Minnesota Physician • September 2020 by Minnesota Physician Publishing

MINNESOTA

SEPTEMBER 2020

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIV, No. 06

A dual pandemic Real virusâ&#x20AC;&#x201D;fake news BY KRISTEN R. EHRESMANN, MPH, RN, AND SARAH LIM, MBBCH

ince the first reports in early January of a cluster of cases of pneumonia of unknown etiology in Wuhan, China, the novel coronavirus SARS-CoV-2 has exploded across the globe and caused the greatest public health crisis in over 100 years. The Minnesota Department of Health (MDH) identified the first case of COVID-19 on March 6, 2020, and by midSeptember, Minnesota had 90,000 reported cases and 2,000 deaths. As we continue to see high rates of community transmission and our case numbers and deaths increase, it is clear that COVID-19 will be part of the fabric of daily life in Minnesota well into 2021 and likely longer.

Two fronts

Recalibrating Medicare reimbursement Proposed CMS guidelines spell disaster BY KIT CRANCER AND ZACHARY BRUNNERT

long-term goal of the current administration has been to increase reimbursement rates to primary care providers. Under the latest Medicare Physician Fee Schedule (MPFS) from the Centers for Medicare and Medicaid Services (CMS), primary care and other clinicians who charge for evaluation and management (E/M) services are set to see significant, and much needed, reimbursement increases. In fact, the new fee schedule recognizes that E/M codes have been chronically underpaid for decades, and primary care is set to receive an increase of around 12% in reimbursement Recalibrating Medicare reimbursement to page 104

We are battling dual pandemics: a virus that has sickened and killed millions, including the young and healthy, and an avalanche of misinformation that at best seeks to minimize the danger and at A dual pandemic to page 124

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SEPTEMBER 2020 MINNESOTA PHYSICIAN

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SEPTEMBER 2020

REQUEST FOR NOMINATION

Volume XXXIV, Number 6

COVER FEATURES Recalibrating Medicare reimbursement Proposed CMS guidelines spell disaster

By Kit Crancer and Zachary Brunnert

A dual pandemic Real virus—fake news By Kristen R. Ehresmann, MPH, RN, and Sarah Lim, MBBCh

DEPARTMENTS CAPSULES .................................................................................. 4 MEDICUS.................................................................................... 7 INTERVIEW .................................................................................. 8

L RS EA IN F L L T H U E N T I AA D E C A R E LE

Publication Date: November 2020

Nominate the 100 Most Influential Health Care Leaders In our November 2020 edition, Minnesota Physician will profile 100 of our state’s most influential health care leaders. In a format featuring photos, bios, and quotes, we will highlight the men and women most responsible for making Minnesota a global model for health care delivery.

Teaming up to serve patients

These individuals will represent every aspect of the industry: physicians,

Bevan Yueh, MD, MPH University of Minnesota Physicians

business executives, political leaders, policy analysts, etc.

MEDICINE AND THE LAW............................................................. 16

you know anyone within your organization you feel should be considered,

We invite you, our readers, to participate in this recognition process. If please fill out the form below and mail it or submit online (www.mppub.

Redefining hospital malpractice Expanded liability for independent contractors

By Besse McDonald, JD, and Julia J. Nierengarten, JD ARCHITECTURE........................................................................... 20

com/top100.html) or via e-mail (comments@mppub.com) prior to Friday October 16. We welcome your input and participation in making this list as comprehensive and meaningful as possible.

Designing inpatient adolescent health DHS and space innovation lead the way By Mark L. Hansen, AIA, and Dave Moga, AIA, NCARB, EDAC, LEED AP

INFORMATION TECHNOLOGY.................................................... 22 A telemedicine check-up

I would like to nominate the following individual(s): Nominee’s name (please include all advanced degrees):

A look at some survey data

Nominee’s title:

By David Holt, JD

Nominee’s affiliation:

CARDIOLOGY............................................................................. 24 Bioprinting 3D heart pumps

Brief description of the nominee’s work and influence:

A concept that is gaining traction By Molly Kupfer, PhD, and Brenda Ogle, PhD

PATIENT PERSPECTIVE................................................................. 26 Caring for the disabled Pandemic-driven new challenges By Joan Willshire, MPA

Nominator information (strictly confidential):

Name: Phone #:

www.MPPUB.COM PUBLISHER

________________________________________________________________________

Mike Starnes, mstarnes@mppub.com

EDITOR___________________________________________________________Richard Ericson, rericson@mppub.com ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com 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.

Email: Send to: Minnesota Physician Publishing: Top 100 PO Box 6674, Minneapolis, MN 55406 Online form: www.mppub.com/top100.html Email: comments@mppub.com For more information, call 612.728.8600

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MINNESOTA PHYSICIAN SEPTEMBER 2020

CAPSULES

Mayo Clinic launches COVID-19 tracking tool Mayo Clinic has introduced an online tracking tool that features the latest COVID-19 data for every county in all 50 states and Washington, D.C., as well as insight on how to assess risk and plan accordingly. “U.S. Coronavirus Map: What Do the Trends Mean for You?” (https://tinyurl.com/mp-covid-map) presents key data and trends. Data include the total number of cases by county and state, new cases per day, positive test rate, and fatality rate, all presented with trends over time and Mayo Clinic guidance on how to take action. “COVID-19 infections continue to rise and fall in many areas of the country, and information at the local level on the prevalence of disease and future trends are more important than ever to help people prevent the spread of infection,” said Henry Ting,

MD, a cardiologist, health services researcher, and educator at Mayo Clinic. “This interactive map, enriched with Mayo Clinic expertise, is designed to be easy to use, with the most current data available and correlated with the latest Mayo Clinic guidance.” Ting, who is Mayo Clinic’s chief value officer, worked with a team of Mayo Clinic data scientists to develop content sources, validate information, and correlate expertise for the tracker—all of which will be enhanced with more real-time data and predictive modeling. Mayo Clinic’s COVID-19 resource center provides guidance on how to wear a mask properly, maintain social distancing, wash hands frequently, and clean and disinfect surfaces. It also includes a self-assessment tool for users to determine whether they have symptoms and should seek medical care, and information for COVID-19 survivors on how to donate plasma to help others.

New CPT codes released for COVID-19 services The American Medical Association (AMA) has published an update to the Current Procedural Terminology (CPT) code set that includes two code additions for reporting medical services sparked by the public health response to the COVID-19 pandemic. Both have been approved for immediate use. The first addition, CPT code 99072, was approved in response to sweeping measures adopted by medical practices and health care organizations to stem the spread of the novel coronavirus (SARS-CoV-2), while safely providing patients with access to high quality care during in-person interactions with health care professionals. The additional supplies and clinical staff time to perform safety protocols described by code 99072 allow for the provision of evaluation, treatment, or procedural services

during a public health emergency in a setting where extra precautions are taken to ensure the safety of patients as well as health care professionals. The second addition, CPT code 86413, was approved in response to the development of laboratory tests that provide quantitative measurements of SARS-CoV-2 antibodies, as opposed to a qualitative assessment (positive/negative) of SARS-CoV-2 antibodies provided by laboratory tests reported by other CPT codes. By measuring antibodies to SARSCoV-2, the tests reported by 86413 can investigate a person’s adaptive immune response to the virus and help assess the effectiveness of treatments used against the infection. Code numbers and long descriptors for each addition: • 99072: Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility

MEDICAL MALPRACTICE ATTORNEYS

Angela Nelson

SEPTEMBER 2020 MINNESOTA PHYSICIAN

Ryan Ellis

Marissa Linden

Jennifer Waterworth

CAPSULES

service(s), when performed during a Public Health Emergency as defined by law, due to respiratorytransmitted infectious disease. • 86413: Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative. In addition to the long descriptors, short and medium descriptors for codes 99072 and 86413 can be accessed on the AMA website at https://tinyurl.com/mp-covid-codes, along with several other recent modifications to the CPT code set that have helped streamline the public health response to the SARS-CoV-2 virus and the COVID-19 disease.

Allina, Blue Cross form value-based agreement Allina Health and Blue Cross and Blue Shield of Minnesota have announced a six-year, value-based payment agreement that aims to reduce the cost of care by 10% over five years. The agreement will share data to inform care delivery and enhance the patient experience in an effort to foster more proactive and preventive care and to reduce unacceptably high rates of health disparities. It also strives to maximize the time available for doctor-patient relationships, streamline the care delivery experience, and simplify administrative requirements. The new agreement is expected to reduce costs. Currently, the portion of payments made by Blue Cross that are tied to achieving optimal patient outcomes are five to 10 times larger than what is outlined in typical outcomes-based risk arrangements. By de-emphasizing the reliance on payments for each health care service delivered, providers can be protected from loss of revenue during

periods of reduced volume—such as the recent pause on scheduled procedures during the pandemic. An increasingly popular alternative in health care contracts, value-based agreements can maintain revenue for a health care system, but with larger payment portions for optimal patient outcomes and quality of care. Allina Health and Blue Cross said they had been planning on the collaboration prior to the pandemic.

St. Luke’s participating in CDC study St. Luke’s is one of six organizations nationally participating in a Centers for Disease Control and Prevention (CDC) study that could have major implications for the treatment of COVID-19. Harmony Tyner, MD, infectious disease specialist at St. Luke’s, will lead the team’s involvement with the RECOVER study (Research on the Epidemiology of COVID-19 in Emergency Response and Healthcare Personnel). In March, with input from her colleagues, she sketched out an idea for a study on the epidemiology of COVID-19, which she submitted to the CDC for grant funding. Since the proposal was similar to another new study, she and St. Luke’s were asked to participate. Along with St. Luke’s, Kaiser Permanente; the University of Arizona; University of Miami; University of Utah; and Baylor, Scott & White are also involved. St. Luke’s is partnering with the Whiteside Institute for Clinical Research, a joint effort between St. Luke’s and the University of Minnesota Medical School Duluth campus, to conduct the study in Duluth. Researchers will review what percentage of patients with COVID-19 are symptomatic, how long the virus sheds, if antibodies to COVID-19 protect people from being re-infected, how long it takes to develop

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CAPSULES

antibodies to COVID-19, and how long immunity lasts. “This project is groundbreaking and it’s exciting to be a part of,” Dr. Tyner said. “It will help us answer many of the questions that everyone is trying to answer about the epidemiology of COVID-19. It will also allow us to learn more about what infection with COVID-19 looks like in real time. That knowledge, in turn, enables us to limit the impact of this virus locally and globally.” St. Luke’s will enroll 500 health care workers to participate in the study. Efforts will be made to fill demographic criteria based on age, gender, and occupation, to ensure that individuals from all demographics are represented. Potential participants will be asked to fill out a questionnaire to see if they qualify. Participants will be asked to complete weekly symptom assessments via text messages, swab their

own noses for COVID-19 every week, and have blood drawn periodically to test for COVID-19 antibodies. Research will conclude by May 2021.

University studies antibodies as possible COVID-19 treatment The National Institutes of Health (NIH) and Operation Warp Speed have chosen a University of Minnesota School of Public Health research team to begin a global clinical trial of synthetic versions of natural human antibodies—called neutralizing monoclonal antibodies—as a treatment for COVID-19. The collaborative study, named ACTIV-3, will investigate whether these antibodies can prevent the virus that causes COVID-19 from infecting more cells in adults hospitalized with the disease.

For use in the trial, antibodies specific to the virus were singled out from the blood of recovered COVID-19 patients and then reproduced. When infused into people sick with the illness, the monoclonal antibodies will cling to the protein spikes surrounding the virus and keep it from infecting healthy cells— in effect, “neutralizing” it. The process may mimic what’s happening naturally in people who can handle the virus relatively well. In stage 1, 300 patient volunteers will be randomly assigned to receive either a placebo or LY-CoV555, a neutralizing monoclonal antibody. All will receive the antiviral drug remdesivir as part of the study design. If LY-CoV555 appears safe and effective, the trial will advance to stage 2 and an additional 700 patients will be randomized and enrolled. Researchers will then compare the number of study participants in

each randomized group who achieve sustained recovery, defined as discharge from the hospital and at home for 14 consecutive days. All participants will be followed for 90 days. Four NIH-funded clinical trial networks with hospitals across the globe are carrying out ACTIV-3. The lead network is the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT), which is led by Professor Jim Neaton in the University of Minnesota School of Public Health. “An advantage of the collaboration among the four networks is that hospitals can be activated to enroll participants in epidemic hot spots in the U.S. and around the world in order to more rapidly obtain answers concerning the safety and efficacy of the treatments to be studied,” said Neaton.

V Alzheimer’s is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

• Severe and persistent muscle spasms, including those characteristic of MS

• Intractable Pain

• Obstructive sleep apnea

• Post-Traumatic Stress Disorder

• Alzheimer’s

• Autism

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS (651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

SEPTEMBER 2020 MINNESOTA PHYSICIAN

MEDICUS

Renée Crichlow, MD, assistant professor and director of Advocacy and Policy in the University of Minnesota Medical School’s Department of Family Medicine and Community Health, has been named as the inaugural Mac Baird Endowed Chair in Family Medicine Advocacy and Policy. Dr. Crichlow is the co-founder of a youth health career mentorship program in North Minneapolis called The Ladder, which engages both physicians and students. TJ Ridley, MD, a sports medicine fellowship-trained orthopedic surgeon specializing in sports medicine and arthroscopic surgery, as well as minimally invasive knee and shoulder replacement, has joined Twin Cities Orthopedics. He offers care for all musculoskeletal conditions as well as activity-related sports injuries, and provides treatments ranging from medications and therapies to surgical and non-surgical procedures. Mindi Kvaal Anderson, MD, a hospitalist, has joined Essentia Health–St. Mary’s Medical Center. As part of the hospitalist team, Dr. Kvaal Anderson cares for patients who are hospitalized due to illness or injury. She earned her medical degree at the University of Minnesota Medical School in Duluth, and completed her residency in family medicine at the Duluth Family Medicine Residency Program. David Ingbar, MD, a critical care and pulmonary physician at the M Health Fairview University of Minnesota Medical Center, is leading a study to determine the safety and effectiveness of mesenchymal stem cells (MSCs) aimed at halting “cytokine storms” related to COVID-19. A patient with COVID-19 and lung failure is the first to be treated in the U.S. under the new FDAapproved clinical trial. Mariya Skube, MD, MPH, has joined St. Luke’s in Duluth. Dr. Skube earned her medical degree and completed her general surgery residency at the University of Minnesota Medical School in Minneapolis. During residency, she also earned her MPH and completed a NIH T32 research fellowship in pancreatology.

CO N C E R T S FO R T V, R ADIO & STREAMING This fall, Minnesota Orchestra, Twin Cities PBS (TPT) and Classical MPR are coming together to bring you a new way to experience the Orchestra. THIS IS MINNESOTA ORCHESTRA is a series of Friday night concert broadcasts, live from Orchestra Hall. Get up-close-and-personal with musician interviews, insights into the music, behind-the-scenes content and much more. All from the comfort of home. SE ASON PRE MIE RE FRI OCT 2 8PM Visit our website for the complete broadcast schedule and details.

minnesotaorchestra.org/thisismnorch /

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All artists, dates and programs are subject to change. PHOTO Travis Anderson.

MINNESOTA PHYSICIAN SEPTEMBER 2020

INTERVIEW

Teaming up to serve patients Bevan Yueh, MD, MPH University of Minnesota Physicians What can you tell us about your ongoing rebranding initiatives?

Benson, MD, FACP, FAAP, chief academic officer, Tim Schacker, MD, vice dean for research, and their teams have led a number of clinical trials that demonstrate how our academic physicians are advancing the standard of care.

In 2019, the University of Minnesota, Fairview Health Services, and University of Minnesota Physicians began a new partnership known as M Health Fairview. This brand encompasses all the facilities and services in our joint clinical enterprise, including those acquired by Fairview when they purchased HealthEast in 2017.

Please tell us about your partnerships with Minnesota health care industry leaders.

One recent example stemmed from the concern that we would run out of ventilators during the COVID-19 crisis. Anesthesiologist Stephen Richardson, in partnership with the University’s Earl E. Bakken Medical Devices Center, worked with Boston Scientific, Medtronic, and UnitedHealth Group to develop the Coventor, a low-cost, simple-to-produce ventilator. These companies used their expertise to refine the ventilator and help get rapid FDA approval.

M Health Fairview is the brand we use to help the public understand who we are. It represents the powerful combination of academic medicine at the Medical School and University of Minnesota Physicians and the operational strength and reach of Fairview Health Services.

Please share some of the new learning that has come from the pandemic.

The pandemic clearly demonstrated the power of academic medicine. Our physicians were in communication with colleagues around the world in late 2019. We knew what was coming and we knew we’d have to prepare—pivoting research and clinical care resources to address the disease and the community impact. Our commitment to saving lives sends us in to overdrive during times like these. I have seen collaboration across specialties and disciplines like never before, a willingness to do things differently for the sake of our patients and the communities we serve. I am hearing a strong desire to continue this momentum to help conquer other challenges in health care today, including health disparities and access to care. What can you share about new learning from operational changes?

We have learned that virtual care is a real option for many kinds of visits. It opens up access—not only for patients far from our metro area, but also for those who are closer. The emergency orders in place during the first months

SEPTEMBER 2020 MINNESOTA PHYSICIAN

“...”

It is critical for us to form new kinds of partnerships.

“...”

The Medical School and M Physicians are the “M Health” in M Health Fairview. We bring research capabilities, innovative care models, and multi-specialty expertise, and we train the next generation of medical professionals.

of the pandemic paved the way for us to provide care to patients in some other states. Now we face licensing barriers to provide broader virtual care across state lines. We are consulting with other health care providers to address these issues and share best practices at an operational level. Please tell us about converting Bethesda Hospital into a COVID-19 facility.

We decided early on that we could provide the best care by creating “cohorts” of COVID patients. This meant keeping patients on dedicated units to improve efficiencies and to improve care. My colleague at Fairview, Mark Welton, MD, floated the idea: What if we make all of Bethesda a COVID hospital? In just over two weeks, our physicians stood up Bethesda to care for COVID patients— the first in the state and one of the first in the nation. We have since demonstrated great outcomes, with higher survival rates than in other metropolitan centers, and an extremely low rate of infections among health care workers. Brad

How are you addressing health disparities in our communities?

Many of our clinicians are involved daily in addressing health disparities. For example, research funded by the Medical School is helping physicians and learners in our family medicine clinics tackle access barriers faced by our Somali, Hmong, and Karen communities. Our Broadway Family Medicine Clinic has been serving the North Minneapolis community for more than 40 years. Tanner Nissly, DO, Kacey Justesen, MD, and their team partner in unique ways to improve both health and health care. Dr. Renée Crichlow’s Ladder Program helps kids from underrepresented populations pursue health care careers. They have also partnered with Second Harvest Heartland to address food insecurity and a lack of education regarding nutrition. They are currently relocating the clinic to a larger site and, with the help of a University grant, are partnering with the College of Design to create an innovative, community-focused clinical space. How are you dealing with institutional racism within your own organization?

Through our partnership with Fairview, we recently launched the Healing, Opportunity,

People, and Equity (HOPE) Commission. Our physicians, Taj Mustapha, MD, and Christopher Warlick, MD, PhD, are part of this commission and focused on dismantling the structural racism that impacts health outcomes and health care. Our leadership will soon include a vice president of diversity, equity, and inclusion to ensure comprehensive focus on any issues of racism or bias in our organization. This new leader will partner with Ana Núñez, MD, FACP, who recently joined the Medical School as its inaugural vice dean for diversity, equity, and inclusion. To respond to the needs of our employees, we have established internal working groups comprised of physicians and staff to address themes from listening sessions we held earlier this summer. I have also asked each of our Board committees to add a goal to their charter statement that relates to diversity, equity, and inclusion. You have a special interest in improving hearing loss. What are some of the most exciting new advances in this field?

Hearing loss profoundly impacts health and quality of life across the lifespan. Hearing

is important for learning and forging social connections, and for maintaining brain health as we age. Prevention of hearing loss is an important public health goal, and we also need better treatment options to restore hearing for the millions of individuals who have already suffered loss. The University of Minnesota is on the forefront of hearing technology development. We have a leading-edge, high-volume cochlear implant program. A team of scientists, engineers, and surgeons, led by Hubert Lim, PhD, Meredith Adams, MD, MS, and Andrew Oxenham, PhD, is conducting a multi-national project funded by the National Institutes of Health to develop the world’s first auditory nerve implant, which will bypass the diseased inner ear to send electrical signals directly to the hearing nerve and on to the brain. Our researchers are also developing novel hearing aid technologies, such as an ultra-hearing device that transmits low-level ultrasound signals non-invasively but directly to the cochlea, so the brain that does not need to compete with distorted sounds coming through damaged middle and inner ear structures. We are also developing technology to treat tinnitus with multimodal neuromodulation.

What are the most pressing issues facing University of Minnesota Physicians?

The crisis of health care affordability is a national conversation and we feel the effects acutely in Minnesota. Health care systems are feeling the cost pressures of providing high quality care and an excellent patient experience, even as reimbursements fail to rise at the same rate. Addressing access issues and health disparities in our communities requires long-term investments that do not see an immediate return. The University of Minnesota Medical School has been a center for solutions in the past, and we are in the best position to find solutions now. Our faculty members are doing some truly amazing things that will change the standard of care. Through science and better health system organization, we will find answers. Bevan Yueh, MD, MPH, interim CEO at University of Minnesota Physicians, also holds leadership positions in the Medical School as vice dean for clinical affairs and as the department head for the Department of Otolaryngology/Head & Neck Surgery.

We’re here for adults, for kids, and best of all... for relief. Just as your patients trust you, you can trust MNGI for the best adult and pediatric GI care possible. Our dedicated, caring team of specialists are uniquely qualified to meet the special GI needs of all your patients–big and small. With clinics throughout the metro and telehealth visits, MNGI offers the appointment access your patients deserve. MNGI–the smartest choice in GI care. Refer your patients using our secure referral site at referrals.mngi.com or call 612-870-5400.

MINNESOTA PHYSICIAN SEPTEMBER 2020

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3Recalibrating Medicare reimbursement from cover over the current fee schedule. Unfortunately, due to a statutory provision requiring “budget neutrality,” any reimbursement increase to one type of clinician essentially requires a decrease to another provider type. In the case of the newest CMS fee schedule, some medical specialists are set to see their Medicare payments slashed by as much 11%. In good times, an 11% cut would be difficult to swallow, but in the current health emergency it’s unsustainable.

The background COVID-19 has already created substantial challenges for health care providers. For the first time, clinicians faced government-mandated restrictions on their ability to care for patients. As restrictions on elective procedures blanketed the country and patient volumes dropped precipitously, mammography screenings nearly ceased with a 90% reduction, most clinics were forced to furlough large swaths of employees, and, in many cases, close facilities entirely. Now, as specialty providers gear up to treat the backlog of patients whose care had been delayed, they face potential double-digit reimbursement reductions from CMS that will have clear implications on other forms of reimbursement. Annually, CMS issues their MPFS, which provides for the payment of over 10,000 physician/licensed clinician services and sets the Relative Value Units (RVU). In formulating reimbursement, CMS calculates a geographical practice cost index (GPCI) for every payment locality, the Resource-Based Relative Value Scale (RBRVS), and the Conversion Factor. The RBRVS is

calculated for each CPT code based on physician work, practice experience, and malpractice insurance costs. Using the geographically adjusted RVU, the Conversion Factor is used as a multiplier to determine the Medicareallowed reimbursement rate. These annual calculations are bound by budget neutrality requirements, meaning increases in certain codes must be offset by reductions in others. The proposed CMS rule states that if revisions to the RVUs cause expenditures for the year to change by more than $20 million, adjustments shall be made to ensure that expenditures do not increase or decrease by more than $20 million. Typically, large-scale payment methodology changes receive significant scrutiny by providers, but with clinicians working to address a backlog and treat patients during a pandemic, these significant reimbursement changes seem to be flying under the radar.

What is in the MPFS During the rule-making process last year, CMS signaled their intention to move forward with the adoption of a new reimbursement methodology and coding structure, increasing payments for evaluation and management codes (E/M) while reducing payments to specialists like radiologists by 8%. This change set out to eliminate the blended payments for certain levels of E/M codes, and to break them out for each of the five levels. At the beginning of August 2020, CMS issued the calendar year 2021 MPFS proposed rule, which is set to become effective on Jan. 1, 2021. Contained in this rule is the finalization of provisions previously outlined in the CY 2020 MPFS and sets the conversion factor at $32.2605, a $3.83 or 10.6% decrease from the previous fee schedule. This is estimated to reduce payments to radiology by 11%, interventional radiology by 9%, cardiac surgery by 9%, physical therapy by 9%, and radiation oncology and radiation therapy by 6%. Others, mainly specialties that focus heavily on office visits, are set to see rates boosted substantially. Adding complexity and confusion is the efforts by CMS to also bundle some types of payment codes. This is requiring extreme process and treatment changes for many who are also affected by the budget neutrality rate cuts.

Impacts to providers and patients These unsustainable reductions come at a time when all health care providers are under extreme financial stress. Coupled with elective procedure restrictions and fear that COVID-19 will impact volumes, these proposed reductions to Medicare reimbursement will not just cause ripples through the health care system, but disruptive waves that will impact the stability of the health care system for providers and patients alike and likely cause further consolidation of the health care system. Decreased Medicare rates will not be the only form of payment to providers that will be impacted. Many states across the country use these CMS rates as a factor in determining their fee-for-service rates, and some even directly peg to a specific percentage of the MPFS. Additionally, many states have moved to a managed care delivery system for their Medicaid beneficiaries, utilizing capitated per member per month payments. These rates are required to be actuarially sound, often set by just a handful of large actuary firms, most of whom heavily weight Medicare rates in making their determinations. Furthermore, these proposed reductions will result in continued downward pressure on provider contracts with commercial payers, as insurers consider government payer rates in contract negotiations.

SEPTEMBER 2020 MINNESOTA PHYSICIAN

Slashing payments to vulnerable specialty providers will also threaten access for patients, including those who are not direct Medicare beneficiaries. These reductions perpetuate the climate in which small physician offices increasingly struggle to keep their doors open. Market forces, paired with a pandemic and decreased reimbursement, have all resulted in communitybased providers closing up shop. Many outpatient imaging centers and radiology groups have been forced to consolidate operations, leaving many patients with an absence in choice. Further reductions to reimbursement will only exacerbate this problem. All health care

American College of Emergency Physicians, and many others continue to press CMS to prevent rate reductions, and to ask Congress to waive budget neutrality requirements for the latest fee schedule. This would allow for primary care and others to receive a much-needed reimbursement increase while also ensuring that specialists don’t have to endure draconian cuts. While large industry organizations have engaged lobbying groups and consultants, these efforts are only as effective as their ability to activate a grassroots network of professionals and directly engage policymakers. This is where you come in.

providers are under extreme financial stress.

Additionally, as we have seen in the nursing home industry, reduced reimbursement in some states can lead to limiting of low-paying payer exposure by providers. As rates fall, and providers face increasing employment costs, many have no choice but to limit their contact with payers that do not reimburse at cost. This risks a growing segment of the population having fewer options when seeking health care services. As it pertains to many specialist services, when patients are often seeking timely answers or treatments, delays in care equate to denial in care.

Making an impact Across the spectrum of specialty providers, a large grassroots effort is emerging as various coalitions are forming to prevent drastic cuts to reimbursement. Advocacy groups such as the American Medical Association (AMA),

Health care clinicians lending their voice to an industry advocacy movement is immensely helpful, greatly impacting the trajectory of the campaign to prevent draconian reimbursement reductions. As groups of surgeons, radiologists, social workers, pathologists, and other specialties come together, there are some simple steps clinicians can take to better ensure the success of this growing effort. First steps include: • Finding out if the medical specialty or professional association retains a lobbyist or industry representative to provide “talking points” for use with Minnesota’s congressional delegation;

Recalibrating Medicare reimbursement to page 344

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MINNESOTA PHYSICIAN SEPTEMBER 2020

3A dual pandemic from cover

Telephone Equipment Distribution (TED) Program

Even the youngest age groups are not safe—as cases of COVID19 increase, we are seeing more cases of the rare but severe complication worst calls the entire disease a hoax. False medical information has spread known as multisystem inflammatory syndrome (MIS-C) in children. online with other outbreaks of infectious disease—2009 H1N1, Ebola, There have been 24 confirmed cases of MIS-C since the pandemic began, Zika, measles—but COVID-19, along with the all of whom have required hospitalization and, resulting public health guidance, has become in some cases, prolonged stays in intensive uniquely politically divisive and suspect. care. There is growing evidence of long-term Institutions such as the CDC and the FDA health consequences to SARS-CoV-2 infection, are no longer seen as neutral and independent. including myocardial damage, pulmonary Nearly half of all Americans say they definitely or scarring, and strokes. COVID-19 is absolutely not probably would not get a COVID-19 vaccine if “just the flu.” Finally, when researchers from the it were available today. The simple act of wearing University of Minnesota examined age-adjusted a mask is seen in some quarters as a partisan COVID-19 mortality, the excess mortality seen political declaration instead of a basic public in communities of color, particularly Native health measure to slow the spread of the virus. Americans and Black people, shows significant We must be clear: COVID-19 is absolutely racial disparities in the effect of this pandemic. not “just the flu.” Data from the MDH shows that since that first case in Countering misinformation March, over 7,100 patients have been hospitalized, including 2,000 who How do we begin to address these dual pandemics: the real virus, and were treated in the ICU and 2,000 who have died. It is important to note the fake news? To start with, despite claims in the media, relying on herd that severe illness and deaths have occurred in every age group, even those immunity through natural infection is not the answer. Herd immunity is the with no underlying conditions. One of the first cases in Minnesota was an epidemiologic principle that when a sufficient proportion of the population Ironman triathlete in his 30s who ended up on ECMO (extracorporeal has immunity to a disease, through prior infection or vaccination, the membrane oxygenation). While he survived, his case offered proof of the likelihood of disease transmission to susceptible individuals is reduced. risk posed by SARS-CoV-2 to younger, healthier people as well as those aged Simply allowing herd immunity to develop by waiting for infections to occur 50 and older. in enough of the population is not an appropriate strategy for COVID-19. The current seroprevalence rate in Minnesota is unknown (though a study is underway), but in early spring a nationwide study reported in JAMA estimated it at only 2.4% overall in the Minnesota metropolitan area. While the rate is almost certainly higher than that now, we are still very far away from the threshold necessary for herd immunity, estimated to be about 50% to 70%. The cost of herd immunity through natural infections will be even more cases, more illness, and more death. Also, while the duration Do you have patients with trouble of natural immunity remains unclear, so far infection does not appear using their telephone due to to provide life-long immunity, as proven by several cases of re-infection. hearing loss, speech or Rather than relying on natural immunity, vaccination of the population will be necessary to manage the spread of COVID-19. physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 ted.program@state.mn.us mn.gov/dhs/ted-program Duluth • Mankato • Metro Moorhead • St. Cloud 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

SEPTEMBER 2020 MINNESOTA PHYSICIAN

While we wait for a safe and effective vaccine, testing, contact tracing, isolation, physical distancing, and masking are the pillars of our control strategy for COVID-19. The practice of isolation and quarantine in the management of infectious disease outbreaks goes back at least to the Middle Ages and probably longer, and is key to beating back COVID-19. Anyone with symptoms of illness should be counseled to stay home and be tested, with positive cases advised to isolate. The benefit of testing, apart from diagnosing those who are ill, is that it allows the identification and quarantine of presymptomatic contacts, who are believed to be responsible for 50% of viral transmission. Everyone should be encouraged to comply with requests from the health department to identify contacts for contact tracing, and it should be emphasized repeatedly that even if you have an asymptomatic or mild infection, you may still transmit to others who may be more vulnerable. When isolating and quarantining an entire population is not realistic, we must rely on other measures, specifically limiting the size of gatherings, maintaining physical distance from others, and wearing a face covering. An

Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers David Schultz, MD Chief Executive Officer Nura Pain Clinics

1. Chronic pain doesn’t take holidays. Although the COVID-19 pandemic has captured the headlines, chronic pain does not relent. According to the CDC, high-impact chronic pain (pain that interferes with work or life most days or every day) affects approximately 20 million U.S. adults.

2. Opioids are a problem. They can also be part of the solution. According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability off ered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

Our thoughts on chronic pain…

3. There is no silver bullet. One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn oﬀ their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we oﬀer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.

If you have a patient struggling with chronic pain and you’d like to discuss the case, please call our Provider Hotline at 763-537-1000. If the situation is urgent, we will do our very best to see your patient the same or next day.

MINNESOTA PHYSICIAN SEPTEMBER 2020

MDH review of COVID-19 community outbreaks in Minnesota found that lockdown fatigue that so many people are experiencing and the desire to they are invariably tied to events where people are gathering in large groups, visit and socialize with our friends and loved ones, but we must not forget the risk that these gatherings pose. not social distancing and not wearing masks. A compelling example of the impact of not following this guidance was a wedding held in southwest The issue of therapies for COVID-19 has also been affected Minnesota at the end of August. Two-hundred by politicization and misinformation. and seventy-five individuals (over the executive Hydroxychloroquine was touted as a miracle order’s limit of 250) celebrated indoors in a therapy by some before definitive data emerged crowded restaurant without social distancing or showing its lack of efficacy. This misinformation masking. At the time of this writing, 77 cases even led to the death of a man in Arizona who Your patients need to hear and one hospitalization have been linked to this ingested fish tank cleaner in the misguided belief from you that this is a real event. These cases have included health care that it would work as prophylaxis. Other theories and urgent concern. workers and teachers, further illustrating how about dubious, unproven, or flat-out dangerous the ripple effects from a single event spread out to treatments have circulated, including bleach, affect other settings like health care and schools. UV light, cow urine, colloidal silver, and the We understand that early messaging about dietary supplement oleandrin. In August, when masking from public health was contradictory to the FDA issued an emergency use approval for the current guidance; however, this early recommendation was made before convalescent plasma over the objections of leading scientists from the NIH there was clear evidence of the risk of asymptomatic and pre-symptomatic that the evidence for its efficacy simply was not there, it was widely seen as spread and when concerns about the lack of PPE for front-line health care having bowed to political pressure, raising major concerns about the vaccine workers were at a peak. approval process.

“Myths”

Positive indications

We do not have the space here to debunk all of the myriad myths about mask-wearing that have popped up on social media and beyond; suffice it to say that we have not seen epidemics of mask-related illness in health care workers who wear them for hours to do their job. We also understand the

The good news is that in the midst of the storm, treatment for COVID-19 has drastically improved. Alternative management strategies for acute hypoxic respiratory failure such as high-flow oxygen and prone positioning can avoid the need for intubation and invasive ventilation. The groundbreaking

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months ago will result in evolving data and evidence. We understand that this is how science works, but our patients may not. Above all, your patients need to hear from you that this is a real and urgent concern; you are a trusted source of information, and your words and opinions have more power than you think. It is vitally important that you continue to reinforce the important messages of testing and contact tracing; staying home when ill or waiting for test results; and following measures such as masking and social distancing. Be prepared to discuss the Wearing a mask is seen in value and worth of vaccines (including flu shots) some quarters as a partisan in anticipation of an eventual vaccine approval. political declaration. Your front-line efforts make a difference!

RECOVERY (Randomised Evaluation of COVID-19 Therapy) trials in the United Kingdom showed that dexamethasone significantly reduces mortality in patients with severe illness, and it is now part of standard recommended therapy. The investigational antiviral drug remdesivir has shown moderate efficacy in clinical trials, and after an initial period of scarcity in Minnesota when the drug needed to be allocated to patients based on clinical priority, is now widely available. Finally, initial reports of monoclonal antibody therapies have been promising. All of this is a far cry from the early days of the pandemic, when clinicians had little to offer patients other than supportive care and a grab bag of potential experimental therapies.

Speaking to patients So what can we do? All of us in the health field are on the front lines of fighting these dual epidemics, whether we are caring for patients or working behind the scenes in the laboratory or in public health. If we do not provide accurate information, conspiracy theories and fringe views will fill the void. It is important that we all reinforce science-based messaging as well as the evolving nature of the pandemic. We are continuing to learn more about how this virus spreads and how it affects the human body, and as we learn, we adapt our guidance. Changing guidance may be frustrating for both physicians and the public, but of course the study of a novel virus that was unknown to science nine

Kristen R. Ehresmann, MPH, RN, is an epidemiologist and director of the Infectious Disease Epidemiology, Prevention and Control Division at the Minnesota Department of Health. Ms. Ehresmann has led numerous outbreak investigations, published in peer-reviewed journals, and been an invited speaker at national meetings. She currently oversees the epidemiologic response for COVID-19.

Sarah Lim, MBBCh, is a board-certified infectious disease physician who was previously an assistant professor in the Department of Infectious Diseases at the University of Vermont. She is now working as a medical specialist at the Minnesota Department of Health on the COVID-19 response.

MINNESOTA PHYSICIAN SEPTEMBER 2020

MEDICINE AND THE LAW

Redefining hospital malpractice Expanded liability for independent contractors BY BESSE MCDONALD, JD, AND JULIA J. NIERENGARTEN, JD

n July 29, the Minnesota Supreme Court issued a decision in Popovich v. Allina Health System in which it determined, for the first time, that a plaintiff may assert a claim of vicarious liability (under which one party is held partly responsible for the unlawful actions of a third party) against a hospital based on the apparent authority of independent contractors providing care in the hospital. In reaching this conclusion, the Court clarified that there is no “hospitals-only exemption from the general rule of vicarious liability based on apparent authority,” and declared that the legal standard to establish an apparent-authority vicarious liability claim only required the plaintiff to demonstrate that the hospital held itself out as a provider of emergency medical care and that the plaintiff looked to the hospital, rather than to a particular doctor, to provide care.

Background Popovich arises out of the alleged negligent medical care from emergency room physicians and radiologists who worked at Unity and Mercy Hospitals, both owned by Allina Health System (Allina). The health system does not employ

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the emergency department physicians or radiologists at these hospitals, instead contracting with Emergency Physicians Professional Association and Suburban Radiologic Consultants to provide this medical care to the public. In this case, the patient went to the Unity Hospital emergency department complaining of dizziness, loss of balance, and blurry vision. An emergency medicine physician attending to the patient ordered a head CT, which was reviewed by a radiologist. The patient was then discharged home. Later that morning, his condition worsened, and his wife called 911. The patient was unresponsive by the time paramedics arrived, and he was taken by ambulance to Mercy Hospital. An emergency medicine physician treating the patient ordered a variety of tests and imaging, including another head CT. The radiologist at Mercy Hospital compared the scan to the one taken at Unity earlier that morning, identifying abnormalities in the scans and noting increased swelling in the patient’s brain compared to the first scan from Unity Hospital. The patient was ultimately transferred to Abbott Northwestern for further care that evening. He was diagnosed with dissection of the left proximal vertebral artery with thrombus and had suffered a stroke, which has left him with serious and irreversible brain damage. The patient’s wife sued Allina, Emergency Physicians Professional Association, the emergency room physicians, and Suburban Radiologic Consultants for medical malpractice. The lawsuit alleged, in part, that the patient suffered a stroke as a result of negligent care provided in the emergency departments of Unity and Mercy Hospitals. Allina moved to dismiss for failure to state a claim, arguing that Minnesota law prohibits a lawsuit against a hospital based upon the purported negligence of independent contractors. The district court granted Allina’s motion and dismissed the case. The plaintiff appealed, and the Minnesota Court of Appeals affirmed the decision, citing a 30-year precedent that a hospital could only be vicariously liable for the actions of a non-employee. The plaintiff then petitioned the Minnesota Supreme Court for review, which that court granted.

The Supreme Court reverses The merits of the plaintiff ’s claims were not before the Minnesota Supreme Court in Popovich. Instead, the Court was asked to determine whether the plaintiff could maintain the vicarious liability claim against the hospital system on a theory of apparent authority where the treating emergency room physicians worked as independent contractors; and, if so, what the “proper legal standard” for apparent authority vicarious liability is in this context. The plaintiff ’s theory—vicarious liability based on apparent authority— was an issue of first impression, so the Court undertook a general review of vicarious liability under Minnesota law to determine whether such liability extends to hospital systems in a situation like this. Minnesota recognizes vicarious liability under two different theories: respondeat superior, where an employer is vicariously liable for its employee’s torts committed within the course and scope of his or her employment; and Redefining hospital malpractice to page 184

SEPTEMBER 2020 MINNESOTA PHYSICIAN

MINNESOTA PHYSICIAN SEPTEMBER 2020

3 Redefining hospital malpractice from page 16

apparent authority vicarious liability against principals for the acts or omissions of their agents in other contexts “despite the existence of other remedies.” The apparent authority, where a business or person (known in this context as a Court noted that hospitals have “a variety of methods” to address the risks principal) is vicariously liable for the torts of another business or individual associated with apparent authority vicarious liability, including establishing (an agent, e.g., an independent contractor) because policies and monitoring the quality of care and the principal has held out the agent as having allocating risk through agreements with independent authority to act on behalf of the principal or contractors, whereas “the typical emergency room knowingly allowing the agent to act on behalf of patient has significantly less bargaining power the principal. and little ability to predict or manage the risks of negligent medical care.” This second scenario (the only one at issue The Supreme Court reversed the here) addressed whether an agent has apparent authority to act on behalf of the principal based on and determined by the principal’s conduct. The Popovich decision made clear that whether the principal has “control” over the agent “is irrelevant to whether there is vicarious liability based on apparent authority.”

Court of Appeals decision.

The Court considered previous vicarious liability cases and concluded that, to the extent previous case law carved out a “hospitals-only exception from the general rule of vicarious liability based on apparent authority,” such opinions erroneously conflated respondeat superior vicarious liability with apparent authority vicarious liability. The Court rejected the hospital system’s argument that patients should be barred from asserting apparent-authority vicarious liability claims against hospitals because patients have “sufficient remedies for medical malpractice” claims. The Court pointed out that Minnesota recognizes

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The answer to the first question before the Court was yes, a plaintiff may assert a claim against a hospital seeking to hold it vicariously liable for the acts or omissions of an independent contractor under a theory of apparent authority.

The Court then moved to the second question before it: What is the applicable legal standard when a plaintiff asserts a claim against a hospital based on a theory of apparent authority vicarious liability? Under a theory of apparent authority, vicarious liability requires a plaintiff to show two things: that the principal “held out” the agent as having authority to act on its behalf or “knowingly permitted” the agent to act on its behalf; and that the plaintiff was aware of these representations of authority by the principal and relied on them. With respect to the first element, the Court pointed to the health system’s public advertisements stressing the quality of its emergency-room care, the nursing and physicians’ skills, the fully staffed nature of the emergency room, and its full-time radiologist “on staff.” The Court said that these “statements to the public . . . satisfy the element of holding out in claims against hospitals based on apparent authority.” With respect to the reliance element, the health system argued that patient-plaintiffs should be required to show “actual reliance” on those representations in order to hold a hospital vicariously liable for independent contractors. This would require the patient to show that the patient would not have accepted care in the emergency room if he or she had known that the people staffing it were not actually agents or employees of the hospital. The Court rejected this argument, instead concluding that reliance focuses on the beliefs of the patient and considers whether the patient looked to the hospital, rather than to a particular doctor, to provide care. Therefore, in order to state a claim for apparent authority vicarious liability, a plaintiff need only show that “(1) the hospital held itself out as a provider of emergency medical care; and (2) the plaintiff looked to the hospital for care and relied on the hospital to select the personnel to provide services to the plaintiff.” The Popovich court then applied this standard to the facts before it and concluded that the plaintiff ’s complaint stated a claim for apparent vicarious authority by adequately alleging that the hospital held itself out as a provider of emergency medical care, and that the plaintiff went to the hospital seeking emergency care and relied upon the hospital to provide an appropriate provider. The Supreme Court reversed the Court of Appeals decision and remanded to the district court, where the medical malpractice litigation will continue under this theory of liability, among others.

What now? What does this mean for hospitals and the independent physician groups that they contract with? Plaintiffs may assert vicarious liability claims

against hospitals under a theory of apparent authority for negligent care provided by the hospital’s independent contractors. This, however, will not change the day-to-day practice of medicine and the clinical care provided to patients. Instead, this decision will likely impact the hospitals’ business collaborations and contractual arrangements with their independent contractors in various ways. For example, hospitals may reexamine indemnification provisions with independent contractors to require that the contractor defend and indemnify the hospital against claims arising from the independent contractor’s negligence. Insurance coverage may also be revisited. Hospitals may require that independent contractors have sufficient liability coverage to ensure indemnification, and independent contractors should consider reviewing their coverage with their brokers and/or insurance coverage counsel to ensure coverage is adequate to support the indemnification agreement. In addition, hospitals may reevaluate outward communication with the public to more clearly identify who is providing the care. For example, hospitals may consider installing signage informing patients that an independent group is contracting to provide the care. Patient-specific documents, such as intake and consent forms, could be used to more thoroughly describe the role and affiliation of each provider involved in the prospective patient’s care. Likewise, when identifying their services in marketing materials and their websites, hospitals may choose to make a clear delineation of who—either the hospital or independent physician groups—is providing specialty services such as emergency department care,

radiology, or anesthesia. Hospitals may also reconsider which services can be provided through hospital-employed physicians rather than through independent physician groups.

The future The practical implications of Popovich are not yet clear. Hospitals may choose to take further measures to delineate for patients when independent contractors provide care, or they may instead choose to pursue other methods of protecting themselves from apparent authority-based vicarious liability claims. From a practice perspective, however, Popovich is unlikely to result in any change in the approach to clinical practice. Besse McDonald, JD, is an attorney in the professional liability–health care practice group at the law firm of Meagher + Geer. Her experience includes defending clients in all phases of litigation, including preparation of initial pleadings, fact investigation, discovery, drafting dispositive and pretrial motions, and trial preparation.

Julia J. Nierengarten, JD, is an associate attorney in the appellate group at the law firm of Meagher + Geer, where she employs her research and writing skills to draft motions, assist with appeals, and consult on litigation issues. She works with attorneys in practice groups throughout the firm.

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MINNESOTA PHYSICIAN SEPTEMBER 2020

ARCHITECTURE

Designing inpatient adolescent health DHS and space innovation lead the way BY MARK L. HANSEN, AIA, AND DAVE MOGA, AIA, NCARB, EDAC, LEED AP

s one of the leading causes of illness and disability around the world, mental illness is a widespread health challenge. Recent data from the World Health Organization reveals that approximately one in four people worldwide will suffer from a mental illness at some point in their lives. While researchers and clinical psychologists continue to dig deeper into mental illness, one thing is certain: these conditions are complex and have many causes. People often assume that mental illness runs in families, which can be true, but genetics are only a small part of it. Mental illness encompasses a variety of disorders, from anxiety to schizophrenia, with levels of severity ranging from no impairment to mild, moderate, and severe. These disorders can occur due to a combination of factors, including a person’s environment and lifestyle. Where the patient lives and the facility in which they receive treatment can play a major role in mental health. According to the National Alliance on Mental Illness (NAMI), young adults aged 18–25 years old have the highest prevalence of any level of mental

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illness at 25.8%. However, the need for mental health treatment is becoming increasingly prevalent in children and adolescents starting at very young ages. NAMI also states that one in six U.S. youth aged 6–17 experience a mental health disorder each year. Mental Health America reports that half of those who will develop mental health disorders demonstrate symptoms by age 14. The time between prenatal and early adulthood is a critical time in brain development. Unfortunately, many of these youth—as well as adults—do not have access to facilities that meet their needs or promote recovery.

Assessing the method of care required Whether the result of a trauma, a chemical imbalance, genetics, learned behaviors, or a combination of factors, an appropriate network of care must be developed which, depending on severity, could deliver care through several modalities, including counseling, outpatient visits both group and private, intensive outpatient therapies, intensive short-stay care, or inpatient treatment. While it is always the goal to treat children in an outpatient setting and allow them to incorporate their treatment plan into their home setting and daily lives, for some youth that just is not the appropriate level of care. We struggle to properly identify the early markers of mental health problems before they reach a crisis level. In the past, care regimens waited for a major event before involving mental health professionals. The goal now is a proactive attempt to identify risk markers and deliver care to stabilize or reverse the illness. Therefore, efforts are being made to provide mental health services to support and promote care appropriate to the illness—taking action swiftly at a time when illness management can occur, an approach that results in fewer rates of suicide, school dropout, homelessness, and involvement in the juvenile justice system. The Minnesota Department of Human Services (DHS) strongly believes that screening for social, emotional, and developmental concerns is essential to early identification of mental health problems in children and youth.

Effect of the physical environment Physical environment has a direct effect on behavior and the healing process. This has been universally substantiated and proves to be increasingly relevant as it relates to health care settings and the overall well-being of patients, family members, and health care staff. According to the National Council for Behavioral Health (NCBH), the physical environment influences mental health by altering psychosocial processes with known mental health causes. Personal control, socially supportive relationships, and restoration from stress and fatigue are all affected by properties of the built environment.

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For patients receiving care at facilities that are not appropriate to their medical needs, or in response to court-ordered care, DHS runs the Child and Adolescent Behavioral Health Services (CABHS) facility in Willmar. The program provides inpatient psychiatric hospital services in a setting for youth who need crisis stabilization, comprehensive assessment, and intensive treatment of specialized mental health problems. When their lease was up on the existing eight-bed hospital in Willmar, DHS opted to develop a new, freestanding 18,000-square-foot inpatient facility. This

new 16-bed hospital allows the state to effectively provide inpatient services to children and adolescents ranging in age from six to 18 years old. The goal of the facility is to create an environment that provides care in a dignified manner within a setting that is age-appropriate in design and provides areas for privacy, independence, and group interaction within a safe, nurturing, and enjoyable space.

The facility also includes a family lounge for overnight stays by parents or guardians to facilitate post-care treatment upon discharge. The facility, which opened its doors to patients in June 2020, also includes seclusion rooms, consult rooms, a large commons area, social and dining area, day lounge, comfort sensory room, restrooms, physician offices, exterior courtyards, and a variety of other ancillary spaces.

To achieve the best physical space for this at-risk population, ligature-resistant fixtures— Response to the need by other which eliminate points where a cord, rope, or bed One in six U.S. youth aged facility types sheet could be looped or tied—and finishes are 6–17 experience a mental Patients with mental health concerns coupled delicately incorporated into the design concept, health disorder each year. with substance use disorders also benefit from offering functional characteristics while providing properly designed facilities. Hennepin County is a safe environment for both patients and staff. leading an effort to keep these patients out of jails The new Willmar facility responds to the need for and hospitals through an extensive renovation sensory stimulation that prompts feelings of safety to its detox center at 1800 Chicago Ave. S. in and comfort while appealing to a large range of Minneapolis. The goal is to create a one-stopages. Circular clouds with pops of color hang from the ceiling soffit in the shop Triage Center that ranges in services from detox to mental health care main commons area. Lowered ceilings and a built-in bed platform in each to assisting clients seeking county services. The 13,000-square-foot space of the private patient rooms provide a space scaled to the patient and offer includes exam/counseling rooms, waiting areas, and staff/support spaces. the sense of feeling “nested” within the room. The patient room wings The design concept was centered around the theme of “Respite in the City.” consist of three contained zones of four, four, and eight rooms, all of which The team developed guiding principles that were referred to often during are in clear sight from the central care provider station. The open floor plan design to ensure the concept stayed true to this theme. Evidence-based creates space for one-on-one therapy sessions, group sessions, a spacious design led to the selected principles, which included: gathering area next to the care station, quiet nooks, and window seats for patients to have “alone” time with oversight provided in a dignified manner. Designing inpatient adolescent health to page 324

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MINNESOTA PHYSICIAN SEPTEMBER 2020

INFORMATION TECHNOLOGY

A telemedicine check-up A look at some survey data BY DAVID HOLT, JD

elemedicine use has expanded rapidly across the United States, largely due to pandemic-related necessity and the challenges posed by in-clinic visits. President Donald Trump declared a national emergency on March 13, 2020, and the Centers for Medicare & Medicaid Services (CMS), Minnesota health agencies, and professional boards quickly moved to loosen restrictions and issue “waivers” for compliance with telemedicine guidelines. Following Minnesota Gov. Tim Walz’ Emergency Executive Order 20-01 declaring a peacetime emergency related to COVID19, the Minnesota Commissioner of Human Services was granted temporary authority by the Governor to waive or modify certain requirements in order to provide essential programs and services during the pandemic, and the Legislature enacted several laws. This article will look at some of the challenges and benefits from Minnesota’s experience with telemedicine thus far.

Pluses and minuses The benefits and drawbacks of telemedicine quickly became apparent as some medical providers were forced to quickly adopt telemedicine to keep their practices running. More data is accumulating rapidly, since the

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COVID-19 pandemic introduced many Americans to telemedicine for the first time. In 2019, in the pre-COVID-19 world, a telehealth study noted that while 9.6% of Americans had used telehealth services, nearly three-fourths (74.3%) said they either don’t have access or are unaware of a telehealth option, according to the 2019 J.D. Power Telehealth Satisfaction Study (https://tinyurl.com/mp-jd-power). Unsurprisingly, patients 65 years old and older—among the populations at highest risk from the virus—were less likely to use telemedicine, representing the lowest utilization rate of any age group (5.3% of those surveyed). The main benefit during the COVID-19 pandemic, of course, is that patients can continue to receive medical care from the comfort of their home without risking exposure to COVID-19 during an in-office visit. Another benefit of telemedicine is the increased access to providers, when distance and geography are eliminated as a barrier. When the telemedicine laws were first passed across the country at the state and federal levels, lawmakers emphasized that telemedicine would increase access to care to rural communities. One limitation of this benefit is that the rural expansion of telemedicine generally relies on a stable internet connection, which is not always reliable. This may not all be about the delivery methods, but rather

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an awareness issue. Awareness of telemedicine was lowest in rural areas, where 72% of respondents were unaware of telemedicine as an option. Not all telemedicine services require an internet connection. Some services are delivered through a simple phone call, but this, along with other electronic delivery modes, is still subject to HIPAA requirements. The Office for Civil Rights (OCR) at the federal Department of Health and Human Services (HHS) has issued guidelines for compliance with patient privacy laws (https://tinyurl.com/mp-hhs-ocr). During the COVID-19 National Public Health Emergency, patients and providers may use popular apps that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype, to provide telehealth without risk that OCR might impose penalties for noncompliance with HIPAA. In addition, Minnesota modified state telemedicine guidelines to include phone calls for eligible providers who render services via telemedicine and can demonstrate that it is safe to do so. (See the Minnesota Healthcare Programs Provider Manual’s webpages on “Telemedicine” and “COVID.” Also, to account for the increased frequency of telemedicine visits, the current limitation of three telemedicine encounters per week is suspended in Minnesota. And finally, much to the delight of physicians working from home, when delivering telemedicine—including via telephone—the distant site (provider’s location) can be the eligible provider’s home. The originating site (patient’s location) can be their home. This is a large departure from previous restrictions.

never be exactly the same as an in-office visit, and that is a concession all providers make in adopting telemedicine technology. Nearly half (48.7%) of patients in the J.D. Power study believe that the quality of care received in a telehealth session is lower than that of a doctor’s office visit, while only 6.2% perceive the quality to be higher, and 45.1% believe it to be the same. Another 43% also believe a telehealth session to be “less personal” than an office visit. The metrics to measure “quality” are certainly up for debate, but a large percentage of patients do report a difference in service. As another drawback, primary care providers in community health clinics in Minnesota are reporting difficulties faced by older patients and A telemedicine check-up to page 304

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Across state lines Rural areas are not the only beneficiaries of elimination of geographic barriers via telemedicine. Providers may, in some cases, work across state lines, creating a new legal maze to determine which services are covered based on patient and provider locations. Beginning on March 6, 2020, Medicare started to temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country. It also removed the telehealth stipulation that telehealth in rural areas can only be provided with specific audio-visual equipment. Minnesota law generally provides that a physician licensed in another state can provide telemedicine services to a patient in Minnesota if their license has never been revoked or restricted in any state; they agree not to open an office in Minnesota, meet with patients in Minnesota, or receive calls in Minnesota from patients; and they register with the state’s board. These requirements do not apply in response to emergency medical conditions, if the services are on an irregular or infrequent basis, or if the physician provides interstate telemedicine services in consultation with a physician licensed in Minnesota (MN Stat. § 147.032). All providers using telemedicine are held to the same standards of practice and conduct that apply to the provision of in-person services (MN Stat. § 147.033).

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Minnesota physicians are also exploring whether they can practice telemedicine with patients outside of Minnesota. Each state has different regulations, which are monitored by the Federation of State Medical Boards (see https://tinyurl.com/mp-state-regs). This is largely a state-by-state consideration and may implicate laws outside of Minnesota.

Patient and physician feedback One drawback to telemedicine is that some patients report that the two types of “visits” are not the same. A remote telemedicine visit will

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CARDIOLOGY

Bioprinting 3D heart pumps A concept that is gaining traction BY MOLLY KUPFER, PHD, AND BRENDA OGLE, PHD

eart disease is the leading cause of death worldwide, due in large part to the low regenerative capacity of the heart. With recent advances in stem cell biology, cardiac tissue engineering with human cells has emerged as an avenue to replace lost muscle after a cardiac event and to produce human models in vitro that can be used for disease modeling and testing of drugs and medical devices. Early engineered heart tissues, pioneered in the late 1990s and early 2000s, consisted of geometrically simple structures (strips or rings) made by casting cardiomyocytes in a protein-based gel. While such tissues can recapitulate the contractility of cardiac muscle, their lack of geometric complexity limits their capacity to reflect clinically relevant characteristics of the heart. That is, while they can generate force, they possess no internal chambered structure with which to pump fluid.

“Printing” cardiac tissue 3D bioprinting, wherein structures are fabricated layer-by-layer utilizing a cellladen “bio-ink” as a substrate, has been proposed as a means to generate more geometrically complex tissues from the bottom up. The concept is gaining

traction, as the ability to print tissues composed entirely of native proteins, cells, and/or biocompatible synthetic components is possible and accessible to many laboratories. Further, robust protocols have been developed for differentiating human-induced pluripotent stem cells (hiPSCs) into a variety of cell types, making it relatively easy to obtain cardiomyocytes ex vivo. However, while researchers have demonstrated the capacity to 3D-print entire heart organ models using biological materials, no one has yet demonstrated electromechanical function of cardiomyocytes within such a tissue. The fact that macroscale contractile function has not yet been achieved in a 3D-printed, perfusable, chambered heart model reflects the challenges associated with handling mature cardiac muscle cells. More specifically, cardiomyocytes do not proliferate or migrate readily. For this reason, it is challenging to achieve the high cell density required for the formation of functional cell-cell junctions while maintaining the structural support needed for an enclosed chamber. Macroscale cardiac function relies on the electromechanical coupling of individual cardiomyocytes to form an organized, synchronously contracting tissue. Traditionally, researchers have taken the approach of differentiating hiPSCs into cardiomyocytes in a tissue culture dish, and then collecting the differentiated cardiomyocytes and 3D printing with them. However, when hiPSCs are differentiated into cardiomyocytes this way, they tend to couple to each other and form a beating monolayer. To collect the cells from such an environment for further downstream applications typically requires one to break up these connections. Hence, to incorporate these cells into an engineered tissue, it is necessary to place them in a context where they can reform these interrupted connections. This is feasible in smaller, millimeterscale tissues, but it becomes challenging in larger, centimeter-scale tissues where the physical distance between cardiomyocytes after printing is too large to overcome.

A new strategy Our alternative approach is to print stem cells, which are highly proliferative, and then induce differentiation of cardiomyocytes in situ following cell expansion. To enable this approach, we sought to develop a bio-ink formulation that: 1. Promotes hiPSC viability; 2. Enables hiPSC proliferation and subsequent differentiation into cardiomyocytes; and 3. Is amenable to printing complex structures. Building on our understanding of how native extracellular matrix proteins modulate cell behavior, we developed an optimized bioink formulation composed of native proteins found in the heart. Some of these proteins were chemically modified to enable photo-crosslinking of the printed construct in order to maintain its geometric shape and structural integrity. To generate the printing template, an MRI scan of a human heart was obtained and scaled to the size of a mouse heart such that the longest axis was

SEPTEMBER 2020 MINNESOTA PHYSICIAN

approximately 1.3 centimeters. In addition, the septum between ventricles was partially removed to provide a throughway such that unidirectional flow could be propagated through the printed structure for ease of nutrient delivery. The structure was further modified to limit the vascular connections to two major vessels extending from the top of the structure, corresponding to the aorta and vena cava from the digital template. Prior to printing, hiPSCs were mixed into the bio-ink, which was then loaded into a syringe. The bio-ink was extruded from the nozzle using a commercial 3D printer and deposited layer-by-layer according to the print template. The tissues were printed into a gelatin support bath so that the relatively low-viscosity bio-ink would maintain its shape prior to photocrosslinking with blue light. After crosslinking, the gelatin bath was washed away, and the structures were cultured for two weeks to allow the stem cells to proliferate and fill the tissue gaps. The stem cells were subsequently differentiated into cardiomyocytes using a previously developed small molecule-based protocol. This in situ differentiation approach enables the cells to form connections to each other as they differentiate, similar to what would happen in human development. The end result is a living pump that mimics the chambers and large vessel conduits of a native heart while housing viable, densely packed, and functional cardiomyocytes. These human chambered muscle pumps (hChaMPs) exhibit robust macroscale contraction. The cellular makeup is primarily cardiomyocytes (approximately 88%), but there are also other cardiac cell types present, specifically endothelial cells and smooth muscle cells. Importantly, the combined cardiac cell cocktail often fully circumvented

the hChaMP, and the thickness of the wall was typically between 100 mm and 500 mm. However, at its thickest regions, we show that the muscularized region can exceed 500 mm, which is much higher than any previously reported values for engineered cardiac tissues. Cells of the hChaMP robustly express protein markers of cardiomyocyte structural and functional maturation, including gap junctions, ion channels, and intracellular machinery associated with the sarcolemma and sarcoplasmic reticulum. These proteins are necessary for the efficient trafficking of ions, which enables contiguous impulse propagation through the tissue. Optical mapping enabled visualization of electrical signal propagation throughout the hChaMP in real time. The average spontaneous APD80 was 499.9 ± 83.5 milliseconds, and action potentials detected on the surface of the hChaMP reflected a dramatic and predicted response to altered pacing frequency and drug stimulation. The location of the structure from which the activity was propagated was stochastic, sometimes from the large vessels, sometimes from a region near the large vessels, and sometimes near the apex. This outcome likely reflects the accumulation of pacemaker cells or immature cardiomyocytes with the capacity for spontaneous membrane depolarization in a given region that dominates and therefore initiates the response. However, in some cases the spontaneous source of depolarization could be overcome, and the directionality of propagation altered via electrical point stimulation at another location within the hChaMP.

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Bioprinting 3D heart pumps to page 294

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PATIENT PERSPECTIVE

Caring for the disabled Pandemic-driven new challenges BY JOAN WILLSHIRE, MPA

or people with disabilities, pandemic-related isolation can be terrifying and tragic. The stress can exacerbate mental illness and other health problems, some of them life threatening. Add the loss of mobility and independence, the disruption of routines, the day program that doesn’t open, the beloved caregiver who doesn’t come, and the lack of support that leaves some families no choice but to institutionalize their loved ones, and you have a sense of what many in the disability community are going through every day due to COVID-19. People with disabilities have been living in isolation for decades, but now their isolation is compounded—particularly for those in congregate living, since many facilities have enacted rules limiting visitation. It’s easy to feel totally alone and without family support because so many people stay close to home, avoid gatherings, and are unable to visit loved ones in a closed facility. The shortage of personal care attendants adds to this issue. Lapses in routine care can turn into crises when people with disabilities go to hospitals, where exposure to COVID-19 is a real danger. When a person with a disability becomes critically ill with the virus, is that person

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the first or the last to receive critical medical care if ICUs are full and ventilators are scarce? A heightened awareness of these issues and a few simple tips could help physicians provide more effective care for patients with disabilities.

Levels of care Several states—among them Alabama and Washington—have seen lawsuits alleging rationing and improper levels of critical medical care being delivered to the developmentally disabled population. In response, states agreed to review and update their medical standards of care to address rationing and discrimination against people based on disability, age, or perceived low quality of life. Excluding certain people with disabilities from access to life-saving treatment such as ventilators based on their disabilities and deprioritizing others based on their disabilities is not the solution to saving supplies or the rationale for choosing who receives critical care during this pandemic. States must also continue to comply with the 1999 U.S. Supreme Court ruling in Olmstead v. L.C., which stated that people with disabilities have a right to access to services in the community of their choice. The medical community must avoid moving people with disabilities into institutional care just to ensure that they are safe. The question is whether or not their safety justifies their segregation. Congregate settings often are not the best solution because of limited support and resources for disabled individuals— as well as heightened risk of exposure to the coronavirus.

Behavioral health issues It is very common for people with physical disabilities to have mental health issues as well. For these individuals, isolation can compound symptoms due to stress and anxiety. Individuals with mental illness may not want to go to a clinic for a variety of reasons, including fear of exposure to the virus. A physical disability could also be the reason stopping them from getting to a clinic with limited access if they start to show signs of the virus. The negative stigma of mental illness is as much of a barrier as stairs in front of a clinic door. Individuals with mental illness may also distrust the medical community due to previous traumatic experiences in and out of hospital settings. Because of this distress, they put off seeking treatment even if they have symptoms. If they contract COVID-19 and recover, they fear having a chronic respiratory condition.

Heightened risk

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According to an article in the June 2020 issue of Disability and Health Journal, COVID 19 appears to pose a greater risk of severe outcomes, including death, for those with intellectual and developmental disabilities (IDD), especially those living in a congregate residential setting. More common disabilities, such as cerebral palsy and Down syndrome, also are in this category, with patients who are more likely to have pre-existing conditions. People with disabilities are used to the uncertainty of medical care. For example, they’re used to having to try things out first to see if tools,

treatment, or equipment intended to comply with the Americans with Disabilities Act are truly accessible.

Staying at home

Clinicians are faced with a new quandary if patients with disabilities who are unable to wear a mask request these exemptions. Physicians have no obligation to provide a mask exemption to patients, if it is not medically warranted. They do, however, have a clear obligation to address individual patient’s concerns, discuss appropriate alternatives, and offer clear recommendations for risk-reducing measures when patients are venturing into public places.

We need to ensure that people get support to stay in their communities and don’t get transferred to nursing homes. For many people with disabilities and the elderly, personal care assistants (PCAs) allow them to live and work independently. Such care is also available in congregate settings, but COVID-19 appears to often with limited support and resources. Living in pose a greater risk ... for the community of one’s choice is the preferred option those with intellectual and for people with disabilities. Patients on medical assistance who are living independently may also consider person-centered assistive technology through organizations such as Live Life Therapy Solutions.

Wearing face masks presents a serious challenge for members of the deaf community, who may count on people speaking louder or being able to read lips. I have found it very difficult to hear and understand people talking with their masks on. Masks compound these challenges to effective communication, particularly under the current six-foot social distancing guidelines.

developmental disabilities.

Talking to patients National public health and infectious disease experts recommend wearing a face mask in public places such grocery stores and pharmacies, where it is hard to stay six feet apart from other people, and many businesses and government agencies may require visitors to wear masks. Gov. Tim Waltz’ Executive Order 29-81 went further, requiring Minnesotans to wear face coverings in certain settings to prevent the spread of COVID 19, but allowed an exemption for people with a medical condition, disability, or mental health issue that makes it unreasonable to wear a face covering.

Some simple tips for doctors: slow down your speech, increase the volume of your voice slightly, and say the person’s name when you enter a room, so they know you are addressing them.

Telemedicine Many clinics now offer expanded virtual medical visits, which can be a good alternative for people with disabilities. However, there is concern Caring for the disabled to page 284

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3Caring for the disabled from page 27 that telemedicine will not meet the needs of all people with disabilities. Sometimes the provider needs to see an individual in person to truly find out what is going on. The deaf community also struggles with the technological connectivity of virtual visits. Broad band for virtual visits has its challenges in the rural areas as well. Still, people with disabilities seek a level playing field, and online medical appointments have advantages. The patient may not look as disabled during a telemedicine encounter. There’s no preconceived notion that comes with seeing somebody walk in using a cane or wheelchair. I know from personal experience that when I went from using a cane to using a mobility device, perceptions changed about what I was capable of doing. Physicians cannot address all of these limitations of telemedicine, but they should be aware of them. One important recommendation for providers is to offer accessible documents, such as large print, audio, and accessible PDF versions of forms and important information prior to the session. Having accessible health care documents on hand helps both medical staff and the patient with a disability, especially when people can’t bring relatives or friends with them into the clinic or hospital during the pandemic. Clinics must allow PCAs and/or guardians to accompany the person with a disability. To illustrate this difficulty, imagine that your health care provider needs a signature acknowledging that you understand a document. You ask to see it, but they tell you it’s only available in a language you

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don’t read. However, they’re happy to help! They briefly and cheerfully describe what their document entails. Unfortunately, you still don’t get the opportunity to read it yourself. You just have to take them at their word. Would you feel comfortable signing the document saying that you understand the agreement? There’s no denying that offering accessible health care documents is the right thing to do. But, beyond that, physicians must be able to show that they are able to “walk the walk” and prove that their organization truly cares about its patients with disabilities. Having alternative formats will also help you avoid accessibility-related lawsuits.

Summing up We need to find a way to live in a COVID-19 world and bring individuals, family, and friends together without creating unnecessary danger for those individuals who have not agreed to the risk or should not be subjected to risk. Joan Willshire, MPA, is CEO of Willshire Consulting LLC. Her focus is on disability inclusion and equity. Previously, Joan was the executive director at the Minnesota Council on Disability for 16 years. Throughout her career, Joan has been active within the disability community and has served on several boards, including the Minneapolis Advisory Committee on People with Disabilities and Accessibility Inc. She was recently appointed to the University of Minnesota Centers for Transportation Studies and Research Executive Committee.

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3Bioprinting 3D heart pumps from page 25 Potential applications The primary benefit of a chambered tissue like the hChaMP is that it can replicate the pump function of the heart, allowing future researchers to trace and track what is happening at the cellular and molecular levels, introduce disease and damage to the model, and study the effects of medications and other therapeutics. To determine pressure volume dynamics as a clinically relevant comparator for this new model system, a conductance catheter harboring a pressure transducer was inserted into one chamber of the hChaMP. The coupling of the pressure transducer with the conductance catheter enabled us to plot both pressure and volume simultaneously as a function of time, which was done for spontaneously contracting and isoproterenol-treated hChaMPs. Pressure-volume vs. time plots were used to generate pressurevolume loops, and from these stroke work could be determined despite the fact that there are no valves to resist emptying and filling. Using the pressurevolume setup, we were able to detect changes in beat rate corresponding to multiple concentrations of isoproterenol. The usual volume moved through the chambers was 0.5 mL and maximum volume moved through the chambers was 5.0 mL, which is approximately 25% that of the average stroke volume of an adult murine heart. Based on these values, we calculated an ejection fraction of 0.7% on average, with a maximum value of 6.5%.

tissues, akin to aggregate-based organoids, but with the critical advantage of harboring geometric structures essential to the pump function of cardiac muscle. The utility of this technology for the field of cardiology is access to a human model system that can sustain flow profiles and exhibit pressure-volume dynamics characteristic of the native heart. This model will therefore be useful for understanding remodeling associated with cardiac disease progression imposed by mechanical insult or genetic predisposition. It will also be useful for testing drug toxicity or efficacy and, given the scale, is amenable to the testing of medical devices, implantation to the heterotopic position in mice, and perhaps, one day, clinical transplantation. Molly Kupfer, PhD, completed her doctorate in biomedical engineering at the University of Minnesota under the mentorship of Brenda Ogle, PhD. She has utilized human stem cells and 3D printing to generate living, contractile cardiac tissue for therapeutic use and in vitro modeling.

Brenda Ogle, PhD, is professor and head of biomedical engineering, professor of pediatrics, and director of the Stem Cell Institute at the University of Minnesota. Her research team investigates the impact of extracellular matrix proteins on stem cell behavior, especially in the context of the cardiovascular system.

Summing up This advance represents a critical step toward generating macroscale

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CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

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CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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3A telemedicine check-up from page 23 the first time, so more data continues to be gathered at a rapid pace. The those who are unfamiliar with telemedicine technology—which often J.D. Power study noted that while 9.6% of Americans have used telehealth includes downloading some sort of application onto an electronic device. services, nearly three-fourths (74.3%) say they either don’t have access or Melvin Ashford, MD, of Minnesota Women’s are unaware of a telehealth option. In addition, Care P.A., reports that “Elderly patients do have patients aged 65 and older were less likely to use issues with the technology. Thankfully as of now telemedicine—maintaining the lowest utilization they allow non-video options. For elderly patients rate of any age group surveyed (5.3%). we simply use a phone call. Telehealth will be Lawmakers and stakeholders in telemedicine For minority patient populations, helpful in extending expert help to other surgeons are already discussing what comes next. Will there is a larger gap in access during surgery but can never replace procedures.” the relaxed regulations stay? Should a national to telemedicine technology. There are additional barriers for low-income telemedicine law be passed? How do we learn patients and minority patients whose preferred from the benefits and drawbacks of telemedicine language is not English. Robert Larbi-Odam, MD, to navigate a post-COVID world? As Dr. Ashford of Community Care Clinics, reports that there is notes, “Medicine was already becoming national an additional cultural barrier with performing any and regional with patients traveling across state in-person visits and using telemedicine with certain minority populations. For lines to visit with providers offering services not available in their area. This minority patient populations, there is a larger gap in access to telemedicine [telemedicine offering] will increase dramatically with enhanced options technology and larger misconceptions about COVID facts, reporting, and and patient acceptance. This also will have a positive impact on the health treatments. Ayan Abukar, CEO of Actioncare Community Clinic, echoes of homebound elderly patients and other populations with limited access this sentiment, stating that the Somali-American population, especially older to care.” patients, prefer in-person visits, which is hindered by any widespread adoption of telemedicine at her clinic. David Holt, JD, is a Minnesota health care attorney practicing at Holt

Summary

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The COVID-19 pandemic introduced many Americans to telemedicine for

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3Designing inpatient adolescent health from page 21 More to do

“Familiarity of Home” creates comfortable spaces that are more welcoming for people in stressful situations and offer a residential feel that works to de-stigmatize the type of space.

In addition to the behavioral health projects currently taking shape in Minnesota, we are making progress in the ability to offer appropriate environments where dignified care is provided. Mental health care of children and adolescents is “Personal Safety” evokes a sense of safety to ease driven by the goal to treat the underlying issue, the anxiety of both clients and staff. The space not just address the symptoms, under a treatment includes a creative use of materials that enhance approach that is proactive, not passive. Favorable safety and offer sightlines to prevent personal harm. We need to continue to outcomes will continue as we are able to expand invest in the health and “Person-Centric” creates a space that is focused patient coverage, care services, and treatment well-being of people facing on a person’s holistic experience as they come into regimens. Considerable time, research, and expertise mental health challenges. the facility—not only the way we design the space, go into the development of mental health facilities but the way the caregivers work in the space to with a primary goal to provide individualized care ensure their focus is centered on the client. plans in a home-like environment that is flexible, “Grounded Natural Elements” that are safe, and secure for both patients and staff. As a strategically designed to pull in natural light through windows by putting society we need to continue to invest in the health and well-being of people client rooms in the center of the space, incorporating nature and art with soft facing mental health challenges. We have come a long way but are continually organic forms in the architecture that resemble natural elements throughout. learning the best methods for creating better care environments. “Sensory Awareness” creates an environment that is sensitive to noise and overstimulation by incorporating dimmable lights and movable furniture with Mark L. Hansen, AIA, NCARB, LEED AP, is a Principal and Project thoughtful textiles. The public “Living Room” includes a bubble wall design Manager/Architect with Mohagen Hansen Architecture | Interiors. feature. The bubbles create an organic shape and provide a soothing distraction. Dave Moga, AIA, NCARB, EDAC, LEED AP, is an Architect/Project

The Triage Center opened to clients in September 2020. As a new archetype we are excited to see how it positively impacts the health of the community.

Manager for Mohagen Hansen Architecture | Interiors.

Carris Health

is the perfect match

Carris Health is a multi-specialty health network located in west central and southwest Minnesota and is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. CURRENT OPPORTUNITIES AVAILABLE FOR BE/BC PHYSICIANS IN THE FOLLOWING SPECIALTIES: • • • • • •

Anesthesiology Dermatology ENT Family Medicine Gastroenterology General Surgery

• • • • • •

Hospitalist Internal Medicine Nephrology Neurology OB/GYN Oncology

Loan repayment assistance available.

FOR MORE INFORMATION: Dr. Leah Schammel, Carris Health Physician

SEPTEMBER 2020 MINNESOTA PHYSICIAN

Shana Zahrbock, Physician Recruitment Shana.Zahrbock@carrishealth.com (320) 231-6353 | carrishealth.com

• • • •

Orthopedic Surgery Psychiatry Psychology Pulmonary/ Critical Care • Rheumatology • Urology

Unique Practice Opportunity

YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.

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

For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com

Contact Mitchell for more information | mitch@brandtmgmt.com 6565 France Ave S Ste 350 Edina

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 based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist

Ely VA Clinic

Hibbing VA Clinic

• Tele-ICU (Las Vegas, NV)

Current opportunities include:

• Nephrologist

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

•

www.minneapolis.va.gov MINNESOTA PHYSICIAN SEPTEMBER 2020

3Recalibrating Medicare reimbursement from page 11

The gist

As CMS appears unlikely to unilaterally walk back large-scale reductions to many specialty providers, at a time when the financial stability of the health care system has been the most at risk, increased advocacy efforts are greatly needed to compel CMS or Congress to take action. The latest move by CMS puts patients and providers in jeopardy, not just by the cuts to direct Medicare rates, but how these will reverberate throughout the provider’s payer mix. If we are to be successful in our campaign to mitigate these proposed reimbursement cuts, a broad and Some medical specialists are set loud outcry and direct engagement will be needed to see their Medicare payments by health care professionals so that policymakers slashed by as much 11%. across the country become aware of the issue and its long-term, negative consequences.

• Contacting members of Congress by email or phone to alert them to the devastation of these cuts, as there are many other issues now consuming the attention of Congress; and • Providing both home and facility/ office addresses as well as the number of employees in the practice, along with any other economic impact information available. At this unprecedented time, every job is significant to a responsive member of Congress.

Engaging elected officials and/or their staff doesn’t have to be complicated. It requires preparation (e.g., talking points), a respectful attitude that refrains from partisanship, and an effort to put the cuts into context based on an issue they may be passionate about, such as job loss or patient access. Because of security reasons, an email or phone call is likely most efficient, which requires that the request (“waive budget neutrality”) to jump out in the subject line or be explained almost immediately.

Kit Crancer is vice president of public policy and executive director of the CDI Quality Institute.

Zachary Brunnert is director of state legislative policy at the Center for Diagnostic Imaging.

One resource, which the authors and others involved in health policy have been involved in developing, is the website DontCutDocs.com. We’d invite anyone interested in getting involved to make this site their first stop.

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.

Opportunities available in the following specialties: • Anesthesiology • Dermatology • Family Medicine • Gastroenterology

• Internal Medicine • Otology • Non-Invasive Cardiology • Psychiatry - Adult

• Psychology - Child • Rheumatology

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: dcardille@olmmed.org • Phone: 507.529.6748 • Fax: 507.529.6622

www.olmstedmedicalcenter.org 34

SEPTEMBER 2020 MINNESOTA PHYSICIAN

URGENT RESOURCES FOR URGENT TIMES. In a pandemic, speed and access to information and resources are vital. Knowledge saves time, and you need all the time you can get to save lives. Introducing the COVID-19 Resource Center. Right here, right now, for you. On our website, you’ll find the latest information and resources for important topics like: • Telemedicine: including best practices and plain language consent forms • Links to infectious disease prevention guidance • Education and resources for healthcare providers on the front lines

You can access Coverys’ industry-leading Risk Management & Patient Safety services, videos, and staff training at coverys.com. All in one place, for our policyholders as well as for all healthcare providers. Thank you. For all that you are doing. You are our heroes, and we are here if you need us.

Medical Liability Insurance • Business Analytics • Risk Management • Education COPYRIGHTED. Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company®

MINNESOTA PHYSICIAN SEPTEMBER 2020

Sofia Lyford-Pike, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

mphysicians.org

Minnesota Physician • September 2020

Articles inside

PATIENT PERSPECTIVE Caring for the disabled

INTERVIEW

CARDIOLOGY Bioprinting 3D heart pumps

INFORMATION TECHNOLOGY A telemedicine check-up

MEDICINE AND THE LAW Redefining hospital malpractice