Minnesota Physician May 2023

PHYSICIAN

A Missed Opportunity

The Prescription Drug Affordability Board

BY REID PORTER

Packed within the Omnibus Commerce Bill, Minnesota recently passed legislation enacting a Prescription Drug Affordability Board (the Board) that lets PBMs off the hook. The Board will do little to help patients and will likely harm future access to medicines. It is a bad deal for Minnesotans and it threatens the patient-doctor relationship, while injecting bureaucrats into the evaluation of whether certain treatments are worth paying for. It also does nothing to stop health insurance plans and their Pubs from making patients pay more for medicines than they do.

Health Care Utilization

Finding the right balance

BY ZEKE MCKINNEY, MD, MHI, MPH

Underutilization in healthcare is not a new concept, but it is one that has not received as much attention as the related problem of overutilization. In a perfect world, “correct” utilization is similar to the concept of the “five rights” of medication use, which describe ensuring the right patient gets the right medication at the right time via the right route of administration and at the right dose. It is fairly straightforward to apply this framework of ensuring the right/correct parameters for medications to other forms of treatment and to testing. While this concept is philosophically correct from the perspective of practicing medicine, it ignores the realities of clinical practice,

Health Care Utilization to page 104

Instead of risking access to medicines and future cures, Minnesota legislators should be focusing on stopping the tactics insurers and Pubs use to keep patients from getting the lifesaving treatments they need.

A Missed Opportunity to page 144

57TH SESSION Publishing November 2023

MAY 2023 | Volume XXXVII, Number 2 DEPARTMENTS

By Zeke McKinney, MD, MHI, MPH

By Reid Porter

By Stephen Taylor, MA

DIGITAL TRANSFORMATION IN HEALTH CARE

Passing the torch

BACKGROUND AND FOCUS:

Every part of health care delivery is being radically transformed by computer technology. From personal devices performing simple and accurate diagnostic procedures, to electronic medical records, credentialing, telehealth and more, every element of health care is in constant transformation. New methods of continuing medical education and the use of social media, as well as advances in medical science, are coming faster than any organization can keep up with. Just as many health care businesses now employ diversity, equity and inclusion officers, those same businesses are now hiring officers of digital transformation.

OBJECTIVES:

Our expert panel of diverse stakeholders will examine this phenomenon. We will discuss the pros and cons of how it has impacted health care delivery. We will compare how care delivery—from clinics to hospitals, to health systems, to public health to insurance companies—is becoming increasingly digital and how to utilize this emerging trend to its best end. What should the role of a digital transformation officer be and how should that office interact within an organization’s leadership structure? We will provide guidance around adopting and building change management into digital transformation strategies.

JOIN THE DISCUSSION

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.

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.

New Allina and Foundation Medicine Partnership

The Allina Health Cancer Institute recently announced a non-exclusive collaboration with Foundation Medicine to use its portfolio of comprehensive genomic profiling (CGP) tests across its cancer care network to help identify the most appropriate treatment plans for patients living with advanced cancer. “Foundation Medicine offers high-quality, well-validated comprehensive genomic profiling tests to help identify unique mutations in each individual’s cancer which may be enabling it to grow or spread,” said Dr. Badrinath Konety, MD, president, Allina Health Cancer Institute. “By reading a tumor’s genetic makeup and analyzing tumor biomarkers via tissue or blood samples, Foundation Medicine’s tests provide our physicians the precise information that can help us create

a personalized cancer treatment plan for each patient.” CGP— also known as biomarker testing or tumor profiling — leverages next generation sequencing to evaluate more than 300 cancer-related genes to detect genomic mutations known to drive cancer growth. The information generated from these tests is delivered in a comprehensive report that can help oncologists identify targeted therapies, immunotherapies, or clinical trial options that are best suited to an individual patient. “While traditional chemotherapy works by killing all rapidly growing cells, targeted treatments work by killing the cancerous cells which harbor mutations identified by CGP. For some patients, targeted treatments may be easier to tolerate and may be able to be used for longer periods of time than traditional chemotherapy,” said Mike Koroscik, vice president, Allina Health Cancer Institute. “By leveraging Foundation Medicine’s

tests across its cancer care network patients can receive the same high level of personalized advanced cancer care regardless of which Allina Health location and which Allina Health physician they visit.” More and more patients can benefit from molecular profiling due to the rapidly growing number of targeted therapies available today. These include novel therapies being developed for less prevalent gene alterations.

Two New Bills Support LGBTQ+ Rights

Gov. Tim Walz recently signed two important bills protecting and supporting LGBTQ+ rights. One bans conversion therapy and another protects access to gender-affirming care. This action builds on his executive order from early March that directed the Minnesota Department of Health (MDH) to compile and present a summary of existing

scientific literature affirming the safety and effectiveness of gender-affirming care. The order informed all health care providers within the state that they could bill health insurance companies for gender-affirming care. After signing the new bills Walz tweeted “In Minnesota, we’re protecting rights – not taking them away.” The conversion therapy ban forbids any medical or mental health care practitioner from offering such therapy to minors and “vulnerable” adults. It also forbids any entities from publishing advertising that refers to LGBTQ+ identities as “a mental disease, disorder or illness” or promises to change a person’s sexual orientation or gender identity. Practitioners who break the law could face discipline from the state’s health licensing boards. Additionally, the law forbids insurance companies and health care plans from paying for conversion therapy. Opponents of these bills, largely following

nationwide Republican agendas, claim they forbid religious-based counseling and stop people from seeking help for unwanted feelings of same-sex attraction and “gender confusion.” Mainstream medical and mental health organizations have disavowed conversion therapy as a harmful form of psychological torture. The bills forbid state legal authorities from honoring any outof-state subpoenas or arrest warrants seeking to bring civil or criminal actions against anyone who helps provide access to gender-affirming care. While 14 states have banned gender-affirming care for transgender youth, some of these states have also had their bans temporarily blocked by courts. Minnesota is now the 22nd state to ban conversion therapy and the fifth state to protect people seeking gender-affirming care: the others are Washington, Colorado, New Jersey, and California. Rep. Leigh Finke (D), Minnesota’s first out trans lawmaker, stated, “Families who have fled are already here, and many more are planning to come. We’re going to be ready to take care of them and to provide them with the health care they need.”

U of M Researchers Develop New Biocomputing Chip

In new research recently published in Nature Communications , a diverse team at the University of Minnesota has developed a platform for a new method of biocomputing: Trumpet, or Transcriptional RNA Universal Multi-Purpose GatE PlaTform. Trumpet uses bacteria-based biological enzymes as catalysts for DNA-based molecular computing. Researchers performed logic gate operations, similar to operations done by all computers, in test tubes using DNA molecules. A positive gate connection resulted in a phosphorescent glow. The DNA creates a circuit, and a fluorescent RNA compound lights up when the circuit is

completed, just like a lightbulb when a circuit board is tested. “Trumpet is a non-living molecular platform, so we don’t have most of the problems of live cell engineering,” said co-author Kate Adamala, assistant professor in the College of Biological Sciences. “We don’t have to overcome evolutionary limitations against forcing cells to do things they don’t want to do. This also gives Trumpet more stability and reliability, with our logic gates avoiding the leakage problems of live cell operations.” While Trumpet is still in early experimental stages, it has tremendous potential in the future. “It could make a lot of long-term neural implants possible. The applications could range from strictly medical, like healing damaged nerve connections or controlling prosthetics, to more sci-fi applications like entertainment or learning and augmented memory,” said Adamala. Lead author and PhD candidate

Approved health care practitioners can certify patients for Minnesota’s Medical Cannabis Program, which provides a treatment option for people who are facing debilitating medical conditions.

For more information on how to enroll, qualifying medical conditions, and more, visit mn.gov/medicalcannabis.

(pictured: Dr. Gigi Chawla, MHA ’17)

As a result, both organizations have agreed to terms that will end the shared ownership of the JV legal entity Blaze Health, LLC. North will regain the 49% ownership stake in 25 primary care clinics, specialty care clinics, and hospice currently held by the parent company of Blue Cross. “At North, our mission-driven teams remain focused on meeting the changing needs of the communities we serve throughout Hennepin County,” said J. Kevin Croston, MD, chief executive officer of North Memorial Health. “Blaze Health was born and launched from a pre-pandemic perspective. Just a few months later, the industry changed in ways that no one could have anticipated.

I truly appreciate the collaboration with Blue Cross, both in our response to the pandemic and the work that went into the JV. I am confident we can best deliver on current and future priorities by continuing to col-

approaches.” “Our new strategic plan at Blue Cross is built on the growth and expansion of value-based care initiatives with multiple care systems and providers throughout our network,” said Dana Erickson, president and CEO of Blue Cross and Blue Shield of Minnesota. “Our experience working in an integrated health care model led to many productive insights and outcomes. I value the ongoing commitment we have with North Memorial Health to improving the health of our communities and I look forward to building upon the learnings that can benefit all Blue Cross members.” Blue Cross members and North patients will not experience any disruption in their health care benefits or medical care. Both organizations are committed to ongoing collaboration. The conclusion of the JV, which launched in January 2020, will have no impact on the longstanding agreement that continues to have North as a valued participant in

Essentia Graduates First Nursing Residency Cohort

In response to the health care workforce shortage crisis and working to equip new nurses with the resources they need to deliver the highest-quality patient care, Essentia Health introduced a nurse residency program in the spring of 2022. A year later, the first cohort of nurses has completed the residency. They’re thankful for the opportunity. “Having the peer support and knowing that there’s staff, or the mentors that we found, they were very willing to be there when we had questions or needed support,” said Ashlynn Murph, a registered nurse at Essentia HealthFargo. Murph was among the 65 Essentia RNs to comprise the yearlong program’s inaugural class. They devoted four hours a month to learning about evidence-based best practices; engaging in practical hands-on exercises; teaming up on small-group

projects; and connecting with some of their more experienced colleagues. The goal was to supplement their nursing-school experiences and expedite career development. When possible, course content was specific to Essentia so that attendees could get a better feel for organizational best practices. Classes were held in-person in Fargo, Detroit Lakes, Brainerd and Duluth. “I think it was cool to have that group of people that you could see every month, bounce ideas off of and just talk to,” said Kaylee Stulz, also an Essentia Health-Fargo RN. “I looked forward to the program once I realized that was something Essentia was offering.” The residency program supports Essentia’s Journey Towards Magnet Designation, a prestigious distinction that honors health care systems for creating and sustaining a culture of excellence among their nurses. “A highlight of the program is clinical reflection time, which allows nurse residents to

connect and grow critical thinking and decision-making skills,” said Lana Helgeson, nursing professional development practitioner at Essentia. “The support the nurse residents receive every month from their facilitator and peers has been invaluable. I want to thank all the graduates for their hard work throughout the year and for leading our evidence-based practice journey.”

Hennepin Healthcare Expands Rehab Services

Hennepin Healthcare and Shirley Ryan AbilityLab (SRA) are joining forces to bring the services and expertise of the nation’s premier rehabilitation hospital to patients of Hennepin Healthcare. An alliance between Hennepin Healthcare and SRA will build on the legacy of high-quality care and services provided by the inpatient rehabilitation team and related therapies at Hennepin Healthcare. SRA is the global leader in physical medicine and rehabilitation for adults and children with the most severe, complex conditions – from traumatic brain and spinal cord injury to stroke, amputation and cancer-related impairment. Founded in 1953, and anchored by its flagship research hospital in Chicago, the organization operates more than 30 sites in Illinois and works with hospitals and health care systems around the world. The alliance will bring SRA’s extensive expertise, data, and analytics to Hennepin Healthcare. SRA will deploy leaders to work directly with Hennepin Healthcare rehabilitation services leadership and frontline clinical care teams. The Hennepin Healthcare rehabilitation team and related inpatient therapy teams and medical staff will remain Hennepin Healthcare employees with no change or interruption in employer affiliation or union status.” This alliance brings the expertise of the top rehabilitation hospital in the U.S. to patients who come to Hennepin Healthcare from across Minnesota and the region,”

said Jennifer DeCubellis, Hennepin Healthcare CEO. “Providing patients the best in rehabilitation medicine and therapies to support them on their journey to get home faster and with optimal mobility is critical and our partnership with Shirley Ryan AbilityLab will make that possible.”

As a teaching and research health care system, Hennepin Healthcare is the right partner for Shirley Ryan AbilityLab’s proven approach to improving safety, quality, and access.

“Central to our mission is expanding our reach — locally, nationally and globally — so that patients have access to the best in rehabilitation care within their communities,” said Peggy Kirk, SRA president and CEO. “We look forward to sharing our clinical and operating expertise with Hennepin Healthcare.”

Children’s Minnesota Opens New Specialty Center

Children’s Minnesota has just opened a second location for specialty care services in Maple Grove. The Children’s Minnesota Primary Care and Specialty Center – Maple Grove (Bass Lake Road) is located in the same building next to the existing Partners in Pediatrics (PIP) Primary Care Clinic. The new location will allow patient families to access more services at one convenient location.

“As the kid experts, access to quality care is one of our top priorities,” said Monica Schiller, vice president of ambulatory services at Children’s Minnesota. “We are excited to open our new Maple Grove location and care for more children and families in the northwest suburbs of the Twin Cities metro.” Specialties are available at the new location are: cardiovascular, ENT (with facial plastic surgery) and pediatric and adolescent gynecology. A cancer and blood disorders program is expected to open later this year.

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

A Proud Tradition of Service

Nicholas Van Deelen, MD, Co-President/CEO and Chief Medical Officer, St. Luke’s

Please share some of the rich history around how St. Luke’s began.

St. Luke’s is a nonprofit health care system based in Duluth, Minnesota. Our two hospitals and more than 40 primary and specialty care clinics serve residents and visitors of northeastern Minnesota, northwestern Wisconsin and the Upper Peninsula of Michigan.

St. Luke’s has provided medical leadership since its founding as Duluth’s first hospital in 1881. It was founded by St. Paul’s Episcopal Church in the upstairs of an old blacksmith shop in response to concerns resulting from a deadly typhoid epidemic (St. Luke’s is now secular). In 1884, St. Luke’s moved to a 38-bed facility, and in 1889, St. Luke’s established the area’s first nursing school. In 1902, St. Luke’s opened a four-story facility with the capability of serving 95 patients.

Even though St. Luke’s has grown into a regional health care system that serves three states, it has retained its renowned patient-centered focus. The high-quality medical staff provides state-of-the-art care in one of the most beautiful settings in the United States.

What have been the biggest developments along the way to becoming the health system St. Luke’s is today?

In the early 2000s, St. Luke’s began changing from a hospital/outpatient facility into a regional health care system. We did this by hiring physicians, most often through practice acquisition of both primary and specialty care clinics. We now employ more than 200 physicians and advance care clinicians.

St. Luke’s leadership in education, starting with opening a nursing school in 1889 (which closed in the mid-1980s) and now serving as a clinical training site for area colleges, medical students, pharmacy students and residents, has been integral to our growth and success.

In partnership with the University of Minnesota Medical School, Duluth Campus, and through a generous trust bequest from Miss Muriel Whiteside, we created the Whiteside Institute for

Clinical Research (Whiteside) in 1996. Whiteside focuses on clinical research, especially in the areas of cancer, lung and heart disease. This allows our physicians to partner with medical students on important research that benefits patients in our region and beyond. One example of our success in research is our ongoing involvement in the RECOVER study for COVID-19 (RECOVER). St. Luke’s is one of six organizations nationally participating in this CDC study. In addition to us, Kaiser Permanente, the University of Arizona, the University of Miami, the University of Utah and Baylor, Scott & White are also involved.

St. Luke’s ongoing physical developments are numerous. From opening several new primary care clinic buildings throughout the region to ongoing development of our hospital campus, we are always focusing on thoughtfully, economically and sustainably evolving our facilities to meet the ever-changing health care needs of our patients. Most notably, in 2012, we built a new five-story medical office building (St. Luke’s Building A) that is serving as the hub of our future campus. The building opened with 35,000-square feet

dedicated to specialty clinics. In 2015, we built out an entire floor to significantly expand our surgical space, including adding a hybrid operating room. In 2020, we completed the infill of this building, with one floor dedicated to an emergency department tripled in size from the previous one and another floor dedicated to stateof-the-art cardiac cath labs, cardiac rehab and cardiac diagnostics.

We are now beginning a significant expansion of Building A, adding two stories for private inpatient rooms for intensive care and cardiac care patients. This will also allow us to make all-private inpatient rooms throughout our hospital.

We have two wholly owned ambulatory surgery centers (in Duluth, MN and Superior, WI), and this year opened Northern Lakes Surgery Center, an ASC in Moose Lake, MN, which is a partnership with Gateway Family Health Clinic.

Many people may not realize just how large St. Luke’s has become. Please tell us about the scope and range of services you provide.

St. Luke’s is a regional health care system serving approximately 500,000 residents of northeastern Minnesota, northwestern Wisconsin and the western Upper Peninsula of Michigan. It includes St. Luke’s Hospital in Duluth, Lake View Hospital in Two Harbors, three ambulatory surgery centers and more than 40 primary care and specialty clinics throughout the region. We have more than 200 employed physicians and advance practice clinicians. We are a charter member of Wilderness Health, a regional health care collaborative working to improve patient quality and outcomes. St. Luke’s provides full spectrum adult and pediatric health care. In addition to our high-quality primary care, we have a busy OBGYN service, a level 2 nursery, a level 2 trauma center, a regional cancer center, a stroke center and a regional heart and vascular center.

What kinds of research projects are being conducted at St. Luke’s?

As mentioned earlier, St. Luke’s is participating in the national RECOVER study. Participation is

We value being good stewards of our resources and our community. “...”

“...”

led by St. Luke’s Infectious Disease Specialist Dr. Harmony Tyner. Her work and findings from the study have been published in the Journal of the American Medical Association. The study focuses on frontline workers who both have and have not been vaccinated. The findings help inform public health guidance nationally.

Another recent research project focuses on the positive effects of early low-dose chest CT screening on rural patients. St. Luke’s Radiation Oncologist and Whiteside Medical Director Dr. Nils Arvold has partnered with Maddy Hinojos, a student a student at the University of Minnesota Medical School, Duluth Campus, and others. They are researching the outcomes of lung cancer patients living in rural areas who get an early diagnosis due to a low-dose CT scan. Lung cancer is the biggest cancer killer in the U.S.; Drs. Arvold and Hinojos discovered that by screening eligible patients with a low-dose chest CT for lung cancer, the historical association between living rurally and having worse lung cancer outcomes disappeared.

We also have a number of other Phase II, III, and IV clinical trials happening.

What are some of the biggest challenges you face?

The challenges St. Luke’s faces are not unlike those being faced by other health systems. We are experiencing extremely high labor and supply costs and low reimbursement rates from governmental payors. This is putting a lot of financial strain on systems.

Having enough staff with the appropriate skills is also a current challenge. We are finding ways to encourage young adults to choose careers in health care. There are thousands of nursing positions left unfilled across the state because people aren’t entering the field like they used to. St. Luke’s is addressing that through the way it recruits and celebrates employees while working closely with our excellent educational partners.

The pandemic also led to people delaying care, and we’ve seen people coming in when they are at a point where they are diagnosed and treated for more serious heart conditions and advanced stages of cancer. We continue to remind patients of the importance of regular visits with a primary care provider and that early care and prevention will improve their health in the long run.

What kinds of changes are you seeing in your patient population?

Our patients are accessing care differently than before. Consequently, St. Luke’s is constantly evaluating the options we provide to make sure that we are available. Whether a patient needs highly specialized care accessed through our stateof-the-art emergency department, an annual appointment with their primary care provider or a virtual visit for a minor condition, St. Luke’s staff are ready to serve, and the options for scheduling are more robust than ever. Additionally, in response to our patients delaying care, the St. Luke’s Primary Care clinics are proactively reaching out to them with a special focus on their wellness. The clinics are scheduling appointments to assist with the management of chronic illnesses like diabetes and asthma and making sure all the preventative measures that were delayed during the worst years of the pandemic are caught up to date.

Please tell us about the St. Luke’s Foundation and some of the work being done there. St. Luke’s Foundation has a mission of

ESSENTIA HEALTH AMBULATORY CARE CENTER, PARK RAPIDS, MN

which include a physician’s understanding of when/how to proceed with a course of action, as well as the patient’s willingness or ability to engage in a physician’s recommendation. Of increasing importance, there are a variety of financial variables impacting whether such clinical care actually occurs. Unfortunately, the financial motivations of patients and physicians, particularly in the U.S., are significant enough to be drivers of health care utilization, independent of other factors affecting individual behavior.

In terms of patients, underutilization occurs when they do not accept or engage in health care testing or treatment that is likely to have a significant benefit. Another spectrum of underutilization is found in functions of health care access, even in cases where the care lacks any question of necessity. An example of this is seen in dramatic insulin price increases resulting in limited access to the medication for diabetics. Other common cases involve insurance barriers, such as high premiums, deductibles, copays, or even outright denials of necessary care by insurers. There are also geographic and temporal issues of access, particularly for highly specialized care. Nevertheless, even when access or cost is not an issue, patients may choose not to engage in the “right” care for a variety of reasons. Bivalent COVID-19 vaccines were widely available at no cost, but there were very low rates of community uptake throughout the country, which may be attributable to a variety of reasons. Similarly, a multitude of non-financial and financial factors impact physicians’ inappropriate under use of health care.

Underutilization by Physicians

There is no shortage of studies evaluating the issue of variation in physician utilization of health care services. To a large degree, physicians suffer from cognitive overload as it pertains to medical decision-making. In particular, the exponential increase in new research, testing and treatment paired with systemic pressures on increasing efficiency and volume, implicitly portend an eventual mismatch in a physician’s ability to make the “right” decision in a relatively small amount of time. As such, physicians’ decisions suffer from cognitive bias in a number of ways, including the inability to continually be up-to-date on the latest recommendations, they may focus on clinical “horses” while dismissing clinical “zebras”. There are challenges communicating with and correctly understanding patients from a myriad of intersecting biopsychosocial identities. These can lead to the potential and presence of differential treatment for patients based on various identifying factors like race, ethnicity, gender, age, socioeconomic status, educational background, or preferred language. Though even when physicians are making (or want to make) the “right” decisions for their patients, often the financial barriers of limited reimbursement, or even coverage in any capacity, preclude them from doing so. The financial mechanisms driving health care administrators’ decisions around specifying patient volumes, basing physician salaries on relative value units (RVUs; not always congruous with volumes), providing staff for administrative tasks, and opening/ closing clinical sites, are major forces in affecting access. These factors have an impact on when and how physicians provide care, and in extreme cases may cause physicians to leave an institution or the field of medicine altogether. The clinical and financial outcomes of physician variation in utilization based on these and other factors have been evaluated in a variety of studies, with some striking results.

 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

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Early studies of utilization often focused on cost savings, while more recent studies tend to evaluate clinical or patient-oriented outcomes. In part, this focus on financial outcomes was a function of considering the economic theory of “moral hazard”, which implies one party in a financial transaction has an incentive to increase its risk because it has a disproportionate share of protection from the risk. Moral hazard is more clear in banking and insurance than in health care. This is due largely to a lack of health care price transparency. Physicians are often unaware of the cost of the care they provide and patients often do not find out their costs for those services until well after they were provided. Lacking the fundamental element of cost, or risk, in assessing how best to utilize health care, moral hazard can occur for both patient and physician in both consuming and delivering care. It is often assumed, by both parties, that a patient’s degree of insurance coverage and amount of out-of-pocket costs is proportional to the amount of health care they consume. Unfortunately this is not always the case and economists criticize interpretations of moral hazard in terms of health care delivery, because they suggest health care mirrors utilization of other goods or services. When people are very ill, they use health care only because it is absolutely necessary, whereas fully-covered preventive services often are avoided simply because the value is difficult to perceive when someone is feeling completely well. As moral hazard applies, if patients don’t have to pay for care, they don’t care how much it costs. If they have to pay for it, they may choose not to seek care. One instance of this effect was observed in a study evaluating emergency department (ED) visits in Oregon, where it was posited that Medicaid patients (who essentially have no out-of-pocket costs),

| Edina | Lake Elmo/Woodbury | Lakeville | Minneapolis | Plymouth

would utilize more preventive (high-value) care versus ED visits (considered low-value), but the exact opposite effect was found: ED visits increased 40 percent in the presence of Medicaid. This finding is likely not surprising to physicians (as much as to economists), in terms of understanding individual behavior as a driver of health care utilization.

The classic example of moral hazard for physicians stems from treatment recommendations and their cost. Related to this is potential profit motivation in the recommendations. With the decline of physician –owned practices, the aspirational and eventual transition to outcomes driven, value-based care, the moral hazard around cost-shifting may become less of a factor. Though profit driven medicine continues to be a significant problem, particularly in privately owned procedural based specialties which are reimbursed at a much higher rate that non-procedural care.

Motivation from profit is likely behind volume based (doing more) as opposed to value based (doing better) care. Well documented increases in spinal fusions from 1990 through 2010 is an example of overutilization. However, physicians do not always follow the expectations of a moral hazard model for reasons such as patient preference, clinician experience, or treatment availability. This begs the question: how do we resolve these patterns of over or underutilization if patients or physicians are not only driven by economic forces?

Assessing Moral Hazard

Assessment of moral hazard in medicine acknowledges the conceptual limitations of this economic theory relative to the behavioral factors driving patients and physicians, and resolves these issues by using “behavioral hazard” models. At the simplest level, even if humans were motivated only by financial considerations, people can make mistakes. However, divergences from expectations of the maximum financial benefit can be observed to have both positive and negative effects on outcomes, and can be explained by the fact that both patients and physicians proceed with health care utilization for a variety of logical and nonlogical reasons. Patients may be motivated by disinterest in following treatment recommendations, for example not wanting to take medications, having challenges with modifying addictive behaviors, distrust/mistrust of health care entities, and/ or by overly or underly misperceiving the severity of their afflictions. Despite preventive care having no out-of-pocket cost under the Affordable Care Act, there are still many instances where such care is avoided, such as colonoscopies. Physicians similarly are impacted by various considerations, whether lacking awareness of contemporary “best” practices, overly relying on their own treatment patterns, seeking

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Under-testing in high-risk patients and over-testing in low-risk patients were divergent problems.

to limit costs for their patients, lacking transparency in health system or patient costs, and/or inadvertently weighting some clinical signs/symptoms as more/less specific than others. This effect was well-demonstrated in a 2022 study by Mullainathan and Obermeyer, where both overutilization and underutilization of acute coronary syndrome (ACS) in an ED setting were evaluated using machine learning, a form of artificial intelligence (AI) algorithm that considered a larger number of variables than a physician could.

ACS was well suited to study in this regard given the potential for severe outcomes if unrecognized, and as a whole, found overtesting was an issue. However, in considering the differences between high-risk and low-risk patients, a different picture emerged where undertesting in high-risk patients and overtesting in low-risk patients were divergent problems, with significant variability found in considering the ED shift where the patient presented. Such findings suggest that broad stroke averaging analyses of populations without considerations of more relevant clinical details may be overly sensitive for overutilization without appropriate specificity for underutilization.

Multiple Variables

At the heart of considering overutilization versus underutilization lies the fact

that there are a multitude of variables that may be impossible for a physician to consider in real-time. Physicians are often left with the overly simple calculus of pursuing too much testing at the expense of unnecessary cost, or too little testing with the potential for significant morbidity/mortality. One of the most famous cases of overutilization is easily observed – and has been well studied – in the management of acute low back pain. Despite a limited set of instances where lumbar magnetic resonance imaging (MRI) is indicated, such as profound lower extremity weakness, fecal incontinence, or saddle anesthesia, this test is one of the (if not the most) overutilized tests in all of medicine in cases where such significant symptoms are not present. However, system pressures to reduce such tests over time may cause some physicians to fall into the opposite trap of not ordering an MRI when one is indicated. Even when considering this issue from these perspectives, there are still the multifaceted layers of bias, including a patient’s degree of perceived pain, a physician’s interest in reassuring a patient, a patient’s biopsychosocial background, and/ or the physician attempting to be protected from malpractice claims. This relatively simple example (in comparison to ACS) demonstrates the perfect storm of factors that create distinct variations in how physicians provide

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Variables being evaluated and the goals being sought may be misaligned.

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The Board has created strong concerns among oncologists, who regularly administer prescriptions in a clinical setting, that it could reduce patient access to breakthrough therapies while adding to difficulties in providing community cancer care, as well as treating rare diseases and other serious illness. Also, it will disproportionately increase costs to independent providers. This concern was not addressed by legislators, and many physicians in Minnesota remain concerned with how the Board will impact access to critical treatments.

Price Controls Limit Medication Access

Research shows that it is simply not true that government can impose significant price controls without damaging the chances for future cures. The Center for Life Sciences Innovation Information Technology and Innovation Foundation was established in 2006. It is an independent 501(c) (3) nonprofit, nonpartisan research and educational institute. It has been recognized repeatedly as the world’s leading think tank for science and technology policy. In a 2019 report, they noted academic studies consistently show a reduction in current drug revenues leads to a fall in future research and the number of new drug discoveries. Policymakers need to keep this cost in mind when setting any policies that affect drug revenues.

A 50 percent decrease in the price of medicines would result in a 25 to 60 percent decrease in the number of new drugs in the pipeline, according to expert estimates. U.S. patients enjoy earlier and less restrictive access to new therapies, a finding that is reinforced by HHS’s own analysis of Medicare Part B drugs, which showed that only 11 of the 27 drugs examined

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Low- and high-risk obstetrics, including advanced maternal age.

Certified nurse midwifery. Gynecologic care, including well-woman screenings and in-office procedures

Gynecologic surgeries, including minimally invasive surgeries and robotics for conditions such as endometriosis and pelvic organ prolapse

Menopause Clinic, including management of peri-menopause

Center for Urinary and Pelvic Health, including urodynamics.

Nutrition and wellness consultations.

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(41percent) were available in all 16 comparator countries, nearly all of which have policies that let the government set the price for medicines.

Nearly 90 percent of new medicines were available within one year of launch in the U.S., compared to just 52 percent in France, 45 percent in Canada and 61 percent in Germany – according to data capturing all 460 new medicines launched between 2012 and the end of 2021. In countries where governments set the price for medicines, such as the United Kingdom, it can take over a year from the time a drug is approved to the time it is available to patients. Some countries have a delay of over three years for a cancer drug to be available to patients.

Biopharmaceutical companies remain committed to research and development, but government price controls at the federal level are already forcing the industry to make hard choices when it comes to investments in research and development (R&D). In fact, a recent survey of major pharmaceutical manufacturers showed that, when asked if they expect to shift R&D investment focus away from small molecule medicines because of the federal Inflation Reduction Act (IRA), 63 percent of those who responded to the question said yes. Now, even before the IRA is fully implemented, Minnesota is piling on.

For companies with pipeline projects in cardiovascular, mental health, neurology, infectious disease, cancers and rare diseases, 82 percent, or more, expect “substantial impacts” on R&D decisions in these areas.

Disturbing Facts

The prices health plans paid for brand medicines increased by an average of just 1.0% in 2021 due to negotiations in the market. It often doesn’t feel that way for patients because insurers and pharmacy benefit managers (PBMs) have increasingly shifted more out of pocket costs on medicines to many patients through high deductibles and coinsurance. So while health plans routinely base patient cost sharing for services like hospital stays and doctor visits on negotiated prices the health plans pay, when it comes to life saving medicines, patients often do not receive these discounts.

More than half of every dollar spent on a brand medicine goes to middlemen like insurance companies and PBMs, as well as hospitals and the government. Just three PBMs control 80 percent of the marketplace, which means they get to decide what medicines are covered and what patients have to pay. More often than not, these middlemen put their own profits before patients.

What Minnesotans Are Saying

A new 50-state poll conducted by Morning Consult found that 87 percent of Minnesotans agree lowering out-of-pocket costs for health care should be a top policy priority for policymakers. A similar majority of Americans in all 50 states support common sense solutions that would help patients pay less for their medicines and provide better oversight of middlemen. Among the most popular solutions for lowering drug prices is ensuring that patients don’t pay more for their medicine than health insurance companies or pharmacy benefit managers (PBMs).

Further findings showed 83 percent of Minnesotans agree lawmakers should require health insurance companies and their middlemen to pass the rebates and discounts they receive directly to patients.

Policy makers need to accurately diagnose the root causes of high prescription drug costs and consider survey solutions. There included:

• Ensuring health insurance companies and middlemen are held

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

56TH SESSION

THE PANELISTS:

The Health Care Workforce Shortage: Facing a crisis

The following report from the 56th session of the Minnesota Health Care Roundtable addresses important issues surrounding the health care workforce shortage crisis. In this session we examine a growing concern that is impacting all industries nationwide. Health care is experiencing the most serious problems, in part due to the pandemic, and response has varied from hospitals laying off 100’s of staff members to offering nurses 6-figure signing bonuses. Our panel addresses these issues; their root causes and explores solutions through the specific lens of the health care industry in Minnesota. We extend our special thanks to the participants and sponsors for their commitments of time and expertise in bringing you this report. This fall we will publish the 57th session of the Minnesota Health Care Roundtable on the topic of digital transformation in health care. We welcome comments and suggestions.

What are the three biggest challenges that the health care workforce shortage poses to your organization?

CAROLYN: It poses important challenges but also an important opportunity. Many individuals are interested in nursing as a first or new career. Aware of the shortage, young people see a career that will guarantee employment options for the foreseeable future. Challenges we experience as one of the academic institutions preparing the future nursing workforce for Minnesota include

LYNDA BENTON, is senior director, Strategic Initiatives, Global Community Impact for Johnson & Johnson.

TENBIT EMIRU,MD, PhD, MBA, is executive vice president and chief medical officer at UCare. She serves on the board of directors for the Minnesota Board of Medical Practice.

RAHUL KORANNE, MD, MBA, FACP, is the president and chief executive officer of the Minnesota Hospital Association and member of the Minnesota Departmrnt of Health (MDH) Healthcare Home Advisory Committee.

J.P. LEIDER, PhD, is the director of the Center for Public Health Systems at the University of Minnesota School of Public Health. He is a senior fellow in the Division of Health Policy and Management.

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 at Regions Hospital.

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

faculty and preceptor shortages, as well as a related inability to adequately expand our class cohort sizes to meet the demands of prospective nurses.

TENBIT: It results in limited access to health care for our members, particularly in greater Minnesota and in communities where people of color live and seek care. We are concerned about access to mental health, primary care and specialty care for our members throughout the state. Due to factors such as the demanding nature of health care jobs, concerns for one’s health and safety and the alarming rate of burnout among health care workers, a sizable portion of the workforce has exited the field. This has been further exacerbated by the pandemic; we simply don’t have enough physicians, nurses and other allied health professionals to meet the needs of our members. Hospitals are closing some or all services in rural communities, and this is further adding to the already existing health inequities.

ABOUT THE SPONSORS:

Johnson & Johnson For more than 125 years, Johnson & Johnson has been proud to advocate for, elevate and empower the nursing profession.We are continuing our legacy of support by working with partners to attract and strengthen an innovative, thriving and diverse nursing workforce, empowered to advance health equity and transform healthcare. Visit nursing.jnj.com to learn more about how Johnson & Johnson supports nurses.

UCare is an independent, nonprofit health plan providing health coverage and services across Minnesota and western Wisconsin. Working in partnership with health care providers and community organizations, UCare serves individuals and families choosing health coverage through MNsure, Medicare-eligible individuals, individuals and families enrolled in Minnesota health care programs, such as MinnesotaCare and Medical Assistance and adults with disabilities.

The University of Minnesota Medical School is a world-class institution with a long history of leadership and discoveries that have changed the practice of medicine. We engage undergraduates in science and medicine, train medical students, produce PhDs in research, and enrich the experience of postdoctoral students, residents and fellows. Founded in 1888 as the College of Medicine and Surgery, it has evolved to become a leader in medical education and research.

The School of Nursing at the University of Minnesota provides its students with a world-class opportunity to learn, lead and discover in a dynamic learning and research environment. Our faculty are nationally and internationally renowned for their leadership, practice expertise and research discoveries. The School offers a wide range of degree programs including a Bachelor of Science in Nursing, Master of Nursing, PhD in Nursing and Doctor of Nursing Practice.

The University of Minnesota School of Public Health (SPH) improves the health and well-being of populations and communities around the world through excellence in research and education, and by advancing policies and practices that sustain health equity. Established in 1944, SPH includes 4 academic divisions and offers 19 graduate degrees covering a wide range of and focus dedicated to improving public health.

Workforce shortage, growing labor cost and the pressure to increase provider reimbursement are all intertwined realities of the health insurance industry. According to the Advisory Board, median labor expense for health systems per adjusted discharge has risen by 45% from 2019 to 2022 while patient volume is almost at the pre-pandemic level with an increased acuity. The increased acuity combined with an equally challenging shortage of post-acute care beds has significantly increased length of stay for hospitals further reducing the already low profit margins. Increase in expenses and reduction in revenue are making some health systems long-term viability questionable. In turn, there has been an increased pressure from health systems to raise reimbursement. The significant workforce shortage is an issue most health systems are facing and must solve for in real-time. This doesn’t leave much flexibility to explore innovative reimbursement models and value-based agreements prioritizing value of care over volume of care. In some cases, health systems are walking away from risk-based agreements given their dire financial situations.

JP: During COVID, governmental public health workers who had worked in their organization for five years or less were far more likely to quit and change organizations compared to their peers. We have to figure out how to retain these staff going forward if we are going to stem the tide of turnover. Prior to COVID, state and local governmental public health had lost over 15 percent of its workforce since the Great Recession. It had also been hit by the onset of the “silver tsunami”, the generational retirement associated with Baby Boomers starting to age out of the workforce. Policy and demographics together are powerful and not unique to public health. However, another issue is unique to public health— it competes with health care, arguably

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the best paying industry, and has all the weakness of the public sector, such as slow to hire, offering relatively less pay and bureaucracy associated with promotions. This has made it difficult to hire and more difficult still to retain during a time when the private sector is competing hard for talent.

RAHUL: Care capacity. Our members rely on their staff to carry out their missions of serving their patients and surrounding areas. Without a robust workforce, the capacity to care for our communities is threatened. Staffing shortages throughout the health care sector have both immediate and multiplying effects. Staffing shortages make it hard to coordinate care for patients. Another issue is reliance on outside talent. Hospitals and health systems have had to rely on staffing agencies to bring in traveling staff to alleviate the staffing shortages. While it helps immediate care capacity issues, it can significantly strain long-term financials as these contracted employees cost exponentially more than permanent staff. Also, there are financial considerations. Labor expenses grew by an average of 7.4 percent in 2022. It is not only the reliance on outside talent using expensive travel agency contracts that is causing labor expenses to grow. To recruit and retain the workforce, we must appropriately compensate our workforce. As with many industries, contracts are growing, and to stay competitive, our hospitals and health systems must offer attractive packages. Labor expenses are not the only costs that are rising. Non-labor costs grew by an average of 9.5 percent in 2022. Inflation is making it difficult for our hospitals and health systems to manage their funds effectively. The discharge gridlock costs hospitals and health systems $37 million a week. Minneosta Hospital Association (MHA) found that in one week of December 2022, nearly 2,000 patients were eligible

for transfer to a continuing-care setting, such as a nursing home, group home or residential mental health treatment facility, but could not be discharged from inpatient care due to a lack of capacity in post-acute care settings. This resulted in 14,622 extra hospital patient days—a data sample reflecting the recent patient census situation in rural and urban hospitals. While those are the largest three challenges to our workforce shortage, it is evident how interconnected they are and the many issues within each challenge as well.

LYNDA: As the most diversified and only health care products company dedicated to maintaining a portfolio that represents its strong pharmaceutical and medtech capabilities, Johnson & Johnson depends on the health care workforce to enable our products to reach patients in need. In addition, we aspire to help eradicate racial and social injustice as a public health threat by eliminating health inequities for people of color, and we believe that a robust, thriving health care workforce is vital to supporting safe, highquality, equitable health care. Finally, guided by our Credo as a company that has championed and supported the nursing workforce for over 125 years, as we recognize that nurses are the backbone of health care, we believe that a nursing shortage, also deemed a nursing “crisis,” is really a health care crisis for us all. Nurses provide handson patient care, help improve access to care, prescribe and administer medications, support and provide education and coordinate services in virtually every corner of every community. They are sometimes a patient’s only access point to health care. For health care to work, it takes a robust, diverse nursing workforce supported and empowered to thrive.

JAKUB: As health care educators, we are challenged to identify and recruit the number of qualified students needed to address the workforce shortage, to make education and training affordable for these students; and to ensure we train students to be workforce-ready in a wide range of settings across the State.

How are you addressing these challenges?

JAKUB: We have well-established and growing pipeline programs that introduce younger students to the health care and science professions. For example, we have programs out of Duluth that recruit and support students from kindergarten through graduate school. The Ladder program in North Minneapolis recruits health professionals to come into the community and mentor students, giving them exposure to successful adult role models, as well as to science and health. All of our health professional schools have active recruitment programs throughout the State. The University has focused on moderating and stabilizing tuition, and we offer a range of support from non-resident tuition waiver scholarships to full-tuition scholarships, as well as half-tuition and donor scholarships. We know that health systems are in need of health professionals who are not only skilled, but ready for teambased practice. Our training has opportunities for interprofessional learning

and experience that helps build that readiness. Since there is a particular need for physicians in rural communities, and data show that doctors often end up practicing where they train, the University has programs to train physicians in smaller communities across the state. For 50 years, the Rural Physician Associate Program has paired medical students with experienced physicians in rural Minnesota. Sometimes these physicians end up training the doctors who will replace them when they retire. We are working to expand training opportunities in rural communities across the State, building on successful programs like the one in Duluth and developing new partnerships as with CentraCare in St. Cloud.

LYNDA: We are continuing our rich history of championing and supporting the nursing profession in three important ways. We know that even now, nurses are undervalued for their impact on health care, so we are advocating and elevating awareness of the fundamental value of nurses in health care through research, advertising, external conference presence, our SEE YOU NOW podcast and storytelling. Second, we are taking action to address fundamental workplace culture and environment challenges that have led to escalating nursing burnout, turnover and vacancy rates, by working to help redefine the workplace culture and environment where nurses can thrive. We support a nurse innovation health system fellowship through Penn Nursing and Wharton Executive Education and through NurseHack4Health hackathons and pitchathons to help nurses define and power-up their innovative ideas to improve health care and bring them forward. Through the Johnson & Johnson Foundation, we are supporting mental health and well-being resources and leadership skill development programs led by SIGMA and the American Organization for Nursing Leadership (AONL), as well as researching new care delivery models for health systems by supporting the work of the Institute for Healthcare Improvement. Lastly, we are working to diversify the nursing profession to better reflect the communities it cares for, as well as strengthening readiness to practice through various nursing scholarships, mentorship/leadership support, continuing education and career resources like nursing.jnj.com.

RAHUL: Addressing the workforce shortage is one of MHA’s top areas of focus. We are working with our members on solutions to retain the employees we have, as well as to recruit our health care workforce for the future. We just hosted our Inaugural Workforce Innovation Conference, where we convened members to learn from each other’s successes and share ideas for recruitment and retention. MHA developed a workforce road map, which is an interactive assessment to help our members identify new strategies for workforce development, connect to resources that will help adopt these strategies and serve as a guide to have meaningful and structured conversations. The Summer Health Care Internship Program (SHCIP) is a program administered by the Minnesota Hospital Association on behalf of the Minnesota Department of Health. The program brings students and employers together to give students experience in a health care environment during the summer months. In 2022, the SHCIP

The impact of nurses in health care is undervalued and their expertise is underutilized.

—Lynda Benton

provided 130 plus students with over 45,000 hours of internship experience in 66 hospitals, clinics and long-term care organizations. As for the financial difficulties facing our nonprofit hospitals and health systems within the State, we must secure immediate financial support from the state legislature. Hospitals and health systems are being nimble and creative with their funds, but all options, other than cutting services or shuttering doors, have been exhausted. We are also advocating within the legislature on several workforce pipeline bills combating harmful legislation that would create additional strain on the health care workforce.

TENBIT: Burnout, turnover, workforce shortage, intense competition for recruitment and rising labor costs are today’s reality for most health care organizations, resulting in limited access for our members. UCare financially supports several provider partner organizations in different ways. For example, we provide funding for Wilder Foundation and Alluma to train mental health professionals in both urban and rural Minnesota to become independently licensed. UCare has also provided financial support to NUWAY, a substance use disorder provider with a program committed to training and supervising licensed alcohol and drug counselors from diverse backgrounds. UCare is partnering with the Minnesota Hospital Association to develop a roadmap and toolkit for health care workforce development. We have also provided year-end funding in 2022 to struggling provider systems that serve a large roster of UCare members.

JP: At the University of Minnesota School of Public Health, I direct the Center for Public Health Systems. Our charge is to support local, state and federal public health partners in the delivery of governmental public health services and activities. About half of what we do is provide technical assistance to these health departments—helping them conduct workforce needs assessments, create workforce development plans, etc. We are also the national lead for the Consortium for Workforce Research in Public Health (CWORPH), which hosts the nationally funded Public Health Workforce Research Center, a jointly funded project from the Health Resources and Services Administration and CDC. Every year, CWORPH members and partners conduct at least eight research projects on matters of national importance to the public health workforce, many identifying evidence-based solutions or interventions around issues related to recruitment, retention, succession-planning and the like. A substantial part of the work that needs to be done in this space related to cost might also be termed “public health modernization,” essentially understanding where public health systems currently are with respect to delivering a core set of public health services

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relative to where they should be. That “gap” is measurable, fillable and needs staffing and funding.

CAROLYN: We are working with other schools of nursing and clinical and community partners to identify solutions that alleviate some of these challenges. The University of Minnesota is collaborating with Minnesota State to reimagine nursing education and address the nursing workforce shortage across Minnesota. Our School of Nursing obtained federal funding to support the strengthening and expanding of our nursing workforce. For example, I lead our HRSA-funded RE Lab initiative (relab.umn.edu), which works with forensic nurses, mentors/preceptors and nurse leaders to encourage trauma stewardship, sustainable work strategies and resilience through intentional competency building—a unique peer and small group mentorship program—and a new nurse residency program established in partnership with the Regions SANE program. Another federally funded program specifically supports Native American nursing students pursuing advanced practice nursing degrees with similar peer mentorship and cultural connection support. Both programs offer financial support for advanced education and have potential to positively influence our nursing workforce pipeline and nursing retention.

How could the Minnesota Legislature help address these challenges?

LYNDA: Minnesota has taken some important steps toward addressing challenges facing the health care workforce, including the nursing profession, through funding and legislation such as the Health Professional Education Loan Forgiveness Program, which provides health professionals and those in training with assistance in exchange for providing care in an underserved area. In addition, a law passed in 2015 requires hospitals to implement workplace violence prevention programs to ensure a safer working environment. The Minnesota Department of Health is working to address mental health needs by creating a website of mental health and resiliency tools for health care workers.

Johnson & Johnson supports the continued efforts of policymakers in Minnesota and across the U.S. to address health care workforce challenges. First, we support funding for pathway and clinical training programs, loan repayment and incentives, mentorship programs, and partnerships with community colleges. We also encourage efforts to increase educational opportunities that will enhance care in underserved areas, including support for nursing faculty and preceptors, and improving access to graduate nurses. Second, we support efforts to combat workplace violence through innovative prevention programs

We simply don’t have enough physicians, nurses, and other allied health professionals to meet the needs.

—Tenbit Emiru

that address the needs of health care professionals, developing programs centered on de-escalation and staff training. Finally, we support adoption and robust funding for wellness programs and initiatives to ensure clinicians can freely seek mental health treatment and services without fear of professional repercussions or career setbacks. The Dr. Lorna Breen Heroes’ Foundation has created clear guidance for hospitals and care facilities to ensure that licensing and credentialing applications are free of intrusive mental health questions.

JP: The Minnesota Legislature plays an incredibly important role in the governmental public health system in Minnesota. The health of our residents and citizenry is supported in large and small ways by the investments of the Legislature. In the space of public health, one such investment relates to the Local Public Health Grant, which funds all manner of chronic disease prevention and promotion at the local level. Recently, the Legislature has also created a special $6 million fund for public health infrastructure and is considering more investment in this space, to ‘modernize’ public health in Minnesota. I lived and worked in the State of Maryland for the better part of a decade, and part of that time, I was working for the Maryland Department of Health. A lot of our inspiration for programs, especially around quality improvement, came from what Minnesota had done. It took me leaving Minnesota to realize just how far ahead of the curve it had been. But while Minnesota had previously been a ‘best in class’ funder of governmental public health in the 1990s, that investment stagnated and waned in the 2000s and has further declined after accounting for inflation since the Great Recession. This has been an issue for state public health funding, and especially local public health funding. Other states, including Oregon and Washington, have reinvested in recent years, and the issue is now in front of the Minnesota Legislature. We are pretty far behind at this point.

JAKUB: The University is the State’s partner in training health professionals to address the growing statewide shortage of caregivers. In addition to education, we work on developing new care models to extend the reach of providers’ skills, for example through telehealth. The Minnesota Legislature could support the University and other educational institutions by providing funding to help increase the number of professionals we can train each year. This means investment in more facilities, more instructional and support staff, and more student support. The Minnesota Legislature could fund programs to attract health care professionals to practice in rural and underserved areas across the state. This could help offset education costs, as well as ease the recruitment and retention issues that Minnesota’s small towns and rural communities are facing.

RAHUL: Expand current programs such as the Health Care Loan Forgiveness program, the Dual-Training Pipeline, and the Summer Health Care Internship Program. Establish a one-time program for students newly enrolled in an accredited allied health technician program, supporting students pursuing a career as a medical laboratory professional, respiratory therapist, radiology technician, or surgical technician. Accelerate entry into the professional

workforce by simplifying administrative processes at the health care licensing boards. Increase Medicaid reimbursement to better support patient care. The number of patients on government insurance programs continues to grow, now amounting to 61 percent of the average hospital’s payer mix. MHA urges the legislature to increase Medicaid reimbursement rates to accurately reflect the current care cost. Alleviate the care capacity crisis across the health care system. There are a significant number of patients with discharge delays from acute care hospitals. Hospitals and health systems are not reimbursed for patients’ ongoing “boarding” and cannot use those beds for new patients in need of acute care. MHA supports additional resources and incentives for hospital decompression sites.

CAROLYN: Anything the legislature does that supports the health and well-being of our entire health care workforce, including nurses, will directly and indirectly help with the challenges we have along the continuum of nursing, from where we do our nursing --- in prevention, at the bedside, in the classroom, to the stage we are in our nursing journey --- the brand new nursing assistant to the established faculty member. The governor’s initiative covering the costs of training and tuition for those interested in joining high-need professions, including nursing, is a significant resource that needs to be expanded, marketed, and sustained. Those who could benefit the most from these amazing resources are not necessarily hearing about them, or being provided supplemental support, such as transportation and child care, to access the training. I also wonder about eligibility and how we might expand these programs to be available to newcomers to Minnesota. Further, while amazing resources support those entering the nursing profession via a variety of pathways, there remains a need for financial investment in those we rely on as preceptors for our future nursing workforce. They often volunteer, or are voluntold, which adds substantial responsibilities to their workload. The moral obligation mantra of “investment in those who follow you” has expected nurses in practice to not say no to these educational needs. But this is not the way many preceptors in other disciplines are compensated/acknowledged for their efforts, it is not morally or ethically okay, it is not role-modeling balance, and it is not a sustainable model in our post-covid nursing shortage and burnout environment. We need preceptors. We need to recognize this and offer solutions that are good for them, good for their clinical systems, good for the learners, and good for academia. I welcome legislative efforts that help us find those solutions.

—Rahul Koranne

TENBIT: Supporting lower cost educational options and technical training programs in the healthcare field, particularly for those in underserved communities. Easing the burden of requirements for documentation in Electronic Health Record (EHR) for providers.

How could the health insurance industry help address workforce shortage issues?

RAHUL: Currently, over 60 percent of hospital patients are on Medicare or Medicaid. These plans reimburse hospitals well below the actual cost of care. The math just does not add up to being anything tenable for hospitals and health

Medicaid reimburses hospitals an estimated 27% below cost.

systems. On average, Medicare reimburses hospitals 20 percent below cost, leaving a $1.6 billion gap statewide. Medicaid reimburses hospitals an estimated 27 percent below cost, leaving an $868 million gap statewide. Commercial insurance contracts also have negotiated limits that constrain revenue growth, and they are moving away from this cross-subsidization. In our move toward value-based and accountable care, Minnesota has many innovative payerprovider relationships because finance and delivery need to work hand in hand because of the financial burden on hospitals.

LYNDA: As payor mixes trend toward lower reimbursement, hospitals are not getting sustainable reimbursement, which trickles down to the workforce, who must do more with less. The burden of the constriction is put on those caring for patients.

JAKUB: We need systems that allow our skilled health care professionals to focus on giving care, rather than completing paperwork. By selecting and streamlining reporting requirements and supporting care models that keep staff working within their skills, it could improve burnout and increase the available number of patient contact hours.

How can workplace dynamics be changed to address workforce shortage issues?

TENBIT: Redesigning workflows to allow professionals to work at the top of their license is a must. There are many duties that can be done by non-clinical people that currently fall under the responsibilities of the providers,. Removing non-clinical work from clinicians’ responsibility will not only address one cause of burnout, it will also lead to efficiency and job satisfaction. In addition, providing flexibility of work schedules such as starting late or early and working part-time to accommodate family responsibilities are pluses.

JAKUB: Prominent issues we see are the desire for more work flexibility and the need for care models that allow care duties to be delegated to the appropriate health professional. People want to perform to their highest capabilities and license. For example, in Minnesota we have nurses leading, delivering and coordinating care. They are treating chronic conditions, diagnosing common problems and educating patients. Similarly, Minnesota pharmacists are practicing at an advanced level to manage medication under collaborative practice agreements with physicians and nurse practitioners. Having these non-physician health care professionals practice more autonomously has shown us a way to reduce health care costs, improve outcomes and provider satisfaction, and ameliorate the growing shortage of primary care providers.

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LYNDA: Even today, the impact of nurses in health care is undervalued and their expertise is under- utilized. We need to replace transactional language like needing to “recruit and retain” members of the nursing profession, and replace it with working together to attract and strengthen an innovative, thriving and diverse workforce. To do this, we need to redesign workplace cultures and environments where nurses are truly valued for their insights and expertise. Nurses deserve a safe work environment where they can provide high-quality patient care, where their ideas are sought out, listened to, and supported, where they can work flexible schedules, where they are fairly compensated, where they can devote more time to patient needs, as opposed to non-clinical tasks or extraneous administrative burdens, where they can continue to grow and flourish in career paths of their choice and where their mental health and well-being is supported. Nurses, like any other profession, are looking for workplace cultures that recognize and value their expertise and actively seek their input on problem areas and ways to improve them. Nurses want to be visible, valued, and heard.

JP: Pay is often highlighted as the reason people leave jobs. That’s partially true: it is often the first reason considered, but it’s not the only reason. People leave jobs because the pay is not good, or they can get paid more elsewhere, but they mostly leave because they don’t like their boss, or they don’t see an internal trajectory that makes sense, or they’re not engaged. That’s true in public health just like that’s true in health care, just like that’s true in government or anywhere else. Sometimes it’s difficult to pay people more or to increase pay bands even on the most in-demand jobs. While that’s an important thing to do, to recruit and retain the best talent, no question, folks get stuck on that too much. There’s a lot that can be done to improve the workplace culture if you are an executive or mid-level manager. Research consistently shows that increasing perceptions around organizational support and employee engagement are within the sphere of control of managers and supervisors - and these really lead to increased job satisfaction and retention. Retention is about pay, but not just pay.

RAHUL: Minnesota hospitals and health systems are also extremely committed to health care professionals as they are critical care team members who care for our patients. We do so by offering nation-leading compensation. Adjusted for cost of living, Minnesota ranks 2nd in the nation for compensation for nurses and in the top 30 percent for physicians nationwide. We provide flexible scheduling- over 57 percent of nurses in Minnesota are working less than full-time. We also offer retention programs such as cash bonuses, tuition

Retention is about pay, but not just pay.

—J.P. Leider

reimbursement, and other valuable perks. Our hospitals and health systems are constantly working on violence prevention, including providing ongoing, regular training for health care staff and refining security and incident response plans. MHA works directly with members to ensure better practices for workplace safety by developing a publicly available workplace violence prevention toolkit. As of December 2021, 100 percent of our members have completed the Preventing Violence in Health Care Gap Analysis. Minnesota’s hospitals and health systems want to ensure that their care spaces are places of healing and safety.

CAROLYN: Nursing shortage cycles are exactly that --- cycles. We have had shortage and surplus cycles for decades, and probably for centuries. Notably, we haven’t had a pandemic strain in over a century, and we know the COVID-19 pandemic has definitely exacerbated our local, national, and global nursing shortage and will be a contributing factor for years. Additional societal factors that influence the nursing shortage, our work, and our workplaces particularly in critical high need areas are community and national economic challenges, racism, sexism, ageism, societal violence and unrest that bleeds into our nursing workplaces. Nurses continue to experience unacceptable rates of violence while they are doing their jobs despite awareness of the problem and risks.

How can employee recruitment and retention policies adapt to address the workforce shortage crisis?

JP: Labor market competition is real and here to stay across practices and even industries, whether you’re talking about clinician poaching or clerical positions. Up and down the labor ladder, where I see folks being successful is on the margins - not in terms of game changing policies but incremental ones. Obviously pay helps move mountains, but that’s not really what I’m talking about. Flexibility and how when and where people work seems the single most critical thing these days. It is more complicated for those operating in clinical environments, but still a conversation worth having. In the space of governmental public health, this has become fairly paramount as so many folks have moved to the expectation of remote work, especially the younger generations who have a wide variety of employment options. Everybody is fairly used to remote work now, which has set a default expectation that will be hard to break going forward. The second major thing that employers can do is consider internal promotion trajectories without being what I’ll call ‘precious’ about the expectation that staff would stay with you forever, as previous generations have. What do promotions look like as incentives and rewards if you don’t expect staff to stay more than three to five to seven years? How can you use these strategically and tactically but also fairly? Because staff leave so frequently when they do not see promotion opportunities, this is critical. In small practice environments, I imagine this could be very challenging in some respects. In government, this is similarly challenging because there are often very few supervisory and management opportunities and a lot of frontline opportunities. Similarly, succession planning has become fairly important because of the large turnover among younger or short tenure staff and those planning to retire soon. Succession planning isn’t something that we talk about or are very planful about. Folks just leave and we lose that institutional knowledge. Maybe we should do better.

TENBIT: Investing in workforce by providing training to expand skillsets, focusing on development, mentorship programs and an equitable approach

to promotions and growth opportunities all increase engagement and satisfaction in one’s career and should be a part of employee retention strategy. The ‘all hands-on deck’ approach to combating COVID-19 put all these efforts on the back burner. Given where we are today, a comprehensive employee retention strategy needs to be priority.

JAKUB: Tuition reimbursement and loan repayment support can aid both recruitment and retention, as can providing benefits that address child and elder care tailored for the health care 24/7/365 workforce. Time flexibility, including part-time vs. full-time employment, is an important factor that could draw more people into the workforce.

RAHUL: Just as hospitals and health systems adapt quickly to our environment and patients’ needs, so must our policies and tactics in the human resource space. We are seeing our members implement tactics such as social media, robust employee referral programs, and other out-of-the-box ideas focused on their missions to recruit the right individuals. We also see them find creative ways to retain their staff, such as bonuses and raises, to peer-to-peer support groups. It is an ever-changing world, and we know our members are doing all they can to retain and attract staff effectively.

CAROLYN: As a nursing faculty member, I believe it is critical that academia take seriously the salary differentials that disincentivize nurses to consider being a nurse educator or nurse researcher. This is not a nursing disciplinespecific challenge; it is well understood across disciplines that choosing academia typically translates into a lower compensation package as compared with an industry position. Historical justifications or explanations of this reality have included flexible work schedules, autonomy to pursue scholarship, job security for tenured positions, and benefits packages; these justifications have weakened over time and are not outweighing other factors, as evidenced by faculty shortages and some concerning faculty turnover trends persisting in schools of nursing. Practice-academic partnerships, joint appointments, and hybrid employment models are certainly possible mitigating solutions but require more investment, implementation, and evaluation. Furthermore, it is important these solutions do not simply add more work to already strained nurses in practice or in academia.

LYNDA: We’re passionate in our belief that the health care system must shift from “recruit and retain” to “attract and thrive.” It’s not enough to keep nurses from leaving – we need to reimagine workplaces that attract nurses to a great place to work and where they can flourish. The good news is that nurses are very communicative about what they want in their workplaces. In addition to safety and support, they are looking for career path opportunities, mentorship, and professional development. Nurses need to see the opportunities for growth and trust that their organization wants to see them advance and thrive. Additionally, innovative nurse leaders continue to develop exciting ways to embed flexibility into nurse staffing and scheduling, which has been a longstanding wish from the frontlines. From gig solutions to virtual options, to encouraging retired nurses to come back through flex scheduling, nurses in some health systems have more options than ever, and responsive health systems are figuring out how to work with these changing dynamics to improve nurse satisfaction and patient care. Health systems can also do more to build their workforce from their local communities, partnering with local elementary, junior and senior high schools, community colleges and universities to attract students into health care careers, and then offer a pathway to enhanced education and career development.

How does corporate leadership responsibility factor into the current crisis and how can it help address the issues?

JAKUB: Corporate leadership needs to be tireless in listening to caregivers and staff. Health care professionals want to be able to focus on patient care, not the bottom line, and they want to be respected as the experts in their fields. Operational decisions should include health care professionals to assess the impact both on caregivers and patients. Valuing health professionals’ input would go far to create better work culture and improve retention.

LYNDA: A nursing shortage is a health care crisis for us all, and more awareness is needed surrounding what is happening and why, to build a pathway out. A health care system without enough nurses cannot function, and the economy cannot thrive without a healthy workforce. Provider shortages have plagued many rural and urban pockets for many years, and there is important work underway to resolve these care deserts, but it is also important to acknowledge that rising nursing vacancy rates will affect every kind of community in the years to come. Regardless of industry or region, the ability of the workforce to get care is essential. We need to work together, from the C-Suite to community to Capitol Hill and beyond, to build a health care system where nurses can grow and thrive, not just survive, to provide better care for their patients as well as themselves.

CAROLYN: Leadership sets the tone of an enterprise. A direct supervisor is the primary reason why someone stays or leaves. Amazing leaders have figured this out, and everyone else really needs to. It is a more productive thought exercise to focus on the leaders and organizations who have done the best through the crisis up until now in supporting the health and well-being of their workforce. What are they doing that is contributing to their employees being committed to their work and workplace, despite difficult and tenuous work environments? What best practices could be learned from them and applied in the organizations that are most struggling with turnover, team dysfunction, and/or employee dissatisfaction or disengagement.

What are some of the barriers to health care industry job access and how might some of them be resolved?

JP: Governmental public health faces a number of the same challenges as the health care industry in the space of recruitment, plus the most challenging aspects of public sector hiring. Recruiting skilled, health-adjacent labor in this market is costly and highly competitive. If you’re looking for clinical

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providers, it seems that most everybody else is, too. If you’re looking for a data-savvy staffer, be prepared to compete with health care, non-profits, and tech. The challenge that public health faces in these regards is deepened by the fact that is fundamentally a public sector enterprise, and so suffers from antiquated hiring practices or timelines, HR information systems, and some odd hiring rules to boot; some places make applicants take civil service exams, for instance. One of the biggest things the health care industry, or governmental public health can do is to modernize hiring. Recognize that employers are competing for applicants as much or more than applicants for employers. Competitive compensation is important, but doesn’t mean a lot if it takes eight weeks to hire somebody when your competition is doing it in three weeks.

TENBIT: There are many primary care - family medicine and internal medicine- residency spots that go unfilled every year. Addressing the gap between salaries of primary care and specialty care providers and providing incentives for those who are willing to live and work in areas that have significant workforce shortage may alleviate some of the problem. The American Nurses Association reported that approximately 60,000 nursing applicants were turned away from nursing schools last year. We should explore the entry requirements and whether they make sense in today’s environment. So often, we have had requirements in place without critically examining if they are still applicable. The same could be stated for some jobs in health care. We should examine if people need to have a degree or certification prior to applying or if on-the-job training is applicable. These are the steps that will not only address the workforce shortage but also help us build a diverse workforce.

CAROLYN: There are numerous barriers to pursuing nursing or advancing in nursing from entry level roles to advanced practice roles that must be addressed to adequately and efficiently overcome our current and predicted shortages.

RAHUL: There are things that legislators can do right now to help address workforce challenges, such as supporting expansion of the loan forgiveness program. The Minnesota Nurses Assoociaion has suggested $5 million for nurses. MHA would support that but would also like to include other health care professionals who are critically important care team members. They could support additional mental health funding potentially with a grant program targeting the mental health needs of health care providers. In the short term, we are asking lawmakers to intervene before matters get even worse. We need loan forgiveness and scholarships for students in all

Nurses continue to experience unacceptable rates of violence while they are doing their jobs.

—Carolyn Porta

areas of health care, including allied health professionals. We must make a significant investment to build the health care workforce pipeline, including programs for career laddering and exposing students to health care careers at an earlier age. We must accelerate entry into the professional workforce by simplifying administrative processes at the health care licensing boards.

LYNDA: The road to a career in health care begins early. I would love to see greater reach into elementary and junior high schools to introduce careers in health care to students, ensuring that quality STEM education is accessible to all more widely and earlier – to ensure high school graduates are prepared to successfully enter and complete nursing or medical degree programs. Financial requirements can also be a significant barrier – this is where scholarships or loan repayment programs can play a role. Mentorship along the way is vital. Further, there is a bottleneck at the higher education level. A lack of nursing educators means 80,000 qualified prospective nursing students are being turned away each year. In other words, student capacity is limited exactly at the time we need more RNs. Health systems can also play a role by employing innovative staffing solutions, such as blended, team-based care models that bring together registered nurses, licensed practical nurses, certified nursing assistants, and patient care technicians to collaboratively care for patients as a team. These approaches create professional health care experiences for more prospective nurses and provide an entry point to the profession.

JAKUB: Barriers like the costs of professional licensure or the time and cost of continuing education can discourage people from joining the health care workforce. Available need-based funding could relieve these issues, and virtual learning has provided flexibility for ongoing education. Immigrants with health care credentials from their home countries face significant obstacles including complicated applications and long waits. Simply centralizing the information on requirements for all health professionals would be a productive step.

What elements of how and where care is delivered could address workforce shortage issues?

LYNDA: Nurses are absolutely transforming where care is delivered, increasing access, and improving outcomes. Virtual models – like those at Atrium Health in North Carolina and the Community Health Network in Indiana are allowing experienced nurses to virtually interact with patients and support care teams on the floor. Nurses are also advancing telehealth capabilities, providing access for patients who may otherwise be unable to receive care, such as those in shelters or rural communities. Nurses are also behind shifts to at-home care and retail health care, and in every example, the role and impact of nurses in community care grows, as does the scope of professional options and flexibility for nurses.

JAKUB: In Minnesota a big issue has been the lack of pay/reimbursement for virtual visits. We learned through the pandemic that virtual visits— whether by phone or video technology—can be an effective way to deliver care and appeal to many patients. Having reimbursement for virtual visits could improve access for all Minnesotans, particularly those in communities that lack accessible health care nearby, particularly in mental health. We also learned during the pandemic that broadband is an essential community infrastructure that not only improves access to health care, but is beneficial and often necessary for employment and education. To ensure equitable access to virtual visits, we must also advocate for rural broadband access

RAHUL: As many communities across Minnesota struggle to retain access to health care services amid growing caregiver shortages, telemedicine allows residents to receive care locally, makes care more convenient, extends the reach of otherwise scarce specialty services, and helps hold down rising health care costs for employers and individuals. Telehealth addresses some intense health care access gaps. However, as health care, we need to embrace newer professionals such as community health workers and programs such as hospital at home. These professions and innovative programs only help further address gaps in health care delivery. This is also an interesting time as we see a nexus of humans, technology, and artificial intelligence all entering the health care industry. Students and staff interested in technology and looking into this intersection will bring a plethora of new careers and ideas to deliver health care better. Despite all of that, there remains a lot of joy in caring for patients in person. As we continue to innovate with technology, we also must remember the value of in-person care in all patient care settings.

CAROLYN: Regarding the how, it is imperative that every health care professional is able to work at the top of their license and/or certification. This is critical yet continues in some health care settings to be strangely controversial. Creativity in health care delivery in the community is particularly critical, supporting individuals and families in their homes, focusing on screening and preventive efforts, and intervening early when indicated. This isn’t done by one discipline; this is a team effort and requires our creativity and collaboration. If we could achieve the goal of all of us functioning at the highest level of our license and doing so with appreciation for the critical contributions of all team members, then we would likely accomplish greater successful prevention of disease and illness, earlier intervention to prevent greater harms or sequelae including avoiding rehospitalization, and improved community-level health --- all of which would positively impact workforce needs and shortages.

JP: Telehealth is rightly on the minds of policymakers and practitioners as we think about shifting how and where care is delivered, but in public health one of the biggest shifts we are seeing right now actually occurred in health care decades ago - labor stratification in clinical delivery and support teams. Community health workers (CHWs) are becoming more common in health departments, and some are being hired to provide certain types of care that nurses used to provide in clinics at health departments. However, many are also going out into the community and connecting with the community outside of the four walls of the health departments. Admittedly, public health nurses have long done this as well. It has been a tenant of public health practice that nurses have done most every position and activity within a health department, but with CHWs more coming into the mix, nurses are starting to have the ability to focus more on their core areas, just as health care did so long ago.

What are ways your organization is leveraging technology to address workforce shortage concerns?

JP: As a research center, we tend to use technology a little bit differently than other organizations. We are all about leveraging datasets - administrative, commercial, you name it, to try and better understand the state of the workforce. There are some specialized products that scrape job posting databases like Indeed or Monster that we can perform research on, to see how many and what kind of jobs are being posted, with what kinds of qualifications for what kinds of salary. We also look at how many degrees are

being conferred by whom over what periods of time, geospatially. That helps us understand emergent areas of shortage and surplus. Finally, an important area of understanding shortage is from workers themselves. Survey data is incredibly important in this regard. There are major surveys in public health, like the Public Health Workforce Interests and Needs Survey, the ASTHO Profile, or the NACCHO Profile, that help us to understand the state of the workforce, what total counts are of the workforce are across various occupations, and what worker perceptions are. This helps build generalized knowledge around intent to leave and job satisfaction, but also specific tools and opportunities for improving recruitment and retention.

LYNDA: Administrative burden is an oftenoverlooked aspect of nursing practice that drives dissatisfaction and turnover. The rate of innovation in health care technology continues to accelerate, with increasing potential to free nurses from paperwork and other lower-skill tasks to focus on high-skill patient care. From scheduling and staffing solutions to portable patient monitors, electronic peer reviews and supply tracking systems, tech will be an important tool in the health system toolbox to best leverage nurses’ time.

need to do something about that. The thing that drives me crazy though about this report? Public health is above 40 perccent, and is not mentioned in the report or in the Star Tribune article. During a pandemic, it is not mentioned, even in the background section. Times are tough for health care organizations and public health organizations, and we definitely should not conflate the two. But when we are talking about workforce shortages, it is probably worth mentioning both and working on both together because of the labor market competition issues and because, during a pandemic and even into recovery, I’d argue that we need to focus on both. The solutions are different but the drivers are similar: everyone is facing stress and burnout, wants higher pay, and wants to be engaged more meaningfully in their work. In these ways, we are better together than apart.

Is

there anything else about the health care workforce shortage crisis that you would like to discuss?

LYNDA: It’s important to acknowledge that while COVID-19 exacerbated the current nursing shortage, the foundational pain points existed long before the pandemic. The first step to solving nursing’s challenges is seeking out, including nurses in the discussion and listening to their concerns and ideas for how to drive improvement. While nurses know what the challenges and opportunities are, nurses, integrated teams and senior leadership must come together to build truly meaningful solutions, leveraging measurable test-and-learn approaches, prioritizing and supporting the mental well-being of health workers and continuing to strengthen leadership and broaden overall skill sets, so that nurses are prepared, capable and energized to lead health care’s transformation.

JP: Last year the Star Tribune made waves when it published an article on the MDH report, “Minnesota’s Health Care Workforce: pandemicprovoked workforce exits, burnouts, and shortages” about how the rural health care workforce in our state is facing massive turnover. If you haven’t seen it, it’s an instructive read. Something like a quarter of the workforce says they are planning to retire in the next five years, or quit. We really

We are currently trying to work on the licensure process with the state licensing boards to expedite the licensing process in Minnesota. At the moment, it is a cumbersome, long, and inefficient process that delays our desperately needed talented workforce starting their positions. We are looking at legislation, and discussions with the board to create a more robust system.Finally, reminding the public that health care shortages are very real is crucial. We must work across sectors and with lawmakers to make significant investments. The question remains: “How can we inspire not just college students but younger students about the joys of a health care career?”

CAROLYN: Most of us are in health care, and health care higher education, because we believe we can be a source of good in some of the most challenging and difficult situations experienced by individuals, families, and communities. We have historically believed we can set aside our own life challenges and concerns and meet our patients, students, and colleagues where they are in that moment. But these last few years have brought us face to face with the finiteness of our capacity, individually and collectively. The shortage is simply a symptom and while it will likely persist for the near-term, my hope is that we can diagnose and address the underlying macro- and micro-conditions that contribute to our shortages.

Corporate leadership needs to be tireless in listening to caregivers and staff.

—Jakub Tolar

different care to different patients. Thus, there continue to be opportunities for physicians to better understand the characteristics of these problems in various contexts.

care, particularly informatics-based solutions leveraging the ways in which computers can perform better than people.

The Role of Informatics

must

The primary problem that these many examples orbit is one of information, where both the variables being evaluated and the goals being sought may be misaligned. In the present health care environment, where so much of utilization is driven by costs, whether to a patient or an insurer, there continues to be a significant focus on limiting or minimizing overutilization. The major risk of an approach driven only by consideration of financial incentives or moral hazard is that it fails to consider the human motivations in decision-making. Whether attributable to preferences, experience, or errors, this may be contributing to increasing underutilization in health care even when such utilization is appropriate. The immensely growing amount of available information via electronic health records (EHR) and medical literature is undigestible by human beings, even expert sources like physicians, especially within the rapid pace of on-the-ground US health care. Fortunately, modern technological solutions exist to aid the approaches to diagnosing and treating utilization mismatches in health

The field of informatics (a contraction of “information science”) includes how data is collected, stored, analyzed and translated into actions, where experts like physicians can use better information management to make better decisions. Computers differ from humans in that computers can perform massive amounts of calculations extremely quickly compared to humans (i.e., computers have greater processing capabilities), whereas humans can not only absorb and retrieve information extremely quickly, but also can draw connections between connected and seemingly-unconnected information in ways computers cannot. The aforementioned study on ACS using AI modeling to include many variables not considered by classic ACS diagnostic algorithms is a good example of when computers have an advantage over people. The same ACS study appropriately acknowledged that physician actions evaluated in that study likely included variables not represented in the EHR, such as a bruise explaining a patient’s chest pain, but nonetheless identified a divergence from expected clinical thresholds for high-risk testing. That study demonstrates a pertinent example of the so-called “fundamental theorem of informatics,” where the combination of human and computer expertise exceeds the expertise of a human alone, as well as a

Physicians and patients

become greater stakeholders in driving how health care is delivered.

computer alone. Using the ACS study as a use case of informatics interventions, several possible solutions emerge to better identify and monitor divergences in care, including recurrent evaluation of clinical ACS algorithms in terms of reviewing physician adherence to such algorithms (physician variability), instances where clinical algorithms incorrectly identify high versus low risk (algorithm sensitivity/specificity), and patient selection in test orders (patient variability). Following such identification, classic informatics interventions such as the use of standardized ordersets, based on diagnostic algorithm output, or alerts, such as triggered by “chest pain” denoted in the EHR, can be aided by more modern applications of AI. The advantage of AI applications of this knowledge is the ability to include much more information than may be considered by humans, constructing probabilistic models of risk by combining existing diagnostic algorithms with computer-generated multivariable models, and continuously monitoring EHR data to provide updated degrees of risk as additional information is generated. However, there remain system-level issues that must be addressed by all stakeholders in order for such efforts to succeed.

System Level Change

First and foremost, physicians and patients must become greater stakeholders in driving how health care is delivered. Dissatisfaction exists for both physicians and patients in terms of the amount of time allocated to the

provision of patient care. It may be an unreasonable expectation for physicians to become better informed and have better outcomes in the absence of more time to leverage the overwhelming amount of information being generated in health care settings. The other major facet of this problem is the ongoing focus on cost as the primary outcome driving system level decision-making, which often misses the individual and social determinants leading human behavior. Lastly, the fragmented nature of health care in the U.S. makes capitalizing on all of these various data sources difficult if not impossible, and is exacerbated by the value of data as a commodity, disincentivizing the sharing of data by various sources. Only when systems maximize using the expertise of all involved entities, not simply those holding the purse strings, will the optimal benefits of growing knowledge be realized. In such a world, the best outcome is neither overutilization nor underutilization, but rather providing the right care to the right people, and deriving appropriate financial thresholds or models from those outcomes rather than the current state of doing the reverse.

Zeke McKinney, MD, MHI, MPH, is the program director of the HealthPartners occupational and environmental medicine residency and an affiliate assistant professor with the University of Minnesota School of Public Health in the division of environmental health sciences.

Physicians suffer from cognitive overload as it pertains to medical decision-making.

Incorporating Behavioral Health into Home Care

BY STEPHEN TAYLOR, MA

Every crisis is also an opportunity. And the COVID-19 pandemic is no exception. While COVID has strained the health care system for years now, it also forced providers around the globe to innovate. The disruption of the pandemic, and the isolation it created for millions of Americans, exacerbated the country’s mental health crisis while necessitating new solutions for serving patients in their homes. Thus, the integration of mental health care and home care has catapulted forward.

Since the onset of the pandemic, use of mental health services from home has dramatically increased, and telehealth was permitted for additional services, including adult rehabilitative mental health services (ARMHS). This shift enabled therapists and practitioners across the state to serve thousands of patients who face numerous barriers to accessing in-person care, which was complicated further by the pandemic.

For the future of mental health care, that’s just the tip of the iceberg. The innovation slingshot sparked by COVID has generated new approaches and technologies that will integrate home care with behavioral health care to improve Minnesotans’ quality of life for years to come. But we’ll have to clear several obstacles along the way.

Challenges in Mental Health Care

Rates of mental health conditions are rising across the U.S. A 2021 CDC report showed 41% of U.S. adults experienced symptoms of anxiety and depression, up 11% from years prior. However, less than 10% of people experiencing mental health concerns receive effective treatment. A handful of challenges can prevent patients from seeking and receiving appropriate care.

The most significant barrier to mental health care is often cost. CNBC reported that an hourly therapy session can range from $65 to $250, and a person with severe depression spends an average of $10,836 annually on health care costs. Many Minnesotans are hesitant to seek mental health care for fear of how it will affect their pocketbooks.

For the 46 million Americans living in rural areas, geography is also a barrier to healthcare. Treatment centers, hospitals and clinics are more concentrated in urban areas, and in-person mental health services are even less common in rural America. More than 112 million Americans live in areas where mental health providers are scarce.

Additionally, many mental health care professionals are not covered by insurance. Just over half of psychiatrists accept commercial insurance, compared to 90% of other healthcare professionals. Consequentially, individuals seeking mental health treatment are five times more likely to seek out-of-network care, substantially raising the cost.

As a society, we’re working to overcome the stigma surrounding mental health treatment. One study published in Mental Health and Prevention denoted the different stigmas people hold about mental health treatment. The messages of “get over it” and “God is all you need,” as well as the feelings of fear, shame and weakness deter those who need mental health help from seeking it.

With America’s aging population, the mental health crisis will be exacerbated in the decades ahead. Nearly one in five older adults has one or more behavioral health concerns, which can stem from many sources, including the loss of spouses, friends, independence and a sense of purpose. And our aging population presents new challenges to home care providers too.

Challenges in Home Care

By 2038 the number of Americans aged 85 and older is expected to more than double, ballooning from 6 million to 14.6 million. And more so than ever before, older adults want to age in place at home.

But home care comes with its own unique set of hurdles. Home care patients often have complex, individualized needs. About two-thirds of older adults have two or more chronic health conditions. Thus, each patient receiving home care requires a specific, personally tailored plan. This complicates caregiver handoffs and can jeopardize continuity of care without proper communication between caregivers and providers.

Additionally, home care lacks infrastructure. Competitive bidding policies of Medicare and Medicaid services caused a 40% decline in durable medical equipment (DME) companies between 2013 and 2017. This pushed a bias toward low-cost and low-quality equipment, yet patients often need

quality equipment and technology to transition from acute care in the hospital back into their homes and communities, especially when dealing with chronic conditions.

As millions of Americans age into their golden years at home, home care and mental health care providers must open the lines of communication and collaborate to best serve the physical and behavioral needs of the individual.

Expanding Access to Mental Health Care

Accra entered the behavioral health space in February 2020 with the acquisition of Lotus Services. Based in Virginia, Minn., Lotus was providing mental health counseling on the Iron Range and was approved to provide ARMHS, helping clients manage the symptoms of mental illness, developing independent living skills and leading more fulfilling lives at home.

The pandemic arrived in the U.S. shortly thereafter, which initially stunted our expansion of mental health services but unveiled the potential of behavioral health care in the home. Later that year, we launched an ARMHS program in St. Louis County.

In March 2022, we acquired Eustice Counseling, a provider of officebased and in-home behavioral health services, also in St. Louis County. The team of mental health providers grew with the acquisition, while adding a new office in Hibbing. Few behavioral health providers exist in northern Minnesota, and just a fraction of those providers offer in-home options.

From its origins in Greater Minnesota, the ARMHS program has grown to serve the entire Twin Cities’ seven-county metro area. Counseling is now available via telehealth to clients throughout Minnesota and in-person at a handful of clinics.

For people who live in remote locations or who can no longer easily get around, these in-home mental health counseling options provide increased access, eliminating a common deterrents to seeking care. Patients can schedule appointments via videoconference or phone and even those without technological acumen can access telehealth.

Telehealth also bypasses stigma by providing discreet ways for clients to receive mental health care and avoid scrutiny from others. Making mental health services available in the home will save lives by getting more Minnesotans the help they need.

Connecting Clients with Doctors from Home

To eliminate more silos in the care system, our nurses can now help facilitate telehealth visits between their clients and the client’s doctor. Recently, a client named Peter was having difficulty communicating his health issues to his physician. His prescriptions and follow-up care were often lost or forgotten, forcing his nurse to spend valuable time tracking down orders and medicines. Peter relied on metro mobility and the burden of finding transportation often prevented him from attending onsite clinic visits, even before the COVID-19 pandemic.

Peter’s nurse helped him establish a virtual visit with a new doctor from a Twin Cities health center. She brought a computer to his home, preloaded with forms and client information, and facilitated a video call directly with the doctor.

Since the nurse knew Peter and his medical history, she could help him make the most of the visit with his physician. At the beginning of the visit, the nurse was able to share information about medications and prior health issues that Peter could not readily relay. She also helped him recall critical medical problems and ask pertinent questions while taking notes to address questions about the doctor’s directions after the call.

At the end of the telehealth visit, the doctor prescribed new medication and a follow-up plan. The home care nurse helped Peter keep track of his medications and will assist him with following the doctor’s new orders.

As we continue to develop partnerships with local physicians and clinics, we plan to expand home care services so our nurses can take vital measurements for the physician and even draw blood for follow up labs, effectively bringing the clinic and care into clients’ homes.

Building a Brighter Future

As mental health and home care providers integrate their solutions and expand the applications of telehealth, we must embrace further innovation and burgeoning strategies to re-envision the care process.

Traditionally, mental health care services have been remedial rather than preventative. Most providers typically serve people with long histories of emotional issues or even serious and persistent mental illnesses (SPMI). By Behavioral Health Care in Greater Minnesota to page 304

Less than 10% of people experiencing mental health issues receive effective treatment.

3 Behavioral Health Care in Greater Minnesota from page 29

the time mental health patients connect with a therapist, their complications are already severe, and they have little to no foundational skills for managing their mental health conditions.

A developmental approach to mental health care will equip future generations with more of the skills necessary to deal with behavioral health issues. This special counseling provides youth with coping skills to manage their symptoms and strategies to get help early on in life. Programs that prevent children from developing SPMIs can help transform our mental health care system from a reactive one into a proactive one, which would profoundly impact society at large.

Foundational change to address the mental health crisis will have impacts on many aspects of life, such as housing. Mental health care services, including the ARMHS program, often connect clients with resources to find and secure available housing. But there is no follow-up once the patients are settled in their new housing.

Providers need to pursue housing stabilization services to help older adults and people with disabilities, including mental illness and substance use disorder, stay in their homes. This assistance with new housing costs, such as rent, security deposits, utility payments and other fees, is designed for the short term. It provides patients with time to develop household management and independent living skills, setting them on a path to a stable life at home.

The traditional practices around mental health prescriptions need an overhaul too. In the past, mental health medication was extremely harsh and

only prescribed for severe cases. Today, psychiatric medications are toned down with fewer side effects and risks. And these medications are often needed to complement other forms of mental health care, like talk therapy.

However, home care providers typically cannot prescribe psychiatric medications. Instead, they must refer the client outside of the agency for additional services and assessments, and then eventually prescriptions. This is another barrier we must eliminate to realize an integrated approach to mental health care and home care.

Summary

Various physical, demographic and socio-economic factors continue to form walls between Minnesotans and mental health care services. But providers and innovators have been chipping away at those walls for years, and their work has been hurled forward by the pandemic, bringing us closer to knocking down some of those walls altogether.

Still, the demand for accessible, affordable care will increase as the population ages, especially in rural communities. Reaching Minnesotans across the state with the quality care they need to thrive will necessitate embracing new approaches, applying novel technologies, and, most importantly, integrating solutions bridging home care with mental health care.

Located in the central Minnesota community of Breezy Point, home to beautiful Pelican Lake, many fine golf courses and pristine wooded landscapes, Cuyuna Regional Medical Center is seeking an experienced Family Medicine physician for its growing multi-specialty clinic.

OUR

FAMILY MEDICINE OPPORTUNITY:

• MD or DO (with 3 to 5 years of experience)

• Board Certified/Eligible in Family Medicine, Internal Medicine or IM/Peds

• Full-time position equaling 36 patient contact hours per week

• 4 Day Work Week

• Medical Directorship available

• No call

• Practice supported by over 17 FM colleagues and APC’s and over 50 multi-specialty physicians

• Subspecialties in – IM, OB/GYN, Ortho, Spine, Urology, Interventional Pain, Gen Surg., and many more

• Competitive comp package, generous sign-on bonus, relocation and full benefits

A physician-led organization, CRMC has grown by more than 50 percent in the past five years and is proudly offering some of the most advanced procedures that are not done else where in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by the ever-increasing range of services offered.

| Cell: (218) 546-3023 www.cuyunamed.org

Stephen Taylor, MA, is a licensed psychologist. He is the director and clinical supervisor of the Accra Mental Health and ARMHS Program.

Patients with regenerative medicine questions?

Regenerative medicine focuses on the body’s natural ability to repair, replace, and regenerate damaged or aging tissues. At MINNESOTA REGENERATIVE MEDICINE (MRM), a specialty clinic of HOGUE CLINICS, autologous bio-cellular agents such as platelet-rich plasma (PRP), fat aspirate concentrate (FAC), and bone marrow aspirate concentrate (BMAC) are used to treat degenerative conditions. To ensure proper placement, ultrasound or fluoroscopy guidance is used when clinically indicated during regenerative medicine treatments.

Regenerative medicine treatment categories at MRM include:

• Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine)

• Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING

• Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT

3A Missed Opportunity from page 15

accountable for their role in creating barriers between patients and the medicines they need.

• Requiring all health insurance plans to cover certain medications used to treat chronic conditions from day one of the plan year.

• R equiring health insurance companies to count patient assistance, such as cost sharing assistance, toward the patient’s deductibles.

• Requiring health insurance companies to cover medicines from day one by offering at least some health plan options that exclude medicines from deductibles and only charge set copay amounts.

• Capping the amount of cost sharing, such as deductibles and coinsurance, that patients pay out-of-pocket for their medicines.

Initiative Failings

The Board fails to address the challenges created by massive consolidation and vertical integration in the health insurance and PBM industry. Currently, only three PBMs control 80% of the prescription drug market, and they own or are owned by health insurance companies, giving these entities unchecked ability to siphon huge profits out of the health care system.

Scott LaGranga, senior vice president of state advocacy for PhRMA recently noted, “ Patients need help affording their medicines at the pharmacy counter, which is why we have consistently supported a number of policies that will directly address this need. Unfortunately, there’s no evidence the prescription board will solve these problems. Instead, Minnesota should

follow the lead of other states that have found ways to save patients money.”

Minnesotan’s need help with their out-of-pocket costs for prescription drugs and there are many policies that other states have passed or are considering to help ensure rebates reach patients at the pharmacy counter, and that patient assistance programs count towards patient deductibles. Policymakers looking for ways to lower costs for Minnesotan’s should be focusing on policies that help patients better afford their medicines at the pharmacy counter.

One way to reign in PBMs and lower costs for patients is by requiring PBMs to make sure the out-of-pocket costs patients pay is based on the lower price the PBM pays. Recently, West Virginia became the first state to pass legislation of this kind to help patients save money at the pharmacy counter. Minnesota’s legislature could pass similar legislation to make a big difference for patients in the very near future.

Policies such as making cost-sharing assistance count towards a patient’s out-of-pocket spending requirements, making monthly costs more predictable and requiring that coverage for some medicines starts from day one would also lower costs for patients without sacrificing access to medicines.

PhRMA and its member companies share the concern that many patients face challenges affording their medicines at the pharmacy. We want to work with the state’s legislature on solutions. Minnesota’s Prescription Drug Affordability Board won’t achieve our shared goal of improving affordability and protecting Minnesotans’ access to the medicines they need.

Reid Porter is the senior director, state relations, public affairs for the Pharmaceutical Research and Manufacturers of America (PhRMA).

Primary Care

We are an independent physician-owned multi-specialty practice with 180 providers located across 13 sites, and-state-of-the-art facilities. Recently voted one of the 14 coolest urban spaces in America, Mankato is a short drive from the metro with abundant nearby recreation opportunities, safe, charming and affordable neighborhoods, outstanding schools and a thriving arts community.

We offer highly competitive compensation, generous benefits and a career choice you will never regret. Leave the burnout and stress behind. We can design a work schedule around your needs and let you concentrate on what you do best – by taking care of patients. If you would lie to learn more please contact:

Dennis Davito Director of Provider Services

1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Unique Practice Opportunity

Join an established independent internal medicine practice

Be your own boss in a collaborative business model with a healthcare philosophy that puts patients first and allows physicians to have complete control of their practice.

The specialties we are looking for are:

Internal Medicine, Family Practice, Preventive Medicine, Cardiology, Dermatology, Allergist, or any other office-based specialty.

Preferred Credentials are MD, DO, PA, and NP.

• Beautiful newly remodeled space in a convenient location

• Competitive Wages and a great Professional Support Staff Contact

Practice Opportunities throughout Greater Minnesota:

Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System

Metro

• Chief of Cardiology

• Cardiologist

• Internal Medicine/Family Practice

• Gastroenterologist

• Psychiatrist

• Tele-ICU (Las Vegas, NV)

•

Current opportunities include: Internal Medicine/Family Practice

Current opportunities include: Internal Medicine/Family Practice

advancing patient care, research and community health. The Foundation provides grants to those in the community that support the community health needs assessment’s priority areas of food access, mental and social well-being, substance use and housing.

Through funds raised annually, St. Luke’s Foundation has also provided support for many important projects at St. Luke’s. That includes a new level 2 nursery, a new emergency department, a new physical therapy space for patient rehabilitation and new cardiac catheterization labs.

St. Luke’s Foundation supports cancer patients with gas cards, grocery cards, lodging and more. They help fund palliative, personal, emotional and spiritual care for patients in hospice. They do so much and show such incredible support for those in need.

What are some of the most surprising things that people might not know about St. Luke’s?

It often surprises people when they learn St. Luke’s was the first hospital in the community,

founded in 1881. We’re proud of our heritage and our tradition of serving our patients. Since we began as a hospital, some are surprised at the depth and breadth of our services. We offer extensive primary and specialty care, at a very high quality.

People may also be surprised to learn about St. Luke’s sustainability efforts. We value being good stewards of our resources and our community. It’s important both to the health of our organization and communities we serve. Therefore, we’ve strived to have a more environmentally friendly impact. We group these sustainability initiatives into three categories, environmental, social and economic. Examples of environmental sustainability are: composting food waste and using compostable products in our cafeteria, redistributing surplus food to those in need, sourcing local food and ingredients when possible and paperless invoicing. Examples of social sustainability include: heating water for laundry with reclaimed steam, collaborations with the Duluth Transit Authority to improve access to public transportation and consulting with Minnesota Power regarding solar energy. Economic sustainability initiatives include: environmentally preferred purchasing

practices, collecting single use devices to be reprocessed for future use or for materials to be recycled and redistributing equipment and supplies to countries in need.

Moving forward, what are the short- and long-term plans for the future of St. Luke’s?

St. Luke’s is excited about the future and the role we play in our region. We will continue to provide the highest quality care available, utilizing the latest technology, delivered in a highly personal way. We are redeveloping our Duluth campus to promote efficiency and comfort, as well as improve access for our patients and our staff. We are working with our Wilderness partners throughout the region to identify ways that we can further support our patients. We look forward to further investing through our role in medical, pharmacy, nursing and allied health education. Long term, St. Luke’s will continue to live our longstanding mission: the patient is above all else.

Nicholas Van Deelen, MD, Co-President/CEO and Chief Medical Officer, St. Luke’s.

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.

available in the following specialties: