Minnesota Physician • February 2022 by Minnesota Physician Publishing

MINNESOTA

FEBRUARY 2022

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXV, No. 11

PHYSICIAN Treating Spinal Cord Injuries Developing a new model of care BY LESLIE MORSE, DO

ccording to the Administration for Community Living (ACL), an operating division of the U.S. Department of Health and Human Services, there is an ongoing need for research that can improve services and outcomes for people with spinal cord injury (SCI)–research that can improve health and function, community living and employment. ACL statistics indicate there are approximately 296,000 individuals living with SCI in the United States; the average age of injury is 43.

Tiered Cost-Sharing Health Insurance Is this the Holy Grail? BY BRYAN DOWD, PHD, TYLER BOESE, AND TIM MCDONALD

he affordability of health care and health insurance in the U.S. is a problem that is beginning to affect the middle class, including those enrolled in employer-sponsored health insurance, the Affordable Care Act Exchanges and Medicare. Prior to the COVID-19 pandemic, the average premium for family coverage health insurance in 2019 was approximately 30% of median household income. Employees in high deductible plans face the potential of several thousand more dollars in out-of-pocket spending. Tiered Cost-Sharing Health Insurance to page 104

While SCI remains a low-incidence condition (estimates are that 17,900 individuals acquire new SCI in the United States each year), the ACL notes it has a profound impact on those who survive the initial trauma. In addition, increased survival rates

Treating Spinal Cord Injuries to page 124

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FEBRUARY 2022

Publishing April 2022

Volume XXXV, Number 11

COVER FEATURES Tiered Cost-Sharing Health Insurance

Treating Spinal Cord Injuries

Tiered Cost-Sharing Health Insurance

By Leslie Morse, DO

Developing a new model of care

By Bryan Dowd, PhD, Tyler Boese and Tim McDonald

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Independence is not a business strategy Matt Brandt CEO, Hudson Physicians

OPHTHALMOLOGY..................................................................... 16 Ophthalmology The “That Condition” of Eye Care

By Gary S. Schwartz, MD, MA and Jacob R. Lang, OD, FAAO PAIN MANAGEMENT.................................................................. 18 Neurostimulation for Chronic Pain

CARE TRANSITIONS Improving the safety net

A Rapidly Evolving Therapy

By David Schultz, MD

BACKGROUND AND OBJECTIVES:

DIVERSITY, EQUITY AND INCLUSION............................................ 22 Addressing COVID-19 Vaccine Equity New partnership provides a roadmap for targeting disparities

By Lucas Nesse, JD

When a patient leaves the hospital and returns to an assisted living facility, or home, they experience a care transition. This term is also used when a patient goes from one physician to another. It can also refer to entering rehabilitation programs or treatment of a condition diagnosed by a physician and then transferred to another type of health care provider. As the spectrum of care teams expands, the number and type of care transitions also expands. Cumulatively these transitions are a leading cause of medical malpractice claims, most of which are easily preventable. Our expert panel will define and explain the most common problems in care transitions. We will examine the negative outcomes that arise from these issues and propose simplesystemic solutions. We will discuss best practice standards that have already been established around these concerns, why they are not more widely followed, and how they can be implemented. We will review technology, which in some cases creates problems, that can be used to reduce them.

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Mike Starnes, mstarnes@mppub.com

ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

As we transition to a post-pandemic business world, health care will lead the way in terms of new policies, procedures and readiness. The Minnesota Health Care Roundtable has adjusted to these dynamics. We now invite our readers to participate in this now remote conference process. If you have questions you would like to pose to the panel, or have topics you would like the panel to address, we welcome your input. Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

MINNESOTA PHYSICIAN FEBRUARY 2022

CAPSULES

Kidney Specialists of Minnesota Partners with Evergreen Nephrology Following a growing trend of venture capital investment in independent medical specialty practices, Kidney Specialists of Minnesota (KSM) founded in 1977, with 16 Twin City locations, has announced an affiliation with Evergreen Nephrology. Evergreen investment in KSM will focus on preventative measures in kidney care such as home dialysis and nutrition with a goal of changing a system that focuses on endstage treatment. Dr. Kyle Onan of KSM said he and other doctors have grown disheartened and discouraged by the large amount of spending that still ends in unappealing outcomes. “Over the last few years, we’ve started to move towards care models that focus on better outcomes, as opposed to fee-for-service arrangements,” Onan said. “But we

also realized that even a group of our size needs help to do that, so we sought out a partner that would help us create an infrastructure and give us a backbone to really change the way we see and take care of kidney patients.” KSM CEO Carrie El-Halawani said insurance companies have tried to tell its doctors how to treat their patients. “Under this model it allows the nephrologist to really be at the forefront, because they are the specialists. They are the ones that are seeing and treating these patients every day,” El-Halawani said. Evergreen was launched in August of 2021 by Rubicon Founders with a goal to provide financial backing to take on the increased cost of care associated with value-based care. Adam Boehler is the founder of both Nashville-based companies and worked during the Trump Administration in the Health and Human Services Agency. He drove efforts at the Centers for Medicare

& Medicaid Services (CMS) Innovation Center (CMMI) and the department of Health and Human Services (HHS) to introduce improved kidney care models (KCC) models. Boehler said the nephrology sector is ripe for disruption, because it accounts for 25% of all Medicare spending. “We’re going to try to prevent kidney disease, we’re going to try to do dialysis at home, and we’re going to try to really accelerate transplants.” Boehler added Evergreen’s partnership with KSM and other nephrology practices nationwide is turning the industry around by incentivizing patient care and outcomes. Boehler said. “At the end of the day, healthcare delivery should be physician-driven.”

Sanford Health Expands Virtual Health Care Footprint Sanford Health, one of the largest rural health systems in the country,

serving 1.2 million people across 250,000 square miles recently unveiled plans to expand its 24/7 access to acute and specialty care through The Sanford Virtual Care Center. The center is designed to become a premier training ground attracting retaining and preparing medical students, residents, and nurses for the next generation of care delivery. With the goal of reimagining care delivery in rural America and transform the health care experience for those living in these communities it will bring affordable, comprehensive, and seamless medical care to people, regardless of their zip code. Through a $350 million gift, design is underway for the 60,000 square–foot Sanford Virtual Care Center and five rural hubs, with construction scheduled to begin on the first phase in the spring of 2022. The center will serve communities across the sprawling Sanford service area and beyond through a network

Opening January 2023

Clinic space and practice opportunities available Matt Brandt | 715-531-6862 mbrandt@hudsonphysicians.com

HudsonMedicalCenter

FEBRUARY 2022 MINNESOTA PHYSICIAN

Hudson

CAPSULES

of hospitals and clinics, allowing patients to access health care using the most advanced technology as close to home as possible, with a particular focus on underserved rural areas. Already a pioneer and leader in the field, Sanford Health providers have performed more than 432,000 virtual consults over the last decade — amounting to roughly 18.8 million miles saved by patients who didn’t have to travel great distances on country roads or through harsh winter weather to get top-notch care. This connectivity has the potential to be a game-changer for the senior care industry by connecting to providers at Sanford-related Good Samaritan Society long-term care locations. This expanded access for seniors who have acute care needs or need to see a specialist will reduce emergency room and hospital visits, lower overall health care expenses, and improve care outcomes. Initial projections include more than 350,000 outpatient visits a year to care from home, reaching more than 11 million lives, and extending care to more than 275 rural clinics across the Midwest. The Virtual Care Center and interconnected satellite clinics will also provide opportunities to host medical residents, fellows, and nursing students for virtual rotations, helping to develop the next generation of virtual care clinicians.

MNA Proposes Bedside Act to Address Staffing Crisis The Minnesota Nurses Association (MNA) and Senator Erin Murphy (DFL-St. Paul), Representative Liz Olson (DFL-Duluth), and Senate Minority Leader Melisa López Franzen (DFL-Edina) have introduced the Keeping Nurses at the Bedside Act, a bill to address the hospital short-staffing and retention crisis. Addressing conditions that are driving nurses away from the profession and hurting patient care, the

bill hopes to fix the under-staffing and retention crisis while improving the quality-of-care patients receive at Minnesota hospitals. The bill would set a firm upper limit on the number of patients any one nurse can be responsible for in the State of Minnesota. It would establish committees of nurses and management at Minnesota hospitals to set staffing levels for units at those facilities. At least sixty percent of all members on these committees would be nurses. “Minnesota’s nurses are indispensable, providing care for the critically sick and dying under soul-crushing conditions. The pandemic is illuminating a staffing crisis that existed long before Covid. Nurses have warned us for years about inadequate staffing, and now our system is breaking under the weight of a sustained pandemic. We can’t staff our hospitals with the National Guard forever. We need to retain our nurses,” said Senator Erin Murphy. “We must move this legislation forward as quickly as possible to address the critical situation facing our state.” The bill includes new measures to recruit and retain workers, including $5 million to launch a new student loan forgiveness program for nurses working at the bedside in Minnesota hospitals and another $5 million for grants to hospitals to establish new mental health programs for nurses and other health care professionals. In recent weeks, hundreds of nurses have spoken out about the unsustainable conditions in Minnesota hospitals. “After twelve months of COVID-19, witnessed from a unique perspective as a union steward and chairperson, I knew that I was not keeping myself healthy, that I was dreading going to work, and I was becoming so disgusted by my employer’s treatment of the nurses and disregard for our safety, that I left nursing,” said Jean Forman, RN. “I left with the conclusion that my moral compass no longer aligned with my employer.

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MINNESOTA PHYSICIAN FEBRUARY 2022

CAPSULES

The nursing shortage is due to unsafe conditions that are within the power of our elected officials and hospital CEOs to improve. I firmly believe that. It’s time to respect the viewpoint and voice of nursing. Protect us so that we can protect our patients.”

St. Luke’s Announces New Obstetrics & Gynecology Clinic St. Luke’s Obstetrics & Gynecology Associates recently announced it will be moving to a new $4.5 million clinic. The clinic will relocate from the lower level of Northland Medical Center to the third floor of St. Luke’s Lakeview Building. “We’re moving the clinic just one building away, but it will be a significant change.” said St. Luke’s Co-President CEO & CMO Dr. Nick Van Deelen. “The project will double the size of the clinic to nearly 16,000 square feet, and greatly enhance the patient experience.”

With experienced specialist physicians, midwives and advanced practice clinicians the new space will help maintain the mission of providing compassionate, contemporary, high quality care. This includes serving both high and low risk pregnancies, infertility counseling and a full range of gynecological care. Robotic-assisted surgery is available as are LGBTQ+ services, a spa-like birthing center and a healthy mom safe baby program. “We’re beyond excited to be modernizing our clinic and providing patients with more comfort, privacy and efficiency,” St. Luke’s Director of Women’s & Children’s Services Lori Swanson said. “Not only will it offer patients a great experience, it will allow us to create more access for our patients to get the services they want. We couldn’t ask for a better space for the new clinic.” The new clinic feature larger exam rooms and increase the number

of those exam rooms from 15 to 24. The number of procedure and ultrasound rooms will also increase, it will feature breastfeeding pods for private nursing and private recessed scales. It will also have a larger lab, a designated non-stress testing room and provide patients with a view of Lake Superior. DSGW is providing architectural services and construction will begin this spring. The clinic is projected to open in January 2023.

Mayo Cuts Service to Some Medicare Advantage Patients To address capacity concerns, the Mayo clinic has recently stopped making appointments for patients in Medicare Advantage health plans whose insurers haven’t negotiated contracts for in-network access. Further concerns could involve reimbursement rates between Mayo and non-network insurers, particularly

UnitedHealthcare. Mayo has seen significant increase in patients coming to Rochester with coverage from “non-contract” Medicare Advantage health insurers — so much so, that the increase threatens to crowd out patients covered by in-network insurers. “There was not a change in policy, but a change in enforcement due to ensuring Mayo has access for our contracted plans (not just Medicare) and those who truly need Mayo’s medical expertise,” said a Mayo Clinic public affairs spokesman. “The impact is to non-contract Medicare Advantage plans. Mayo does not have contracts with these plans so there should not have been any expectation of access to the Mayo Clinic by these plans.” Non-contract Medicare Advantage plans are insurance companies who have not negotiated payment rates with Mayo to provide health care services. Between 2019 and 2021,

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FEBRUARY 2022 MINNESOTA PHYSICIAN

Interested in learning more about the state’s Medical Cannabis Program? Sign up for a free symposium for medical professionals on April 7-8 (3 CME hours available). For details, go to https://bit.ly/CannabisCME.

OFFICE OF MEDICAL CANNABIS

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April Concerts

THOMAS SØNDERGÅRD

rehabilitation, spine, and sports and orthopedics. “I look forward to forming additional partnerships that allow us to build upon the exceptional work at Allina Health and explore more research opportunities,” said Dr. Konety. “Medical research is an integral piece in our mission to improve the well-being of those we serve. What we learn through research impacts how we care for our patients, the treatments we use and the way our patients are able to live their lives both day-today and long term. Medical research provides the knowledge and insight to become better health care providers so we can continually enhance care for our communities.” Dr. Konety came to Allina Health in October 2021 from the Rush University System for Health in Chicago where he served as The Henry P. Russe, Dean and Senior Vice President for Clinical Affairs. He is a urologic surgeon and previously had served as the Associate Dean of Strategy and Innovation at the University of Minnesota Medical School.

KEVIN JOHN EDUSEI

the number of Minnesota patients coming to Mayo with coverage from non-contract Medicare Advantage insurers nearly doubled — reaching 3,200 patients last year. During that same two-year period, Mayo also saw a 42% increase in out-of-state patients with non-contract Medicare plans, last year exceeding 7,000 patients. At least half of that increase came from seniors with UnitedHealthcare coverage. Non-contract Medicare Advantage plans usually reimburse the hospital at a lower rate than contracted plans. Among the state’s largest Medicare Advantage insurers, Mayo Clinic is out-of-network at UnitedHealthcare, HealthPartners and Allina Health Aetna. As of January, more than 111,000 beneficiaries in Minnesota were enrolled in Medicare health plans offered by those three insurers. Mayo is in-network for Medicare Advantage plans from Blue Cross and Blue Shield of Minnesota, Humana, Medica and UCare.

SHOSTAKOVICH, MOUSSA AND RAVEL APR 7–8 Kevin John Edusei, conductor Ning Feng, violin

SYMPHONY IN 60: SØNDERGÅRD CONDUCTS LA MER APR 13 Thomas Søndergård, conductor

Allina Health Names Chief MDH launches System Research Officer Badrinath Konety, MD, was recently Naloxone Finder In an ongoing effort to prevent drug overdose deaths, the Minnesota Department of Health (MDH) is making it easier to get the potentially life-saving medication naloxone to people who need it by launching a digital map of where it can be found in nearby. People can access the Naloxone Finder map online, type in a zip code or address, filter by distance, and the map will display pharmacies, naloxone access points, and syringe service programs that typically have naloxone in the area chosen. The Naloxone Finder tool provides contact information, address, and other guidance so one can confirm with the sites whether it currently has naloxone available. Naloxone, also known as Narcan®, is a potentially lifesaving drug that can reverse an opioid overdose. Since the map’s launch in December, more than 4,600 visitors have accessed it.

STAR WARS IN CONCERT: RETURN OF THE JEDI WITH THE MINNESOTA ORCHESTRA APR 21–24 The Movies & Music series is presented by

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announced as Chief System Research Officer. This new role is in addition to his current role as President of the Allina Health Cancer Institute. “This position links research with all clinical activities, and I’m excited to see Dr. Konety’s vast experience and knowledge build upon the tremendous, life-saving research connected with the Allina Health name,” said Hsieng Su, MD, Allina Health senior vice president and chief medical executive. “This head of research role is a perfect fit for Dr. Konety who has more than a decade of health care leadership experience and is a well-published researcher.” Continuing the mission to advance studies and research that improve patient outcomes, refine models of health care delivery and enhance population health, Allina Health has conducted more than 600 research studies in the areas of cancer, cardiovascular, care delivery, infectious disease, neuroscience, nursing,

SUNWOOK KIM PLAYS BRAHMS APR 28–30 Gemma New, conductor Sunwook Kim, piano

F R E E T I C K E T S F O R H E A LT H C A R E W O R K E R S Visit minnesotaorchestra.org/health-professionals to learn more.

minnesotaorchestra.org | 612-371-5656 All artists, programs, dates and prices subject to change. PHOTOS Edusei: Marco Borggreve; Søndergård: Martin Bubandt; New: Roy Cox. Star Wars © 2022 & TM Lucasfilm Ltd. All Rights Reserved © Disney.

MINNESOTA PHYSICIAN FEBRUARY 2022

INTERVIEW

Independence is not a business strategy Matt Brandt, CEO of Hudson Physicians

At a time when primary care is increasingly

success due patient demand far outpacing a supply of providers and no matter the model we end up rationing the care we can provide via triaging, long waits, or quick fix treatment.

consolidated, it seems like Hudson Physicians is becoming increasingly independent. What can you share about the dynamics involved with this process?

After your experiences leading Multicare Associates, a large independent primary care practice which became part of a larger system, what strategies could other practices consider to ensure young

What are some of things you have found to be successful in dealing with the pandemic?

There “...” are many different models and methods available to create partnerships.

“...”

There are a couple things that have shaped Hudson Physicians business strategy. The first is St. Croix County is the fastest growing and highest average per capita income county in Wisconsin. The working family demographics of the area lend themselves well to a multispecialty primary care group. The second is the continued expansion of outpatient services. This creates opportunities to develop ancillary business lines such as home sleep studies, imaging centers, surgery centers, infusion centers, hearing aid dispensing, etc. The last item is the changing of the hospital from a community hospital to a large integrated system hospital. HealthPartners purchased the hospital from the local municipalities and over the course of time has switched to a more hub and spoke model with Regions (St. Paul) and Lakeview (Stillwater) being the hub and Hudson more as a spoke. This strategy diverges from Hudson Physicians strategy with our desire to grow and offer more local services and specialties.

Be there for the patients. During the pandemic many healthcare providers constricted the hours, sites, and services they offered or put more barriers in place before patients can be seen. I understand why some of these things were done early in the pandemic but many groups where slow to adjust back to patient demand. In my mind one of the best things a practice can do is be there for the patients when and where they need care. If you are not available patients will find others who are. Hudson is one the fastest growing areas in our region. What challenges does this pose as you look ahead to meeting the increasing needs for care?

hospital it would make more business sense to partner with the hospital in some way. The good news is there are many different models and methods available to create partnerships and maintain some level of independence. There are also different partners available beyond just the hospital, it could be independent practice associations, insurance carriers, or private equity, etc.

Yes a practice in a growing market is a good thing but that is only if you can keep up with it. As mentioned above if we can’t continue to hire additional physicians, staff etc., then patients will find someone else to meet their care needs. This creates an opportunity for competitors to enter the market.

How do you incorporate behavioral and

What can you tell us about how this project

You’ve begun construction on a new facility.

mental health care into the services you

got started and what it will entail?

this practice option?

provide and how has this been helpful to

An experienced healthcare leader once told me, “A desire for a physician group to be independent is not a business strategy.” My experience has taught me this is a true statement and if physicians desire to remain independent they must think strategically about whether a physician owned practice is a viable business model and be flexible on how to achieve “independence.” As mentioned above Hudson Physicians has some market dynamics that create an ideal situation for a private practice, however if we were in a more rural environment with a high government payer mix and a small community

Behavioral and mental health care is a large part of what primary care does and I think we are good at meeting those first level needs such as treating ADHD and depression however where the barrier exists is those more complex patients when the primary care physician needs to work with an expert to help with diagnosis and treatment. Over the years we have tried imbedding mental health providers in the clinic, creating a “hotline” for doctors to connect on complex patients, and numerous other programs. All have had limited

Hudson Physicians started doing some strategic planning in 2019 to project the number of doctors needed to care for the Hudson area if it continues to grow at its current pace. First we determined our minimum space needs for the next 15 years. Then we started to explore possible options, including expanding in our current location on the hospital campus. However, the hospital was unable to provide us with adequate expansion space and we started to explore nearby locations. We wanted to stay close to the intersection of I-94 and Carmichael Road. After exploring several locations, we decided to purchase 16 acres just northeast of

independent-minded physicians will retain

FEBRUARY 2022 MINNESOTA PHYSICIAN

your patients?

the intersection. The raw land allowed us the flexibility to develop exactly what we wanted. We are currently constructing the 160,000 square foot Hudson Medical Center, which will include 77,000 square feet of clinic space for Hudson Physicians primary, specialty, and urgent care clinics. Hudson Physicians is working with specialty partners Associated Eye and Twin Cities Orthopedics who are also leasing space in the building to develop an Imaging Center, Surgery Center and Physical Therapy/Rehabilitation unit. What kinds of new partnerships do you think will be necessary to provide the

via telemedicine. Most patient visits involve additional diagnostics such as lab or imaging, so patient demand for telemedicine visits has not been high since patients need to visit the clinic anyway. The area telemedicine has helped is with follow up visits. Patients and physicians like the ability to schedule a follow up telemedicine visit for things like medication checks or mental health visits. In the past these were often not done or reliant solely on the patient if something was not going well to follow up. If you could fix three things about how health care delivery works today, what would they be?

best care to your patients?

how you provide care?

1. Technology – in general healthcare IT systems are still behind the times and in many cases are creating more work i.e., we basically have transitioned to electronic paperwork. My hope is the next evolution of EMR and healthcare software is able to help with better patient engagements, allow physicians to focus more on patients, and offer all this up in real time.

Telemedicine has not greatly impacted Hudson Physicians. Less than 5% of our visits are performed

2. Focus spending on patient care – I am a healthcare administrator, so I

Hudson Physicians core business is primary care so partnerships with specialty clinics is what we are focusing on. We are looking for groups committed to practicing and building a practice in the Hudson area making this a hub or key market not just simply an outreach site. What impact has telemedicine had on

understand I do not personally see patients and am I technically overhead. Commenting on this is probably a little bit ironic but the longer I work in this field the more I realize how much money is being spent managing the overly complex administrative burden of our current healthcare system that could and should be invested into direct patient care. 3. Increase healthcare spend on primary care – to improve quality and lower the cost of care we must shift from an episodic sick care approach to one that is more comprehensive and preventative. The easiest way to accomplish this is to increase access to and the utilization of primary care. Matt Brandt, is the CEO of Hudson Physicians. Prior to this position the served as the CEO of Multicare Associates and has held other executive level positions in Twin City area practices.

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3Tiered Cost-Sharing Health Insurance from cover At the same time, numerous studies have shown there is wide variation in both providers’ (hospitals’ and physicians’) prices and practice styles (quantities of prescribed services) within the same market area, including low value and wasteful care, and there is little evidence to suggest that price and quality of care are related. Given the conjunction of affordability problems, wide variation in the cost of care and lack of correspondence between cost and quality of care, it might seem obvious that the solution would be to tell patients where to find lower cost care and share the savings with patients who choose lower cost providers. Yet that is not the approach taken by the vast majority of employers. Instead, employees are placed in high deductible health plans, often with little information to help them find lower cost care. As a result, employees tend to cut back on both high and low value services. Employees are left to shop for each individual service, with no single entity responsible for care coordination or total cost of care.

Health care reform initiatives At the federal level, many health care reform initiatives focus on provider payment, including capitation, bundled payments, shared savings, fee withholds, global budgets and accountable care organizations with downside risk. These initiatives generally are invisible to the consumers, and the results thus far have been lackluster at best. Another class of health insurance benefit designs, including reference pricing and tiered cost-sharing, take a very different approach. These

initiatives simply examine the variation in providers’ historic prices and practice styles and pass that information on to employees in the form of varying out-of-pocket costs. Those approaches give employees the information they need to identify lower cost providers, and employees who choose lower cost providers share the savings. The opportunity to gain patients simultaneously gives providers an incentive to lower their costs. None of these approaches to health care reform are a “holy grail” that will provide a painless pathway to affordable, high quality health care services. However, our analyses have convinced us that tiered cost-sharing represents an improvement over many current reform proposals and health insurance benefit designs and that it has features both patients and physicians might find appealing. Interestingly, Minnesota is home to one of the nation’s longest, most comprehensive and most fully developed examples of tiered cost-sharing.

State Employee Group Insurance Program (SEGIP) The State of Minnesota is the largest employer in the state and has been using a tiered cost-sharing health insurance benefit design to cover its 130,000 employees and dependents since 2002. That program is referred to as the State Employee Group Insurance Program, or SEGIP. The SEGIP system creates a different set of incentives than the health insurance benefit designs medical practices typically face in the current market. The SEGIP system has a strong orientation towards primary care. During the November open enrollment period each year, state employees choose from one of three health plans and designate primary care clinics for themselves and their family members for the coming calendar year. Employees with dependent coverage can choose a different clinic for each family member, but all family members must choose clinics covered by the same health plan. Employees are required to receive most of their care through their primary care clinic or a referred provider. The primary care clinic is held responsible for the employee’s total annual risk-adjusted cost of care, but because they help direct patients to specialists and hospitals, they also can influence total cost of care. Based on their total annual risk-adjusted per-capita cost of care over the previous two years, each clinic is placed into one of four cost-sharing tiers. Premiums are held constant across the tiers and health plans, but the tiers vary by deductibles, copayments and the patient’s maximum annual out-ofpocket cost. Patients choosing clinics with higher risk-adjusted total cost face higher cost-sharing. The differences in cost-sharing across the tiers are substantial. For example, the family coverage deductible ranges from $500 in Tier 1 (the lowest cost tier) to $3,000 in Tier 4 (the highest cost tier). Office visit copayments range from $30 in Tier 1 to $90 in Tier 4, and maximum annual out-of-pocket spending limits for family coverage range from $3,400 to $7,200, excluding prescription drugs. Over 80% of SEGIP members choose clinics in the lower two costsharing tiers. The threat of losing patients to lower cost clinics provides a strong incentive for primary care clinics to reduce the total cost of care. Once clinics are told their initial tier assignment, they are given the opportunity to discount their fees in order to remain in their current tier or move to a more desirable tier. Approximately 25% of the clinics currently operate under negotiated price discounts, generally in the 10%-20% range.

FEBRUARY 2022 MINNESOTA PHYSICIAN

Several features of the SEGIP system would be of interest to physicians. First, patients in the SEGIP system receive a clear signal regarding each primary care clinic’s total cost of care and a strong financial incentive to choose lower cost clinics. Thus, higher cost primary care clinics need to consider the possibility that patients will switch to a lower cost clinic. That’s not true in payment systems like bundled payments and shared savings that are invisible to the patient. Second, the SEGIP system introduces an element of uncertainty for individual clinics. A clinic’s tier is determined by its relative position on the distribution of clinics’ total cost. Therefore, a clinic’s tier assignment can change even if it makes no changes in its prices or practice style if the prices or practice styles of other clinics change.

avoidable use of health care services. Small independent primary care practices may have fewer resources to collect and process that information than clinics that are part of larger health care systems.

A potential advantage of tiered cost-sharing for physicians is the wide latitude offered to health care providers in setting their prices and practice styles. The SEGIP system includes virtually every hospital and clinic in the State, and there are no in-network versus out-of-network providers determined by the health plans. Currently, health care providers in the SEGIP system are subject to the medical policy Employees who choose lower cost and utilization management programs employed by providers share the savings. the three participating health plans. But in theory, health care providers in a tiered cost-sharing system could set their prices and practice styles at any level they like, while recognizing that decisions resulting in higher cost might result in their patients switching to lower cost clinics.

Third, the SEGIP system could affect referrals from primary care clinics to specialists and hospitals. Primary care clinics are responsible for total cost of care, of which specialists’ and hospitals’ prices and practice styles are an important component. As a result, primary care clinics may take a greater interest in their referral patterns. Independent primary care clinics may have more discretion over their referral patterns than primary care clinics owned by an integrated delivery system.

Fourth, if reducing the total cost of care becomes an important part of remaining competitive in the market for health care services, then primary care clinics may need help identifying low value care and ways to reduce

SEGIP is working to improve the information that State employees have when selecting their primary care clinic by distributing information on clinics’ tiers and quality of care directly to State employees through emails. That information is tailored to the clinics most frequently chosen by employees based on their zip code of residence. The emails highlight those clinics that are moving up or down a tier for the coming Tiered Cost-Sharing Health Insurance to page 304

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3Treating Spinal Cord Injuries from cover

length of hospital stay averaged about 18 days. Diseases of the genitourinary system are the leading cause of rehospitalization, followed by diseases of and aging of individuals with SCI have created the need for new researchthe skin. Respiratory, digestive, circulatory and musculoskeletal diseases based information to improve clinical services, community support and are also common causes of rehospitalization. Despite improving mortality a wide variety of outcomes for this population. rates, individuals with SCI continue to be at The relatively low incidence of SCI increases the increased risk of experiencing acute and long-term need for collaboration that involves investigators health complications, including secondary health with the necessary expertise and combines the conditions. Pain is a leading secondary complication number of research participants who are available after SCI and may significantly affect functional for testing interventions and for achieving other ability and independence, psychological well-being, We view disability as an rigorous research aims and approaches. ability to return to work and quality of life. important aspect of diversity.

Hospitalization and rehospitalization Even though lengths of stay in hospitals (11 days) and acute care units (31 days) have declined recently, these injuries place a significant burden on the health care system, the patients and their families. The financial burden depends on the SCI itself and the age at which it occurs. Estimated lifetime costs of treating the injury range from $1.2 million to $5.1 million in 2019 dollars (these estimates do not include any indirect costs such as losses in wages, fringe benefits and productivity). The average yearly expenses (health care costs and living expenses) and the estimated lifetime costs that are directly attributable to SCI vary greatly based on education, neurological impairment and pre-injury employment history. Since 2015, about 30% of persons with SCI were rehospitalized one or more times during any given year following injury. Among those rehospitalized, the

SCI Research To improve the lives of those with SCI and to reduce the overall burden on the health care system from these injuries, the University of Minnesota’s Department of Rehabilitation Medicine led the process of receiving funding from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), in partnership with regional health care experts, researchers and consultants who have SCI (lived experience). As a result, we were one of 14 recipients in the U.S. that received $2.2 million over five years to improve patient care, research SCI and broadly share our findings. The research will be done under the auspices of a Minnesota Spinal Cord Injury Center of Excellence; patient care will be managed under the Minnesota Regional Spinal Cord Injury Model System (MN Regional SCIMS). In addition to the NIDILRR grant, our work is partially funded by the University of Minnesota (U of M) Medical School, the U of M Department of Rehabilitation Medicine and Regions Hospital. We also have the support of local and national community and consumer advocacy organizations.

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The MN Regional SCIMS is a multidisciplinary continuum of care for people with SCI, including the following services: emergency medical, acute care, acute rehabilitation and post-acute care. We will serve individuals with traumatic SCI in Minnesota, North Dakota, South Dakota, Iowa, Wisconsin and Northern Michigan. Our catchment area serves a wide geographic region of medically underserved areas. Therefore, a model system gives us the opportunity to meet the needs of this population and add diversity to the national SCI database. The system of care —and our research— will be built on a foundation of diversity, equity and inclusion. We welcome and value the voices and perspectives from all individuals with intersecting identities and lived experiences, and we believe those diverse perspectives significantly contribute to excellence in medicine and rehabilitation. We view disability as an important aspect of diversity and are committed to providing equitable access to resources for all employees, students and research participants. To better serve diverse populations, we have assembled a leadership team that is representative of women (65%), people of color (29%) and individuals from other traditionally underrepresented groups, such as those with physical disabilities (18%). Our core model system activities, including clinical care and research, are focused on improving health and function after SCI and reducing or mitigating secondary health complications. Acute care rehabilitation services and ongoing health maintenance are essential for preventing and managing

these complications. Care will be provided by the world-renowned resources of Courage Kenny Rehabilitation Institute (CKRI), Mayo Clinic, Regions Hospital and the University of Minnesota/M Health Fairview. Collectively, we provide the following services: • Trauma care. • Inpatient rehabilitation. • Outpatient care. • Health and wellness programs. • Adaptive fitness and activity-based therapy. • Vocational rehabilitation. • State-of-the-art technology, such as neuromodulation, noninvasive magnetic stimulation, robotic devices and electrical stimulation, to support independent living.

Administration and collaboration

Research projects Our research efforts are aligned with NIDILRR’s long-range plan focus area of health and function, which is aimed at developing an evidence base for interventions that maximize the independence of people with disabilities. Consistent with that agenda, the MN Regional SCIMS’s research activities focus on maintaining health, minimizing hospitalizations and maximizing community living outcomes. Our team collaborates with local, national and international members of the SCI research community in many ways, including serving on society committees, advisory boards, journal editorial boards and various SCI-specific research groups. One of our initial research projects will focus on identifying an effective pharmacological treatment for severe neuropathic pain in SCI–a primary issue affecting quality of life. Identification of an oral medication that is effective, safe and well tolerated would represent a major improvement in the clinical approach to this kind of neuropathic pain. Part of our research will be to identify and validate predictive biomarkers of neuropathic pain after SCI and response to pharmacological therapy. This work is innovative as it seeks to develop a new, mechanism-based pharmacological intervention for neuropathic pain in SCI.

Treating Spinal Cord Injuries to page 144

Transforming Healthcare

Our Executive Committee, led by myself and Dr. Kimberley Monden (UMN), oversees all project activities, including dissemination and implementation. The committee is comprised of the project directors, directors of clinical care, directors of research and representatives from the Community Engagement Committee, which includes individuals with lived experience, and leaders of SCI community organizations. Each member of this committee serves as a direct link to their site leadership and staff. We will include a rotating presence of individuals with lived experience from our Community Engagement Committee to ensure diverse perspectives from the

SCI community. This committee meets quarterly to monitor progress toward project goals. Other committees include the Clinical Care Committee, the Data Management and Analysis Committee and the Research Committee.

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3Treating Spinal Cord Injuries from page 13

Dissemination of information

Enabling valuable research findings to be used in the field requires a strategic Another initial research project seeks to answer the question: Is meeting the approach to dissemination rather than simply making stakeholders aware SCI physical activity guidelines associated with health-related and psychosocial of the information. To effectively convey information, it is necessary to outcomes? Since the development of the guidelines in 2011 and their make the information accessible for end-users refinement in 2018, no study has yet to demonstrate and to ensure the information and dissemination the health benefits of meeting the SCI physical strategies fit the target audience’s needs. This is activity guidelines versus not meeting them. To achieved by direct involvement of stakeholders in address this question, we will conduct a multi-site, planning and implementing these strategies. cross-sectional observational study with the primary Pain is a leading secondary We will use Integrated Knowledge Translation goal of determining whether SCI physical activity complication after SCI. (IKT) guiding principles to ensure that our guidelines are associated with improved healthpartnership with the community is relevant, useful related and psychosocial outcomes. While crossand avoids tokenism. These principles were developed sectional in nature, the findings from this study will by a multidisciplinary group of SCI researchers, be used to design future clinical trials testing the clinicians, people with SCI, representatives from SCI health benefits of meeting these guidelines. community organizations and funding agencies. As a model system, we will also collect high-quality, representative They recommend that partners: longitudinal data that will increase the racial, ethnic and socio-economic • Develop and maintain relationships based on trust, respect, dignity diversity of the National Spinal Cord Injury database. This database is and transparency. hosted by the University of Alabama at Birmingham, the source of all the SCI data cited in this article. We will also advance a robust research portfolio • Share in decision making. focused on increasing the health and well-being of individuals with SCI. To • Foster open, honest and responsive communication. ensure that our research findings are widely available, we will implement a • Recognize, value and share their diverse expertise and knowledge. multi-year dissemination plan to share our clinical expertise and scientific • Maintain flexibility and be receptive. results with multiple audiences, e.g., clinicians, researchers, individuals with lived experience, advocates, payors, and policymakers.

• Meaningfully benefit by participating in the partnership. • Address ethical concerns. • Respect the practical considerations and financial constraints of all partners. Using the IKT guiding principles will ensure meaningful engagement of the right research users at the right time throughout the SCI research process. Our dissemination activities will be planned and executed by both our Executive Committee and Stakeholder Engagement Committee. Our dissemination vision is focused on multiple media through which we can best communicate appropriately tailored information with all our target audiences. We have included both a media/marketing specialist and medical writer in our dissemination strategy to ensure our communications are of high quality.

Conclusion

We expect the Minnesota Spinal Cord Injury Center of Excellence and the Minnesota Regional Spinal Cord Injury Model System to catalyze SCI work across Minnesota. It is the first step toward bringing together all these outstanding resources and expertise to operate as a team. It’s the way we will help improve outcomes for people with SCI. We welcome your participation and collaboration.

CMY

Leslie Morse, DO, is a physiastrist, department head, professor of rehabilitation and co-project director of the Minnesota Regional Spinal Cord Injury Model System Center. She also works with the U of M Medical School and M Health Fairview.

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OPHTHALMOLOGY

Dry Eye Disease The “That Condition” of Eye Care BY GARY S. SCHWARTZ, MD, MA, AND JACOB R. LANG, OD, FAAO

ne, thing that most medical specialties have in common with one another is they each have their version of That Condition (TC). Regardless of what type of doctor you are, you know what we are talking about. TC is that niggling condition that patients and doctors usually define by symptoms, rather than by disease entity. The symptoms can be chronic or acute, constant or intermittent, stable or progressive, and although they are usually neither life- nor sight-threatening, they are often significant enough to affect patients’ daily activities and quality of life. TC is usually multifactorial with many internal and external influences. It is difficult to both diagnose accurately and treat completely, and for these reasons, patients tend to hop from doctor to doctor in search of a cure. Almost every medical specialty will have their version of TC. For gastroenterologists, it is belly pain; for neurologists, it is headache; for dermatologists, it is itchiness; for gerontologists, it is dizziness; for many specialties, it is low back pain. In eye care, it is dry eye. As seen with other specialties’ versions of TC, dry eye is chronic, multifactorial, difficult to both diagnose properly, treat fully, and typically not life-threatening.

When we were in training twenty years ago (for JRL) and more (for GSS), research on Dry Eye Disease (DED) was scant. There were very few in-office tests at that time, and of those that were available, few were accurate, reproducible or frankly useful. Treatments were limited to over-the-counter lubricating eye drops, punctal occlusion, eye masks, room humidifiers and the advice to spend winter in a more humid area than Minnesota. Tropical areas, such as Hawaii and Florida, were recommended; the deserts and mountains of the American West were to be avoided. Despite our best efforts, the majority of patients did not see real improvement, and most continued to doctor-shop, hoping to find someone who could understand their problem enough to heal them. Out of all this demand was born the DED specialty. Although the optometry schools and medical school departments of ophthalmology have had important roles in the development of this specialty, for-profit therapeutics and device companies have taken the lead in much of the progress. And they are smart to lead this effort because DED affects an estimated 30 million Americans. It is also one of those chronic conditions that that gets worse with age. As the population ages, more people suffer from DED, with each individual suffering more with each passing year. Here is a brief look at the developments in diagnosis and therapy over the last 25 years.

Diagnosis The first step in curing patients of a condition is gaining an understanding of it. For DED, this means understanding what normal tears look like and how they differ from abnormal ones. DED is typically caused by more than just a decrease in the volume of tears, and so the name of the specialty is an unfortunate misnomer. Tear Film Dysfunction would be a better name, but DED is easier to market and for patients to grasp; it is therefore here to stay. In keeping with the early misunderstanding that all DED was caused by the eyes’ failure to make enough tears, most of the available tests from 20-30 years ago merely measured the volume of tears that a patient produced. The following analogy points out the problem with this system: managing a patient’s tear film problem by measuring only their tear volume is akin to managing a patient’s blood dyscrasia by measuring only their hematocrit. We eventually realized that tear volume was not always consistent with patients’ symptoms or examination findings. For example, many DED patients complain of watery eyes. Once we knew there had to be something else at play, it was only a matter of time before we figured out what that was. If the problem cannot always be attributed to the quantity of tears, it must often be attributed to their quality. Researchers looked at what constituted normal tears and discovered a rich combination of water, salts, organic molecules, e.g., hormones and enzymes, mucin, lipid, cells, e.g., inflammatory, bacteria, and other materials. They then looked at the tears from patients who were diagnosed with DED and found that different patients had abnormal amounts of any or all of what is normally found. Based on these observations, different tests have been marketed in an effort to identify the source of any patient’s problem.

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One type of in-office test looks at the concentration of materials that are dissolved in the tears, the tear osmolality. The thinking here is that having a higher concentration of solutes in the tears is an indication that there is not enough solvent (in this case, water). Developed in 2007, the TearLab® is an example of a desktop device that can measure a patient’s tear osmolality within just a few seconds. Knowing a patient’s osmolality was one of the first reproducible tests that allowed eye doctors to confidentially diagnose a patient with DED. Other tests, such as LipiView®, look at the DED affects 30 million lipid component of tears. It not only images the lipid producing glands (Meibomian glands); it also measures the thickness of the tear’s lipid layer and how it varies from blink to blink. The understanding is that a layer of lipid on the anterior surface of the tear film acts like a tablespoon or two of olive oil on top of a boiling pot of pasta–it smooths and quiets the surface. The problem with the lipids we tend to develop as we age is not the amount we make, but a problem with viscosity. This problem goes hand in hand with what is seen with lipids in other parts of the body, and the Western diet probably contributes to this in addition to aging. More highly viscous lipids in tears have a consistency more similar to butter than olive oil and disrupt the surface of the tears instead of quieting it. Knowing how a patient’s lipids contribute to their DED is an important weapon in the Dry Eye specialist’s arsenal. Another in-office test measures the inflammatory components dissolved in a patient’s tears. InflammaDry® is a small, disposable device that resembles an OTC urine pregnancy test or at-home COVID-19 test. By touching the tip of the device to a patient’s tear film, the Dry Eye specialist can determine whether a patient has an overabundance of inflammatory mediators, specifically MMP-9, contributing to their symptoms. If this is the case, the clinician will be more likely to tailor their treatment plan to include anti-inflammatory medications.

The birth of a new specialty As has been seen historically in all fields of medicine, the development of more diagnostic and therapeutic opportunities have led to greater complexity and need for sub-specialization, and that is exactly what is happening with regard to DED. The typical eye doctor will see a handful of patients each day with some level of complaints related to DED. It may be a 70-year-old who comes in for a cataract check and says, “My eyes get tired at the end of the day while I’m reading.” Another could be a 52-year-old accountant who says, “I an estimated have difficulty seeing spreadsheets by mid-day Americans. because everything gets fuzzy.” Another could be a rheumatoid arthritis patient who says, “My eyes feel scratchy and irritated from when I wake up in the morning until I go to bed at night.” Each of these patients is probably experiencing DED, and as stated above, their problems are usually neither life- nor sight-threatening. For each treatment, success will depend on a combination of factors: • The patient’s ability to explain the effect of their problem on their daily functioning. • The time, money and energy they want to invest in treating the problem. • The doctor’s level of expertise, interest, patience and time. • Any other of a myriad of components. Dry Eye Disease to page 264

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Treatment As our ability to diagnosis DED has expanded, so has our ability to treat it. For patients with a decrease in the volume of their tears (aqueous deficiency), there are medicines and devices designed to increase that volume. Long-term medical therapies such as topical cyclosporine and lifitegrast eyedrops have been shown to increase tear volume by decreasing inflammation. Shortacting strategies that involve stimulating the nerve centers that control lacrimation include varenicline nasal spray (Tyrvaya™). Eyelid punctal occlusion can also increase the volume of tears on the surface of the eye by blocking the route of egress; choices here include dissolvable or permanent punctal plugs or permanent closure of the punctum by handheld cautery. Treatments have also been developed for those patients whose DED is primarily due to the lipid dysfunction of their tears. Oral omega-3 fatty acid supplements have been used to help patients make less viscous lipids, more similar to those they produced years or decades earlier. Devices such as LipiFlow® and Intense Pulsed Light treatments can help patients clean out those eyelid sebaceous glands that are clogged with abnormally viscous oils, allowing them to be replaced with newer, thinner, more olive oil-like secretions.

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PAIN MANAGEMENT

Neurostimulation for Chronic Pain A Rapidly Evolving Therapy BY DAVID SCHULTZ, MD

lectrical stimulation has a long history of being used in medical practice; as early as 1500 BC, practitioners in ancient Greece and Rome used electric eels to treat pain. Scientific inquiry into mechanisms of pain led Melzack and Wall to introduce the gate control theory in 1966. This theory postulated a “gate” within the spinal cord dorsal horn which could be opened or closed to regulate pain transmission. Two years later, neurosurgeon Norman Shealy, MD, implanted the first neurostimulation system into the thoracic spine of a human and electrically stimulated the spinal cord to successfully relieve intractable cancer pain. Since then, spinal neurostimulation has grown to be a worldwide, multibillion-dollar industry with multiple corporate vendors rapidly introducing new, minimally invasive technologies to block pain through electricity. This article hopes to cut through the hype of neurostimulation to explain the mechanisms of action, evidence-based benefits and downsides of this rapidly evolving therapy. Neurostimulation is now used widely in the US and Europe by pain specialist physicians to treat a multitude of neuropathic chronic pain

syndromes when more conservative therapies, including medication management, physical therapy, interventional pain procedures and surgeries have failed. Neurostimulation devices are sometimes described as cardiac pacemakers for the nervous system, since many vendors of cardiac rhythm technology, including Medtronic, Abbott and Boston Scientific also manufacture neurostimulation systems.

Common neurostimualtion therapies The most common neurostimulation therapy is spinal cord stimulation (SCS). It has been used to successfully treat regional pain in the upper, mid or lower body for the past three decades. Peripheral Nerve Stimulation (PNS) and more recently, Dorsal Root Ganglion (DRG) Stimulation are similar technologies increasingly used to treat more focal pain in specific body parts. The science and technology of neurostimulation has gradually evolved since its introduction in 1968 with especially rapid innovation occurring from 2015 to the present. Currently, there are several multibillion-dollar health care corporations including Medtronic, Abbott, Boston Scientific and Nevro, along with a multitude of smaller companies, all rapidly and aggressively researching, developing and bringing new and increasingly effective variations of neurostimulation to market. The global neurostimulation device market was valued at 4.4 billion dollars in 2018 and is expected to reach 11.3 billion dollars by 2026. Neurostimulation has been shown to affect biochemical and molecular changes within pain processing systems in the spinal cord dorsal horn and may also have actions within other areas of the spinal cord, the peripheral nerves and the brain which contribute to pain relief. Basic science research has revealed the complex nature of neurostimulation, but we still do not have a complete understanding of the mechanism of action despite years of study.

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Early stimulation systems that followed Dr. Shealy’s initial implant targeted the spinal cord dorsal columns with a low frequency (60 Hz) electrical current that mimicked firing of the A-beta neural fibers involved in vibration sensation. When we touch our finger on a hot stove, we may shake the burned finger to feel better. It is thought that shaking generates vibratory impulses in the dorsal column A-beta fibers that modulate pain processing within the spinal cord dorsal horn. A-beta fiber transmission is thought to block pain by filling up the dorsal horn gate with vibratory input, effectively closing the gate to pain input. Electrical stimulation of dorsal columns mimics natural vibration and creates a pain-relieving buzzing, vibrating sensation called paresthesia in the affected body region. Paresthesia-based systems are effective at relieving neuropathic pain and dominated neurostimulation from its inception in 1968 through the mid2010s. Unfortunately, paresthesia sometimes becomes uncomfortable and tiresome for patients over time, and in 2015, high-frequency stimulation at 10,000 Hz (HF-10) was shown to provide better pain relief without paresthesia. By 2016, HF-10 became a popular stimulation waveform and within two years replaced paresthesia stimulation as the dominant modality. However, high-frequency stimulation is power-intensive requiring daily

and is nociceptive in nature, whereas chronic spinal radicular pain may recharging and is more sensitive to anatomic migration than other types persist beyond the resolution of inflammation and be neuropathic in nature, of stimulation. In 2016, Abbott introduced a low-power alternative called generated by an irreversibly damaged spinal nerve root. Neurostimulation burst stimulation which does not require recharging. Burst waveforms are has proven to be effective for neuropathic pain but there is minimal evidence intermittent and mimic natural nervous system impulses more closely than that it is effective for nociceptive pain. When a paresthesia stimulation and HF-10. In addition, patient with neuropathic pain is implanted with the burst spinal cord stimulation waveform has a neurostimulation device, the constant burning been shown to reduce catastrophizing in chronic element of nerve pain is reduced, whereas pain pain patients by stimulating the medial spinal from an acute fracture, sprain or strain of the pathways, which input into the emotional centers Spinal neurostimulation has affected body part would not feel different. of the brain. Other technology vendors have grown to be a worldwide, recently iCompontroduced novel waveforms and Trial neurostimulation multibillion-dollar industry. programming algorithms, such as Medtronic’s One great advantage of neurostimulation compared Differential Target Multiplexed Stimulation and to surgery and other invasive interventions is Closed-Loop Stimulation, which ultimately may patients may trial stimulation therapy before provide multiple effective stimulation options that deciding whether to undergo a permanent can be targeted to specific patient needs. implant. In the United States, a successful trial of neurostimulation is required by health care payers in order to approve Composition of neurostimultion systems authorization for a permanent surgical implant of a device which can cost Regardless of the waveform produced, neurostimulation systems are close to $25,000. typically comprised of an electrode array designed to be implanted into the central or peripheral nervous system and connected to a power source with an integrated computer chip. These are called internal pulse generators (IPG), which are usually implanted under the skin but can be external to the body. Neurostimulation systems share many attributes of cardiac pacemakers and are produced by some of the same vendors–Medtronic, Abbott and Boston Scientific. Neurostimulators may be programmed to deliver a variety of electrical waveforms to a variety of neural targets and have the potential to relieve pain by stimulating the brain, spinal cord, dorsal root ganglion and/or peripheral nerves. Many systems are designed to allow software programming updates that can be transmitted wirelessly to the device as technology advances. IPG batteries are available in rechargeable and non-rechargeable forms, with battery life lasting from three to ten years depending on the power output required to control pain.

Chronic pain conditions Neurostimulation has a strong evidence basis and has been scientifically proven to effectively treat challenging chronic pain conditions such as peripheral neuropathy, chronic radiculopathy and nerve pain after joint replacement and to improve blood flow and relieve pain in chronic limb ischemia. After rigorous evaluation of the existing evidence for efficacy and safety, SCS, PNS, and DRG stimulation has been approved in both the US and European Union to treat intractable neuropathic pain. Neuropathic pain occurs when there is damage to the nervous system at the spinal cord or peripheral nerve level. Common neuropathic conditions include post-spinal surgery pain syndrome, which is the most common indication for neurostimulation, as well as peripheral neuropathy, complex regional pain syndrome and post-herpetic neuralgia. Neuropathic pain differs from nociceptive pain in that nociception involves pain impulses generated by painful tissue pathology that course through a normal pain-sensing nervous system to be processed as pain sensation in the brain. Common nociceptive pain problems include rheumatoid arthritis, osteoarthritis, fractures, sprains and myofascial pain, none of which are typically responsive to neurostimulation. With respect to spinal pain syndromes, acute spinal radicular pain may be caused by an irritated and inflamed spinal nerve root

For a neurostimulation trial, a temporary system is placed non-surgically with electrodes advanced through needles under fluoroscopic guidance to the nervous system targets. The temporary neurostimulation wires are then connected to a power source outside the body to mimic the effects Neurostimulation for Chronic Pain to page 204

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3Neurostimulation for Chronic Pain from page 19 signals to the brain and are easily accessible from the epidural space in the of a permanently implanted system. It is typically an outpatient procedure cervical and thoracic regions of the spine. Stimulating dorsal column fibers and may last up to one week. This neurostimulation trial demonstrates can provide regional pain relief in the neck and arms, trunk and ribs or to the patient, the implanting physician and the low back and legs. For DRG stimulation, the health insurance payer what the system would be neural target is the dorsal root ganglion which like if permanently implanted, thereby allowing contains the cell bodies of the pseudounipolar for informed decision making. Currently, the neurons responsible for dermatomal sensation. outcome of a neurostimulation trial is judged DRG stimulation is dermatome specific and can Neurostimulation has a strong by subjective feedback from the patient; the deliver electrical pulses to block pain in a specific evidence basis and has been outcome must provide at least 50% pain relief body part such as the foot, knee, hip, groin or scientifically proven to effectively and improvement in physical functioning to be rib. DRG stimulation has proven quite useful in treat challenging chronic pain. considered successful. Soon, rapidly evolving cases of localized neuropathic pain following joint technology in wearable devices should allow a more replacement, hernia surgery and zoster infection objective determination of trial success by tracking (post-herpetic neuralgia) and is the treatment real-world physical data, including the amount of of choice for complex regional pain syndrome. time upright, number of walking steps, heart rate variability, quality of sleep, Peripheral nerves can also be stimulated to provide focal pain relief along opioid consumption and other measurable parameters correlating with pain with the distribution of the nerve in cases of neuralgia, as first demonstrated relief and functional ability. by Wall and Sweet in 1967. Importantly, a trial of neurostimulation is an image-guided needle procedure with no surgical incision and without any obligation to proceed to a surgical implant. The trial procedure itself typically takes under one hour in an outpatient facility and can be described like placing an epidural catheter to relieve labor or post-operative pain. The neural targets for spinal cord stimulation are the spinal cord dorsal columns, which transmit pain

While neurostimulation offers non-destructive, reversible and medicationfree pain relief for many patients, it is also relatively expensive, not always effective and may have technical failures. During trial stimulation, approximately 40-50% of patients fail to respond with adequate pain relief to justify permanent implant. Furthermore, once implanted, stimulation therapy can fail, and explant rates for ineffective stimulation are relatively high.

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Below are a few real-world examples of neurostimulation outcomes from my personal experience trialing, implanting and managing neurostimulation patients for the past 25 years: Ms. A had severe bilateral foot and ankle pain from chemotherapyinduced peripheral neuropathy. Although her cancer had essentially been cured, she was taking high doses of oral opioids for her bilateral leg and foot pain, with poor pain control and unacceptable side effects of somnolence and constipation. We trialed a spinal cord stimulation system (with SCS good results) and then implanted a permanent SCS, which provided excellent pain relief and allowed her to taper and discontinue opioids. The system has now been in place for six years and continues to function well. Mr. B had successful left hernia repair with mesh in 2019, but developed chronic pain at his groin surgical site, which was severe and refractory to nerve blocks and medications. He was taking daily opioids with poor pain relief and side effects. We trialed and implanted a DRG system, which allowed us to specifically target the left L1 and L2 dermatomes by placing a tiny electrode onto the DRGs at left L1 and L2. Mr. B achieved good pain relief and is scheduled for IPG replacement for end of battery life seven years after implant. Ms. C had severe low back and leg pain after multiple lumbar spine surgeries with instrumented multi-level fusion. Her pain was adequately controlled with oral opioids but her prescribing doctor would not continue opioids and tapered her off. We trialed her with an SCS system with excellent results. After permanent SCS implant, her pain was initially well Neurostimulation for Chronic Pain to page 264

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DIVERSITY, EQUITY AND INCLUSION

Addressing COVID-19 Vaccine Equity New partnership provides a roadmap for targeting disparities BY LUCAS NESSE, JD

early a million Americans have perished from COVID19 – a startling figure that has had an immense impact on how we deliver care more equitably. This tragedy has exposed deeply disturbing health disparities between White Americans and Black, Native American and other people of color, while also revealing that our health care system has significant work to do to build trust with diverse communities. In Minnesota – where more than 12,000 people have died from the disease – COVID has resulted in a renewed call to action among our state and health care leaders in how we address these longstanding health equity issues at a community level. An example of this coordinated response is the recent public-private partnership between the State of Minnesota, Minnesota’s nonprofit health plans and county-based health plans to improve vaccine equity rates among disadvantaged communities. Recognizing that there were significant differences in the rate of vaccinations, these groups, including the Minnesota Department of Health (MDH) and the Department of Human Services (DHS), came together last year to form a unique and successful strategy to address vaccine equity. While MDH houses data on immunization and ZIP codes with the

YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.

biggest structural inequity and vaccine disparities, health plans have the staff and expertise to reach members and connect them with lifesaving vaccines. With a shared goal of driving increased COVID vaccination rates among those who live in areas with a high social vulnerability index (SVI), this Vaccine Equity Partnership focused on those individuals. The effort included a number of actions that will serve as a vital blueprint for advancing health equity in our state moving forward, including consistent fact-based messaging, robust outreach, and most important – listening to the needs of the community while answering their questions.

SVI and how it targets health disparities The Centers for Disease Control and Prevention’s (CDC) social vulnerability index uses 15 indicators grouped into four themes that comprise an overall SVI measure. High SVI communities generally have higher rates of poverty, insufficient housing, racial/ethnic minorities, and lack access to transportation when compared to low SVI communities. SVI has been traditionally used by the state and others to determine where to best allocate resources to help those most in need. Sharing SVI information with health plans allowed for a number of advantages, including focused outreach and aligned messaging to highly disadvantaged communities throughout the state. SVI was selected as a vaccine equity metric, in part, to help prioritize Black, Indigenous and other communities of color (BIPOC) disproportionately impacted by COVID19 get vaccinated. More broadly, Medicaid members were also noted to be experiencing vaccination disparities and so were prioritized early, as well. Using SVI, MDH ranked the ZIP codes and divided them into quartiles based on their SVI score. Through this methodology, MDH discovered that although Minnesotans living in high SVI ZIP codes represented 29% of Minnesota’s population, in May of 2021 they represented 32% of Minnesota’s COVID-19 cases, 39% of hospitalizations and 38% of deaths. Health plans participating in the vaccine equity partnership – including Blue Cross and Blue Shield of Minnesota, HealthPartners, Hennepin Health, Medica and UCare – were able to use this key SVI data from MDH to be focused in their outreach.

Methods of engagement Early on, it was determined that consistency in messaging would be a crucial goal in outreach related to the partnership. This alignment is paramount in building trust with BIPOC populations given historical trauma related to the health care system, as well as misinformation found within all communities. Members would hear a consistent message about COVID vaccines across the board. Health plans would also help their family members get vaccinated, regardless of a family member’s health plan – something our partners called a “no wrong door approach”. For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com

Health plans used MDH/DHS-approved messaging about vaccine safety and efficacy, as well as FAQs to provide to their members. DHS also created a rapid approval process by which plans could create more specific messages ©2013 Paid for by the U.S. Air Force. All rights reserved.

FENRUARY 2022 MINNESOTA PHYSICIAN

for their members through a multitude of formats, including phone calls, text messaging, postcards, billboards, emails and other forms of outreach. During phone outreach, health plan staffers directly scheduled COVID vaccination appointments, answered questions related to the vaccine, assessed the need for additional services – like transportation or interpreters – and coordinated further care as needed. MDH and DHS also met with health plans regularly to discuss successes and challenges related to their outreach, and ways to pivot if necessary.

a variety of ways to receive the vaccine (such as mobile vaccination sites and drive-through clinics) and dispelling vaccine misinformation with the help of trusted leaders in the community.

These relationships proved to be vital in encouraging BIPOC communities to receive the COVID vaccine. By engaging trusted leaders, such as community health workers, who understand the issues and can communicate to their community in their own languages and their own cultural context, the partnership was able to reduce barriers. We Consistency in messaging would be a crucial goal in outreach. learned that creating shared narratives, addressing misinformation and acknowledging past trauma experienced by people of color in the health care system are best done within a community setting and with buy-in from community leaders.

Additionally, MDH provided plans with a list of local independent pharmacies and communitybased organizations that the state had relationships with to better reach focus communities. This allowed health plans to make decisions on where to host vaccination clinics, expand community connections, seek collaboration and target outreach to unvaccinated members in economically disadvantaged areas and at increased risk for severe COVID disease.

Partnership results and lessons learned During the first four months of the partnership (Phase 1), more than 640,000 outreach attempts were made to reach members living in the highest-risk SVI ZIP codes, driving a 55% increase in the number of members living in high SVI ZIP codes who received at least one dose of the vaccine. Health plans were successful in decreasing barriers to vaccine access through scheduling transportation and interpreter services for members, promoting

The partnership also bolstered trust between health plans and a variety of other groups, such as community-based organizations, as well as state and local public health agencies. This trust grew through sharing information and mutual problem solving to collectively accomplish the goal of vaccinating Minnesotans. Half of the participating health plans reported that they developed a new relationship with at least one community organization and three of them indicated that they developed a new relationship with at least one local public health agency and at least one other health plan. Addressing COVID-19 Vaccine Equity to page 244

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability? Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

MINNESOTA PHYSICIAN FEBRUARY 2022

3Addressing COVID-19 Vaccine Equity from page 23 well for the state and Minnesota health plans – and can create a roadmap for Setting a pathway for solving health disparities all parts of the health care ecosystem to work together, including providers and Minnesota health plans will continue working together on unified, statewide others on the front lines of care delivery. As we develop pathways to address messaging on COVID-19 vaccines, especially as health disparities more quickly, we must also more children become eligible to get vaccinated expand the ways in which we engage. Sometimes for the disease. Most recently, health plans and that will mean working with a competitor, a the state came together on N95 and KN95 mask regulator, an unfamiliar stakeholder, or a group distribution efforts amid the Omicron surge earlier that is on the opposing side of the industry. It this year – another example of how we pooled our won’t always feel comfortable or natural. Health Health disparities remain collective resources to protect our most vulnerable plans set aside competitive interests to work with pronounced for Minnesota. through this partnership. each other – along with state regulators – to get shots in arms and prevent more unnecessary deaths But as we look ahead – and beyond this from COVID. This steadfast commitment to pandemic – health disparities remain pronounced serve the best interests of Minnesotans over all else for Minnesota. Diabetes, asthma, mental illness, just goes to show that we can get so much more as well as maternal and infant mortality, are all accomplished by working together. So, let’s continue to find that common health issues in which deep inequities persist and will continue to widen if ground to drastically reduce health disparities in our state. left unaddressed. However, through stakeholder partnerships like the one we formed to improve equity in COVID vaccination, we know it is possible to improve methods that reduce other health issues. There is also opportunity to use this partnership to address the social drivers of health – necessities such as food, housing, education and transportation – to bring about better health outcomes overall for under-resourced communities in our state. One of the most important lessons we learned from the partnership was the value in aligning communication and resources. This approach worked

FEBRUARY 2022 MINNESOTA PHYSICIAN

For more information on the Vaccine Equity Partnership and participating health plans visit: https://www.health.state.mn.us/diseases/ coronavirus/vaccine/mnsvivaxsum.pdf Lucas Nesse, JD is CEO of the Minnesota Council of Health Plans.

Patients with regenerative medicine questions?

Regenerative medicine focuses on the body’s natural ability to repair, replace, and regenerate damaged or aging tissues. At MINNESOTA REGENERATIVE MEDICINE (MRM), a specialty clinic of HOGUE CLINICS, autologous bio-cellular agents such as platelet-rich plasma (PRP), fat aspirate concentrate (FAC), and bone marrow aspirate concentrate (BMAC) are used to treat degenerative conditions. To ensure proper placement, ultrasound or fluoroscopy guidance is used when clinically indicated during regenerative medicine treatments.

Regenerative medicine treatment categories at MRM include: • Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine) • Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING • Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT

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3Dry Eye Disease from page 17 Because most eye doctors do not have the appropriate combination of expertise, interest, patience and time to fully treat each patient’s DED, most patients go under- or untreated, accounting for the large amount of DED television commercials, magazine ads and doctor-jumping.

specialized clinics, and others are referred there by primary care or eye care providers who don’t have the requisite combination of expertise, interest, patience and time necessary to take care of these patients appropriately. At this stage, Dry Eye specialist and Dry Eye clinic are informal designations.

Summary

There is no formally recognized subspecialty At some fundamental level, DED is That of or fellowships in DED, nor is there a Dry Condition of the eye care world. Fortunately, For each treatment, Eye accreditation body or board. A significant we practice at a time when the diagnostic and success will depend on number of optometrists and ophthalmologists treatment options have developed to the point a combination of factors. are committed to gaining the expertise to focus that the overwhelming majority of patients can on treating DED in their practices. In taking be helped, if not cured. Treating these patients on this commitment, they are creating practice requires not only an understanding of what is models that combine the necessary ingredients available, but also an interest to do so. The Dry of experience, interest, patience and time to treat Eye specialist and Dry Eye clinic are two new these patients who have this problem. For the Dry Eye specialist, treating developments in the arena of eye care that should help patients receive the That Condition presents an opportunity to help patients that others have care that is necessary to help them with this chronic, frustrating problem. failed. Once established, Dry Eye specialists can be found spreading the gospel on podia at conferences, as guests or hosts of podcasts or as authors Gary S. Schwartz, MD, MHA, is President, Associated Eye Care and of articles in both peer-reviewed journals and non-peer-reviewed magazines. We are also seeing the birthplace of the Dry Eye clinic, either within established comprehensive eye clinics or as standalones. These clinics are staffed with providers and technicians who are skilled at diagnosing and managing all aspects of DED. Some patients find their own ways into these

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3Neurostimulation for Chronic Pain from page 20

Conclusion Neuropathic pain is a very difficult problem with no easy solution. A damaged nervous system is often not fixable. Although surgeries may correct the structural problems causing nerve impingement and irritation, pain often persists because nerves have been irreversibly damaged by the underlying condition. Medications such as gabapentin and pregabalin may be effective for some patients but are often not adequate enough on their own to treat severe neuropathic pain. Neurostimulation offers an Neuropathic pain is a very difficult excellent alternative for patients and is rapidly problem with no easy solution. evolving so that newer stimulation modalities may provide effective pain relief for more patients in the future.

controlled, but pain relief gradually faded over the next year despite multiple reprogramming efforts. She developed pain at the buttock IPG implant site and ultimately had the SCS system removed because of lack of efficacy after 18 months. There was no infection or malfunction of the system noted at explant. Two successes and one failure. This seems to be the nature of neurostimulation–a wonderful, low-risk therapy that provides profound relief of neuropathic pain without medication for some patients, whereas for others, lead migration, lead fracture and/or fading efficacy over time results in therapy failure and high explant rates of SCS systems.

David S. Schultz, MD, MHA, is the medical director and founder of Nura pain clinics. Dr. Schultz is a board-certified

Outcomes Recently published outcome studies indicated that approximately 20% of SCS systems are explanted prior to battery depletion and only 40% of SCS patients choose to have their systems re-implanted when the IPG battery expires after years of therapy. Contrast this with neuromodulation using a pain pump for targeted spinal drug delivery, where greater than 95% of pain pump patients choose to have their pump re-implanted when the battery reaches end of life.

anesthesiologist with additional board certification in pain medicine from the American Board of Anesthesiology, the American Board of Interventional Pain Physicians, and the American Board of Pain Medicine. He has been a full-time interventional pain specialist since 1995.

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3Tiered Cost-Sharing Health Insurance from page 11

cost-sharing tells patients where to find lower cost providers and shares the savings with patients who choose those providers.

year, and the quality measures currently include diabetes, vascular care and pediatric asthma obtained from Minnesota Community Measurement.

Conclusion

The health care affordability problem needs to be addressed, and the current We have published two analyses of the SEGIP system. The first study variation in providers’ prices and practice styles (Dowd, Huang, and McDonald, “Tiered Costsuggests it is possible to do so by using data already sharing for Primary Care Gatekeeper Clinics,” available to change the incentives faced by both American Journal of Health Economics, 2021, 7(3); patients and providers. pages 306-332) confirms that State employees are We currently have a research project underway aware of clinics’ tiers and consider the clinic’s tier Tiered cost-sharing represents studying what barriers exist for clinics attempting when choosing a clinic for the coming year. The an improvement over many to reduce low-value care and improve their referral second study (McDonald, et al., “Primary Care current reform proposals. processes. We are seeking physician input and the Clinic Responses to a Tiered Insurance Network,” interests of physicians willing to provide leadership American Journal of Managed Care, 2021, 27(9), and a professional voice to the approach of sharing pages e316-e321) summarizes the results from a savings with patients for choosing better quality, small sample of interviews with SEGIP’s primary lower cost providers. care clinics. The findings from that study indicate that clinics have two reactions to tiering. First, they Bryan Dowd, PhD, is a professor in the Division are concerned about losing patients to lower cost clinics, and second, they are of Health Policy and Administration (HPM) in the School of Public Health at the concerned about developing a reputation as a high cost clinic. The clinics also University of Minnesota. A copy of this article with a full set of references is express interest in greater transparency in the tier assignment process and how available from Bryan Dowd at dowdx001@umn.edu. to reduce low value care and avoidable utilization. Tyler Boese is a PhD student at HPM. To summarize, SEGIP’s tiered cost-sharing system offers an improvement Tim McDonald is a PhD student at the Pardee RAND Graduate School. For over ineffectual provider payment reforms that are invisible to patients. And unlike large deductible health insurance benefit designs per se, tiered more information, contact Tim McDonald at tmcdonal@rand.org.

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TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

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Minnesota Physician • February 2022

Articles inside

PAIN MANAGEMENT

OPHTHALMOLOGY