INTERVIEW

Preserving independent practice

Owen O’Neill, MD Infinite Health Collaborative

Please tell us about Infinite Health Collaborative (i-Health).

We like to say that i-Health is a modern approach to a timeless idea. We’re an independent practice of like-minded physicians representing several unique specialties, including cardiology, colon and rectal conditions, family medicine, orthopedics, and women’s health. All of us believe that independence in health care enables physicians to focus on each patient’s individual goals without limitations, and that’s the inspiration behind i-Health. By empowering patient choice—arming patients with the tools to make their own educated health care decisions—we are earning their trust and keeping health care personal. In a nutshell, we deliver valuebased care, enable physician autonomy, and preserve patient choice.

Please tell us about Revo Health and the services it provides for i-Health physician groups.

Revo Health, a management services organization, helps practices develop value-based care services and provides support across several departments often referred to as “back of house.” These include revenue cycle, finance and accounting, human resources, information technology, quality, marketing, and more. Sharing these resources creates efficiencies and cost savings, fosters collaboration, and consolidates our expertise. Revo takes care of the business side, so physicians can focus on taking care of patients.

What kind of framework for growth and sustainability of independent physician practices does i-Health provide?

There’s power in numbers. By banding together, we preserve our independence and strengthen our voice in the industry. These days, many small practices are getting squeezed out or bought up by large systems, and transition to becoming employed by the system. i-Health is physician-owned and led, however, so every new physician to join becomes a fellow partner and retains ownership stake in the business. Another major advantage for our operating divisions is collaborative learning. Innovative operational initiatives such as developing prospective care bundles and collecting outcomes data takes time to develop. We’ve all experienced different We believe patient-physician “...” relationships are the heartbeat of health care. “...”

stages of growing pains, so we help each other avoid re-inventing the wheel.

How can independent physicians be the drivers of the industry’s improvement?

We believe patient-physician relationships are the heartbeat of health care, and we intend to keep it that way. Independent physicians have autonomy to guide patients without the limitations of larger systems, and ultimately enable patients to make their own educated health care decisions. Getting back to basics and putting the power back in patient’s hands is how we believe the industry moves forward.

What are some examples of how independent physician practice contributes to innovation in the health care industry?

Our independence enables us to mobilize and test new ideas quickly without the red tape of many larger systems. In the past couple of months, for example, OB-GYN specialists from our women’s health operating division launched curbside obstetric care in response to COVID-19, performing routine checkup tests that cannot be done virtually: blood pressure, baby’s heartbeat, position of the baby, and vaccines. Similarly, Twin Cities Orthopedics (TCO) launched virtual care in under seven days, going from zero telemedicine infrastructure to providing over 1,000 virtual care visits per week. The best part is we did so without sacrificing the patient experience. Niney-nine percent of TCO’s virtual care patients say they would recommend this service to family and friends.

What can you tell recent medical school graduates about the opportunities and benefits presented by the independent practice of medicine?

Our model, which centers around the patientphysician relationship, is the original health care model. Many physicians are attracted to independent practice because it reminds them why they got into medicine in the first place. i-Health provides immediate and long-term financial stability, and independence puts you in control of your own destiny. By building a strong reputation, and delivering exceptional care day in and day out, the sky’s the limit to your potential.

What are some of the ways i-Health members encourage patients to be active participants in their health care decisions?

It sounds so simple to do this, but it’s not our job to tell patients what to do. We encourage patients to be in control of their own health, and it’s our job to guide patients to make the best decisions for themselves. We accomplish this by clearly explaining diagnoses, walking them through options, listening to their concerns, and answering their questions. We also use anonymous clinical outcomes data from over one million survey submissions to set realistic expectations. For example, we can tell patients considering a hip replacement that six months after surgery, 97.93% of total hip arthroplasty patients reported little to no pain lying in bed and turning over.

What benefits can i-Health provide to self-insured employers?

It’s amazing how many employers are simply unaware of the freedoms they have when it comes

to customizing their benefits plans. For example, they can partner with us tomorrow to give their employees more surgical care options and better outcomes via our TCO EXCEL Surgery & Recovery program, without changing anything else about their existing plan. It’s a simple add-on model, and the best part is it actually reduces costs across the board. In fact, some local employers have already identified i-Health as a preferred tier inside of their health plans, effectively encouraging their employees/patients to consider value-based care options.

New health care legislation is informed by considerable input from health plans, hospitals, and the pharmaceutical industry, but very little from physicians. How can i-Health help address this inequity?

This is a big reason why we were inspired to band together in the first place: to grow our shared voice in the industry. A voice that is focused on patient care and the delivery of innovation in the market. We deliver value-based care, which means we have actual data to prove how we can improve outcomes and patient satisfaction, while also reducing costs. We’re putting the data to good use in these conversations.

What can you tell independent physicians who may want to become part of i-Health?

We live and succeed on our own reputation, and often take the road less traveled, which isn’t for everyone. We were founded upon the promise that no matter what, the care of our patients would always come first. It’s in our DNA, and it’s what drives us every single day. The freedom we are granted as an independent practice allows us to be innovative, create meaningful solutions to complex problems, and deliver on that fundamental promise. And, ultimately, it’s how we provide value. If your core motivation as a health care provider aligns with our core principles, and you share our vision for the future of value-based care, then we would love to get to know you better.

The recent government response to cancel “elective” surgeries brings up several important issues. What are your thoughts on this?

On the orthopedics side in particular, we have seen many patients suffering as a result of elective surgery restrictions. We have observed increased opioid drug use and suicide attempts from patients dealing with severe pain and immobility, in addition to prolonged pain leading to poor long-term outcomes. Prolonged waiting causes stress physically, mentally, emotionally, and financially. Treatment for many of these patients was initially categorized as elective or non-essential when the COVID-19 pandemic began.

The good news is that we have developed comprehensive safety protocols that have enabled us to perform more surgeries in a safe, COVID-free environment within ambulatory surgery centers. We are using a clinical risk stratification tool to determine which surgeries can be performed first, we’re testing patients and employees for the virus, we’re screening at entrances, and much more. Our patients and their families have high expectations for their care, and we want our safety standards to exceed those expectations.

Owen O’Neill, MD, is a board-certified orthopedic surgeon with fellowship training and subspecialty certification in sports medicine. He is a board member for both Infinite Health Collaborative and Twin Cities Orthopedics.

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3 When elective procedures aren’t elective from cover the overall health care system. Safe outpatient care is not a “nice to have” option, but rather a significant part in providing continued services and

A non-essential surgery or procedure is a surgery or procedure that can be allowing hospitals and the rest of our health care system to focus on other delayed without undue risk to the current or future health of a patient. Examples emerging priorities. of criteria to consider in making this determination include: a. Threat to the patient’s life if surgery or procedure is not performed. Defining elective Surgery is defined under Minnesota Statute 144.7063, subdivision 5z as follows: “Surgery b. Threat of permanent dysfunction of an means the treatment of disease, injury, or deformity c. extremity or organ system, including teeth and jaws. Risk of metastasis or progression of staging. We owe it to patients to establish clinically based definitions on what is urgent/ by manual or operative methods. Surgery includes endoscopies and other invasive procedures.” While there are mentions of “elective outpatient

While the guidance was helpful for triaging in emergent versus elective. surgery” under Minnesota statute, that term or the short term, several significant matters were not related terms are not defined. That undoubtedly considered, and delays in necessary care developed presented a problem when the Governor and public as the duration of the executive order continued. health officials were considering the executive order. In fact, when Executive Order 20-09 was

Physicians clearly understood the need for issued, the supporting documents made it clear an immediate shutdown to evaluate the crisis and be in “survival” mode, that Minnesota does not have its own definition of “elective surgery or making assessments and recommendations for reducing the spread of the procedure.” The Minnesota Department of Health attempted to clarify the virus, response capacity, personal protective equipment (PPE) supply levels, issue with its “FAQ: Executive Order Delaying Elective Medical Procedures” etc. But there needed to be a next step after that. Deferring care for one (https://tinyurl.com/mp-mdh-faq). That document explained the reasoning to two weeks for some patients was acceptable but was ultimately harmful behind the order and provided direction from professional and academic when those same patients had to be deferred for four weeks or more. organizations, but did not reflect a Minnesota perspective. It is unfortunate Additionally, Minnesota failed to seize upon the opportunity to recognize that conversations about what constitutes “elective” have never taken place, that free-standing ambulatory surgery centers (ASCs) play a critical role in but now we have that opportunity.

Additionally, it would be nearly impossible to determine when and where the term “elective” first took hold and became a catch-all for any procedure or surgery that wasn’t performed as the result of an emergency, but it is terminology that needs a fresh look. The term may have become commonplace for the purposes of reimbursements, insurance, and coverage. We can’t turn back the clock, but we owe it to patients to establish clinically based definitions on what is urgent/emergent versus elective with medical necessity versus purely elective for screening or cosmetic reasons. In Minnesota, we can do better. Now is the time to focus on what “elective” means for the higher purpose of patient health and providing care.

Not all elective procedures are the same

By general definition, “elective” means chosen by the patient rather than urgently necessary; one that it is open for choice, is optional, voluntary, discretionary, and not required. However, while the patient might have some flexibility or control in scheduling that procedure, the actual procedure is often not discretionary or a matter of choice in terms of their health.

Additionally, not all procedures are the same in their immediacy, and deferment can mean different things for different patients. Without a proper understanding of how different procedures affect a patient’s current or future health, it isn’t possible to make well-informed decisions that are included in a broad executive order.

Three scenarios demonstrating the various interpretations of “elective” with regard to medical urgency:

1. Patient A has a positive stool hemoccult as a screening test for colorectal cancer. Patient B has occasional gross blood in his stool

and a 5-pound weight loss. Both are not emergencies, and delays or more. While there is an obligation to public health, there is in care can have long-term consequences, but Patient B should be also a need to focus on the needs of patients. Identifying steps assessed with colonoscopy as soon as possible. would allow for some elective procedures to resume following an 2. Patient A can no longer play tennis and needs a right knee immediate shutdown. replacement. She has gained 10 pounds while not being able to Conclusion exercise. Patient B has significant right knee arthritis and can no longer walk up a flight of stairs. She lives in a two-story home. Again, neither case is an emergency, both need knee replacements, and Patient B should be minimally delayed from surgery. Free-standing surgery centers COVID-19 has presented Minnesota with an opportunity to do better for patient care, especially in times of crisis. Now is the time to have discussions that will lead to better solutions for the future. 3. Patient A cracks a crown on his second molar which needs dental repair. Patient B do not pose a threat to inpatient care or ICU beds. Scott R. Ketover, MD, AGAF, FASGE, is a bites into an apple and cracks off a crown practicing gastroenterologist and President and CEO on his front tooth. He works as a television of MNGI Digestive Health (previously Minnesota anchorman. Both can still eat, neither has Gastroenterology), one of the largest independent a medical emergency, yet there are different gastroenterology practices in the country. He degrees of urgency for their respective completed his medical degree, residency, and dental care. GI Fellowship at the University of Minnesota. Dr. Ketover also serves as the A better solution for Minnesota Chairman of the 3,000-physician member Allina Integrated Medical Network, While I am not advocating for every term to be defined in Minnesota a Minnesota Accountable Care Organization (ACO). He is a Fellow of the statute, it has become increasingly clear that before there is another AGA and the ASGE. surge or the next health pandemic strikes, there should be meaningful discussions between those who govern and those who provide direct patient care.

Ultimately, the goal would be a mutually accepted and agreed-upon process for leaders and physicians to follow when executive orders are issued in the future.

Here is my prescription for those leadership discussions and a roadmap for the future:

• Work to acknowledge the value of ASCs and the critical role they can play in an overwhelmed health care system. Free-standing surgery centers do not pose a threat to inpatient care or ICU beds and provide an important method to deliver high-quality care that does not require an overnight stay in a hospital. Safe outpatient care is not a “nice to have” option, but rather a significant part of the overall solution.

• W ork to establish clinically based and mutually accepted definitions of “elective,” acknowledging there are differences between what is urgent or emergent versus elective with medical necessity versus purely elective for screening or cosmetic reasons.

Come to an understanding that “elective” refers to timing and scheduling of a procedure, but it does not mean the procedure isn’t needed. There could also be conversation about PPE use for various procedures, so hospital supplies do not feel unnecessarily threatened in time of crisis.

• Work to identify interim steps between “survival” shutdown mode and “all clear” that can be activated during future executive orders. Interim steps would recognize that there are dangers to postponing all procedures within a broad category.

Deferring care for one to two weeks might be acceptable for some patients, but a continued postponement can ultimately be harmful when those same patients are deferred for four weeks

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3 Elective Surgery from cover

The lessons learned to date could help to ensure that elected officials understand and consider the impacts on patient care, and craft sound decisions that serve both physicians and the public during the current pandemic and in the future.

One practice group’s experience

Mankato Surgery Center is one of many providers across the state that struggled to define “essential.” With ownership split evenly between Mankato Clinic, a multispecialty facility, and the Orthopaedic and Fracture Clinic of Mankato, Mankato Surgery Center provides a safe, low-risk alternative to hospital surgical suites, where patients might have had broader exposure to the coronavirus. Ambulatory Surgery Centers (ASCs) such as ours offer outpatient, same-day procedures that allow hospitals to free up bed space and focus on their potential COVID influx.

The Governor’s earlier orders had included three criteria for essential procedures: “a. Threat to the patient’s life if surgery or procedure is not performed; b. Threat of permanent dysfunction of an extremity or organ system, including teeth and jaws; and c. Risk of metastasis or progression of staging.”

Our Board of Directors and surgeons had questions about what to do with patients that did not fall into category a, b, or c. For example, patients whose pain tolerance did not meet the criteria outlined, or those who needed to be mobile and working with a torn meniscus, did not qualify under this definition. Was this type of patient treatment “essential”?

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Under EO 20-03 and the state’s Peace Time Emergency, we could have been fined and charged with a misdemeanor if the procedures we continued to perform were not “essential,” even though we did not know the definition of that term. The order was more robust than we had seen in other states with similar orders. We struggled from March 23 to April 9 to find a definition, all the time striving to balance patient’s surgical needs, business changes, and the daily demands under a changing health care environment.

As we began looking for detailed information and guidance, our first thought was what needed to be done with regard to documentation in the event of a state inspection and risk perspective based on a surgeon’s decision, and how we would “defend” cases we had scheduled as essential. The surgery center board ultimately decided to accept our surgeons’ medical judgement in determining which cases fell into the Governor’s new order. “Essential only” had been described as loss of limb, organ failure, or permanent nerve damage, but our center’s orthopaedic owners decided to have a group of physicians review each surgery case to determine if it was necessary. That process assisted in the defending of “essential” cases to be allowed during the Governor’s order.

Speaking as the center’s administrator, I believe that this approach represented good risk coverage in the event we are audited in the future by the state during a retrospective COVID-19 review. The multispecialty clinic and the orthopaedic clinic also reviewed essential cases with some of the specialty associations, including the Association of Ophthalmology. On March 18, they had already published what they considered to be “urgent and non-urgent” cases. We looked for each specialty to do the same until we started to see information in the surgery centers on what they were doing, to allow for a comparison with industry standards.

Collaborating with outside resources

After learning that some ASCs had closed sites and others had slowed cases, as we did, we decided to collaborate with the Minnesota Ambulatory Surgery Center Association (MNASCA). By collaborating with this association, we believed we could reach Gov. Walz to explain our positions and concerns about defining “essential cases only,” and could send a united ASC message.

The initial MNASCA contact was a letter to Gov. Walz’s office, followed by an in-person visit with the Governor’s staff, in which we explained our PPE and ventilator usage and offered to assist potentially strained hospital systems. We also explained the differences between ASCs and hospitals, which include separate PPE and ventilator needs. Mankato Surgery Center does not have the same supplies required in the hospital or among COVID19 front-line workers. We have special packs for specialties, with all our supplies in a surgical pack, along with a few surgical gowns outside of the pre-made surgical packs. We have our own glove supply and we use surgical masks on hand, and did not intend to ask for additional supplies.

Tom Poul, MNASCA’s legal legislative counsel, and MNASCA President Tom Stevens initiated weekly calls with their members, and invited the Minnesota Department of Health (MDH) team to collectively hear from association members who had been affected by the “shut down” order. A number of ASC administrators have been part of these ongoing calls to help the ASC members navigate through the perils of the pandemic, and are looking to both influence and to assist in changes to impact any future MDH or Governor’s directives. Following these contacts—which also included metro-area surgery centers—the Governor’s office gave MNASCA the option to follow less restrictive MDH guidelines for surgery until Gov. Walz could make an announcement to resume elective cases.

In the literature centers to see what space was available for use if ventilator patient overflow On April 9, the Journal of the American College of Surgeons published an options made sense, and to use the center if space was needed. article outlining a stratification system intended to help surgeons determine We are not over the pandemic yet, but lessons learned to date could help when to proceed with medically necessary operations. This Medically Necessary us assess what went well and what needs more work in the future. During Time-Sensitive Prioritization (MeNTS) tool was developed to define necessary this pandemic, some providers sought approval to sterilize and reuse N95 surgeries and to reduce the burden on the health system. masks. The FDA moved quickly on approving some In addition, on April 17, four medical associations sterilizing units to re-sterilize N95 masks and to help issued a “Joint Statement: Roadmap for Resuming facilities slow the rapid depletion of PPE supplies. Elective Surgery after COVID-19 Pandemic.” While rapidly approving equipment or products may

Both of these resources helped validate the produce unexpected consequences in the future, this choices we had made previously to remain open as a relatively low-risk Covid-19 facility option for We could have been fined and charged with a misdemeanor. is one example of public officials responding quickly. The policies unfolding now during the patients. It is an ongoing balancing act for our board pandemic—both in government and within health to feel confident we are making choices for the best care organizations—have and will most certainly interest of patients and employees. Outside resources affect future policy in the face of continuous changes. to “hang our hat on” is always to preferable to paving Policymaking is a moving target. Mankato Surgery our own way. Center will continue to follow guidelines from the Feedback, concerns, and responses CDC and other specialty resources to adapt to changing circumstances. Some of our Board members and surgeons believed that the restrictive order Closing thoughts could harm patients who did not fit the Governor’s profile of “loss of limb, As we move forward, we must ensure that elected officials understand organ or cause permanent nerve damage.” In addition, they were concerned the impact of their decisions on physicians and patients, ensure physician about patients in constant pain, as well as essential workers who are in need autonomy, and recognize the unique needs of patients across the state. of a shoulder repair or knee surgery. Those types of patients just fell out of the executive order into a holding pattern. Joleen Harrison, RN, BSN, PHN, CASC, is administrative director at

Jesse Botker, MD, FAAOS, who practices at The Orthopaedic and Mankato Surgery Center. Fracture Clinic of Mankato, said this about the order’s directives:

“I would say that the ban is going to have down the road effects due to delays in care such as higher opioid use which may lead to dependence, increased disease progression that could lead to decreased function and loss of work. Surgery centers are ideal spots to allow patients to receive much needed procedures in an environment that can reduce COVID transmission risk.”

Throughout this period, physicians also struggled to determine how to serve patients who relied on opioids to manage chronic pain that fell outside of the order’s description. The solution should not have been to prescribe additional pain medications to carry them over until an unknown date. We felt as a surgical center that we could put new practices in place with what we knew at the time, to create a relatively low COVID-19 symptomatic facility to remain open as part of the solution.

In the wake of the EO to prioritize surgical cases, we have put in place new processes, policies, and procedures based on guidance from the CDC and MDH. These include mask requirements for patients and staff, COVID swab testing or no COVID testing for patients and staff, airborne precautions with N95 masks if needed, and recommendations for extended PPE use. The goal is to increase patient service under a systematic approach. We are prioritizing patients that have been waiting or taken off the surgery schedule for more than a month. The surgeons decide which patients to put in the new surgical line-up. We inform all patients on these COVID-19 issues, and have explored changes in telemedicine services, developing new policy and payment services.

Looking ahead

Legislators and policymakers should understand what ambulatory surgery centers are and how they can play a role in any future pandemic. Some ASCs in the metro area are affiliated with a hospital system and had reviewed their

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