insecurity, in 2017 HealthPartners conducted an assessment on 110 patients at Regions Hospital who had been readmitted. One in five of these patients stated they did not follow their recommended 20

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Nicole Bailey, MPH

Gina Houmann, MPH, RDN, LD

nutritional plan and 35% of those said it was because they could not find or afford food.

Recognizing the importance of increasing access to healthy foods to address food insecurity, the health system partnered with University of Minnesota, Valley Outreach and the Food Group to co-found SuperShelf, a project to transform food shelves with increased access to healthy, appealing and culturally appropriate foods.6 Initial results show the program is scalable and can increase access to a variety of healthy and culturally-appropriate foods in food shelves.7 SuperShelf has spread to food shelves across Minnesota and funding from the National Institutes of Health is enabling the organizations to study the public health impact of this important work.

Food Insecurity Screening and Referral in Clinical Settings

In order to address food insecurity in the clinical setting, HealthPartners partnered with Hunger Solutions Minnesota, a

Sarah Johnson, MBA, MPH, RDN, LD

statewide hunger relief organization, to pilot screening and intervention programs in its clinics and hospitals. The health system then adapted Hunger Solutions’ SNAP Rx screening and referral process. During this process, patients are screened for food insecurity using a two-question validated tool called the Hunger Vital Sign.8 Patients are referred to Hunger Solutions which then provides referrals to nearby community food resources like food shelves and meal programs.

Screening

In the outpatient setting, the health system piloted the SNAP Rx program with adults at clinics in Stillwater, Sartell, and St. Paul.

Following established best-practices, patients received the screening questions in written form, usually at check in, then returned the form to rooming staff.9 Patients who screened positive for food insecurity were referred to Hunger Solutions via a fax process.

In an inpatient setting, Regions Hospital built the screening questions into the

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admitting process with the RN asking both screening questions. Care teams integrated much of the process into the electronic health record (EHR) and automated communications when possible.

Referral

After screening, patients who screened positive were referred to Hunger Solutions’ Minnesota Food HelpLine via a faxed referral. The HelpLine contacted patients and connected them with food resources in their local community including local food shelves and SNAP benefits. SNAP Rx reported the outcome of the call to the patients’ healthcare providers, so they knew their patients had been assisted.

Hunger Solutions made two attempts to contact all referred patients and conducted follow-up calls after two weeks to see if they had connected with the appropriate resources, needed any additional clarification, or applied for SNAP. A six week follow-up call was also made for patients who applied to SNAP to determine if they had been accepted into the program and whether they needed help addressing any issues they may have encountered.

Results

During the clinic pilot, which ran from January to September 2017, Hunger Solutions received 80 referrals and contacted 55% of the referred patients. They found

that 44% of patients were eligible for SNAP. In a survey of participating clinic staff and all clinics involved in the pilot, 97% of the respondents agreed that the program was valuable and would recommend program expansion. Clinic staff reported learning more about food insecurity and became more comfortable talking about food insecurity with their patients.

They reported that patients gave positive feedback to the screening and some even thanked them for doing it even if they were not experiencing food insecurity.

During the inpatient pilot, which ran from May to December 2018, 8.2% of the 1,014 patients screened positive for food insecurity. Hunger Solutions received 107 referrals. Additional evaluation is needed to determine whether the referral rate is a result of patient authorization, process, or other issues. Of the 107 referrals, 54% were successfully contacted by Hunger Solutions and 45% of those contacted qualified for SNAP. A summary of the screening, referral and follow-rates is found in Table 1.

Lessons Learned:

The two screening and referral pilot studies revealed the potential for healthcare partnerships with SNAP Rx to provide resources to patients regarding food insecurity and other social determinants of health. The pilot also revealed challenges

# Screened

#/% positive screens

Referrals to Hunger Solutions

Referrals reached on 1st Attempt

Referrals reached on 2nd Attempt

Total/% referrals reached

SNAP Eligible

Clinic/ Outpatient January 2017September 2017

NA

5-6% (Estimated)

80

32

12

44/55%

35

Hospital/ Inpatient May 2018December 2018

12,185 (90.3% of patients)

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Next Steps

Initial results from the SNAP Rx pilot and SuperShelf are promising. The next step is to scale these programs to help connect the 1 in 10 Minnesotans who experience food insecurity with healthy, culturally-familiar food. Meanwhile, it’s paramount that the healthcare industry continue exploring ways to address this issue in the clinic and beyond.

Nicole Bailey, MPH, SNAP Outreach Coordinator, Hunger Solutions Minnesota.

1,014/ 8.22%

107

30

27

57/53%

48*

Table 1: *100% of referrals reached by Hunger Solutions also were screened as qualified by Bridge to Benefits for other resources tied to additional social determinants of health such as housing, income or health care.

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and opportunities to bring screening and referral to scale in the hospital and clinic system including: • Training and communication are critical for successful integration. Stigma about poverty and food insecurity exists among patients and providers which may result in less consistent or accurate screening. Universal patient screening, as well as staff and patient education on food insecurity and social determinants could reduce stigma and increase screening accuracy.

• Closing the loop from patient referral back to providers to share outcomes of calls from the HelpLine is important and helps determine whether the patients were successfully connected to food or other resources.

• Variable workflows, documentation and referral methods make consistent screening and referral difficult to implement and document. Early iterations used an antiquated fax form that created a barrier to successful referrals. A fully-integrated system could improve the process.

• Food insecure clients lack access to fruits, vegetables and other more nutritious foods. Transforming food shelves to improve access to and appeal of healthy foods shows promise.

The Journal of the Twin Cities Medical Society

Gina Houmann, MPH, RDN, LD, Clinical Education Program Manager, HealthPartners Institute.

Sarah Johnson, MBA, MPH, RDN, LD, Clinical Nutrition Manager, HealthPartners Regions Hospital.

References available upon request.

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Serving the Underserved

Accountable Health Communities: Going Beyond the Medical Diagnosis

I

magine needing to get to your scheduled doctor’s appointment to get your medications refilled, but due to unexpected car problems, you have no way to get there. You end up missing your appointment and scrimping on your prescriptions to make them last while you save money for the unanticipated repairs.

Weeks later, you end up in the Emergency Department via ambulance because you have run out of medications.

The scenario is not unique and can be avoided if the right resources are in place.

At Allina Health, providing exceptional medical care is just one aspect of improving health. We believe that understanding our patients and the whole context of their lives is key to delivering excellent care and improving health. We recognize social determinants such as food, housing, and transportation have a significant impact on health, and our research shows it’s important we support our patients’ overall health by also assessing and addressing their health-related social needs.

As part of this commitment, in May 2017, Allina Health was one of 31 organizations nationwide awarded an Accountable Health Communities cooperative agreement with the Centers for Medicare & Medicaid Services. The Accountable Health Communities model is based on a growing body of evidence that shows healthcare providers play an important role in identifying and supporting patients in addressing their barriers to health.

The goal is to test whether systematically screening patients with Medicaid and/or Medicare insurance for health-related social needs and connecting patients to community resources impacts healthcare quality, utilization and costs. Participation in the Accountable Health Communities model has allowed Allina Health to accelerate and scale our efforts to address social determinants of health.

How Does it Work?

Through the Accountable Health Communities model, care teams screen patients with Medicare and/or Medicaid insurance in our 76 primary care clinics, three hospitals and various other clinical care settings for five health-related social needs using a CMS Accountable Health Communities screening tool.

By Eric B. Barth, MD

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The tool screens for needs in the following domains: • housing instability (e.g. homelessness, low housing quality); • food insecurity (e.g. lack of access to food, use of food stamps or other government subsidized food programs; • access to transportation (e.g. lack of reliable transport options); • difficulty paying for heat, electricity or other utilities; and • concerns about interpersonal safety (e.g. intimate partner violence, child abuse, elder abuse).

The screening results are entered into the patient’s electronic medical record. If a patient identifies a need, the care team will provide them a “Community Referral Summary,” an automatically generated list of community resources tailored to the patient’s unique needs produced through a curated resource software called “NowPow,” which is integrated with the Electronic Medical Record (EMR). In addition, patients who also identify they have received care in an emergency room more than two times in the last year are randomized to receive additional assistance navigating to community resources.

All providers within the Allina Health system, can access a version of NowPow that can be used to provide resource information to any patient as part of usual care. A few other health systems locally have also contracted with NowPow to make this tool available to their providers and patients.

Results

In the first six months of implementation (June-December 2018), more than 76,000 Allina Health patients completed screening for health-related social needs through the Accountable Health Communities model. Twenty-five percent of patients screened identified at least one need, with the most frequently identified need being food access (57%) followed by housing instability (44%).

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The Accountable Health Communities model supports Allina Health care team members in caring for their patients. One staff member recently shared this interaction: “A young female patient was having a hard time getting to her medical appointments. With the help of the NowPow [community resource database] system, I was able to refer her to Cars for Neighbors and helped her find the best public transportation options to get her to appointments. I was also able to find her a new food pantry, since the one her family had used previously closed down. This patient is just one of many who have benefitted from this project and also expressed gratitude and excitement about this work.”

Consistently screening and providing support for patients with health-related social needs represents transformational work for Allina Health. In the six-month evaluation survey, 94% of care team member respondents agreed Allina Health should help address patient health-related social needs, and 71% of respondents indicated they believe the Accountable Health Communities model enhances the patient experience.

Another staff member shared this story: “One patient comes to mind…an older male veteran. He was looking for resources to help with utility payments and home repair. I found resources offered in his neighborhood through the NowPow system. He expressed his appreciation

and we agreed to work together on his goals. After a few days, he called me back to confirm that he received the community resources he needed. He found this process helpful.”

The Accountable Health Communities model has changed how we support patients. It is one of the ways we will significantly advance how we interact with patients and community partners.

It has broadened our scope of care and helped us get to know our patients on a deeper level. That builds trust between the patient and care team, leading to better health outcomes.

The Accountable Health Communities model cooperative agreement with the Centers for Medicaid and Medicare Services continues until the spring of 2022. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The project described is supported by Funding Opportunity Number CMS – 1P1-17-001 from the US Department of Health & Human Services, Center for Medicare & Medicaid Services.

Eric B. Barth, MD is board certified in Pediatrics. He completed medical school at the University of Texas Southwestern Medical School and completed a Pediatrics residency at Children’s Medical Center of Dallas. Dr. Barth is affiliated with Mercy Hospital and The Mother Baby Center at Mercy with Children’s Minnesota.

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Sponsored Content

Serving Sexual and Gender Minorities in Health Care Contributed by Carrie Link, MD

The colleagues that inspire me most with their devotion and tireless effort are the clinicians working with underserved populations experiencing health disparities. Like the clinicians developing these programs, I trained not only to be an excellent clinic provider but also to advocate for the disadvantaged in my community and ultimately improve their health. However, as I was regularly seeing patients in my clinic and at my hospital who could be categorized as underserved, I began noticing who wasn’t represented. I began to ask the question: “Who lives in this neighborhood that we are failing to serve?”

By the time I was in practice, I had already developed an interest in providing care for sexual and gender minorities. I coled our GLBT-Med Interest Group in medical school. I joined advocacy groups and completed electives during both medical school and residency. Gender and sexual minorities have been identified by Health and Human Services1 and its Office of Disease Prevention and Health Promotion’s Healthy People 2020 initiative2 as a group deserving increased attention due to the health disparities they disproportionately experience,3 and I was “prepared” to provide medical care 24

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to this specific underserved population. So where were they?

What Is a Sexual or Gender Minority, Anyway?

Sexual minorities are those people whose sexual orientation or behavior is not heterosexual. This includes orientations such as bisexual, lesbian, gay, pansexual, asexual, and queer, among others. Estimates of their prevalence in the population are difficult to determine, as studies often incompletely identify members of these groups. For example, in 2014, the CDC reported that 1.6% of US adults were gay/lesbian and 0.7% were bisexual; however, this study leaves out a large population of people with same-sex behaviors. In 2002, the National Survey of Family Growth reported that 4% of men and 11% of women participated in same-sex sexual activity, greatly increasing the prevalence of likely sexual minorities.7,8 Gender minorities are those people whose gender identity does not match their sex assigned at birth. Gender identity can be defined as one’s internal sense of one’s gender or as Dr. Katie Spencer, a provider with University of Minnesota Health Gender Care and coordinator of Transgender Health Services at the University of Minnesota Program in Human Sexuality, says, “Gender identity is how you feel in your head and your heart.” For example, if you feel female and you were assigned female at birth, you are considered cisgender. Gender minorities include people with identities such as transgender, gender nonbinary, and genderqueer.

Estimates vary, but the reported number of US adults who identify as gender minorities ranges from 0.05-0.58% of the population,

or over one million people.4,5 Prevalence of transgender or gender-questioning youth in Minnesota, according to the MN Student Survey, was 2.7% in 2013.6 What Health Disparities Does This Population Experience?

Health status and care utilization among cisgender vs. transgender youth was studied in a large, population-based study in Minnesota. The youth reported significantly poorer health status, lower rates of preventive health checkups, and more visits to the nurse’s office than their cisgender peers.6 Health disparities experienced by sexual and gender minorities are largely related to the experience of minority stress and discrimination. These are particularly acute for gender minorities who lack more of the civil protections that have been enacted by the LGBT civil rights movement and who experience sociocultural pressures across multiple domains. Where people live, learn, work and play, there are social norms around gender. Even our language is binary (and hence exclusionary). Ever try to greet someone without implying that you know their true gender? You may have to ditch

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the universal “sir” and “ma’am” to do so.

These cumulative, daily stresses have led to a much higher incidence of violence/bullying, substance use, poor mental health, homelessness, education and employment struggles and poor healthcare access/experiences in this population.3 In medical clinics, trans folks can encounter resistance, confusion, and outright harassment when attempting to introduce themselves, use a bathroom, fill out a form, have insurance billed appropriately for their pap smear, or respond to a provider’s inquiry about their inaccurately listed health maintenance triggers. Just imagine: your body doesn’t match your internal gender, and you go to the doctor and fill out a form that implies your gender doesn’t exist, and on top of that, a provider might call you the wrong name and expect to examine your body, too?

No wonder health care feels unsafe to gender nonconforming patients.

Even if a well-trained provider is trans-competent and highly respectful, healthcare systems promote cisnormativity, which can lead to chronic health care underutilization by trans and nonbinary patients and also poorer outcomes. Unfortunately, directly disrespectful care is not rare, and there is a growing literature base documenting the shared negative experiences of trans people when accessing medical care.

For example, in a large national survey, onethird of those who saw a healthcare provider in the past year reported having at least one negative experience related to being transgender, including being refused treatment, verbally harassed, physically or sexually assaulted, or having to teach the provider about trans people in order to get appropriate care.3 The unique problem facing this population is an inability to safely access care, causing a disparity in care utilization. Even seeking or providing health care can trigger harm to the patient. Just presenting an insurance card may “out” a patient as transgender, which may not be safe and could subject them to verbal harassment or physical violence.

generic attempts to improve the situation by putting my name on provider directories and attending community events proved fruitless in increasing the number of my trans or nonbinary patients. I’m here and I want to help, I thought! But these sentiments were and simply are not enough. Finally, I decided to focus on what service means to me: to take my privilege and power and do something about the lack of safe access to health care for our trans and nonbinary community members.

The barriers trans and nonbinary people must overcome to access care can seem insurmountable. The burden, however, is on the providers and the healthcare system to reduce those barriers and improve access to services. Providers must take responsibility to ensure safe access to care as a first step.

We can creatively problem solve the system and take on tasks like establishing inclusive language, respecting pronouns, updating intake forms, and providing gender neutral bathrooms in clinics, in addition to learning the primary care guidelines for transgender and gender-nonbinary people.9,10 At my provider site, Smiley’s Clinic, we take pride in our service to sexual and gender minorities, and we have taken steps to train providers and modify the clinic site and processes to continually improve healthcare delivery (Figure 1).

As we engage in service, our understanding of the healthcare system and the causes of

Service Underserved groups suffer from scarcity of all kinds: resources, access, agency, visibility, and understanding. My medical training did not prepare me for the scarcity of safe access.

How could I utilize newly minted clinical skills when the patients I am trained to work with don’t feel safe to enter the building? My MetroDoctors

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The Journal of the Twin Cities Medical Society

health disparities evolves, and we can continue a cycle of improvement that dives deeper and deeper into the root of the problem.

Health disparities can be addressed through honest introspection, constant attention, and improved visibility of and engagement with the community actually experiencing the disparity. For those of us not experiencing the healthcare disparity, these efforts are key.

We must constantly educate ourselves about the lived experiences of our patients if we are to begin to understand their resilience, strength, and story. As we ask “Who lives in our neighborhood that we are not serving?,” we make patients visible and spaces safer and hopefully continue to improve the experiences of all people in our healthcare system.

Carrie Link, MD, is a University of Minnesota Health physician and Medical Director of the University of Minnesota Medical Center Family Medicine Residency Program at Smiley’s Family Medicine Clinic. She is also part of the University of Minnesota Health Gender Care clinical team. She attended the University of Minnesota Medical School and completed a residency in Family Medicine in 2010, training at Smiley’s Clinic. Dr. Link serves as the Service Learning Longitudinal Project Director and participates in clinical education and research and provides primary care for all ages and all genders.

References available upon request.

Figure 1. Improving the Health Care of Transgender and Gender Nonconforming Patients: Initiatives at Smiley’s Family Medicine Clinic (University of Minnesota Health)* •

• • •

• • • •

Presenting provider lectures about transgender and gender nonconforming patient (TGNC) health care focused on terminology and definitions, barriers to health care, hormonal and surgery options, and data on potential risks with hormone treatments Offering staff trainings on use of preferred names and pronouns throughout clinic visits Creating an accessible TGNC provider care manual developed from existing protocols Providing TGNC patient access to prescriptions for feminizing and masculinizing medications, using an informed consent process that follows WPATH standards of care Providing single-stall, gender-neutral bathrooms throughout the clinic Modifying the electronic medical record so that it shows preferred names and pronouns and includes specific TGNC note templates and order sets Building a referral network for TGNC-related services beyond primary care, including local mental health providers, surgeons, and voice therapists Educating rotating medical students about TGNC primary care

*Adapted from figure in Hinrichs A, Link C, Seaquist L, Ehlinger P, Aldrin S, Pratt R. Transgender and gender nonconforming patient experiences at a family medicine clinic. Acad Med. 2018 Jan;93(1):76-81.

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Embracing Community-based Public Health Advocacy

I

began my public health advocacy fellowship with one goal: to work alongside stakeholders who were advancing the Community Health Worker (CHW) profession in Minnesota. Because Minnesota is viewed as a national leader in CHW policy, I expected the most meaningful avenue to achieve this goal to begin and end at the capitol.

Admittedly, I was wrong. I was wrong to think that the grandeur of passing legislation should precede something so inherent to all of us: the role of our communities.

There are three broad levels of advocacy in health care: patient-level, community-level, and legislative-level.

Advocating for the needs of patients is an essential component of being an effective medical provider. Moreover, the legislative level of advocacy is often viewed as the most heroic and attractive; doctors, nurses, and other healthcare personnel seen testifying in their white coats and scrubs. What I have painstakingly learned in the past several years is that efficient, meaningful, and equitable changes in health care tend to fall outside of the two aforementioned tiers of advocacy. Instead, healthcare providers must become comfortable stepping beyond their clinics, beyond the capitol walls, and into the communities where their patients live, grow, and work.

Advocating for public health is not limited to efforts aimed at increasing vaccine rates or providing radon testing.

By Lucas Zellmer

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While initiatives like these are obviously important, we now understand that meeting some of an individual’s most basic needs can change the trajectory of their health and well-being.

This means that the fight for safe housing, effective transportation, and access to quality education belongs in the same breath as other ‘traditional’ health care and public health causes. Perhaps more importantly, this means that advocating for the social needs of a patient necessitates a fundamental appreciation of how their community and social circumstances affect the decisions that patient may make.

We must also recognize that the status quo of acute, traditional medicine is often counterproductive to the health of patients and their communities. For example, failing to understand why a single mother will not prioritize her child’s medical appointment over her job that provides the child with food and shelter only perpetuates the patient’s medical needs and widens the gap between health care and the community. To think that physicians will suddenly begin ‘prescribing’ bus passes or making home visits a regular part of their practice, despite the well-documented evidence in favor of such interventions, is not realistic. I do think it is reasonable, however, to

The Journal of the Twin Cities Medical Society

understand the consequences of tradition. Traditional health care and health advocacy have recently yielded heightened chronic disease rates, the opioid epidemic, and skyrocketing healthcare costs. Perhaps now, in the face of these mounting healthcare challenges, we will be forced to re-evaluate what it means to advocate for health and well-being.

To advocate is not to push an agenda or promote self-interests; advocating is using one’s privilege, voice, and expertise to fight for the futures of those around you. Healthcare systems are currently faced with a unique task: enhancing the health of patients and populations using interventions that extend beyond the scope of traditional medical practice.

Embracing the importance and potential of advocating at the community-level is a powerful first step.

Lucas Zellmer, Medical Student, Dr. Pete Dehnel Public Health Advocacy Fellow 2018-2019.

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Physicians Serving Physicians

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We welcome you to join us at our confidential monthly meetings which are held by a community of physicians (only) to offer mutual support, education, and discussion of issues that are unique to physicians in recovery.

Confidential Peer Support and Consultation for Individuals & Organizations: 612-362-3747 • www.psp-mn.com

Free Confidential Wellness Resources for Minnesota Physicians & Their Families LifeBridge provides a safe harbor to empower and equip you with the tools you need to take care of yourself as well as your patients.

Minnesota physicians, residents, medical students, and their immediate family members qualify for four free, confidential counseling sessions to address stressors like: • Depression and anxiety • Relationship issues • Loss and grief • Financial concerns In addition to counseling services, LifeBridge offers a comprehensive, web-based resource with a rich library of interactive tools and information about wellness and other everyday life issues.

Physician Wellness Resources: 800-632-7643 and mention PSP • www.psp-mn.com/wellness

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TCMS Annual Celebration May 6, 2019

Board Member Matt Kruse, MD and PSP Executive Director Stephanie Malone.

Right on cue, Board Member Caleb Schultz, MD instructs all attendees to pull out their cell phones and place a call to MN State Senators to pass statewide Tobacco 21 bill.

TCMS President Ryan Greiner, MD served as the Annual Celebration emcee.

Medical Students Bruce Gregoire and Kevin O’Donnell (center) with Drs.Leslie King-Schultz and Board member Caleb Schultz.

Dr. D. Eric Beck and Medical Student/ TCMS Foundation Board member Dip Shukla.

MMA CEO Janet Silversmith and TCMS Past-President Mick Belzer, MD.

Dr. Cora Walsh (L) and Board member Kristen Helvig, MD.

Drs. George Edmonson and TCMS Past-President Anne Murray.

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TCMS President Dr. Ryan Greiner presents the 2018 First a Physician Award to Dr. Nancy Guttormson.

The Journal of the Twin Cities Medical Society

Missy and Dr. Kent Wilson with Drs. John Moore and TCMS Past-President Stuart Cox.

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Environmental Health —

Helping the Most Vulnerable Survive and Thrive in Times of Rapid Climate Change Traditional models of how we care for patients are evolving — as is our knowledge of what factors influence disease. The Minnesota Department of Health Climate and Health Profile provides a comprehensive overview of how changes in our state’s climate impact the health of our patients.1 At the intersection of health care and climate change, the underserved and more vulnerable are facing more frequent and more intense disruptions to their health than others.2 Acute and chronic climate events can have a wide range of impacts on the mental health of these same groups, and should be considered as we try to understand and respond to their healthcare needs.3 By combining population vulnerability indicators (e.g. the elderly, children, homeless, minorities, chronically ill) with

By D. Eric Beck, MD, FACP

historic climate hazard data, a geographic “composite vulnerability” has been developed for those facing extreme heat, air pollution, flooding and other events. In the Minnesota Climate Change and Vulnerability Assessment, the Twin Cities area had a Composite Air Quality Vulnerability Score that was among the highest in the state, showing that groups here suffer higher rates of asthma and COPD than in other counties.2 Most Americans recognize that pollution from fossil fuels is a risk to human health. But the Yale Program on Climate Change Communication showed that many participants in a recent study were not aware of the specific health problems related to air pollution.4 This suggests there is great opportunity for our healthcare community to improve the education we provide to our patients and their caregivers, about how air quality is related to their health and quality of life. Physicians

can lead by supporting efforts to mitigate and adapt to effects of climate change, by helping to educate patients and communities about health risks related to climate change, and by adopting lifestyle changes that increase sustainability and reduce our environmental footprint.

References: 1.

Minnesota Climate and Health Profile Report, MDH 2015. https://www.health.state.mn.us/ communities/environment/climate/docs/mnprofile2015.pdf.

2.

Minnesota Climate Change Vulnerability Assessment Summary, MDH 2019. https://www. health.state.mn.us/communities/environment/ climate/docs/mnclimvulnreport.pdf.

3.

Mental Health and Our Changing Climate: pp.

31-38, 2017. https://ecoamerica.org/wp-content/uploads/2017/03/ea-apa-psychreportweb.pdf.

4.

Yale Program on Climate Change Communication, 14 May 2019. https://climatecommunication.yale.edu/publications/ do-americans-understand-how-air-pollutionfrom-fossil-fuels-harms-health/.

5.

Climate Change and Health: A Position Paper of the American College of Physicians. Ann Intern Med. 2016. https://annals.org/aim/ fullarticle/2513976/climate-change-health-position-paper-american-college-physicians.

TCMS Celebrates First Fellowship Cohort TCMS celebrated the work of our first cohort of medical student participants in the Dr. Pete Dehnel Public Health Advocacy Fellowship at an open house in May. Key lessons learned throughout the year-long fellowship included: • Researching the context of the project/issue, including who is currently working in this space and what past efforts have taken place • Being persistent and flexible • Working in partnership with impacted people and staying human-centered • Staying true to your values and using them to guide your work • Fostering a culture that supports public health initiatives One of this year’s fellows, Lucas 30

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Zellmer, also shared a note reflecting his experience in the program: “Being a Dr. Pete Dehnel Public Health Advocacy Fellow allowed me to appreciate the impact that state and local policy has on medical practice. As a fellow, I formed lasting relationships, contributed to a grassroots movement, and extended my medical education beyond the classroom and into the community.”

TCMS is deeply grateful for Dr. Pete Dehnel and the other physician mentors who made this project possible, and is excited to work with a new group of medical students beginning in September. Next year’s cohort will be working

to address issues including disparities in maternal mortality, advancing healthy eating through agricultural policy, increasing participation in Minnesota’s organ donor program, and expanding syringe exchange programs.

2018-19 Dr. Pete Dehnel Public Health Advocacy Fellowship program participants.

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I n M emoriam DANIEL CONLON, MD, passed away on May 14, 2019. Dr. Conlon was a graduate of the University of Minnesota Medical School and a family physician practicing at the Bloomington Lake Clinic for 37 years.

Dr. Conlon joined the medical society in 1965.

PATRICK DALY, MD, passed away on January 24, 2019. Dr. Daly completed a residency at the University of Minnesota and had a private medical practice in St. Paul.

Dr. Daly joined the medical society in 1974.

BRADLEY JOHNSON, MD, passed away on May 11, 2019. Dr. Johnson received his medical degree from the University of Minnesota. He practiced Family Medicine for over 30 years at the Golden Valley Clinic. Dr. Johnson joined the medical society in 1968.

JOSEPH KISER, MD, passed away on April 11, 2019. He was trained as a general and thoracic surgeon, and was a founder of the Minneapolis Heart Institute and Children’s HeartLink. Dr. Kiser joined the medical society in 1966.

FRANK MORK, MD, passed away on April 6, 2019. Dr. Mork completed his medical training at Creighton University, and practiced as a radiologist at Methodist Hospital in St. Louis Park, MN. Dr. Mork joined the medical society in 1964.

HARDIN OLSON, MD, passed away on April 4, 2019. Dr. Olson attended George Washington Medical School where he trained in Obstetrics and Gynecology. He practiced at North Clinic in Robbinsdale and, after retirement, at the University of Minnesota Medical School. Dr. Olson joined the medical society in 1966.

THOMAS STILLWELL, MD, passed away following a tragic plane accident on May 8, 2019. Dr. Stillwell completed his residency in Urology at the Mayo Clinic and practiced at Minnesota Urology in the Twin Cities. Dr. Stillwell joined the medical society in 1991.

ROBERT WAGNER, MD, passed away on May 18, 2018. Trained at Cornell University Medical College and The New York Hospital, Dr. Wagner practiced Obstetrics and Gynecology at Southdale OB/GYN. He joined the medical society in 1958.

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The Journal of the Twin Cities Medical Society

CAREER OPPORTUNITIES

Please also visit www.metrodoctors.com

Lakeview Clinic has what you are looking for! Join an independent, physicianowned group of 50 providers in the SW Metro.

Be a part of a collaborative work environment in a primary care group of family physicians, internists, pediatricians, general surgeons and OB/GYNs. • 4-day work week with 32 contact hours achieving excellent work/life balance • Excellent compensation with a 2-year partnership track to earn in the top 10% in the state • Outstanding benefits including 100% paid family health insurance and dental insurance, 401K and profit sharing • We have 4 sites in the southwest metro: Chaska, Waconia, Norwood, and Watertown

Due to retirements and growth, we are currently looking for: ◦ Internal Medicine ◦ Pediatrician

CONTACT: administration@lakeviewclinic.com PHONE: 952-442-4461 ext. 7215 WEB: www.lakeviewclinic.com

Join our physician family Practice with us and build lasting relationships with our patients and communities. With 12 hospitals, 56 primary care clinics, 55 specialty clinics, and 40 pharmacies, we are one of the most accessible systems in Minnesota.

Why practice at Fairview?

• Patient-centered organization, striving to own the complexity of care • Competitive benefit and compensation plans • Career development in leadership, committees, Lean, and quality initiatives

Visit fairview.org/careers Email recruit1@fairview.org Call 1-800-842-6469

TTY 612-672-7300 | EEO/AA Employer

July/August 2019

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LUMINARY of Twin Cities Medicine

By Marvin S. Segal, MD

STEVEN VINCENT, MD DEDICATION may be the best single word to describe our current Luminary.

From early beginnings in Plymouth, Michigan, Dr. Steven Vincent was accepted directly from high school by the University of Michigan to a unique combined pre-medical/medical school program which was Family Practice (FP) oriented. The highly compressed six-year curriculum stimulated his interest in geriatrics, maternal and child health, and economic population health.

After graduation, he and his Minnesotan wife-to-be moved to the Twin Cities for his FP residency at Smiley’s Clinic/Fairview-St. Mary’s Hospital. Their South Minneapolis seeds were planted, becoming their family home for many years to come.

How convenient that location would be to the Cedar Riverside neighborhood, home of the People’s Center (PC) — a clinic that has a rich 50-year history — where he biked or walked to work almost daily over much of the next four decades. Steve lived in the neighborhood that he served . . . “I liked the idea of being an integral part of my community.” He first began working at the PC as a bearded and long-haired physician volunteer and retired as its Chief Medical Officer in 2018.

Interspersed with the often part-time work at Cedar Riverside were other local sites where he was able to be engaged as a private practitioner. One of those positions, with the Southside Community Clinic, he chose after passing up a more comfortably lucrative position due to his personal “need” for more meaningful service to those mainly without health insurance and/or significant economic or social resources. Such clinics provided a safety net for that population and Steve dedicated much of his medical career energy and superb clinical skills toward that goal. “I was focused on practicing in the inner city.”

Dr. Vincent also participated in full scale FP, his hospitalized patients utilizing Minneapolis Children’s, North Memorial and Abbott Northwestern — where he also worked evenings and weekends as an emergency room physician for nearly 20 years.

Dr. Steve’s firmest career attachment has been with the PC Clinic and Services of Cedar Riverside. He participated in its maturation as patient volumes increased, more full-time staff was added, and its designation as a Federally Qualified Health Center (FQHC) came about. Concurrently, its patient 32

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population composition underwent notable ethnicity changes as the community moved from a more diverse population in the later 20th century to immigrants of Ethiopian and now mainly East African Somali descent. Throughout this evolution — much of which he modestly admits to presiding over — the good doctor and his clinic, alone and in collaboration with other community clinics, remained dedicated to providing care to those of greatest need. “Helping the underdogs” has always been of importance to him, as he looks forward to today’s political-economic disparities becoming aligned in the interest of improved health care.

Since his recent retirement from the PC, Dr. Vincent has found similar professional gratification — utilizing his talents in caring for veterans in rural VA clinic settings — while continuing to be motivated by his mission of meaningful service to the needy. He is further energized by closeness to his accomplished three children and his community-educator wife.

He may even find more time for his favorite leisure pursuits: baseball, cooking and outdoor activities.

This story of Dr. Vincent emphasizes the fact that our medical profession offers a variety of avenues leading to “just doing good.” One need not have a lengthy bibliography, numerous academic plaques of honored accomplishments or international acclaim to really make a difference.

We are proud to have introduced you to our Luminary and his profound DEDICATION to our community and our profession . . . Steve Vincent has really made a difference.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

6/14/19 12:44 PM

is for cardiology.

University of Minnesota Health Heart Care As leaders in heart care interventions for over 60 years, we make innovative care our mission.

We’ve transformed lives with major breakthroughs in valve replacements, transplants, cardiac resuscitation and other pioneering techniques to treat heart disease. With multiple centers and clinic locations throughout the region, we’re just a heartbeat away.

We see patients six days a week.

Learn more about our expert, innovative care.

Visit MHealth.org/heartcare

University of Minnesota Health is a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. Š201 University of Minnesota Physicians and University of Minnesota Medical Center

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