INTERVIEW

Moving Medical Education Beyond the Classroom

Meghan Walsh, MD MPH FACP

Besides your work as a hospitalist, you are the chief academic officer at Hennepin Healthcare. Please tell us about what that work entails.

Hennepin Healthcare is a teaching hospital and clinic system. We have over 300 residents and fellows physicians who train in over 30 specialties here. We also have nearly 100 medical students who come to Hennepin for their clinical training. Once you are a practicing physician, you are also expected to continue to advance your knowledge in your specialty. My job is to ensure this clinical learning environment is the best it can be for all of these learners, from a college student interested in medicine to a first year medical student to a seasoned faculty physician who has been in practice for 40 years. I also play a role in strategy for the organization—ensuring we are a dynamic learning organization now and well into the future. I have the best job!

As a teaching hospital, how has the importance of what HCMC provides increased with the changing ways physicians are fulfilling CME requirements?

Medical education has been a key part of our mission for over 100 years. So much has changed and evolved in how we teach and how we learn during this time. Advancing technology, competency-based medical education change and the practice of medicine in this complex environment has led to new knowledge gaps and needs and opened the door to novel ways to close those gaps. We have moved beyond the classroom and traditional teaching methodology. Technology has allowed us to create more engaging coursework that is more flexible and comprehensive. This was critical during the peak of COVID -19, as it allowed us to continue to safely teach and learn in new ways. We have also developed incredible simulation-based training that allows us to hone our skills in high acute settings, improve teamwork training and continuously improve our competency with rare but essential procedural skills. Our future will require more partnerships with communities in Greater Minnesota to share expertise and advance our collective knowledge and practice.

Our community “...” partnerships are critical to our mission. “...”

The Hennepin Healthcare Research Institute (HHRI) has been active since 1951 improving health care and is recognized as a national leader. What are some of the projects they are working on now?

HHRI plays a critical research role in Minnesota. Many are surprised that we consistently rank in the top 10% nationally of institutions receiving National Institutes of Health (NIH) grant funding. Our four focus areas of research align with our expertise as a health care safety net: addiction medicine, trauma, infectious disease and health services research.

Our unique role as teachers, researchers and clinicians, as well as our commitment to equity and inclusion, placed us at the leading edge of research and care during the pandemic. If you were a patient coming to Hennepin in the early stages of the pandemic, you had the opportunity to participate in Remdesivir trials (COVID antiviral therapy,) convalescent plasma immune therapy trials, COVID-19 PCR testing with rapid result turnaround, life support and intensive care for the sickest of our patients. As one of the first labs to build testing protocols, we quickly became the testing resource for the state and other health systems in town. But our mission led us to the focus on the disparities arising from this pandemic. We brought testing to skilled nursing facilities and jails to quickly test and isolate affected patients in these high risk settings. When we deploy research alongside great clinical care and train others to these evolving systems, we quickly iterate our care to meet any clinical challenge; navigating the COVID-19 pandemic was no exception.

More recently, we have nurtured greater partnerships with our community and plan to attend Open Street Festivals to co-create solutions to the health care challenges facing Minnesotans. The future of research is ending the disparities that exist in health care today.

While HCMC is perceived as a safety net hospital, there are several other hospitals with a much higher percentage of Medicare reimbursement. What are some of the misconceptions about your patient mix?

I don’t think people understand the truly unique role Hennepin Healthcare holds in the Minnesota health care landscape. While there are other hospitals that take care of more patients covered by Medicare, HCMC stands alone in the percentage of revenue that comes through Medicaid (health care paid by a state and federal partnership for people who meet certain requirements around income, disability and family status). In data provided to us by the Minnesota Department of Human Services, adult patients covered by Medicaid getting primary care from our system have significantly higher rates of chronic conditions than other Minnesota adults on Medicaid. In that same data set, we see our adult patients have experienced homelessness at more than double the rate of other Medicaidcovered adults. Lastly, the majority of our patients identify as BIPOC, reflecting the dynamic diversity of the communities we serve.

What are some of the other things people may not understand about HCMC?

Most people know that we are an adult and pediatrics Level 1 Trauma Center, but we are way more than that. We have a downtown hospital and eight primary care and specialty clinics throughout the metro area. We have a cuttingedge Hyperbaric Chamber which supports the region; last year we had over 5,500 treatments. We also have an integrated emergency care set of services, including our Emergency Department which had over 93,000 visits last year and 87,000 ambulance runs. The Midwest Poison Control Center resides here. Our mental health care is some of the best in the state and includes inpatient care, outpatient care and the Redleaf mother baby center. Our community connection care ring includes hospice care and Minnesota Visiting Nurses Association home care, as well as the jail and healthcare for the homeless services.

When our state faces an emergent health risk, we are there. We have experts in Emergency Preparedness who have led us through the I-35W bridge collapse and the COVID-19 pandemic.

In every session, the State Legislature considers bills that impact how healthcare is delivered. What are some of potential improvements you would like to see enacted?

The flexibilities in health care regulations during the public health emergency (PHE) provided a time to test some innovations in health care we otherwise would not have been able to trial, and we made some incredible strides forward because of them.

During the PHE, patients on Medicaid were able to stay enrolled without additional paperwork for a full year, instead of jumping through the hoops of reenrollment multiple times per year as we did pre-PHE. Previously, many people would churn off and on the program throughout the year, causing significant costs to the state, insurance companies and providers, as well as major disruptions to patient care when people suddenly found themselves without insurance coverage because they had moved and missed a letter, or missed a deadline or their income varied one month to the next. Throughout the PHE, the federal government allowed continuous eligibility for anyone on Medicaid, verifying eligibility only once per year. Verifying eligibility one time per year was be a game changer for consistency in care and lowering costs to our system for unnecessary bureaucratic and administrative burdens.

Allowing easier access to telehealth during the PHE has changed how we provide care, as we were opening up clinical connections frequently missed before. These flexibilities in telehealth must continue for patient access–we could take their lunch hour to meet with a doctor instead of taking a half day of vacation, they could forego a three hour drive from Greater Minnesota and instead spend 30 minutes on video with a specialist. The access to video for appointments was apparent, but we must not let access to audio be considered a second rate service. Video is ideal, but in those situations where it is not possible, we need to ensure audio continues to be reimbursed at a rate that incentivizes the option to keep it available to patients.

Moving Medical Education Beyond the Classroom

to page 284

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3Co-opetition from cover

businesses yield several benefits. This concept considered many elements, the main one being that every competitor and customer gained from a shared relationship between organizations that may have been perceived, or themselves perceived, as competitors. The simultaneous cooperation and competition between businesses could yield several benefits. The main benefit is that every competitor and customer sees an exponential gain from the relationship.

Applications in health care

Applying this business theory in the health care industry might brings added levels of nuance and complexity. As the term co-opetition probably does not resonate in the vocabularies of most health care leaders, when given industry specific context, we might find the concept is not as foreign as it may seem. Two years ago, working as a consultant, this term first entered my vocabulary when it was mentioned by a colleague as we were assisting clients.

Fraught with the challenge many health care organizations face of losing independence and finding themselves at the table of a merger/acquisition, or even worse, closing their doors, many organizations facing these dilemmas are looking for ways to avoid them and actually thrive.

Becker’s Hospital CFO Reports, published in December 2021, identified 73 closures of rural hospitals over the past 10 years with a bit of an increasing trend. About 60 million people—nearly 1 in 5 Americans — live in rural areas and depend on their local hospitals for care. The number of rural hospital closures steadily increased over a four-year period, with a record-breaking 20 hospitals shutting down last year. In a rural setting, there may be less opportunity for co-opetition; however, many of the hospitals that shut down over the past decade still provide some health care services, such as urgent care, primary care or long-term care.

In about the same period as the Becker findings, Deloitte published a report showing an annual average of 84 heath organizations had some sort of merger or acquisition. While such pairing of organizations is highly driven by building better economies of scale, aspects of ensuring high quality and better outcomes are still critical.

The article further identifies through a survey done with health care executives who had been part of a merger and acquisition that 80% saw significant capital investments and another 70% achieved some of their transactions projected for cost structure efficiencies. While this reflects positively for mergers and acquisitions, organizations developing a more co-opative structure can see the same.

With the importance of managing costs, operating with less margin and new threats of consumerism entering the industry, much of this is not surprising. We have to recognize that health care is a consumer-driven industry. Patients are realizing a lot more of the cost out of their pocket, and they are playing a much bigger role in where and how they get care. So what do we do to survive, especially as we see new entrants in the market like Walmart, Best Buy and Amazon, who are very nontraditional providers, as well as increased competition with greater systemization through mergers and acquisitions and even more care offered virtually? There may be an answer in co-opetition.

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

Someone recently said that co-opetition has a bit of a spongy definition, but it is really quite simple. It is nothing more than collaborating with those likely seen as competition to achieve gains that are exponentially greater for both parties and consumers than that of working independently. To some degree, we already do this with various arrangements in health care, like outreach programs, third party arrangements for knowledge and resource sharing; even referrals can reflect a form of co-opetition. Fast forward my career a bit. I left health care consulting and returned to the direct patient care setting where I found myself in the throes of this very model of co-opetition. Two years ago, our organization sold a 118,000-square-foot hospital which provided every bit of inpatient, outpatient and surgical care. Our average daily census had been steadily declining. In our case, as a pediatric orthopedic center of excellence, we were finding many of our procedures could be accomplished in an ambulatory space without hospitalization.

We now lease an 18,000-square-foot medical office as an ambulatory care clinic. The interesting thing is we still provide inpatient/outpatient surgeries and have patients admitted for inpatient stays when necessary. To do this, we collaborated with a direct competitor and lease time from them to do surgeries and admit patients when necessary.

What are the wins in a relationship for both parties? We no longer have to cover the overhead costs of unused space and staff resources to be operational. Our competitor gains an increase in utilization of their ORs and additional inpatient stays for the kind of patient they know how to manage. For the patient, the gain is they get the best care.

This sort of win also happens in the reverse for us. Previous competitors are asking us to operate and staff programs which they struggled to keep running but want to keep as a viable offering to their patient populations. While it helps that we are a subspecialized provider for pediatric orthopedics, the variations for these kind of relationships are considerable. A good example is that independent radiology programs are now in place in many competing organizations. Similarly, medical specialty practices may become the complimentary partner supporting health care organizations who curate or create the assembly of care services for populations of patients.

Such co-opetition is really not that new, and while it may feel that way to the health care industry, the world has a history of such efforts. The moon landing just over 50 years ago is remembered as the culmination of a fierce competition between the United States and the USSR. But in fact, space exploration almost started with cooperation. President Kennedy proposed a joint mission to the moon when he met with Khrushchev in 1961 and again when he addressed the United Nations in 1963. It never came to pass, but in 1975 the Cold War rivals began working together on Apollo-Soyuz, and by 1998 the jointly managed International Space Station had ushered in an era of collaboration. Today a number of countries are trying to achieve a presence on the moon, and again there are calls for them to team up. Even the hypercompetitive Jeff Bezos and Elon Musk once met to discuss combining their Blue Origin and SpaceX ventures. There are several benefits to co-opetition. Co-opetition to page 294

Making it work

The expanded adoption of co-opetition in health care will combine existing approaches from other industries with the unique dynamics of providing patient care. To reach co-opetition’s best potential, it will be important to develop careful strategies and ask difficult internal questions. How can we reposition what may have been a competitive and possibly adversarial relationship with a nearby health care entity to one of shared goals for mutual gain?

Can we create a focus on the centrality of multiple stakeholders in forming, executing, and developing co-opetition? The parties will have to agree on how far to extend their cooperation, who is in charge, and how to terminate the arrangement should it no longer make sense. They will need to agree to acknowledge that the benefits of shared knowledge and resources outweigh continued investment in dysfunctional competition. There is an emotional aspect to this approach, and some people will embrace the idea of no winners or multiple winners while others will be steadfastly against it.

Fostering co-opetition can allow organizations to do the following: • Share strengths. Companies can combine their unique advantages and complementary strengths so that each can benefit while remaining in competition with each other. This allows them to create a more complete product together. • Distribute the workload. Coopetitors can grow their business network and merge their workforces to take on projects that are too big for one company. • Team up against larger competitors. Smaller companies, especially technology startups, may be in competition with each other and a larger, well-established company. Cooperating can allow the smaller companies to rival the larger one. • Improve market performance. Competitors can work together to penetrate new markets or develop existing ones. Developing existing markets means providing a better product or service to the current customer of a company. Market penetration means tapping into new markets through collaboration with competitors in target markets. • Foster technological innovation. Competitors working together drive innovation. Each company involved in the relationship can add what they learn from the collaboration to their own products or services.

• Establish industry standards. Competitors in the same industry can share data and drive adoption of a given technology. Doing this can assist in developing standards and requirements that help the industry without jeopardizing a company’s intellectual property or core competency.

3COVID-19 Litigation from cover

As the pandemic raged on, these organizations and authorities emphasized an unprecedented need for health care providers and facilities to make difficult decisions such as care prioritization, staffing changes and purposeful allocation of personal protective equipment and diagnostic tests. Doctors, nurses and other health care providers had to wear the same N95 protective face mask for numerous patient visits across numerous shifts, which would More than 15,000 lawsuits have have been unheard of before the pandemic. Assisted been filed related to COVID-19. living and aging care facilities limited or halted visits from family members, and patients had to enter hospitals alone to limit exposure and spread of the virus.

It is in the context of these fast-changing situations and decisions made under unprecedented strain on our health care system that COVID-19 litigation lays. By some estimates, more than 15,000 lawsuits have been filed related to COVID-19, with approximately 360 filings directed toward the health and medicine communities.

Aging services claims

The majority of the claims we are seeing so far are primarily filed against the aging services community, although there is certainly no shortage of claims against hospitals, individual medical providers, airlines, cruise lines and insurance companies.

The claims against the aging services community are mostly based upon the facility’s infection control protocols and staffing procedures at the time. These claims are typically wrongful death claims due to a loved one contracting COVID-19 while they were a resident at the facility or personal injury claims as a result of a health care provider’s limitation of the types of procedures being performed. We are also seeing claims against facilities for allowing health care providers to provide direct patient care versus telemedicine, and we’ve seen claims for the opposite scenario when the facility chose to provide care via telemedicine. These claims are typically plead in the general sense to avoid the litany of state and federal immunities and defenses available to these communities.

Claims related to COVID-19 treatment

The next largest subset of claims are those against hospitals and health care providers for delivering care and treatment directly to COVID-19 patients. These claims arise out complications that occurred as a result of the specific treatment rendered, such as intubation or off-label use of other vaccines and therapeutics.

Recently, we have also seen claims arising from delays in treatment due to public health organization recommendations regarding the prioritization of medical procedures. For example, rescheduling laparoscopic meniscal tear repairs with further development of the tear. The other type of claims we are seeing filed at this juncture are within the employment context. These claims are premised on wrongful termination/reduction in force, failure to notify of COBRA benefits, workers’ compensation and other employment-related matters. Another factor is the statute of limitations may be approaching on many of these claims, depending upon the state in which they are filed.

The next wave

Following the direct treatment claims, we have seen significant litigation involving vaccinations and vaccination mandates. Vaccination lawsuits focused on factors such as:

• How and when the vaccine was administered.

• Availability of the vaccine (or lack thereof). • Scheduling of second doses and boosters. • Conditions of the vaccination site, i.e., whether people had to wait outside in the heat in long lines.

Defenses for COVID-19 lawsuits

Virtually every organization and individual in the health care industry is compelled to defend against coronavirus lawsuits, and there are some important defenses available for these claims. Here is an overview of the most common defenses that we have used over the last two years.

The Public Readiness and Emergency Preparedness Act (PREP Act)

By way of background, the PREP Act (Act) was first enacted on December 30, 2005, as Public Law 109-148, Division C, Section 2. It amended the Public Health Service (“PHS”) Act, adding Section 319F-3, which addresses liability immunity, and Section 319F-4, which creates a compensation program. These sections are codified at 42 U.S.C. 247d-6d and 42 U.S.C. 247d-6e, respectively.

Originally, the Act was intended to protect vaccine manufacturers from financial risk in the event of a federally declared public health emergency. As such, the Act was specifically designed to encourage the rapid production of vaccines to protect American citizens in the case of a potential public health threat. COVID19 was not the first time that the Act was invoked. Declarations under the Act were issued during the avian flu outbreak, H1N1 pandemic and Ebola virus. The Act’s protections in these instances were focused on their respective vaccines.

The Act provides broad immunity from suit and liability to any “covered person” with respect to all “claims for loss arising out of, relating to, or resulting from” the “administration” or “use” of a “covered countermeasure” if a declaration has been issued with respect to that countermeasure. The Act states: [A] covered person shall be immune from suit and liability under Federal and State law with respect to claims for loss caused by, arising out of, relating to, or resulting from the administration to or the use by an individual of a covered countermeasure if a declaration under subsection (b) has been issued with respect to such countermeasure.

“Loss” is broadly defined as “any type of loss,” including death, physical injury, mental injury, emotional injury, fear, property loss and damage and business interruption loss.

Moreover, the immunity applies to any claim “that has a causal relationship with the administration or use by an individual of a covered countermeasure.”

The powers and protections of the Act lie dormant in the United States Code until the Secretary for Health and Human Services (HHS) issues a declaration identifying the scope and applicability of the Act in response to a unique public health emergency. In this case, on March 10, 2020, the Secretary of HHS issued the implementing Declaration invoking PREP Act immunity for “recommended activities” undertaken in response to the COVID-19 pandemic from February 4, 2020 through October 1, 2024.

Since its initial publication, the declaration has been amended seven times, both expanding the scope of immunity and clarifying and emphasizing that the Act is a complete preemption statute. The far-reaching coverage and implications of the COVID-19 Act’s declaration and amendments are enormous enough to write volumes of legal literature and dozens of law review articles. For the purposes of brevity in this article, a short discussion of the terms and elements of PREP immunity are sufficient.

Covered Persons

“Covered Persons” under the Act include manufacturers, distributors, program planners, and qualified persons, as well as their official agents and employees who prescribe or use covered countermeasures. The declaration specifically states that the immunity conveyed specifically applies to manufacturers, distributors, program planners and qualified persons.

Of the more ambiguous “Covered Persons” listed above, “program planners” include those who supervise or administer a program dealing with covered countermeasures and includes those people who establish requirements, provide policy guidance or supply technical or scientific advice or assistance to provide a facility to administer or use a covered countermeasure.

COVID-19 Litigation to page 264

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

Transforming Healthcare