INTERVIEW

Creating a WellCare Ecosystem

Craig Samitt, MD, MBA Blue Cross Blue Shield of Minnesota

As a payer, you have a fairly unique perspective on the pandemic. What are some of the most surprising things you have seen that you can share with physicians?

In our professional lifetime, we have not seen, or been taught, how to deal with one crisis − let alone many simultaneous ones. A pleasant surprise for me, both as a physician and payer, has been how much the local care delivery and business communities have rallied and worked in lockstep to care for the sick and needy, to keep employees safe, and to work hard to preserve jobs and protect livelihoods.

The explosion of telehealth has been a major byproduct of the pandemic. What can you share about your plans around ongoing reimbursement for these services as well as experiences with your own Doctor on Demand program?

I’ve long hoped that virtual care would become more of a mainstream option for care delivery, but would not have wanted that transformation to be fueled by a pandemic. In 2019, we paid about 65,000 telehealth claims, and through the first three quarters of 2020, we saw more than 2 million telehealth claims. Patient response to no-cost access for services offered by Doctor On Demand was tremendous. We will continue offering expanded virtual care benefits for members and pay parity with in-person visits for providers into 2021. Before extending the program further out into the future, we first want to assure that telehealth delivers all that patients hope and expect − more convenient, high quality, and over lower cost healthcare. Through telehealth and other improvements that are needed in our industry, we have an opportunity to pivot to value in response to this pandemic. We should not squander that chance.

Some of the current thinking at BC/BS MN involves the idea of the health care ecosystem. Please tell us about this.

While we currently reference our industry as a Healthcare System, I’d prefer that we aspire

Our industry cannot be “...” the barrier to progress. “...”

to be something better. Let me call it a Wellcare Ecosystem. What if our industry truly lived the expression “an ounce of prevention is worth a pound of cure?” What if we rewarded prevention, avoidance, social health, mental health, wellness, eliminating systemic racism − everything we can argue is in the “ounce?”

Similar to a rainforest, health care has a complex ecosystem with interdependent stakeholders that don’t all need to work in lockstep at the same time. Healthcare stakeholders need to be aligned around the same goals and incentives, with everything focused on delivering better care at a lower cost for patients and better health for our community. I believe our current system is unsustainable if left on its current course. The fewer that can afford health care, the fewer in our community that benefit. The more that industry stakeholders work in opposition, the more patients are caught in the middle. My hope is that a transition to an ecosystem centered on wellness will put our industry back on track.

Many people say the employer-sponsored health insurance model is unsustainable. What evolution do you see in this field?

I’m a strong advocate for universal coverage, and believe that all Minnesotans should have access to high quality, affordable healthcare. To achieve this goal, and to preserve consumer choice, I’m hoping that we can adopt a “no wrong door” approach that offers high-value care options for all that want and need it. 180 million Americans are insured by employersponsored coverage today. While that amount may erode over time, many employers enjoy this model and view it as a key tool in attracting and retaining top talent. That said, the primary reason employer-sponsored health insurance is unsustainable is the rising cost of care. As such, I envision that we will see employers become more aggressive in working with plans and providers to use price transparency, innovation, technology, virtual care, selective networks, and other means to improve quality and drive down costs.

Another problem involves hospital costs. How will the role of the hospital change, both in the metro and outstate?

From the start of the pandemic, we have witnessed the critical role that hospitals play in providing emergent and intensive care. Postpandemic, I predict we will see the role of hospitals in our ecosystem continue to change. As the population ages, there will be increasing demand for complex and emergent care and appropriate elective inpatient care. In the future, hospitals will likely address this growing demand not through additional bed capacity, but by safely and effectively shifting lower acuity, non-emergent, non-intensive care delivery to other venues, such as ASCs, doctor offices, patient homes and telehealth. As we have seen at Blue Cross via our growing partnerships with North, Allina, Mayo, Minnesota Oncology, Minnesota Healthcare Network and others, I envision that high-performing hospitals will

increasingly become population health companies − with an intensified focus on ambulatory, social and behavioral health as a complement to inpatient care.

What work is BC/BS MN undertaking to address cultural diversity and systemic racism?

One of the challenges in our industry is we’ve been asked to − or forced to − stay in our lanes. As I mentioned previously, I believe systemic racism and cultural bias is part of the “ounce of prevention.” If we are to play a role in transforming healthcare, organizations like Blue Cross and Blue Shield of Minnesota need to be more than just a claims company, a sickness management company, and a payment company. Given that our strategic plan is all about reinventing our industry by reinventing ourselves, we are undertaking a bold and comprehensive portfolio of racial and health equity and diversity equity and inclusion efforts. In doing so, we are getting into the equity business, social determinants of health business, and racial justice business. While I don’t have the space here to add all that we’re doing, I’d be happy to fully share all that we’re doing for those that are interested. Needless to say, we aren’t being shy, remaining silent, or avoiding risks in this space. We are taking bold action to advance true racial and health equity for our team, for those that we serve, and for our community at large.

You have said that the biggest problem facing health care is the resistance to change. What can you tell us about this?

My hope is that all that we’ve been through in 2020 will lead to a fundamental reinvention of our industry. How is it possible that we can cost so much as an industry and yet preserve the gaps we’ve seen through this crisis? I’m referring to coverage gaps, care delivery gaps, equity gaps and others. If we come out of this crisis and see premiums rise, ongoing inequities, worsening coverage, or a return to a fee-for-service payment chassis, that would only compound the tragedy. Our industry cannot be the barrier to progress. We must be the drivers of reinvention of our own industry.

Another concept you have put forth is the idea of becoming the “un-health plan”. What does this mean?

At a recent meeting, I heard someone appropriately point out that “if the healthcare industry doesn’t propose change, change will likely be imposed.” I’ve long advocated for reinvention of our industry from the inside-out rather than awaiting disruptive innovators or regulations driving change from the outside-in. For me, reinvention isn’t incremental change. It requires transformation. So becoming an un-health plan isn’t about becoming modestly better. It’s about leading a paradigm shift that drives material improvement in patient satisfaction, access, quality and affordability.

Are there any final thoughts you would like to share with physicians as we move into 2021?

In addition to my heartfelt thanks and gratitude, I wish our physician colleagues much health, safety, rest and healing heading into the New Year.

Craig Samitt, MD, MBA is the President and CEO of Blue Cross Blue Shield of Minnesota. Since 2018 he has been responsible for overseeing the strategy and operations of the state’s first and largest health plan.

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability?

Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing

The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

3Responding to Human Trafficking Victims from cover

researchers, and health educational institutions. HEAL Trafficking, the International Centre for Missing & Exploited Children, and the National response, which spans across state agencies (health, human services, and Association of Pediatric Nurse Practitioners were key partners along with public safety), tribal nations, nonprofit organizations, and various systems. the National Human Trafficking Training and Technical Assistance Center

Health care providers play a critical role in identifying and assisting in this project. The report, “Core Competencies for Human Trafficking human trafficking survivors. Whether seen in Response in Health Care and Behavioral Health an emergency room, community clinic, dentist’s Systems” was released earlier this year and is office, or treatment center, survivors seek care from available on-line. several different medical and behavioral health Summarizing the Core Competencies professionals, yet these providers may not always know that their patients or clients are suffering from, or are at risk of, trafficking or exploitation. Survivors are often hesitant… when it comes to sharing details. The core competencies, which the report defines as “skills needed for professionals to most effectively conduct their work,” were developed according to Survivors are often hesitant, ashamed, or even a set of guiding principles based in public health fearful when it comes to sharing details beyond approaches. These approaches include prevention; what is necessary to meet their immediate health trauma-informed, culturally responsive, and care needs. patient- or client-centered practices; promotion

For these and many other reasons, experts of individual agency and empowerment; holistic from around the United States were summoned responses; coordination across disciplines for wrapby the United States Department of Health and Human Services, around services; and referrals to appropriate service providers. So too, the core Administration for Children and Families, Office on Trafficking in competencies take into account other factors such as access to quality health Persons for a three-year-process to develop a set of “core competencies” to care; societal or environmental influences; relationships with other disciplines better identify and respond to the health care and behavioral health needs including law enforcement, child protection, and legal services; and conscious of human trafficking survivors. or unconscious biases held by providers. There are six core competencies and

These core competencies were designed with four key constituencies one universal competency outlined in the report, briefly described below: in mind: Individual practitioners, health institutions or organizations, Universal Competency: Use a Trauma and Survivor-Informed, Culturally Responsive Approach

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mohagenhansen.com The universal competency of using a trauma and survivor-informed, culturally responsive approach is considered an “umbrella framework” for all of the other competencies in the report. Trauma-informed care is focused on building trust and rapport with patients or clients while recognizing that trauma experiences, including racial, cultural, and historical trauma, determine willingness or hesitancy to disclose harm. Policies and practices should include informed consent for all aspects of patient or client care and intake or screening protocols that do not cause further harm.

Organizations and institutions must ensure that their professionals are well-trained in trauma-informed approaches. Further, supports should be in place for professional responders in the event of vicarious trauma and burnout that can come from serving individuals and populations experiencing extreme trauma like human trafficking.

In terms of research and education, universal competency promotes multidisciplinary-focused research strategies designed to identify health disparities and develop innovative approaches to care provision. Educational settings should strive to equip students with trauma-informed approaches to identifying human trafficking survivors while also giving them the tools they need to identify their own vicarious trauma resulting from service provision.

Finally, universal competency promotes the active engagement of persons with lived experience in human trafficking in advisory and leadership roles both on the direct-care and organizational or institutional levels as well in the development or delivery of curriculum. Researchers should strive to create partnerships with persons who have lived experience and fully integrate their expertise into all aspects of research design and delivery.

This engagement of persons with lived experience dovetails with the priority of ensuring all efforts to respond to human trafficking, whether in direct care or through institutional policy, research, and education, are culturally responsive, driven by cultural humility, and inclusive of all races, genders, sexual orientations, ethnic and religious groups, and abilities.

Understand the Nature and Epidemiology of Trafficking

Competency 1 uses a social-ecological model to demonstrate the connections between society, community, relationship, and individual dynamics in responding to human trafficking. In so doing, this competency recognizes the dynamic Providers can connect clients with community-based services. interplay of activities that encompass trafficking and exploitation (sex and labor), as defined under law as well as through policy and practice. This competency supports research that looks at the distinctions between sex and labor trafficking (as well as their interrelationships) and promotes integration of human trafficking curriculum in all levels of education, and particularly for future health care and behavioral health professionals. Provide Patient- or Client-Centered Care

In terms of trafficking and related social determinants of health, Competency 4 promotes patient or client-centered interviewing practices, Competency 1 highlights the many economic, cultural, and social contexts which span from the setting in which the interview occurs to the parameters that enhance trafficking risks, including adverse childhood experiences, poverty, racial inequities, homelessness, disabilities, mental illness, migration, and more. The competency promotes understanding of risk/ Responding to Human Trafficking Victims to page 124 protective factors in direct services, organizational and institutional policy, research approaches, and curriculum.

Evaluate and Identify the Risk of Trafficking

Competency 2 underscores the concept that disclosure of trafficking is not the goal of an interaction with a survivor; instead, screening tools should be tailored toward detecting indicators (sometimes referred to as “red flags”), tailoring care based on these indicators, and making appropriate referrals. These tools are most effective when evaluated for their reliability and even validated.

When the focus is taken off of a disclosure (which can feel like pressure to a patient or client) and directed toward identifying risks, creating harm reduction and safety plans to reduce risk, and building trust and rapport, it is more likely that a survivor will feel comfortable seeking help either in the moment, or at a future time, from the provider.

Risk assessment is most effective when a patient or client is assured that they are in a confidential setting. Any instances of when confidentiality is broken (such as mandated reporting) should be explained up front so the patient or client can make informed decisions about what to share. Organizational and institutional policies should be written in the strongest terms to protect information gathered from patients and clients. So too, researchers and educators should seek to promote concepts around confidentiality and autonomy as part of trauma-informed and patient- or client-centered practices.

Evaluate the Needs of Individuals Who Have Experienced Trafficking or Individuals Who are at Risk of Trafficking

Competency 3 underscores the importance of engaging the patient or client in shared decision-making when developmentally appropriate. For trafficking survivors, many of whom have had their sense of control stripped away, the ability to participate in – and even lead – decision making is a critical part of healing. Creating an individual plan of action, especially in partnership with a trusted health care or behavioral health provider, can give a survivor options where they did not have them before. This competency also promotes the importance of a multidisciplinary teams approach bringing together health care, behavioral health, law enforcement, public health, social services, the legal system, schools, and other organizations, as well as persons with lived experience, to develop protocols for responding to the needs of survivors. These teams can conduct needs assessments of community resources that span from individuals to organizations and institutions and identify critical gaps. Such assessments can be created in partnership with researchers and educators to ensure that they are not only rigorous in methodology but also specially tailored to different populations, sustainable, and supported by training for all involved.

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3Responding to Human Trafficking Victims from page 11

apt to meet their needs. It is crucial that health care and behavioral health specialists actively engage survivors in recovery and healing, a process that of informed consent, the types of questions asked, and the availability of can last a lifetime. professional language interpreters. Centering the patient or client entails meeting them where they are – using age-appropriate language, being aware Use Legal and Ethical Standards of trauma responses or triggers, collaborating on a Competency 5 underscores protection of legal rights of trafficking survivors. For example, mandated reporting care plan, explaining procedures, ensuring safety, (for child or adult protection) may be required and promoting informed consent by explaining when a youth or family is involved. The patient confidentiality protections as well as mandated or client should be informed about a mandated reporting requirements. reporter’s responsibilities. Mandated reporting

Organizations and institutions can support Screening tools should be tailored can also change the relationship with the patient these direct service interactions by writing clear toward detecting indicators. or client, particularly if the patient or client feels policies and procedures and ensuring that all staff betrayed by the health care or behavioral health are trained to follow them. Case review may be specialist inviting intervention of systems like law helpful to address complex situations or to provide enforcement, child protection, or adult protection. learning experiences. “No Wrong Door” access Organizations and institutions should have to health services will ensure that policies and clear policies in place for how and when mandated training give staff the ability to meet the needs of reporting occurs as well as how patients and clients a survivor no matter where they seek help; this may entail adjusting service are informed about reportable events; so too, educational programs should provision in the moment or making a warm hand-off to more appropriate explain the different forms of reporting. Researchers may want to engage services. Researchers and educators will benefit from this knowledge in terms in further study about how mandated reporting influences the delivery of of better understanding survivor needs, the efficacy of team approaches, and health care or behavioral health services. promoting effective ongoing training for professionals. Other legal considerations include HIPAA, patient consent compliance,

Trafficking survivors are resilient – they have many strengths that can health care record protections, ICD-10 documentation of trafficking in be leveraged into their care plans, ensuring they receive assistance most patient records, patient rights laws, minors consent to health care laws,

A Human-Centered Approach to Behavioral Health

Promoting a caring and healing environment through the power of relationships from staff, patients, and their families. EAPC.NET

victim rights laws, consequences of immigration status, parental rights, and much more. It is not incumbent upon all health care or behavioral health practitioners to know how to respond to every legal issue but they should have a clear idea about where to find resources, how to address certain situations without causing harm, and where to access educational materials for patients and clients.

Integrate Trafficking Prevention Strategies into Clinical Practice and Systems of Care

Competency 6 promotes prevention as part of any public health strategy to address human trafficking. A primary prevention focus, for example, includes screening for adverse childhood experiences and the social determinants of health, implementing knowledge of parenting and child development, and connecting patients and clients, as well as their families when appropriate, with community resources that address the risk factors for human trafficking and perpetration. Organizations and institutions are encouraged to develop training to raise staff awareness about the relationship between violence and health, as well as the intersections of human trafficking with other forms of harm such as domestic violence, sexual violence, and child abuse. Researchers and educators should integrate elements of health disparities, health equity, and the social determinants of health into their efforts.

In terms of secondary prevention, providers should apply concepts of risk and harm reduction in work with individuals currently experiencing human trafficking or exploitation. All staff and providers should have training on how to help patients and clients work to reduce risk – and such training and approaches should be made without bias or judgment. In addition, providers can connect clients with community-based services to support basic needs. Researchers can amplify the importance of risk reduction models and strategies for survivors of trafficking while educators can incorporate risk reduction concepts into curriculum.

Finally, tertiary prevention focuses on long-term strategies, sustaining health and safety planning for patients and clients, and continuing to address protective factors and resiliency strategies with patients to reduce further trafficking and exploitation. This approach requires a long-term commitment to quality health care access, research into effective aftercare and support services, and education about the long-term recovery needs of trafficking survivors – all informed by the wisdom of persons with lived experience.

Minnesota Efforts

The Minnesota Department of Health is in the process of developing statespecific human trafficking training for health care providers based on input from practitioners and survivors for release later in 2021. Input is welcome in the development of this curriculum. Please contact caroline.palmer@ state.mn.us if interested.

Caroline Palmer, JD is Safe Harbor Director, Injury and Violence Prevention Section, Minnesota Department of Health.

What is human trafficking?

Human trafficking is the sale of a person for the purpose of sexual acts or forced labor. Minnesota law uses the following definitions: • Sex trafficking – receiving, recruiting, enticing, harboring, providing, or obtaining by any means an individual to aid in the prostitution of the individual; or receiving profit or anything of value, knowing or having reason to know it is derived from an act (of sex trafficking).

• Labor trafficking – recruitment, transportation, transfer, harboring, enticement, provision, obtaining, or receipt of a person by any means, for the purpose of debt bondage or forced labor or services; slavery or practices similar to slavery; removal of organs through the use of coercion or intimidation; or receiving profit or anything of value.

Report suspected human trafficking

• If you or someone you know is in immediate danger of being trafficked, call 911. • To report a suspected trafficking situation, call the National

Human Trafficking Hotline at 1-888-373-7888, send the text

HELP to 233733, call the BCA at 1-877-996-6222 or email bca.tips@state.mn.us.

Victim resources

• Safe Harbor Minnesota connects trafficking victims with support services. Get information online or by calling 1-866-223-1111. • The National Human Trafficking Resource Center provides a map-based list of victim resources. Information can also be obtained by calling 1-888-373-7888.

Human Trafficking Investigators Task Force

The Human Trafficking Investigators Task Force is led by the Bureau of Criminal Apprehension with assistance from metro area sheriffs and police, Homeland Security Investigations and the Ramsey County Attorney’s Office. Task force members work with more than two dozen agencies to identify incidents of human trafficking and apprehend and aid in the prosecution of such crimes.

Criminal justice agency resources

Task force members and affiliate agencies are specially trained to investigate human trafficking crimes. Contact the BCA at 651-7937000 for assistance with a human trafficking investigation. BCA Training and Auditing also provides advanced training and support to local agency personnel.

3The Future of Gastroenterology from cover

It serves as a second set of eyes for polyp detection and identification, enhancing the quality of patient care and patient outcomes with aided detection of cancerous and benign polyps, diagnosis of irritable bowel disease (IBD), and other gastrointestinal issues.

AI also serves as an extra hand for EHR documentation with tools that automatically learn and adapt based on the data entered, improving Physicians and AI developers clinical efficiency and accelerating workflows. must work together. In doing so, AI can reduce physician burnout, redundant data entry, and the likelihood of missed information and human errors.

AI-augmented screenings can improve patient outcomes, while AI-powered data collection can help providers ensure more complete patient communication and education.

For advancing therapies, AI often uses machine learning to expedite the process of trial and error, and for clinical trials AI can assist with recruitment through the automated surfacing and qualification of patients.

Collaborating with Primary Care

Physicians and AI developers must work together to advance GI care–it won’t happen without both parties actively participating. AI developers like Iterative Scopes need clinicians to offer their expertise and guidance to make sure the technology meets their needs, while physicians can lean on AI developers to develop solutions that can help them keep pace with the ever-growing demand.

Primary care providers should start asking patients if they would like AI to be a part of their care plan. We have shown that through augmentation with AI we are able to help providers to practice at the top of their license. Through the use of AI, we are able to standardize the interpretation of what is and isn’t a polyp, what constitutes severe IBD disease and what doesn’t. This really reduces the disparity in outcome that we are seeing today in medicine and also reduces patient anxiety in which physician they should be entrusting their lives to.

Present State of Artificial Intelligence

When providers think of AI in gastroenterology, they typically only think of polyp detection. Here are new ways AI is being used in GI.

Machine learning

Machine learning is an application of artificial intelligence that enables software to learn and adapt using algorithms and statistical models, not explicit instructions. The application analyzes and draws inferences from data patterns and adjusts accordingly. One example of machine learning that is being used in GI today is with Provation Apex Procedure Documentation, which uses machine learning on two distinct levels: facility and individual user.

On the facility level, the software learns the most common and most logical selections across the organization over time to predict the most likely choices and elevates them for the physician’s consideration. At an individual user level, machine learning further limits mouse movements with “Smart Buttons” that augment each physician’s favorites menu.

Optical character recognition (OCR)

Optical Character Recognition (OCR) is a type of AI that makes it possible to recognize the text in scanned documents and images of various file formats, and convert the text into a searchable and editable format.

One example of OCR in healthcare software can be found in an anesthesia quality reporting solution, Provation SurgicalValet. Plans are underway to enhance the anesthesia billing ‘Charge Capture’ feature to use OCR to convert scanned or faxed invoices and other documents of various file types into discrete data to auto-populate data like date of birth, name, and MRN, and then auto-sort and store these documents in the electronic patient record.

National language processing (NLP)

Natural language processing (NLP) gives machines the ability to read, understand and derive meaning from human languages. One example of NLP use in GI can be found in a leading procedure documentation solution, Provation MD, for automated Adenoma Detection Rate (ADR) reporting. The software’s NLP engine automatically extracts data from scanned lab results and codifies the pathology data into discrete results. Data processing is conducted dynamically, on the fly, and is not stored in physical memory to help protect PHI. The results then automatically populate the electronic pathology follow-up form for review, sign-off, and ADR reporting.

Adenoma Detection Rate, or ADR, is a quality measure for endoscopy facilities and professionals that is defined as “the rate at which a physician finds one or more precancerous polyps during a normal screening colonoscopy procedure for patients over 50 years old.” Professional societies, including the American College of Gastroenterology (ACG), have determined the benchmark rate should be at least 25% in men and 15% in women.

For any site that performs gastrointestinal (GI) procedures, determining endoscopy ADRs and understanding their importance is crucial. Physicians with the best ADRs are most successful in detecting precancerous adenomas in the colon and helping patients avoid colorectal cancer. In fact, according to the New England Journal of Medicine, for every 1% increase in a physician’s ADR, a person’s risk of developing colon cancer over the next year decreases by 3%. Risk of death decreases by 5%.

AI for clinical trials

AI has a broad application in clinical trials, including that of assisting with clinical trial recruitment through the automated surfacing and qualification of patients into the trial as well as automated end-point scoring or determination of severity of diseases. We are working on a few such projects including being able to replicate currently used endoscopic severity grading but with a lower variance and bias, and higher reproducibility than clinicians are able to achieve on their own.

A look at the future

The future of AI in gastroenterology is very exciting. Advances are coming almost faster than the industry is able to keep pace with. As we move forward here are some of the areas to follow:

Enhanced voice to text

Voice to Text has become fairly commonplace in GI documentation solutions, replacing the popular process of manually transcribing and coding Providers should start asking procedures notes that were dictated by a physician patients if they would like AI into a recording device. However, today, the text to be a part of their care plan. collected is very likely to be “free text” and not tied to discrete data and automated coding. That means any procedure notes captured using Voice to Text still requires significant manual review and coding and will be nearly impossible to data mine. AI can enhance Voice to Text enabling the captured text to be automatically converted into structured data, making it available immediately for data mining and analytics, quality reporting, and clinical trial recruitment–drastically reducing manual entry, calculations, and human error.

Intefrated AI-powered scopes and documentation software

Today, AI-augmented polyp detection is normally done at the scope The Future of Gastroenterology to page 314

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