MINNESOTA
APRIL 2022
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXVI, No. 01
PHYSICIAN Improving Psychiatric Health Addressing the challenges BY TODD ARCHBOLD, LSW, MBA
B Health Capability Advancing the potential to flourish and thrive JENNIFER J. PRAH, PHD, MSC, MA, MSL
M
edical science is evolving at an unprecedented rate. Advances in diagnostics, surgery, pharmaceuticals, technology, and more, are developing more expeditiously than the ability of the health care delivery system to keep pace. In some cases, before an important advance has become accepted best practice, new advances in the same field have already occurred. Fundamental approaches to health have not received the same attention. Health capability is an emerging paradigm that addresses these concerns and reexamines some of our most basic assumptions about health in ways that allow us to Health Capability to page 124
ryan was deep into their annual departmental audit, a process he was familiar with after eight years with the firm. He was a rising star in the company, and this year he was a new manager with several reportees and additional financial incentives at stake dependent upon a successful year. Bryan had been up late several days in a row, skimping on meals and getting little quality sleep. On this particular day, the team struggled to get information from a third-party online database and tech support was unresponsive. With a deadline looming, Bryan began to feel dizzy and tightness in his chest. He could feel his heart pounding and began breathing rapidly. He Improving Psychiatric Health to page 164
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APRIL 2022
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Publishing May 2022
Volume XXXVI, Number 01
COVER FEATURES Health Capability
Improving Psychiatric Health
Advancing the potential to flourish and thrive
Addressing the challenges
By Todd Archbold, LSW, MBA
DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Pursuing better health and better healthcare Janet Silversmith, JD CEO of the Minnesota Medical Association
HEALTH CARE POLICY.................................................................. 18 Legislative Session Overview
CARE TRANSITIONS
Examining some health care bills
By Zachary Brunnert ADMINISTRATION....................................................................... 20 Removing Barriers to Care
Improving the safety net
The role and impact of health plan care coordinators
By Amy Rewey, Florence Okoampa, Kathleen Keogh, APRN, CNP, Diane Anderson, RN, BSN, CCM and Heather Quist, RN
BACKGROUND AND OBJECTIVES:
GASTROENTEROLOGY................................................................. 22
When a patient leaves the hospital and returns to an assisted living facility, or home, they experience a care transition. This term is also used when a patient goes from one physician to another. It can also refer to entering rehabilitation programs or treatment of a condition diagnosed by a physician and then transferred to another type of health care provider. As the spectrum of care teams expands, the number and type of care transitions also expands. Cumulatively these transitions are a leading cause of medical malpractice claims, most of which are easily preventable.
Microbiome Health Recognizing a symbiotic organ
By Byron Vaughn, MD and Carolyn Graziger
Our expert panel will define and explain the most common problems in care transitions. We will examine the negative outcomes that arise from these issues and propose simplesystemic solutions. We will discuss best practice standards that have already been established around these concerns, why they are not more widely followed, and how they can be implemented. We will review technology, which in some cases creates problems, that can be used to reduce them.
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ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.
As we transition to a post-pandemic business world, health care will lead the way in terms of new policies, procedures and readiness. The Minnesota Health Care Roundtable has adjusted to these dynamics. We now invite our readers to participate in this now remote conference process. If you have questions you would like to pose to the panel, or have topics you would like the panel to address, we welcome your input. Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.
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BC/BS MN Files Lawsuit Against COVID Testing Lab Blue Cross and Blue Shield of Minnesota is taking legal action against COVID-19 testing laboratory GS Labs, LLC (GS Labs) to recover more than $10 million in overpayments made since the start of the pandemic. The complaint, which was filed recently in the U.S. District Court of Minnesota, alleges that GS Labs committed fraud against Blue Cross by submitting tens of thousands of claims using inflated cash prices over the past year. According to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, in the absence of a contractual payment agreement, each COVID-19 testing provider is required to post specific cash prices on their public website, which insurers are then required to pay. Blue Cross alleges that GS Labs consistently and intentionally posted inflated cash prices on their public website
in order to charge significantly larger amounts to Blue Cross than what it was willing to accept from individual cash-paying customers. Blue Cross billing data shows that GS Labs consistently charged more than five times the median market rate for its most commonly administered COVID-19 diagnostic test. Additionally, GS Labs embarked on a pattern and practice of administering additional tests for the sole purpose of increasing the total amount charged to Blue Cross. “It is our claim that GS Labs intentionally disregarded and misinterpreted federal guidelines for the sole purpose of maximizing profits during a public health emergency,” said Scott Lynch, senior vice president of pharmacy and chief legal officer at Blue Cross and Blue Shield of Minnesota. “After months of attempts at goodfaith negotiations, we were unable to reach an agreement with GS Labs that would put in place appropriate COVID-19 testing practices at a fair
price. It’s egregious price-gouging like this that ultimately drives up the cost of health care for everyone.”
New Law Allows Medical Cannabis Flower Sales in Minnesota Goodness Growth Holdings, Inc. a physician-led, science-focused cannabis company and IP developer, announced last week that its Minnesota operating subsidiary, Vireo Health of Minnesota LLC, has launched a full line of cannabis flower in Minnesota’s medical cannabis program. The launch of cannabis flower is in accordance with Minnesota’s new regulations allowing certified medical cannabis patients in the state to purchase cannabis in its natural form, as dried whole flower. Governor Tim Walz signed the legislation to allow cannabis flower sales last year. The new law will greatly improve Minnesotans’ access to natural, affordable cannabis flower that is state-tested and
safer than cannabis flower purchased from the illicit market. “We applaud Gov. Walz, the Minnesota State Legislature, and the Office of Medical Cannabis for its decision to allow flower sales to certified cannabis patients in Minnesota” said Chairman and Chief Executive Officer, Dr. Kyle Kingsley. “Allowing the sale of cannabis flower will greatly benefit existing patients, bring new patients into the program, and ensure the continued viability of Minnesota’s medical cannabis program. Flower sales will reduce the cost of medication for many patients, while also significantly increasing product optionality and diversity.” At launch, there are a wide variety of strains and product formats at all eight of Green Goods® dispensaries in Minnesota. Select strains will also be available for purchase at all other registered medical cannabis dispensaries in the state to help ensure that all Minnesotans have access to a wide variety of cannabis flower strains. Green Goods
WE’VE EXPANDED WAYS TO HELP YOUR PATIENTS Two new medical conditions are accepted for Minnesota’s Medical Cannabis Program: • Sickle cell disease • Chronic motor or vocal tic disorder Patients with these conditions can be certified now. Visit mn.gov/medicalcannabis to view the full list of qualifying medical conditions.
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Join Minnesota’s Medical Cannabis Program! As an approved health care practitioner*, you can certify patients to participate in the state’s Medical Cannabis Program. This program provides a treatment option for patients who are facing debilitating medical conditions, helping to improve their quality of life. *Health care practitioners eligible to participate are: Minnesota-licensed physicians, physician assistants and advanced practice registered nurses.
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will continue to make new strains available for patients throughout the year. Minnesota’s medical cannabis patients have already shown a positive response to these new regulations. To purchase cannabis flower, patients are required to set up a consult with a certified pharmacist at a registered medical dispensary. Over 2,000 patients scheduled consults on the very first day consults were made available.
Medicare Telemedicine Coverage Extended Recently, as part of the Consolidated Appropriations Act of 2022 (the “Omnibus Bill”), President Biden extended coverage of Medicare telemedicine services. This will include professional consultations, office visits and office psychiatry services conducted via telemedicine for 151 days after the end of the designated public health emergency (“PHE”). It is unclear whether the latest PHE declaration will be renewed or when it will be terminated. Prior to the PHE, in order to qualify for Medicare coverage of telehealth services, a patient had to be in a physician’s office, hospital, or other healthcare facility located in a qualified geographical health professional shortage area (HPSA), a county that was not included in a Metropolitan Statistical Area as of December 31st of the preceding year, or an entity participating in a federal telemedicine demonstration project. Furthermore, telehealth services had to be provided through CMS authorized technology. Changes made in March 2020 as part of the government’s response to the COVID-19 pandemic waived these location and technology requirements for the duration of the PHE. These waivers of location and technology requirements are now extended further under the Omnibus Bill. Additionally, the Omnibus Bill expands the types of practitioners eligible to provide telehealth services to patients. Prior to the PHE, Medicare
covered telehealth services only if offered by physicians, physician assistants, nurse practitioners, clinical nurse specialists, nurse-midwives, clinical psychologists, clinical social workers, registered dieticians or certified registered nurse anesthetists. Under the Omnibus Bill, the list of qualifying practitioners has been expanded to also now include occupational therapists, physical therapists, speech-language pathologists and audiologists. Other changes include delaying in-person requirements for the provision of mental health services and extending coverage of telehealth services rendered by federally qualified health centers to provide telehealth services for the same 151-day post-PHE period.
Mayo Clinic Launches Limb Loss and Preservation Registry Over 2 million Americans have lost a limb and that number grows by nearly 185,000 per year. Over half are the result of vascular disease with trauma, especially combat, and other medical conditions accounting for the rest. These individuals face unique and lifelong health care challenges. To address improving outcomes from these issues, the Mayo Clinic has recently received authorization from the Federal Risk and Authorization Management Program to begin operating the Limb Loss and Preservation Registry, a national collaborative warehouse for data on people who have lost limbs and may or may not have access to prosthetics. The registry will be the first of its kind in the U.S. The goal of the Registry is to generate knowledge about which advances make improvements in the care of people with limb loss and limb difference. Mayo is in sole charge of registry development and operations, reporting to the National Institutes of Health and the Department of Defense. The project will alleviate significant data gaps about limb loss
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in the U.S. “Until now, there has been little evidence on effective clinical practices and technologies in this field,” says Kenton Kaufman, Ph.D., a Mayo Clinic researcher and head of the project. “This data repository is being hailed as the first national registry of its kind, geographically and demographically providing data that will improve prevention, treatment and rehabilitation efforts for this population. The Limb Loss and Preservation Registry is vitally necessary for the future of patient care, technology advances, and a range of other sustainable efforts in the prosthetic field”, says Dr. Kaufman. The data gap is considerable. In some cases, available statistics are over two decades old, and longitudinal data has never been collected. The registry will help manufacturers with data and feedback on how to improve the next generation of prosthetic devices. It will show insurers possible alternatives
to amputation and how devices can improve patient lives. Data will help hospitals and therapists understand long-term use of prosthetics and reasons why problems may occur after patients leave rehabilitation centers. Overall, the registry will help clinicians make the best-informed considerations about prosthetics and treatments. To learn more about the registry, visit its website.
UCare Names New President and CEO UCare Board Chair, James Pacala, M.D., recently announced that the Board’s CEO Search Committee selected Hilary Marden-Resnik as the organization’s next President and CEO. Marden-Resnik’s appointment follows a five-month period as interim President and CEO after Mark Traynor left UCare to pursue a career in teaching. During her time as interim leader, Marden- Resnik led the
organization through record-breaking growth, achieving enrollment of more than 630,000 members. Marden-Resnik and the management team also provided strategic direction for UCare’s ongoing pandemic response, technology transformation, Medicaid RFP submissions and plans to expand to Iowa. Prior to her interim role, Marden-Resnik served as UCare’s SVP and Chief Administrative Officer since 2010, providing strategic oversight and executive leadership for claims and configuration, customer service, human resources, information technology and the project management office. She also co-led the strategic planning, member experience, and equity and inclusion functions. “Hilary embodies the type of leader UCare needs at this exciting juncture,” said Dr. Pacala, UCare Board Chair. “She understands how UCare needs to grow and evolve to meet our strategic priorities and support our employees,
members, providers and community and regulatory partners.” “I am excited to lead UCare into a future of opportunity, growth, and increased access to care for current and new members,” added Marden-Resnik. “The Board’s confidence in me to lead UCare inspires me to do my best on behalf of our members and the communities in which they live and alongside the hardest working, people powered health care team in town!” Marden-Resnik joined UCare after a decades-long career working for Minnesota health care providers. She was Vice President of Human Resources at Hennepin County Medical Center (HCMC) – now Hennepin Healthcare – in Minneapolis. Marden-Resnik also held positions as Director of Human Resources for HealthEast, Human Resources Manager for Fairview Health Services, and employment and health law attorney for the Gray Plant Mooty law firm.
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APRIL 2022 MINNESOTA PHYSICIAN
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North Memorial Buys Fairview Out of Maple Grove North Memorial Health recently announced its full ownership agreement of Maple Grove Hospital following the expected purchase of the final 25% stake from Fairview Health Services. The transaction will close on or before May 2, 2022. The new ownership structure supports North Memorial Health’s vision to create a comprehensive modern medical campus to meet the growing needs of Maple Grove and the northwest metro communities. “We’ve had a positive, successful partnership with Fairview Health Services through the years,” said J. Kevin Croston, MD, Chief Executive Officer, North Memorial Health. “This was a joint decision that is right for both organizations and we look forward to continued collaboration in other areas.” “Today’s announcement gives both organizations the ability to target investments in places that help us best serve patients,” said Hayes Batson, Chief Financial Officer, Fairview Health Services. “This transaction does not change our steadfast dedication to serving and caring for the residents in the northwest metro area.”North Memorial Health’s future plans for Maple Grove Hospital focus on expanding customer care capacity for the rapidly growing community, especially in the areas of emergency, imaging and in-patient services. Since opening 12 years ago, Maple Grove Hospital has become the largest birthing center in the state and continues to receive the Press Ganey Guardian of Excellence Award for overall inpatient experience. “This is an exciting step forward toward expanding the Maple Grove campus to empower customers to achieve their best health, while also keeping families close to home,” said Andy Cochrane, Chief Hospital Officer, North Memorial Health. “We are committed to providing the same high level of care and quality
our customers expect throughout the transition and into the future.”
Medica Offers Homebased Kidney Testing Medica has recently announced a new partnership with Healthy.io, whereby at-risk plan members can test their kidney function using their smart phones at home. Based in Tel Aviv, Healthy.io is a global leader in smart phone medical applications. Members with diabetes and/or hypertension will receive free albumin-to-creatinine ratio urine tests. Members take the test in the comfort of their home and receive results immediately, which they can share with their health care provider to determine if care is needed to prevent chronic kidney disease. CKD affects 37 million Americans, and 80% of individuals at risk for this disease fail to get tested for this life altering chronic condition. Healthy.io’s smart phonebased ACR home testing solution has the potential to simplify the health care experience by expanding access to care, reducing costs and improving patient health. “We know that 8 in 10 Americans who are at risk for chronic kidney disease don’t take their annual urine test, leading to delays in detection,” said Paula LeClair, US GM of Healthy.io. “Medica is committed to finding health care solutions that make our members’ lives easier, healthier and happier,’’ said David Webster, M.D., Chief Clinical and Provider Strategy Officer at Medica. “Through our relationship with Healthy.io, we can provide at-risk members a simple way to get tested and assess their kidney function with immediate results.” A recent study in the United Kingdom showed that this at-home screening solution raised test adherence from 0 percent to 50% among patients who had not done a urine test for kidney disease in the previous year The test is pending FDA 510(k) clearance and is currently for investigational use only.
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MINNESOTA PHYSICIAN APRIL 2022
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INTERVIEW
Pursuing better health and better healthcare Janet Silversmith, MA, CEO of the Minnesota Medical Association
For those who may be less familiar with
environment – both socio-economic and practice setting – in which physicians care for patients.
the MMA, what can you tell us about the organization?
We’ve also made some internal changes that I’m proud of, such as adding more diversity to our board and elected leadership.
With more than 11,000 individual members across the state – from all specialties, all practice types, and representing diverse opinions and viewpoints – the MMA is the state’s oldest and largest professional association for physicians and physicians-in-training. Among our most distinguishing attributes is our advocacy voice on behalf of medicine – the profession of medicine – not the interests of medical practices, facilities, or other particular business interests.
What can you tell us about ways the MMA has responded to COVID?
From day one, we had two primary goals in mind – to help shape the state’s pandemic response with the perspectives and experiences of practicing physicians, and to help keep physicians (member or not) across the state informed and connected. I’m really proud of the countless ways in which we did – and continue to – accomplish those goals. There were two very specific things that we did during the pandemic that were extremely well received – we quantified and documented the financial impact of the pandemic on physicians and physician practices, and we launched a public education campaign called Practice Good Health. Through the Practice Good Health campaign, we deliberately leveraged the public’s trust and confidence in physicians and amplified accurate, current, and evidence-based information on how Minnesotans could best protect themselves from the virus, including direct appeals from physicians to mask up and to get vaccinated.
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APRIL 2022 MINNESOTA PHYSICIAN
Physicians make a “...” difference every day in the lives of the patients they see.
“...”
My favorite fun fact about the MMA is that it is five years older than the State of Minnesota, having been founded in 1853. Although the original purpose of the organization remains intact after 169 years – to improve health and healthcare for all Minnesotans – our current work is focused on the most significant issues and challenges of today.
And, like everyone else, the pandemic forced us to do our work in new ways. For us, that meant new ways of reaching and engaging physicians. Some of those ideas, such as our noontime virtual Physician Forums, have been so incredibly popular that we plan to continue them beyond the pandemic.
As some of the traditional ways that members used to get involved have changed, and in recognition of how busy our members are, we needed more flexible options for their involvement. One way we responded was with the launch, in mid-2020, of The Pulse, which is a new online policy development and membership polling tool. This tool, which is incredibly easy for members to use, has significantly expanded the number and diversity of members who influence and inform our policy development and advocacy work. In fact, given its ease of use and accessibility, other state medical associations are now working to adopt the tool for their own use. To remain relevant, every association, including MMA, must embrace change as a constant. As a result, we work very hard to listen to our members, and our prospective members, to understand their needs, interests and concerns, and to involve them directly in our work. The MMA is involved in a lot of advocacy work, including legislative advocacy. Please
Aside from the pandemic-related work, what
tell us about some of your advocacy priorities.
can you tell us about some of the changes
Yes, advocacy is one of our essential functions. Consistent with our mission, our advocacy has both a public health focus and a medical practice focus. Legislatively, we are involved in a significant number of issues as we work to protect the patient-physician relationship from outside interference, promote public health, and improve access to high-quality, safe, and affordable care.
that have occurred at the MMA since you started as CEO?
I assumed the CEO role in January 2018, which after the past two years, feels like a very long time ago. I think the most important change in that time has been a new and very clear strategic plan that leverages our unique expertise and defines clear outcomes we want to achieve. Our mission, which I believe in so strongly, is to make Minnesota the healthiest state and the best place to practice medicine. The MMA’s elected physician leadership, through our strategic plan, has fully embraced the dual aims of that mission with specific work to improve community and public health, as well as specific work to improve the
In 2022, we actively pursued three legislative proposals. One of these proposals, included in the House omnibus health and human services bill, would protect patients who are taking medications for chronic conditions from having their medications and coverage changed mid-year by their health plan. Many health plans and pharmacy benefit managers (PBMs) make frequent changes
to their formularies or preferred drug lists as they chase rebates or discounts. These frequent changes mean that many patients who are doing well on one drug must switch to a different medication that may or may not work as well for them. For some, that means additional office visits or lab tests; for others, it means delays or gaps in their treatment or, worse, emergency room visits, hospitalization, or other complications. The legislation would continue to allow health plans and PBMs to make formulary changes to manage drug costs but would protect any patients already on such medications from having to switch to another medication until the end of their insurance contract year. Another 2022 proposal would begin the process of creating an electronic repository for completed POLST (Provider Orders for Life Sustaining Treatment) forms. Many patients with serious, life-limiting conditions have worked with their healthcare team to translate their treatment goals and preferences to a POLST form, which is a medical order. But because it is a paper form, EMS and other healthcare professionals are often unable to easily find the form when called to a patient’s home or when a patient is admitted to a facility. As
a result, patients’ preferences may not be followed. An easily accessible POLST repository, as is available in several other states, would help ensure that patients’ wishes are honored. The final proposal we advanced in 2022 builds on Minnesota’s long-time commitment to patient safety. Patients who experience an adverse event still often complain that they encounter a deny and defend atmosphere and do not receive a complete explanation of what happened. Our legislative proposal would facilitate adoption of the evidencebased CANDOR (Communication and Optimal Resolution) model in Minnesota by protecting from discovery communications and documents that are created for purposes of resolving an adverse event with a patient. The CANDOR process involves immediate disclosure of an adverse event to a patient and/or their family and includes communication with the patient throughout the entire investigation and resolution. The CANDOR process has been shown to improve patient safety, better support healthcare team members involved in the event, and decrease malpractice claims. I also want to note that our advocacy work extends well beyond the legislature. For example,
we work on the regulatory side with state agencies, directly with public and private health plans/ payers, with community-based organizations. We are also active in legal advocacy, primarily through the filing of amicus briefs. Some of the recent legal cases we have been involved in include support for the state’s eviction moratorium during the pandemic (Heights Apartments, LLC and Walnut Trails, LLLP v. Tim Walz and Keith Ellison) and support for the City of Edina’s ordinance prohibiting the sale of flavored tobacco products (RJ Reynolds v. City of Edina). Also, in partnership with the Minnesota Hospital Association, we cautioned that mental healthcare in Minnesota could be negatively impacted if physicians and other mental health providers can be held legally responsible for the behavior of any patient for whom they prescribe medications containing a black box warning (David Smits, as Trustee for the Next of Kin for Brian Short, et al., v. Park Nicollet Health Services, et al).
Pursuing better health and better healthcare to page 104
Opening January 2023
Clinic space and practice opportunities available Matt Brandt | 715-531-6862 mbrandt@hudsonphysicians.com
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3Pursuing better health and better healthcare from page 9 The MMA Foundation is an important part of the MMA. What can you tell us about the foundation and its work?
The MMA Foundation, under the executive leadership of Kristen Gloege, is a critical partner in helping us make Minnesota the healthiest state. Founded in 1958, the MMA Foundation was originally focused on providing low-cost loans to medical students. While the Foundation is still committed to supporting future physicians, today much of the direct funding to students occurs via project-based scholarships to support student research or community service activities. The Foundation recently expanded its statewide reach by launching two grant programs to fund physician-led projects aimed at improving community health or advancing health equity. We also maintain an active physician volunteerism program to help safety net clinics and other non-profit organizations expand access to care. I’m also proud of the Foundation’s work to fund physician-led,
suicide prevention training in medical groups across the state. Additional initiatives are in the works for 2022. What is the MMA doing to address physician burnout?
This is such a critical issue that, for many, has been made worse over the course of the pandemic. Importantly, our work to reduce burnout and support professional satisfaction and well-being recognizes that the factors driving burnout are broad. This is not a simple problem of physicians not being resilient enough or one that can be solved with free yoga classes or pizza. Rather, the factors driving burnout are individual, practice/organizational, and external (e.g., socioeconomic, regulatory, cultural). As a result, we are working in all those areas. To support individual well-being, the MMA offers educational resources and programming, including our annual Reclaim the Joy of Medicine conference. To help address practice/ organizational sources of burnout, we have convened wellness leaders and champions from practices and systems across the state to share
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.
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strategies, lessons, and challenges, and to identify how, together, we can accelerate this work statewide. Finally, our advocacy work addresses some of the biggest external sources of burnout, such as prior authorization. Health equity initiatives have become part of every health care organization. What are some of the ways the MMA is responding to these issues?
Improved health equity is a key strategic outcome for the MMA, and we have invested new resources to reflect that commitment. We have also been very intentional about defining a focus for our work that leverages our strengths as a medical association. Our three current streams of work are focused on: diversifying the physician workforce; addressing the social drivers of health, particularly housing; changing the culture of medicine – inside the MMA and externally – to mitigate structural racism and implicit bias. Pursuing better health and better healthcare to page 224
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3Health Capability from cover understand what health means in a wider and fuller context. As a health care delivery system, from a regional, national and global perspective, it is necessary for us to rethink how we approach health care.
What is Health Capability? Health capability is the ability to be healthy; it is a power to perform with the potential for achieving desired ends, as was cited in an article entitled “Health Capability: Conceptualization and Operationalization” by Prah Ruger in a 2010 edition of American Journal of Public Health. It entails individual aptitude and is a cradle to grave concept which requires life-long abilities and aptitudes that enable optimal health. Health capabilities are key strengths resulting from individual and societal commitment of human, financial and physical resources with the goal of helping people thrive. There are inherent differences in individual health capabilities and by looking at them empirically we can begin to understand why personal skills and health benefits alone are not enough to be as healthy as possible and that a narrow biomedical model for disease is also insufficient. We can see that even people in the best external conditions can still have poor health. The health capability model captures the dynamic, interactive, multidimensionality of both health and flourishing. It considers the overlap of biology and genetic predispositions with macro, social, political and economic environments, public health, health care systems and intermediate social contexts such as economic status and political empowerment.
Health capability employs a more flexible approach to health care than linear approaches that are limited to one-to-one associations among variables. This kind of reductionist approach looks at basic relationships first and then the sum of the principal subcomponents, producing a data set that can be difficult to interpret and to comprehensively represent a person’s lived experience. Health capability accounts for both internal and external factors on an individual level and allows for contemporaneous multiple relationships among factors. This overlapping feature offers a nuanced, sequentially interactive, dynamic and multidimensional understanding of individual ability to be healthy. It reveals heterogeneity in the influence of irreducibly social experiences. A valuable element of this model is how, over time, it allows multisectional, longitudinal, inter-sectorial and institutional analysis and design. It considers heterogeneous relations among individual and societal level variables (e.g., income, education, race and racism, sexism and gender discrimination, hetero-normativity and LGBTQIA2S+). By measuring and using a different construct we can better address problems around lack of information on the direct health impact of external factors. Rather than drawing inferences about individual health based on group or macro level characteristics (e.g., race, gender, or socioeconomic status), health capability incorporates external factors into the individual level and considers impacts of the individual on society.
The Health Capability Profile To understand this more clearly, we have created a health capability profile comprised of 15 different health capabilities which encompass 49 separate health functionings and agencies. The goal is for each and every person to reach their highest health potential, their full health capability. The profile provides a full picture of a person’s lived experience and of their journey toward reaching their healthiest and most flourishing potential. The capabilities are internal and external and include: • Internal Capability 1: Health Status and Health Functioning – Your state of health. • Internal Capability 2: Health Knowledge – Knowing about your health and knowing how to be healthy. • Internal Capability 3: Health-seeking Skills and Beliefs, Selfefficacy – Believing in yourself and your health. • Internal Capability 4: Health Values and Goals – Valuing health. • Internal Capability 5: Self-governance and Self-management and Perceived Self-governance and Management to Achieve Health Outcomes – Managing your health, achieving health from within. • Internal Capability 6: Effective Health Decision-Making – Making good decisions in health. • Internal Capability 7: Intrinsic Motivation – Being self-motivated toward health. • Internal Capability 8: Positive Expectations – Having positive expectations about one’s health and flourishing. • External Capability 9: Social Norms – Cultures of health and expected behaviors in society. • External Capability 10: Social Networks and Social Capital for Achieving Positive Health Outcomes – Connecting to others for health.
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• External Capability 11: Group Membership Influences – Health norms of your social groups. • External Capability 12: Material Circumstances – Having material circumstances that support health. • External Capability 13: Economic, Political, and Social Security – General feelings of security. • External Capability 14: Utilization and Access to Health Services – Receiving health care when needed. • External Capability 15: Enabling Public Health and Health Care Systems – Effectiveness of health systems.
When we adapt these capabilities, encourage them in ourselves, in others and in our communities, it is important to consider three questions: (1) why are they important, (2) what do they look like and (3) how do I do it. Valuing health is important because we live in a world of finite resources, including one’s own resources of time, attention, and energy. Health will be compromised if it is not prioritized and understood to be central to a good life.
Health capability presents a dynamic, flexible, detailed, multi-dimensional topology.
Examples To look at the structured thinking behind these capabilities let’s examine #4, an internal capability, Health Values and Goals. Within this capability is a sense of agency and valuing setting health-related goals such as managing cholesterol levels. It includes valuing lifestyle choices such as moderate vs. excessive drinking and the ability to recognize and counter damaging social norms. Health values and goals is the internal capability of valuing ones health, including health-related goals and health-promoting behaviors. Examples of this are regular exercise, a healthy diet, and an active lifestyle. Importantly, it also includes the ability to recognize and counter social norms that undermine the value of health and to persist in these values despite negative social messaging.
We can recognize when a person sets these priorities through their words and actions. They will speak positively about health and work to explicitly counter social norms that damage health. How they structure their daily schedules, their free time, their plans and both short and long term priorities will also speak to the value they place on health.
It is important to note that health values and goals are continuously developed. Part of how one values health is through asking some core questions such as: why is my health important to me? What resources am I committing to my health? What goals can I set to become healthier? How might I change some of my unhealthy lifestyle habits and what social norms may be detracting from my health? To continue this analysis, let’s look at an external capability, #9, Social Norms. Health Capability to page 144
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3Health Capability from page 13 Social norms may vary based on culture however they are to be evidencebased and scientifically valid.
influenza immunizations, respectful and anti-discriminatory expectations about behavior and empathy and care towards helping its members thrive, everyone benefits. It is important that health care and public health providers ensure that underserved populations and communities are not put at risk by power imbalances in either the parent-child relationship or by unscientific beliefs of the parents.
They include the extent to which health seeking behaviors and healthseeking skills are viewed favorably (e.g., minimal use of alcohol, abstinence from drugs, safe sex We can develop the health capability of social practices) or unfavorably (e.g., alcohol abuse, norms with the promotion of positive public moral obesity within the family). They also include the norms through individuals as well as institutions extent to which healthy behaviors are adopted by such as the media, academia, governmental Health capability incorporates the majority or minority of the individual’s societal agencies, and popular culture. external factors into the population and by whom within this population. individual level. Applying the Health Capability Profile They include the extent to which discrimination Practical applications of the health capability or anti-discrimination is the dominant social profile consist in a three-step process. norm and how this impacts the provision of health care and public health services. How do these The first step is to adapt the profile to the health factors lead to disparities in access? How do social condition and to the setting under consideration. norms ameliorate disparities in health care access The second step is to document the adapted and how do they provide decisional latitude or power in familial contexts profile through both quantitative and qualitative data collection. Surveys that are conducive to each person’s health agency? are created that incorporate response from all stakeholders of the health care Social norms are particularly important as an external capability because they shape our beliefs and actions. They provide guidance to what is acceptable, normal, valuable and important, and to what is expected in order to belong to society. Living in society that encourages and sustains people to be active agents of their own health is a critical capability. When society includes positive scientifically accurate norms such as childhood vaccines,
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process, including nurses, physicians, community resource centers, and patients themselves. The analysis of the data draws from a synergistic approach that adopts a position of equal value for quantitative and qualitative data creating mixed methods results. This analysis uses 1-100 health capability scores and the creation of flow diagrams at the individual level. In utilizing these steps and creating a data analysis plan, there are multiple layers. First, the individual level
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through the documentation of individual health capability profiles. Profiles are unique to each individual at the point in time they are created. They offer multi-level analysis and show strengths vs. vulnerabilities at a glance, as well as highly granular data. Individual profiles are intrinsically dynamic and nuanced and allow for optimal circumstances (e.g., absence of symptoms) as well as enabling conditions. Profiles can reveal multiple causes and thereby better describe people’s complex experiences. In the analysis plan, there is also a cross cutting level of investigating each of the 15 health capabilities and a regional/ community level.
methodology of this study are available in an article entitled “Applying the Health Capability Profile to Empirically Study Chronic Hepatitis B in Rural Senegal: A Social Justice Mixed-Methods Study Protocol.” by Coste, Marion, Mohammed A. Badji, Aldiouma Diallo, Marion Mora, Sylvie Boyer, and Jennifer J. Prah that is in press for 2022 publication in the protocol journal BMJ Open.
Conclusions To summarize, health capability presents a dynamic, flexible, detailed, multi-dimensional topology. It includes individual factors, socio-cultural aspects and institutional features that together create health and flourishing. It accounts for and captures interactions among individuals and their environment. It can be applied to empirical studies using a mixed methods social justice design. Its implementation science identifies gaps among observed health capabilities and the optimal health capability level. The health capability profile demonstrates how individuals and societies can work together for each and every person to reach their highest potential, their full health capability and ultimately flourishing.
The final step in applying the profile is to employ the results to foster policy change and improved health capability for all. Indeed, the individual profiles identify cumulative and heterogeneous effects, which help address equity concerns. They also showcase underlying vulnerabilities and illustrate how to build collective resilience. Finally, they highlight strengths and present positive examples on how to achieve optimal health capability. Health capabilities can be promoted in many ways, including community-wide sensitization that improves knowledge and fosters evidence-based social norms around health care, or through motivational interviews and community outreach, which can be implemented alongside institutional reform in a more comprehensive approach to health policy.
Health Equity, Economics and Policy, at the University of Pennsylvania’s School
Case Studies
of Social Policy and Practice and the Perelman School of Medicine. She is also
As discussed, health capability is a flexible model and can be applied to each and every situation that involves health. The health capability profile is adapted to specific conditions and settings, for example, in addressing chronic hepatitis B virus in rural Senegal. Details about the
Jennifer J. Prah, PhD, MSC, MA, MSL is Amartya Senior Professor of
the founder and director of the Health Equity and Policy Lab (HEPL).
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3Improving Psychiatric Health from cover As a young adult embarking in a new chapter in life, Eugene was feeling good about his mental health. As a teenager he struggled with a learning disability and experienced traumatic racial discrimination. His longstanding therapist helped him through many challenging periods in his life. Now, upon starting a new job, he learned that his therapist was out-of-network with his insurance plan. Unable to afford the costs, he sought a new in-network therapist, but was National polls show 42% of Shawna was finishing the second trimester of unable to find a provider who shared the same race teens are concerned about her junior year. She was getting top marks in her or ethnicity. Eugene began experiencing intense becoming severely depressed. classes and recently began a part-time job at the anxiety at work, and his new therapist failed local grocery store. She saw a therapist regularly to grasp the impact of his past life experiences. for anxiety and depression and spent a lot of time He lacked rapport with this new supervisor, online with social media. Her parents were helping who criticized his performance. His self-worth her plan college visits this spring, with aspirations plummeted as he quit his job and subsequently of being an artist. During dinner with her parents one evening, Shawna was dropped the new therapist. Eugene was able to rejoin his parent’s insurance unusually quiet. She unexpectedly became tearful and told her parents she plan and started a new job search. hated her life and had been cyberbullied online by several classmates. She Mental illness is real, common and treatable. Bryan and Shawna are began to sob uncontrollably, and her sadness turned into anger and shouting experiencing extreme symptoms of some of the most common illnesses, about feeling controlled. She slammed the door to her room and told her anxiety and depression. Eugene is among the majority of BIPOC individuals parents she wanted to die. She was not responding to her parents’ pleas who have been a target of racism in the US and are twice as likely to to talk through her locked bedroom door. They burst through, finding her experience severe emotional distress than White Americans. Access to acute hiding under her covers. She shouted to her parents, “Leave me alone! I took care, like Bryan and Shawna need, or specialized care, such as a BIPOC some pills so I don’t have to be here anymore!” provider who specializes in trauma for Eugene, is increasingly difficult. All quickly sat down and struggled to get his bearings straight. “What the hell is happening?” he thought to himself. Befuddled, his colleagues immediately went to his aid, confused by the sudden physical change. Bryan struggled to breathe, and his hands began to tingle. A colleague called 911,and he was rushed to the local hospital with suspicion of a heart attack.
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Psychiatric Emergencies Bryan and Shawna represent nearly 14% of emergency department (ED) visits that are a result of a psychiatric crisis. Bryan is among the one-third of US adults who will experience a panic attack in their lifetime. On his way to the hospital, he will likely get an EKG in the ambulance. He will receive additional diagnostic testing upon arrival to the ED to rule out lifethreatening medical conditions like cardiac arrest. He can expect being in the ED anywhere from 4 to 12 hours for observation and receive an antianxiety PRN medication for stabilization. Bryan will likely be discharged from the ED with a short supply of a medication with instructions to follow-up with a psychiatrist and psychotherapist. There is a 50% chance that Bryan will follow-through with those referrals. Shawna represents nearly a third of teens that report cyberbullying. Recent national polls show 42% of teens are concerned about becoming severely depressed, and nearly 1 in 10 teens who have attempted suicide. She will likely be boarded in the ED for anywhere from a day to a week while awaiting admission to a psychiatric bed for treatment, which will likely require a transfer to a different facility. There is a 40% chance she will be discharged while waiting for that much needed bed. In both cases, their crises were very real and unfortunately common. Their symptoms are both highly treatable with the correct intervention. Most importantly, we can create systems that can prevent these crises from occurring, crises that not only stress our health care systems, but also create inherent trauma for the patients and family members involved. Both M Health and Centracare have opened special units for these cases called EmPATH (emergency psychiatric assessment, treatment and healing).
Unlike traditional ED’s which need to manage a plethora of medical crises, the EmPATH units are designed to be low stimulation and have access to mental health professionals to help with calming and stabilization. ED’s have become the most common entry point for those in crisis, and that number has grown by nearly 40% in the last 20 years, even more for youth. Nationally, this represents an estimated 50,000 mental health-related emergency room visits per day, or over 600 per day across Minnesota. The most alarming trends in recent years are the increase in suicidal thoughts or attempts and drug/chemical overdoses. While Bryan and Shawna’s cases are not uncommon, additional factors such as medical comorbidities, cultural differences, social determinants, family dynamics and parental issues (for youth) can quickly complicate situations–requiring more than just psychiatric treatment, but intensive social intervention and support. This is also where our health systems have a propensity to apply the empirical allopathic approach to medical care that often fails to address complex biopsycho-social-spiritual elements. If Eugene should experience a crisis, the providers involved will need to be sensitive to his cultural background, past experiences with the US health care system and his previous trauma. While the psychosomatic symptoms of anxiety can easily be confused with a variety of medical conditions, providers must connect with patients in authentically compassionate ways to uncover often hidden mental health concerns. According to the CDC, nearly 2.3% of all ED visits result in a transfer, yet in the case of a psychiatric crisis, independent studies have shown it is closer to 15%. The odds of a psychiatric patient waiting for care in an ED is nearly five times greater than for any other health condition–oftentimes
resulting in days in an ED awaiting the appropriate care for their condition. The wait time to access psychiatric care can range from several hours to several days. This situation, known as “boarding,” has become increasingly common as a shortage of psychiatric care providers and barriers to accessing care have become amplified. A robust study conducted in 2014 showed that over 40% of psychiatric ED visits resulted in discharge, presumably without any meaningful treatment other than ad hoc medication administration and outpatient referrals, which are rarely followed up upon.
History of Psychiatric Hospitals Throughout the United States in the late-1800’s, expansive federal psychiatric hospitals were built to create safety and sanctuary for those with severe mental illnesses. These hospitals, commonly known as insane asylums, provided care across the nation to nearly 560,000 individuals. These institutions often sprawled over half a million square feet and cared for nearly two thousand at a time. A psychiatrist named Thomas Kirkbride was the founder of moral treatment aiming to provide comfort and healing to patients who may have previously been considered untreatable. Some patients with conditions such as mania or bipolar disorder (though it was not called that at the time) were able to receive treatment for weeks to months at a time before returning to their communities, typically with increased family or social support. Many other patients with more severe conditions, like schizophrenia, developmental disabilities or autism, often became indefinite residents who built longstanding relationships and even Improving Psychiatric Health to page 284
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HEALTH CARE POLICY
Legislative Session Overview Examining some health care bills BY ZACHARY BRUNNERT
M
uch like the rest of the country, the Minnesota Legislature “returned to office” in a hybrid fashion at the end of January. With the Senate operating mostly in-person, the House’s operations continued to be split in-person and virtual, with floor sessions in-person and committee hearings being held online. As session has progressed, the House announced the further reopening of offices in late March, and in another step towards normalcy, Rathskeller Café reopened their doors in the building. With lawmakers and advocates again filling the halls of the state house, the hustle and bustle has returned to St. Paul. The state is in the middle of the two-year budget cycle, which runs through June 30, 2023, and projections of the estimated surplus continue to grow. Initially, surplus expectations were around $7.7 billion, but the latest estimate in February forecasted a $9.25 billion surplus. In response to the updates from the Office of Management and Budget, Governor Tim Walz and Lt. Governor Peggy Flanagan released a revised budget plan. Their new proposal includes direct payment to taxpayers, $500 for single filers and $1,000 for those filing jointly, and $215 million to recruit certain
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frontline health care workers over a three-year period. The so-called “Walz Checks” have received a tepid response from Senate Republicans who would prefer to lower the tax burden on Minnesotans. Their proposal would lower the first tier of the state’s income tax from 5.35% to 2.8%. Additionally, there continues to be jockeying between the chambers on how to distribute payments to frontline workers. The 2021-2022 biennium has seen over 4,500 bills filed in the House of Representatives, and over 4,200 filed in the Senate. That is a very large number of bills competing for committee time prior to deadlines. For 2022, those deadlines included March 25 for committees to act favorably on bills in their house of origin, the April 1 deadline for committee to act favorably on bills or companion bills that met the requirements of the first deadline, and then the April 8 deadline for committees to act favorably on appropriation and finance bills. If bills meet these deadlines, then it is a sprint to win approval in both chambers before session adjourns on May 23. Given the breadth of health care bills filed, we’ve outlined some of the topics being discussed by policy makers. Reinsurance: Over five years ago, lawmakers passed the Minnesota Premium Security Plan, a program that partially reimburses health plans in the individual marketplace for high-cost claims to control these costs. This was initially funded with state dollars, but some of that cost has shifted to the federal government after the state received a State Innovation Waiver from CMS. Minnesota estimates that the costs of these individual health plans are roughly 20% less on average than they would be without this program. This session, HF 3717 sponsored by Representative Zack Stephenson and SF 3472 sponsored by Senator Dahmns, Senator Utke, Senator Benson, and Senator Rosen, are moving through the legislature to extend the sunset of this program to 2027. The Senate version of the bill is now cross chambers and in the House having superseded the House bill. Access to Diagnostic Mammography: SF 989 sponsored by Senator Nelson and HF 447 by Representative Acomb look to expand access to health care services regarding the diagnosis of breast cancer by prohibiting cost-sharing requirements for follow-up diagnostic mammography. This legislation will allow citizens greater access to essential women’s health care at a time when it is estimated that nearly half of annual breast cancer screenings and other diagnostic studies were delayed due to the COVID-19 pandemic and resulting limitations on elective procedures. Prohibitive cost barriers can limit access to these essential follow-up services and a patient’s inability to pay should not prevent them from obtaining a potential lifesaving early diagnosis. This increased ease of access will directly impact the health outcomes of patients by requiring coverage for additional follow-up services at no cost to the patient. White Bagging: Some provider groups are pursing legislation to limit a new payer practice known as “white bagging”. Insurers, in certain cases, have been requiring clinically administered medications, like ones you would find at an infusion center, be dispensed by a pharmacy designated
by the insurer. Proponents of the bill say this practice contributes to delays in patient care if the shipment of medication is delayed or is received in an inappropriate dosage, and increases costs to patients when billed to their pharmacy benefit versus their medical benefit. Additionally, this practice can lead to drug waste when doses sent by the specialty pharmacy cannot be used by another patient if their treatment regime is changed.
spending for claims-based payments and non-claims-based payments for the most recent available year, reported separately for Minnesotans enrolled in state health care programs, Medicare Advantage, and commercial health insurance. The report must also include recommendations on changes needed to gather better data from health plan companies and third-party administrators on the use of value-based payments that pay for value of health care services provided over volume of services provided, promote the health The 2021-2022 biennium has seen of all Minnesotans, reduce health disparities, and over 4,500 bills filed in the House support the provision of primary care services and of Representatives, and over preventive services. The House version of the bill 4,200 filed in the Senate. has been heard in committee.
In Minnesota, SF 3265 sponsored by Senator Koran and Senator Klein had an informational hearing on March 7, and the House companion bill, HF 3280 sponsored by Representative Freiberg, had an informational hearing in the House Health Finance and Policy Committee on March 1. These bills look to establish definitions of “clinically administered drugs”, prohibit payers from requiring coverage of these medications as a pharmacy benefit instead of a medical benefit, and prohibits the practice of having to transport these medications to their provider.
Nurse Licensure Compact: Efforts are again underway to allow Minnesota to join nearly 40 other states in the Nurse Licensure Compact (NLC), and the purpose of the bill is to allow nurses licensed in one state of the compact to be able to practice in another, although this measure is not without opposition. While SF 2302 sponsored by Senator Nelson is now cross-chambers and referred to the Health Finance and Policy Committee in the House, there will be an uphill climb in the chamber. The bill is opposed by the Minnesota Nurses Association as they state it would lower Minnesota’s high standards of licensure. Proponents of the measure argue that simplifying licensure will increase ease of access for patients in underserved communities.
These issues are just some of the myriad of health care related bills being considered this legislative session before adjournment in late May. As each week goes by, the halls of the state house continue to grow fuller and fuller with lawmakers and advocates as the operations behind the legislative process return to business as usual. Zachary Brunnert is the director of state legislative policy for RAYUS Radiology.
POLST Registry: Known as a Provider Order for Life-Sustaining Treatment, these mobile orders help direct EMS and end of life providers to the wishes of their patients. This differs from an advance health care directive in that a POLST is signed by a provider. The Minnesota Medical Association established the first standardized POLST form over a decade ago, and now efforts are underway to direct the Minnesota Department of Health to establish an advisory committee, consisting of members representing various licensed health care providers, to study the development of a statewide POLST registry. HF 3360 sponsored by Representative Morrison and SF 3339 sponsored by Senator Housley have been filed on this issue, and they will help ensure a patient’s medical treatment preferences are followed by all health care providers. All-Payer Claims Database: All-Payer Claims Databases (APCD) began to first be adopted and implemented over a decade ago, with roughly half of states having some form of data repository, as health care transparency efforts took hold. These databases often include medical claims, pharmacy claims, dental claims, and eligibility and provider files collected from private and public payers and are directly reported to states from insurers. HF 3696 sponsored by Representative Schultz and Representative Elkins, along with SF 3689 sponsored by Senator Nelson aim to add data contractual value-based payments to the mix of data already being collected. Additionally, these bills require the Commissioner of Health to provide a report to the legislature by next February on this data, and in particular, the report must include specific health plan and third-party administrator estimates of health care MINNESOTA PHYSICIAN APRIL 2022
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ADMINISTRATION
Removing Barriers to Care The role and impact of health plan care coordinators BY AMY REWEY, FLORENCE OKOAMPA, KATHLEEN KEOGH, APRN, CNP, DIANE ANDERSON, RN, BSN, CCM AND HEATHER QUIST, RN
I
n the shared pursuit of improving health outcomes, reducing costs and enhancing the patient experience, health plans and their partners have realized that a collaborative approach to care management is far more efficient than going it alone.
Enter the care coordinator, who brings all these goals together for the benefit of the member. Care coordinators within a health plan assist their members by streamlining health care across the continuum. This may include navigation of benefits, help with insurance prior authorization, managing appeals processes and accessing basic services. These complexities can create additional stress and delays in care for members. With case management, the coordinator works with providers, hospital staff and community-based organizations to ease the burden. Health plan care coordinators, for instance, can work with members to help them access stable housing, healthy food, reliable transportation to appointments and financial assistance. There are several ways a care coordinator can be assigned to someone. Some insurance products, like Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (MSC+)—which cover members 65 and older who have Medicaid and Medicare benefits— automatically provide a care coordinator. Other products use various reports and referral sources to determine if a member needs care management. There are also complex medical conditions—such as cancer, eating disorders, high-risk pregnancies, renal disease and gender care—in which a coordinator would be assigned to a member. Family members or the members themselves can also request care coordination depending on the health situation. Care coordination leaders from Minnesota’s nonprofit health plans shared their perspectives on how they work toward their goal of ensuring whole person care for their members. They also shared how their work can improve health equity and access to fundamental needs.
What is a Care Coordinator? The care coordinator role includes assisting members through: • Assistance in establishing care with a primary care physician. • Education on health-related conditions and preventive health screenings. • Coordination with other agencies including the county, community resources and providers. • Support during member transitions, including creating a safe transition plan. –Kathleen Keogh
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Why does a health plan have a role in coordinating care for members? We have a unique vantage point to identify gaps in care and set goals to reduce gaps in equitable care. At HealthPartners, we work closely with our care delivery partner to ensure best outcomes. As both a health plan and care system, providing care coordination helps us live up to our mission and values. It also makes access to care, benefits and services easier and more efficient for members. By developing a trusting rapport, we help them navigate the complex health care system and connect them with the appropriate support entities across the continuum of their benefits. We can easily connect with others in the HealthPartners system to reduce gaps in care and reduce hospitalizations. A care coordinator can also access claims information on supplies, equipment or care received elsewhere. –Florence Okoampa
With whom do care coordinators work to bring that holistic experience to members? Describe how a care coordinator might work with these folks to promote better outcomes for members. Care coordinators use a collaborative, interdisciplinary approach. This provides access, resources and support for members to maintain optimal health and achieve their health care goals. The partners they work with include: • Providers: Care coordinators assist members in establishing care with a primary care physician and with accessing specialty providers including mental health, dental care and others. They support a member’s access to their providers by assisting with transportation to appointments and assisting members with scheduling appointments. • Hospitals/Nursing facilities: Care coordinators maintain communication and provide support during periods of transition with a stay in a hospital, rehabilitation center or nursing facility. They participate with discharge planning to support the member’s care plan, provide continuity of care and to assist members to achieve positive outcomes upon discharge. • Community-based organizations: Care coordinators work with other agencies, including county services, community resources and providers to address social drivers of health, such as housing needs, care services (such as home care, nursing or therapy) and medical supply needs. Collaboration with the county includes working with county-based financial workers, case managers and regulators to help ensure the member receives the care and support they need. • Interdisciplinary health plan team members: Care coordinators work collaboratively with pharmacy, behavioral health, case management and others to coordinate care, identify and assist with any gaps in care and support the member’s individualized plan of care and health needs. Care coordinators may also collaborate with a member’s family, guardian or power of attorney to support the member’s care and needs. –Kathleen Keogh
What are the implications of a member not having things like transportation, food, help with appointments and other assistance? How does that impact health?
Describe what kinds of cost-savings can result from care coordination/case management.
The effect care coordination has on health outcomes cannot be discounted. When a member has these barriers, this can prevent an individual from In a recent article of The American Journal of Managed Care (Feb being able to access the care or support they need 2020, Vol. 26, Issue 02), a study looking at to achieve better health outcomes and improve care management programs showed that with their quality of life. For example, if a person incorporation of care management, total medical does not have reliable transportation or has food expenditures were reduced by over $7000 per year “With incorporation of care insecurity, they will not have the ability to attend per patient. The study further showed that patients management, total medical their appointments, get diagnostic testing or pick receiving care management had fewer inpatient expenditures were reduced by up their medications. They might not be able to days in facilities, fewer hospital admissions and over $7000 per year per patient.” afford their medications or follow a recommended fewer specialist visits. In my experience as a nurse, –Heather Quist healthy diet that could improve their chronic I know and have heard from UCare members what medical condition. –Diane Anderson a difference it makes in their lives. I feel blessed that my work can provide this much-needed care. What role do you see care coordination in –Heather Quist
promoting health equity and addressing health disparities for members?
Care coordination can promote health equity when it is approached with intentionality—not as an afterthought. Blue Cross is intentional about working to match care coordinators and members based on race, ethnicity, language and lived experience, which we know can be extremely impactful in terms of health outcomes. Care coordinators and case managers function in a member-centric way, listening to member needs and desires and advocating for the right care at the right time and place. Actively working to remove barriers to equitable care is a key component of successful care coordination. –Amy Rewey
Amy Rewey is vice president, care management, at Blue Cross and Blue Shield of Minnesota.
Florence Okoampa is an MSHO/MSC+ supervisor at HealthPartners. Kathleen Keogh, APRN, CNP is director of care delivery and coordination at Medica.
Diane Anderson, RN, BSN, CCM is a case manager with Sanford Health Plan. Heather Quist, RN is a Medicare care manager with UCare.
Care coordination – leading the way to better outcomes Care coordination has emerged as a powerful way to improve patient outcomes and lower medical costs. These services can be extremely beneficial to patients who have chronic and complex medical conditions, who often need additional support. Coordination can also help to address health disparities in vulnerable communities. This article is brought to you by the Minnesota Council of Health Plans.
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3Pursuing better health and better healthcare from page 10
The response and interest in this work has been humbling. We have had so many physicians and trainees volunteer their time and contribute their experiences, ideas, and expertise. Later this year we will be publishing the initial results of an internal historical analysis that we commissioned to examine MMA’s own role in perpetuating or supporting discrimination or racism. I look forward to sharing that report with our members and the community, and I hope it will spark further dialogue about how we can continue to move organized medicine forward. I also hope it might stimulate similar analyses by other organizations. What are some of the things you’d like to accomplish as the MMA CEO?
The MMA is an organization governed by and driven by its members. So, the most important thing I can do is foster a culture and facilitate the means by which all physicians and physicians-intraining are welcomed, supported, and empowered to raise their voice in pursuit of better health and better healthcare.
As the organization’s first female CEO I am particularly focused on ensuring the organization’s leadership and membership reflect the diversity of Minnesota physicians and trainees. The MMA is not an issue-specific organization or a single specialty organization. As a result, we have rich and vigorous debates about policy and advocacy. I believe that is a critical strength of the organization that needs to be preserved.
Finally, I need to give a big shoutout to the MMA’s dedicated and professional staff. Any accomplishments I have made or will make are only possible because of our incredible team.
Before becoming CEO, I had a long history in health policy, including more than 20 years leading policy at the MMA. Prior to that, I started my career in health disparities research, with a specific interest in disparities among Native Americans. As a result, I’m really proud of the MMA’s focus and increased investment in health equity, and I am committed to seeing this sustained and expanded. I’ve also witnessed a lot of changes in healthcare and have seen how physician support and collegiality has withered. We need physicians to know and recognize that the MMA is a trusted place for physicians to come together, support each other, and bolster the profession.
There have been many changes in medicine since MMA’s founding in 1853, but physicians tell us that the value of MMA remains largely unchanged – to learn from colleagues, to advance medicine, and to improve the health of patients.
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What would you like doctors to know about how their participation in MMA activities can benefit them and their patients?
Dr. Charles Mayo once said, “All who are benefited by community of life, especially the physician, owe something to the community.” Physicians make a difference every day in the lives of the patients they see. Through their membership and participation in MMA, they are able to amplify and accelerate that impact. Janet Silversmith, MA, is the CEO of the Minnesota Medical Association.
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GASTROENTEROLOGY
Microbiome Health Recognizing a symbiotic organ BY BYRON VAUGHN, MD AND CAROLYN GRAZIGER
M
edicine has long recognized that the health of the gut is related to overall human health. We have known that the function of a healthy gut, from stomach through the colon, was important to a range of health conditions and status. Shakespeare recognized the stomach as the “Storehouse and the shop of the whole body” (Coriolanus). What we didn’t fully appreciate until the early 2010s is that it is actually the microorganisms (bacteria, fungi and viruses), populating the gut, collectively called the gut microbiota, that mainly determined that health status. In fact, there are multitudes more bacteria in our guts than there are cells overall in our bodies–a vast, interactive population that we are just now beginning to meaningfully understand. We now recognize the intestinal microbiota as a symbiotic organ needed for our survival. There are more cells and genes in the intestinal microbiota than the human body. If you were to weigh the intestinal microbiota, they would be about three pounds, roughly the same as the human brain. Starting at birth, the intestinal microbiota teach our immune system how to distinguish harmful bacteria and are essential in developing a
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healthy immune system. In fact, germ-free mice that are maintained in a sterile environment die early as they are severely malnourished and immunocompromised. The intestinal microbiota is essential for digestion of certain foods, in particular vitamin K and the B group vitamins. Moreover, the microbiota are involved in other complex metabolic activities, such as drug metabolism. Microbes produce and are influenced by certain types of neurotransmitters. The collective genomes of the microorganisms in the gut are called the intestinal microbiome. With the advent of low-cost mass sequencing, it became possible to measure the diversity and relative abundance of different species within the bacterial genome of our guts. The Human Microbiome Project, launched in 2007 by the National Institutes of Health, was an ambitious undertaking that laid the initial groundwork. Using these tools, researchers could begin to characterize what constitutes a healthy microbiome vs. the divergence or “dysbiosis” observed in various disease states. As the largest lymphoid organ in the body, the lining of the gut or colon serves a vital role as the barrier that keeps healthy bacteria where they’re supposed to be. And every sort of inflammatory gut disease can impinge on that role. We know that almost every disease affecting humans, from rheumatoid arthritis, liver disease and multiple sclerosis, to pulmonary hypertension has an effect on the gut microbiota. There are studies underway on a number of these conditions to see if we can determine which comes first – does the disease lead to dysbiosis in the microbiota or do microbiota issues cause the disease? Altered microbiota are associated with almost every disease affecting the human body. For example, inflammatory bowel disease, pulmonary hypertension and autism all have consistent alterations of the intestinal microbiota. By healing or restoring the intestinal microbiota, can we heal the systemic diseases? Given the nearly 400 IMT (Intestinal Microbiota Transplantation) studies currently listed on clinicaltrials.gov, it is clear there is keen interest in finding answers. We do know that antibiotics, a critically important tool in treating infectious bacteria during this past century, have had a significant impact on the microbiota by decreasing the diversity of bacteria found in the gut. This phenomenon is markedly more prevalent in developed countries. C. diff, or Clostridioides difficile colitis, is a rather common result of antibiotic use that has historically, and ironically, been treated with antibiotics, which isn’t always successful. C. diff can be a devastating condition of the colon that can lead to severe damage or even death if not treated effectively. Unfortunately, a number of people who develop C. diff infection develop recurrent infections after their course of antibiotics. This leads to a vicious cycle of antibiotics to treat C. diff, but the antibiotics also devastate the healthy bacteria. The devastated healthy bacteria are then unable to protect against recurrent C. diff infection. This is one condition where microbiota transplantation makes a significant difference. Originally known as fecal microbiota transplantation or FMT, the procedure was recorded nearly 1700 years ago by a Chinese researcher who
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administered it orally with limited success. However, in 1958, surgeons in Colorado performed an experiment to treat a few patients critically ill with pseudomembranous colitis using fecal enemas from healthy donors. The success of that procedure led to a limited number of treatments over the following two decades with a 94% success rate. Today we treat recurrent C. diff with IMT as the most effective way to replenish the healthy diversity of bacteria that will support recovery, with treatment methods now including an encapsulated, freeze-dried preparation of purified intestinal bacteria that is administered orally.
about whether the use of IMT has the potential to reduce infection rates and/or complications of graft vs. host disease in patients with a type of acute leukemia. Recruitment is nearly complete as of Spring 2022 and results are expected soon. In addition, there are local studies on the microbiome’s impact on obesity and pre-diabetic conditions. All of these studies make the microbiota and its health of great interest to patients and their families, leading to complex regulatory issues. To understand how to regulate treatments, first there needs to be ways to define what the microbiota actually is. Is it an organ? Is it a supplement? Is it a drug? If a person takes ten different probiotics, is that a microbiotic supplement?
There are multitudes more bacteria in our guts than there are cells overall in our bodies.
Increasingly, patients are choosing this option when a surveillance colonoscopy is not indicated. This procedure is so effective it is now recommended in multiple guidelines for the treatment of recurrent C. diff infection. While there remain regulatory issues with widespread availability of IMT, novel microbiota-based products are likely to be FDA approved for recurrent C. diff infection in the near future.
The next disease where IMT may play an important role is ulcerative colitis. The University of Minnesota is one of the first to study the use of capsule-based IMT material for treating ulcerative colitis and Crohn’s disease. Early results from small pilot randomized controlled trials suggest that IMT may work about as well as some biologic therapies, with approximately one in five patients achieving remission of the colitis. Treating the microbiota is a paradigm shift for patients with ulcerative colitis. Typically, treatment is aimed at suppressing the immune system. However, this approach is likely over-treating a person’s intestinal microbiota. It is unlikely that IMT alone will cure ulcerative colitis, as in the case of recurrent C. diff infection. However, treating the microbiota along with the immune system will hopefully lead to more patients living normal lives. Ultimately, with enough understanding of the interaction between the intestinal microbiota and the immune system, ulcerative colitis may be cured. Safety of IMT remains one of the key concerns related to the widespread implementation for indications such as C. diff. The University of Minnesota developed a national registry to track efficacy and safety outcomes of IMT in the real-world setting. This registry represents the largest cohort of IMT patients treated with encapsulated IMT material. The first results of this registry are due out later this year. In addition to safety, the University of Minnesota’s Microbiota Therapeutics Program is examining changes in body composition over time following IMT, developing a novel pediatric formulation for IMT administration among other ongoing projects. The University has one of the most robust clinical programs for both trials and treatments in the world. Our program is the only one in the U.S. at an academic medical center that can produce its own material in a GMP certified facility. That on-campus facility allows the University to support a number of trials in other parts of the country by producing their materials.
The FDA has classified microbiota treatments as a biologic therapy that is regulated much like a drug. That opens the door for the commercialization of new microbiota derived therapies that may be coming to the market within this year. One type in development is not IMT, but rather a mixture of purified spores produced by healthy bacteria separated from fecal matter. This collection of spores (SER-109) appears to be significantly better than placebo at preventing C. diff from recurring. If the FDA approves this therapy, it would be a pivotal tool in the treatment of recurrent C. diff infection. Microbiome Health to page 264
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Volume XXXII, No. 05
CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD
U
niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.
Physician/employer direct contracting
CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144
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The University’s clinical and research team is supporting studies on Crohn’s disease, hepatitis, cirrhosis of the liver, and on autism’s connection to a healthy microbiome. Overall, hundreds of patients have been enrolled in these trials. An interventional trial conducted in collaboration with the Masonic Cancer Center is nearing completion. This trial is seeking answers
Physician/employer direct contracting to page 124
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3Microbiome Health from page 25 Until a microbiota-based therapy is approved, the FDA has allowed IMT to be conducted for treatment of C. diff refractory in standard therapy, but for all other conditions, access to IMT is still rather tricky. Patients must be part of a clinical trial to access IMT for most conditions, which requires physicians to file an application for an Investigational New Drug or IND, a lengthy and complex procedure.
What’s In the Future Our deepening understanding of the microbiome will lead to a much healthier population in the future. In fact, discoveries related to the microbiome will definitely lead to great advances in medicine. Certainly, antibiotics have been a significant advance in medicine, allowing deadly diseases of the past hundred years to be treated effectively. In many ways antibiotics herald the age of modern medicine. Infections like streptococcus pyogenes or aureus, bacterial meningitis, tuberculosis and pneumococcal pneumonia are now treatable rather than commonly fatal, saving hundreds of thousands of lives each year. At the same time, we now recognize and can manage the unintended consequences of the use of antibiotics and their effect on our organs. Beyond just C. diff, we are also faced with multi-drug resistant organisms as a result of widespread use of antibiotics both in people and in the food we eat. Along with antibiotics, we must also learn to protect our intestinal microbiota. By treating the microbiota and its important function, we can prepare patients for the impact of necessary antibiotics.
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Unlocking the secrets of the microbiome will be as influential on human health as our understanding of the human genome is proving to be. In combination with the increasing proficiency of big data science to ferret health knowledge from vast quantities of information, we will be able to pinpoint treatments in the future for a variety of microbiota-related conditions. For example, C. diff will move from being a common hospital acquired infection to a very rare occurrence in the future. IMT may also aid in preventing the development of multi-drug resistant organisms. We will be able to target these organisms in our gut for elimination, while building a more rigorous library of knowledge for promoting health. With the understanding that a healthy gut bacteria environment will help us live longer and better, the microbiome will influence all parts of human health. For now, the easiest way to improve the health of our gut microbiota is by giving them the food they need to thrive: mostly soluble fiber. In other words, eat your oatmeal. Byron Vaughn, MD, is an associate professor of medicine and gastroenterologist at the University of Minnesota Medical School. Carolyn Graziger is a research associate in the Microbiota Therapeutics Program at the University of Minnesota Medical School.
Carolyn Graziger, is a research associate in the Microbiota Therapeutics Program at the University of Minnesota Medical School.
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3Improving Psychiatric Health from page 17 had jobs within the boundaries of the hospital. Over time, some of the ideals of moral treatment became overstretched and ineffective, leading to poor care, mistreatment and even neglect. Overcrowding became an issue as care conditions deteriorated– leading to many of the ill-perceptions that exist in the modern day of psychiatric institutions.
partially realized and to the benefit of very few. The advent of managed care in the 1980s further exacerbated challenges in accessing care by allowing market forces, rather than population indices and epidemiology, to drive necessary capacity.
Psychiatric Tomorrow
Health
Care
Today
and
While the federal psychiatric hospital system of the past was not designed to respond to acute In 1965, the introduction of Medicaid and The ongoing costs to treat psychiatric crises, they did keep many vulnerable Medicare sparked a series of policies that became behavioral health conditions individuals with severe mental illnesses safe and known as “deinstitutionalization” aimed at contribute to nearly 45% of prevent many crises altogether. Today, patients like replacing long-term psychiatric hospitals with total health care spending. Bryan, Shawna and Eugene are left navigating a community mental health services. Around fragmented and confusing spattering of mental this same time, more effective – and potent– health services and providers. As our understanding psychotropic medications such as Thorazine of mental health has advanced and become broader, became much more popular in treatments. Over there’s been a necessary focus on awareness, the next 50 years, capacity in psychiatric hospitals decreased by nearly 90%, education and prevention–investing in upstream solutions. There’s now a resulting in nearly 480,000 individuals with several mental illnesses leaving wider breadth of care options ranging from online help, support groups, hospital settings to less intensive community treatment centers. While some partial hospital programs and hospital care. However, many services remain of these individuals received appropriate and effective care, many found siloed and often lack capacity for culturally diverse or competent care. As themselves struggling with homelessness and tangled in the US prison individuals seek more specialized care, access barriers and provider shortages system. There have been numerous studies that illustrate the drastic increase become a major issue. Over half of individuals experiencing diagnosable in the number of individuals with mental illnesses in the prison system, symptoms of a mental illness will never get the treatment they require. with an uncanny correlation to deinstitutionalization. The nation’s goal of moving psychiatric care to less restrictive community settings was only
Improving Psychiatric Health to page 304
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3Improving Psychiatric Health from page 28 Some of the most innovative health systems provide a streamlined continuum of mental health services and integrative behavioral health services. Primary care providers are most often the first point of contact to identify and provide early intervention of a budding mental health condition. Most will admit to a lack of training or resources to either adequately assess or treat mental illnesses. Nearly 80% of psychotropic medications are prescribed in the primary care setting. Current evidence-based treatment protocols for anxiety and depression include the combination of medicine and the appropriate psychotherapy or psychosocial intervention–specific care paths that usually require up-to-date knowledge on provider access. The importance of culturally competent mental health care for individuals like Eugene is critical as well. The annual national investment in mental health research is an abysmal 4% of total health research funding, despite the fact that some studies have shown the ongoing costs to treat behavioral health conditions contribute to nearly 45% of total health care spending. It is critical that mental health professionals are in tune to cultural differences and needs of all patients to develop a truly therapeutic relationship. These factors will influence how symptoms are experienced by individuals, how they are explained and ultimately cared for effectively. Studies have shown that promoting a strong sense of connection to culture and ethnicity is linked to lower suicide risks and higher resiliency. Our mental health systems must outwardly promote care settings that embrace a culture of equity and inclusion. This includes practicing a variety of culturally-sensitive ways to promote services in the community. This
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means using culturally and linguistically appropriate forms of talking about symptoms and treatment. Practice settings should display a variety of artwork, furniture and aesthetics that reflect multi-cultural awareness and appreciation. All care providers should be familiar with names, terms, and basic concepts of traditional and non-western healing practices; even a basic familiarity has proven to significantly improve outcomes. We need to ensure that access to training programs for aspiring mental health professionals is equitable and inclusive, and we need to take a hard look at possible implicit biases in these processes or other unconscious exclusion criteria that need to be eliminated. In Minnesota, far fewer BIPOC mental health professional trainees complete their supervision hours and licensure exams than their White trainees. The mental health care system of the future requires fundamental parity and better access through robust care navigation. We can do this by integrating mental health providers in all health care settings and require all health care workers receive ongoing training in assessment of mental illnesses. Health care leaders must promote mental wellness among the workforce and normalize the conversation in our communities. When we can increase awareness of mental illness and decrease the stigma, we can begin providing earlier intervention and prevent crises. These preventative efforts can happen in schools through education, within households by having meaningful conversations about mental health, and at clinics and hospitals with better screening and assessment. Mental illness is real, it is common, and it is treatable. Todd Archbold, LSW, MBA is the chief executive officer at PrairieCare.
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