Minnesota Physician March 2023

PHYSICIAN

Privatized Medicaid and MinnesotaCare Bills could lead to review of zombie programs

BY KIP SULLIVAN, JD

Long COVID

Facing a shadow pandemic

BY KATE MURRAY, MPH, AND RUTH LYNFIELD, MD

Amiddle-aged patient complains that he still hasn’t recovered from COVID-19 after several weeks. In addition to persistent digestive issues, he is sidelined by extreme fatigue after minimal activity, whereas last year he was running half-marathons.

Another presents with dizziness and a racing heart upon standing, frequent migraines, and issues with memory and concentration so severe that she has lost her teaching job. She can’t identify any significant health events other than having mild COVID-19 four months ago. Her blood tests are unremarkable.

Long COVID to page 104

Congress enacted legislation authorizing the Medicare and Medicaid programs in 1965 because the insurance industry didn’t want the elderly and the poor. Oddly enough, today the insurance industry covets the elderly and the poor. Today, half of all Medicare beneficiaries are enrolled in insurance companies that participate in what is known as the Medicare Advantage program, and two-thirds of all Medicaid recipients are insured through insurance companies. Here in Minnesota, all MinnesotaCare recipients and eighty-five percent of the enrollees in Medical Assistance (MA), as Minnesota’s Medicaid program is known, are enrolled in insurance companies.

Privatized Medicaid and MinnesotaCare to page 144

By Kate Murray, MPH,

Lynfield, MD,

By Kip Sullivan, JD

THE HEALTH CARE WORKFORCE SHORTAGE: Facing a crisis

BACKGROUND AND FOCUS:

Vaccine Confidence

Promoting

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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.

OBJECTIVES: JOIN

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.

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.

M Health Fairview Opening New Highland Park Facility

The existing Highland Park M Health Fairview Clinic is moving into a nearby new building with services opened in the last days of February. The 26,000-square foot facility, constructed by Ryan Development, will anchor the newly built Highland Bridge Medical Office on the corner of Ford Parkway and Mount Curve Boulevard in St. Paul. The existing clinic, located two blocks away, will close. The new clinic will provide primary care services – including family medicine, women’s health, mental health and urgent care. There will also be a Fairview pharmacy located on the first floor of the building. M Health Fairview Rehabilitation Services, which offers physical therapy and sports medicine for a variety of conditions, including pelvic health,

space offers expanded women’s health and mental health services.

“We’re excited to expand our offerings in women’s health for residents of the growing Highland neighborhood and beyond,” said Heather Uhr, a women’s and children’s service line manager. “Expecting families will be able to access compassionate, personalized OB/GYN, midwifery, and family medicine care for all their needs from conception to well-child visits.” Behavioral health care and counseling for children, teens, and adults will be provided through virtual and in-person visits. In addition, Behavioral Health Home services will be provided for patients insured through Medical Assistance or a Prepaid Medical Assistance Plan (PMAP). This team-based service is designed to meet patients where they live, by addressing social determinants of health and setting realistic whole-person health goals. Our

in the community that will make health care access easier than ever for the thousands of future residents in St. Paul’s Highland Park area, while ensuring uninterrupted care for existing patients. “Our Highland Park clinic has been at its current location for over 25 years, and we’ve been a part of the neighborhood for over three decades,” said Sara Johnson, MD, medical director of the Highland Park clinic. “We’re excited to grow into our new space down the street and continue to serve the growing Highland and Hiawatha neighborhoods for decades to come.”

Avera Grant Integrates Behavioral Health with Primary Care

Avera has received a $100,000 grant through the South Dakota Community Foundation’s Beyond Idea Grant (BIG) Program to further integrate behavioral health services

into primary care visits in Brookings County. A concept known as Integrated Behavioral Health is the gold standard for behavioral health care in any setting, per the American Academy of Family Physicians. “Integrated Behavioral Health adds providers within primary care to increase access and care coordination while improving prevention and reducing barriers,” said Nikki Eining, outpatient clinical therapist for Avera Medical Group Behavioral Health in Brookings and project director. While 75% of primary care visits nationwide include a mental health component, most of South Dakota lacks access to behavioral health services in any setting. Brookings County is a federally designated Mental Health – Health Shortage Professional Area. Suicidality increased in 2022 to exceed the 10-year average of suicide attempts. By innovating via integrated behavioral health, this pilot will reduce the disparity while increasing ease and

access to care. Training for clinicians will increase their knowledge about identifying and referring behavioral health concerns. Equity training will help support cultural sensitivity and referrals for Hispanic and Native American patients. Another aspect of this grant is collaboration with South Dakota State University to identify behavioral health access gaps for Native American students. “Mental health has long been identified as an urgent need across South Dakota. Suicidality, drug abuse and family crises are just a few of the societal problems that result. We want to prevent these tragedies and help individuals and families experience higher quality of life,” said Ginger Niemann, Senior Program Officer with the South Dakota Community Foundation. “Solving this issue will take innovation and collaboration. We selected this project for BIG funding because it not only will benefit Brookings County, but could serve as a model for making behavioral health services more accessible and timely for patients in need.” “We are incredibly grateful for the grant funding to launch this project and we are excited to see the difference it makes as this concept gains momentum,” Eining said.

Tri-County Rebrands as Astera, Opens New Hospital

Tri-County Health Care, serving central Minnnesota since 1925, has changed its name to Astera Health. With the name change comes the opening of the new 125,900 squarefoot Astera Health hospital. The new facility integrates technology with a healthy environment which improves the patient experience and efficiency for staff and ensures a sustainable future for health care in their service area. Astera Health hospital is located on a beautiful new property west of Wadena along Highway 10. When Tri-County Hospital was built 50 years ago, inpatient care accounted

for 90 percent of its patients, and the facility design reflected that care. Patients expected to stay multiple days and needed the right care and environment for an extended stay. Improved technology and best medical practices have led to shorter hospital stays and allow many post-surgical patients to go home the same day. As a result, inpatients now only account for 13 percent of care provided. This shift means outpatient care is the primary focus. Astera now offers its patients a facility that reflects the strength of the communities it serves. The old facility, with its disjointed layout offering care in three separate buildings with multiple entry points, could not meet those expectations. At a recent ceremony President and CEO Joel Beiswenger shared his thoughts about the hardships endured throughout the construction process, including the COVID-19 pandemic and numerous supply chain issues. “This has liter

Approved

For more information on how to enroll, qualifying medical conditions, and more, visit mn.gov/medicalcannabis.

100 years.

(pictured: Dr. Gigi Chawla, MHA ’17)

CAPSULES

DHS Announces $5.7M in Grants to Curb Opioid Addiction

The Minnesota Department of Human Services (DHS) has awarded $5.7 million to 12 grantees to expand the services available to support people suffering from opioid use disorder and make it easier to get help. Almost all the funding is going to organizations primarily serving Native communities, Black communities and communities of color disproportionately impacted by the opioid epidemic. The new investments will address gaps in Minnesota’s continuum of care for Native people and people of color with opioid use disorder and help better serve all Minnesotans. Organizations receiving grants serve the Twin Cities metropolitan area, greater Minnesota and Tribal Nations, while others provide services statewide. The number of opioid-involved deaths in Minnesota reached 924 in 2021, up

from 343 in 2018. Native Americans and Black Minnesotans are experiencing the opioid epidemic more severely. Native Americans are seven times more likely to die from a drug overdose than White Minnesotans, while Black Minnesotans are twice as likely to die from a drug overdose. “Minnesota can not and will not accept this continued pain and heartbreak for families and communities,” said Human Services Commissioner Jodi Harpstead. “With this funding, our partners can save lives now and in the years to come through a range of programs that are person-centered, trauma-informed and culturally responsive.” The new grants will support culturally specific practices, including primary prevention and overdose prevention, workforce development and training and expansion and enhancement of the continuum of care. The funding includes $1 million for services focused on the East African population. The current grantees were

selected after extensive review, with a focus on increasing access to treatment, reducing opioid overdose-related deaths and addressing unmet needs for prevention, treatment and recovery services. The Department of Human Services and the council requested proposals in April 2022. In the coming months, the Opioid Epidemic Response Advisory Council will announce additional funding recommendations and begin soliciting proposals for new funding.

Regions Hospital Receives $2.5M to Expand Clinical Simulation Training

The Ortto Bremer Trust recently donated $2.5 Milion to expand the HealthPartners Clinical Simulation Center located within Regions Hospital. This high-tech form of training allows a nurse to slip on a virtual reality headset and step into an emergency department where t hey prepare for

a massive blood transfusion ahead of an imaginary trauma patient’s arrival. “The high-quality care that we deliver is supported by continuing education opportunities like those offered by the Clinical Simulation Center,” said Megan Remark, president of Regions Hospital. “This donation is going to improve the learning experience for the thousands of clinicians we train each year and ultimately contribute to a more prepared and effective workforce to care for our communities.” HealthPartners Institute’s Clinical Simulation Center trains 8,000 health care workers each year. Simulations include specific procedures performed on computerized mannequins to practicing for specific patient care situations. While many of these health care workers are part of HealthPartners, trainees also include local medical and nursing students, emergency medicine and fire department personnel and even local high school students who

are exploring careers in health care. Research shows that simulation is associated with improved response times during emergency scenarios that require chest compressions and defibrillators, and it’s associated with better clinical performance outcomes. Three-dimensional printing is one of the notable upgrades to the simulation center’s equipment. These printers can be used to make replicas of patient’s body parts, giving clinicians an opportunity to practice surgical techniques and other procedures before conducting them in real life. “Simulation allows healthcare to create individual and team experiences that could take years to acquire otherwise,” said Dr. Benoit Blondeau, chair of the department of surgery at Regions Hospital. “It also creates a safe environment to frankly discuss what went wrong in real-time instead of a narrated review later.” Virtual reality headsets will also be part of the simulation center enhancements. These tools can be programmed with clinical scenarios that provide lifelike experiences in a low-stakes environment. Care team members can then rehearse best-practices to help prevent things like medication errors, the most common adverse event in hospitals, according to recent data published in the New England Journal of Medicine. The new simulation space will be almost 7,000 square feet on the first floor of Regions Hospital.

BC/BSMN Expands Rural Provider Network

Blue Cross and Blue Shield of Minnesota (BC/BSMN) and Homeward, a new company focused on improving nationwide rural health care delivery, recently announced a new value-based collaboration designed to increase access to health care for outstate Minnesotans. This spring, Blue Cross Medicare Advantage members in 24 Greater Minnesota counties will have access to Homeward’s services, which include in-home visits, community-based visits, and

technology-enabled clinical services including telehealth. The two organizations are working together to identify qualifying patients who are not currently engaged to receive the care they need or have known gaps in care. Over time, Homeward and Blue Cross plan to continue expanding the offering to additional Minnesota counties. Through partnerships with regional health systems and providers, Homeward coordinates care, including high-quality referrals and additional support post-discharge, with a focus on delivering improved health outcomes across rural populations and communities. The company recruits locally and in a manner that supports local workforces, including existing clinics and hospitals. Homeward offers a full-risk value-based arrangement for Medicare Advantage members, meaning payment for care is 100 percent tied to improving health outcomes and reducing the total cost of care. “Our agreement with Homeward is another important step for Blue Cross’ nationally recognized Medicare Advantage plans,” said Dr. Mark Steffen, senior vice president and chief medical officer at Blue Cross and Blue Shield of Minnesota. “Blue Cross and Homeward will be working with local hospitals, clinics and care systems in each community to ensure that, together, we can work to solve one of the biggest challenges in the healthcare system today. We are excited for the opportunity to increase our support for populations and communities that are in need of more health care resources.”

“I cannot be more proud to partner with the largest health plan in my native state of Minnesota to deliver care,” said Dr. Jennifer Schneider, co-founder and CEO of Homeward, who grew up in Winona. “Homeward’s mission is personal, and the opportunity to provide an end-to-end care experience for deserving individuals is a privilege. I am grateful for Blue Cross’s innovative approach and commitment to delivering the best care experience and outcomes.”

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Treating Complex Sports Medicine Pathologies

Corey A. Wulf, MD, Twin Cities Orthopedics Bioengineering Lab

Please tell us about the mission of the new Twin Cities Orthopedics Bioengineering Lab.

Part of TCO’s mission, from the time of our inception, was to advance orthopedic care for our community. This has been accomplished by providing cutting-edge, evidence-based care to our patients along with a long history of research and education. The TCO Bio Lab is the next step in that commitment. The lab will provide the resources needed to perform basic science research which is critical to the development of new technologies and surgical techniques. In addition to being able to provide bench-tobedside 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 resident and fellow education in the country.

An important component of this mission focuses on Bioskills. Please discuss some of this work.

We host our own Sports and Foot/Ankle Fellowships. The TCO Bio Lab will be an advanced training area to support these Fellowships, and it will also be a facility that trainees, fellows and curious surgeons from across the country can come together to learn new techniques and technology advancements right here in Minnesota. There are still so many questions that we are exploring in regard to optimal implant design, fracture care and reconstruction techniques. We can now provide our faculty and fellows the opportunity to pursue answers that ultimately enhance patient care. In addition, we will be open to outside vendors hosting lab training sessions and conferences. From testing new tools to the latest technology, our space will allow for true innovation and will give surgeons the opportunity to try out new techniques before bringing them into the operating room.

What are some of the reasons there can be a considerable lag time between when

between pathology and treatment. For example, it may be due to a knowledge gap in understanding the pathology, or that the pathology is well understood, yet doesn’t have an adequate solution/ treatment. The TCO Bio lab can be utilized to address both issues. Accurately defining anatomy, understanding the functional stresses and strains on native anatomic structures during normal activity and comprehending their failure modes are essential in defining appropriate treatment and, more important, in preventing future occurrences. Developing treatment strategies, such as anatomical reconstruction, and being able to test their effectiveness prior to implementation in patients can reduce lag time and, theoretically, minimize complications and poor outcomes. Finally, in regard to a procedure such as an anterior approach to hip replacement, a technique that has been developed after the majority of practicing

surgeons did not have exposure during their training, the lab provides an access point to learn and practice the technique in a cadaveric setting and reduces the barriers to implementation for those surgeons through education and exposure

There are numerous university-based bioengineering programs, as well as many in the private sector. How do you foresee collaborating with these colleagues?

Collaboration brings the best ideas and resources together. This can advance discovery and increase the power of studies by creating larger data sets. There are numerous examples of multiinstitutional/center studies that have been able to identify significant findings that could not be demonstrated by smaller data sets despite being well designed. We have already started collaborating with physicians from other centers by allowing them to come in and use our Robotic Joint Testing system to analyze complex problems and find solutions. This is a specialty piece of equipment that allows us to be on the forefront of orthopedic research, and we believe allowing other groups to use it alongside our experts can lead to key advancements.

We’re in constant collaboration with the Training HAUS Sports Science Lab located next door and nationally recognized for excellence. Together, our innovative industry leaders will work to gain a broader understanding of joint mechanics.

Collaboration also allows complex problems to be broken into subsets of simpler questions. This allows for parallel exploration with simpler designed studies that can be investigated simultaneously. The subparts are then shared and reconstructed to solve the more complex problem more quickly quicker than what could’ve been done on one’s own. TCO looks forward to collaborating when the opportunity arises.

There are a number of advances in joint mechanics, including robotic testing. Please tell us about some of this work.

Human anatomy is inherently complicated. Orthopedic surgeons are making continual advancements to recreate the functional anatomy

Collaboration brings the best ideas and resources together. “...”

that existed prior to an injury or degenerative process. Our Robotic Joint Testing system is a tool found in only a handful of labs across the country and is used to perform mechanics testing on cadaveric joints to simulate their functionality more accurately. Having the robotics component allows for us to test various surgical techniques, implants and soft tissue reconstructions to gain a better understanding of how well we are able to recreate functional anatomy. Restoring native range of motion and joint function can help patients return to the activities they love.

How does the lab plan to incorporate 3D printing into its research?

3D printing technology has revolutionized the way medical research is conducted, especially in the area of implantable devices. We are incorporating 3D printing into our research by creating implantable devices and surgical tools that facilitate repair and healing in novel ways. This technology can be used to design and produce custom hardware quickly and costeffectively, allowing for more rapid development of new medical devices.

Some examples of the custom hardware that can be created using 3D printing include cutting guides, retractors and reamers. These devices can be printed using metal materials, and the lab’s goal is to produce surgical instrument prototypes that can be used in the operating room. This approach can help to expedite the device design and production process compared to traditional machining methods, which can be timeconsuming and expensive.

The lab plans to use 3D printing technology to create and test new medical devices for proof of concept and FDA approval. This process can be much faster than traditional methods, which can take months or even years to complete. By using 3D printing technology, the lab can create and test multiple iterations of a device in a shorter period of time, which can ultimately lead to faster and more effective medical treatments.

Please tell us about the work you are doing with joint mechanics and soft tissues.

When we think of orthopedics, the first thing that comes to mind is bones. However, the musculoskeletal system is much more complex

than just bones. It includes a variety of structures such as ligaments, tendons and cartilage, as well as nerves and other soft tissues. Understanding the complex interactions between these structures is critical to developing effective treatments for musculoskeletal injuries and diseases.

Our initial goals in this area are to better understand the mechanical interactions of these structures. The lab plans to use a variety of techniques, including biomechanical testing, imaging and modeling, to study these structures and their functions.

Another area of focus will be on understanding the role of soft tissues, such as ligaments and tendons, in joint stability and mobility. These structures are critical for maintaining joint integrity and transferring forces between bones and muscles. By studying the mechanical properties of these structures and their interactions with other joint structures, the lab hopes to develop new treatments for ligament and soft tissue injuries.

Treating Complex Sports Medicine Pathologies to page 264

These are just two examples of the many faces of long COVID— symptoms that people experience four or more weeks after their acute COVID-19 infection.

Health care providers worldwide are grappling with this puzzling group of conditions, some without recognizing long COVID. Clues around potential causes, diagnostics and treatments are slowly emerging, but in the interim, providers and patients need guidance and support.

Groups like the Long COVID program at the Minnesota Department of Health (MDH) and the MDH Long COVID Guiding Council of clinicians are working to fill those gaps by sharing and disseminating new evidence and best practices as they emerge and encouraging health systems to implement these best practices. Similar multidisciplinary collaboratives have convened in other states, but a local effort can better assess and meet the needs of Minnesota’s unique health systems and communities.

What We Know and What We’re Still Learning

Long COVID—also called long-haul COVID, post-COVID conditions, post-acute sequelae of COVID-19 and chronic COVID-19—has become a shadow pandemic in the wake of COVID-19. Between 5-30 percent of people who have had COVID-19 will experience long COVID. Prevalence is hard to measure because of varying definitions, heterogeneity of presentation and duration, overlap with other conditions, lack of identification and likely underdiagnosis. However, long COVID is affecting people across the lifespan, from children to older adults.

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.

SARS-CoV-2—the virus that causes COVID-19—was initially framed as a respiratory pathogen, but has been shown to directly or indirectly impact nearly every organ system of the body. Theoretical mechanisms include that the virus damages the lining of small blood vessels, causes micro-clots, persists in viral reservoirs, reactivates other latent viruses, spurs ongoing inflammation, triggers autoimmune-like conditions and other possible pathological processes we’re only beginning to grasp. There may be subtypes or multiple diseases grouped under the umbrella term of long COVID.

The symptoms of long COVID vary from person to person. They can range in severity from mildly annoying to outright debilitating, with extreme fatigue, dizziness, cognitive dysfunction (“brain fog”), shortness of breath and other symptoms intense enough to prompt a visit to the emergency room. In a subset of cases, long COVID can seriously disrupt work, school, mental health, family life and daily activities.

Onset and duration of symptoms can be highly variable. They might persist from the acute infection or they can manifest some weeks after apparent recovery, presenting as a new chronic condition. For others, symptoms are more episodic, improving for a time only to re-emerge after physical or mental exertion, stress, illness or other “triggers.” People with severe long COVID may meet diagnosis criteria for conditions like dysautonomia, postural orthostatic tachycardia syndrome (POTS) or myalgic encephalomyelitis, also known as chronic fatigue syndrome or ME/CFS. Because the symptoms and timelines are so varied, there is not yet an agreed-upon clinical case definition for long COVID, and existing definitions from the Centers for Disease Control and Prevention (CDC) and World Health Organization are purposely broad.

Although severe illness and certain pre-existing conditions increase the risk of long-term complications after acute COVID-19, many people with long COVID were previously healthy and/or had only a mild acute infection. Vaccination appears to reduce the chances of developing long COVID, but it may still follow breakthrough infections. Similarly, milder variants and increased population immunity have lowered but not eliminated the occurrence of long-term symptoms. While use of certain medications during the acute infection are showing promise for reducing long COVID, more study is needed. Just as COVID-19 is not going away, long COVID is also unlikely to go away.

Beyond the obvious impacts on the health and well-being of individuals, the burden of long COVID has implications for the health care system, the workforce and the economy. It’s estimated that up to four million Americans have left the workforce because of long COVID so far, with many yet to return. Associated job loss and reduced hours may account for 15 percent of the labor shortage. Medical costs for patients can soar as they seek tests and specialists not covered by insurance.

The far-reaching toll of long COVID also appears to follow the disproportionate impacts that COVID-19 has had across populations and communities, further exacerbating the health inequities that predated the pandemic. Rural and low-income areas, Minnesotans of color, Native Americans, the LGBTQ community and people with disabilities and chronic conditions will bear the largest burden. People in higher-risk occupations during the height of the pandemic, such as health care, education, service industries and other jobs that required in-person work have been shown to experience higher rates of long COVID as well.

Likely Underdiagnosed

Given the myriad presentations of long COVID and lack of standardized definitions or protocols, it’s not surprising that many providers have struggled to identify, diagnose and manage post-COVID conditions—even if they’re aware of them. The ICD-10 code (U09.9: Post-COVID-19 condition, unspecified) scarcely shows up in medical records, despite the likely high prevalence.

A lack of public awareness compounds the problem: people with long COVID might recognize that they have lost some degree of health or function, but fail to make the connection to a recent infection with COVID-19. The complexity, uncertainty and evolving knowledge around postCOVID conditions make communications and messaging around long COVID a challenge for both health care and public health personnel.

Stigma may also play a role. Patients with similar post-infection conditions like ME/CFS and chronic Lyme disease have been dismissed for decades, and long COVID may be written off as simply anxiety or a deficit in healthy living habits. While studies have indicated that many patients with long COVID experienced increased anxiety and depression, the impacts on mental health often stem from the loss of normalcy, stability and identity felt by those who are facing a new chronic illness or disability.

The dearth of sufficient diagnostic tools can perpetuate this dismissal, as most routine tests—as well as expensive, specialized imaging—may

fail to show any abnormalities. Many providers order tests to exclude or understand overlapping chronic conditions, but stop short of making a long COVID diagnosis.

Potential Treatments, Management and Support

While there is not yet a cure for long COVID, symptoms can often be reduced or managed with help from a health care team. Care guidance varies and continues to evolve, but many patients make progress with different combinations of physical and occupational therapies, medications, coordinated care and strict pacing regimens. Rehabilitation specialists may be able to apply treatments and therapies for known conditions that are similar to or overlap with long COVID, such as POTS, mast cell activation syndrome, and traumatic brain injury. The general approach is often to target the most pervasive symptoms and focus on regain of function or adaptation to a “new normal.” Mental health professionals can assist patients in psychosocial adaptation. Referral to social services may help ease the stress of lost wages and alleviate concerns around household bills and food insecurity.

Peer support, such as online patient groups, can be a literal lifeline, although unmoderated forums can also harbor misinformation and suicidal

Long COVID to page 124

Symptoms of long COVID vary from person to person.

ideation. Still, validation and solidarity can be very helpful, particularly for people with long COVID who have faced stigma, loss of employment, mounting medical bills, new disability or strain on relationships. Caregivers may also benefit from peer support. A handful of health systems have launched their own forums and group therapies, which could serve as a model for others.

Many patients get better on their own after several months, while others get worse, progressing toward disability. We are still learning why. Even people who gradually recover from long COVID may need support for several months, such as assistance with daily tasks, social services or accommodations at work or school. As of July 2021, long COVID and post-COVID conditions can qualify as a disability under the Americans with Disabilities Act (ADA). Documentation from providers is crucial for connecting long COVID patients to the accommodations and support they need to stay employed, improve recovery and live their fullest life.

Efforts Underway, but More Work Needed

Researchers in Minnesota and around the world are investigating the potential etiologies, subtypes, treatments and prevention for postCOVID conditions. The White House has pledged an “accelerated,

whole-of-government effort” to address long COVID, and in 2021, the National Institutes of Health (NIH) launched a billion-dollar initiative to study risk factors and run clinical trials. Yet progress is slow, and awareness and resources are lacking. The NIH trials have struggled with mistrust and lack of participation from patients.

Meanwhile, many clinics and hospitals have set up their own approaches to serving long COVID patients. Some have identified a small team to coordinate care and services, while others have stood up comprehensive long COVID specialty clinics. Various interim care guidance has been published.

However, the lack of consensus around diagnosis and treatment, variation in awareness and divergent resources available across providers can trickle down to the patient experience. Specialty clinics may not be accessible, and rigorous schedules of follow-up appointments impractical. For those without insurance or a regular provider, it may be nearly impossible to find a clinician they trust who can identify and provide care for long COVID, particularly in the space of a primary care visit.

Recognizing these disparities, MDH began efforts to understand how and where patients are receiving care for long COVID across Minnesota. Clinicians have expressed that there is little communication among providers who see long COVID patients and that a coordinated learning network would increase access to care and the quality of the care that is provided.

The Long COVID Guiding Council of Minnesota Clinicians

MDH began recruiting Guiding Council members in late 2022, in partnership with Stratis Health and consultants from the former Institute for Clinical Systems Improvement (ICSI). We recognized the importance of bringing a small but diverse group of clinicians to the table with representation from primary and specialty care. In addition to experience with long COVID patients, areas of expertise include physical medicine and rehabilitation, infectious disease, pulmonology, traumatic brain injury, post-viral illness, rural health care, pediatrics, geriatrics and long-term care. It was also crucial to include not just the big health systems with specialty clinics and research teams, but also Federally Qualified Health Centers and community clinics, rural hospital systems, the Veterans Administration and many others. We are also gathering input from people with long COVID, caregivers, support services, community leaders and other health care practitioners.

The Guiding Council began convening in January 2023 and will meet monthly through at least early summer. Participants are enthusiastic about sustaining this learning network for many months or years to come, as guidance and treatments evolve. This infrastructure can aid in rapid dissemination of new evidence and best practices, as well as support implementation in different health systems serving diverse communities across the state. The group has discussed existing definitions and guidance, tools and education for providers and systems-level approaches to improving care and access. Outcomes will be summarized and posted on the MDH website at a future date at this site: www.health.state.mn.us/diseases/ longcovid/providers.html

is not yet a cure for long COVID.

To better understand the lasting effects of COVID-19 on the lives of Minnesotans, MDH is also conducting a statewide phone survey over the next few months among people who have had laboratory-confirmed COVID19. Results will be used to identify and guide future activities to address long COVID. We have prioritized partnerships throughout our work, engaging with communities, employers, schools, local public health, other state agencies and national workgroups. Currently the MDH long COVID program is funded by a CDC COVID and Health Equity grant grant through June of 2023. A proposal to extend MDH’s long COVID work has been recommended by Governor Tim Walz and Lieutenant Governor Peggy Flanagan. The proposal builds on the foundation and partnerships MDH has fostered since 2020 and provides a sustained and equitable public health response to long COVID throughout Minnesota. It also includes resources for vital capacity-building for communities and local public health, enabling more tailored messaging and approaches and bolstering patient-led support.

A Call to Action

Long COVID will continue to challenge patients and providers for years to come. As the urgency around COVID-19 recedes, we must acknowledge that while COVID-19 may be a limited respiratory illness for many, it can also result in unpredictable, long-term, life-altering symptoms for others.

The impacts on health and well-being, communities, health care systems, the workforce and the economy cannot be ignored.

There is also hope: new clues and success stories are emerging every day. As knowledge about long COVID grows, health care practitioners can educate themselves and their patients. They can explore what their system or clinic is doing to address long COVID, watch for evolving care guidance and share patient resources. And when confronted with a patient struggling to recover from a COVID-19 infection, they can consider: Could this be long COVID?

Guidance for providers, resources for patients and much more can be found at www.health.mn.gov/ longcovid. If you would like to provide input about your experience with long COVID in the clinical setting, please fill out the brief survey at https://survey. alchemer.com/s3/7147319/Long-COVID-Survey

Kate Murray, MPH, is the program manager for Long COVID and Post-COVID Conditions at the Minnesota Department of Health. She also holds a Master of Public Health degree in administration and policy.

Ruth Lynfield, MD, is the state epidemiologist and medical director for the Minnesota Department of Health, as well as a board-certified pediatric infectious disease specialist.

It’s estimated that up to four million Americans have left the workforce because of long COVID.

How do we explain the insurance industry’s eagerness to participate in Medicare and Medicaid when Congress enacted those programs precisely because the insurance industry didn’t want to insure the elderly and the poor? Answer: The insurance companies are being overpaid.

Congress has been notified dozens of times over the last forty years that Medicare pays more to insure Medicare beneficiaries through insurance companies than it does to insure beneficiaries in the traditional (or original) Medicare program. In its March 2022 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) stated, “The MA [Medicare Advantage] program has been expected to reduce Medicare spending since its inception … but private plans in the aggregate have never produced savings for Medicare…”

Measuring Overpayments

MedPAC and other observers are able to measure the overpayments to insurance companies in Medicare because they have a handy yardstick with which to make such measurements—the original fee-for-service (FFS) unprivatized portion of Medicare. Half the enrollees in the Medicare program remain in the original program. Those enrollees are roughly comparable to the half that are insured through Medicare Advantage plans. By comparing the per capita cost of the original program with the per capita cost of the Medicare Advantage program, analysts can get a rough measure of how much the Medicare Advantage plans are overpaid. (The comparison is rough because healthier Medicare beneficiaries enroll in Medicare

Advantage plans, and the algorithm that MedPAC and others use to adjust costs to reflect health status is crude.)

Unfortunately, the research on the impact of privatization on Minnesota’s public health insurance programs is not as rigorous. The legislature failed to conduct research prior to 1983, which is when the legislature began the privatization process, to determine whether HMOs could save money. In 1983, it passed a law authorizing the Department of Public Welfare (DPW) to participate in a “demonstration” promoted by the Reagan administration, in which Medicaid recipients would be forced into HMOs in two counties (Hennepin and Dakota). DPW was so unsure of the claims made for HMOs that it wrote into its application to the federal government a requirement that HMOs receive subsidies and be allowed to offer worse coverage than the MA program offered. By 1996, the legislature still had no evidence that HMOs could save MA money. That was the year the legislature authorized DPW’s successor, the Department of Human Services (DHS), to force MA and MinnesotaCare recipients throughout the state into “managed care organizations,” (MCOs), as insurance companies that employed managed care tactics were being called by then.

Zombie Programs

Since 1996 the privatized versions of MA and MinnesotaCare have been on autopilot. They have become zombie programs: hey don’t deliver the savings they were supposed to deliver, but they won’t die because the legislature refuses to ask whether they are saving money. And now that the great majority of MA and MinnesotaCare recipients are in HMOs, there is no comparable population in a FFS, unprivatized program against which to compare the costs incurred by the MCOs. And so we must look to other types of evidence to determine whether Minnesota’s grand privatization experiment worked.

For starters, we know privatization raised Medicare’s costs by driving up administrative costs. In the private sector, insurance companies incur overhead costs equal to about twenty percent of their revenues; their overhead is about fifteen percent when they participate in a public program like Medicare. How are they supposed to cut utilization sufficiently to pay for that fifteen percent overhead? They don’t have the ability to do that without harming patients.

Privatization has the same effect on Medicaid. According to research published by the Lewin Group, a subsidiary of UnitedHealth Group, insurance companies that participate in Medicaid generate the same level of overhead costs—about fifteen percent. As the Lewin Group put it, “MCOs must typically achieve roughly a fifteen percent savings on overall medical costs vis-à-vis the FFS setting simply to break even.” Other experts agree. In a 2006 article, the Wall Street Journal reported, “[A]ccording to Martha Roherty, director of the National Association of State Medicaid Directors, …. [a]t Medicaid HMOs, only eighty percent to eighty-five percent of premium dollars generally go for medical costs.”

A small body of research indicates Medicaid privatization not only forces taxpayers to pay for insurance industry overhead, but it drives up the administrative costs of the state agencies that run Medicaid (DHS in Minnesota’s case). Several experts who observed the Medicaid privatization fad as it spread across the nation in the late 1980s and early 1990s have

3Privatized Medicaid and MinnesotaCare from cover

commented on the additional burden that supervising MCOs places on state agencies. “Medicaid managed care programs have proven enormously taxing for state Medicaid agencies to put into operation and then manage effectively,” reported Freund and Hurley in a 1987 evaluation of the earliest Medicaid privatization demonstrations. Michael Sparer, a nationally recognized expert on Medicaid, wrote in 1998: “Medicaid managed care actually increases the state’s regulatory role. State Medicaid officials need to select health plans, determine capitation rates (and struggle with risk adjustment), supervise the marketing and enrollment process, ensure quality of care, consider whether to adopt special programs to protect safety-net providers during the transition to managed care, and so on.”

Inside the Numbers

The research suggests DHS’s administrative costs doubled during the 1990s, from 4-5 percent of expenditures (the pre-privatization level cited by the 1991 report of the Minnesota Health Care Access Commission) to 10 percent, as DHS pushed MA and MinnesotaCare recipients in all counties into MCOs. The total increase in the cost of Minnesota’s Medicaid program caused by additional administrative costs might be on the order of twenty percent-fifteen percent MCO overhead that the taxpayer didn’t have to pay for prior to privatization, plus another 5 percent added on to DHS’s overhead. And this doesn’t take into account the increase in the administrative costs inflicted on providers. If we assume the MCOs cut utilization (both necessary and unnecessary) by 5 percent, the net increase to the taxpayer would be fifteen percent.

Is fifteen percent the correct number? It’s a reasonable estimate, but we don’t know for sure. It wasn’t supposed to be this way. When DPW applied to the Health Care Financing Administration (HCFA) in 1981 for permission to experiment with HMOs within the MA program in Hennepin and Dakota counties, DPW promised HCFA it would conduct a rigorous study of the effect of HMOs on utilization and costs. DPW promised to “provide HCFA with adequate data to evaluate the demonstration’s effectiveness in increasing enrollment, impacting cost savings, and enhancing health care competition.” DPW said it would collect utilization data from the HMOs in the “experimental counties” (Hennepin and Dakota), collect utilization data in several adjacent control counties, and compare aggregate expenditures in the experimental and control counties. On the basis of these assurances, HCFA granted DPW permission to run its proposed demonstration over a three-year period, December 31, 1985 to December 31, 1988.

Soon after the demonstration began, the HMOs refused to provide the necessary data to DPW. DPW asked HCFA for an extension of the study period, but in September 1987 HCFA refused. Congress and the Minnesota legislature took DHS and the HMOs off the hook by enacting bills that permitted DPW/DHS not only to continue its privatization “experiment” but to expand it into all Minnesota counties even though the rigorous examination DPW had promised had not been done.

In 1993, a DHS employee, Steven Foldes, made the last known attempt to conduct the study DPW had promised HCFA. He sought to compare

the quality and cost of care for MA recipients in Hennepin and Dakota counties with the quality and cost of care provided to MA recipients by doctors paid FFS in five other metropolitan counties that had not yet been privatized. He compared 1991 utilization rates for 121,402 FFS MA recipients with 98,578 MA HMO recipients enrolled in one of four HMOs—Group Health, Medica, Metropolitan Health Plan, and UCare. Again, the HMOs refused to deliver to DHS the necessary data. In his final report, Foldes noted the HMOs’ failure to deliver usable data and called for more research.

Foldes was, however, able to draw firm conclusions about two preventive services— mammography and Pap smears. “[T]he health plans had a comparatively 5 percent higher rate of Pap smear use,” he wrote, “but the fee-for-service setting had a comparatively 35 thirty-five percent higher rate of mammogram use.” Because HMOs claimed they were much better than FFS doctors at delivering preventive services, these findings were embarrassing to the HMOs. They persuaded DHS to conceal the study from the public. But someone leaked the study to the Star Tribune, which published a front-page article about it on March 13, 1994. Under the headline, “Study shelved after HMOs complained,” the article opened with these sentences:

Private plans in the aggregate have never produced savings for Medicare.

“Minnesota officials suppressed a study raising questions about HMO care for poor people...The study was the first attempt by the Minnesota Department of Human Services to see whether the state was saving money by sending Medical Assistance patients to health maintenance organizations…”

Deaf Ears

Neither the legislature, then in the hands of Democrats, nor then-governor Arne Carlson, a Republican, called for hearings into the HMOs’ conduct, nor did they demand that DHS take appropriate steps to force the HMOs to cooperate. DHS, which had abolished Foldes’ position when it shelved his study, did not initiate a follow-up study.

In the summer of 2004, a half-dozen members of the Minnesota Universal Health Care Coalition and I asked House minority leader Rep. Matt Entenza for help extracting from DHS a statement on whether the insertion of MCOs into MA and MinnesotaCare had saved money. In December 2004, DHS Commissioner Kevin Goodno replied to a letter from Rep. Entenza with this statement:

“There no longer remains a credible comparison group of fee-for-service recipients against whom to compare the groups now enrolled in managed

care. We do not have a methodology that could accurately assess whether managed care has cost us more or less than fee-for-service.”

That is where we stand today. Minnesota law still describes MA and MinnesotaCare privatization as a demonstration even though the rigorous study of the “demo” promised by DPW four decades ago never occurred. And it still describes the privatized counties as the “experimental” counties. Some experiments never die.

Legislative Response

Two bills introduced this year in the Minnesota legislature might, just might, trigger a discussion of the impact the grand privatization “experiment” has had on the cost of MinnesotaCare and MA. One is HF 96/SF49, the MinnesotaCare “buy in” or “public option” bill supported by Governor Tim Walz. This bill would eliminate the income eligibility ceiling on MinnesotaCare. That provision in the bill has been widely reported. A section near the end of the bill that has not been widely discussed would require DHS to prepare an estimate of alternative “models” of MinnesotaCare, one of which has to be a deprivatized MinnesotaCare.

Another bill that could trigger a good discussion (if not a review) of the “experiment” is SF404/HF816. This bill, authored by DFL Senator

Privatized Medicaid and MinnesotaCare to page 304

The legislature refuses to ask whether they are saving money.

Partner with the right choice

We know considering the next step in care can be overwhelming for your patients and their families. Let us partner with you to make the process as simple and seamless as possible.

Whether your patient needs 24-hour care, rehabilitation therapy or care at home, referrals to the Good Samaritan Society are easy and convenient:

• Call the Good Samaritan Society location nearest you to speak to an expert

• Call (855) 446-1862 to speak to a specialist about services and locations in your area

• Visit our Referral Partners page at good-sam.com to use our simple online referral form

Our levels of care and services include:

• Assisted living – Residents live independently in a community setting that helps take the stress out of daily living. Extra support and services are available if needed.

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• Home-based services – Clients receive customized, in-home medical or non-medical care within the comfort of their home with extra support for meals, medications and more.

• Independent living – Seniors enjoy maintenance-free living in a community of friends and neighbors with meals and other amenities available.

• Long-term care – Those who need 24-hour care and services receive the assistance of licensed nursing or rehabilitative staff.

• Rehabilitation therapy –Individuals recovering from a hospitalization, illness or injury receive quality inpatient or outpatient services using physical, occupational and speech therapies to enhance their recovery.

When you choose the Good Samaritan Society, your patient will be cared for by dedicated experts there to promote their well-being.

Here for patients and providers

The Good Samaritan Society has provided seniors with compassionate, quality care and services since 1922.

As part of our work, we partner with you to provide the best outcomes for your patient –supporting them physically, emotionally and spiritually through the health care journey. When you entrust them to our care, we will always have services to support them so they can experience healing and wellness. We’re your partner in care today and into the future, and we look forward to serving you.

If you have questions about referring patients or want to learn more about our services, please call (855) 446-1862 or visit our Referral Partners page at good-sam.com.

The Importance of Multimodal Therapy

Tools for treating chronic pain

BY CODY FOSTER, MD

Chronic pain is a major health issue affecting millions of people globally. It can have a debilitating impact on lives, preventing people from enjoying activities they love and limiting the quality of their day-to-day life. Recent surveys indicate that approximately 50 million adults in the U.S.—more than one in five—report experiencing pain every day or most days, most commonly in their back, hips, knees, or feet. People with chronic pain say it limits their functioning, including social activities and activities of daily living.

Chronic pain is generally defined as pain persisting for longer than 12 weeks despite medication or treatment. Clinicians may use various determinations, but a general rule of thumb is that the pain has lasted beyond the expected duration after an acute injury or illness or is present without any history of an injury or insult.

Taking a Multimodal Approach to Treatment

Treating chronic pain is not a one-size-fits-all endeavor. To optimize outcomes, it is critical to form a multimodal treatment strategy. A multidisciplinary approach has been shown to be one of the most effective ways to manage chronic pain. A combination of medications, physical

and behavioral therapies, injections, neuromodulation and in rare cases, implantable pain pumps should be considered in order to provide patients with the best possible results. Physicians who specialize in interventional pain management typically offer a full range of such options and work with their patients to develop a course of treatment aimed at helping them manage their chronic pain to the best extent possible.

Classifying Pain

For all physicians considering the challenge of chronic pain management, it may be helpful to review the different types of pain classification:

• Somatic pain is felt in the muscles, bones or soft tissues. It is typically localized and can be intermittent or constant. It is often described as an aching, gnawing, throbbing, or cramping type of pain.

• Visceral pain comes from the internal organs and blood vessels and is typically more diffuse than localized. Visceral pain tends to be referred to other locations, and can be accompanied by symptoms such as nausea, vomiting, or tension in lower back muscles. It can be intermittent or constant, and is typically described as being dull, squeezing, or aching.

• Neuropathic pain occurs when the nervous system is damaged or not working properly. It can be experienced at the various levels of the nervous system, from the peripheral nerves to the spinal cord and the brain. Nerve pain can be described as shooting, sharp, stabbing, lancinating, or burning.

Tools in the Pain Management Toolbox

A multimodal approach to managing chronic pain often involves “layering” options that range from conservative to highly interventional.

Conservative management. The least invasive options for many patients include first-line therapies such as topical analgesics, physical therapy, acupuncture, chiropractic, transcutaneous electrical nerve stimulation (TENS) therapy and massage therapy. For some patients experiencing mild or temporary pain states, these interventions can be enough to manage the problem. For individuals who experience ongoing pain, these interventions can be helpful adjunctive therapies alongside other more intensive approaches.

Medication management. Depending on the type of pain and its severity, doctors may opt for either short- or long-term use of over-thecounter medications like nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, anticonvulsants, neuropathic agents and in severe cases, opioids. While these medications can provide short-term relief, they may not be sufficient to manage chronic pain.

Regarding the use of narcotic pain relievers (such as fentanyl, buprenorphine, oxycodone, hydrocodone, hydromorphone, morphine and methadone), and practitioner education in the last few years has been extensive. Education has reduced the number of opioid prescriptions and underscored their use as a tool for management of acute pain, which is their

primary indication. There is considerable research showing that the use of opioids for chronic pain does not provide substantial benefit beyond the acute care period. Most providers are increasingly aware of this, and educating their patients about opioid risks and benefits is an ongoing responsibility of all physicians.

There are several non-narcotic prescriptions which can be used to manage chronic pain. The group of gabapentinoids (gabapentin and pregabalin) can be particularly effective, especially for neuropathic pain. Another commonly used medication is duloxetine, a serotonin and norepinephrine reuptake inhibitor, often used for neuropathic pain in combination with gabapentin. For myofascial pain, muscle relaxers such as tizanidine, baclofen, and cyclobenzaprine can be helpful for certain patients.

50 million adults in the U.S.— more than one in five— report experiencing pain every day or most days.

Medical cannabis is increasingly understood to be useful for select patients, with about a 50–60% reported success rate in reducing pain. Anecdotally, people who have previously used marijuana recreationally seem to respond well to it in a pain management context, because they understand what having cannabis in their system feels like. Other patients who have not used cannabis previously may not care for the side effects and therefore not report such positive results. In general, though, many physicians and patients agree that cannabis can be helpful to try in low doses and safely ingested in oral form. A comprehensive, multidisciplinary pain practice typically has physicians who can certify patients for medical cannabis.

Interventional Therapies

There are several interventional procedures that can be effective in addressing chronic pain, starting with local injections in the joint, spine or nerves. These can be trialed as part of a treatment plan for certain types of chronic pain, particularly in cases where the specific sources of pain have been identified. For example, injections can treat arthritis, nerve blocks can relieve neuropathic pain and epidural steroid injections can assuage radicular back and neck pain. When combined with physical therapy, these targeted treatments may help reduce inflammation and improve mobility.

In cases where injection therapy does not prove adequate for ongoing pain relief, other advanced interventional therapies may be utilized. The technology and practice of implantable pain control devices is advancing rapidly, with life-changing outcomes for many more patients than ever before. These devices deliver very low doses of specifically targeted pain relief around the clock and present less risk of addiction and fewer side effects, removing concerns around either forgetting to take or taking too much medication. Peripheral nerve stimulation (PNS) therapy delivers an ongoing series of electrical pulses to a targeted area of a peripheral nerve, reducing the pain signals that are sent from the body to the brain.

For other cases, spinal cord stimulation (SCS) can be an effective solution. SCS therapy also uses electricity to modulate the way pain signals are sent from the body to the brain, with the modulation being done at the level of the spinal cord. One of the most common indications for SCS is “failed back syndrome”: people who have had surgery on their back but continue to have low back pain and possibly leg pain. SCS therapy can

also be used for other indications, such as painful neuropathies including diabetic neuropathy and alcohol-induced neuropathy, as well as complex regional pain syndrome involving chronic arm or leg pain that develops after injury or illness. The data supporting use of spinal cord stimulation for chronic pain is favorable. The technology of today has greatly improved compared to even five or ten years ago, and results are getting better. Neuromodulation does not work for every patient, however, and we don’t ever promise or expect 100% pain relief; the goal is typically a 50–75% reduction in pain, enough to improve comfort, mobility and quality of life. In some cases where systemic medications, surgeries, interventional procedures and neurostimulation implants have failed, pain specialists may recommend an intrathecal drug delivery system, also known as a pain pump. The pain pump is surgically implanted in the abdomen or upper buttock and delivers a steady supply of medications directly into the intrathecal space where the spinal cord is located. The medications—typically a combination of an opioid and a local anesthetic—can be provided in very low doses, directly at the site of where those medications work on the spinal cord. Intrathecal drug delivery is sometimes referred to as a targeted drug delivery because it primarily targets spinal binding sites for pain relief, bypassing the blood

The Importance of Multimodal Therapy to page 204

3 The Importance of Multimodal Therapy from page 19

brain barrier by infusing the therapeutic agents into the cerebrospinal fluid. Because of the targeted delivery, it reduces the mental side effects associated with systemic opioid management. Intrathecal drug delivery has flourished since its inception because it is uniquely effective. Many experienced pain physicians consider it to be “the best therapy for the worst pain.”

Physical and Behavioral Therapy

In conjunction with other interventions, it is paramount for pain management physicians to utilize physical and behavioral therapy as part of the treatment plan for chronic pain patients when indicated. Physical therapists can teach patients exercises that focus on posture, mobility, balance and strength-building that can provide long-term relief from chronic conditions like arthritis, fibromyalgia and low back pain. Behavioral therapy can also help patients address underlying mental health issues that commonly go hand in hand with chronic pain. When patients have depression or anxiety that is not well controlled, their chronic pain is often quite challenging to treat effectively.

Referring to a Pain Specialist

Gaining control over a patient’s chronic pain can present a real challenge to primary care physicians and other general practitioners. Faced with a

patient that proves refractory to usual treatments, doctors may consider referring the patient to a specialist in pain management. Primary care clinicians should be aware of their options for referring a patient suffering from chronic pain in order to provide them with the best hope for achieving long-term relief. An experienced specialist may be able to tailor treatments specifically targeted for their patient’s condition, which can be invaluable when handling complex cases such as chronic pain conditions.

As opposed to acute pain, wherein physicians often know the etiology of a patient’s pain, chronic pain often requires a more extensive workup to identify the source or sources of a patient’s painful condition. This can be especially true when it comes to spinally mediated pain, which is the most common complaint chronic pain physicians encounter. The spine is a complex anatomic structure. The task a pain specialist undertakes is to find out what may be causing the pain, utilizing advanced imaging, tests and interventional therapies, which are often diagnostic as well as therapeutic.

When a patient is initially seen by a pain specialist, the physician takes a full history, reviews the referring provider’s notes and any diagnostic

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The Caregiver Stabilization Act

BY CAMEO ZEHNDER, JD

Imagine for a moment you’ve been caring for your hospital’s tiniest patients in the neonatal intensive care unit (NICU), and one patient has been there for nearly a year. The stress, the cost and the time away from their family is really taking a toll on the parents. To make matters worse, your patient was stable and ready for discharge to home months ago. However, around-the-clock care to monitor the child’s well-being, and equipment at home is needed and there are no home care nurses available to take on that job—the job that you know will allow this family to gain some sense of a new normalcy with their child.

You know your patient should be experiencing all the first-year milestones in their own home, surrounded by family and friends cheering them on and supporting the parents through all the hardships a medically fragile child brings. But yet, as holidays and milestones roll around, the family spends their days and nights in their child’s small hospital room. They’ve voiced their concerns that they are emotionally and financially at the end of their rope and how their lives are being so drastically impacted by the lack of home care nurses in the area.

Unfortunately, this isn’t fiction. This scenario is playing out in hospitals across the country every day.

Nationwide Workforce Shortages

Workforce shortages have been plaguing industries across the board for several years, but the home health care industry seems to be taking one of the bigger hits. Home care nurses are a vital part of the health care industry, but do not reap the same benefits other hospital health care workers do. Home care nurses are paid significantly less than what nurses in hospitals are paid—35-55 percent less to be exact. This makes recruiting and retention nearly impossible in an already competitive job market. Home care nurses are caring for a child who was one day in the NICU being cared for aroundthe-clock, and the next day is ready for discharge but needing that same care at home. The level of care the child needs hasn’t changed, just the environment in which that care is taking place.

Home care nurse wages are limited by reimbursement levels established by Minnesota Medicaid. All agencies providing this service must work diligently to streamline all internal processes and operational costs to allow the maximum wage possible for the nurses. Even so, the reimbursement does not leave room for competitive wages when compared to hospital or clinic settings.

While the home care nurse workforce shortage is a challenge statewide, the impact is felt even more for families living in rural parts of the state. Patients in Greater Minnesota can see longer delays in discharging to home and less coverage once there, as the workforce is already limited in these areas, and competition with clinic jobs is untenable.

 Head Injury/Concussion

 Epilepsy/Seizures

 Headache/Migraine

 Neck/Back Pain

 Sleep Disorders

 Movement Disorders

 Parkinson’s Disease

 Tremors

 Alzheimer’s Disease

 Dementia

 Muscle Weakness

 Carpal Tunnel Syndrome

 Sciatica  Neuromuscular Disease

 Muscular Dystrophy

 Dizziness

 Numbness

 Stroke

 Multiple Sclerosis

 ALS

As of 2022, a survey from McKinsey & Company stated that about 32 percent of registered nurses are considering leaving their direct patient care roll. Their reasons for leaving the profession included insufficient staffing and pay, lack of support at work and the emotional toll the job takes on a person. It is time home care nurses are supported, valued and equally compensated members of the health care team. Organizations, doctors, families and legislative officials are ready to take a stand to combat this crisis by rolling out legislation that will increase the reimbursement rates for home care nursing services. This legislation can put new measures into place to help recruit and retain workers in the home care health industry.

Advocating for Patients

For many years, home care companies and representatives of the Minnesota Home Care Association have been advocating for improvements in the reimbursement rate, or more aptly, the pay for home care nurses. Currently, home care nurses’ wages are locked in based on the amount of reimbursement they receive from Medicaid and other private insurance companies. Over the past year, Minnesota lawmakers like Senator John Hoffman have been working toward finding ways to bridge the pay gap between home care and hospital care nurses. “Thousands of Minnesotans are struggling to live their lives with the dignity they deserve because they cannot get the daily care they need,” said Senator Hoffman. “Without this care, these Minnesotans are often unable to work, unable to get the medical care they need, and

Blaine | Edina | Lake Elmo/Woodbury | Lakeville | Minneapolis | Plymouth

for some, are put into life-threatening situations. It’s a crisis that we must address as soon as possible.

Senator Hoffman has introduced a solution to the State Senate regarding the crisis facing the health care industry with the Senate File 1830. This bill will help reform the reimbursement model and allow nurses to be paid for their skill set, not the environment where they practice. The bill focuses directly on home health care, but there are other areas of health care that are also lobbying for reimbursement increases, such as long-term care, personal care assistants and support for the disabled community. If passed, the proposed legislation will increase the reimbursement for these services by 55 percent, which will allow for a significant increase in the wages for nurses caring for these complex patients at home.

In 2023, Minnesota has a projected record budget surplus of $17.6 billion. The increase in reimbursement rates could be funded through this surplus. It is understood that these rates have a significant economic impact, but investing this way now will bring long-term stability, savings through reduced hospital stays, and ultimately, serve as a step in the right direction to solving this health care crisis. Most important, however, it will allow the complex children in need of nursing care to live in the comfort of a loving home as a family instead of in a hospital. “We have a historic opportunity to make sure those who provide essential care are receiving the wages they deserve,” said

Senator Hoffman. “Now with an unprecedented budget surplus, we must boldly lead and live up to our responsibility of one Minnesota.

Transitioning from Hospital to Home

Supporting families throughout their whole home care journey—from the day they first go home to the day they no longer need home care services— is the aim of many providers. Bringing an infant home with a tracheotomy, a ventilator and a gastrostomy tube is an overwhelming experience for parents. Supporting these families with knowledgeable, confident nurses who can care for the child and let the parents be parents allows the child and family to meet and exceed medical milestones and outcomes. It has been proven time and time again that children‘s medical outcomes improve when they can be at home in a familiar environment with their family surrounding them.

These children can’t go home without nursing support. In the current state of the home care nursing crisis, hospital discharges are sometimes delayed over 90 days. In the NICU, costs are as high as $5,000 per day, which means a family could accrue upwards of $450,000 in avoidable health care costs if the appropriate nursing care was available at home. According to a study conducted by the Minnesota Hospital Association, a single week in December

Home care nurses are paid significantly less than what nurses in hospitals are paid.

Vaccine Confidence

Promoting trust during an infodemic

SHEYANGA BEECHER, CNP, MSN, MPH

The COVID-19 vaccine was developed under an unprecedented campaign labeled “Operation Warp Speed.” Nine months after the World Health Organization (WHO) declared the COVID-19 pandemic, a nurse from Queens, New York received the first US COVID-19 vaccine on December 14, 2020. Over the next four months, almost 900 million doses of COVID-19 were administered globally. In April of 2021, the Centers for Disease Control (CDC) and Food and Drug Administration (FDA) reported that the Johnson & Johnson vaccine had led to six cases of increased blood-clotting and one woman had died. This fueled an emerging, well-developed arsenal of COVID-19 vaccine disinformation available on various media outlets and communication platforms, including print, radio, podcasts, television, digital media, Facebook, WhatsApp, etc. Conspiracy theorists and anti-vaxxers deftly maneuvered the fear and uncertainty of the COVID-19 pandemic and helped fuel a resurgence in vaccine hesitancy. Unfortunately, the hesitation was not just regarding the COVID-19 vaccine, but also impacted attitudes and beliefs about essential childhood vaccines. Rates began to decline, leaving communities vulnerable once again to vaccine preventable diseases.

A Negative Ripple Effect

By July 2022, WHO and UNICEF called attention to this alarming trend, signaling a “red alert” for child health, evidenced by the largest sustained decline in childhood vaccinations in 30 years. The UNICEF Executive Director indicated that while they expected a lag in immunizations, the continued decline could not be attributed to pandemic related disruptions. Diphtheria, tetanus, toxoid and pertussis vaccine rates as well as the first dose of measles vaccine rates dropped to their lowest levels since 2008. In addition, there were notable gaps in HPV and polio vaccine series.

This global trend directly impacted the health of Americans. In June of 2022, an unvaccinated adult in New York contracted polio and became paralyzed. This was the first documented case of polio in America in nearly a decade. The single case was enough to declare a public health emergency, and wastewater samples indicated that polio had been circulating for several months. The virus was able to spread because of the greater frequency of international travel and lower immunization rates in particular New York communities.

Nationally, there was an increase in measles cases, including here in Minnesota. Last year, 22 children in the Twin Cities were infected with measles- fourteen of these children had traveled overseas (Denmark, Kenya, Somalia) where measles was common and circulating. These children then infected an additional eight unvaccinated children. In all, at least nine of these children were hospitalized.

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To establish herd immunity and control the spread of measles, at least 95 percent of a community needs to be vaccinated. However, the rates of measles vaccination vary widely across neighborhoods and schools. Some are well covered at the 95 percent level, and others are concerningly low, at 50-60 percent. Pockets of under-vaccinated communities always pose the greatest risk for outbreaks of vaccine-preventable diseases. Although numbers in Minnesota for the 2022 measles outbreak (22 cases) were not as high as the 2011 outbreak (26 cases) and the 2017 outbreak (75 cases), public health research shows we are at definitely at risk of another outbreak knocking on our door. How do Minnesotans prevent this, especially during a time when misinformation is readily available and shared?

Defining an Infodemic

In 2020, the WHO coined the term ‘infodemic’ to describe too much information, including false or misleading information, in digital and physical outlets during a disease outbreak. Can we attribute the resurgence in vaccine hesitancy and declining immunizations to the infodemic? What role does such a phenomenon have for declining childhood vaccine coverage and does this phenomenon impact all populations equally?

In 2022, the Hennepin Healthcare Pediatric Mobile Health team partnered with the United States Office of Assistant Secretary for Health (OASH) to determine factors that improve vaccine confidence and increase vaccine uptake. The Pediatric Mobile Health (PMH) team interviewed community leaders representing public health agencies, the education

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sector, media firms and Black Indigenous and People of Color (BIPOC) facing organizations. The team also held focus groups with Latino and other community members and surveyed PMH patients. Results from the community assessment, over eight months, indicate that increasing access to vaccines and promoting trust are key strategies to promote vaccination, especially in BIPOC communities residing within Minneapolis and the neighboring cities.

Early in the pandemic, the ability to access health care was highlighted a significant barrier for many families. Due to shelter-in-place orders and restricted capacity of health facilities, families fell behind in routine preventative care. One community leader noted, “parents fell behind on their children’s vaccinations due to COVID. Also, the modes through which they would typically receive important health care reminders and education have been unavailable because of the lockdown and social distancing.” Of course, access to preventative care such as immunizations was only exacerbated for some high-risk populations who had always faced challenges with reliable transportation, child care, etc. As another community leader noted, “Even if there was adequate supply, lack of access to vaccines has made it difficult for my community members to maintain their vaccination status.” In addition to vaccines being more accessible, participants requested that accurate information about vaccines should be more readily available. Information

should be shared in the communities and relayed from trusted community members who looked like them and preferably spoke the same language.

In addition to barriers to access, some participants expressed that safety and efficacy concerns influenced the decision to vaccinate themselves or family members. Some of this shift in thinking was a result of the infodemic associated with the COVID-19 vaccine roll out.” As one community member noted, “It’s a lot of information to absorb”, and often, misinformation is more available than accurate information. A community leader noted, “I could depend on the reliability of early childhood vaccines to persuade people to take the COVID vaccines. Now people’s resistance to COVID vaccines is driving mistrust of early childhood vaccines.”

In general, participants were aware vaccines are important and effective in preventing disease. One person said the inoculations she received as a child have maintained her health into adulthood: “the effectiveness grows with you. I don’t have too many ER stays. I rarely get sick.” A patient who identified as Latino said, “I know a person in Honduras who was not able to vaccinate her daughter, and her daughter was infected with polio. Her daughter did not recover from polio and is now paralyzed.

Vaccine Confidence to page 264

Resources, tools, solutions.

Often, misinformation is more available than accurate information.

Disability Hub MN, you can put an essential resource directly in your patients’ hands. From explaining health coverage options to submitting medical benefit applications, Hub experts are uniquely positioned to support people with disabilities.

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3 Vaccine Confidence from page 25

So, it is important for my kids to be vaccinated.” Others did not have such personal experiences with vaccine-preventable disease, primarily because vaccines have been so effective. Other participants found vaccines were necessary merely because they were a requirement for school.

Building Trust

While most patients reported that vaccines were safe, some did have safety concerns. Several individuals believed that vaccines caused illness; for example, flu shots give people the flu. One stated, “In early childhood, everything is developing newly. Those side effects are tremendous and can be more harmful than the infection itself.” Another person said early childhood vaccines could put children at higher risk for Autism and other diseases, adding “their chances would be different had they not been vaccinated.”

Not getting vaccinated is not risk free.

nobody because everybody lies. I’m doing my own research now and determining what’s best for me. At the end of the day, it has to the right decision for me and my family.” Another person said trust is “earned, not just given. I lost my dad to COVID, and it took the trust away.” This participant went on to say that ongoing conversations about health concerns with his primary care provider could potentially restore trust. During an infodemic, the volume, noise and social media algorithms of misinformation can easily influence a patient’s viewpoint, especially if they are lacking a trusted relationship with their health care team.

During this community assessment, a common theme emerged. Participants were most interested to receive their health information from trusted sources. The majority of participants indicated they first trusted a health care provider followed by a family member and then a trusted community leader. This approach was shared equally among racial/ ethnic groups. However, sometimes a reputable, trustworthy source was lacking. One person indicated she does her own research; “I don’t trust

Trust between the health care team and patient is under-valued. We sometimes place greater emphasis on academic credentials, titles, years of experience, patient load, etc. However, our patients may expect otherwise from us. One participant stated, “Doctors should have conversations with their patients, listen to their concerns and then guide them in the right direction with sound medical advice.” Notably, this participant stated a provider should listen first, and then offer medical advice. In busy clinics where one patient arrives late, another arrives early, and appointment slots are only 15 minutes long—it is easy to only offer the essential medical advice. Devoting time to sit in the space of uncertainty with a patient, acknowledging and seeking an understanding of their fears and concerns, may not result in an immediate positive vaccine decision, but it may build on the development of a trusting relationship. As providers, it is difficult to compete with the technology and speed of anti-vaccine information. Investing in strategies and partnerships to provide culturally sensitive, accurate vaccine information and developing trusted relationships with our patients is imperative.

Primary Care

We are an independent physician-owned multi-specialty practice with 180 providers located across 13 sites, and-state-of-the-art facilities. Recently voted one of the 14 coolest urban spaces in America, Mankato is a short drive from the metro with abundant nearby recreation opportunities, safe, charming and affordable neighborhoods, outstanding schools and a thriving arts community.

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Physicians are a trusted source of vaccine information and advice. When the opportunities arise, it is important to be curious about the patient’s concerns and empathize. When we meet a patient “where they are”—not just physically but in terms of values and communication style— the level of trust will grow. It can be helpful to acknowledge how difficult it can be to process so much competing, often unreliable information from social media, the internet and other sources. Even something as simple as noting scientific facts, such as “you can’t catch a disease from the vaccine”, or addressing vaccine fertility concerns, such as reassuring patients that mRNA cannot be incorporated into our DNA, may be helpful.

Our research clearly identified physicians as a trusted source for information to help families make vaccine decisions and to keep the dialogue around them open. If you have personal experience of a patient or infant contracting a vaccine-preventable disease, it can help build trust to share these stories. It can also be helpful to encourage vaccinated patients to encourage their friends and families to do the same. These people can be powerful advocates, and everyone should remember that not getting vaccinated is not risk-free.

Sheyanga Beecher, CNP, MSN, MPH, is the medical director of pediatric mobile health at Hennepin Healthcare. She is a pediatric nurse practitioner with a Master of Science degree in Nursing and a Master of Public Health degree from Johns Hopkins.

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The Caregiver Stabilization Act from page 23

2022 demonstrated a staggering 2,000 patients who were eligible for discharge but unable to transfer due to lack of capacity in post-acute care settings. Other studies show children with medical complexity represent only 1 percent of the pediatric population, but account for an estimated 30 percent of pediatric health care costs and 86 percent of hospital charges in US children’s hospitals. However, only 2 percent of Medicaid spending is attributed to home health care. We can do better by investing in home care services.

While Medicaid and commercial insurance plans help with the financial burden, the economic and emotional costs are significant. Home care is not only the more cost-effective option for medically complex patients, but it also allows the family unit to be in an environment where everyone succeeds. When nurses are available at home, parents don’t need to sacrifice their career and split their time between hospital visits, work and home.

It is very important to see the Caregivers Stabilization Act move forward so that home care nursing will have the ability to competitively recruit and retain these exceptional nurses for our families in need and get these children at home where they belong. This bill addresses the critical flaw in a system that has undervalued the importance of experienced, knowledgeable and professional caregivers in a home setting and instead keeps children in the hospital.

Dr. Brooke Moore, a pediatric pulmonologist at Children’s Respiratory and Critical Care, understands how the home care nursing shortage is affecting not only the families, but the hospitals as well. She is advocating for change

in hopes of turning the crisis around. “With the lack of home care nurses, it is difficult to send our medically complex children home where they will thrive when they are stable enough to do so,” says Dr. Moore. “This shortage has a ripple effect on the health care system. It’s keeping children in the hospital longer than necessary, and it’s preventing admitting other children who need specialized care due to space restraints in hospitals. We must be the voice for this change, so these children and families, present and future, can improve medical outcomes with quality care in a home-based setting by nurses who are compensated fairly and equally for the level of care they provide.

Working Together for Change

In a medically complex world, many advocates for those who are affected is the key to making sure their voices are heard and a sustainable change is made. Passing the Caregiver Stabilization Act will allow home care nurses to be recognized for the care and skill they bring as opposed to the environment where they practice. It will help children transition out of the hospital as soon as they are medically stable, ultimately saving valuable state healthcare dollars.

To support this critical legislation (SF 1830/ HF 2087), please contact your representative and senator to share the importance of this reimbursement increase. This topic has support in both the House and Senate, as well as from both political parties. Medically fragile children’s lives depend on these changes. Please reach out today.

Cameo Zehnder, JD, is the chief administrative officer at Pediatric Home Service.

Dr.

results to date. As previously mentioned, physical therapy is often a first line intervention for patients. If psycho-social stressors are present, behavioral health consultation is warranted. Additional workup such as diagnostic tests and imaging will then be considered if indicated. Once this workup has been initiated, the pain physician can hopefully find the source of the chronic pain and begin interventions and allied therapies in a more targeted approach. This all happens concurrently with the patient working with physical therapy, seeing a behavioral health therapist, and optimizing a medication regimen along the way as indicated. A comprehensive pain clinic often has physical therapy and behavioral health specialists on site as a part of their practice and can offer a multidisciplinary approach to chronic pain under one roof.

A Focused, Intensive Approach

Many pain specialty practices offer a chronic pain program—an intensive, focused initiative designed for patients who may have exhausted their therapeutic options, are no longer seeking a specific diagnosis or additional interventions, and are simply living with chronic pain they are likely to have for the rest of their lives. Our program, and programs like it around the country, combine education with physical and behavioral therapy. Patients learn principles for self-management: quality nutrition, good sleep hygiene, smoking cessation, benefits of exercise in improving mental and physical health—basically how all the components of their own behaviors are going to help them manage their pain better and improve their quality of life.

These programs are usually quite intensive, with patients coming every day or several days a week for the duration of the program, which may be four to eight weeks in length.

Educating Patients and Setting Expectations

When we think of patients achieving relief from their chronic pain, we typically mean their pain has become minimal enough that it doesn’t unduly affect their daily life. Chronic pain is challenging to treat; the longer the body experiences a hyper-excitable state while in pain, the more the brain remodels and adapts to the chronic pain state. This phenomenon is known as central sensitization and can present as a vicious cycle which can be hard to break. Breaking this cycle is what a pain specialist’s care team works toward. A key part of chronic pain management is educating patients about their health and their options, making sure they understand time to therapeutic effects, setting realistic expectations for each modality and helping them play a positive role in their pain relief journey.

Today more than ever before, there are options that can help nearly every patient. Taking a multimodal, multidisciplinary approach gives us the greatest chance of achieving significant pain management and improved quality of life.

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.

• Active Aging Services - Geriatric Medicine/Palliative Care

• Dermatology

• ENT - Otology

• Family Medicine

• Gastroenterology

• Pediatrics

• Psychiatry - Adult

• Psychiatry - Child & Adolescent

• Rheumatology

Cody Foster, MD, practices at Nura Pain Management and is board certified in Anesthesiology and Pain Medicine.

What types of improvements to implantable devices are you working on?

Implantable devices have revolutionized the field of orthopedics by providing effective treatments for a variety of musculoskeletal injuries and diseases. However, there is always room for improvement when it comes to these devices, and we are actively working on developing new and improved implantable devices.

One area of focus for the lab is improving the mechanical characteristics of implantable devices. This includes load to failure, which is a measure of how much stress a device can withstand before it breaks or fails, and fatigue failure that occurs when a device breaks down over time due to repeated loading and unloading. By improving these characteristics, the lab hopes to develop devices that can withstand higher loads and last longer in the body.

In addition to these areas of focus, the lab is also working on developing new and innovative

implantable devices that can provide better outcomes for patients. This includes devices that can be customized to individual patients, devices that can promote tissue regeneration and repair, and devices that can be used in minimally invasive procedures.

We are incorporating 3D printing into our research by creating implantable devices and surgical tools.

Overall, the lab is focused on developing implantable devices that are safer, more effective and longer-lasting, and that can provide better outcomes for patients with musculoskeletal injuries and diseases. By leveraging the latest advances in materials science, engineering and medical research, the lab is making significant contributions to the field of orthopedics.

How can physicians get involved with this new research facility?

A lot of doctors, and other healthcare professionals, end up finding personalized ways to care for orthopedic patients. Sometimes these innovations are viable improvements of standard best practice. These pioneers may want to share and develop their ideas, but do not have the resources or connections to move forward. We can provide assistance in these instances. Further opportunities exist around fine-tuning surgical and diagnostic skills, keeping up with the latest scientific advances, and even improving rehabilitation practices. We were designed to advance the field of orthopedic medicine and are here to collaborate with our colleagues in the field in any way that is possible.

Corey A. Wulf, MD, is a surgeon at Twin Cities Orthopedics with specialized sports medicine training. He played a key role in the development of the Twin Cities Orthopedics Bioengineering Lab.

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• Full-time position equaling 36 patient contact hours per week

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• Practice supported by over 17 FM colleagues and APC’s and over 50 multi-specialty physicians

• Subspecialties in – IM, OB/GYN, Ortho, Spine, Urology, Interventional Pain, Gen Surg., and many more

• Competitive comp package, generous sign-on bonus, relocation and full benefits

A physician-led organization, CRMC has grown by more than 50 percent in the past five years and is proudly offering some of the most advanced procedures that are not done else where in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by the ever-increasing range of services offered.

3Privatized Medicaid and MinnesotaCare from page 16

Alice Mann and DFL Representative Tina Liebling, would restore to MA recipients the freedom to choose their doctor. SF404/HF816 is a very simple bill. It amends the statute that authorizes DHS to “develop criteria to determine when limitation of choice may be implemented in the “experimental counties” by adding this clause: “but shall provide all eligible individuals the opportunity to opt out of enrollment in managed care.”

There is obviously a moral and an economic argument for the freedomto-choose bill. The moral argument is that the legislature should never have forced MA recipients to choose between having health insurance and retaining their freedom to choose their doctor. Can you imagine the uproar if Congress had tried to do that to the elderly?

The benefit of SF404/HF816 to taxpayers should be obvious at this point:. If a substantial number of MA recipients were to leave the MCO MA program and enroll in the FFS MA program, that would create the “credible comparison group” (to use former DHS commissioner Goodno’s phrase) that DHS and other analysts need to derive a more precise estimate of how much privatization has cost the taxpayer.

Deprivatization, however it is achieved, will deliver at least two benefits to doctors. Returning the MA program to its original form—a public agency that reimburses all doctors according to the same FFS schedule— will eliminate differences in physician payment that are due primarily to differences in the negotiating clout physicians have vis a vis the MA plans

they contract with. It will also restore autonomy over decision-making to MA patients and their doctors. A third possible benefit is an increase in MA reimbursement rates. That might happen if the legislature were to decide to allocate some of the savings from deprivatization to higher physician pay.

Last month, hearings were held on the public option and freedomto-choose bills in the House and Senate health policy committees. If one or both of these bills do lead at long last to a debate about the pros and cons of privatization, we can be sure the insurance industry will urge legislators and the public to adopt a double standard, one for the insurance industry and one for all of us who think privatization was a mistake. The industry will promote evidence-based health policy for critics of privatization, but will apply to themselves the bloviation-based, “because we say so” standard that brought us privatization in the first place. For any observers—legislator or non-legislator—who might find themselves confused by the debate about whether privatization saved money, I suggest a simple tie-breaker: support deprivatization on moral grounds. Forcing MA and MinnesotaCare recipients to give up choice of doctor in exchange for health insurance is just plain wrong.

Kip Sullivan, JD, is a member of the advisory board of Health Care for All Minnesota.

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