45 minute read
INTERVIEW
Serving pharmacists and patients Sarah Derr, PharmD Minnesota Pharmacists Association
Please tell us about the history of the Minnesota Pharmacists Association (MPhA).
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MPhA—formerly known as the Minnesota State Pharmaceutical Association (MSPhA)—was founded in 1883. Meeting in St. Paul that year, a group of 12 influential druggists made plans and preparations to organize a state pharmaceutical association. MSPhA later produced the other institutions of pharmacy in Minnesota: the state Board of Pharmacy, established in 1885, and the University of Minnesota’s College of Pharmacy (CoP), established in 1892. Over the last 137 years, MPhA has served all pharmacists, student pharmacists, and pharmacy technicians. MPhA continues to be the organization that represents all pharmacists in the state of Minnesota. (See DiGangi, Frank E., A Century of Service and Leadership. 2003.)
There are other associations of pharmacists in Minnesota. What can you tell us about them and how you all work together?
The other organization that is well known in Minnesota is the Minnesota Society of Health System Pharmacists (MSHP). This organization’s members are mostly comprised of pharmacists from health systems and in administrative positions within hospitals. Another smaller organization is the Minnesota College of Clinical Pharmacy (MCCP), which has members serving in clinical roles, such as those working in the clinic and those working in specialties such as renal failure, hematology, and oncology. The other major player in Minnesota pharmacy is the CoP, which not only graduates PharmD students, but also plays a large role in keeping alumni connected and serving in large leadership roles in the profession.
About a decade ago, the Practice Act Task Force was created, now known as the Minnesota Pharmacy Alliance. This brings together MPhA, MSHP, MCCP, and the CoP to discuss how we can best serve Minnesota pharmacists. The Alliance works closely together, especially on legislative issues, to ensure that we are one voice. This group works on several issues throughout the year.
Prior Authorization is an issue that impacts most physicians in many ways. How does it impact pharmacists and what are some potential solutions to these problems?
Prior Authorization can be a challenge for all health care professionals. Pharmacists are impacted when a patient brings a script to the pharmacy that requires a prior authorization that the prescriber was not aware of. In these cases, the pharmacist has to contact the clinic to get a prior authorization. This can cause a delay in the patient getting their medication. Additionally, plans change their formularies at least once a month, if not more often. This can cause the need for a new prior authorization mid-year, which then can lead to further delay in patients getting their medication.
Potential solutions are to stop health plans from changing their formulary mid-year. In addition, once a patient has had a prior authorization for a medication, we could eliminate the need to renew prior authorization each year.
Prescriptive authority for non-diagnosable conditions is an issue for the MPhA. What can you tell us about this?
MPhA has been pursuing prescriptive authority during the 2020 legislative session. We are pursuing conditions that do not require a diagnosis, such as nicotine replacement for smoking cessation, emergency opioid antagonists such as naloxone, and self-administered hormonal contraceptives. We are pursuing these three areas because they all are medications that a patient can have dispensed at the pharmacy. Pharmacists are the most accessible health care professionals, and they see patients, on average, 25 times a year. When a patient is ready to quit smoking, it is best that they get the medication and counseling that they need at that point in time, before they change their mind.
Medication administration by pharmacists is another important issue. Can you explain your work in this area?
Pharmacists are well trained to counsel and teach patients how to administer their medications. Many patients are not comfortable administering injectable medications on their own. Pharmacists are well equipped to administer these medications. In the 2019 legislative session, the Minnesota Pharmacy Alliance passed legislation to allow pharmacists to administer long-acting injectables for mental health and substance use disorders. In 2020, the Minnesota Pharmacy Alliance has efforts underway to expand this to all injectable medications so that patients have the access to the medications that they need. Additionally, pharmacists are the most accessible providers and are often closer to the patient’s home than to the clinic.
Several states have recently passed legislation around PBM transparency. These bills are now being challenged on the Supreme Court level as ERISA violations. Please explain why the legislation was necessary and why it is being challenged.
In the 2019 legislative session, the Minnesota Pharmacy Alliance passed legislation to regulate the PBMs through the Commerce Department. This is extremely important, as the PBMs are not well
regulated and there is little transparency regarding where the dollars go. If the Supreme Court were to agree with the Pharmaceutical Care Management Association (PCMA), this would mean that all private plans would be exempt from the transparency bill that we passed in Minnesota. We will continue to monitor the Rutledge v. PCMA Supreme Court case.
Pharmaceutical prices are a major health care issue. What plans do you have to address these issues?
One of our most important plans is to pass legislation that provides transparency for PBMs and begins to regulate PBMs. This year, Minnesota Attorney General Keith Ellison worked with a group to create the “Report of the Minnesota Attorney General’s Advisory Task Force on Lowering Pharmaceutical Drug Prices.” MPhA will continue to work with Minnesota stakeholders to see how we can continue to lower medication costs.
What is your position on Minnesota’s new insulin legislation?
MPhA spent much of the 2019 session working with state legislators to ensure that the insulin legislation worked for both patients and pharmacists. The bill that was passed works well for both patients and pharmacists, as it utilizes existing programs through the manufacturer programs.
Interoperability of patient data across health system lines is an area of increasing concern. How does this impact patients on a pharmacy level, and what are some potential solutions?
Pharmacists are well trained to monitor medication and provide suggestions to changes in patients’ medications. In order to do this at the highest capacity, pharmacists need access to lab results and other information that can help pharmacists make informed decisions. Even readonly access can be helpful, although two-way communication is ideal so that the pharmacist can share any suggestions they may have.
How could health care delivery benefit from better communication between pharmacists and physicians?
Communication between pharmacists and prescribers is vital in order to provide the best patient care. By communicating with the prescriber, a pharmacist can provide the highest level of patient care. Access to the EMR is helpful for pharmacists to evaluate the effectiveness of drug therapy, as labs can assist in making medication decisions.
What have been the biggest issues your members have had to deal with related to the COVID-19 pandemic?
The biggest challenges have been access to personal protective equipment, ensuring that the patient is getting the medication for a legitimate medical reason, and payment for services. PPE is a large issue, as initially pharmacists were not considered “necessary” health care professions. This has since changed, thankfully. Medication shortages, particularly with hydroxychloroquine, have been a concern as prescribers are writing scripts before a patient is sick. This has improved, but there continue to be shortages of albuterol inhalers. Pharmacists have long fought to be paid for their services, and this continues to be an issue. Pharmacists are also concerned that they will not be paid to perform COVID-19 testing or administer a vaccine once it is available.
Sarah Derr, PharmD, is Executive Director of the Minnesota Pharmacists Association.
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But these policymakers did so with no explanation of how system-wide measurement was supposed to be done accurately, and without any reference to research demonstrating that accurate system-wide measurement is financially or technically feasible. The Minnesota Health Care Access Commission (in 1991) and the Minnesota Health Care Commission (in 1993) were the first of several commissions to exhibit this “shoot-first, aimlater” mentality. Both commissions recommended the establishment of massive data collection and reporting systems, and both articulated breathtaking expectations of the “report cards” these systems would produce. According to the latter commission, for example, the data collection and number crunching would facilitate “feedback of data that reflects the entire scope of the health care process, from the inputs or structural characteristics of health care to the processes and outcomes of care.” (p. 134) Yet neither commission offered even the crudest details on how such a scheme would be executed nor what it would cost, and, not surprisingly, neither commission offered evidence supporting their high hopes.
In 2008, two other commissions and the Minnesota Legislature exhibited the same casual attitude toward evidence and details. That year, the Legislature, egged on by the commissions, passed a law requiring the Minnesota Department of Health (MDH) to create a “standardized set” of quality measures for Minnesota that would be used to punish and reward “health care providers” (Minnesota Statutes, Section 62U.02). The law offered a few guidelines (such as MDH should “seek to avoid increasing the administrative burden on health care providers”), but it offered no details on how MDH was supposed to create useful measures.
Policymakers at the federal level have exhibited the same attitude. Like the half-dozen commissions that have advised the Minnesota Legislature over the last three decades, the Medicare Payment Advisory Commission (MedPAC) has endorsed measurement and P4P schemes for Medicare on the basis of zero empirical evidence and without working out the details. As the Minnesota Legislature followed the evidence-free recommendations of the Minnesota commissions, so Congress has followed MedPAC’s undocumented recommendations. MedPAC’s influence is most apparent in the Affordable Care Act of 2010 and the 2015 Medicare Access and CHIP Reauthorization Act, which enacted the nation’s largest P4P program (the insanely complex Merit-based Incentive Payment System).
The proliferation of reporting and P4P schemes has triggered “significant rethinking of measurement activities at the federal government, by national measurement organizations and health care payers, and within state governments,” as MDH put it in a February 2019 report to the Legislature. (p. 8) Minnesota’s Legislature is among those doing some rethinking. It enacted a law in 2017 that requires MDH to develop a “framework” for evaluating MDH’s “performance” measurement program which was authorized by legislation enacted in 2008. Because feedback is useless if it is not accurate, MDH should make accuracy the single most important criterion in evaluating any proposed quality or cost measure. MDH should use this opportunity to explain to the Legislature why MDH’s measurement system and systems like it are grossly inaccurate. A report card that measures a micro-fraction of all services delivered will be grossly inaccurate. 3 A futile quest from cover
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Three impediments to accuracy
The inaccuracy of “performance” measurement has three distinct causes: 1) It measures a tiny fraction of the thousands of services a clinic or hospital delivers (the “bundled product” problem); 2) it is usually very difficult to determine which patient “belongs” to which doctor or clinic (the “attribution” problem); and 3) for all but the simplest of medical services, it is impossible to adjust scores accurately to reflect factors outside physician or hospital control (the “risk-adjustment” problem). I will illustrate each problem with an example, then examine each in more detail.
The “bundled product” problem is the easiest to understand. To illustrate this problem, consider this analogy. Imagine that you want to issue cost and quality report cards on Home Depot, Menard’s, and Lowe’s. For the sake of discussion, let’s say these stores sell ten thousand different items—appliances, tools, construction materials, paint, repair services, plants, etc. You decide your report card will issue grades on just five items—sod, circular saws, tile cleaner, varnish, and dry wall. You ignore the other 9,995 items and services. How useful is your report card?
Like home supply stores, clinics and hospitals sell thousands of services. There are 8,000 services doctors bill for (that’s roughly the number in the Current Procedural Terminology manual, the document all doctors use
to find codes to put on their claim forms), and 68,000 diagnoses (that’s the number of diagnoses listed in the current iteration of the International Classification of Diseases maintained by the World Health Organization). MDH currently lists 29 measures on its website.
To illustrate the “attribution problem,” consider again the “optimal diabetes” measure discussed in Part I (https://tinyurl.com/mp-sullivan-p1) of this two-part series—a measure that Minnesota Community Measurement (MNCM) and many other report-card manufacturers use. This measures the percent of a doctor’s or clinic’s diabetic patients who have their blood sugar and blood pressure under control, who take aspirin and statins, and who don’t smoke. Obviously, the first step in calculating these percentages is to determine which patients “belong” to which clinic. But how do you do that? If you don’t do it accurately, you will be rewarding or punishing doctors for patients they don’t see.
To illustrate the third obstacle to accuracy—inaccurate adjustment of scores to reflect the impact of factors outside physician or hospital control—imagine that you have chosen the blood pressure measure within the “optimal diabetes” measure to be one of a handful of quality measures in your report card. You know that blood pressure is determined by multiple factors doctors have no control over, including patient age, income, education, willingness to exercise, stress levels at home and work, insurance coverage for and the price of blood pressure medications, etc. How do you adjust the scores on your report card to make sure they measure only physician expertise and not all those other factors?
Now imagine how inaccurate your report card is going to be if you can’t solve even one of these problems, never mind all three.
The bundled product problem: Treating to the test
Even the most expansive measurement-and-reporting schemes measure only a tiny fraction of the thousands of medical services sold in modern societies. Consider furthermore that each service can be evaluated at least four ways— by process measures (did the diabetic patient’s A1c levels get measured?), outcome measures (is the diabetic’s A1c level under 8?), structural measures (does the hospital have a catheterization lab?), and patient satisfaction as measured by surveys. The possible number of “quality” measures is in the tens of thousands. Compare tens of thousands to, for example, the 30 or so enforced by MDH and its contractor, MNCM, over the last 15 years.
A common argument presented by proponents of reporting schemes is that scores on some of the handful of measured services increase over time. But measurement proponents never investigate whether improvement on those scores was financed by “treating to the test,” that is, by shifting resources away from patients whose care was not measured. Common sense and a small body of research indicates that’s in fact what happens: the use of a tiny fraction of services that MNCM and other P4P proponents measure has induced teaching to the test. If in fact improvement on a few scores is financed by a worsening of the quality of unmeasured services, overall quality (at both the system and provider level) may not have improved at all. And if patient preferences were bulldozed by providers under pressure to honor the priorities set by report card producers, overall quality may have gotten worse. In either event, a report card that measures a micro-fraction of
A futile quest to page 124
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all services delivered will be a grossly inaccurate reflection of the quality of the providers subjected to measurement.
Unlike the bundled product problem, the attribution problem does not afflict all measurements. We know, for example, exactly which hospitals and which surgeons performed bypass surgery on which patients. If we want to prepare a report card on heart surgeons or the hospitals where heart surgery is performed, we don’t have to make up arbitrary, complex rules to assign patients accurately. But we do have to make up arbitrary and complex rules to attribute patients to doctors, clinics, and hospitalclinic chains when the report card measures services like those in the “optimal diabetes” bundle.
The most widely used attribution rule is to assign patients (without their knowledge) to a clinic or hospital-clinic chain if, during a baseline (or “lookback”) period of one or two years, patients made a plurality of their visits to the clinic or chain. Thus, if I visit Clinic A three times in 2019, Clinic B once, and Clinic C once, the plurality-of-visits rule will “attribute” me to Clinic A for the “performance year” 2020. Even if I never set foot in Clinic A in 2020, the doctors in Clinic A will be rewarded or punished based on my blood pressure, my blood sugar levels, whether I resume smoking in 2020, etc., outcomes they were totally unable to influence during 2020. Health policy analysts and consultants measure the integrity of these attribution algorithms (or the lack thereof) by measuring their “leakage rates”—the rate at which patients fail to seek care often enough during the “performance year” to be assigned to the same clinic the next year. Research on the leakage rates of “accountable care organizations” (groups of clinics and hospitals) and “medical homes” (single clinics), for which the plurality-of-visits method is used, equal an astonishing 30% to 40%. As you can imagine, the addition of all those phantom patients to the denominator of measures like the “optimal diabetes” measures, and the subtraction of so many real patients, substantially augments the noise-tosignal ratio of such measures.
The risk-adjustment problem
The third major contributor of noise to “performance” measures is crude risk adjustment. Risk adjustment is done to adjust scores for factors providers and insurance companies have no control over. The most efficient way to convey the unacceptable inaccuracy of today’s risk adjusters is to review the inaccuracy of the nation’s most widely used, most studied, and probably most accurate risk adjuster—the one CMS developed Feedback is useless if it is not accurate. 3 A futile quest from page 11 A futile quest to page 134
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3 A futile quest from page 12
in the early 2000s to adjust payments to Medicare Advantage plans. This method, known as the Hierarchical Condition Categories (HCC) model, can only predict 12% of the variation in spending among Medicare enrollees. To understand how bad that is, consider these statistics reported by MedPAC: the HCC overestimates spending on the healthiest 20% of beneficiaries by 62% and underestimates spending on the sickest 1% by 21%. MedPAC has made it clear they have no expectation that the HCC can be made substantially more accurate.
As these statistics suggest, inaccurate risk adjustment punishes providers who treat an above-average proportion of the sick and the poor and rewards those who treat an above-average proportion of the healthy and higherincome. This worsening-of-disparities effect can be seen, for example, in the outcomes of the Hospital Readmissions Reduction Program (HRRP), a program foisted on the fee-for-service Medicare program by the Affordable Care Act. The HRRP punishes hospitals with 30-day readmission rates above the national average. CMS uses a risk adjustment method similar to the HCC to adjust readmission rates for factors outside hospital control, but the risk adjuster is so bad it routinely punishes hospitals with sicker patients. Research published in the last three years indicates the HRRP may be killing heart failure and pneumonia patients.
MDH, MNCM, and other “performance measurers” use riskadjustment schemes that are even cruder than the HCC, and in some cases they use no risk adjustment at all. MDH uses payer mix —the percent of patients insured by Medicaid, Medicare, and private insurers—as its risk adjuster. Unlike CMS, which reports the accuracy rate of its adjuster for at least cost (as opposed to quality), MDH has never reported what percent of the variation its payer-mix method explains. In a 2017 report to the Legislature (https://tinyurl.com/mp-2017-mdh), MDH did concede that “risk adjustment can typically only explain a fraction of differences in quality between providers,” and they knew of no way to improve the accuracy of their crude payer-mix method. But, MDH concluded, that’s OK because the payer-mix method is “reasonable.” (p. 14)
Learning from failure
In its 1993 report to the Legislature, the Minnesota Health Care Commission based its breathtaking expectations of “performance” measurement on this breathtaking assumption: “The commission assumes that the dimensions of health care quality can be defined and measured in a useful and equitable way.”(p 134) The commission endorsed this assumption without even acknowledging the sources of white noise discussed here—the bundled product, attribution, and risk adjustment problems—much less suggesting ways to overcome them. None of the subsequently appointed commissions questioned the 1993 commission’s fanciful assumption. Nor did the Legislature. It’s time Minnesota policymakers admit that that assumption was based solely on groupthink, that the assumption persists to this day because of groupthink, and the assumption must at long last be rejected.
Rejecting that assumption does not mean rejecting measurement. The issue at hand is not whether measurement is useful, but whether inaccurate measurement is useful. Nor does it mean abandoning all efforts to improve the quality of medical services or the health of Minnesotans. It means abandoning the default diagnosis that all problems in our health care system are due to defects in our doctors and hospitals, entertaining the possibility that those problems that might be within provider control are due to insufficient resources, and abandoning the comforting myth that it’s possible to adjust “performance” scores accurately to reflect factors outside provider control. Above all, it means accepting the obligation to ensure that measurements are accurate before they are unleashed on Minnesota’s doctors and hospitals.
Kip Sullivan, JD, is a member of the Health Care for All Minnesota Advisory Board. He was a member of Gov. Perpich’s Health Plan Regulatory Reform Commission. His articles have appeared in the New England Journal of Medicine, Health Affairs, and other peer-reviewed journals.
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A personal perspective
Recently, I had the opportunity to testify on behalf of this proposed legislation before the House Health and Human Services Committee. Committee testimony is one way that potential changes are brought forth for a bill. In addition, numerous stakeholders also have a chance to meet with the bill’s authors and recommend changes. For a bill like this, organizations such as the Minnesota Council of Health Plans have had extensive input, resulting in changes such as lengthening the period of time a utilization review organization (URO) would have to respond to a prior authorization request from what the bill’s authors initially proposed. The initial proposal was to have a 36-hour limit on responding for all requests (down from the current law that allows 10 days for a standard determination or 72 hours for expedited requests), but as the bill has progressed, that time has increased to four business days for standard and 48 hours for expedited responses.
While I understand the desire of insurance carriers to lower and control health care costs and the role of prior authorization in addressing that goal, patients and their families often endure long waits to see if the prior authorization will be approved. That same 2017 AMA survey found that 30% of the time, the wait to get a response to a prior authorization request was at least three days. At our hospital, we have had occasions where inpatients needing to go home with durable medical equipment (DME), such as feeding pumps, have experienced delays in getting approvals. Rather than wait for the prior authorization approval and delay their child’s discharge, families end up having to pay for the pumps out of pocket and hope that, in the end, their insurance company will authorize the equipment and reimburse them. Patients should not have to wait for essential equipment or services.
In addition, I am very aware of the roadblocks that the current prior authorization processes can present to a clinician wanting to provide the best care for his or her patients. There is an unspoken message by insurance companies and pharmacy benefits managers (PBMs—another type of URO), that clinicians are not able to decide which tests or medications a patient needs and that these UROs are better able to decide this. A 2019 Medical Economics article, “The impact of prior authorizations” (https:// tinyurl.com/mp-prior-authorization), stated that “ Most doctors view prior authorizations as an attack on their autonomy, their years of training, and their ability to care for their patients. Plus, there’s the time wasted and revenue lost due to haggling with payers over approval for drugs and tests.”
At the Committee hearing, a representative of the Minnesota Council of Health Plans actually stated that health plans may know more than the clinician about what medications or tests are best for a patient. The Blue Cross Blue Shield of Minnesota website states the following about what their decisions are based on: “Blue Cross makes prior authorization decisions using the Blue Cross Medical Policy. This policy includes evidence-based guidelines from the World Health Organization. Registered doctors and nurses regularly review these guidelines.” (See https://tinyurl.com/ mp-prior-authorization2.) 3 Prior authorization from cover
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Current practices
Prior authorization affects patients and clinicians in obtaining approval for procedures, inpatient admissions, medications, and durable medical equipment. The process of obtaining this authorization is time consuming on the part of clinicians and their office staffs and often seems to be designed to delay or prevent approval in the best interests of the insurers, not the patient. The 2017 AMA Survey found that 14.6 hours per week were spent by physicians and staff completing prior authorization work. I recently heard from a nurse in one of our clinics that she had spent over 13 hours on the phone over the period of a month trying to get one medication approved for a patient. Clinics and hospitals across the state have staff dedicated solely to processing prior authorization requests and appeals. In my hospital, we estimate that we have about 30 full-time equivalents (FTEs) on the front end working on prior authorization and another 10 FTEs on the back end fixing prior authorization issues. The administrative costs of handling these prior authorization matters are enormous.
We have all experienced problems with obtaining prior authorization approval for a medication or DME on a Friday afternoon for a patient awaiting discharge from the hospital, when the insurance company prior authorization department, or another URO such as a pharmacy benefits manager, tells you they are closed over the weekend. At the recent Committee hearing, one
legislator asked the same representative of the Minnesota Council of Health Plans who testified that insurance plans may know better what medications or procedures a patient may need than their clinician, why insurance plans can function on a Monday–Friday, 8–5 schedule, if hospitals and doctors function 24/7? The Health Plans representative did not have a good answer for this question. As previously mentioned, the proposed legislation would shorten the time health plans or UROs are allowed to review a prior authorization request to speed approvals (although, as mentioned above, the current version does not go as far as would have been liked).
There are also cases where delays in prior authorization for outpatient medications can lead to increased morbidity and possible emergency room visits and hospitalization. At our hospital, we have seen situations where prior authorization for outpatient IVIG administration for patients with immune deficiencies or treatments for patients with hemophilia were delayed, resulting in complications for patients. Any potential savings the prior authorization process purports to provide are immediately lost when a patient finds themselves in an emergency department, the most expensive, least efficient place to receive care.
Other examples
Another problem with current prior authorization processes is that often, URO personnel may be using algorithms that “help” them decide when to approve or deny a request. They may have little to no medical training to make these decisions. One example where the current law can create delays is in our Pediatric Cardiovascular Intensive Care Unit, where we have often received denials and delays in getting a medication called sildenafil approved for our patients. You may know this generic drug by its more common brand name, Viagra, and I wouldn’t be surprised if many of you may have the same response that some URO reviewers have, which is, “why would a pediatric patient need Viagra?” However, in pediatric cardiology or intensive care, this drug is commonly used to treat pulmonary arterial hypertension. The medication helps to reduce the pressure. Having a URO not understand this often delays treatment and discharges from the hospital. Current law requires that a licensed physician in Minnesota make the prior authorization determination. This new law would require that this physician also “have experience treating patients with the illness, injury, or disease for which the health care service has been requested.” Requiring a pediatric cardiologist, intensivist, or neonatologist to review the request would expedite the response and most likely lead to approval.
Finally, in pediatrics, we have also seen situations where our young patients in the hospital are denied liquid preparations for a medication by a URO and instead told we must prescribe a tablet. While it is common sense to any of us with children or grandchildren that young children often can’t swallow pills, apparently that doesn’t fit into a URO algorithm, especially if the tablet form is less expensive. Having a knowledgeable physician make these decisions will help.
Summing up
Rep. Morrison and Sen. Rosen’s bill to streamline and improve the prior authorization process is a significant step in the right direction. The bill also provides much needed transparency to the prior authorization process by requiring health plans to list annually how many prior authorization requests they received and what the outcome of those requests was. Prior authorization can play a role in helping reduce health care costs, but all too often it delays or compromises patient care while adding administrative costs and burden. We can do better, and this legislation is a great start.
Get involved
Prior authorization affects all physicians and health care providers. Reach out to your state representative or senator to share your thoughts on House File 3398 and Senate File SF3204. Search for names and contact information at www.gis. leg.mn/iMaps/districts/.
To check the status of either bill, visit www.leg. state.mn.us/leg/legis. This webpage also includes a link to sign up for the Legislature’s “MyBills Personalized Bill Tracking” email service, which delivers alerts on specific bills. Sheldon Berkowitz, MD, FAAP, is a general pediatrician as well as the Medical Director for Case Management, Utilization Management and Clinical Documentation Improvement at Children’s Minnesota. He is also the PresidentElect of the Minnesota Chapter of the American Academy of Pediatrics. He has testified at the Minnesota Legislature several times in the last year. • 67% of patients rate their pain reduction between 50-100% • 74% of patients rate their headache reduction between 50-100% • 64% of patients rate their use of medications decreased 50-100% • 109% increase in Lumbar Extension ROM & strength • 165% increase in Cervical Rotation ROM & strength
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Recognizing Minnesota’s Volunteer Physicians
By Richard Ericson
Each year, Minnesota Physician Publishing recognizes physicians and health care providers who have volunteered their medical services. Whether volunteering at home or overseas, these caregivers help people in need and come away with a revitalized sense of their work. Their compassion, commitment, and generous spirit reflect the deeply held values in Minnesota’s medical community.
Gregory Beilman, MD
University of Minnesota Physicians
Greg Beilman, MD (at left above), has led four annual “surgical camps” at the Ruth Gaylord Hospital in Kampala, Uganda, where doctors spend one week providing free surgeries to lowincome patients. The Ruth Gaylord Hospital—in Maganjo district, Kampala, Uganda—was established eight years ago with funds from the Friends of East Africa Organization.
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In its “Global Surgery 2030” report, the Lancet Commission estimates that an additional 1.27 million surgeons, anesthesiologists, and obstetricians are needed by 2030 to provide safe and affordable surgical care across the world. Faculty at the University of Minnesota are working to increase the absolute size of the workforce and the skill of the existing workforce in Asia, Africa, and Central America.
To further address this global challenge, Dr. Beilman is working to grow surgical capacity in Uganda with the creation of a sustainable, socially responsible collaboration between the University of Minnesota and Kampala, Uganda’s Makerere University. Advancing research activities, providing surgical expertise, creating a bidirectional short-term training program in surgery and anesthesia, and training residents from both institutions in global surgical research, are a few of the benefits of a sustained collaboration.
Dr. Beilman is a general and critical care surgeon for University of Minnesota Physicians and a professor in the Department of Surgery at the University of Minnesota Medical School. Currently, Dr. Beilman is singularly focused on leading the COVID Command Central in his role as senior vice president and medical director of Acute Care Operations with M Health Fairview. He earned his medical degree and completed his residency at the University of Kansas, School of Medicine. A fellowship in surgical critical care led Dr. Beilman to the University of Minnesota Medical School, where he has remained as a faculty-physician, treating patients during some of their most vulnerable moments and training the next generation of medical providers.
Stephen Dunlop, MD, MPH, FACEP, a board-certified emergency medicine physician-scientist with formal training in public health, advanced ultrasound techniques, and tropical medicine, has partnered with colleagues in low- and middle-income countries (LMICs)— primarily in Tanzania and Kenya—for more than a decade. In Tanzania, he has been involved with the development of emergency care.
A founding member of the African Federation for Emergency Medicine, Dr. Dunlop initially sought to work in a resource-limited hospital serving the world’s most vulnerable patients. “It became clear that I could make a much greater impact through education and systems development,” he said. “However, there was a huge discrepancy between where funding streams were aimed, what conventional wisdom was on the biggest issues facing LMICs, and what the reality was on the ground within ‘emergency departments’ across Sub-Saharan Africa.”
Dr. Dunlop now concentrates on epidemiologic analysis of burdens of disease; education of emergency medicine residents in Sub-Saharan Africa; advocacy aimed at U.S.-based funders; and administration of an emergency
department that now has the first residency-trained emergency medicine physician in Northern Tanzania. Among his many other roles, he serves as codirector of emergency services at Arusha Lutheran Medical Centre in Arusha, Tanzania, which expects to see 70,000 patients in 2020.
He currently has active research collaborations in Tanzania, Kenya, and Uganda, including studies on the use of ultrasound for elevated intracranial pressure in cryptococcal meningitis, lung ultrasound for diagnosis of pediatric pneumonia, and acute coronary syndrome among urban Tanzanians. At Hennepin Healthcare, his interests include health issues faced within immigrant communities.
“This experience provides me with a unique perspective on how to tackle our current and future global health challenges that our patients, both at home and abroad, face,” Dr. Dunlop said. “Global emergency medicine is a prime example of a multifaceted approach to health maintenance, and places me at the intersection where efforts in public health fall short, attempts at restoration of health begin, and the data for future public health intervention can be collected.”
Brent Nelson, MD PrairieCare
Brent Nelson, MD, is an interventional psychiatrist and technologist who has volunteered his time to work with Stillpoint Engage and Doctors Without Borders in Johannesburg, South Africa. He is Chief Medical Information Officer (CMIO) at PrairieCare, and is an assistant affiliate professor at the University of Minnesota.
Outside of his time practicing psychiatry, he provides training and education to humanitarian aid outreach workers around the world on topics that range from the neurobiology of stress to coping with trauma and building resiliency in the field. We know that most humanitarian aid workers are illprepared to cope with the stress and trauma that can happen either directly or vicariously through their work in many developing areas of the world. It is paramount that these workers find ways to cope with the challenges that many face in the field—including trauma, isolation, and anxiety. His style of teaching includes a balance of science, theology, experience, and storytelling. Dr. Nelson’s passion for teaching others, and his openness to new idea, allows him to quickly build rapport with his audience and allow for profound learning and lasting memories.
Most humanitarian aid workers are ill-prepared to cope with the stress and trauma (of their international work).
As a technologist, Dr. Nelson is working with the non-profit Stillpoint Engage (Minneapolis) to develop a web-based application that allows humanitarian aid workers to access ongoing training materials to bolster resiliency. This app will also help them remain connected to their peers and supervisors while deployed in the field. This innovative application will help track levels of stress and overall functioning while workers are managing their daily duties. The long-term vision is to incorporate a degree of machinelearning or artificial intelligence that will help predict patterns and behaviors in humanitarian aid workers that put them at-risk for trauma or mental illnesses.
The combination of the learning content that he delivers and the online application he is building will be the groundwork for true transformation and enhancement of the humanitarian aid community. Dr. Nelson is passionate about this work, and has worked selflessly with countless stakeholders and third-party experts to help bring this critical training and technology to the individuals who need it. He has made contributions in almost every aspect of this initiative and has proven himself invaluable as a psychiatrist, teacher, visionary, and application developer.
Michael Nelson, MD
University of Minnesota Medical School
Michael Nelson, MD, a professor in the Department of Radiology at the University of Minnesota Medical School and a radiologist in breast imaging, volunteers at the Kilimanjaro Christian Medical Center (KCMC) in Misho, Tanzania.
This service was inspired by former University of Minnesota Medical School faculty member, Helmut Diefenthal, MD, who recognized a need to expand and improve radiological services in Tanzania. Dr. Diefenthal founded the East Africa Medical Assistance Foundation (EAMAF) to accomplish that goal and serve the communities there. Dr. Nelson, a student of Dr. Diefenthal, shared his commitment to world health.
Dr. Nelson volunteered to be one of the first to travel to Tanzania through EAMAF in 1989. During that first visit, he served as a board examiner, and since then, he has served on EAMAF’s board and traveled to Tanzania over 30 times to volunteer at KCMC in various capacities, helping to build the program into what it is today.
One of his proudest accomplishments is helping to install the first mammography unit in East Africa. Once the diagnostic radiology infrastructure for the 18 million Tanzanians whose main referral hospital was KCMC was in place, treatment was the next challenge that Dr. Nelson addressed through his volunteer efforts.
The Foundation for Cancer Care in Tanzania (FCCT) was formed to expand treatment options by working closely with EAMAF. FCCT raised money to build a cancer treatment center in Tanzania that now sees 75 to 90 patients per day and provides chemotherapy.
This partnership, which included leadership from Dr. Nelson, contributed to a decline in mortality rates, such as the mortality rate of Burkitt’s lymphoma, from 85% to less than 15%. In 2018, Dr. Nelson received the American College of Radiology (ACR) Foundation Global Humanitarian Award for his service at KCMC for the last 25 years. In the time that he has served, he has seen the average life expectancy rise by decades. Dr. Nelson continues to go to Tanzania; in 2019, his time was spent conducting breast and liver cancer workshops.
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Mary Owen, MD
University of Minnesota Medical School, Duluth campus
Mary Owen, MD, assistant professor and executive director at the Center of American Indian and Minority Health (CAIMH) at the University of Minnesota Medical School, Duluth campus, administers multiple programs that support Native students. The school is second in the nation for graduating American Indian and Alaskan Native medical doctors, thanks in large part to recruitment efforts by Dr. Owen and her colleagues.
After completing her undergraduate studies, Dr. Owen worked with the Alaska Alliance for the Mentally Ill and the Alaska Psychiatric Institute while receiving health care at the Alaska Native Medical Center. “There were no Native people who were taking care of patients. There were no Native doctors and very few Native nurses,” she said. Dr. Owen resolved to become a doctor. After completing her residency, she moved to her home town of Juneau, Alaska, as a family physician at the Southeast Alaska Regional Health Consortium.
In her current capacity at the Duluth campus, Dr. Owen opens career paths for other new physicians. “I love it because I get to help get Native students into medicine,” she said. “I tell students, you can be a doctor in our communities or you could be a neurosurgeon who mentors Native students. But you have to give back. That should be required of all medical students.”
That same commitment extends to the larger population as well. Dr. Owen teaches an American Indian Health seminar, open to all students, that addresses health disparities and the gap in health care between the “haves” and the “have nots.” “It isn’t just the Native communities,” she says. “Outside of our community, the same immense health disparities affect many groups. The health seminar covers the ways we can make change.”
Outside the walls of the Duluth medical school, Dr. Owen continues her parents’ legacy of community advocacy and service in Juneau. In addition to encouraging medical students to volunteer and serve their communities, she has written proposals to support even more students—starting as early as grade school—to pursue careers in the health care field.
She practices with the Fond du Lac Band of Lake Superior Chippewa.
Brianne Barnett Roby, MD Children’s Minnesota
In October 2019, Dr. Roby traveled to Hermosillo, Mexico, with Children’s Surgery International (CSI), a Minnesota-based, nonprofit volunteer organization that provides free medical and surgical services to children in need around the world. Dr. Roby has been volunteering with CSI since 2016, and has served on its Board of Directors since 2017. In addition to her own trips to Hermosillo, Vietnam, and Liberia, she also helps recruit surgeons for similar missions to Ethiopia, Liberia, and Tanzania. She had planned to provide care in India this year before that trip was canceled due to COVID-19.
In Hermosillo, a city of over 800,000 people in the state of Sonora, Dr. Roby and her team work alongside the local CIMA Hospital and St. Andrew’s Children’s Clinic, which is based out of Nogales, Arizona. She describes this as “essentially an international cleft team, in that we base the care on what patients in the United States would get for cleft care.” Services include not only cleft lip and palate but also alveolar bone grafts, orthodontic work, and cleft rhinoplasty.
Over three days each trip, Dr. Roby’s team typically screens about 120 children and performs around 60 surgeries. She then works closely with the local nursing staff to help care for the patients after surgery.
“It feels like a continuity clinic just like I would have in the United States,” she says. Her team is comprised of four surgeons (three pediatric facial
plastics/cleft surgeons and one oral surgeon), one lead anesthesiologist and four others on the anesthesia team (anesthesiologist or nurse anesthetist), 1–2 pediatricians, operating room nurses, recovery room nurses, and floor nurses.
Each and every time she visits Hermosillo, Dr. Roby is touched by how warm, kind, and patient the children and their families are as they wait to be screened or have surgery, even after traveling hours or even days to get to CIMA hospital to be evaluated.
Dr. Roby has a special place in her heart for Hermosillo because, she says, “many of the kids I have operated on I did their cleft lip at a few months of age and returned a year later to do the cleft palate surgery.” She also loves that the parents, St. Andrew’s Clinic, and volunteers at CIMA Hospital keep her posted on the recoveries of the patients and, “each year we are greeted warmly like we’ve been friends forever.”
THE COMFORTS OF HOME
The newly expanded neonatal intensive care unit at Essentia Health in Fargo, ND provides a beautiful, home-like environment for the tiniest of patients and their families. Equipped with advanced medical technology and designed to provide a calming, nurturing atmosphere, this specialized design encourages positive family interaction and overnight stays.
EAPC.NET/EH-NICU
David Schultz, MD Nura Pain Clinics
Even before Gov. Tim Walz’s Shelter-at-Home directive was issued, Nura Pain Clinics recognized that some of its patients would require an elevated level of in-home care during the COVID-19 pandemic. Dr. Schultz (pictured first from left with care team members) is founder and medical director at Nura, whose multidisciplinary approach to chronic pain includes targeted spinal drug delivery via pain pumps for its most extreme cases—a treatment unavailable to patients who can’t travel to the clinic or who have limited financial resources.
Dr. Schultz directed his mobile care team to waive charges for many of those patients. “We did not want cost to stand in the way of patients receiving the care they need during this pandemic, and decided to use our mobile care team to provide in-home visits for high-risk patients in need, regardless of insurance coverage,” he said. “We’ll continue to do so until this crisis is past.”
The in-home visits are available on a case-by-case basis. Nura’s mobile nurses provide a variety of in-home patient care, including medication management, refills of pain pumps, medical evaluations, and arranging telemedical consultations directly with physicians as necessary.
The decision to offer the free service comes at a time when Nura has had to furlough over 50% of its staff while elective pain procedures are on hold. For Schultz, though, it’s a case of patients over profits. “We’re providing free homecare for selected patients who are high risk for COVID-19, and who we feel would be put in jeopardy by leaving their homes during the crisis,” he said. “We feel it’s the right thing to do regardless of payment.”
The vast majority of Nura patients requiring in-home care are those with pain pumps. Normally these patients visit the clinic every few months to refill the devices. Without timely refills, these patients could go into withdrawal, end up in an ER, or take up an inpatient bed that hospitals are trying to reserve for COVID-19 patients. Switching patients off of their pump medication and onto high-dose oral opioids for short-term care during the pandemic would create other potential problems.
The home visits may save lives of some high-risk patients. “If I had to go out into the public with my immune system, generally I [would] pick up every bug around,” said Nura pain pump patient Brenda Standmark.
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