INTERVIEW

“The Patient Revolution” Victor Montori, MD Mayo Clinic

One of the central themes in your book is careful and kind care. Please tell us what you mean by this.

Health care should be careful in that the care plan should respond well to the patient’s situation, the response should be based on the best available research evidence, and it should be safely implemented. Health care should also be kind in that it must respect the patient’s precious and limited time, energy, and attention, avoid delegating unnecessary medical errands to patients and caregivers, and must form care plans that can be made to fit well within each patient’s daily routine. This often requires collaboration between clinicians and patients.

Please tell us what you mean by industrialized medicine and the problems it causes.

At the core of industrial health care is the notion that what happens at the point of care is the “delivery of care” by a provider (a person or an institution) and patient. Patients are expected to be engaged and activated to do their part in this care delivery. Payers judge the care delivered in terms of its quality and cost. Patients are not the reason for health care’s actions but are uncompensated employees. In this way, industrial health care has corrupted its mission. Typically, industrial health care focuses on care for “people like this” (not for this person), disregards continuity of care, promotes transactional interactions, focuses on documentation of care rather than on the care itself, and seeks to optimize financial outcomes rather than human ones. It is cruel to patients and clinicians alike. In industrial health care, whatever “value” is accrued flows away from the clinical encounter and to management and funders. Accountability is also inverted. Clinicians and patients are held accountable by the administration, rather than managers asking themselves, how might I enable care to be easier, better, safer, more equitable, and more effective today for patients and their clinicians?

Reform and innovation “...” are simply insufficient tools to address the problem. This is why we need a revolution. “...”

You speak widely about the burden of treatment on patients. How do physicians respond to that idea?

Clinicians respond with sympathy as they find themselves overwhelmed by industrial health care. They spend half the time with patients clicking on fields in the medical record, a task that must often continue at home. They experience workloads that exceed their capacity and sometimes key actions must be skipped to get through the day. This produces moral injury and burnout, with clinicians leaving the practice or cutting down on their patient care times. This burden is repeated with patients, particularly people living with multiple chronic conditions, who have to accommodate not only the demands of living but also the demands health care makes. When these demands exceed a patient’s capacity, they may not complete all the tasks and will be labeled, cruelly, as noncompliant. About 40% of patients living with chronic conditions reported being overwhelmed. Clinicians interested in co-crafting programs of care that makes sense to patients must face not just time pressures but also the need to meet practice standards and performance metrics that are often in conflict with the notion of minimally disruptive medicine. Clinicians bear witness to this churning, how it limits access to care, how it overwhelms patients, how it often fails to improve their patients’ situation, and how it leaves them dissatisfied.

One of the problems you discuss in Why We Revolt is the corruption of evidencebased medicine (EBM). What are the signs of this corruption?

“Evidence-based” was added as an adjective to better describe a form of medicine in which we carefully and judiciously draw from the best available research to figure out with our patients how to respond to their problematic human situation. The main advance of EBM has been to note that not all observations and certainly not all research evidence are equally credible, and no matter how credible, no piece of evidence ever tells us how to care. Care is formed in response to this patient, not to patients like this. Research evidence alone is not enough. It must also include what we can glean from experience and expertise of the clinician and the patient. When research evidence is motivated by a purpose different from supporting patient care (i.e., to gain FDA approval or increase market share) the questions asked and the findings published are tainted by a desire to further industrial goals. In this way, the evidence base becomes corrupted because of biased methods, results, and publication. Clinicians and patients are left to make decisions based in part on the wrong information, making care less safe and effective, i.e., less careful.

Another theme is “timelessness in care” and the problems time constraints create. Please share some of your thoughts on this.

Care is a fundamentally human activity. Humans process complex information through thoughtful contemplation: space to talk, observe,

reflect, and be silent. These actions take time and give care its natural tempo. This is why it is silly to demand for care to be efficient. We should not waste resources, time key among these. But we should also not accelerate the tempo of care arbitrarily. Like a ballerina, there is no wasted move, but also no haste in the movement. There is a certain length of care that enables time to become dense and deep. Sometimes this requires visits to be longer, but not excessively so. Sometimes what is necessary is the continuity of relationship— not with the institution, as industrial health care would have it—but with a caring clinician so that the time for care that matters spans across multiple moments. Careful and kind care takes time. This does not refer to length only, but also to depth. It does not refer to duration only, but also to rhythm.

What is the biggest challenge you are facing in building a movement?

The biggest challenge is how well industrial health care fits with the rest of the world in which we are asked to flourish. In this world, we live distracted lives, pressed for time, and expected to achieve more, faster, and with less. Demands for high efficiency reach education, mentorship, family care, friendships, craftmanship. This industrialization of human activities includes health care, and when it reaches those other ones, it often produces “value” while betraying and abandoning its essence, its purpose. Despite this corruption of its mission, whole economies—from clinician income to retirement funds—depend on the economic success of industrial health care, of having it remaining as it is. As we have seen during COVID-19, health care can collapse while health care payers celebrate unprecedented profits. It can celebrate the creation of value and yet fail to offer protective equipment to its clinicians and cruelly let patients die alone because their loved ones cannot be allowed at their bedside. This is why reform and innovation are simply insufficient tools to address the problem. This is why we need a revolution.

How can physicians get involved?

The central requirement of a revolution is to visualize a better alternative and a path towards it. The Patient Revolution’s vision of careful and kind care for all puts care at the center. In this future, the ability to care becomes the guiding force by which resources are managed, strategies planned, and executions judged. It expects citizens to take the lead and clinicians to soon join an effort to upend what is there in exchange for something better. We are working to develop some larger initiatives in pursuit of this goal. In the meantime, our website (https://patientrevolution.org) offers some tools for patients and clinicians, not to compensate for the lack of care in industrial health care, but to offer glimpses of this future, and to let clinicians and patients experience together the possibility of a better alternative.

Victor Montori, MD, is professor of medicine at Mayo Clinic. He is a practicing endocrinologist, researcher, and author and a recognized expert in evidence-based medicine and shared decisionmaking. Dr. Montori co-developed the concept of minimally disruptive medicine and works to advance person-centered care for patients with diabetes and other chronic conditions. He is the author of the book Why We Revolt: A Patient Revolution for Careful and Kind Care.

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.

3Keeping Politics Out of Science and Public Health from cover Our nation has a dire need for science-based, nonpartisan information about the pandemic and the critical nature of public health preparedness in general. Public trust and faith in science are critical when it comes to population health, especially during a pandemic. Unfortunately, however, we have COVID-19 Magnifies Existing Problems in Our Health Care System seen an unprecedented amount of politics injected into our health care Now more than ever, it’s time to put science and health care above politics by delivery system. So much so that even masks and redefining the goal in human, not political terms and physical distancing have become political issues. supporting a positive, practical, and lasting approach. Unlike previous national emergencies, such as 9/11 United States of Care is a nonpartisan nonprofit that brought the country together, the COVID-19 co-headquartered in Minneapolis and founded in pandemic has only fueled our nation’s political divide. An example is the deluge of misinformation about Our nation has a dire need for science-based, 2018 by Minnesotan Andy Slavitt, a former Acting Administrator of the Centers for Medicare and the pandemic — whether it’s the constant downplaying nonpartisan information Medicaid Services. Its mission is to ensure that every of the dangers of COVID-19, attacks on public American has access to quality, affordable health care health institutions, or amplification of false medical regardless of health status, social need, or income. treatments — spreading on social media and elsewhere, Since March 2020, our work has been oriented which we’ve seen create real-life consequences. around COVID-19. Specifically, the need for practical

Every day we are confronted with headlines that solutions that address both the immediate challenges remind us of the reality that COVID-19 does not care if you’re a Republican of the crisis and long-term gaps in our health care systems — laid bare by or Democrat. It also doesn’t care if you, or your patients, are tired of it or think COVID-19 — to ensure people can access affordable, high-quality care. the threat is overblown. Looking ahead, the pandemic, economic recession, and national

Building trust is enormously important in neutralizing misinformation discussion on race have created a renewed call for action in America. It and overcoming increasing skepticism around an eventual COVID- simply isn’t enough to get “through the crisis” and go back to the system we 19 vaccine, and we all share a responsibility in this critical work. Health had before. We believe this moment is an opportunity to work together to officials are doubling down on calls for flu shots to prevent systems from build a health care system that serves all of us better. being overrun in the coming months. That starts by understanding and addressing health care disparities, examining the role of virtual care, investing in communities to improve health, and reimagining job-connected health care. The invaluable perspectives of physicians on the frontlines of COVID-19 are especially important in the larger policy conversations to come, post-election.

Compassionate, Comprehensive, & Personalized care for adult and pediatric patients with neurological conditions, including:

           

Head Injury/Concussion Epilepsy/Seizures Headache/Migraine Neck/Back Pain Sleep Disorders Movement Disorders Parkinson’s Disease Tremors Alzheimer’s Disease Dementia Muscle Weakness Carpal Tunnel Syndrome Sciatica Neuromuscular Disease Muscular Dystrophy Dizziness Numbness Stroke Multiple Sclerosis ALS And other neurological disorders

612.879.1500 NoranClinic.com

Blaine | Edina | Lake Elmo/Woodbury | Lakeville | Minneapolis | Plymouth Health Disparities

Sadly, it isn’t a surprise that people of color have disproportionately experienced the pandemic’s burden. Despite some perceptions that systemic racism is not a public health issue, overwhelming facts prove otherwise. COVID-19 simply magnified the problem that already existed.

Two years ago, USofCare launched an initiative with Minnesota health systems, community leaders, and Wilder Research to develop a roadmap to end disparities in health outcomes throughout the state. The goal was to listen to individuals and communities facing structural barriers and to put forth policy solutions aimed at better addressing racial disparities in the short-term and ultimately eliminating them in the future. The work resulted in a Feasibility Study, The Role of Health Care in Eliminating Health Inequities in Minnesota, and a Systems Transformation Framework. We urge institutions to utilize this tool to ensure all people — particularly those most underserved — can live the healthiest life possible.

As physicians we must ask questions like what more can we all be doing to advocate for change in the systems where we serve? How can providers check our own biases to provide the highest level of care to all our patients?

Looking at Virtual Care in the Right Way

From the moment the pandemic forced providers to reimagine the way they care for patients, and regulatory flexibilities were granted — COVID-19 unleashed a revolution in virtual care.

While there’s no denying that virtual care has filled a critical gap in the enormous anxiety, uncertainty, and frustration. Although we do not know system left by the sudden restrictions on physical visits, serious questions when the pandemic will end, for many, the psychological, physical, and mental remain surrounding the future of virtual care post-COVID. scars may never go away. Our nation finds itself at a crossroads. The lessons we

We recently launched a new initiative to explore how virtual care can best choose to learn from COVID-19 will shape policy and decision-making for function as an innovative tool to help groups — disproportionately impacted generations to come. by health inequities — access care in a whole new way. While the pandemic has highlighted so much of

We are starting our work with a listening tour to what’s wrong with our national health care system, connect with people throughout the US and better it’s also highlighted what’s right – the people. understand their experience with virtual care. We’ll Americans are finding hope amid the crisis – in be pairing what we hear with research, evidence, and We must rethink our religion, their families, and stories of people helping input from experts on how virtual care has helped 75-year-old system of job- others. They are forever grateful and inspired by to break down barriers to accessing care - or in some connected health insurance the extraordinary efforts of our nation’s physicians, instances, create new ones. We’ll use this information nurses, and other medical workers on the front lines. to produce tools and resources policymakers and We are faced with a unique opportunity to build a health systems can use to create a virtual care system stronger health care system for the future — one that that works for all of us. We then plan to bring together truly serves all – and we must do everything we can expert leaders to support the implementation of these to that end. resources and evaluate their impact over time. We also especially want to hear the perspective of physicians. Our questions include: Emily Barson is the Executive Director of United States of Care. How have you embraced virtual care since COVID-19 started to take hold in the US? How can we think about virtual care as a tool towards achieving more Penny Wheeler, M.D., is the CEO of Allina Health and a Founder’s equitable access? Council Member of United States of Care.

Investing in Communities to Improve Health

The interlocking economic and public health crises have created the imperative to reframe what constitutes health as more inclusive of mind, body, spirit, and community. Providers are increasingly partnering with patients to gain a better understanding of their comprehensive healthrelated social needs.

As one example, Allina Health is part of the Accountable Health Communities cooperative agreement with the Centers for Medicare and Medicaid (CMS). It has been screening its patients for basic needs such as food, housing, transportation, and interpersonal safety, then supporting patients with unmet needs to connect to community resources.

Please visit us online, we’d love to hear for you. (https://unitedstatesofcare.org/) for updates and the latest resources.

Specialists in Musculoskeletal Pain Treatment

We need to continue to accelerate approaches that support this type of multidimensional health care delivery.

Rethinking Job-Connected Health Insurance

During the past seven months, the pandemic has magnified the risks to the more than 160 million people who have their health security connected to their jobs. In fact, it’s estimated that as many as 14.6 million people may have lost their job-connected health insurance benefits. These compounding effects of the pandemic have helped people see that one individual’s health is linked to the health of all, and we need to re-examine the precarious state of job-connected health insurance for people, employers, and our economy. We must rethink our 75-year-old system of job-connected health insurance, which can leave half the US population vulnerable to losing both their job and health security at the same time.

Here again the voice of physicians is crucial. How does the system of job-connected health insurance help or hinder your patients’ ability to access the care they need?

Reflections on 2020 and Looking Ahead

For the overwhelming majority of Americans, 2020 has been a year filled with

Effective Non-Opioid Treatment Evidence-based Biopsychosocial Approach Active Therapy Multidisciplinary Care Team Quality Outcome Reporting

PDR Outcomes

• 67% of patients rate their pain reduction between 50-100% • 74% of patients rate their headache reduction between 50-100% • 64% of patients rate their use of medications decreased 50-100% • 109% increase in Lumbar Extension ROM & strength • 165% increase in Cervical Rotation ROM & strength

Scheduling 952.908.2750 Edina | Chanhassen | Burnsville Coon Rapids | Maplewood

www.PDRclinics.com

3What’s 20% Over the National Norm? from cover issues report that improvements in access/options are almost impossible to some troubling trends regarding the region’s health care infrastructure. now to protect our community and the patients we serve. Our region is not unique in struggling with these issues and our findings Because of CentraCare’s size and many contributions to the community, may be of interest to health care providers in identifying solutions that are acceptable to all other areas with similar demographics. In order health care providers as well as to employers and to promote continuous quality improvement and policy makers has been challenging. other innovation through competition – which obtain once a critical mass of consolidation has occurred. Hence, our efforts maintain and foster a strong, community-based health care infrastructure -- Minnesotans in St. Cloud and beyond should be able to choose their physician and have options for choosing the location of their care. This is important for many The cost of healthcare in the St. Cloud market, for 2019, was 19.6% higher than the national average. However, with the recent closure of the HealthPartners clinic in St. Cloud this fall, and the pending closing of Physicians Neck and Back Clinic at the end of 2020, the concerns have been heightened, not only by CMHI, but also by employers and public reasons, including: privacy concerns, to assure officials concerned about health care costs and the continuity of care, and preserve trust between necessity to be focused on continuous excellence in physician and patient to ensure quality care. all health care services provided. Further, many patients are uncomfortable navigating a large health network The HealthPartners clinic in Sartell, which was closed by its parent and specifically seek out smaller clinics. company in Bloomington, provided a critical alternative option for primary

Rapidly expanding healthcare systems across the country are increasingly care -- including prenatal care -- and was a clinic that received high marks using their immense and expanding market power to limit healthcare choices. in several quality surveys over the years, challenging other local physicians This is not in the best interests of communities over the long term. An to compete with their exceptional standards. example of such a rapidly expanding system is that of CentraCare in Central Across America, studies have shown that consolidation of health care is Minnesota. As a result of their expansion and consolidation of the local and contributing to costs in general. According to information shared earlier this regional market, our region is experiencing higher health care costs and the year by the St. Cloud Area Chamber of Commerce, Central Minnesota is erosion of patient choice and access. Studies of such health care marketplace experiencing higher health care costs when compared to other areas. The Cost of Living Index compiled by The Council for Community and Economic Research shows that the cost of healthcare in the St. Cloud market, for 2019, was 19.6% higher than the national average. Comparatively, healthcare costs are just 5.5% above the national average in Minneapolis and 6.1% above the national average in St. Paul. (Report published February 2020 for calendar year 2019, comparative data for 266 cities).

Physician Coaching That Works! Just as top professional golfers improve by hiring a swing coach, physicians can improve by hiring a professional coach.

- Physician in Crisis? - Provider Suffering from Burnout? - Practice Partnership Challenges? - Develop Physician Leaders - Need to Improve Metrics?

24 years of experience have proven our evidence-based coaching consistently produces positive outcomes. Coaching Works! Even in the most challenging situations.

Call for a FREE consult.

Timothy R. McClernon, Ph.D. CEO, Managing Partner 612.321.8066 (cell)

Learn more: PeopleArchitects.com

Physician Coaching Leadership Coaching Clinical Team Building

According to the Chamber, “The index measures regional differences in the cost of consumer goods and services, excluding taxes and nonconsumer expenditures, for professional and managerial households in the top income quintile. It is based on more than 50,000 prices covering almost 60 different items for which prices are collected three times a year by the St. Cloud Area Chamber of Commerce. The composite index is based on six components - housing, utilities, grocery items, transportation, health care and miscellaneous goods and services.”

Legislative and employer-funded research from across the nation indicate that health care costs increase as a geographic area’s health care services/ providers consolidate. Consolidation, especially with the sale of the St. Cloud Medical Group a few years ago and now the closure of the HealthPartners Clinic, is one of the troubling trends which the CMHI providers believe needs to be addressed by the community. The group has looked at some of the laws enacted in other states in hopes of curbing the escalating sales of physician practices to large hospital systems.

In September of this year, the Rand Corporation released “Rand 3.0” which finds that consolidation is “a key contributor” to increased prices and price variability, recommending that “...employers can support efforts to promote competition in health care markets by opposing consolidation among existing providers and by promoting entry of new, lower-priced providers.”

Additionally, the experience of healthcare providers during the COVID- Simplicity Health clinic remained open during the entire pandemic closures 19 pandemic has reinforced our belief that independent, smaller, and more during the Spring of 2020. nimble providers are an important part of the healthcare system that must Because of CentraCare’s size and many contributions to the community, be protected. At a recent, virtual meeting of the St. Cloud Area Chamber, identifying solutions that are acceptable to all health care providers as independent providers gave examples of their well as to employers and policy makers has been flexibility – due in large part to their smaller challenging. Certainly, the community deserves size – to adapt to the safety needs created by state a vibrant hospital system that can serve as a mandates and patient concerns. critical regional center for our surrounding towns. For example, the physicians at St. Cloud Orthopedics met daily during the beginning of the Health care costs increase as a geographic area’s health care However, innovation flourishes and quality is enhanced when patients have access to alternative crisis to make decisions without delay for patients services/providers consolidate. healthcare choices and we believe that competition that needed care. While the situation was urgent leads to greater effort. for some individual patients, the urgency regarding As leaders of CMHI, we hope to initiate further the shortage of personal protective equipment discussion on several problematic trends which, if (PPE) and the lack of definitive knowledge on how reversed in a collaborative manner, can lead to the exactly the coronavirus was spreading, required vibrant, high quality health care delivery system decisive and timely action to respond to each patient’s situation. which will benefit our community is so many ways. The following are areas

St. Cloud Surgical Center expanded its safety and cleaning protocols and we have identified as needing improvement to help redirect the troubling then continued to adjust them, without delay, as more scientific information trends we discussed earlier, both in Central Minnesota and nationwide; was made available. Because the physicians who use the Surgical Center Issues of concern: offer a variety of services, it was critical that each procedure and each patient could receive customized care at truly a time of crisis. • Encouragement of patient choice and privacy - Example: Ending

Another example of highly valuable nimbleness by a small provider was seeing independent practitioners Simplicity Health. The primary care clinic was first in the community the practice of financially penalizing employees and families for to provide electronic (telehealth) office visits and car visits to ill patients. What’s 20% Over the National Norm? to page 344

STATE OF THE ART CARE FOR OUR TINIEST PATIENTS

Community support helped build a technologically advanced, state-of-the-art NICU that feels like a home to our patients and their families, giving them privacy and comfort while improving outcomes.

EAPC.NET/EH-NICU