Minnesota Physician February 2023

PHYSICIAN

Health Care Prebunking

Can people be immunized against disinformation?

BY PATRICK BOYLE

Debunking lies about health and medicine is vital but often occurs too late to change the minds of those who get duped. An expanding strategy, prebunking, exposes people to disinformation tactics so they can recognize and resist false messages. Consider the following examples:

Trouble Ahead

Medicaid disenrollment looms

BY MATTHEW L. ANDERSON, JD

Arguably, the most significant and underappreciated health policy response to the COVID-19 pandemic is quietly coming to an end and creating the potential for the largest increase in uninsured residents in Minnesota’s history. Minnesota’s physicians, as well as health care employees from clinic receptionists to finance office staff members, should prepare to help approximately 1.5 million Minnesotans who receive health coverage through the state’s Medical Assistance (Medicaid) and MinnesotaCare programs avoid losing coverage entirely.

Early in 2020, Congress saw the importance of ensuring that as many people as possible had uninterrupted health coverage, especially for purposes of making testing and

Trouble Ahead to page 104

The first COVID-19 lie that the man posted on social media drew only three likes: “Coronavirus tests are not very reliable, so the official numbers of infections and deaths are based on faulty data.” Boring. A guide from a web community devoted to coronavirus disinformation sent the newcomer advice about how to stir things up: “Just sharing scientific-sounding content about coronavirus isn’t going to do the trick.” The man needed to build credibility for his messages, and “credibility is easy to fake.”

Health Care Prebunking to page 144

Some physicians rely on Nura for assistance pinpointing the cause of the pain. while others turn to Nura for total pain management of complex cases.

By Matthew L. Anderson, JD

By Patrick Boyle

Energy Sustainability

Retro-commissioning aging facilities

By Matt Wade, PE and Jonathan Hunley, CHFM

THE HEALTH CARE WORKFORCE SHORTAGE: Facing a crisis

BACKGROUND AND FOCUS:

Prior to the pandemic, it was widely recognized there were serious workforce shortage issues facing health care delivery. Those concerns are now much worse. From physicians, to nurses, to behavioral health, to public health, to assisted living and long term care, every kind of licensed health care professional faces demand that far outstrips supply. This problem is trending steeply upward and can only manifest in serious negative outcomes. Lack of access creates higher cost, preventable increases in morbidity and mortality and systemic burnout.

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.

Our expert panel will examine the root causes of the health care workforce shortage. From industry entrance barriers, to workplace dysfunction, to career satisfaction we will present examples and potential solutions. We will dissect the complex interactions between elements of health care governance and explore how industry sectors can work together more closely to solve shared problems. We will explore the numerous initiatives already underway to address these issues and share suggestions for how best to address them.

OBJECTIVES: JOIN

We invite you to participate in the conference development process. If you have questions you would like to pose to the panel or have topics you would like the panel discuss, we welcome your input.

Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

U of M Announces Plans for New Hospital

The University of Minnesota recently announced the “MPact Health Care Innovation” proposal, which includes plans for a new hospital on the east bank of the Twin Cities campus. It entails buying back its health care facilities from Fairview Health Services, which announced plans to merge with Sanford Health this year. The University says the new hospital would be part of a future medical center that encompasses several blocks. U of M President Joan Gabel says it’s necessary, calling the school’s other hospitals “old”. A newly designed state-of-the-art hospital complex would move clinical and academic medicine forward for the next 50 to 100 years “ It advances care, wellness and health in ways that only a hospital associated with a leading research university can provide,” said President Gabel. The proposed

Fairview/Sanford Health merger is drawing increasing criticism. Leaders from those health systems recently attended a community meeting hosted by the Minnesota Attorney General’s Office. Nurses, union leaders and lawmakers expressed their concerns for several reasons.

There was similar backlash when the two proposed to merge in 2013. Even the University has questions as it is moving ahead with the MPact Health Care Innovation proposal.

“We have no control over that, we’re moving forward with our vision, yes,” said Senior Vice President for Finance and Operations Myron Frans. Planning and construction will take five years, or more, so it is important to begin now to secure the necessary public funding and to plan facilities that will support the top-ranked Medical School and the people of Minnesota. The University will need public support to buy back those buildings, as well as construct

the new hospital, which will cost at least a billion dollars. Since the proposed Sanford merger, Fairview states it has engaged in good faith with the University of Minnesota and brought forward many options for how they could fit into the new partnership. Despite repeated requests, they claim to have had no opportunity to meet with university leadership. They further state they look forward to working together with the University to better understand the details of the MPact Health Care vision and determine fair market value for the assets it may require.

SPH Study Cites Increase in Ransomware Attacks on Health Care

The annual number of ransomware attacks on health care provider organizations more than doubled from 2016 to 2021, exposing the personal health information of

nearly 42 million individuals. A new report from the University of Minnesota School of Public Health (SPH), published in the Journal of the American Medical Association (JAMA) Health Forum, shows that ransomware attacks on healthcare providers are not just increasing in frequency, they are also becoming more severe — exposing larger quantities of personal health information and affecting large organizations with multiple health care facilities. To conduct the study, researchers created a database called the Tracking Healthcare Ransomware Events and Traits (THREAT), a unique tool that for the first time allows researchers to track the occurrence of ransomware attacks on health care provider organizations. In the first-ever comprehensive analysis of ransomware attacks on U.S. health care providers, researchers documented that between 2016 and 2021:

• 374 instances of ransomware attacks on health care delivery organizations exposed the personal health information of nearly 42 million individuals.

• R ansomware attacks more than doubled on an annual basis, from 43 to 91 per year.

• T he number of individuals whose personal health information was exposed increased from approximately 1.3 million in 2016 to more than 16.5 million in 2021.

• Disruptions in care for patients as a result of ransomware incidents occurred in 166 — or 44% — of attacks.

• A mong health care delivery facilities, clinics were the most frequent targets of ransomware attacks, followed by hospitals, ambulatory surgical centers, mental/behavioral health facilities, dental practices and post-acute care organizations.

“As health care delivery organizations have increased their reliance on information technology to serve their patients, they have unfortunately also increased their potential exposure to cybersecurity risks, such as ransomware attacks,” said Hannah Neprash, lead author and an assistant professor at SPH. “Despite this increased risk, information about the frequency and scope of these attacks is limited to anecdotal news coverage. This study and the development of the THREAT database addresses this gap, providing the first peer-reviewed analysis of the threat that ransomware poses to health care providers and the millions of patients they serve.” Further research is needed to more precisely understand the operational and clinical care consequences of ransomware attacks on health care providers.

TCO Opens New Bioengineering Lab

The Twin Cities Orthopedics Bioengineering Lab (TCO Bio Lab) opened recently in Eagan on the Viking Lakes campus. It’s the first independent facility of its kind in Minnesota. Dedicated to achieving world-class outcomes, the lab features state-of-the-art technology and resources. Physicians and researchers will be able to conduct industry-leading research studies and training. “The TCO Bio Lab will be one of the top facilities in North America,” said TCO’s Dr. Robert LaPrade. “In addition to being able to provide bench-to-bedside answers for treating complex sports medicine pathologies in the research portion of the lab, it will also allow surgeons to hone their skills and develop improved surgical procedures in the Bioskills Lab. This lab will also provide one of the top opportunities for

(pictured: Dr. Gigi Chawla, MHA ’17)

techniques,” said TCO’s Dr. Jeffery Seybold. “We can now provide our faculty and fellows the opportunity to pursue answers that ultimately enhance patient care.”

HCMC Announces $100M+ Downtown Campus Remodel

Hennepin County Medical Center (HCMC) CEO Jennifer DeCubbelis recently released an announcement describing a journey to reimagine the healthcare system. The goal is to create a new kind of healthcare campus and more information is available at hennepinhealthcare.org/ ourfuture. The ambitious project is slated to begin later this year and take 8 years to complete with well over $100 million as an initial projected budget. The plan will modernize one of region’s most important trauma hospitals and shrink its footprint. Over the past 18 months,

more than 3,000 stakeholders including patients, neighbors, Hennepin Healthcare team members, and healthcare and business leaders have engaged in the design process to create a healthcare system that will meet their needs while advancing equity and justice. Currently the sprawling facility consists of several buildings cobbled together over eight city blocks in what has become prime downtown real estate. Some of the existing buildings are over 80 years old, beyond their useful life and regularly require urgent repairs. Part of the redesign will include a new inpatient hospital tower at Eighth Street and Chicago Avenue. Parking concerns must be addressed prior to that construction. These parking concerns include a new 1,000 space ramp on an existing surface lot and demolition of existing parking ramp space. Another element of the new campus plan includes existing

building space that will be repurposed. Between the new construction and demolition, DeCubellis said the project will “really re-energize that side of Minneapolis.” The final bed count of the new tower is yet to be determined. Patients and team members will be better served by a more compact, state-of-the-art, secure, and sustainable health care campus. Another element of the plan includes an expansion of its Clinic and Specialty Center, which was completed in 2018. This facility was originally designed to accommodate a 3-story expansion of the upper floors on the southeast corner of the building. Finishing these floors will allow for consolidation of the remaining downtown campus clinics into the building. New hospital facilities take many years to plan and construct, so part of the work includes development in a way that won’t interrupt ongoing patient care.

Herself Health Opens in St. Paul to Serve Older Women

A new clinic designed to deliver advanced primary care to women over 65 is now open for business in the Highland Park neighborhood of St. Paul at 2004 Ford Parkway. The company received $7 million in seed funding from Juxtapose. Herself Health, co-built by Juxtapose and CEO Kristen Helton, is starting with three physicians on staff. The clinic is the first fully value-based advanced health care business focused exclusively on women age 65 and up. The practice focus links women’s health goals with their life goals, taking into account a patient’s physical, mental, social, sexual, and spiritual needs while targeting common concerns like osteoporosis, weight management, and emotional well-being. “With the launch of Herself Health, we are breaking the mold of

one-size-fits-most health care, which traditionally falls short of providing the best care for women of this generation,” said Herself Health CEO Kristen Helton. “Our innovative and patient-obsessed care experience empowers women to keep growing bolder in mind, body, and spirit.”

Herself Health is built by women for women, bringing keen insight and empathy to traditional primary care. Today, women are misdiagnosed at higher rates than men, take longer to diagnose, and often express frustration at not feeling heard. These issues are compounded with health care’s universal shortcomings, including not giving patients enough time with doctors and expecting them to navigate their own care across specialists. “At Juxtapose, we partner with leaders who have a proven track record and a clear vision for the opportunity ahead,” said Jed Cairo, Founding Partner at Juxtapose, a leading creation-oriented investment firm. “From her work in research and startups to Amazon, Kristen has a strong track record of transforming insights around customer and patient-led needs into comprehensive and delightful health care experiences. We’re thrilled to partner with her as she works to redesign value-based care for the growing population of aging women.” “Kristen and Herself Health have created a model for health care that will give a wider population elevated and meaningful experiences they wouldn’t otherwise have access to,” shared Mindy Grossman, Herself Health board member, “I’m thrilled to partner with a founder and company who share the mission of democratizing wellness for all.”

St. Francis Announces Shakopee Campus Expansion

St. Francis Regional Medical Center and its owners Allina Health, HealthPartners Park Nicollet and Essentia Health, have recently announced plans for to build a new

outpatient surgery center on their Shakopee campus. The ambulatory surgery center will be located on the southeast corner of the hospital campus and will include the addition of a TRIA Orthopedics clinic.

“Investing in our growing community by adding an outpatient surgery center provides patients a convenient, lower cost local option for surgeries and procedures closer to home,” said Amy Jerdee, president of St. Francis Regional Medical Center. “The new surgery center offers increased access to specialty care on our campus and brings TRIA, a leading orthopedic provider, to the community.” Construction on the St. Francis Surgery and Endoscopy Center will begin this spring. The 46,000 square foot building will house the new surgery center, the TRIA clinic and orthopedic urgent care, as well as future service offerings. Expected to open in early 2024, the surgery center will be owned by St. Francis and managed by HealthPartners Park Nicollet. “We are proud to have served the health care needs of Shakopee and the surrounding communities for more than 20 years,” said Laura Loberg, vice president of surgical services at Park Nicollet. “As our communities continue to grow, we’re committed to meeting the health care and sports medicine needs of the community by providing high-quality, affordable and convenient care.” New specialists in surgical care will work in tandem with long-time experts from St. Francis in multiple specialties, such as orthopedics, general surgery, plastic surgery, and gastroenterology. The TRIA clinic and orthopedic urgent care will build TRIA’s footprint in Shakopee to serve the broader southwest region with the full complement of orthopedic and sports medicine services. “From youth athletes to active seniors, we’re seeing unprecedented demand for orthopedic care,” said Dean Olsen, MD, TRIA orthopedic surgeon and the orthopedic surgery medical director at St. Francis.

Upcoming Concerts

RAPSODIE ESPAGNOLE

FRI FEB 3 8PM

SAT FEB 4 8PM

Carlos Miguel Prieto, conductor

Gabriela Montero, piano

DVOŘÁK’S NEW WORLD SYMPHONY

THU FEB 16 11AM

FRI FEB 17 8PM

Kazuki Yamada, conductor

Alexandre Kantorow, piano

ERIN KEEFE PLAYS BERNSTEIN

THU FEB 23 11AM

FRI FEB 24 8PM

SAT FEB 25 8PM

Dalia Stasevska, conductor

Erin Keefe, violin

DVOŘÁK’S

SYMPHONY

FRI MAR 3 8PM

SAT MAR 4 8PM

NO. 7

Dima Slobodeniouk, conductor

Kari Kriikku, clarinet

GABRIELA MONTERO

ERIN KEEFE KARI KRIIKKU

KAZUKI YAMADA

Providing a Supportive Environment for Children and Their Families

Angela Kade Goepferd, MD, medical director, Gender Health Program, Children’s Minnesota

What does gender-affirming health care mean?

According to the American Academy of Pediatrics (AAP), gender-affirming care is developmentally appropriate care that is oriented toward understanding and appreciating a child’s gender experience. What that means when you’re in the Gender Health clinic at Children’s Minnesota is providing a supportive environment for children and families to ask questions to health care professionals who specialize in the care of transgender and gender-diverse youth. Questions can range from how to address bullying in school, to how parents or caregivers can support their child who may be exploring their gender expression and/or gender identity. Transgender and gender-diverse youth often face significant discrimination in their daily lives in the form of bullying, harassment and sometimes violence, and many LGBTQ youth struggle to identify a single supportive adult they can trust. Transgender and gender diverse youth and their families deserve to have a safe and accepting place to have their questions answered by an expert in gender health, just like a child who has diabetes, asthma or cancer would seek specialized care to optimize their health outcomes. And just like other specialized health care, gender-affirming care is supported by evidence-based research and the expert opinion of every major medical society in the United States.

Please tell us about the work you do at the

Children’s Minnesota Gender Health Program.

The Gender Health Program at Children’s Minnesota offers comprehensive care for youth who identify as transgender and gender diverse. Our approach to transgender and gender diverse kids includes understanding and supporting the whole child within the context of their family and community, which includes understanding both their medical as well as their mental health needs. Children’s Minnesota Gender Health Program is an integrated care model, mirroring best practice as defined by the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) version 8, where each new intake into our program includes both mental health assessment as

correcting rampant misinformation about genderaffirming care and associated treatments being spread in the media. Despite the advances made in recent years for LGBTQ equality and equal rights, transgender and gender diverse youth continue to face regular harassment and discrimination, which jeopardizes both their physical and mental health. Studies show that 80% of transgender kids will face regular harassment in schools, and their suicidality rates are known to be high, up to 40-50%. Working with families to

programs and clinicians with harassment and threats, we have also formed close coalitions with each other to make sure we are doing all we can to keep our patients and families safe, as well as protect our clinic staff and each other.

What are some of the misconceptions about the work you do?

First and foremost, many folks assume that being seen in a gender health clinic equates to receiving gender-affirming medical intervention or treatment that results in permanent changes.

A gender-affirming approach to care can be life saving for these kids.“...”

When in fact, many of our patients are not receiving any medical treatment, and use our program to access resources, support and information. We also commonly are able to offer reversible medical interventions, such as menstrual suppression and/ or puberty suppression and several non-medicationbased gender affirming interventions, including voice therapy, gender-affirming shapewear and mental health support. One of the biggest misconceptions about what we do at the Gender Health clinic is that we perform gender-affirming surgeries. In our program at Children’s Minnesota, we do not perform surgery, and for minors to access gender-affirming surgeries, typically chest reconstruction, is still very rare in general. There are also critics, particularly in the media and social media, who think gender-affirming care is not necessary for children who identify as transgender and gender-diverse and can wait until they reach adulthood. However, this “wait and see” approach results in worse mental health outcomes, and we know that taking a gender-affirming approach to care can be life-saving for these kids. A research brief from The Trevor Project found genderaffirming health care can decrease a child’s behavior and emotional issues, and has positive

effects on body image and overall wellbeing while reducing thoughts of suicide

Recently Mayor Jacob Frey signed an Executive Order designating Minneapolis as a safe haven for gender affirming care. What can you tell us about this?

Executive Order 2022-04 signed by Mayor Jacob Frey establishes the city of Minneapolis as a safe haven for gender-affirming healthcare. The order prohibits all City departments and City staff from taking any enforcement action against health care providers or individuals exercising their right to gender-affirming health care in Minneapolis. It also affirms the rights of minors living apart from their parents to make their own medical decision regarding gender-affirming care, in accordance with Minnesota law. Children’s Minnesota was one of the organizations the mayor’s team consulted with when drafting the order. I was honored to be invited to speak at the signing ceremony and to stand among other local advocates who work tirelessly to advance the rights of transgender youth and adults. This executive order sends a strong message to transgender and gender-diverse families in Minneapolis, that they matter and they

belong and they deserve access to high-quality gender-affirming care. Also, Minneapolis was not the only local government to take action on gender-affirming care. Hennepin County recently announced it has invested in services that expand accessible, reproductive and gender-affirming health care for all, with an emphasis on addressing health and racial equity disparities.

Legislation has been proposed in several states that would impose criminal penalties on physicians, clinics and individuals seeking care for gender-health related issues. What can you share about this?

There has been a trend among more conservative led states to restrict or even criminalize genderaffirming care. In 2022, the governor of Texas directed the Texas Department of Family and Protective Services and other state agencies to investigate certain gender-affirming services as child abuse. In response, families of transgender children in Texas rushed to social media, pleading for help and support and, in some cases, attempted

treatment of COVID-19 widely available across the population. The Families First Coronavirus Response Act (FFCRA) offered enhanced federal financial support of Medicaid programs if states agreed to keep people continuously enrolled in coverage through the end of the federal public health emergency. Like every other state in the country, Minnesota acted quickly to adjust our Medicaid and MinnesotaCare programs to stop conducting almost all annual eligibility renewals or otherwise ending coverage for people enrolled in Medicaid or MinnesotaCare.

As a result, state, county and Tribal Nation employees and state public program enrollees have not gone through the eligibility renewal process for three years.

Record Low Numbers of Uninsured Minnesotans

Largely because of the continuous enrollment policy, the number of Minnesotans enrolled in Medicaid and MinnesotaCare increased significantly since 2019. According to the Minnesota Department of Human Services (DHS) “Renew my Coverage” webpage, the number of residents enrolled in the Minnesota’s health coverage programs grew by 28% to approximately 1.5 million. And conversely, according to the Minnesota Department of Health, the percentage of Minnesotans without health coverage dropped to only 4% in 2021 -- lower than in any year since 2007 or longer.

For residents who are financially and/or medically vulnerable, these gains in coverage brought greater access to care – not only coverage for COVID19 testing and treatment, but also comprehensive coverage for physical care,

OB & GYN CARE

FOR ALL STAGES OF LIFE

Low- and high-risk obstetrics, including advanced maternal age.

Certified nurse midwifery. Gynecologic care, including well-woman screenings and in-office procedures

Gynecologic surgeries, including minimally invasive surgeries and robotics for conditions such as endometriosis and pelvic organ prolapse

Menopause Clinic, including management of peri-menopause Center for Urinary and Pelvic Health, including urodynamics. Nutrition and wellness consultations.

Infertility evaluation and treatment.

Early, late, and Saturday appointments 763-587-7000 OakdaleOBGYN.com

mental and behavioral health services, substance use disorder treatment, dental care, and prescription drugs. Health coverage also provided more economic security and stability.

For Minnesota’s physicians and other health care providers, these federal and state policy changes secured an important source of payment. Per DHS data, Medicaid and MinnesotaCare provide reimbursement for approximately 40% of all births, health coverage for 40% children living in Minnesota, and pay for approximately 50% of all nursing home care and substance use disorder treatment.

According to DHS, before the pandemic in 2019, Medicaid and MinnesotaCare paid approximately 21 million claims to physicians and other individual health care professionals. These state public health coverage programs accounted for 25% of all health care spending according to the Minnesota Department of Health.

With 330,000 more residents enrolled in these programs today, in part due to the continuous enrollment policy, the number of claims paid to physicians and other health care professionals, as well as the proportion of health care spending from state public health coverage programs are likely even higher.

Financial Impact

While higher enrollments in Medicaid and MinnesotaCare naturally result in additional state spending on the programs, this increase in spending is more than offset by the enhanced federal funding Medicaid programs have received during the COVID-19 public health emergency. According to the Minnesota Department of Management and Budget’s (MMB) analysis, the continuous coverage policy increased state spending by an estimated $200 million per year, but the state receives approximately $950 million more per year in enhanced Medicaid funding from the federal government. Accordingly, this enhanced federal Medicaid funding has contributed to Minnesota’s historic budget surplus.

In the last days of 2022, Congress passed the Consolidated Appropriations Act, which included provisions ending the continuous enrollment policy on March 31, 2023. Consequently, states are preparing to restart their eligibility renewal processes. DHS expects to begin sending notices to the first group of enrollees in April with decisions about their renewals being completed by July. According to the department’s plans, all Medicaid and MinnesotaCare enrollees will have their eligibility renewals processed by the end of June 2024.

The renewal process requires enrollees to submit documentation and complete the forms necessary to demonstrate they remain eligible for public health insurance programs. DHS will send enrollees notices letting them know when they will receive renewal paperwork and explaining the next steps in the process. State, county, and Tribal Nation employees will review the documentation submitted by employees and determine if their coverage will be renewed or end.

Each month, DHS expects renewal determinations to be made for approximately 60,000 enrollees, with even larger volumes needing to be processed during the last quarter of 2023 when MinnesotaCare enrollees need to apply if they want coverage in 2024.

Accompanying the end of the continuous enrollment policy, the Consolidated Appropriations Act established a schedule for reducing the

enhanced financial support state Medicaid programs received over the past three years. In its updated budget forecast, which will be released in early March, MMB will account for the phase out of both the additional costs associated with the continuous enrollment policy and the gradual loss of enhanced federal funding.

DHS described restarting the renewal process after three years and with 28% more enrollees as “a significantly larger volume of work than has ever occurred in the state’s public health care programs’ history.” It also poses the risk of causing the largest increase in residents without health coverage in decades.

Maintaining Coverage

Before the COVID-19 pandemic, people often lost coverage during the renewal process. Naturally, some people lost coverage because they were no longer eligible for Medicaid or MinnesotaCare. Many people, however, lost coverage even though they remained eligible to keep their coverage in the programs. Loss of coverage could result from, for example, failing to receive notice of the need to re-enroll because of a change of address, not completing the necessary paperwork, or missing some of the documentation necessary to demonstrate income or disability status. In other words, people eligible to remain in Medicaid or MinnesotaCare lost their health coverage even when the renewal requirements were expected, routine, and involved state, county and Tribal Nation employees processing many fewer applications each month.

According to DHS, “Minnesota’s public health care programs have complex, paper-based renewal processes,” and successful re-enrollment requires collaboration of state, county, and Tribal Nation employees who process renewals, as well as navigators and individual enrollees.

The Kaiser Family Foundation estimates that before the continuous coverage policy more than 10% of Medicaid enrollees lost coverage each year even though they likely remained eligible. Using today’s enrollment figures, this means we could expect 150,000 residents who continue to experience significant economic and medical vulnerability will lose their health coverage in the next year as the eligibility renewal process is restarted.

DHS, however, anticipates that an even larger portion of enrollees might lose their coverage. “Enrollees likely experienced many changes in the last three years that will complicate their renewal and make it harder to get in touch with them, including moving, changing jobs or experiencing an illness.”

All 1.5 million Minnesotans enrolled in Medicaid and MinnesotaCare, most of whom have no experience with the re-enrollment process, will need to document their ongoing eligibility for public health programs or they will lose the health coverage they rely on for access to physician services and other clinical care.

Moreover, just as most Medicaid and MinnesotaCare enrollees have no experience navigating the re-enrollment process, many state, county, and Tribal Nation employees who will shoulder the burden of processing a dramatically larger number of renewal applications each month have no experience administering the renewal process because they started their jobs

during the public health emergency. Even employees with experience are out of practice.

Consequently, the U.S. Department of Health and Human Services estimated that ending the continuous coverage policy could result in 15 million residents across the country losing health coverage. The Department further estimated that 6.8 million of those who lose coverage will do so despite continuing to meet eligibility criteria for keeping coverage.

As a result of reinstating the eligibility renewal process, it is possible that Minnesota’s historically low rate of residents without health insurance could jump from 4% to more than 6% over the next 12 to 18 months. With each percentage increase in the state’s uninsured population, the health care system as a whole experiences lower utilization of physician services, especially primary and preventive care services, and increased strain on higher-cost emergency department services. In addition to the health consequences resulting from delayed or never diagnosed and treated health conditions, individuals losing health care coverage experience greater stress and anxiety. Even when they receive care from an emergency department, they may leave the hospital with health care debt that takes years to repay and keeps them from building financial security.

Trouble Ahead to page 124

The number of residents enrolled in the Minnesota’s health coverage programs grew by 28%.

The loss of health coverage has impacts throughout the health care system. Because a large majority of those who will lose coverage receive their benefits through Medicaid managed care arrangements, managed care organizations and county based purchasing plans will lose capitation payments when their enrollees lose coverage. In addition, they may bear higher costs when enrollees’ health conditions grow more acute during gaps in coverage because of delayed or missed primary and preventive care.

Physicians and clinics can also expect to lose revenue as previously covered patients forego routine and low-acuity care after losing public health coverage. Conversely, federally qualified health clinics, who provide an array of integrated primary care and outpatient services to people who are uninsured on a sliding-fee scale basis, may experience higher patient volumes and, as a result, greater staffing challenges.

To minimize the likelihood of residents who remain eligible for Medicaid or MinnesotaCare from losing coverage, DHS began outreach efforts encouraging enrollees to update their contact information. While official notices for renewals will be sent through U.S. mail, the department will attempt to raise enrollees’ awareness of the renewal process through social media, text messages, and other communication avenues, as well as

through efforts of counties, Tribal Nations, navigators, health plans, and community-based organizations.

How You Can Help

Physicians, clinics, hospitals, insurers and other health care stakeholders can help mitigate the loss of coverage for Minnesotans who remain eligible for Medicaid and MinnesotaCare. Encourage patients, as well as family members, friends and co-workers, to update their contact information, including their mailing address and phone number, with their county or state. In addition, they can get more information about the renewal process and sign up to receive email alerts when new information is available at the Minnesota Department of Human Services’ “Renew my Coverage” webpage: mn.gov/dhs/ renewmycoverage.

In helping raise awareness among patients, family members, friends and neighbors, avoid making assumptions about an individual’s source of health coverage.

Approximately 80% of Minnesota’s Medicaid and MinnesotaCare enrollees receive their benefits through managed care organizations, and therefore, may appear to have commercial insurance coverage.

While people over age 65 may be enrolled in Medicare, many also receive important health coverage through Medicaid.

The loss of health coverage has impacts throughout the health care system.

Minnesota’s Medicaid and MinnesotaCare enrollees are almost evenly split between the Twin Cities metropolitan area and Greater Minnesota.

One family member might qualify for public health coverage while other family members are enrolled in an employer-sponsored or individual health plan. Some people qualify for Medicaid coverage even though they are enrolled in their employer’s health insurance plan.

Emphasize the importance of watching for and responding to notices from the DHS arriving via U.S. mail, as well as information they might receive from the department or their county, Tribal Nation, or health plan.

Refer patients and others to the DHS dedicated webpage (mn.gov/dhs/ renewmycoverage) for more information about the renewal process.

Post or provide copies of downloadable and printable materials about the renewal process available from DHS. In addition to English, these resources are available in Spanish, Somali, Hmong, Vietnamese, and Russian languages. (https://mn.gov/dhs/renewmycoverage/communications-toolkits/)

While the end of the continuous enrollment policy and reimplementation of the Medicaid and MinnesotaCare renewal processes will be disruptive for some enrollees, physicians can help their patients keep their coverage or transition to private insurance. In addition to encouraging patients to watch for and respond to renewal notices, physicians can refer patients to the DHS website and resources, as well as to their health plan, for more information about the renewal process and how to prepare for it. For patients who are ineligible to remain enrolled in Minnesota’s public health coverage programs, physicians can encourage them to look into whether their employer offers

affordable coverage, explore coverage options and subsidies available at www.mnsure.org, or seek assistance from a navigator.

While the end of the continuous coverage policy presents daunting challenges, it also affords an opportunity for open discussions about the importance of health coverage. By asking every patient about their source of coverage; encouraging people to watch for and respond to notices from DHS and their health plan; and providing information about enrollment in Medicaid, MinnesotaCare, employer-sponsored plans, or potentially subsidized plans available through MnSure, Minnesota’s physicians can not only help prevent unnecessary loss of health coverage, but also build a stronger relationship and sense of trust with their patients.

Matthew L. Anderson, JD, is a senior lecturer in the Health Policy and Management Division of the University of Minnesota’s School of Public Health and a freelance consultant. He previously served as Assistant Commissioner for Health Care and State Medicaid Director at the Minnesota Department of Human Services.

The guide helped the man fabricate an expert in his next post: “Dr. Hyde T. Payne, a renowned health authority at the University of Life who has worked on the government’s COVID taskforce, says that there have been no deaths actually caused by COVID!” That drew more than 3,000 likes, and the likes grew exponentially with each new lie. After the man posted footage of a street riot — falsely claiming it was a protest against “Big Pharma” for suppressing evidence that radiation from mobile phone networks causes COVID-19 — he became an online conspiracy star.

Fortunately, the exchanges were fictional; they occurred within the confines of a web-based game designed to teach people about disinformation techniques so that they can better recognize and resist them. The game, Go Viral!, employs a growing strategy to combat disinformation: Rather than debunk specific false claims after they spread, it seeks to inoculate people against such claims by prebunking them beforehand. The idea is that teaching people how information is manipulated might be more effective than correcting the misinformation.

“Prebunking is about providing people with a weakened dose of disinformation and showing them a simulation of the types of attacks they might be facing, just as vaccines offer snapshots of the types of pathogens that might invade the immune system,” says Sander van der Linden, PhD, a social psychology professor at the University of Cambridge in the United Kingdom and co-creator of Go Viral!. “Once you know what to look for, you [the person receiving disinformation] can neutralize” those attacks.

It’s a sort of media literacy training that attempts to overcome some drawbacks of traditional debunking against misinformation (which is erroneous) and disinformation (which is intentionally incorrect). The whacka-mole nature of beating down deceitful tales after they appear is insufficient to have a broad impact on its own, especially when countless such tales travel almost instantly through electronic communication. For example, a study of misinformation about mpox on TikTok in May 2022 looked at 153 videos that featured conspiracy theories about the disease. Within an average of 30 hours after being posted, the videos had collectively drawn 1.5 million views.

In addition, communications experts say that while providing facts to correct misinformation and disinformation works with those who have not firmly bought into an erroneous claim, providing facts alone leaves many people unsure of whom to believe. “The knowledge deficit model means there’s something wrong with the public that you’re going to correct. You’re going to give them facts and they’re going to see the light,” says Dominique Brossard, MPS, PhD, chair of the Department of Life Sciences Communication at the University of Wisconsin–Madison. “Two decades of social science research will tell you that this does not work.”

“Debunking is especially difficult with conspiracy theories, which are often believed at an emotional, rather than rational, level,” wrote Beth Goldberg, research program manager at Jigsaw, a Google unit that confronts emerging threats to open societies. When Jigsaw interviewed dozens of conspiracy theory propagators, “we found that their deeply-held beliefs … were resistant to rational or factual counter-arguments” from experts, family, or friends.

To be sure, various approaches are needed to combat disinformation, including doctors providing science-based information to patients, health systems posting clear facts on easy-to-find web pages, and social media companies removing blatantly untrue posts.

But “a purely reactive mode is not appropriate,” Food and Drug Administration Commissioner Robert Califf, MD, wrote recently this year in a memo to staff that prioritized finding new ways to counter health misinformation. The U.S. surgeon general, in an advisory last year, called for measures to “equip Americans with the tools to identify misinformation” when it reaches them.

Getting Beyond Just the Facts

Stoking fear. Blaming scapegoats. Exaggerating partisan grievances. Sowing doubts about scientific consensus. Those are among the common tactics used in disinformation campaigns about all sorts of issues, from health to politics to culture, going back decades. In the 1960’s and 1970’s, for example, tobacco companies funded sham studies and ran ad campaigns to sow public doubt about the scientific consensus that smoking causes cancer. Fast forward to today, when attacking scientific consensus has been a tactic of disinformation about COVID-19. Researchers at American University and the Harvard T.H. Chan School of Public Health have identified the five most common tropes (i.e., narrative themes) in COVID-19 disinformation as “corrupt elites,” “vaccine injury,” “sinister origins,” “freedom under siege,” and “health freedom.”

Those frameworks make for influential messaging, as evidenced by their success at stirring up confusion, distrust, and conflict. But the techniques also present a vulnerability. Exposing people to the common tactics of disinformation messages, regardless of the issue that those messages target,

The impact of exceptional senior care

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is simpler and more scalable than trying to debunk a never-ending plethora of specific deceitful claims. Researchers have found that educating people about standard disinformation tactics makes them more likely to reject disinformation that they subsequently read or hear about such issues as climate change, agricultural biotechnology, and anti-vaccine conspiracies.

“You can inoculate people with specific facts against a specific piece of misleading information,” Van der Lind notes. “But in order to scale it [the inoculation], you expose people to weakened doses of the techniques used to produce all kinds of misinformation and ways on how to spot them.”

Inoculation strategies have been used for over a half century to defend against various types of mental manipulation, including brainwashing, according to “A Practical Guide to Prebunking Misinformation”, published last year by Cambridge, Jigsaw, and BBC Media Action. The guide notes that inoculation involves two basic steps: forewarning people that they might encounter misleading information, and preemptively refuting the misinformation.

The latest prebunking strategies that teach about disinformation tactics follow those steps through several formats, including text, video, and infographics, and are distributed mostly through social media and websites. For example, a video about scapegoating created by Truth Labs for Education

— developed by Cambridge, the University of Bristol in the United Kingdom, and Jigsaw — uses a South Park cartoon clip of a town meeting where furious residents debate who to blame for an epidemic of cursing among children. They march into the street chanting en masse the culprit they identified: “Blame Canada!” The point is that disinformation doesn’t need evidence to cite a scapegoat; it just needs a vague, easy target, such as immigrants or big government.

In recent years researchers have developed at least three online games to teach people about misinformation and disinformation techniques: Go Viral! (about COVID-19), Harmony Square (about pitting people in a community against each other), and Bad News (about creating a fake news site about such issues as climate change). The games’ creators hope the entertainment value will draw in users who would not enroll in something that feels like a class.

In each game, the player takes the role of someone learning to use the techniques. “Beware: misinformation is designed to trick you,” Go Viral! tells players at its introduction. “So why not walk a mile in the shoes of a manipulator to get to know their tactics from the inside?”

The game consists of text messages between the player and a guide. The guide helps the player develop increasingly liked and shared social media messages by contriving claims, using emotionally hot words (such

3Health Care Prebunking from page 14

Limiting the spread of health misinformation is a moral and civic imperative.

Workforce Research in Public Health

A new collaborative consortium

BY J.P. LEIDER, PhD

There is a common aphorism: jack of all trades master of none. Though it doesn’t quite apply to physicians in this day and age, physicians are increasingly expected to be scientific experts with financial and business acumen, and ever more advanced technological skills, in order to practice medicine. For those who run their own practices, they also must have expertise in labor market dynamics, which is a profession unto itself.

Questions of how to recruit and retain a competent workforce have long been a challenge in managing a clinical practice, just as they have been in governmental public health, through boom and bust times alike. Labor shortages have always been an issue. How long have we talked about looming physician shortages, or nursing shortages, or physician assistant shortages? Today it seems that they are worse than they have ever been. What seems different now is that the crunch is everywhere, and since all labor is more interconnected than ever, shortages in some areas affect others. One such area is the public sector generally, and in public health specifically. This is where the University of Minnesota’s School of Public Health (SPH) is conducting nationally-oriented research that will address some of the most challenging workforce issues in the field.

Workforce Development Research in Health Care Delivery

There are nine health workforce research centers in the United States. They focus on a variety of areas, all with a similar focus- how do the issues facing our health care workforce affect the delivery of care and, ultimately, the population’s health? These nine centers cover the emerging workforce, allied health, oral health, behavioral health, and other areas. Public health has recently been added to the list and this new focus likely reflects the challenges wrought by response to COVID-19. We have seen declines in this particular workforce, which has the potential to impact areas of population health such as the delivery of clinical services, protective inspections, and population based services in our communities. SPH leads an endeavor to research the public health workforce through a new collaborative model called the C onsortium for WOrkforce R esearch in Public Health (“CWORPH”), which includes five additional universities:, Columbia, Eastern Tennessee State University, Indiana University, Johns Hopkins, and University of Washington. CWORPH also includes additional partners that represent and serve public health practitioners across the U.S..

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Substantial investment in public health workforce development was made in the aftermath of the bioterrorism attacks of 2001. Primarily this was in the space of preparedness training, but also there were somewhat broader investments in public health research. It wasn’t until the late 2000s that public health centers started to take hold and many online trainings became widely available. SPH is well known for developing a number of these trainings, some which are still available today. As part of the new “Minnesota Prepared” joint partnership with the Minnesota Department of Health, SPH is revitalizing some of these offerings by updating technology and content. Additionally, SPH partners with the Region V Public Health Training Center (RVPHTC), based out of the University of Michigan. Any provider can get training for free from the RVPHTC regarding public health and preparedness issues, as well as relatively inexpensive continuing education credits. There is also a new leadership institute available to public health and primary care practitioners through the RVPHTC, which CPHS supports. It is our charge to better connect the public health and primary care workforces, and ensure training is available to all.

Range of Projects

While training is, by volume, the largest portion of workforce development, research plays an incredibly important role. The new Public Health Workforce Research Center, supported by HRSA and CDC along with CWORPH, is tasked to help solve some of the most persistent questions in our field. Largely these relate to how to count the workforce, how to recruit and retain the workforce, and how to build and maintain pathways from colleges and universities into the workforce. Each year, CWORPH conducts at least eight projects, and rapidly disseminates their findings in concert with practice partners. It is definitely not a situation where we unilaterally identify problems for the field and provide answers when the projects conclude. The community tells CWORPH what the problems are and everyone works

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together to find those answers and quickly share the data. Projects include:

• Turnover assessment of the public health workforce

• Description of roles of nurses in COVID-19

• Strategies to convert a temporary surge of workers into a permanent workforce

• Characterizing variation in workforce composition

• C omparison of occupations in the public health vs. private sector workforces

• Identifying gaps from agency workforce development plans

• Review of state hiring laws

• E stimating workforce supply

• Roles of community health workers

• Career ladders in recruitment and retentionAir-Change Analysis

Resource Allocation

Some of these projects are more technical than others. Some may be a little more exciting. Not all of them reach out and grab you - it is workforce research, after all. All of our projects have a focused and important role to play in understanding why and how the public health workforce has withered over the past 15 years. A major reason is the lack of top-down investment and misuse of initial funding. But it’s not just about money and the lack of it. Those in a clinical setting can connect with this ideathat resource allocation is more than just about top-line decision making. There are cascading consequences of dollars and cents, and so to rebuild the system, we have to understand so many components of the budgets that got cut and how those systems got set up ages ago.

In our first year, our aim is to understand some very fundamental aspects of the public health system. This includes understanding nationwide geographic and demographic population distribution, examining public and private sector methods of collecting data, and comparing this data and ways in which occupations are changing over time. Two topics may be of particular note to physicians. One is that HRSA and CDC are particularly interested in how nurses operated in the context of COVID-19 response. Over the last 40 years, the role of nurses in the public health sphere has dramatically changed. Previously, nurses operated mostly in a clinical context because, throughout the mid 1900s, public health provided extensive safety net clinical care. Starting in the 1970’s and throughout the 1980’s especially, there was a push to have public health offload a lot of its clinical care to community health centers and the private sector. The thinking that changed the landscape was that public insurance was more widely available, allowing an increased number and more providers to take on the extra work. In theory, public health could leave that side of care to the people who could deliver it best, between private providers and FQHCs and other community health centers. Then public health could focus on what it does best - populationbased services, direct inspection/regulation, and some clinical prevention if needed. But where did that leave nurses? Nurses had been the largest part of the public health workforce, essentially forever. In many parts of the country they still are, but in the past several decades the size of the public health nursing workforce has shrunk drastically. Part of that has been competition from the private sector, and part of that is that now over a third of nurses in public health do non-clinical work, jobs that might be better performed by staff with other training. Nurses are often placed into jack-of-all-trades type

positions, and what one of the things we are trying to find out is what they were asked to do in the context of COVID response. Everything, perhaps?

A second question and study that is being undertaken this year is the rise of Community Health Workers (CHWs). CHWs largely did not exist in the public health workforce two to three decades ago. There were some states that had strong contingents of this workforce, but CHWs were not highly utilized nationally, though they played incredibly important roles in the delivery of health care services. Now we are seeing that more health departments are employing CHWs. Indeed, in Minnesota the CHW is one of the positions that health departments say they are trying to hire and having a hard time doing so in the context of the labor market challenges we are currently experiencing. Our study seeks to characterize that CHW workforce especially.

A New Research Partnership

While the projects themselves are interesting, the story of how CWORPH came to be is as well. We constructed our six-member consortium to cover a number of topical areas and expertise in the space of public health and health care workforce research. My specialty is public health systems generally, and Janette Dill, the Deputy PI on the HRSA/CDC-funded Center has worked for many years on topics related to the health care workforce. Heather Krasna at Columbia University is an expert in topics of recruitment, while Michael Meit at East Tennessee State University and the ETSU Center for Rural Health Research is a national leader in rural public health and health care. Valerie Yeager at Indiana University is a qualitative methods expert and has broad expertise in public health workforce, including on issues of workforce development and Workforce Research in Public Health to page 204

 Epilepsy/Seizures

 Headache/Migraine

 Neck/Back Pain

 Sleep Disorders

 Movement Disorders

 Parkinson’s Disease  Tremors

 Multiple Sclerosis

3 Workforce Research in Public Health from page 19

recruitment, while Beth Resnick at Johns Hopkins University is a public health systems researcher that has worked extensively during COVID-19 on issues of bullying and harassment. Betty Bekemeier at the University of Washington is a public health nurse and researcher with extensive experience across a broad array of public health workforce and systems issues.

CWORPH is advised by the National Consortium for Public Health Workforce Development, and it has a number of practice partners on a technical expert panel, including:

• A ssociation of State and Territorial Health Officials (ASTHO)

• National Association of County and City Health Officials (NACCHO)

• A ssociation of Schools and Programs of Public Health (ASPPH)

• Big Cities Health Coalition (BCHC)

• Public Health Accreditation Board (PHAB)

• MissionSquare Research Institute

• de Beaumont Foundation (dBF)

• State Associations of County and City Health Officials (SACCHOs)

• Public Health Training Centers (PHTCs)

Conclusion

Oftentimes, federal RFPs let you submit under different models. This one would have let an applicant go in as an individual university or as a consortium. Submitting as a consortium was the only thing that made sense, even though we would have been competitive as single universities. The issues facing the public health workforce are just too thorny for one organization to tackle on their own. It made sense to leverage everyone’s strengths to figure out together what the problems were and to try and solve them, together. Public health is inherently collaborative, and it would be counter to this idea for a single university to create a model -no matter how well-meaning - that would attempt to solve all these problems on its own. A consortium where many perspectives collaborate to identify the problems and work with federal partners to pick, research and solve them means that we identify the most important issues, apply the most rigorous methods to solve them and then rapidly disseminate the results. This sort of rapid cycle approach is an exciting way to do applied research at a time when public health workforce issues are in the lime-light and actually getting investment - and at a time when workforce shortages in health and health care face an unprecedented need for quick and concise resolution.

J.P. Leider, PhD, is the director of the Center for Public Health Systems at the University of Minnesota School of Public Health. He is a senior fellow in the Division of Health Policy and Management and on the affiliate faculty at the Center for Bioethics.

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HEALTH CARE FACILITIES DESIGN

Energy Sustainability

Retro-commissioning aging facilities

BY MATT WADE, PE AND JONATHAN HUNLEY, CHFM

The primary goal of health care is to prevent disease and improve the quality of life. In this pursuit, environmental issues have suffered. Consider the following statistics:

• Inpatient care is ranked by the EPA as the second largest commercial energy user in the U.S.

• Health care facilities consume close to 10% of the total energy used in U.S. commercial buildings, spending over $8 billion dollars on energy a year.

• The health care sector creates 8.5% of U.S. greenhouse gas emissions. While physicians are rarely responsible for making decisions about facilities energy usage, some baseline knowledge around these issues may prove useful.

Bon Secours Mercy Health (BSMH) is a national leader in a growing group of health care systems that have decided to commit to a “do no harm” policy by working to eliminate the negative health and climate impacts of their energy consumption. Recently named a recipient of the Practice

GreenHealth “System for Change” award, BSMH believes in a commitment to developing a sustainable culture through environmental stewardship and working with others now and in future generations. Sustainability initiatives for BSMH have included obvious measures such as recycling, using more sustainable products and implementing energy-efficient systems and practices as part of new construction projects. But there were other ways to save money and improve efficiency within their current systems and buildings that do not bear a heavy price tag.

Facilities Sustainability

Sustainability initiatives don’t need to be limited to new construction projects or large expenditures. Recently, a growing potential for savings has been identified in older and aging facilities. Older HVAC systems generally were not energy efficient in their original design and the impact of time on these systems often leads to a worsening of their energy impact. In addition, changes in the use of facilities over time can lead to energy-intensive systems used in areas that no longer truly need such systems. Rising utility costs further underscore the need for change in some of these older facilities.

To combat these forces, in the spring of 2021 BSMH partnered with CMTA to begin to collect energy data from some of its older facilities and conduct an exercise where this data was benchmarked to compare one facility to another. One common building benchmark used as a measuring stick to compare energy use in facilities is the Energy Use Intensity (EUI). This is simply a ratio of the total energy used in each facility divided by the square footage of the facility. Calculating a building’s EUI allows a facility management team to assess how a given building performs relative to other similar buildings. These benchmarks are then compared with data from similar facilities around the country to assess need.

After BSMH completed its facilities benchmarking process, one facility stood out as the lowest performer – Lourdes Hospital in Paducah, KY. Lourdes Hospital is a regional hospital building with 306 staffed beds. This facility was significantly worse in energy use (12 %) than the median US hospital property and 14% worse in total energy cost ($/sf).

Investments were planned for the facility to renovate several older building systems including the central utility plant, however, reducing utility costs and improving system efficiency prior to that became the priority. With this goal in mind, BSMH issued a challenge to CMTA: identify low-cost and no-cost changes which could be implemented at their facility to reduce emissions and utility costs immediately. These costs would need to focus on areas outside the central utility plant and the floors slated to be renovated. To meet the challenge, CMTA applied a retro-commissioning strategy to their existing building systems.

Retro-commissioning

What is retro-commissioning? Many are familiar with commissioning: the process of verifying that the actual operation of an installed system meets its design. This has a simple application to new construction projects. But

what about renovations or existing buildings? There is a process called re-commissioning, however, this process often falls short in an existing facility.

Consider, for instance, the system that was designed 50 years ago and no longer is serving its intended purpose. Does re-commissioning such a system to verify that it operates in line with its 50-year-old design worthwhile? Most often, the answer to this question is ‘no’ and another solution is needed. Retrocommissioning is the process of marrying the active control and facility design with re-commissioning to achieve improved energy performance and efficiency in older systems. This process is not limited to the verification of a sequence of operations written fifty years ago, but instead asks the question – ‘how should this system operate today, given the current use of the facility?’ The retro-commissioning process at Lourdes Hospital in Paducah, KY leveraged retrocommissioning in the following areas: ventilation optimization, air-change analysis, HVAC system speed, scheduling study, steam evaluation, and planning for the future.

Ventilation Optimization

One key user of energy in a facility is the amount of outside air intake that occurs to keep the facility ventilated. Much of the ventilated air is a calculated amount and is required by local codes. However, deferred maintenance or equipment failure often leads to systems that allow far more outside air than required. This leads to large efficiency reductions and potentially, even comfort and humidity issues. To ensure that the facility ventilation system was optimized, we conducted a survey of all the major existing air handling systems to track and observe the operation of the air handler outside air dampers. As part of the survey, one air handler was identified which had dampers that had been manually adjusted but were no longer controlled by the building automation system (BAS). This led to the air handler operating far above the minimum outdoor air exchange rate as required by code. Identifying and correcting just this one issue led to savings of nearly $10,000 per year.

Air-Change Analysis

In addition to requiring a certain amount of outside air, codes require that hospital HVAC systems must circulate a certain volume of air through the unit filters every hour. This requirement is referred to as a system’s air-change rate. The issue that arises in older facilities is the use of spaces change, but air-change rates are often not re-evaluated to match the rates required by modern codes and their current use. As part of the study, we completed a code review and analysis of air handling systems and their respective air-change rates. These calculations revealed several air handlers which, either through a change in use or insufficient commissioning, were far over-supplying the code-required air changes to the space. In addition to excess fan, heating, and cooling energy, this also increased the required reheat energy. Identifying these locations as part of the retro-commissioning effort allowed the facility team to reduce fan speeds and their associated cooling, heating, and reheating loads. In one particularly significant case, an existing surgery air handler was able to have its airflow cut in half while still fulfilling the spaces health and sanitation requirements. This simple adjustment resulted in savings of approximately $25,000 per year.

HVAC System Speed

Most modern hospital HVAC systems are now designed with variable volume fan technology. This means they can speed up or slow down fans and cooling/heating as required to meet changing building loads. Often in a facility, the quick and easy way for a construction team to set up these HVAC systems is to pick an initial system speed that is substantially higher than required and use this higher fan speed to commission the system. While this may simplify the construction of HVAC systems, the end result often is HVAC systems with fans running harder than necessary to achieve building conditioning but cannot turn down fully as required to achieve optimal energy performance. In addition to poor system set up, at times deferred maintenance or construction activities within the facility can cause clogged filters, building intakes, or coils. These clogged portions of the HVAC system introduce unnecessary load which results in HVAC systems that need to run harder to produce the same amount of cooling.

We surveyed the existing building systems to determine areas where HVAC system speeds had not been optimized. Through this survey, several opportunities throughout this facility were identified and corrected which led to significant energy savings. In one case, an air handling system was

A growing potential for savings has been identified in older and aging facilities.

3 Energy Sustainability from page 23

identified in which the original fan speed was set nearly 30% higher than necessary. Adjusting the speed setting of this system saved the facility an estimated $7,500 per year. In addition to these savings, several maintenance projects and clogged air intakes and coils were identified which resulted in additional savings for the facility.

Scheduling Study

Modern HVAC control systems generally turn on when spaces are in use and then turn off or at least slow down when people leave for the day. This capability is referred to as ‘system scheduling’ and is a critical component of optimal energy performance. However, these schedules can often get muddied in a large health care facility that has been renovated and re-purposed over the years. As building uses change, sometimes the HVAC schedule no longer fits the needs of the space. As part of the retro-commissioning effort, each area of the building was reviewed with maintenance staff to compare how it was programmed to operate versus how each area was actually used.

In several instances, our study revealed HVAC systems that were programmed for patient care or 24/7 operations but now, housed administration areas or visitor spaces that were only occupied during

specialist to add additional schedule programming to ramp down or shut off the HVAC system entirely during unoccupied periods to greatly reduce airflow during off hours. In one instance, implementing this strategy saved the hospital approximately $8,500 per year. In addition, our study found three key air handlers which had a user override in place that had removed the scheduling feature from these units entirely. Re-instituting the proper scheduling of the three air handlers led to an annual energy savings of $58,000 per year.

Steam Evaluation

Most aging healthcare facilities’ source of primary heating is steam. Large steam boiler systems are centrally located and pipe steam throughout the facility. Over the system life cycle they can suffer from poor energy performance through failing components. A key element of this piping system is called a steam trap. These devices remove excess moisture from the steam piping and are located throughout the facility. Over time, these steam traps will fall open, allowing valuable building steam to escape into the atmosphere. As a part of this project, a full steam trap survey was completed to determine if these devices were still operating as required. The survey discovered that over 30% of the steam traps in this existing facility had failed. Fixing these traps resulted in energy savings of over $22,000 per year.

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These changes reduced the carbon footprint of this existing facility by over 95 metric tons per year.

Planning for the Future

In addition to surveying and identifying low-cost and no-cost changes for the facility, part of the retro-commissioning process was assisting the facility to prioritize future energy saving investments. The full survey of their facility included collecting data on the existing HVAC systems and establishing a rank for which systems were the greatest priority for replacement or upgrades to save additional energy dollars. In addition, the report identified specific areas for improvement and suggested energy projects along with their anticipated cost and savings. As a result, the facility now has a roadmap for the future to continue to improve its energy efficiency.

Impact

At the end of the retro-commissioning process at BSMH Lourdes Hospital, over 30 major HVAC systems were evaluated, with over 27 low-cost and no-cost changes implemented along with helping the facility to develop a roadmap for future energy-saving projects. The process saved nearly 8% energy use in the first year of operation, taking their EUI from 252 KBTU/ SF to 238 KBTU/SF. After reviewing utility cost data from the facility, these changes are projected to save the facility $181,000 in its first year. In addition, their environmental impact as a result of these changes reduced the carbon footprint of this existing facility by over 95 metric tons per year – the

equivalent of taking an additional 20 cars off the road per year and savings in cooling energy were able to offset water use by nearly 672,000 gallons per year – the equivalent of an Olympic sized swimming pool a year.

Conclusion

Energy savings and a reduction of a health care facility’s energy use are not limited to the realm of new construction or major renovations – it is possible through retro-commissioning to achieve significant energy and cost reduction.

An easy place to start is benchmarking facilities and comparing the data to like facilities through EPA’s Energy Star Target Finder website. If your aging facility’s EUI is approaching or above the median value, a retro-commissioning process is a simple next step. Although the process is straightforward, it takes time and effort to achieve significant results. But it is possible to reduce energy use and retro-commissioning can be a helpful tool in the march toward a more cost-effective and sustainable future.

Matt Wade, PE, is a mechanical engineer at CMTA.

Jonathan Hunley, CHFM, is the director of infrastructure, Bon Secours Mercy Health.

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it is possible through retro-commissioning to achieve significant energy and cost reduction.

to move their families out of Texas. Pediatricians and other clinicians across Texas began to reach out to their colleagues across the country, asking for help in caring for their patients. For these reasons, Marc Gorelick, MD, president and CEO of Children’s Minnesota, and myself sent a letter to the Texas governor to formalize our opposition to the directive. Texas is only one example. Several states in recent years have passed anti-LGBTQ policies. The harm caused by these policies goes beyond what’s written in the legislation. Research shows that transgender youth living in states where legislation is introduced that seeks to ban them from competing in sports, accessing health care or public facilities, causes increased stigmatization and contributes to increased rates of depression, anxiety and suicidality. Therefore, protecting access to inclusive and gender-affirming care can literally be lifesaving for transgender and gender diverse kids.

Related to this topic, clinics nationwide have received threats around providing this care. What can you share about this?

Well, we certainly don’t go into pediatrics

expecting to be harassed and threatened for the care that we provide to kids. Unfortunately, however, patients, families and clinicians at children’s hospitals are the focus of a fear and misinformation campaign. According to the Human Rights Campaign

Gender-affirming care is supported by evidence-based research.

Foundation, anti-equality, online extremists are leading a coordinated campaign of hate against hospitals and providers. The people leading the campaign are spreading misinformation and falsehoods about gender-affirming care to spur threats to children’s hospitals, care providers and other staff. Boston Children’s Hospital, Children’s Hospital of Pittsburgh, University of Wisconsin and other hospitals around the country have experienced threats, harassment — even a bomb scare — for

providing health care to children and teenagers in their gender health Programs. The Gender Health Program at Children’s Minnesota has also faced harassment on social media. In addition, I’ve received harassing and threatening messages on my social media pages. This is not strictly an LGBTQ issue; it’s an issue for everyone who needs safe and secure access to care at a children’s hospital. Families and children should be provided the care they deserve without the fear of being attacked. The care that takes place between a medical provider and patient families is sacred and should be protected at all costs

As with all elements of health care delivery there are cultural and equity concerns around gender health. What are some examples?

Identifying as LGBTQ is only one piece of a child’s identity. It intersects with other aspects – race, culture, ability – to make up their entire identity. Sadly, we live in a society where if you’re not white, straight and male – you are at increased risk for harassment and discrimination.

Providing a Supportive Environment for Children and Their Families to page 284

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3Providing a Supportive Environment for Children and Their Families from page 26

For LGBTQ youth who are Black, Indigenous, Latinx or any other race or ethnicity, that harassment can be compounded. For example, the “Erasure and Resilience: The Experiences of LGBTQ Students of Color” report found that 40% of Black LGBTQ students experience both anti-LGBTQ and racist harassment at school. As health care providers, we need to acknowledge our patient’s entire identity and take that into account when we are asking them questions and offer the appropriate support. According to a 2020 report from The Trevor Project, 44% of Black LGBTQ youth seriously considered suicide in the previous 12 months, including 59% of Black transgender and nonbinary youth. That same report found that 49% of Black LGBTQ youth sought out psychological or emotional counseling from a mental health professional in the past 12 months, but were not able to get it. The research found that Black youth who had access to one LGBTQaffirming space attempted suicide at 50% lower rates compared to Black LGBTQ youth without access. What these numbers tell us is that while

ensuring access to gender-affirming care is important for all kids, it can be particularly lifesaving for Black, Indigenous, Latinx and other communities of color.

What advice do you have for physicians treating patients with gender-identity related issues?

In so many ways, we have made significant progress when it comes to the health and wellness of LGBTQ youth. We have expanded our language as a society to include more options for sexual and gender identities. More pediatricians are comfortable providing primary care to LGBTQ youth, particularly sexually diverse youth, compared to 10 years ago, even if some still struggle to understand how to best support gender-diverse youth. My advice is to listen to your patients and community and respond to the care that they need. Listen to the experts on your staff and in your community about what inclusive and equitable care looks like. Remember that supporting all kids and families, means supporting and celebrating LGBTQ kids and their families. On the individual patient level, take the time to ask each patient’s name and

pronouns and challenge yourself to “get it right”. Remember that just like all kids and teenagers, transgender and gender-diverse youth are on a journey to understand their identities and figure out where they fit. Give them time, messages of unconditional love and support, and make sure they can access the resources they need along the way. On a system level, strong support of hospital leadership, up to the level of the CEO, for diversity, equity and inclusion, will lend itself to developing innovative programs to address health inequities, such as our Gender Health program. We know that with the right support and access to gender-affirming care, transgender and gender diverse kids can grow up to be happy, healthy, safe and strong. And that’s what we want for all our patients and families; we want to help them thrive.

Angela Kade Goepferd (they/she), MD, is the chief education officer and medical director of the Gender Health Program at Children’s Minnesota. In addition, they currently serve on the Board of Directors for Rainbow Health, an LGBTQ health and HIV advocacy organization.

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With more than 35 specialties, Olmsted Medical Center is known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

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building a conspiracy theory to offer a simple explanation for the crisis and a disliked scapegoat (“Big Pharma”). The player becomes administrator of an online community of skeptics.

More Efforts Needed

Even the practice of refuting specific claims has moved more toward prebunking. Abbie Richards watches for disinformation on TikTok and warns people ahead of time about myths coming down the pike, including bogus health remedies that seem likely to gain traction among people who are understandably eager to find simple fixes to frustrating problems.

“There is so much health misinformation, especially when it comes to weight loss and fitness,” says Richards, a research fellow at The Accelerationism Research Consortium, which studies movements to destabilize democratic societies.

A study led by vaccine researchers at several institutions in Canada used both approaches — refuting specific information and teaching disinformation tactics — to educate people about COVID-19 vaccines. One group of participants were told that mRNA vaccines cannot change someone’s DNA and that the vaccines were studied with plenty of time to establish their safety. They were also shown some of the tactics that might be used in disinformation against the vaccines, such as stirring fear and citing fake experts. They then received the type of disinformation that had been refuted

by the prebunking materials. Another group got only the disinformation. Participants in the first group subsequently reported significantly more intent to get vaccinated than those in the second, according to the study published last spring.

It remains to be seen if such strategies can gain widespread traction. Because the impact of one-time educational interventions tends to fade over time, learners might need booster interventions, says “A Practical Guide to Prebunking Misinformation”. And getting the prebunk messages and educational materials to audiences in places where misinformation is often spread (such as through private message apps) remains a challenge.

For now, prebunking is an innovative strategy within the range of approaches needed from governments, institutions, and individuals.

“Health misinformation is a serious threat to public health,” the surgeon general’s advisory said last year. “Limiting the spread of health misinformation is a moral and civic imperative that will require a whole-ofsociety effort.

Patrick Boyle, is a senior staff writer with the Association of American Medical Colleges. This article first appeared in AAMCNews and is reprinted with permission of the Association of American Medical Colleges.

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