INTERVIEW

Improving the Experience of Health Care

Hilary Marden-Resnik, President and CEO

During your time as interim president and CEO, you led UCare through a period of considerable growth. What can you tell us about this?

I assumed the interim role when UCare was in a strong position as a leading Medicaid, Medicare and Individual and Family Health Plan provider. As a result of our successful 2020 RFP response to serve the Prepaid Medical Assistance Program and MinnesotaCare members in the sevencounty metro, we saw enrollment growth in these programs in 2021. We have a 46% market share of Individual and Family Plans sold through MNsure because of our well-priced and welldesigned plans. We continue to attract retirees to our high-value Medicare Advantage plans.

We also grew our workforce to keep pace with the increasing complexity of our business, to improve member and provider experience and to launch new capabilities in, for example, our equity and inclusion, community response and technology transformation work.

What were some of the UCare responses and lessons learned during this ongoing pandemic?

We learned how agile we can be to respond to a public health emergency. We pivoted quickly to keep employees safe by immediately transitioning them to work at home in March 2020, without disrupting our members and providers. As part of our mission to remove barriers to care, we developed a community response team to support our members’ ability to get needed care during the pandemic. They focused on contacting high-risk members first.

As members’ use of telehealth services increased, we enhanced our support for those services. Our members also had access to our mental health hotline. We provided older, isolated members with iPads to help them stay connected. And we distributed more than 95,000 KN95 masks to the community. Before vaccines were available, we temporarily removed member copays for COVID testing, treatment and hospitalization, and we discounted premiums. Once vaccines were available, we helped members get their vaccines, hosting 85 vaccine clinics and arranging transportation and interpretation services.

Please discuss the good and the bad of Medicare Advantage plans.

As a continuous Medicare Advantage plan provider since 1998, we believe firmly that such plans are among the best options for Medicare enrollees because they combine original Medicare with extras such as dental, prescriptions, OTC, vision, hearing, fitness and healthy food savings. These plans also offer care coordination for members who can benefit from it. And Medicare Advantage plans can be more affordable than supplement (Medigap) plans.

Medicare Advantage plan enrollment has been growing nationally and locally because savvy seniors have picked up on the advantages of these all-in-one plans. Their popularity creates a crowded marketplace for consumers. Over the last few years, several new national, for-profit plan competitors entered our market, and that competition drives us to differentiate the value of being a regional, nonprofit health plan with strong community connections. This year UCare earned a 5-Star Medicare rating for quality, the highest possible rating. As a long-term Medicare Advantage plan with a loyal membership of over 116,000 members, we continue to see growth opportunity in this business line.

UCare offers the services of what you call Medicare de-complicators. What are some of the most common things these people do?

This question cuts to the core of our mission to make health care more accessible for everyone. Our Medicare de-complicators are spread throughout UCare—from our sales and customer service representatives on the frontlines to our marketers, member experience, clinical and operational staff behind the scenes. The de-complicators simplify the complexities of health care and health coverage for our members and prospective members. Our sales team offers 1:1 consultation or community meetings to help shoppers find the plan that best fits their needs.

We have a Say it Simple initiative that requires all communications to be written at an 8th grade reading level or lower. We define and explain insurance terms such as coinsurance, deductibles, out of pocket maximum, etc., in simple and relatable ways. We use infographics to illustrate concepts. We limit the number of words in each sentence. Health care can be so overwhelming, and we want to take the stress out of it by de-complicating it for our members and prospective members.

What strategies do you have for diversity equity and inclusion issues?

These strategies are inspired by our goal of being an anti-racist organization. We focus on four dimensions of diversity, equity and inclusion— clinical, community, county and culture. We engage in clinical interventions to improve access, care and outcomes—especially in communities

We want physicians to “...” know how deeply we value their partnership in serving our members with quality care. “...”

with the greatest health care disparities. We provide community support to address social drivers of health, such as food insecurity and education gaps. We also support countless county public health initiatives. Internally, we’re focused on building on our already very strong and mission-driven culture through enhanced focus on diversity, equity and inclusion.

Last year we hired our first VP of Equity and Inclusion to lead a new Department of Equity and Inclusion, and our board of directors has evolved its committee structure to ensure the board carries out its work with an even greater focus on equity. We’re also supporting the Minnesota Medical Association’s development of anti-racist cultures among Minnesota health care organizations, as well as the Minnesota Hospital Association (MHA) Workforce Development Roadmap initiative, addressing the workforce crisis and opportunities to diversify the workforce.

What can you tell us about your plans to offer services in Iowa?

We submitted an RFP response in May to serve members of Iowa’s Medicaid programs and expect to learn the results later this summer. Our plans to offer services in Iowa support our strategic growth goals. Iowa presents our first major expansion opportunity outside of Minnesota and Western Wisconsin. We are excited at the prospect of bringing our community-based, nonprofit approach to Iowa. Our strong midwestern values and long history of service and innovation for Medicaid members would make us a strong partner with Iowa if we are awarded a contract. Some examples of innovations are our Mobile Dental Clinic, drive-through vaccine and flu shot clinics and our Community Response Team.

Care coordination is becoming an increasingly important issue. What kinds of services are you offering in this area?

Care coordination is a vital service we provide our members—particularly benefiting members with multiple and complex health needs. Care coordinators are our members’ allies and advocates. They stay in close contact with members to help them get connected to care. Care coordination helps ensure: member access to health care and community and waiver services, improved member outcomes and the living arrangement of choice for our members.

Care coordination at UCare is a collaborative process; it helps connect all the health care dots for our members through assessment, planning, facilitation and advocacy for options and services to meet our members’ needs. We help members receive access to care, social or community supports, a safe living environment and self-reliance. An important aspect of how we coordinate care is including awareness and sensitivity to culturally appropriate issues.

Health care workforce shortage issues present a growing crisis. What are some potential solutions to these complex problems?

We are so grateful for the health care heroes who have provided care throughout the ongoing pandemic. Burnout and resignations continue to be a real concern, though. A potential solution includes providing more tuition support and

Improving the Experience of Health Care

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Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability?

Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing

The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

3The Moral Law Within from cover

to understand the lives of my patients outside of the clinic room, changed to understanding and addressing social drivers, and now recognize that unless we address the root causes of social drivers, there will not be sustained improvement in the health of those we serve.

For many diagnoses, we should consider societal and structural elements, what Dr. Rishi Manchanda, the CEO and founder of Health Begins, describes as community-wide social determinants of health and the causes of those social elements, the structural determinants of health. Examples would be supermarket redlining as a structural determinant of health and a food desert as a social determinant of health. The social risk factor that would then appear as a result of these is food insecurity. In order to be more effective clinicians, we must address the social risk factors. Further, sustainable improvement on the health of populations requires addressing the social and structural determinants of health.

The business imperatives for this approach are clear—health care costs are reaching unsustainable levels. Nevertheless, the greatest reason to change is a moral one. I know little about philosophy, but I have thought a lot about Don Berwick’s 2020 Health Affairs Viewpoint, “The Moral Determinants of Health” that begins with a reference to the 18th century philosopher Immanuel Kant and the “moral law within.” What Dr. Berwick notes is that the research is clear on what is needed to improve health, but societies don’t invest in those things—for example, shunting more of health care spending to what will prevent illness, such as addressing the high rates of incarceration in Black and other diverse communities or supporting elders suffering from loneliness, versus paying to repair the effects of a lack of investment and disinvestment in what is known to improve health. The pressures that ensure the status quo are powerful. But the more powerful force would be if more of us, including those of us working in health care, attended to the “moral law within,” advocating for what is right even if it is not immediately in our personal or organizational best interests. This approach would result in improved and equitable health outcomes.

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A Framework for Better Care

There are frameworks that can be used to improve the health of populations through the implementation of strategies beyond medical care and which can address health inequities. One I worked on with colleagues at the Alliance of Community Health Plans while I was a senior vice president and the chief medical officer for UCare recognizes that health inequities are due to a complex web of social and structural factors and is a framework that can be used by healthcare providers. The framework begins with identifying at least one equity issue to fully address, then using data and analytics to identify root causes—and solutions for those root causes that act at the individual, community and systemic levels.

The individual level involves work within your immediate sphere of influence—your patients. An example might be addressing the issue of poor pregnancy outcomes by identifying pregnant people who are at risk for an adverse health outcome and reaching out to them to connect them to their health plan for care management support. At the community level, organizations work with others to make a community-wide impact. Using the same pregnancy outcome example, a health care organization may use philanthropy to support a community-based organization that provides doula services, which have been shown to improve health outcomes. At the systemic level, health care providers might choose to advocate for insurance coverage of doula care.

As you assess your patients and determine that, in addition to providing medical care, they need other supports, there are many community-serving organizations you can access which can serve as resources for your patients. For example, the Wilder Foundation African American Babies Coalition has a number of initiatives to foster the healthy development of Twin Cities’ African American babies that include the Integrated Care and High Risk Pregnancy Initiative (ICHRP). This initiative connects parents and families to needed resources at NorthPoint Health & Wellness Center in Minneapolis, the Ramsey County Care Collaborative, and other resources in Ramsey County. ICHRP also trains others, including health care providers, on how to provide culturally relevant care to diverse communities.

Another example of a Minnesota community-serving organization providers can support and refer patients to is Juniper. It is actually a network of organizations across Minnesota that offer evidence-based health promotion programs for adults that include falls prevention, fitness classes and programs that provide education on how to live well when aging or if living with a chronic health condition. Many of Juniper’s offerings are free, ask for a donation or in some cases are a covered insurance benefit. For example, Tai Ji Quan: Moving for Better Balance, is an evidence-based falls prevention program offered through Juniper. It is available online and in person at various sites across Minnesota.

Many providers have changed how they practice and now determine whether patients need health promotion services similar to those Juniper provides. Also, providers are increasingly assessing patients for social drivers

of health in order to connect them to community-based resources that can address the social need. An example of this is asking about food insecurity by asking a patient or family if they worry their food will run out before they have the resources to buy more, then giving them information about available food shelves and where to get information about supplemental nutrition benefits.

Incorporating a New Approach

Assessing for social drivers of health is integral to the work of Leap Pediatric and Adolescent Care, a St. Paul practice I recently started. We focus on advancing health equity and removing barriers to health and wellness, in part through collaborations with local county public health and communityserving organizations.

Before the pandemic, families were resilient even in the face of significant barriers; however the pandemic has made it more difficult for them. I can walk from my home in St. Paul to neighboring areas where many people have no regular source of health care, including pediatric and adolescent care.

St. Paul is diverse. Almost 50% of us are Black and/or of Indigenous communities, Asian, or Hispanic. Twenty percent are foreign born, and 30% speak a language other than English at home. Unfortunately, one in five St. Paul children live in families with incomes below the poverty level. Many children in St. Paul are behind on their well child visits and immunizations. Children with chronic medical problems in some St. Paul neighborhoods are

more likely to be hospitalized for their condition when compared to children living in an adjoining neighborhood. Access to care is challenging. There is very little to no pediatric/adolescent primary care in many areas of St. Paul, known as Health Services & Resources Administration Primary Care Health Professional Shortage areas. Leap Pediatric and Adolescent Care is located in one of these areas and commits to identifying and addressing social drivers of health. We also commit to having a staff that Medical care alone is represents the patients, families and communities insufficient for achieving we serve. Studies have shown that patients from better health outcomes. Black, Latino and Indigenous communities are more likely to trust health care systems that have doctors and staff with similar cultural experiences. This trust can lead to improved health outcomes. I’m one of the few Black doctors in Minnesota, and over the years, families have said they brought their children and adolescents to me because I am Black. However, it is challenging and takes time to build trusting relationships with patients, even if you do have common cultural and social experiences. Many people in the U.S. distrust health care organizations and doctors. In fact, before the pandemic, one survey found that less that 60% of participants from the U.S said that doctors can be trusted. Fewer people from diverse communities trust doctors, and many report being treated unfairly by health care systems. The Moral Law Within to page 124

3The Moral Law Within from page 11

Building Trust

Trust with patients can be built. It requires consistently showing we care about them and will give them the time required to meet their needs. I remember a patient experience leader advising me to always ask a patient and family if there was anything else I could do for them before I exited the exam room. I have found that asking this question very rarely added significant time to the visit and gave patients and their families a moment to make sure we had discussed what was important to them. The same approach of asking how we can be of service is useful if a provider or health care organization hopes to enter into a relationship with a community and community-serving organizations.

We also build trust with patients and communities by providing culturally congruent care. Cultural congruence involves learning about the cultural beliefs and values of the individuals and communities being served and being open to integrating those beliefs and values into the care we provide. I recently spoke to a health care leader and mental health practitioner who asks patients whether they use or would like to incorporate traditional healing practices into their care. She has found some patients achieve better outcomes when traditional healing is used alongside our conventional mental health treatments. I asked her how she knows where to send

patients who want to incorporate traditional healing practices into their care plan and don’t know a good source of this care. She said she asks people in those communities for recommendations —– they know the best healers to recommend. The pandemic, our profound health disparities, the widespread lack of trust in health care—these all indicate the need to change how health care functions in Minnesota and the U.S. This change is necessary, so we are mandated to allocate Advocate for an approach to more money and attention to the causes of health that is beyond and more poor health and to the practices that promote effective than medical care. wellness. Systems need to be built that address the social drivers of health, connect patients to health promotion services, humbly partner with community-serving organization and build trust with the communities we serve. Such systems are possible if we all attend to the “moral law within” and advocate for an approach to health that is beyond and more effective than medical care. Julia Joseph-Di Caprio, MD, MPH, is president and founder of Leap Pediatric and Adolescent Care. She has also served as senior vice president and chief medical officer at UCare and held several physician leadership roles at Hennepin HealthCare.

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