Minnesota Physician April 2023

PHYSICIAN

XXXVII, No. 01

Generation Now Nursing

Redefining the value proposition

BY CAROLYN PORTA, PhD, RN, MPH, FAAN

Mission Management

Connecting hospital trustees and physicians

BY DANIEL K. ZISMER, PhD

During a presentation to a not-for-profit community health system all-boards retreat, I asked the following question of the system CFO: “What do you need as a profit margin from commercial third party payers to compensate for losses on uncompensated care, and reimbursements from governmental payers.” I didn’t ambush him: he was prepared with the answer, “from 38-43%”. There was an audible gasp by one of the board participants, who happened to be a senior executive from a large publicly traded company. He followed with: “There it is, another hidden healthcare tax.

Mission Management to page 104

Nurses have a crucial role in health care, serving as the mycelia that connects, communicates, supports and intervenes on multiple aspects of patient care. Mycelium (plural mycelia) is a root-like structure of a fungus that is made up of a large mass of branching, thread-like hyphae that are far-reaching, connected and critical to the health of nearly every species of plants, as well as to animals. This comparison of nursing to mycelium highlights the complex network that nurses compose and operate within, being responsible for “transporting critical nutrients and communication across various species.” Nurses provide essential health care services in diverse brick and mortar, virtual, community, work and home-based settings, offering round-the-clock care, care coordination, support, advocacy and education with our diverse

Generation Now Nursing to page 144

By Daniel K. Zismer, PhD

By Carolyn Porta, PhD, RN, MPH, FAAN

Allina

Burnout

Regaining the joy in providing patient care

By Sheldon Berkowitz, MD, FAAP

THE HEALTH CARE WORKFORCE SHORTAGE: Facing a crisis

BACKGROUND AND FOCUS:

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

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

OBJECTIVES: JOIN

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

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

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

U of M Medical School Ranks Eight in Public School Research Funding

Recently the 2022 Blue Ridge Rankings were released, and the University of Minnesota Medical School has moved to number eight (up from number 13 last year) for funding from the National Institutes of Health among all public medical schools. With more than $340 million in funding, the U of M Medical School earned 554 NIH awards in disciplines such as biochemistry, emergency medicine, otolaryngology, neurology and family medicine and community health. “I’m especially proud of what this represents—the incredible work of our faculty and researchers in pursuit of medical discovery, treatments and cures,” said President Joan Gabel. “This important achievement adds to the University’s legacy of translating

Minnesotans and the world.” Tim Schacker, MD, vice dean for research at the Medical School stated, “Our faculty and the staff who support them have worked hard to succeed in the competitive environment of NIH funding.” The Medical School Research Office has been instrumental in aligning resources and priorities. For example, the Academic Investment Research Program (AIRP) at the Medical School invests seed funding that leverages successful NIH grant applications. This year alone, the Medical School invested $13.7 million in large center grants that returned more than $122 million in externally funded grants.

“The value of the ranking is that first it acknowledges the incredible work of our faculty and staff, in partnership with the State of Minnesota, to advance health and health care in areas of greatest need, like cancer, aging and infectious disease,” said

Medical School and vice president for clinical affairs. “The ongoing benefit is the reputational pull faculty, staff and students—the ability to work with the best—that will continue to build on itself. This means the best physicians and teams are here providing care to Minnesotans.” The Blue Ridge Institute for Medical Research is a nonprofit organization that ranks U.S. medical schools by NIH grant awards each year. Learn more about NIH funded research from the U of M Medical School at www.med. umn.edu/blue-ridge-rankings.

Jones-Harrison Opens Onsite Dialysis Center

Jones-Harrison Senior Living (Jones-Harrison), an independent industry leader for over 135 years, has recently expanded its services to include an onsite dialysis center. Providing assisted living, memory care, long-term care and transitional

care/rehabilitation, Jones-Harrison

can now add life-sustaining kidney care to its list of residential services. Through a partnership with DaVita Dialysis, a national leader in the dialysis field, this new service improves residents’ lives in many ways. Those with kidney problems can dialyze conveniently and comfortably where they live, which reduces stress, provides smoother care coordination and eliminates travel time and costs. The ability to receive treatment where they live improves convenience and flexibility, while advancing patient quality of life. It also leads to improved outcomes. Coordinated, high-quality onsite care can yield fewer adverse events and hospitalizations while mitigating population exposure to COVID-19 and other infectious diseases. The new service can streamline hospital discharge and potentially reduce readmissions and length of stay. The new facility was created by remodeling almost 700

square feet of existing space. There are six stations with recliner chairs and up to 12 people can dialyze per day. Appointments may be scheduled Monday-Saturday and are managed by an onsite RN, dialysis technician and Jones-Harrison Staff. The space includes a large screen TV, Internet, ceiling air diffusers and a biomedical storage room. It is the second onsite dialysis center in Minnesota. “By listening to what our community, we recognize the need for this new model of onsite dialysis services. It allows residents who depend on dialysis to do so right where they live, which is life-changing,” said Annette Greely, CEO of Jones-Harrison Senior Living. “We continue to innovate for our community and are excited to collaborate with DaVita, which positions Jones-Harrison as a top choice for senior living in Minneapolis.” Dan Viaches, president of DaVita SNF Dialysis, added, “We bring 20 years of experience as a leading kidney care provider and appreciate Jones-Harrison Senior Living trusts us to deliver high-quality care to the patients they serve.”

New Surgery Center Opens in Moose Lake

St. Luke’s and Gateway Family Health Clinic have partnered together to open the new Northern Lakes Surgery Center in Moose Lake. The multimillion-dollar investment expands health care in the region by bringing high-quality surgical care and outstanding clinical outcomes to the residents of Moose Lake and surrounding communities in a stateof-the-art facility. “Now in the convenience of our own community, people are able to have several types of surgeries and procedures from colonoscopies to cataract surgery to gallbladder removal without needing to drive 100 miles,” said Gateway Clinic Administrator and Northern Lakes Surgery Center Board Vice President Eric Nielsen, MBA, CMPE. “Giving our patients this

added convenience and helping them avoid long trips, especially in the winter, is invaluable.” Other features of the new facility include accessibility, with close parking and private patient pickup after surgery. As a freestanding surgery center, Northern Lakes Surgery Center also has typically lower costs than for surgical services provided in a hospital setting. “We are excited to partner with Gateway, not only to offer health care that’s more accessible and affordable, but also to provide the highest quality of care,” said St. Luke’s president, CEO & CMO Nick Van Deelen, MD. “We value being a trusted part of the communities we serve and look forward to serving more of our neighbors in the Moose Lake area.” The surgery center uses approximately 9,000 of the 25,000 square feet of the building in St. Luke’s Plaza, with the additional space for future tenants. To learn more, visit www. NorthernLakesSurgery.com.

CAPSULES

The Hub is accessible to any health and human service organization in Minnesota, including hospitals, emergency departments, counties, shelters, residential programs, group homes, foster care agencies and more. Users submit case information into the Hub, which connects them to providers across the state. The Hub helps to match appropriate providers based on selected criteria that includes the recommended care setting, age, gender, diagnosis and other medical needs. All users can view open cases and collaborate on any of them to help those in need. The Hub facilitates weekly video calls that are open to all users to interact in real-time. The most common “boarding situations” are in hospitals and emergency departments. Users in any setting may use the Hub to connect with safe living and mental health treatment settings such as group homes and residential programs. The Hub is managed

by the statewide Psychiatric Assistance Line (PAL) through a grant from the Minnesota Department of Health and with administrative support from the Metro Health Coalition and AspireMN. There is no protected health information (PHI) stored in the Hub. It does not collect names, birth dates or any patient contact information. Each case is assigned a real-time random ID number that includes biological gender and age for reference. Clinical information is selected from drop down lists that include things like presenting factors, diagnosis and other special needs. Only users who create cases can edit them. For more information, please visit:https://mnpsychconsulthub.com/.

CMS Advances Prior Authorization Reform

The Centers for Medicare & Medicaid Services (CMS) has recently taken

important steps toward right-sizing the prior authorization process imposed by Medicare Advantage plans on medical services and procedures. Among many proposed reforms, CMS is addressing new provisions for Medicare Advantage plans that would:

• Disallow prior authorization as a tool used to delay or discourage care.

• Give beneficiaries access to the same items and services as they would have under traditional Medicare.

• E stablish a utilizationmanagement committee to review their clinical coverage criteria and ensure consistency with traditional Medicare guidelines.

• Disallow denial of care ordered by a contracted physician based on a particular provider type or setting.

• Keep prior authorization

approvals valid for the duration of the course of treatment.

• Provide beneficiaries with a 90-day transition period where during which a prior authorization would remain valid for any ongoing course of treatment when beneficiaries change plans or enter Medicare Advantage.

• Disallow retroactive denial of coverage for a lack of medical necessity after a priorauthorization approval.

A Kaiser Family Foundation analysis found Medicare Advantage plans denied two million prior authorization requests in whole or in part, representing about six percent of the 35 million requests submitted in 2021. While about 11 percent of denials were appealed, the vast majority—82 percent— of appealed denials were fully or

partially overturned, raising serious concerns about the suitability of many of the initial denials. The AMA has been a leading advocate for these reforms. Current AMA President Jack Resnick, MD, said “Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health. To protect patient-centered care for the 28 million older Americans who rely on Medicare Advantage, physicians urge CMS to finalize the proposed policy changes and strengthen its prior authorization reform effort by extending its proposals to prescription drugs.” Data on AMA initiatives around these reforms can be found at Recovery Plan for America’s Physicians.

MDH Convenes Long COVID Guiding Council

The Minnesota Department of Health (MDH) has partnered with Stratis Health and consultants from the former Institute for Clinical Systems Improvement (ICSI) to form the long COVID Guiding Council (Guiding Council), a network of 20 primary care providers and specialists who are treating long COVID patients from across the state of Minnesota. The focus of the Guiding Council is to develop strategies to educate providers and help them implement processes and policies that will improve access and quality of long COVID care. “Clinicians are telling us that there is very little communication among the care providers who see long COVID patients and that a coordinated learning network would increase access to care and the quality of care that is provided,” said Dr. Ruth Lynfield, state epidemiologist and medical director. “We still have a lot to learn about long COVID. But laying the groundwork to expand awareness about the emerging evidence and the available treatments is an important first step toward improving

outcomes for those suffering from the impacts of long COVID.” The effects of COVID-19 can vary greatly, from cold and flu-like symptoms to life-threatening complications. Recovery can be similarly complicated. Not everyone who contracts COVID-19 makes a fast or full recovery. Tens of thousands of Minnesotans face ongoing or new symptoms such as shortness of breath, extreme fatigue, headaches, dizziness, brain fog and more. With appropriate medical care, many people can manage their symptoms and improve their health and quality of life. Unfortunately, all too often Minnesotans experiencing lasting symptoms after a COVID19 infection do not recognize they are experiencing long COVID. “Making sure we prevent disparities in access to diagnosis, treatment and supports for long COVID is critical,” said Dr. Nathan Chomilo, medical director for Medicaid and MinnesotaCare at MDH and Guiding Council member. “For Minnesotans served by our Medicaid program, that starts with ensuring that recognition and diagnosis captures how long COVID may compound challenges they already face and includes ensuring the supports and services they need are covered.” To better understand the lasting effects of COVID-19 on the lives of Minnesotans, MDH has launched two post-COVID surveys among people who have had COVID-19—one statewide and one in McLeod County. More information about long COVID and MDH’s work, along with resources and recovery support information, are available on the MDH long COVID website.

Hands flying on a keyboard. Feet whirling across a stage. A blur of mallets in action.

Summer at Orchestra Hall 2023 is four weeks of programming celebrating motion. Minnesota Orchestra Creative Partner and pianist Jon Kimura Parker returns alongside our summer Artist in Residence, the pioneering breaking collective BRKFST Dance Company, to share a summer of music that moves us.

Jon Kimura Parker, Creative Partner

Approaching Minnesota Health Care Through a New Lens

The University of Minnesota has recently launched the MPact 2025 strategic plan initiative, with a multi-pronged far-reaching agenda. What can you tell us about this?

MPact 2025 was inspired by the State of Minnesota and reflects the University’s deepened commitment to the core mission of research, teaching and service. It addresses access to opportunity and forward-thinking innovation that advances the University’s land-grant mission and impacts the world. Since this strategic plan’s inception, the University has set records for graduation rates, research funding, start-ups, patents, philanthropy and the number of Minnesota high school graduates enrolled as freshmen; and increased student career outcomes 10 percent over the national average. The University has been elevated into the top 25 among public universities and to number 2 in the United States for work related to promoting good health wellbeing.

In alignment with MPact 2025, the University’s plans for the future of University of Minnesota Health—announced earlier this year—include partnering with the State to reacquire key health care facilities on the Twin Cities campus, as well as committing to and planning for a new state-ofthe-art hospital. This is all rooted in the discovery that has routinely positioned the University’s Medical Schools of Nursing, Dentistry and Public Health and Colleges of Pharmacy and Veterinary Medicine as among the world’s most innovative.

This vision aligns closely with the University’s commitment to develop and embrace new and leading health care delivery models, continues our focus as a leading health research university and ensures that we continue to produce both the next generation of health professionals, as well as med-tech and health science discoveries based on our research.

One element is the MPact Health Care Innovation Vision. What can you share about this?

The MPact Health Care Innovation Vision was created to advance health care around patient and community needs—striving for innovative treatments and cures and immediately using our

intersection that is academic medicine is where our doctors and researchers excel.

The five points of this vision are: a world-class academic medical center integrating teaching and research with top-notch clinical care; University governance and control of key Twin Cities campus health care facilities to ensure the University’s public obligations are never compromised; a strong affiliation with partners throughout the state; planning for a state-of-the-art hospital with the concurrence and support of the Legislature; and addressing current facilities’ needs at the University Medical Center East and West Bank and Masonic Children’s Hospital.

But we cannot rest on our laurels. Dramatic changes in health care—leading up to, but especially following the pandemic—require a different approach. And one that is focused on accessibility to the best care across the entire State of Minnesota. For example, the University is working through hubs of health care, such as Duluth and St. Cloud, and investing in those areas by bringing academic medicine’s pursuit of innovative

treatments together in collaboration with health care systems in every corner of our state.

A commitment to this vision means residents in Greater Minnesota will continue to feel the impact of our work. The University has affiliation agreements with nearly every health system operating in Minnesota. These collaborative health professional education relationships along with our Rural Physician Associate Program (RPAP), medical and pharmacy programs on the Duluth campus and expanding nursing and medicine relationships in St. Cloud with CentraCare will continue to serve Greater Minnesota.

Perhaps the most striking element of this vision is building a new $1 billion hospital on east campus. What can you tell us about

As part of the MPact Health Care Innovation vision, University Regents approved a request to the Minnesota Legislature for $950 million in 2023. Referred to as UMN Health, this request is the first phase of the MPact Health Care Innovation Vision plan: acquiring and operating the current health care facilities on the Twin Cities campus and launching their operations under the University’s leadership.

UMN Health seeks legislative support to reacquire key campus facilities—including the University Medical Center East and West Bank facilities, Masonic Children’s Hospital and the Clinics and Surgery Center—and cover operating costs for the projected transition period before clinical revenues again support operations.

This one-time investment would pay countless dividends and have a tremendously positive impact on Minnesotans and their health for generations. A building transfer that leaves Minnesota’s interests with a Fairview-Sanford centric merger, designed without University involvement, would undermine the future of Minnesota’s only public academic health system.

What does it entail when we hear about a new state-of-the art hospital?

The aging East and West Bank hospitals and

Jakub Tolar, MD, PhD, dean of the University of Minnesota Medical School

Education and research are investments in the future of medicine. “...”

facilities cannot provide the platform for a worldclass academic health center for decades to come. Minnesota’s expectations for the next generation of treatments and cures, including well-trained health professionals cannot be met in facilities from the last century. A newly designed, stateof-the-art hospital is critical to the University’s mission and the long-term health of Minnesotans. This hospital may be designed to facilitate the transformative discovery that has routinely positioned the University of Minnesota health sciences schools and centers among the world’s most innovative. It will also serve Minnesota’s needs for health care delivery, education and innovation for the next century, advancing health and well-being as only a hospital associated with a leading research university can. Prior to a new state-of-the-art hospital, we will need to reacquire and update the current facilities to meet current community and research needs.

Why is University governance and control vital to this project?

It is essential that public assets—developed thanks to public support and investment and serving essential public needs—remain within

Minnesota under University governance. Minnesotans see the benefits of having the U of M health professional schools and programs in their backyard every day because of the impact the University’s mission has on health care delivery at all levels. Minnesotans have access to leading edge care, and the reputation of our health professional schools and programs attracts world-class faculty and scientists to teach and train the next generation of health professionals for our state’s families and communities. That said, we know that health care is changing rapidly. Patients’ needs and expectations are evolving and this investment in Minnesota can position our state as a global leader in this changing environment.

The University’s valued partnership with the State has been critical to our shared success for the past 170 years, and it continues today. The reacquisition of the current facilities is tied to their ongoing charitable and public purpose of bringing forth accessible and state-of-the-art care to Minnesotans. These facilities are tied to public purpose and commitments of teaching, research and service and date back to the University’s founding in 1851. Treating these Minnesota assets as commercial

fodder rather than recognizing their public value ignores their original purpose of serving the state.

Seven of the top 10 hospitals in the U.S. have university affiliations, why is this important?

We have learned that private health care nonprofits frequently see education and research as expenditures to cut. That conflicts with the public health mission of the University. We believe education and research are investments in the future of medicine and the health of a population.

Our focus is to ensure the best care for Minnesota patients and to deliver greater impacts to all Minnesotans through the University’s research, education and outreach mission. This model of care bridges the brightest minds from across the world to solve the most complex to most everyday health care challenges.

How will the new hospital enhance all of the world class research and care the University currently provides?

While not in our current request to the legislature, a new hospital in the future could

St. John’s Hospital, Linear Accelerator, St. Paul, MN

What’s the point here, how is this related to the topic of “mission management” and why does it matter? The point is so long as community health systems require this level of profitability from commercial payers, they will operate under the risk of these payers exerting downward pressures on utilization and price, leaving them vulnerable to the costs of their defined mission responsibilities. But what can governing boards do? After all, aren’t community hospitals required to provide needed services to all, regardless of ability to pay? The answer to the question is all community health care trustees have a fiduciary duty to oversee the mission strategies of the organization they govern as one component of an overall, integrated financial and strategic plan. One key side note: the misunderstanding of the term “fiduciary”. Too often trustees see the term as one having to do with “finances,” and while that assumption is partially right, a “fiduciary” is one entrusted with the welfare of another - a real person or organization. The responsibilities, and accountabilities extend to and beyond aspects of the financial. As such, trustees’ duties as fiduciaries extend to and through the financial into mission management of the organization, along with all related oversight of how non-trustee leadership manages the organization.

An Eight Point Framework

What follows is an eight point framework for trustees to apply in fulfilling their fiduciary duties related to mission management. Following the presentation of the framework is a discussion of how competitors are motivated to respond to unmanaged missions by community health systems.

Defining the Mission

The term “mission” for community health systems is common parlance in boardrooms. What is often lacking is an accepted definition of how that converts to action together with understandable management performance reporting for a board. On one hand, it can be argued that “all we do is our mission.” On the other, sometimes the traditions of governing boards is that “all we lose money on is our mission.” Trustees need to be clear that “not for profit” designations are a product of tax code regulation. All businesses require sufficient profit performance to remain in business. Generated financial losses on services reimbursed by governmental payers, for example, are not contributions to mission work. The trustee questions here relate to definition of mission, together with the categories of related activities, costs and financing methods, i.e., how mission costs are financed.

Health Care Economics in Highly Competitive Markets

Commercial payers have the leverage to exert downward pressures on price and services utilization. When this happens, it can create “excess supply” or loss of provider productivity. Hospitals and all other providers become engaged in market share battles, they scramble to, not always successfully, take market share from competitors.

Competitive market strategies are expensive and often inefficient. Add unmanaged mission strategies to the economic mix, and health system bottom lines can shift to “red ink” status quickly and severely. Digging out from under the pressure with typical responses, such as staff layoffs, adds to the expense burden while leadership attempts to right the ship. The trustee questions here relate to the risks of utilization and price pressures from the most important third party payers, along with understandings of where and how they are likely to exert these pressures, specifically the programs that generate required profits for the organization. Most community health systems make most of their profits from a handful of clinical services. Trustees need to know what’s on this list.

Managing Clinical Service Line Portfolios

All community health systems operate from business models composed from portfolios of numerous clinical service lines and programs. Each produces a different economic performance signature, meaning the financial performance of each varies. Not all clinical service lines are profitable. Some necessarily operate at losses, such as surgical specialties supporting expensive primary care strategies. The key to financial success, overall, is dependent upon “portfolio balance”, the more profitable service lines balance out the losses produced by the lesser performers. It is easy to lose sight of the financial interdependence of the services that compose the whole. When overall system financial performance turns negative, the sorting of what goes and what stays is complex. Trustees are not often involved in such decisions due to a lack of expertise and experience. But this lacking is not justification for not asking the right questions, including how portfolio management implicates not only financial performance, but mission performance as well. Mission strategies that rely upon funding from a few highly profitable clinical programs put organizations at risk for precipitous shocks to the revenue and expense structures of the “ profit makers.” The key trustee questions here relate to breakdowns of “ bottom line” performance of the organization, such as “ which programs contribute most to the profitability of the organization.”

Capital Assets and Ambulatory Care Strategies

For many smaller to mid-sized community health systems, the majority of their operating revenues derive from ambulatory services. The trend to ambulatory services

Hennepin Cty: 1800 Chicago Avenue Triage Center | Minneapolis, MN

delivery is expected to accelerate. Many community health systems are locked into an aging and inefficient capital asset structure which may still be functional, but is less than optimally productive when applied to productivity and efficiency demands of modernized ambulatory care environments. The challenge is the cost related to the required transition, especially when health systems are burdened with debt and expensive mission strategies. The key trustee question relates to how the existing capital asset structure lends to demands for competitive ambulatory care strategies.

Competition or Collaboration Referring back to the comment about “competitive inefficiency”; in many community health systems, affiliated physicians are also active competitors with the independent hospital medical staff. Independent physician providers affiliated with community hospitals have a right to act in their own best interest, even if in competition with a community hospital where they hold medical staff affiliation rights and clinical privileges. Risks related to inefficient competition increase when community hospitals are forced to compete with affiliated independent physicians, especially in such services as ambulatory surgery, imaging centers physical therapy programming, infusion therapies centers and in-office procedures services. The facts are that these services will likely be delivered at a fraction of the cost as compared with hospitals providing the same services. . Third party payers naturally move to lower cost opportunities for health plan enrollees. Community

health systems and leadership teams may chide independent physicians for their “disloyalty,”, but these providers operate private businesses. They are not in the business of committing to self-stylized community health care missions. They are in the business of practicing a profession profitably. Their business models facilitate a lower cost service with quality and patient satisfaction held to high standards. The trustee questions here relate to where the organization is at risk for competitive physician strategies and whether the health system competes or collaborates.

Mergers Solve All Problems?

A common, but mostly misled, assumption is community health system mergers automatically lead to improved economies and localized financial performance. The key operative term in this assumption is “automatically”. No merger results in automatic financial performance improvement. Those who lead the merger need to achieve operating economies based upon expense reductions, primarily staff reductions somewhere in the merged system. Promises made by the larger party in the merger (typically referred to in transaction management as the “acquirer”) often include “nothing will change after the transaction is closed”, and “local governance and management will continue to control the community health system”. Such promises are either lies or are simply naïve. Whether referred to as “mergers”, “combinations”, or “acquisitions”,

Mission Management to page 124

We are an independent and locally owned facility dedicated to the expansion of outpatient technologies and providing convenient high-quality care at a lower cost. This beautiful new 160,000 sq ft facility includes ample parking and an onsite café.

The right mission questions are never independent of the right financial and operational questions.

improved financial performance improvement is never automatic. The trustee questions here relate to the post-transaction plan of the party in the driver’s seat; the acquirer.

Competing with Private Equity Historically, health systems didn’t concern themselves with independent physicians as competitors because of perceived inabilities to raise adequate capital. Over the last few years, private equity players have entered many geographic and specialty markets with cash to buy physician practices, specifically those capable of acquiring the same higher-margin services as those coveted by health systems. Private equity-backed service ventures aggressively pursue targeted niche business strategies. Their missions are not the same as community health systems. Alternatively, independent physician groups that aggregate to form partnerships focused on the more profitable clinical service lines— outpatient surgery, imaging, rehab services and multi-specialty clinic services facilities— are designed with the ability to access affordable bank financings to fund competitive ventures. Here again, the mission strategies usually differ from community health systems. Such ventures are often attractive to commercial payers due to their ability to under-price community hospitals. The trustee questions here relate to leadership’s assessment of the risk profile for such competitive strategies, including alternatives to straight-up competition.

Investments in Population Health

An increasing number of community health systems are investing in “population health strategies” as part of their mission. Population health strategies typically focus on such initiatives as health status improvement, as well as primary and secondary disease prevention efforts for the general population and for specific population cohorts at risk; both adult and pediatric. While the mission goals are laudable, most community health systems are ill-equipped to be in the population health business, including how to make programmatic investments that will pay off financially. Trustee questions here relate to the organization’s internal competencies, capabilities and specialized operating systems requirements to be in the business, to a point where a sufficient financial return is accessible.

Responding to Unmanaged Missions

Trustees of not-for-profit community health systems are often reticent to probe deeply into the “mission questions” at board meetings for fear of being ostracized and labeled as one who “only cares about money.” Unmanaged missions have brought down more than one community hospital.

In a personal and hopefully instructive vignette, I had the unpleasant job of telling a community health system local board they no longer had the financial where-with-all to continue going it alone. The board

Mission Management to page 264

No merger results in automatic financial performance improvement.

3Mission Management from page 11

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health care team members, colleagues and stakeholders. Nurses are similar to mycelium in their ability to adapt and respond to changing conditions as they nourish, heal and communicate.

With advancing technologies, treatments and disease processes, nurses are constantly learning and adapting their skills to deliver optimal preventive, curative and supportive healthcare. Amid the technology and “mechanization” of health care, nurses are a stable force for patients, delivering fast-paced, complex, evidence-based and high demand physical and emotional patient care. Nurses are also often best positioned to offer realistic and honest assurances, sometimes a hug or a hand to briefly hold, while always striving to create safe, welcoming and “home-like” environments. We are routinely the first health care team member to notice or hear about changes in patients’ conditions and to then alert physicians or other health care team members to potential issues or needed interventions. We know early detection is critical for preventing adverse events and improving patient outcomes. We also know that when health care team communication and coordination is healthy and multi-directional, we effectively bridge the gaps among preventive care, life-saving acute care, rehabilitative or chronic care efforts and the next stage of restoration— recovery or end-of-life care. When communication pathways are not healthy, we threaten our value-based care delivery and we risk errors, extended stays, rehospitalizations and decreased patient and family satisfaction and health.

Threats to our Health Care Ecosystem

Differential diagnoses are a critical part of the diagnostic problemsolving process in health care. Similarly, identifying the root causes of communication breakdowns within health care teams requires a systematic approach which considers all possible contributing factors and rules out distractions. One factor we know contributes to communication breakdown among physicians, nurses and other health care team members is the persisting and unsafe staffing ratios. The COVID-19 pandemic uniquely exaggerated the complex and dangerous dynamics behind staffing decisions.

Examining the full complexity of the contributing factors to staffing problems is well beyond the scope of this article, but needs to be briefly addressed. The federal government, early in the pandemic, offered significant compensation to hospitals for patients specifically admitted to treat COVID-19. Admitting these patients rapidly in response to need and in response to an arguably unfortunate federal financial incentivization, created an urgent need for additional staffing. This need was beyond that already in play because of personal or family member infections, etc. The number of patients quickly and dramatically exceeded the average census of the intensive care units, the step-downs and the hospital itself. Core staff were doing what they could, but grew to be overwhelmed. Health care system administrators had to turn to travel agencies placing nurses and other health care workers at very high costs established within their contractual agreements; agencies were then able to offer bonuses no one could compete with. This staffing service offered immediate solutions, but had relatively quick cascading and compounding consequences—including permanent staff resigning positions to join neighboring hospitals or travel nurse agencies for the short-term financial gains. Those staff knew they would have a job to return to when they completed the short-term and high-paying travel placements. While COVID-19 presented a significant crisis moment in health care around the world, the U.S. and in Minnesota, today many of the dynamics have resolved and returned to equilibrium. For example, travel nursing has and will always offer slightly higher compensation, as it historically has compared with local markets. However, the agencies are not drawing nurses away from their permanent positions as they were in the height of the pandemic, nor are they compensating at the extremely high rates and bonuses offered when hospitalization burden was intense.

care for adult and pediatric patients with neurological conditions, including:

 Head Injury/Concussion

 Epilepsy/Seizures

 Headache/Migraine

 Neck/Back Pain

 Sleep Disorders

 Movement Disorders

 Parkinson’s Disease

 Tremors

 Alzheimer’s Disease

 Dementia

 Muscle Weakness

 Carpal Tunnel Syndrome

 Sciatica

 Neuromuscular Disease

 Muscular Dystrophy

 Dizziness

 Numbness

 Stroke

 Multiple Sclerosis

 ALS

 And other neurological disorders

Without seeing hospital financial records (pre-pandemic to present), it’s unclear the extent to which the federal funding offset the short-term costs of labor, if at all, and how this has contributed to system financial strains. Some health care systems are clearly struggling; others are reporting record earnings. Here in Minnesota, when the state of the COVID-19 emergency subsided, the nursing unions brought attention to the persisting challenges with safe staffing and their compensation structures; they continue to do so today with some pending legislative efforts. But even with those efforts and the efforts of health care systems, an extraordinary number of nurses are choosing to leave the field of nursing altogether for all the reasons we know e.g., burnout, moral distress, fatigue, personal health, family health, health care system and leader factors, among others. This loss of any nurses, and of expert nurses particularly, is certainly exacerbating the workforce shortage, —today and as predicted.

Looking at the Challenges

Back to the problems that arise when nurses are understaffed and

overworked. They may not have enough time to communicate effectively, and worse, to safely deliver the care their patients deserve and need. When communication is disrupted or inadequate, important information is being missed or misunderstood, which also negatively impacts patient care. In an ideal world, nurses would function in optimal scheduling assignments and safe staffing ratios. They would have the space and energy to take in the big picture of every patient, their needs and assets and their support system or its absence. They would put into motion all the steps and actions critical to the wellbeing of that patient and their family. Similarly, we know physicians are experiencing shortages and staffing constraints resulting in their own experiences of being overworked. This further threatens care team health and can exacerbate persisting care delivery problems. For example, one physician will outline a plan and orders that are subsequently altered by a newly assigned physician or are in contrast to the orders of another specialist, leaving the nurses and other team members struggling to discern and clarify which plan elements to carry out.

Communication breakdowns among health care teams can arise from a range of factors well beyond unsafe staffing ratios. Some of these factors include hierarchical structures within health care organizations, time constraints, team member turnover and inadequate training in effective communication and teamwork. In these inherently hierarchical

settings, some nurses may be reluctant to voice their concerns or insights. Some physicians might be better positioned than their nursing team members to advocate for improved staffing ratios, to elevate systemic concerns to leadership and the C-suite and to advance culture change initiatives that prioritize open communication and collaboration.

The distinct contracts physician groups have inherently set them apart from the settings in which they deliver care; this arrangement allows for a different type of leverage with institutions and their leadership teams. Obviously, not all physicians are in this situation. For example, hospitalists are employed by the institutions like nurses and other health care disciplines and might feel similar constraints. Understandably, some physicians might not perceive they have leverage or power different from nurses or others, but many do, and should advocate for and support members of their multidisciplinary teams when opportunities to do so arise. Ultimately, physicians are prioritized to be compensated by health care institutions; as such, they are heard. Currently, the MN legislature is considering bills that would address some of the more difficult and contentious factors among nurses, unions and health care systems. Legislators and their aides welcome conversations with all

stakeholders, including physicians, who can aptly describe the challenges and opportunities as seen from their valuable perspectives alongside nurses in healthcare delivery.

Time constraints in high-stress environments everywhere, and for example, in emergency departments or intensive care units, may make it challenging for health care team members to effectively communicate or collaborate, or even refer to each others’ notes in the electronic health record (EHR). The amount of “health care” time dedicated to sitting in front of a computer—for everyone—is ridiculous, and arguably driven primarily by billing and legal purposes rather than for optimizing patient care or team communication. Thankfully, this problem is in the sights of technological innovators exploring ways in which artificial intelligence and machine learning solutions can be applied to our health care delivery systems.

Physicians, nurses and so many other members of our teams are obligated to complete copious amounts of documentation in EHRs (and on paper in many parts of our state and country); our equally copious amount of time studies and eye tracking studies have adequately described the problem. What we need now are solutions—solutions that allow us all to focus on what brought us to health care in the first place—that opportunity to care,

to heal, to support and to bring a glimmer of light to people, families and communities experiencing difficult and dark moments.

Optimizing the Role of Nursing

As a physician, you may appreciate the analogy of the mycelial network to the health care team. Although the underground network of fungi may seem simple, it is actually highly efficient, resilient and vital to the health of the ecosystem. Similarly, a well-functioning health care team is composed of diverse individuals who work together in a coordinated and effective manner to provide the best possible care for their patients. When each member of the team fulfills their role and communicates effectively with others, the interconnected team result can be a beautiful dance of healing and connection. Mycologist Paul Stamets describes a similar interconnectivity; mycelium plays a fundamental role in forest health as it grows in the bear scratches on a tree trunk and becomes a food for the bees, which strengthens the bees’ immune systems so they then can more fully pollinate the forests, and so on.

Sadly, even our best functioning health care teams are doing so in a system that is very broken. Here in the U.S., our health care economics are

Generation Now Nursing to page 284

Sanford Health East Interstate Avenue Clinic has doubled down on its commitment to building hope through better mental and behavioral healthcare by reconfiguring three neighboring practices into more accessible, wellness-driven environments that preserve patient dignity. The JLG-designed new Behavioral Health practice gives patients privacy with an exclusive waiting area and entrance while giving providers a place of refuge in the centralized core, open gym, and outdoor courtyard. This is healthcare design that elevates the everyday — bridging the gap between silence and seeking help.

To learn more about JLG, contact Todd Medd, tmedd@jlgarchitects.com or Kristine Sallee, ksallee@jlgarchitects.com

Behavioral Health Care in Greater Minnesota

A new inpatient facility in Bemidji

BY CRAIG CLARK, NCARB

High suicide rates, substance use and limited access to behavioral health care services have long plagued rural areas of Minnesota. Unfortunately, these issues have reached alarming levels, highlighting the dire need for more targeted resources and interventions in these communities. As a result, a new health care center was recently constructed in Bemidji, MN, to tackle these challenges. The Sanford Bemidji Crisis Center (Center) provides increased access to mental health services and will create a lasting impact on community well-being.

In recent years, Minnesota has witnessed a steady rise in suicide rates. According to the Minnesota Department of Health, the state’s suicide rate increased by 40.6 percent between 1999 and 2016. Rural areas have been disproportionately affected, with the suicide rate in these regions being approximately 50 percent higher than in urban areas. Several factors contribute to this disparity, including limited access to mental health care, economic stressors, social isolation and cultural stigma surrounding mental health.

Substance use is another significant issue in rural regions throughout the country, as it is closely linked to mental health problems and suicide. In

2017, the Minnesota Department of Human Services reported there were 401 opioid-involved overdose deaths in the state, with rural areas being hit particularly hard. A lack of access to comprehensive addiction treatment services and social and economic challenges has made it difficult for residents to find the help they need to overcome substance use disorders.

Access Issues

One of the main barriers to accessing behavioral health care outside of urban neighborhoods is the distance to care facilities. According to a 2019 Minnesota Department of Health report, 62 percent of Minnesotans live in mental health professional shortage areas. With limited public transportation options and a scarcity of mental health professionals, residents often travel long distances to access the necessary care. Proximity can be particularly challenging for those with limited resources or mobility issues, leading to delayed or missed treatment and worsening mental health outcomes.

“The new facility represents an important continuum of care for the area. We already have a vast array of community-based mental health services, but because of our local needs assessment, a gap in crisis services was identified,” said Jay Coughenour, regional administrator of Sanford Behavioral Health. “We recognize the needs of our population are vast, and in order to meet people where they are, you need significant bandwidth. So, the more services we have, the better we are at meeting people and their needs.”

Before the Center opened its doors in 2022, patients experiencing a mental health crisis would travel significant distances to receive the care they needed and then wait sometimes for hours. Having this resource close to home allows patients to stay connected to their families and support systems. The decision to build a behavioral health and crisis center in Bemidji, MN, came after a thorough analysis of out-of-state mental health issues, financial factors related to construction, ROI projections and the facility’s value to the community. As a result, Bemidji-based EAPC Architects Engineers (EAPC) and Kraus-Anderson Construction formed a partnership for building the facility, with each party contributing their expertise in treating health care design experience and construction capabilities.

The partnership with Sanford Health and Kraus-Anderson Construction allowed EAPC to leverage experience with past crisis crises, residential treatment and detox facilities in creating the innovative new behavioral health project. After more than a year of staff interviews, research and collaboration with Sanford leadership, the building design evolved significantly, with a strong focus on the groundbreaking EmPATH concept (emergency psychiatric assessment, treatment and healing). The final design, a culmination of extensive planning, boasts the only facility in the state to treat juveniles and adults under the same roof, as well as the first EmPATH facility for minors in Minnesota.

The Center is a dual-purpose facility that offers inpatient and urgent care services catering to patients with behavioral health needs. With eight

inpatient hospital beds and the EmPATH unit, which operates like an ED for behavioral issues, the facility provides comprehensive care for patients who require longer-term treatment. Services offered include medical exams, psychological assessments, medication assistance and counseling.

Construction Details

Built to meet hospital standards and building codes, this 12,500-square-foot facility is meticulously designed to provide a secure, healing and welcoming environment for patients coping with mental health issues. The architectural team focused on various design elements to achieve this goal, including calming and soothing color schemes, the use of natural light and aesthetics to foster a connection with nature and carefully planned spaces to maximize privacy while minimizing sensory overload.

praised the facility for its comfortable environment and commitment to shared health promotion.

Incorporating EmPATH

Designing behavioral facilities presents unique challenges.

A critical component of the facility is the EmPATH program, which has revolutionized urgent care services for patients with behavioral health needs. The EmPATH unit offers timely, specialized care for patients in crisis, including comprehensive assessments and personalized treatment plans. By providing dedicated space for urgent behavioral health care, the program helps destigmatize mental health issues and ensures patients receive appropriate care while alleviating the burden on traditional emergency departments.

Safety is a top priority, so the design incorporates anti-ligature fixtures, tamper-resistant materials and furniture designs that reduce the risk of self-harm or harm to others. The architects also aimed to create spaces that encourage positive social interactions and allow staff to supervise patients effectively, while simultaneously providing patients with a sense of autonomy and control over their surroundings.

Designing behavioral facilities presents unique challenges due to the emotional sensitivity and vulnerability of patients. The construction process requires meticulous attention to every detail, prioritizing safety and minimizing the potential for self-harm or harm to others. Features such as laminated glass, anti-ligature door hardware, alarm sensors and rounded corners, along with multiple exit routes, are immediately noticeable in these facilities. More subtle elements like soft seating, a residential ambiance, dimmable lighting, views of nature, a spirituality room, carefully selected colors and textures and open spaces for relaxation and de-escalation contribute to the calming atmosphere essential for patient well-being. For those experiencing emotional challenges, low-stimulation rooms offer a serene space for patients to find solace and tranquility.

Cultural sensitivity is essential to the facility’s design, especially considering its proximity to three Native reservations. Traditional Native healing practices can be incorporated into a patient’s treatment plan upon request, and a designated room for ceremonies and smudging accommodates the spiritual exercises of all patients.

The facility has emerged as a model health care center in addressing both patient care and staff well-being. Recognizing the impact of staff burnout on the mental health field, the center has implemented measures such as adequate staffing levels, professional development opportunities and open communication. Additionally, the facility’s design prioritizes efficient people flow, streamlined records access and a comfortable environment. The combination of these factors has reduced staff burnout and created a more efficient workplace.

The Center’s focus on staff safety and well-being has also contributed to its success. Comprehensive safety protocols and training in de-escalation techniques have created a safer work environment, reduced job stress, and improved overall job satisfaction. As a result, both patients and staff have

“EmPATH programs are transforming how behavioral health and crisis centers support individuals facing mental health crises nationwide. As the need for mental health services continues to rise, these programs provide essential, compassionate care to people when they need it most,” explained Coughenour.

Between 2006 and 2014, mental health-related ED visits saw a 44 percent increase, as reported by a 2018 study in the “Journal of Emergency Nursing.” With more people seeking help in emergency departments, hospitals have been strained, leading to longer wait times for care.

Behavioral Health Care in Greater Minnesota to page 234

Making History

Allina Mercy Hospital physicians vote to unionize

BY QUY TON, MD, MPH, KATIE ESSE, MD, JESSICA BOLAND, MD AND TOMAS MURDYCH, MD

The recent surge in consolidation of hospitals and clinics and widespread dissolution of independent physician practices has led to profound structural changes in the practice of medicine in America. As more physicians are subsumed under fewer and larger corporate entities, the ability of physicians to maintain professional autonomy and clinical independence is being severely compromised. According to the American Medical Association (AMA), in 2012, 60 percent of practices in the U.S. were physician-owned, 23 percent of practices had some hospital ownership and only 5.6 percent of physicians were direct hospital employees. A recent study sponsored by the Physicians Advocacy Institute found that the share of physicians employed by hospitals, health systems or corporate entities grew from 62 percent in 2019 to 74 percent in 2022. Final decision-making power over crucial health priorities has been consolidated among relatively few non-clinical executives, representing a major shift in power from physicians to administrators. This changing climate of health care corporatization has increased interest in and movements toward unionization among physicians nationwide. At

the center of physician unionization efforts at Allina Mercy Hospital is a desire to reclaim the profession and uphold the autonomy and fair working conditions that are declining as health care becomes more centralized.

These changes sap the morale and health of physicians and negatively impact the physician-patient relationship. Indeed, health care is unlike any other industry because of the previously sacrosanct physician-patient relationship that is at the heart of medicine and health care. The physicianpatient relationship is unique as physicians have an ethical and fiduciary responsibility to first do no harm and to act only in the best interest of each individual patient. Physician autonomy allows doctors to advocate for their patients even on nonmedical matters. In contrast, corporate executives, by definition, prioritize the financial solvency and overall “health” of the corporation they lead. Many patients also recognize that third parties (i.e., insurance and pharmaceutical companies, administrators and policymakers/ politicians) have been intruding on the physician-patient relationship. These intrusions can negatively impact patient care, increase moral injuries physicians face and result in sub-optimal and morally ambiguous care.

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The corporatization of health care prioritizes and increases hours of bureaucratic tasks such as documenting visits, reviewing charts, completing paperwork, attending required trainings, and responding to billing/coding/ insurance disputes. A 2016 study in the Annals of Internal Medicine found that doctors spend two hours on desk work for every one hour with patients. This increase in documenting care rather than providing it combined with a loss of control over their profession have led to escalating moral injuries that have taken their toll on physicians. According to the 2023 Medscape burnout and depression survey, 53 percent of physicians (up by 26 percent since 2018) reported that they are burned out and 23 percent reported feeling clinically depressed. Over 75 percent of doctors indicated burnout had at least a moderate impact on their life and 43 percent reported that it has a severe impact. The highest levels of burnout are among emergency medicine and hospitalist physicians. Every year, women and minority physicians consistently report higher levels of burnout and depression. Another survey reported that one in ten physicians reported suicidal ideation over the past year.

Unions as a Counterbalance

The moral injuries incurred in this new health care climate were further exacerbated during the COVID-19 pandemic. At Mercy Hospital, physicians were the only front-line workers to initially not have their COVID-19 sick pay covered even though Minnesota law required it. Physicians were the only group to receive a pay cut during the pandemic when a retirement benefit was unilaterally removed from them while executives maintained it. For some physicians, these top-down actions imposed on them in the midst of the pandemic were the final straws that convinced them of the need to unionize.

Few doctors are unionized across the country, a function of doctors historically owning their own practices. In recent years, health care consolidation has squeezed out small private practices and more hospitals have chosen to employ doctors directly. Within Allina and other large health

corporations, few physician-owned specialty groups remain as most private specialty groups are being forced out in favor of corporation-employed specialty groups. Cost-savings are cited as justifications for the subsequent disruptions in patient care and physician careers.

When physicians owned their group practices, they did not need unions. Their practices were largely autonomous, and they could negotiate directly with hospitals and maintain clinical independence. As employees of corporations, physicians do not have final decision-making capacity over decisions affecting their working conditions and how they care for patients. At Allina, even physician leaders who have worked there for decades have tried to advocate for positive changes within the corporate structure and yet, were powerless to do so. Non-unionized individual employees do not have a collective voice and, more importantly, a collective process to negotiate and maintain autonomy and clinical independence. Executives implement their priorities and specific policies, which can have negatives impacts on employees and patients.

In a corporate structure, many employees do not voice their opinions for fear of futility or reprisals, especially when most have at-will employment contracts. Most physician employees (including at Allina) can be terminated for any reason or no reason. One of the first changes unions typically negotiate for (and usually win) is to change at-will employment to just-cause employment, which requires adequate justification for termination. This single change allows physician employees to advocate for themselves and their patients without the insecurity inherent in at-will employment contracts.

At Mercy Hospital, physicians began a unionization movement at great personal risk when they took steps to explore the process of creating a physician union. Some have been intimidated by administrators and are justifiably concerned they can be removed from their jobs and blacklisted. After filing for unionization, risk of termination has decreased as national labor laws can provide some protections against retaliation. However, fear of retaliation remains.

Deny and Delay

Over a century of unionization in other industries and increasing corporate interest in fighting unions have spawned a $340 million per year cottage industry of law firms that specialize in anti-union campaigns. Anti-union law firms deploy well-orchestrated and precisely timed campaigns to discredit and defeat union efforts by employing a wide range of coercive and subversive tactics to achieve their goal of preventing or breaking up unions by any means possible. Besides direct intimidation of union leaders, they have used other subversive methods to identify potential union organizers. The methods include posing as fellow employees to infiltrate pro-union meetings, conducting surveys under the guise of Diversity, Equity and Inclusion (DEI) and establishing advisory councils to decrease the perceived need to unionize.

Many corporations fighting unionization efforts claim to want open dialogue and debate over unionization. However, these claims of wanting to educate employees do not hold up to scrutiny. Corporations hire large law firms

that specialize in anti-union campaigns with the singular goal of defeating unionizing efforts. Meanwhile, corporations supported by dozens of antiunion lawyers maintain full control of all forms of communication, including company emails, direct mail and all forms of oral communication. They do not allow access to physical spaces or work time for union supporters to speak uninterrupted nor allow union organizers to set foot on corporate property.

In February, Allina physicians at Mercy Hospital, in compliance with federal regulations, filed a petition with the National Labor Relations Board (NLRB) for corporate leadership to recognize their union. Despite signatures supporting the union from about 70 percent of the bargaining unit (which far surpassed the NLRB 30 percent minimum requirement to hold an election), corporate executives decided to require a union election. The petition to unionize is a rare organizing push by physicians but is not uncommon among other health care workers, including nurses, pharmacists and food service and maintenance staff. The 150 Allina doctors are organizing to create the first physician union in the state and only the second private-sector union in Minnesota to include physicians. The new union would represent Allina-employed physicians at Mercy Hospital’s two campuses in Coon Rapids and Fridley.

Making History to page 224

Many employees do not voice their opinions for fear of futility or reprisals.

3 Making History from page 21

Allina Health then issued a statement: “We deeply respect and value our physicians, their contributions to our organization, and the critical services they provide our community … We respect their rights as employees to support or oppose a union.” In seeming contradiction to this statement, Allina executives hired the world’s largest anti-union law firm to coordinate a multifaceted and precisely timed anti-union campaign. This firm wrote the playbook often used to fight unionization in other industries. Allina leadership is closely following their various strategies, including denying and delaying union victories.

During the six weeks between filing of the union petition and the election, corporate leadership hired a law firm to coordinate a comprehensive and sophisticated anti-union campaign while remaining behind the scenes. Each week, several “town hall” meetings on unionization were led by executives and administrators ostensibly as part of efforts to educate physicians about all sides of the issue. Instead, Mercy physicians were inundated daily with anti-union messages from multiple sources. Corporate leadership held dozens of captive audience anti-union meetings in place of regular department meetings, posted many anti-union flyers containing misleading information, sent countless anti-union emails (directly from executives and nearly all physician-administrators), created an anti-union Allina

website, mailed several official letters directly to physician homes, and during the last week, sent numerous text messages to personal phones.

Furthermore, Allina executives promised other system hospitals they would re-institute the retirement benefit they recently rescinded and would make the first continuing medical education (CME) increase in over 20 years. Such promises made before or after union elections could violate labor laws. Similar to anti-union efforts at Starbucks and Amazon, corporations and the law firms supporting them employ strategies to prevent unionization from spreading to their other sites.

During the anti-union campaign, union supporters were accused of sowing discord and division among work colleagues and it was suggested by leadership that by forming a union, physicians could betray their families, their patients and their Hippocratic Oaths. We believe the exact opposite is true. Full-time physicians/clinicians are the only ones in health care who are 100 percent ethically bound to act in our patients’ best interests. If physicians abrogate their responsibility to maintain their professional autonomy by allowing third parties to further erode the physician-patient relationship, then physicians would be violating our oath to “first do no harm.”

The Vote: A Clear Mandate

On Tuesday, March 28, history was made. After a long and difficult election

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“yes” votes won, authorizing a new union with 64 percent support.

process, unchallenged “yes” votes won, authorizing a new union with 64 percent support. The NLRB agents tallied the non-contested ballots, resulting in 67 “yes” votes for unionization and 38 “no” votes against unionization out of 105 votes.

Additionally, 30 votes were “subject to challenge”, including 14 voters who were not on the agreed upon list of eligible voters. Maximizing the number of challenged votes is a strategy that was temporarily successful in delaying union ratification. After lawyers presented their cases, the NLRB determined that the remaining challenged votes were no longer sufficient to affect the results of the election. Now that the challenged votes are resolved, the physician union victory should be indisputable.

However, corporate leadership still refuses to recognize the union. They now claim that three physicians tainted the election results by pressuring doctors to vote yes. This allegation is completely untrue.

The anti-union rhetoric before the election and the ongoing deny and delay tactics after a clear union victory continue to amplify the moral injuries physicians face. Allina physicians are ready to work in partnership with leadership on good faith negotiations towards a new collective bargaining agreement that will benefit patients, physicians and the communities they serves.

A Look at the Future

It appears inevitable that physician unions will become widespread across the country as a means to recover the professional autonomy and clinical independence physicians lost when most became employees of health corporations. The continued decline of physician autonomy and the progressive erosion of the physician-patient relationship are not sustainable. Structural changes, including unionization, are needed to help reverse these prevailing forces in health corporations and the American health care system.

Per the AMA, “Unions are not a panacea. They are tools available to certain physician employees and can be sought as a response to growing tensions within large hospital systems … The large health care systems currently gaining traction can lack avenues for physician advocacy and meaningful participation in organizational governance. As a result, a new trend is likely to emerge: the pursuit of physician unions ... union-organizing attempts are on the rise in the health care industry … Since January 2022, the NLRB has received 153 petitions for representation to initiate the unionization process in the health care industry overall.” Physician-trainees are leading unionizing efforts among physicians, with an estimated 15 percent of U.S. medical residents already organized under the Committee of Interns and Residents in recent years.

Unionization among physicians would lead to a leveling of power and allow for a more natural balance between the priorities of health corporation leaders and the rights and responsibilities of physicians and their patients. An appropriate balance within health care corporations is needed—one that is similar to the balance between public health officials, who prioritize the health of populations, and physicians, who prioritize the health of individual patients. Physician unions can help flatten the current top-down hierarchy of health corporations. Unions introduce an important structural change that can elevate physicians and patients by enabling shared decision-making responsibilities. Increasing physician agency can help address the feelings of moral ambiguity and powerlessness that many physicians and patients feel in the current corporatized health care system. Physician unions can and will serve as necessary counterweights that balance corporatized health care.

Hopefully there will be swift recognition of the new union so that time and resources are directed toward addressing issues important to delivering the best possible patient care. The election results at Mercy Hospital demonstrate a clear mandate to create a physician union and to begin good faith negotiations for a new contract that addresses what motivated physicians to come together to advocate for themselves and their patients. The time has come to usher in a new era of health care by deciding to be innovative and boldly recognize this new physician union. The time has come to demonstrate the true value and benefits that a more equal partnership between physicians/patients and executives/administrators can bring to patients, employees and health care delivery as a whole. Only with a more equal decision-making structure and actual access to the room where things happen and final decisions are made, will conditions exist that genuinely empower all sides to engage in truly fair and fruitful discussions. Only as equal partners working together to make decisions can patient care be optimized and delivered as the function of the organization for the health of the communities it serves.

Quy Ton, MD, MPH, is a hospitalist at Mercy Hospital.

Katie Esse, MD, is a neurohospitalist at Mercy Hospital.

Jessica Boland, MD, is a intensivist at Mercy Hospital.

Tomas Murdych, MD, is a hospitalist at Mercy Hospital.

Written on behalf of the Coordinating Committee of the Mercy Physician Union / Doctors Council SEIU.

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Burnout Repositioned

Regaining the joy in providing patient care

BY SHELDON BERKOWITZ, MD, FAAP

Many clinicians and nurses are leaving health care due to experiencing burnout. When I started my career as a pediatrician 40 years ago, I can’t recall ever hearing about this topic, or people leaving the field of medicine due to burnout. Yes, there has always been frustration with various aspects of health care, but these frustrations seem to have increased in the last decade. In my mind, three main reasons have contributed to this burnout, at least in the outpatient practice of medicine: electronic medical record (EMR) usage, increased oversight and the COVID pandemic.

EMRs have been both a lifesaver (literally in some cases) and a major hassle. Having access to a patient’s medical records easily, without sifting through reams of paper records, as well as ready and immediate access to laboratory and other diagnostic results, has been wonderful. However, there is increased demand to make sure

documentation meets all regulatory and billing requirements, as well as meeting other third party requirements. Documentation of a patient’s visit can often require substantial time at the end of a long clinic day and extend into the evening—often impacting a clinician’s time with their family and their work-life balance.

Increased oversight takes many forms, including outside agencies requiring certain quality metrics are met (which may or may not actually improve patient health and wellbeing), either for ongoing accreditation or pay for performance “bonuses.” Oversight can also refer to the loss of autonomy that many clinicians experience as those in leadership positions tell them how they “need” to practice, rather than allowing the clinicians to decide what is in the best interests of their patients and families and how best to provide this care.

Finally, although I retired from my clinical practice of pediatrics in May 2020, as the COVID pandemic was just getting started, I know from talking to my former colleagues and from what I have read, that stresses in

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practicing have only increased. Doing more with less, caring for patients for whom there often is nothing that could be done and the lack of faith by many patients and families in what they were told by public health officials and their own clinicians has driven many to leave health care.

None of these problems have easy solutions to help counteract clinician burnout. However, I recently had an eye-opening experience that reminded me of why many of us went into health care and maybe holds a message for how to offset some of the contributing factors leading to burnout.

Earlier this year, I traveled to Warsaw, Poland, with International Medical Relief to provide medical care for Ukrainian refugees (or guests, as we learned to call them) currently living in Warsaw. My experience over that week was remarkable. We provided care for patients and families who were living in shelter situations, some for over 7 months. My fellow clinicians and I provided care for both their acute (e.g., cough, sore throats, acute anxiety, muscle aches) and chronic (e.g., hypertension, congenital heart problems, depression) problems. We often just listened to their stories as they needed to share them. We were told to take as much time with each patient as needed (something I had never been told in my entire medical career) and did not feel rushed to see the next patient. We documented minimally what we thought was necessary and didn’t worry about billing since there was none. While confidentiality and privacy were important, we often saw patients in the same small space as our colleagues were seeing their own patients.

We didn’t have to worry about HIPPA violations, and we did the best we could, realizing we couldn’t solve all their problems. The patients and their families were very grateful for the care they received. No one complained about waiting to be seen, something that is a regular occurrence in most practices these days. I realized that providing care like this is why we all went into medicine.

Being able to spend the time needed (not allotted) to care for the patient would

It is my belief that if everyone feeling burnt out providing health care in our current U.S. system could spend time on a medical mission like the one I went on, or others around the world, it would likely help them to regain their sense of joy. This joy is felt both in providing needed care without a lot of oversight or metrics needing to be met and the positive feedback from the patients and families receiving the care. Clinicians could be recharged to return to the U.S. and provide care in our system. We need to look with fresh eyes at our current health care systems and figure out how documentation could be improved to what is clinically needed (not administratively needed). We need to lessen decision-making from “above” and return it to the local level of a clinic. We must focus on true quality care, not metrics being met, while also being able to spend the time needed (not allotted) to care for the patient. This would help all clinicians and then, perhaps, many would not feel it necessary to leave the health care profession due to burnout.

Sheldon Berkowitz, MD, FAAP, is a retired pediatrician and past president of the Minnesota chapter of the American Academy of Pediatrics.

Practice Opportunities throughout Greater Minnesota:

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also help all clinicians.

3Mission Management from page 12

chair responded with “well we fought the good fight for the sake of the community,” and to an extent he was right, they did try. However, with hindsight, it was obvious that the red lights had been flashing for some time. “Mission” was top of mind, mission management wasn’t.

The right mission questions are never independent of the right financial and operational questions, when posed by community health system trustees. If trustees don’t ask them, assume no one else will. Mission management is as important as every other aspect of organizational management. Mission management is complex and is interwoven with the tapestry of all of organizational governance and management.

Here is a finer point to put on the mission and physician business strategies cited above. Trustees will often assume that all independent physicians work to advance the mission of the community hospital where they hold a medical staff affiliation. To be sure, independent physicians can certainly appreciate and share in efforts to advance the mission of health systems where they spend a portion of their professional life. Trustees should not, however, assume or confuse the mission responsibilities of physicians in independent practice. They have first, and foremost, a fiduciary responsibility to their own organizations. When they exercise their duties in this regard, and the results are deemed by health system boards and leadership teams to be opportunistic, or even disloyal, trustees should step back and objectively assess the motivations at play. Missions of independent practices can certainly intersect with those of community hospitals, but they need not be one and the same.

Community health systems continue to employ physicians, across all specialties, as one key tactic central to a comprehensive organizational strategy. When successfully designed and executed, these multi-specialty provider integration strategies can be a powerful economic “flywheel” for the overall financial and mission strategy. As with the independent physicians, integrated and employed providers can have an affinity for the missions of the community health systems they serve; still they are practitioners of a profession. Organizational missions can certainly live within and through the integrated provider strategies. Integration of providers adds a level of complexity to health system strategies, calling for due education of the trustees/fiduciaries who oversee performance of the whole, mission included.

Finally, a principal question to be asked by trustees, relative to the risk of mission strategies and related costs, is: “how could our competitors use our mission to their advantage?” More specifically, “how could competitors, whether local, regional or national, exploit our more profitable clinical service lines, the ones that fund our mission?” This question typically generates rich discussions in the board room.

Daniel K. Zismer, PhD, is professor emeritus, endowed scholar, and chair, School of Public Health, University of Minnesota. He is also co-chair and CEO, Associated Physician Partners, LLC and the co-founder of Castling Partners. dzismer@appmso.com.

3 Behavioral Health Care in Greater Minnesota from page 19

Therefore, a primary goal of EmPATH programs is to reduce the number of mental health-related ED visits.

Another essential benefit to this specialized program is that it helps lower the need for inpatient psychiatric hospitalization. By offering dedicated care in the right environment, these programs make it possible for patients to receive the treatment they need without being hospitalized.

Furthermore, EmPATH programs have proven effective in providing comprehensive care that addresses the root causes of patients’ crises, resulting in fewer return visits to the emergency department. This means better outcomes for patients and more efficient use of health care resources.

Continued

A key focus of the program is patient-centered care. By creating a calming and supportive environment for those in crisis, patients report high levels of satisfaction with their experience. In addition, this nurturing atmosphere helps build trust and rapport between patients and health care providers.

A 2021 study in the “Journal of Behavioral Health Services & Research” showed that patients treated in EmPATH units had a 35 percent lower risk of returning to the ED within 30 days compared to those in traditional ED settings. This reduced likelihood of return visits suggests that these specialized programs effectively provide comprehensive care addressing the root causes of patients’ crises.

EmPATH programs have revolutionized how behavioral health and crisis centers care for patients, offering practical and compassionate support when needed most. By reducing ED visits, improving patient outcomes, enhancing patient experiences and combating stigma, these programs make a significant difference in the growing demand for mental health care. Continued investment in and expansion of such programs is crucial for ensuring that individuals in crisis receive the help they need.

The Sanford Behavioral Health facility in Bemidji, MN, is a pioneering mental health and crisis care model focusing on patient experience, staff satisfaction and implementing the EmPATH. This innovative approach has successfully delivered high-quality care to those with behavioral health issues, prompting the company to replicate and adapt the rural Minnesota model for other facilities nationwide.

As part of its long-term vision, the health care behemoth is striving to expand the behavioral health and crisis center model nationwide. This ambitious initiative aims to enhance access to mental health care services and improve outcomes for individuals across the country. By prioritizing both patient care and staff well-being, this approach is poised to create a lasting positive impact on the communities served by these facilities.

One significant benefit of expanding this model nationwide is the reduction of stigma surrounding mental health care. By providing accessible, high-quality mental health services in a welcoming environment, these centers encourage more individuals to seek help and engage in conversations about mental health. This increased openness contributes to breaking down barriers and fostering a culture of understanding and acceptance.

Improved patient satisfaction is another key outcome of this expansion. As more people gain access to these state-of-the-art facilities, they will experience the benefits of a comfortable environment, efficient care and dedicated staff. This heightened level of satisfaction not only encourages continued engagement in mental health care, but also serves as a testament to the effectiveness of this model.

The nationwide expansion of the behavioral health and crisis center model will contribute to the development of a healthier, more resilient population. By addressing mental health concerns early and comprehensively, these centers can help prevent the escalation of issues and support individuals in overcoming challenges. In turn, this will lead to improved overall health, increased productivity and a stronger sense of community.

Craig Clark, NCARB, is a licensed architect in Minnesota, North Dakota and Nevada for EAPC Architects Engineers. Based in Bemidji, MN, Craig has over 30 years of experience in architectural design, construction projects and management. He has designed for a variety of building types, with a specialty in behavioral health facility design.

Julie Benson, MN Academy Family Physician of the Year

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Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

Dr.

investment in and expansion of such programs is crucial.

3Generation Now Nursing from page 16

not properly aligned with our health care delivery, and this must change. Hospital leadership must be at or above operational profitability. Fee-forservice payment structures persist and undermine the value-based care models we know are more effective and efficient. Prevention strategies— primary, secondary and tertiary—are undermined by reimbursement emphasis on intervention and treatment, as are strategies aimed at mitigating harmful social and structural determinants of health. Efforts to recruit and retain a healthy health care workforce are at best inadequate, and at worst, abusive. One sneak peek at nurse twitter belies the cynicism, sarcasm, frustration and disassociation with those offering pizzas, lunches, lanyards, etc. Watch how nurses are recognized during Nurses’ Week (May 6-12, 2023) and make your own assessment.

Consider the business industry, where offering unlimited paid time off (PTO) is routine in their job postings and hires, not only for leaders but for all employees. Why are they able to do this? I believe it is because many have created a work environment their teams want to contribute to: feel they are cared for, belong, valued for their contributions and valued for who they are in that team. One hospital in Canada has offered “unlimited vacation,” albeit with some caveats (prior approval and getting your work done). I’m not sure how this plays out for their nurses, but it holds promise if implementation is not burdensome and those who use the benefit are not punished by their peers or leaders. Imagine unions, human resources, health care system leaders and workforce members finding common ground

in creating a culture that actively promotes the health of every health care worker and team. And by health I mean the whole health—the day-today culture, the staff-supervisor relationship, the intra-health care team members’, the system structure supporting team members’ physical safety and the invisible environment that welcomes every team member to belong and fully contribute.

We all see it, know it and live it every day. Our U.S. health care system, much like a forest, cannot be completely torn down and rebuilt from scratch. However, just as a forest fire can reset and renew a forest, disrupting the health care system can also lead to new growth and improvements. The mycelium network, deeply protected and underground, is a critical player in the regrowth of a forest and forest life after a fire. Similarly, health care professionals across Minnesota, the health care team members, the health care administrators, the payers and plans, the pharma industry, the tech innovators and the patients and communities we serve—must draw from our collective strength, resilience, innovation, stubbornness and creativity to extract and bring forth new and radical growth that positively disrupts and transforms our health care delivery, economics, incentives and rewards. There is no alternative.

Carolyn Porta, PhD, RN, MPH, FAAN, is an associate vice president of clinical affairs and nursing professor at the University of Minnesota. She also sees patients as part of the Regions Hospital SANE program.

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

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reflected by the ever-increasing range of services offered.

focus on the patient experience and maximize the patient care impact from dedicated University clinicians. It could be designed to ensure an optimal education experience for future health care professionals and facilitate the clinical discovery needed to ensure leading-edge care delivery and innovation into the next century.

At this time, we are more focused on reacquiring current facilities from Fairview ownership. We must do that first so these public facilities are not placed at risk by a merger with Sanford Health.

What is the role the state legislature will play in bringing this project to light?

Our state officials and representatives have an important role. Our ongoing partnership with the State of Minnesota goes beyond one request—we have 135 years of supporting each other and holding each other accountable. Today, the University of Minnesota educates a majority of health care providers in Minnesota—from cancer care and nurses to public health professionals. The Medical School is the only public medical school in the state

The same is true for our College of Pharmacy and School of Dentistry—the only schools of their kind in Minnesota. The College of Pharmacy educates a majority of the state’s pharmacists— health professionals who provide critical roles in community and public health. Our School of Dentistry graduates 73 percent of the dentists practicing in Minnesota, as well as 68 percent of the licensed dental therapists. Additionally, the School of Nursing educates a majority of the nursing leaders and educators for the state, while the College of Veterinary Medicine provides critical collaborations in cancer research and understanding of diseases that move from animals to humans.

None of these health science schools could have succeeded without state support, and none of these practicing health professionals would be serving the state of Minnesota. The state partnership continues to be a lynchpin of success, and this project is no different.

What are some of the hurdles you expect the project to encounter?

The landscape is moving quickly. We are addressing the most timely hurdle as this piece publishes—negotiating the transfer of charitable

assets back to the University from Fairview Health Services. We are proposing $950 million of support from the legislature; however, these negotiations will take place on the public stage with input from our state representatives.

How will this project will help leverage future strategic partnerships?

The University has agreements with nearly every health system operating in Minnesota— well beyond our M Health Fairview joint enterprise. We maintain clinical relationships in Duluth and Rochester, as well as extensive collaborations with Mayo Clinic on clinical trials and research. These relationships, plus our Rural Physician Associate Program, medical and pharmacy programs on the Duluth campus and currently-expanding nursing and medicine relationships in St. Cloud with CentraCare, will continue to serve Greater Minnesota. Minnesotans in every part of our state will benefit from the innovation planned from this initiative.

Jakub Tolar, MD, PhD, is dean of the Medical School and vice president for clinical affairs at the University of Minnesota.

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