Minnesota Physician • March 2020 by Minnesota Physician Publishing

MINNESOTA

MARCH 2020

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIII, No. 12

Improving access to care Expediting the licensure process BY JON THOMAS, MD, AND RUTH M. MARTINEZ, MA

he Interstate Medical Licensure Compact went live in 2015 after the law was passed by seven states (Alabama, Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming). That same year, Minnesota became the eighth member state when the Minnesota Legislature unanimously passed the law, and 29 states, the District of Columbia, and the Territory of Guam have now joined the agreement. In October 2015, member states met for the first time as the Interstate Medical Licensure Compact Commission. Their task was to develop the expedited licensure process, codified in statute for eligible physicians, that improves license portability and increases patient access to care. In April 2017, about a year and a half after that first meeting, the first license was issued through the Compact. Minnesota has issued hundreds of expedited licenses through the process. Until recently, though, the Minnesota

Surprise billing Causes and potential remedies

Improving access to care to page 124

BY ROBERT W. GEIST, MD

he $25,000 surprise bill arrived after the patient, himself a physician, had a radical prostatectomy and was discharged from the hospital two days after surgery.

We will examine why surprises occur, the congressional fights over price-fixing panaceas, why price fixing never works, and other possible remedies that do not involve price fixing.

Surprises big and small The post-op big surprise was created by federal regulation. If the skill of the surgeon gets you out of the hospital in two days instead of three days or more, you pay more. Why? Surprise billing to page 104

MARCH 2020 MINNESOTA PHYSICIAN

NNESOTA’S MI

MARCH 2020

REQUEST FOR NOMINATION

Volume XXXIII, Number 12

COVER FEATURES

Surprise billing

Improving access to care Expediting the licensure process

Causes and potential remedies

By Robert W. Geist, MD

By Jon Thomas, MD, and Ruth M. Martinez, MA

DEPARTMENTS CAPSULES

INTERVIEW

Advocating for patients and providers Rahul Koranne, MD, MBA, FACP Minnesota Hospital Association (MHA)

VALUE-BASED REIMBURSEMENT 14 Integrated Health Partnerships v2.0: A win-win for patients, systems

By Mathew Spaan, MPA, and Sara Bonneville, MS, MPP HEALTH CARE QUALITY REPORTING 16 Re-evaluating “performance” measurement Minnesota’s teachable moment

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

BEHAVIORAL HEALTH 20 Project 2025

In our November 2020 edition, Minnesota Physician will profile 100 of

Partnering with physicians to reduce suicide

photos, bios, and quotes, we will highlight the men and women most

By Christine Moutier, MD, and Alex Karydi, PhD

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

LONG-TERM CARE 22 Developing an Assisted Living Report Card A mandate of the 2019 ElderCare Act

By Tetyana P. Shippee, PhD; Tricia Skarphol, MA; and Odichinma Akosionu, MPH NEPHROLOGY 26 Dialysis 2020 A look inside the black box By Jennifer Cramer-Miller

our state’s most influential health care leaders. In a format featuring responsible for making Minnesota a global model for health care delivery. business executives, political leaders, policy analysts, etc. We invite you, our readers, to participate in this recognition process. If you know anyone within your organization you feel should be considered, please fill out the form below and mail it or submit online (www.mppub. com/top100.html) or via e-mail (comments@mppub.com) prior to September 25. We welcome your input and participation in making this list as comprehensive and meaningful as possible.

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

By Kip Sullivan, JD

Nominee’s title: Nominee’s affiliation:

Brief description of the nominee’s work and influence:

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 MARCH 2020

CAPSULES

Information blocking and interoperability rules under review by AMA Since last year’s release of proposed rules from the Office of the National Coordinator (ONC) and Centers for Medicare and Medicaid Services (CMS) implementing the 21st Century Cures Act’s provisions on information blocking and interoperability, the American Medical Association (AMA) has engaged regularly with policymakers to refine the proposals so they meet the needs of patients and physicians. “As the AMA reviews the new rules, we will pay special attention to policies aimed at creating efficiencies in data exchange, reduction in physician burden, and patient control over and access to their data,” said AMA President Patrice A. Harris, MD. The AMA’s review will examine: • Privacy controls requiring transparency and security

• More clarity and a reduction in the complexity of information-blocking exceptions for physicians.

safeguards for patients who access health information apps. • Rules prohibiting vendors from charging excessive fees.

• Less aggressive and separate EHR implementation timelines for vendors and physicians.

• A usage-based fee structure to limit EHR vendor fees and prevent physicians from incurring costs for exchanging health data that complies with federal requirements.

Pediatric Home Service, RSVP Home Care form new partnership

• Programming tools to improve physician and patient access to health information. • More stringent requirements on EHR testing and usability. • Limiting unnecessary and inappropriate access to EHR data from insurers and other non-clinical entities.

Pediatric Home Service (PHS), an independent comprehensive home care provider, recently partnered with RSVP Home Care, a pediatric specialist group serving patients in Ohio and Kentucky. RSVP Home Care and their adult division, Pulmonary Partners, provide specialized in-home enteral nutrition, respiratory care, and equipment to patients. For the next six to 12 months, RSVP Home Care will carry a cobrand with PHS before transitioning

to a unified brand under the Pediatric Home Service name. Pulmonary Partners will maintain the existing name. “Our shared values and critical eye for quality is why we choose to partner with RSVP Home Care,” said PHS’s Chief Clinical Officer Judy Giel. “RSVP Home Care team provides care that mirrors the level and expectations we have for our teams. As such, clinical and operational teams from each organization will remain in place.” Patients will not see a disruption in services or care. Their primary clinician, access to equipment and supplies, billing, and ordering will remain consistent.

Nura Pain Clinic expands its facilities Nura Pain Clinics’ newly renovated site at 7400 France Avenue in Edina makes it the Twin Cities’ oldest— and now newest—multi-disciplinary

MEDICAL MALPRACTICE ATTORNEYS

Angela Nelson

MARCH 2020 MINNESOTA PHYSICIAN

Ryan Ellis

Marissa Linden

Jennifer Waterworth

CAPSULES

pain clinic. Nura is now the sole occupant of the 20,000-square-foot facility, which offers comprehensive pain management treatment, including chronic pain evaluation, medication management, physical therapy, and behavioral health counseling, as well as interventional pain procedures and surgeries. This multi-disciplinary approach benefits patients who otherwise may receive fragmented and poorly coordinated pain management by multiple providers at multiple locations, according to David Schultz, MD, Nura’s founding physician. Schultz also cited Nura’s use of implantable pain control options of neurostimulation and precision-targeted drug delivery, both of which provide new treatment modalities as practitioners pursue alternatives to opioid-based treatments for patients with complex chronic pain. Renovation highlights include two state-of-the-art operating rooms; a warm, salt-water pool for physical therapy; an onsite research division; and a more patient-friendly layout for those undergoing treatment, as well as their family members and friends.

Nursing homes invest $6.7 million annually in improvements More than 100 nursing homes across Minnesota have begun kicking off 36 projects to promote better care and quality of life for their residents. The projects, funded by the Minnesota Department of Human Services (DHS), range from efforts to improve mental health and social connections to reducing falls and infections. At $6.7 million per year, the Performance-based Incentive Payment Program (PIPP) provides up to 5% in additional operating payments to nursing homes throughout the state. PIPP lets nursing homes dedicate resources to quality improvement and requires them to meet specific goals related to care, resident quality

of life, workforce, and other issues. Since 2006, the program has funded more than 300 projects. Eighty percent of Minnesota nursing homes have participated. “Collectively, these performance improvement projects make a big difference and improve the lives of thousands of nursing home residents,” said Minnesota Human Services Commissioner Jodi Harpstead. “We’ve seen ground-breaking improvements in areas like resident sleep quality and falls prevention. Nursing facility staff are invested in making improvements and excited about sharing successes with their peers.” This round of PIPP funding goes to organizations across the state during fiscal year 2020.

New development will include senior living units North Memorial Health and Ryan Cos. plan to build a mixed-use development that will include 400 units of multifamily living and 150 units of senior living on a 100-acre site in Maple Grove. The plot is centered around Maple Grove Hospital, and the development includes additions to the hospital. It will be one of the largest developments in city history, according to a report Ryan sent to the Maple Grove Planning Commission. The plans refer to the site as the “Minnesota Health Village.” The plans say Maple Grove Hospital could get either a direct expansion, smaller medical office buildings—which would serve in a supportive capacity—or both. In all, the development calls for 339,350 square feet for health care use (which could be part of the hospital expansion, or could be used for non-hospital health care space like a clinic) and 302,400 square feet for medical office space. The current plans are subject to change and have to be approved by the Planning Commission.

MAR 1

Pieta Brown & David Huckfelt

Ethereal Roots Songwriting

MAR 8 BeauSoleil avec Michael Doucet

Louisiana French Music

feat. Petra Haden, Hank Roberts & Luke Bergman

MAR 2

Bill Frisell: HARMONY Jazz Guitar Giant

MAR 9-10

David Sanborn Jazz Quintet Influential Contemporary Sax Giant

feat. Chieli Minucci, Eric Marienthal, Karen Briggs & Lao Tizer “All Stars” Album Release

MAR 11

Special EFX All-Stars

Blistering Blues Guitar

Top Shelf Contemporary Jazz

MAR 17-18

Altan

MAR 20

SFJAZZ Collective Celebrates Miles

Davis’ “In a Silent Way” & Sly and the Family Stone’s “Stand!”

St.Patrick’s Celebration

MAR 26

Tinsley Ellis Searing Blues-Rock Guitar “Ice Cream In Hell” Album Release

Jon Cleary

Ana Popovic

MAR 15

APR 1

NOLA Piano Master

612.332.5299 dakotacooks.com

Walter Trout

MAR 30

Canned Heat Guitarist

Chris Botti

APR 2-5

International Jazz Superstar

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CAPSULES

CIDRAP launches COVID-19 resource center The Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota has launched an online CIDRAP COVID-19 Resource Center that provides information for public health experts, business preparedness leaders, government officials, and the public regarding the novel coronavirus disease (COVID-19). The CIDRAP COVID-19 Resource Center will highlight the latest news developments, relevant scientific literature, and guidance from leading agencies, including: • Frequently asked questions on COVID-19, including how the virus is transmitted, what you can do to reduce exposure, and when we can expect a vaccine.

• Relevant information for employers. • A comprehensive bibliography. • Up-to-date news from the U.S., across Asia, and around the world. • Links to COVID-19 content on websites from the U.S. Centers for Disease Control and Prevention, the World Health Organization, and other key agencies. • Links to the latest maps, case counts, epidemiologic curves, and other useful data. • The COVID-19 Resource Center is made possible with support from the University of Minnesota Office of the Vice President for Research and the Bentson Foundation.

Report shows progress in follow-up depression care, antibiotic overuse In its “2019 Minnesota Health Care Quality Report” (online at https://tinyurl.com/hcn2mncm), MN Community Measurement cites encouraging signs in two key areas: Depression care. Rates of follow-up depression care, improvement of symptoms, and remission measured at 12 months all increased significantly compared to the 2018 report. The statewide average for the depression follow-up measure improved to nearly 30 percent, although four medical groups (HealthPartners Central Minnesota Clinics, Essentia Health, Park Nicollet Health Services, and Entira Family Clinics) achieved rates above 50 percent for this measure. Two medical groups (HealthPartners Clinics and Park Nicollet Health Services) achieved rates above

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the statewide average for all eight depression measures included in the report, and an additional four medical groups (Entira Family Clinics, Essentia Health, HealthPartners Central Minnesota Clinics, and Mankato Clinic) achieved above-average rates on seven of the eight measures. Avoiding overuse of antibiotics. When a patient takes antibiotics that are not medically necessary, it can cause negative side effects and lead to antibiotic resistance, one of the most urgent ongoing threats to the public’s health. Fortunately, avoiding antibiotic treatment in adults with acute bronchitis improved from 35.8% to 45.5%, with gains occurring broadly across many medical groups.

Patients with regenerative medicine questions?

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

Regenerative medicine treatment categories at MRM include: • Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine) • Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING • Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT

8 Hogue Clinics locations in Minnesota www.mregm.com • (763) 447-2500 or Toll Free (866) 219-4699 MINNESOTA PHYSICIAN MARCH 2020

INTERVIEW

Advocating for patients and providers Rahul Koranne, MD, MBA, FACP Minnesota Hospital Association (MHA) How will your perspective as a physician help inform your leadership of the MHA?

Employers and community service organizations are critical partners in promoting population health. The growing trend of employers offering wellness programs helps enhance health and reduce overall costs. Community organizations enhance health in many ways, from stocking food shelves to offering community wellness programs to training neighbors on mental health first aid.

MHA’s new vision statement is that Minnesotans are healthy and have access to the right care at the right time in the right place. To achieve this bold vision, everyone in the delivery system—clinicians, other professionals, leaders, volunteers, and board members—must deeply collaborate. I have been privileged to serve as a physician and leader across almost all the parts of the care continuum, from Minnesota’s smallest hospital system to one of its largest integrated delivery networks. These experiences guide how I live MHA’s mission and values every day.

Payers and providers must work together to serve patients. If a patient’s insurance plan includes a covered benefit, they expect to be able to use their insurance for that medical service. We are part of a coalition that includes the Minnesota Medical Association, the Minnesota Ambulatory Surgery Center Surgery Association, and other provider and specialty groups supporting legislation to improve the prior authorization process. Patients feel anxiety waiting for necessary procedures to be approved. Providers experience unnecessary delays, adding frustration and administrative costs to the health care system. The coalition does not seek to prohibit the use of prior authorization, but to have a smarter process that works for all stakeholders—providers, employers, payers, and, most importantly, patients. Another policy issue is “surprise billing.” What can you tell us about this?

MHA supported passage of a Minnesota law protecting patients from surprise bills. The law, which took effect Jan. 1, 2018, limits patients’ financial responsibility to the amount they would have paid for in-network services, ensures patients have access to emergency care, and requires a health plan and nonparticipating provider to negotiate payment. We believe this has helped hold down surprise bills in Minnesota.

MARCH 2020 MINNESOTA PHYSICIAN

“...” I am passionate about strengthening collaboration across the health care continuum. “...”

Prior authorization has generated proposed legislation at both the state and federal levels. What is MHA’s position?

What role can patients themselves play in shaping the future of health care?

What can you tell us about MHA’s work with other health care stakeholders and your initiatives to accelerate this collaboration?

Strong partnerships across all health care industry stakeholders are critical to MHA’s new mission: “Advance the health of individuals and communities through leadership, advocacy and collaboration on behalf of Minnesota hospitals and health systems.” I am passionate about strengthening collaboration across the health care continuum— insurers; federal, state and local government agencies; and community organizations in the health and social service sectors. One example is MHA’s active collaboration with the Minnesota Department of Health (MDH) to disseminate timely resources related to COVID-19. How do you see the role of employers and community service organizations in shaping the future of health care?

Just over 50% of Minnesotans receive health care coverage through their employers, so employers play a crucial role in ensuring that coverage options meet the needs of their workforce.

Patients are our most integral partners in shaping the future of health care. MHA’s new vision highlights patients’ position at the center of the health care experience and is focused on the health and well-being of individuals. Most health systems in Minnesota have active patient and family advisory councils that help patient and family voices influence care improvement. Minnesotans are engaging in the dialogue about how providers, payers, employers, suppliers, individuals, and government can improve the quality of care while reducing overall cost. Please tell us about your work with the Department of Human Services (DHS) to improve the quality of care for mental and behavioral health patients.

Since 2015, MHA and our partners have helped secure additional state funding for the entire mental health continuum, from upstream services like school-based mental health to the state’s community behavioral health hospitals and Anoka Metro Regional Treatment Center. Stateoperated services have increased capacity, helping patients access the right care at the right time in the right place. We also strongly supported the federal Excellence in Mental Health Act, which funded community-based mental health services that work with hospitals and health systems to ensure that mental health care is accessible in local communities. You launched the Health Care and Law Enforcement Coalition to improve care for individuals involved with law enforcement. Please tell us about this work.

This coalition convened in August 2016 to build relationships between health care and law enforcement organizations. Together with the Minnesota Department of Health and the Minnesota Sheriff ’s Association, hospital security, police departments, county sheriff offices, and hospital EMS, we created a roadmap (https:// tinyurl.com/mha-roadmap) of best practices and resources that help leadership and direct care staff to improve collaboration between health care and law enforcement and help provide safety and security for patients, families, and providers while creating a compassionate and healing environment. Minnesota has been recognized by CMS as a high-performing state for health care. How has your work tied into this recognition?

In 2019, MHA and partners from Illinois, Michigan, Minnesota, and Wisconsin formed a new quality improvement organization, Superior Health Quality Alliance, which aims to improve the quality of health and health care for patients, clinicians, health care organizations, and communities across our state and beyond. I am excited to share our work and learn from others

so the health of individuals across this region can continue to improve. Hospitals in Greater Minnesota face many unique challenges. What can you tell us about these issues?

I had the privilege of working in Minnesota’s smallest critical access hospital system for five years. I know personally that hospitals and health systems work hard to provide the right care at the right time in the right place while ensuring high quality and patient safety. Hospitals and health systems continuously adjust their service lines depending on the needs in their community, which services are better provided at a larger nearby hospital, and the skills and experience of their health care workforce. The roles of governmental and commercial payers, employers, individuals, and suppliers are just as critical in reducing overall costs and ensuring adequate access. It is difficult for not-for-profit health care providers to reduce overall costs without the support of these partners. When it comes to reducing overall health costs in Minnesota, we are all in it together.

Three patients. Who is at risk for diabetes?

There are sometimes conflicts in how physicians and hospitals approach shared problems in health care delivery. What are some examples and potential solutions?

Minnesota is consistently ranked as one of the best states for physicians to practice. MHA’s work on reducing health care burnout since 2016 shows high levels of engagement, satisfaction, and values alignment between physicians and health system leadership. Over the past 21 years, I have leveraged these shared values to continuously improve patient care and the health of Minnesotans. Good partners sometimes have healthy, respectful conflicts to make the overall system even better. I have found that when you consistently keep patients at the center of decision-making, finding effective, shared solutions becomes the most important goal. Rahul Koranne, MD, MBA, FACP, is the new president and CEO of the Minnesota Hospital Association (MHA). He guides the association’s work to advance the health of individuals and communities through leadership, advocacy, and collaboration on behalf of Minnesota hospitals and health systems.

When there are no signs or symptoms, you may not know until it’s too late. Act now. Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk. • Refer your at-risk patients to a proven lifestyle change program and help cut their risk of developing type 2 diabetes in half.

1 in 3 adults are at risk!

• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications. Find groups in Minnesota at www.health.mn.gov/diabetes/programs

Minnesota Department of Health DIABETES PROGRAM

MINNESOTA PHYSICIAN MARCH 2020

3Surprise billing from cover Because under Medicare regulation, two days is not considered a hospital admission; the regulators have named this fantasy “observation,” as if it was completely different from any other hospital stay. Why would two days in the hospital be different from three? Because Medicare is then off the hook for post-hospitalization rehabilitation care. (That is what happened to my wife’s hospital roommate; “observation” cost her a $32,000 surprise for necessary prolonged rehabilitation.) The hospital can also benefit; regulation allows the hospital to balance bill observation patients for as much as 20% of the “observation” costs and thus can supplement the low Medicare payment received. Bingo! A $25,000 surprise! Discharge quicker (or even sicker) may cut Medicare costs, but this can be a particularly cruel regulatory joke.

anesthetist after a colonoscopy done by an in-network doctor in an outpatient facility advertised as in-network. For a surprised network patient, who assumes that they were in-network, this amounts to false advertising. No surprise; the consensus is that these “surprises” are unfair. It is estimated that 40% of patients were hit with a surprise bill in 2018.

The surprise billing perpetrators

[If you get] out of the hospital in two days instead of three days or more, you pay more.

A second, more common type of big surprise bill scenario is described by Doug Badger, former White House and Senate health policy expert: “… even if someone goes to the emergency room at a hospital in their insurance network, if the doctor on duty that night happens to be out-of-network, the patient could suddenly be faced with a bill that is thousands of dollars—and not covered by their network insurance.” Other common surprise balance billings may involve an elective procedure. The surprise bill may come from an independent non-network

Regardless of the type of surprise billing, it seems clear that all the players involved are gaming the system, i.e., the mercenary Medicare regulators, hospital systems, and commercial insurance corporations. If networked systems of insurance corporations offer inadequate network medical coverage, patients will continue to find non-network physicians as a source of their surprise bills.

Non-network doctors are not in the networks for good reason; they do not want to accept inadequate working conditions and/or pay. The actual perpetrators of surprise billings have inferred that doctors are to blame. With good intent, Congress and the administration want to protect patients from alleged victimization.

Legislation and positions The political response. In 2019, a bipartisan “No Surprises Act” was introduced in Congress. It mandated fixed in-network insurance carrier median prices, which non-network doctors must accept. For the first time, Congress seemed poised to impose Medicare-like provider rate-fixing mandates onto private contracts. The winner would be the network corporation with non-negotiable pay rates and low payroll costs. The victims would be the non-network doctors and their predictable absence would decrease patient access to quality care. No surprise; a war over how to fix prices then erupted between insurance carriers (self-described “payers”) and providers of hospital system and of doctor services.

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The “payer” position. Insurance corporations, (aka, Managed Care Organizations or MCOs) favored the “No Surprise Act.” They argue that fixed rates would eliminate surprise billings. A question: would federally price-fixed services imposed on non-network clinicians eventually be imposed on in-network clinicians? Potentially, this could be a boon to low corporate payrolls, profitability, and industry stock market prices. The provider position. The American Hospital Association (AHA) and clinicians propose instead to use more flexible government-certified independent “baseball-style” (two party) arbitration to fix payment rates. Is there a better alternative? We’ll explore some later. Meanwhile, the price-fixing war continues.

Past price-fixing failure Insurance corporations, whether the mini ACO (hospital-staff Accountable Care Organization) or mega MCO model, often claim that their calling is to be stewards of the nation’s medical money. Fixing prices of medical goods and services prices is thus “necessary.” Did it ever work? Not in the history of the world, nor in the history of U.S. medicine after price fixing began in the 1970s.

Federal price fixing of Medicare and Medicaid services and HMO low “negotiated” prices of clinician services for over five decades has never put a dent in medical market cost inflation. Various delay and denial barriers to care are more effective for rationing use of premium dollars. Over decades, the adverse effect of fixing low prices and other onerous regulations has put many primary care clinics out of business and driven doctors into employment in large merged hospital systems, if not into retirement. Curiously, the battling price fixers, the corporate insurance carriers and provider hospital systems, boast that patients are spared from being involved in haggling over money, i.e., patients’ premium and tax money.

profit-driven rationing barriers, which often masquerade as “conserving the nation’s scarce resources.”

Any alternative to price-fixing surprises? Can patients be protected from nasty medical care surprise billings without futile price fixing? Why not?

Forty percent of patients were hit with a surprise bill in 2018.

Hidden contracting between corporation giants instead of open contracting between patient and doctor ought to be a warning. It is scary, when price fixers claim they are protecting anyone but themselves, and when patient choices guided by price are suppressed by the appearance of “free” prepaid care. Lack of transparent prices for patient services is a popular part of the prepaid care game, but the results may not be pretty. When prepaid services appear to be “free,” and patients are “nobly” spared corporate money haggling disputes, the delayed results observed have been increased demand, increased premium prices with rising deductibles, futile price-fixing panaceas, and rationing through lengthening queues for ill patients. It is the ill, once the object of medical care, who suffer onerous

Emergency treatment. In emergency care situations, Doug Badger and co-author Brian Blaze note that it is neither feasible nor useful to predict the costs. They recommend that Congress should amend the Emergency Medical Treatment and Active Labor Act (EMTALA) to “…reserve rate-setting to the circumstance in which a patient receives emergency care at a non-network hospital.” Would this be a fix for surprise billings? Maybe for some, but not in carrier network hospitals, as we have already seen.

An unexplored statutory solution for Minnesota and other states would be that those carriers with inadequate personnel to cover the services in its facilities be mandated to pay the fees of non-network providers; a realistic patient protection objective. Elective treatment. A pre-procedure contract price is the remedy to eliminate surprise billings. Badger and Blaze suggested that, “Providers who don’t give patients a good faith estimate in advance would be prohibited from Surprise billing to page 344

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

MINNESOTA PHYSICIAN MARCH 2019

3Improving access to care from cover

requires an applicant to meet the following statutory requirements in order to receive a Letter of Qualification. Applicants must:

Board of Medical Practice (Board) was not a full participant in the 1. Be a graduate of a medical school accredited by the Liaison Compact. It did not have approval by the Federal Bureau of Investigation Committee on Medical Education, the Commission on (FBI) to perform criminal background checks, Osteopathic College Accreditation, or a a necessary requirement for full participation medical school listed in the International in the Compact. Prior to the FBI’s approval of Medical Education Directory or its recent state legislation, the Board could issue equivalent; expedited licenses for providers in other states 2. Have passed each component of the United that had issued Letters of Qualification, but The Board found itself within the States Medical Licensing Examination could not issue Letters of Qualification for crosshairs of the FBI. (USMLE) or the Comprehensive Osteopathic applicants within the state. Minnesota licensees Medical Licensing Examination (COMLEXnow have the opportunity to fully participate in USA) within three attempts, or any of its the Compact process. predecessor examinations accepted by a state Individual physicians and large systems will both benefit from this development. For example, Mayo Clinic Health System is now able to license its physicians and export its expertise in multiple states. Minnesota physicians practicing in regional health care systems or who primarily practice telemedicine will also benefit from portability.

Letters of Qualification The Compact law sets forth the qualifications for participation pursuant to a Letter of Qualification and outlines the process for physicians to apply for and receive expedited licenses in member states. The Letter of Qualification serves as the ticket to expedited licensure in other states. Qualification

medical board as an equivalent examination for licensure purposes; 3. Have successfully completed graduate medical education approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association; 4. Hold specialty certification or a time-unlimited specialty certificate recognized by the American Board of Medical Specialties or the American Osteopathic Association’s Bureau of Osteopathic Specialists; 5. Possess a full and unrestricted license to engage in the practice of medicine issued by a member board; 6. Never have been convicted, received adjudication, deferred adjudication, received community supervision, or deferred disposition for any offense by a court of appropriate jurisdiction;

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7. Never have held a license authorizing the practice of medicine subjected to discipline by a licensing agency in any state, federal, or foreign jurisdiction, excluding any action related to nonpayment of fees related to a license; 8. Never have had a controlled substance license or permit suspended or revoked by a state or the United States Drug Enforcement Administration; and 9. Not be under active investigation by a licensing agency or law enforcement authority in any state, federal, or foreign jurisdiction.

The problem An additional statutory requirement of the Compact law is for performance of an FBI criminal background check of an applicant that “includ[es] the use of the results of fingerprint or other biometric data checks compliant with the requirements of the Federal Bureau of Investigation, with the exception of federal employees who have suitability determination in accordance with Code of Federal Regulations, section 731.202.” Although Minnesota was an early adopter of the Compact, the Minnesota Board of Medical Practice was unable to perform the criminal background check required in order to issue a Letter of Qualification. In the process of implementation of the Compact law, the Board found itself within the crosshairs of the FBI. The FBI raised concerns that Minnesota law enabled sharing of criminal history record information (CHRI). The Board had never intended to share such information with anyone outside of government, but the state was still unsuccessful in obtaining approval from

MARCH 2020 MINNESOTA PHYSICIAN

the FBI to conduct criminal background checks for current licensees seeking to participate in the Compact process. The criminal background check was mandatory for processing a Letter of Qualification. The FBI explained that changes to Minnesota law—as well as laws in three other states—were necessary to specifically address their concerns. The Board committed itself to addressing the concerns raised by the FBI. Unfortunately, the FBI was not able to provide statutory language that would be acceptable. They would only agree to review language after it had been presented to the Legislature. Over the course of three legislative sessions in 2017, 2018, and 2019, the Board worked with the Minnesota Bureau of Criminal Apprehension, Minnesota’s liaison to the FBI, representatives from the Minnesota Medical Association, and state legislators to amend statutory language responsive to the FBI’s concerns.

This process should also facilitate the deployment of telemedicine. Minnesota has a telemedicine registration that allows physicians in other states to practice via telemedicine, provided they don’t set up shop in this state. Each state has varied requirements for telemedicine practice.

Concerns and clarifications

The criminal background check was mandatory.

In 2017, the Minnesota Legislature passed an amendment to the Medical Practice Act intended to address the FBI’s concerns. The FBI reviewed the language in July 2017 and communicated its conclusion that the amending language did not satisfy the parameters of Pub. L. 92-544, the federal criteria for performance of criminal background checks, as outlined below: • The statute must exist as a result of a legislative enactment; • It must require the fingerprinting of applicants who are to be subjected to a national criminal history background check;

Critics of the Compact process have expressed concern that the expedited licensing process would compromise state sovereignty. However, the Compact only impacts the administrative process of issuing licenses and does not impact states’ authority to regulate and enforce medical practice standards and state laws. The process maintains a state’s sovereignty.

Critics also expressed concern that the Compact would compromise patient safety by preventing regulation across state lines. They argued that under current state laws a problem physician could continue to practice in another state until the complaint was adjudicated and made public. They also argued that complaint and investigatory information isn’t shared freely among the states. Under the Compact, the opposite is true. In fact, the Compact requires establishment of a coordinated information system that requires member states to report and share complaint, investigation, and disciplinary information with other member states. The Compact law also Improving access to care to page 324

• It must expressly or by implication authorize the use of FBI records for the screening of applicants; • It must identify the specific category of applicants/licensees falling within its purview, thereby avoiding overbreadth; • It must not be against public policy; and • It must not authorize receipt of the CHRI by a private entity. The FBI found that Minnesota’s statutory authority to perform criminal background checks for health care professionals seeking licensure was limited to new applicants for licensure and did not include authority to perform criminal background checks for current licensees. As a result, the Board continued to pursue legislation to address the FBI’s ongoing concerns. Additional amendments were passed by the Minnesota Legislature in May 2019.

The solution In January 2020, three years after implementation of the Compact and following several modifications to state laws, Minnesota received the FBI’s approval to obtain criminal background check information for the purpose of full participation in the Interstate Medical Licensure Compact. Prior to the FBI’s approval, the Minnesota Board was limited to issuing expedited licenses to incoming applicants from other member states but was unable to issue Letters of Qualification to current Minnesota licensees. As a full participant in the Compact process, Minnesota physicians will now have access to the Compact process of expedited licensure. This will allow Minnesota physicians to be better positioned to serve patients by removing barriers and enabling access to qualified medical care. MINNESOTA PHYSICIAN MARCH 2019

VALUE-BASED REIMBURSEMENT

Integrated Health Partnerships v2.0: A win-win for patients, systems BY MATHEW SPAAN, MPA, AND SARA BONNEVILLE, MS, MPP Fewer emergency department visits. Fewer hospital stays. More clinic visits. Lower costs—resulting in $401 million in Medicaid savings over six years.

ow are more than two dozen innovative Minnesota health care delivery systems making this happen? They are participating in a state program designed to create incentives to provide highquality, efficient care to people enrolled in Medical Assistance (Minnesota’s Medicaid program) and MinnesotaCare, whether through managed care organizations or fee for service. The Integrated Health Partnerships (IHP) program, launched by the Minnesota Department of Human Services (DHS) in 2013 with six providers and 100,000 enrollees, now has 25 health systems and nearly 440,000 enrollees. This means that nearly 40% of Minnesota’s approximately 1.1 million Medicaid and MinnesotaCare beneficiaries receive their primary care through an IHP. By incentivizing providers to be innovative and improve care delivery, the program helps achieve the Institute for Healthcare Improvement’s Triple Aim of improving the experience of care, increasing the health of populations, and lowering per capita costs. At the same time, providers maintain flexibility to meet the needs of their respective communities.

How the program incentives work Health care delivery systems that show an overall savings across their Medical Assistance and MinnesotaCare population, while maintaining or improving the quality of care, may receive a portion of the dollars saved. Systems in which health care spending increases over time may be required to pay back a portion of that money. DHS launched the original 2013 IHP program after the Legislature authorized DHS to develop and implement a demonstration project to test alternative health care delivery systems. In fact, Minnesota was one of the first states to implement an accountable care organization model in its Medicaid program. In 2018, DHS launched IHP 2.0, with an added focus on social determinants of health because adults and children enrolled in Medical Assistance consistently face several social risk factors. Adults with substance use disorder or serious and persistent mental illness, experience homelessness, or live in deep poverty (defined as incomes 50% below the Federal Poverty Level) have worse health outcomes. Similarly, worse health outcomes are also experienced by children with a parent who experiences these same factors, or with a parent involved with the child protection system. In addition to the social determinants of health emphasis, IHP 2.0 differs from the original model with the creation of two tracks for delivery systems:

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• Track 1 participants have no shared risk. In other words, there is no potential for shared financial gains or losses. Track 1 is designed for smaller provider groups or independent practices that could not previously participate due to low attribution and lack of capital to take on downside risks. • Track 2 IHPs have shared risk, with the standard risk being reciprocal or equal upside vs. downside. We also built into Track 2 an incentive to partner more directly with community-based organizations, in exchange for greater gain-sharing potential. For example, under a reciprocal arrangement, an IHP may choose to earn half of any savings in a given year up to 8%; however, they would also be on the hook for up to 8% in losses if they came in more expensive than their target. Both tracks offer the benefit of a new payment type, the populationbased payment (PBP), which essentially is a combination of pre-paid savings and the type of payments used in primary care medical home models. The payment is modest, but meaningful, averaging approximately $4.50 per member per month, and is paid quarterly. The payment is tied to specific quality metrics, including health equity metrics. Additionally, the PBP payment amount is directly tied to an IHP population’s clinical and social risk. (See sidebar for details.)

How do systems get rolling on one of these tracks? Through an annual Request for Proposals (RFP) process, potential IHPs submit an application that includes a specific intervention(s) based

on local demographics, social risks, and population health factors. As DHS evaluates proposals, we have an opportunity to work together with the potential IHP to discuss and refine its proposed initiative aimed at addressing social determinants of health. IHPs and DHS are often able to create a dynamic conversation that likely wouldn’t otherwise occur. These conversations enhance system-state relationships. Systems’ proposals must be realistic, data driven (when possible), and integrated into their overall workflow. Systems must also engage in formal, sustainable community partnerships. DHS is a facilitative partner, providing access to robust and timely data, detailed data analytics and reports, and ad hoc support throughout the IHP contract.

county, city, law enforcement, health system, mental health crisis providers, and others. They work together to make policy, system, and environmental changes; address barriers for community members and staff; and provide services directly to community members in county jails and elsewhere with the common goal of providing better continuity of care and helping individuals to achieve better health outcomes. Community members who are incarcerated can receive care through the IHP’s correctional care program located within the jail system, and can Systems that show an maintain that care with the same system through overall savings … receive a any of their clinic locations or through a coordinated portion of the dollars saved. care clinic established specifically to meet their unique needs and circumstances.

Three systems with three different approaches Examples of participating providers: One larger, integrated health system located outside of the Twin Cities has established or joined with other organizations on multiple initiatives. One such partnership has led to the implementation of a multi-level and coordinated approach to address the needs of community members who have contact with law enforcement for behavioral health-related issues. Partners include the

The second is a small, independent health care system located in a federally designated food desert in rural Minnesota. This organization has established at least a half-dozen strategies aimed at addressing a lack of access to healthy foods among lower-income families. Their strategies include screening, program enrollment and follow-up in food shares that can be picked up; home-delivered food shares for older adults; food sent home in schoolchildren’s backpacks for weekends; meals provided upon hospital discharge to reduce readmissions; emergency relief boxes available at all of the system’s clinic sites to any food-insecure patient with immediate needs; Integrated Health Partnerships to page 304

• The magnitude of an IHP’s average per member per month (PMPM) population-based payment is adjusted to reflect its attributed population’s clinical or social risk factors. To adjust the payment for clinical risk (or medical complexity), DHS uses the Johns Hopkins ACG (Adjusted Clinical Groups) risk adjustment tool to identify relative risk and then assign a PMPM amount. • Following the adjustment to the payment for medical complexity, DHS also applies a payment modifier that adjusts the PMPM for social complexity, which is defined as the relative proportion of attributed individuals experiencing certain social risk factors within the IHP’s population. • Once the clinical and social risk adjustments are made, DHS calculates the IHP’s average PBP PMPM. The total quarterly PBP payment is then calculated by multiplying the IHP’s average PBP PMPM by its total attributed member months for the respective quarter. • For Track 2 IHPs, the PBP is added to the total cost of care PMPM for the respective measurement year when calculating the IHP’s total cost of care performance results.

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Details on how population-based payments (PBPs) are determined:

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HEALTH CARE QUALITY REPORTING

Re-evaluating “performance” measurement Minnesota’s teachable moment BY KIP SULLIVAN, JD

easuring and reporting in health care has gone through three phases corresponding roughly to the 1990s, 2000s, and 2010s. During the 1990s, policymakers claimed “report cards” on the quality of clinics, hospitals, and insurance companies should be published so that “consumers” could avoid the bad actors and patronize the good ones. The doomed hospital mortality report card (dubbed the “hospital death list”), published for a few years in the early 1990s by the former Health Care Financing Administration (now CMS), and the useless report card on Minnesota insurance companies published by the Minnesota Health Data Institute in 1995, are examples. In the early 2000s, by which time it was obvious report cards had accomplished little because “consumers” didn’t use them, Minnesota and federal policymakers decided that if report cards were not going to shift market share from the bad actors to the good, then payers (insurance companies, government programs, and self-insured employers) should punish and reward doctors and hospitals directly with bonuses and financial penalties based on report card scores. This new use of report cards was dubbed “pay for performance”

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(P4P) circa 2003. By the late 2000s, quality scores on report cards were being arbitrarily smooshed together with cost scores to create scores that allegedly measured “value.” With a few exceptions (Consumer Reports, CMS’s website), insurance companies were now off the hook; in the new millennium, P4P would apply only to “providers” (doctors, hospitals, nursing homes, etc.). By the late 2010s, the proliferation of P4P and “value-based purchasing” schemes had created a backlash. To take three prominent examples: • In 2017, the Minnesota Legislature enacted a law that required the Minnesota Department of Health (MDH) to re-evaluate a state law passed in 2008 that required MDH to establish a statewide measurement-P4P program. • In 2018, the Medicare Payment Advisory Commission (MedPAC) decided to reverse their earlier support for P4P as it applied to doctors, and recommended to Congress the repeal of the Meritbased Incentive Payment System, a vast P4P scheme inflicted upon doctors who treat Medicare enrollees by the 2015 law known as MACRA (Medicare Access and CHIP Reauthorization Act). • In 2019, the Minnesota Medical Association (MMA) withdrew from Minnesota Community Measurement (MNCM, a group founded by Minnesota insurers and the MMA in 2005 to measure the cost and quality of clinics and hospitals), primarily because MNCM’s measurement system was not improving health. Critics raised three objections to the rising tide of “performance” reporting: 1) it is inaccurate, which unfairly punishes providers who treat sicker and poorer patients and, conversely, unfairly rewards providers who treat wealthier and healthier patients; 2) it imposes high costs on providers; and 3) it aggravates physician burnout. Today, even former proponents of report cards and P4P are asking whether the costs exceed the benefits. They clearly have. There are multiple reasons, the single most important of which is that measurement is grossly inaccurate. Now is the time for Minnesota and federal policymakers to look back over the last three decades and re-evaluate “performance” reporting. Here in Minnesota, MDH should lead the way.

Minnesota’s teachable moment

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The 2017 law authorized MDH to review MDH’s Statewide Quality and Reporting System (SQRMS), a program authorized by legislation enacted in 2008 and implemented in 2010. The 2017 law was so vaguely worded that it gave MDH discretion to do what it thinks best. Here are the instructions for MDH, such as they are, in the 2017 law: “[D]evelop a measurement framework that identifies the most important elements for assessing the quality of care, articulates statewide quality improvement goals, ensures clinical relevance, fosters alignment with other measurement efforts, and defines the roles of stakeholders.” (Minnesota Laws 2017, Chapter 6, Article 4, Section 3). There was additional language requiring MDH to reduce the total number of measurements, but that was it. The law offers no useful information on the problem the Legislature wanted solved, nor on the solution.

The 2008 law was equally vague. It instructed MDH to create a Task Force) and aspirations such as “Individuals should be empowered with information on the quality and cost of care....” (p. 57, Legislative Commission). “standardized set” of quality measures for Minnesota “health care providers” (Minnesota Statutes, Section 62U.02). It also said the measures should This information vacuum would make it difficult for any agency to select be used to punish and reward providers, and MDH should “risk adjust” “performance” measures for SQRMS (MDH currently uses 29), evaluate provider rewards and penalties to reflect the health those measures, and create the “framework” the status of their “populations.” But that’s essentially Legislature asked for in 2017. MDH acknowledged all the Legislature said. Like the 2017 law, the this difficulty in their February 2019 interim 2008 law offered no definition of the problem nor report to the Legislature (https://tinyurl.com/ any information on the solution, that is, on how mp-framework). “The Quality Reporting System Several sessions of the MDH was supposed to measure accurately the has not been paired with an explicit quality Legislature have engaged quality of tens of thousands of services offered by improvement strategy or related goals,” they wrote. in very sloppy policymaking. Minnesota’s 143 hospitals and 25,000 doctors. “As a result, we at MDH do not have firm criteria The reports of the two health care commissions published early in 2008 (the Health Care Transformation Task Force and the Legislative Commission on Health Care Access), both of which urged the Legislature to authorize systemwide quality and cost measurement, were equally vague and baffling. Neither commission identified the problem they wanted solved, and neither offered any details on their proposed solution. Rather than define the problem, the commissions offered sweeping complaints in the most abstract terms possible, such as, “The quality of health care is uneven...” (p. v, Transformation Task Force) and, “The current payment structure is episode driven....” (p. 57, Legislative Commission). Rather than describe solutions, the commissions offered exhortations such as, “We need to come together as a community to agree on what constitutes high quality care” (p. 5, Transformation

for adding and removing measures, and we do not have a good sense for whether measures are impactful....” (p. 7). If MDH doesn’t know what SQRMS’ goals are or whether SQRMS is working, you won’t be surprised to learn that the “stakeholders” MDH has invited to help create the “framework” appear to be equally clueless. In the same report, MDH stated that the “stakeholders” they have interviewed “agree that there needs to be a clear sense of why a Minnesota-specific measurement system is ... needed....” Obviously, they lack that “sense” now. MDH is in this quandary because several commissions and several sessions of the Legislature have engaged in very sloppy policymaking. Those Re-evaluating “performance” measurement to page 184

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3Re-evaluating “performance” measurement from page 17 Transformation Task Force report offered this example to illustrate the “variation” problem: “[T]he percentage of diabetics receiving optimal care policymakers recommended solutions to problems they defined in only the ranges from 1% to 20% across Minnesota clinics.” (p. 4) The task force crudest and most abstract terms; their “solutions” consisted of evidencecited a 2007 report by MNCM for that statistic. free aspirations for “performance measurement” MNCM’s report stated that “optimal diabetes rather than detailed, evidence-based programs; care” was defined as having been received by a and they dumped their evidence-free aspirations diabetic patient who met all five of these criteria: on MDH with the unrealistic expectation that their hemoglobin A1c was less than 7 percent MDH would somehow translate their vaguely The single most important (today it’s less than 8); their blood pressure was articulated aspirations into a useful program. principle of the new “framework” less than 130/80 mmHg (today it’s less than MDH should now do what the Legislature and should be accuracy. 140/90); their LDL-cholesterol was less than 100 multiple commissions have refused to do since mg/dl (today it is “taking a statin”); they were 2008: squarely address the question, Why do we taking aspirin daily (if they were between ages 41 need SQRMS and programs like it? They should and 75); and they didn’t use tobacco. begin by clearly defining the problem they think a measurement scheme like SQRMS can solve, and You don’t have to have a PhD in anything to then present a detailed, evidence-based description of a measurement scheme know that these are not measures of “physician quality.” Those outcomes that will solve or at least ameliorate the alleged problem without making are the result of multiple factors, only one of which is physician expertise. other problems worse. If MDH finds they cannot do that, they should say so. Dozens of other factors outside physician control contribute to those outcomes, including patient income, literacy, willingness and ability to Defining the problem: “Variation” is not a diagnosis exercise, access to transportation, whether their insurance requires high outThe 2008 commissions and the 2008 Legislature did an awful job of of-pocket payments for medications, etc. MNCM’s “optimal diabetes care” defining the problem they wanted MDH to address. The closest they came measure is no more a quality measure than precinct-level crime rates are a to defining a problem was their evidence-free assertion that “variation in measure of the quality of the police departments in those precincts. Crime quality” was the primary cause of high health care costs, and variation rates reflect the impact of numerous factors outside the control of the police. was due to factors under the control of doctors and hospitals. The 2008

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Accuracy: The cornerstone of the new “framework” MDH should interpret the word “framework” in the 2017 law to mean a set of principles that guide the Legislature and other policymakers in all future decisions about how to improve the health of Minnesotans. Note I did not say “all decisions about how to improve quality.” Because so many factors that affect health are outside the control of the medical sector, it’s a huge mistake to assume that improving health and improving the quality of clinics and hospitals are synonymous. The Legislature should recognize that the single most important principle of the new “framework” should be accuracy. The accuracy principle must take precedence over all other measurement criteria for the simple and obvious reason that feedback of any sort is useless if it is not accurate. In fact, inaccurate feedback can be worse than useless if it leads to harmful consequences, such as punishment of safety-net hospitals or addiction clinics. And yet one looks in vain for the word “accuracy” in nearly all legislation, commission reports, regulations, and commentary on measurement schemes. It is very difficult to explain this casual attitude toward accuracy. Policymakers understand, presumably, that providers are not omnipotent, but they have convinced themselves it’s possible to “risk adjust” scores to account for factors providers have no control over. The new framework should explicitly state that providers are not omnipotent, that the vast majority of “performance” measures in use today are grossly inaccurate, and that it is either financially or technically impossible to make them more accurate. To anticipate the cries of outrage from “performance” measurement proponents, the new framework should also explicitly reject the folklore that Minnesota’s health care system can only be improved with “performance” reporting. It should lay out a more rational approach to improving the health of Minnesotans that abandons crude, static measurement at 30,000 feet and instead relies primarily on targeted solutions designed to address carefully defined problems. The new framework could begin with a statement like this: “Policymakers should not assume that deficits in the health of Minnesotans are caused by factors controllable by health care professionals, but should instead do research on a problem-by-problem basis to determine the most likely causes of the problem.” The framework should urge policymakers to follow this decision tree: • First determine whether the problem is within the control of health care professionals.

affordable. Conversely, the Legislature will know it should not ask MDH to issue annual report cards on the percentage of clinics’ diabetics who have their blood sugar levels under control. Proponents of “performance” measurement will no doubt oppose the decision tree described above on the ground that it’s possible to adjust scores for factors providers have no control over. I will discuss this myth in a separate article next month. Kip Sullivan, JD, is a member of the Health Care for All Minnesota Advisory Board. He was a member of Gov. Perpich’s Health Plan Regulatory Reform Commission. His articles have appeared in the New England Journal of Medicine, Health Affairs, and other peer-reviewed journals.

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• If it is, determine whether their failure to address the problem is due to some defect in them or to insufficient resources or maldistribution of resources (this would include an investigation into whether excessive prices contribute to the resource problem). Thus, to take an example of an issue currently in the news, if the Legislature decides it wants to increase the percentage of diabetics who have A1c levels below 8 percent, it should ask MDH first to determine whether doctors really don’t know anything about A1c levels, or whether the problem lies elsewhere, for example, with the high price of insulin and/ or high out-of-pocket costs for insulin. If MDH determines the problem isn’t caused by physician stupidity, but is rather caused largely or in part by the high cost of insulin, a factor physicians can obviously do nothing about, the Legislature will know it should do something to make insulin more

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BEHAVIORAL HEALTH

Project 2025 Partnering with physicians to reduce suicide BY CHRISTINE MOUTIER, MD, AND ALEX KARYDI, PHD

p to 45% of people who die by suicide visit their primary care physician in the month prior to their death. Suicide challenges the entire medical system and the services they perform. The ability of physicians to assess, intervene, and monitor suicidal behavior presents both a responsibility, and a significant opportunity, to save lives. Yet such a burden becomes especially daunting if the professional providing care is ill-prepared for such a situation. A science-based approach, coupled with outside resources, could help physicians prevent suicide.

By the numbers It has been well documented that medical professionals from a wide range of specialties and settings will encounter individuals at risk for suicide. But many of them do not have confidence in dealing with such challenges, and the majority have minimal to no training to competently deal with a clinical situation to prevent suicide. In 2018, the Harris Poll and the American Foundation for Suicide Prevention (AFSP) found that, while 94% of American adults believe mental health is equally important as physical health (https://tinyurl.com/mp-suicide01), most do not know how to identify changes in mental health that signal serious risk, nor what to do in response.

The Centers for Disease Control and Prevention identified suicide as the 10th leading cause of death in America, accounting for 48,344 deaths in 2018. The U.S. suicide rate has risen nearly 30% over the past two decades (https:// tinyurl.com/mp-suicide02), and one American now dies by suicide every 11 minutes. Overall mortality, particularly in the middle years, is increasing as a result of the so-called “deaths of despair” due to suicide, alcohol, opioids, and liver disease (https://tinyurl.com/mp-suicide03). In an era with greater technological advances and potential connectivity, research on suicide demonstrates that many forces are still active that may increase risk: human experiences of isolation, struggle, loss, and unmet expectations, alongside low mental health literacy. Additionally, overreliance on a sense of self-sufficiency and fear of judgment are barriers to opening up on deeper levels in our relationships, and fully integrating suicide prevention into actionable steps available through physicians, homes, and communities. Interpersonal connectivity is a basic need. When we lose that connection, whether due to changes in culture, modern frenetic living, or shame that drives people to hide their true internal experiences, then the prevalent experience of unaddressed mental health conditions and other types of suffering can contribute to the rising suicide rate.

Physicians: The front line

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Physicians can learn to discuss these human experiences without shaming patients, and can become more sophisticated at recognizing moments for effective intervention that may lead a person who is struggling down a new, healthier path in which they connect to help. Additionally, allowing our patients to share these experiences more freely with trusted individuals can lead to better health outcomes in multiple areas, including suicide risk reduction. The medical community could partner with community resources to achieve these goals. A common understanding of medical science—including neuroplasticity and epigenetics—could lead to a more compassionate, trauma-informed patient approach, and could also benefit K–12 education and workplace wellness. For example, envision settings where:

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• Basic foundational knowledge of neuroscience could teach children and adults strategies that protect and enhance cortical brain development, steps to prevent psychiatric illness could start early, and suicide prevention could be built into every pediatric clinic and school. • A society in which front-line citizens (e.g., first responders, health care professionals, teachers, legal/financial advisors, probation/ corrections officers, and addiction counselors) are trained in basic mental health first aid and suicide prevention, and in which we move beyond the sense of shame so often related to distress or suicide. • The RAISE (Recovery After an Initial Schizophrenia Episode) early prevention/intervention model (https://tinyurl.com/mp-suicide04) is applied to prodromal or burgeoning mental illness with treatment and self/family strategies as part of treatment.

• Biomarkers for suicide (https://tinyurl.com/mp-suicide05) and predictive analytics (https://tinyurl.com/mp-suicide06) are further refined and scaled to the national level so that every patient in primary care has the benefit of mental health screening and suicide preventive interventions, just as they do for other leading causes of death.

• Employ evidence-based treatment modalities for high-risk patient populations. These include cognitive behavioral therapy for suicidal cognitions and behaviors (CBT-SP) and dialectical behavior therapy (DBT) for adults with borderline personality disorder, as well as for adolescents with elevated suicide risk.

• Providers adapt system-wide transformations to promote safer suicide care (https://tinyurl. com/mp-suicide-07).

Partnering to address suicide

• New methods in suicide prevention research aimed at better risk detection.

Forty-five percent of people who die by suicide visit their primary care physician in the month prior to their death.

These advances are at various stages of progress. New recommended care standards were recently released for better detection and clinical care that reduces suicide risk (https://tinyurl.com/mp-suicide08). The American Foundation for Suicide Prevention (AFSP) began as a grassroots effort, when a small group of families who’d lost loved ones to suicide banded together with scientists in an effort to learn more. As we have grown and expanded to become the nation’s largest suicide prevention organization, with chapters in every state, what we do is still rooted in communities. We fund research, provide community education, and serve as a catalyst for cultural transformation and suicide rate reduction through initiatives like Project 2025 (https://tinyurl.com/ mp-suicide09) and creating a culture that’s smart about mental health.

Project 2025’s goal is to reduce the annual suicide rate in the United States by 20 percent by the year 2025. Through system dynamics modeling, and with guidance from leaders in suicide prevention research and practice, AFSP has identified four critical prevention areas that, with strategic investments and partnerships, can be targeted to significantly reduce the suicide rate and save more than 20,000 lives over five years. The four critical prevention areas represent the settings with which a significant number of those at risk for suicide will come into contact, and thus the settings in which we must intervene to prevent as many suicides as possible. These four critical areas are firearms, health care systems, emergency departments, and correctional systems. AFSP is scaling up evidence-based solutions that can and will reduce the rate of suicide in this country.

• An approach to clinical suicide risk assessment that incorporates underutilized tools like Reasons for Living and other tools intended to support those struggling with suicidal thoughts. • Integration of suicide prevention practices into primary care.

• A health system framework called Zero Suicide that stresses high-risk follow-up contact and evidence-based treatment that can save lives.

• Research about the impact of the media—and social media, in particular— related to mental health and suicide prevention

Tools and trainings Caring for suicidal patients can be challenging, especially in emergency departments, without easy access to mental health specialists. The American Project 2025 to page 254

We remain hopeful because we see the seeds of change glimmering around the U.S.—through the leadership of our scientific community and our delivery mechanism for education, advocacy, and loss support through a chapter network in all 50 states. We see that suicide prevention is not only possible, but that we are gaining momentum in creating a culture that is smart about mental health, including making sure that front-line citizens such as health care professionals are aware of effective, evidence-based strategies to reduce rates of suicide. We must all work together in the field of medicine with partners of many types—health system leaders, tech and corporate leaders, media, education, and policymakers—to mount an effective suicide prevention plan critical to stemming this rising tide. New developments and current thinking include: • Recommended language changes that can eradicate the stigma that often prevents patients from seeking help from their providers (e.g., the recommendation to stop using the phrase “commit suicide,” as suicide is a complex health outcome, not a moral failing). MINNESOTA PHYSICIAN MARCH 2020

LONG-TERM CARE

Developing an Assisted Living Report Card A mandate of the 2019 ElderCare Act BY TETYANA P. SHIPPEE, PHD; TRICIA SKARPHOL, MA; AND ODICHINMA AKOSIONU, MPH

he number of assisted living (AL) settings is steadily increasing nationally and in Minnesota there are currently about 1,300 AL communities. AL is commonly defined as the senior living option that combines housing, support services (e.g. meals), and health care, as needed. AL is meant to provide more assistance than an independent retirement community but less medical and nursing care than a nursing facility. As per the new licensing framework passed by the Minnesota Legislature, AL is defined as “a licensed facility that provides sleeping accommodations and assisted living services to one or more adults.” AL includes dementia care. AL is distinguished from other residential long-term care options, and especially skilled nursing facilities, by its philosophy of service delivery that aims to maximize independence, individual choice, dignity, autonomy, and quality of life. However, as residents’ care needs become more complex, there has been more focus on the importance of appropriate and quality clinical care supports for AL residents as well as other measures of quality. Lack of data on AL quality. Although there is a growing trend of people choosing to live in AL settings compared to nursing homes (NH)

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when they can, little is known about the quality of AL care. For reference, Minnesota has built a nationally acclaimed Nursing Home Report Card (http://nhreportcard.dhs.mn.gov/) that includes various measures of NH quality, including clinical care. Yet, no such tool exists for ALs. Concerns over issues like poor staff quality, resident acuity, and safety escalated to the state level and resulted in a legislative bill for a new licensing framework for AL settings. The Elder Care and Vulnerable Adult Protection Act, passed in May 2019, provided funding for the development of a report card that will include annual resident quality of life and family satisfaction surveys, as part of a multi-pronged effort to encourage and reward quality. AL report card goals. The report card is slated for 2021 and the goal is to provide consumers and their families enough information to make informed decisions about which AL communities best fit their needs. Its secondary aim is to help AL providers improve quality of care services and supports they provide. The AL report card can provide important information about various aspects of consumers’ well-being to aid physicians and other care providers in navigating client care if their patients are also AL residents. The report card may be useful for physicians by including information about what clinical care services and supports are offered/available, the experiences of care for consumers, how the quality of care may impact well-being, and the potential remaining gaps in clinical care services. Data collection and dissemination. The development of the AL report card began in the spring of 2019 and is a multi-phase effort towards a quality measurement system. The first phase included efforts to identify domains, subdomains, and existing AL quality indicators based on a national review of peer-reviewed literature; review of various reports; and interviews with national experts. Nine AL quality domains were identified: 1) resident quality of life; 2) resident and family satisfaction; 3) safety; 4) resident health outcomes; 5) staff; 6) physical and social environment; 7) service availability; 8) core values and philosophy; and 9) care services and integration. Each domain has a set of elements of subdomains and potential indicators that can be used to measure those elements (e.g., safety and policies around resident safety/accountability practices). Phase 2 (Summer–Fall 2019) sought to gather feedback from pertinent stakeholders in Minnesota on the domains and subdomains of AL quality that were identified from national work. During this phase, we aimed to address three questions: 1) Which domains of AL quality are also highly supported by Minnesota stakeholders?; 2) What sub-domains and associated measures were most important to stakeholders when measuring resident quality of life and family satisfaction?; and 3) What are areas of consensus across all stakeholder groups and which areas are more stakeholder-dependent (e.g. providers as compared to family members of AL residents)? Various outreach initiatives to elicit stakeholder feedback were conducted in the fall of 2019, including a state-wide online survey with 822 respondents; 13 public presentations, which included a variety of provider groups; a statewide livestream event with 266 attendees and five focus groups (four with AL residents and one with consumer advocacy

organizations). The overarching goal of this feedback was to inform the development of a quality framework for the AL report card.

Findings Our findings indicate a high level of support among Minnesota stakeholders of the domains of quality that were identified in the national work. The domains of AL quality endorsed as most important were: 1) quality of life; 2) staff quality; and 3) resident safety. The lowest-rated domains were physical and social environments of AL (vs other domains). As far as sub-domains of quality of life, stakeholders viewed dignity/respect, staffrelated items, and security as very important when measuring quality of life and found staff competency, respect from staff, and care experience as very important for resident and family satisfaction. Lastly, we found that domains of quality were highly consistent across stakeholder roles. Differences between stakeholders mainly included higher importance placed on the social and physical environment of the AL by residents and other focus group participants than those who participated in the survey and other outreach efforts.

Planning for the report card There are currently five phases planned for this project: 1. Phase I. In January–June 2019, the University of Minnesota conducted a literature review on AL quality which produced nine AL quality domains. 2. Phase II (July–December 2019) focused on gathering stakeholder input on research findings.

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3. Phase III (January–June 2020) includes the development and testing of resident and family surveys, measurement development, and the start of planning for the report card website. 4. Phase IV (July 2020–February 2021) will finalize surveys and resident and family surveys will start to be conducted, along with the development of the AL report card website 5. Phase V (March–June 2021) will include the analysis and release of the first round of survey results. Phases I and II have been completed and are described in more detail in this article. Phase III work is underway with resident and family surveys being developed. Refinement of these surveys will come from input from provider and advocate focus groups, in addition to testing with AL residents. Work in the early phases will pave the way for a website that tracks AL quality measures of most importance to consumers. We believe this work is salient for physicians, who might make their patients and caregivers aware of this initiative. During patient consultations, physicians may discuss the assisted living choices with patients and their families and how best to meet patient needs. Some strategies to that regard are included below: • Share with patients and caregivers where they can sign up online for updates on the assisted living report card development. • Encourage patients and caregivers to get involved at different Developing an Assisted Living Report Card to page 244

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3Developing an Assisted Living Report Card from page 23 stages of project development and get engaged when the results are posted.

assisted living care services and supports. We encourage all health care providers to learn more about the project.

Visit https://tinyurl.com/mp-AL-report-card2 for additional details, Overall, this work of developing an AL report including project milestones, links, and contact card aims to address some of the significant trends information for those who wish to participate, in AL care and how this impacts quality of care for submit questions, or sign up for email updates. AL residents, especially for the areas of increasing resident acuity and the growing proportion of Tetyana P. Shippee, PhD, is an Associate residents with diagnoses of Alzheimerâ&#x20AC;&#x2122;s disease Physicians can play a Professor at the University of Minnesota School and other dementias and cognitive impairment role in this process. of Public Health, Division of Health Policy and in those who use AL. In addition, the growing Management, whose research focuses on quality of investment through home and community-based long-term services and supports and health equity. waivers (publically supported programs to meet the needs of people with disabilities and older adults) nationally and in Minnesota, has resulted Tricia Skarphol, MA, has worked in public health in AL providers needing to address the variability in quality of AL services research at the University of Minnesota for over 17 years. provided for those on waivers, which better helps these consumers choose settings that work best for their needs and will also report these investments Odichinma Akosionu, MPH, is a PhD student and a Research Assistant at to payers. Physicians can play a role in this process as older adults increasingly the University of Minnesota, School of Public Health, Division of Health Policy turn to AL, as not only the place to provide them with services, but also a and Management, doing research at the intersection of long-term care and place they can call home.

Learn more The report cardâ&#x20AC;&#x201D;and the planning leading up to itâ&#x20AC;&#x201D;may help physicians assist their patients, families, loved ones, and caregivers in navigating

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racial and ethnic health inequities.

3Project 2025 from page 21 College of Emergency Physicians and the AFSP appointed a working group to create an easy-to-use suicide prevention tool for ED providers. The “ICAR 2E” mnemonic (see sidebar for highlights) may be a feasible way for practicing ED clinicians to provide evidence-based care to suicidal patients. To achieve the goals of Project 2025, AFSP sought a partner with shared values and expertise in primary care. SafeSide Prevention, founded by Tony Pisani, PhD, Associate Professor of Psychiatry and Pediatrics at the University of Rochester Center for the Study and Prevention of Suicide, now teams with Kristina Mossgraber, a suicide attempt survivor, and with primary care providers at the University of Rochester to teach and model best practices.

Summing up Suicide prevention is a complex challenge, but we remain resolute. The nation’s readiness for effective pro-mental health and suicide prevention strategies is growing like never before, and the scientific field regarding suicide has matured enough to provide answers. We don’t have time to waste. Let’s work together to reduce suicide in the U.S.

What you can do Physicians can play a key role in identifying suicide risks in their patients and providing support intended to save lives. Primary care providers are at the front line, since 45% people who die by suicide visit their primary care physician in the month prior to their death. In addition to the scientific background on suicide risks and prevention presented in this article, consider participating in Project 2025 (details at https://tinyurl.com/mp-project2025). While developed for emergency department physicians, the ICAR 2 mnemonic provides tips for all health care professionals. Visit https://tinyurl.com/mp-icar2e for recommendations regarding each of the mnemonic’s steps intended to: • Identify suicide risk. • Communicate with patients. • Assess for life threats and ensure safety.

Christine Moutier, MD, is Chief Medical Officer at the American Foundation

• Risk-assess patients.

for Suicide Prevention.

• Reduce these risks. • Extend care as necessary.

Alex Karydi, PhD, is Project 2025 Director for the American Foundation for Suicide Prevention.

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NEPHROLOGY

Dialysis 2020 A look inside the black box BY JENNIFER CRAMER-MILLER

ccording to the National Kidney Foundation, over 500,000 Americans with end stage renal disease (ESRD) require dialysis for survival. Renal replacement treatment becomes necessary when patients have lost 85–90% of kidney function (resulting in a glomerular filtration rate of less than 15) and is typically performed three times a week at in-center clinics. The payment and treatment for kidney failure, however, is distinctive from other health care sectors. First, bold legislation in 1972 allowed Medicare reimbursements for all ESRD patients, regardless of age or income. Second, two for-profit corporations, Colorado-based DaVita Inc., and German-based Fresenius Medical Care, have emerged with 70% control of the dialysis market and 5,000 clinics across the country.

What does industry dominance by two dialysis providers mean for patients? The nation-wide consolidation of dialysis providers has reduced industry competition. This begs the question: what is the impact on patient choice? A March 2017 Clinical Journal of the American Society of Nephrology (CJASN) article, “Consolidation in the Dialysis Industry, Patient Choice,

and Local Market Competition,” evaluated this inquiry. This analysis of in-center hemodialysis clinics between 2001 and 2011 revealed an 8% decrease in the number of uniquely owned dialysis providers. The number of facilities, however, increased by 54%, “and patients experienced an average 10% increase in the number of competing proximate facilities from which they could choose to receive dialysis.” What many patients lost in provider choice, they gained in clinic locations. Yet, the Centers for Medicare and Medicaid Services (CMS) Administrator, Seema Verma, noted in a recent initiative, “Rethinking Rural Health,” that one in five Americans—about 60 million people—live in rural areas. Rural ESRD patients have reduced access to primary care physicians and nephrologists and increased travel times to dialysis centers. Statistics from the Minnesota Department of Health show that rural hospitals with dialysis services decreased 11.8% between 2009 and 2018. Advancements in telehealth and other virtual services allow easier health care team connections for doctor consultations and communications, but many rural areas lack adequate broadband access. Barriers to access, delivery, and oversight of dialysis care remains a pressing issue for rural ESRD patients.

How do ESRD patients evaluate the quality of dialysis facilities? For many years, patients could not easily evaluate the performance of dialysis clinics. But in 1997, the Balanced Budget Act directed CMS to provide information on the quality of dialysis, according to the Medicare & Medicaid Research Review article, “Developing Dialysis Facility-Specific Performance Measures for Public Reporting.”

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In 2000, CMS created Dialysis Facility Compare (www.medicare.gov/ dialysisfacilitycompare), a website that compiles data to allow patients to review the quality of over 7,000 dialysis facilities. Medicare now grades dialysis centers on the following nine health statistics: mortality rates, hospitalizations, blood transfusions, hypercalcemia levels, hemodialysis clearance rates for adults and children, peritoneal clearance rates for adults, total patients with fistulas, and the number of patients using catheters over 90 days. This data offers clinic-specific performance on quality indicators to inform patients as they select a dialysis facility with their nephrologist. Despite readily available clinic performance data, the dominance of two main dialysis providers elicits unease among patient advocates. They cite a hefty list of settlements as a reason for growing concerns.

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Consider these recent settlements: In 2018, DaVita Medical Group paid a $270 million settlement to CMS for False Claim Act allegations that inaccurate information submitted to Medicare resulted in inflated payments. In 2019, Fresenius resolved allegations that they overbilled Medicare for unnecessary Hepatitis B testing with a payment of $5.2 million.

Inaccurate information submitted by providers to increase Medicare payments undermines the dialysis program for those who need it. Plus, Americans taxpayers pick up the tab. The government response to fraudulent practices also highlights the intersecting interests between dialysis providers, Medicare, and patient safety. For example, after a 2012 case alleging that DaVita over-used and double-billed the government for vials of the anemia medication, Epogen, Medicare changed their fee-for-service reimbursement structure. Rather than reimburse for the quantity of Epogen used per patient, Medicare “bundled” services and medications into a set payment. The result? In a complete reversal, Medicare incentivized dialysis providers to use less Epogen, as opposed to more. Where does this leave patients?

“Advancing American Kidney Health Initiative”: A new focus for the dialysis industry

The current Trump administration and CMS Administrator Seema Verma have noted the complicated interplay between cost control and patient care. In 2019, an Executive Order signed by President Trump, the Advancing American Kidney Health Initiative, launched sweeping goals and priorities to simultaneously improve kidney health and reduce Medicare costs. The Two for-profit corporations ... have primary goals for this initiative endorse actions emerged with 70% control of the that both government and physicians can dialysis market implement to improve patient outcomes:

Medicare coverage, reimbursement rates, cost control, and patient safety When a patient is on Medicare solely due to ESRD and covered by a group health plan (GHP), Medicare is the secondary payer for 30 months. After this 30-month coordination period, Medicare becomes the primary payer. Between 1983 and 2011, according to the 2017 CJASN article, Medicare reimbursements were “virtually unchanged, leading to significant declines in reimbursement after adjusting for inflation.” The bigger dialysis providers, with improved economies of scale and purchasing leverage, managed reduced fees better than smaller ones, fueling their ascendency within the industry.

Accelerate prevention care. Because chronic kidney disease (CKD) often has no symptoms in the early stages, patients often have progressed to an advanced stage by the time they seek medical care, often leading to a crash (unplanned) start on dialysis. But we know that diabetes and high blood pressure are the two main risk factors for kidney disease, and African Americans, Hispanics, and American Indians face a higher risk. Individuals over 60, as well as people with kidney disease in their family, are also at higher risk for CKD. According to Dr. Mark Rosenberg, a nephrologist at the University of Minnesota Medical Center, focusing on high risk populations is essential Dialysis 2020 to page 284

Similar to other for-profit companies, dialysis companies cut costs when they face revenue shortfalls. But unlike a Big Box retailer, cost reductions in the dialysis industry affects patient outcomes. For example, Medicare reimburses a fixed amount for a dialysis treatment—so payment for a three-hour dialysis treatment is the same rate as for a four-hour treatment. Even though the Dialysis Outcomes and Practice Patterns Study (DOPPS) reports that longer runs are associated with better patient outcomes, are longer runs considered? The answer depends on the central mission— patient care or profits?

Staffing and oversight In the U.S., technicians are the primary in-center dialysis staff members. A high school education is required for dialysis technicians before completing training and a CMS-approved certification exam. A registered nurse is on site at each facility. CMS Medicare requirements (outlined in the “Conditions for Coverage”) require a physician to see a dialysis patient at the dialysis center once every three months, with monthly mandated nephrologist office visits.

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In contrast, many European countries and Japan require a majority or all of dialysis staff to be nurses. Of course, there are many factors that contribute to patient outcomes, but it is interesting to note that dialysis mortality rates are highest in the United States and lowest in Japan. If altered staffing ratios between technicians, nurses, and doctors were beneficial for patient outcomes, would staff changes be considered by dialysis providers under current reimbursement rates?

MINNESOTA PHYSICIAN MARCH 2020

3Dialysis 2020 from page 27 for better prevention and awareness strategies. When nephrologists are involved earlier in the care of patients with compromised kidney function, patients can be educated to make more informed decisions about renal replacement options.

“better for patients’ self-sufficiency, and better for their physical health.” DaVita, Fresenius, and other clinics set up home dialysis training, typically after a nephrologist recommends this treatment option to his or her patient. According to the National Kidney Foundation, home treatments can be performed in short daily or nocturnal treatments, and often result in fewer medications, improved neuropathy, better sleep, and increased energy.

Increase rates of kidney transplantation. Donate Life America statistics reveal that approximately 100,000 Americans are waiting to receive a kidney, and a three–five year wait is Every U.S. taxpayer More frequent Medicare-covered weekly home average for a deceased donor. The initiative strives stands to benefit. hemodialysis treatments (five to six times a week) to improve these statistics by reforming the organ also reduce hospitalizations costs that occur on days procurement and management system to increase between in-center treatments (when patients’ blood donor supply, encourage living donation, and chemistries build up). Also, home hemodialysis is increase the support that living donors receive for less expensive because direct care from technicians lost wages and childcare expenses. In addition, and nurses is unnecessary after the home training physicians and patients should advocate for extended lifetime coverage of is complete. Home dialysis patients, similar to in-center patients, require immunosuppressant medications for kidney transplant patients. Currently, Epogen to increase their red blood cell count. Filled through their dialysis anti-rejection medications for patients under 65 are covered by Medicare for center pharmacy, patients receive this Medicare-covered medication and three years post-transplant. If patients cannot afford to continue taking the inject it subcutaneously at home. medication that keeps their transplant viable, they will return to dialysis, Yet, statistics from the United States Renal Data System (USRDS), the and the cycle begins again. national data system that collects, analyzes, and distributes information Favor home dialysis treatments over in-clinic dialysis treatments. about kidney diseases in the United States (www.usrds.org), cites that only On March 4, 2019, HHS Secretary Alex Azar addressed the National 8% of ESRD patients (in 2016) chose home hemodialysis treatment. This Kidney Foundation on the benefits of home dialysis, and explained it is could be partly due to the high number of patients that experience crash dialysis starts, and to lack of education. As more physicians encourage qualified patients to transition from an in-center facility to home hemodialysis, overall costs and patient outcomes should improve.

What’s next? Upcoming kidney care innovations, improvements, and progress Since Medicare first folded ESRD into its coverage, there have been few technology improvements for dialysis machines. But now, the Advancing American Kidney Health Initiative payment incentives award innovative and improved renal equipment and supplies. As a result, the U.S. Department of Health and Human Services (HHS) and the American Society of Nephrology (ASN) have joined forces to accelerate improvements for individuals living with kidney disease. Enter Kidney X, (www.kidneyX.org), a public/private partnership attempting to jumpstart dialysis industry innovation to benefit millions of kidney patients worldwide. The initial KidneyX prize competition focused on redesigning dialysis and included patient-centered treatment options. Dr. Mark Rosenberg, past President of the American Society of Nephrology, is encouraged, “KidneyX and the Executive Order have clearly signaled that the doors are open for innovation in the kidney space and the time is now to get into it.”

New incentives spark competition DaVita, Fresenius, and emerging competitors are paying attention to these incentives to spark dialysis innovation. For example: • On March 2, 2020, CMS Kidney Care (a CVS Health company), released a press statement announcing their strategic partnership

MARCH 2020 MINNESOTA PHYSICIAN

with Satellite Healthcare, a non-profit provider of dialysis services. Their goal is “to provide comprehensive kidney care, and to expand awareness of and access to transplantation and in-home dialysis initially in two locations, Los Angeles and Austin, Texas.” • The health care company, Baxter International Inc., announced an investment of $500 million dollars for dialysis innovation in response to incentives for home dialysis care from the Advancing American Kidney Health Initiative. • The Reuters article, “U.S. Seeks to Cut Dialysis Costs with More Home Care Versus Clinics,” reports that Fresenius strives to increase their home dialysis customers “to more than 15% by 2022 from around 12% currently.” • The same Reuters article reports that DaVita is moving forward to improve their patients’ experience with enhanced technology including telehealth and remote monitoring.

What can patients and physicians do to advocate for reduced costs, increased access, and strengthened regulations? With improvements on the way, there is more to be done. Patient and physician advocacy for increased kidney research funding through both the NIH and KidneyX is critical to address the public health burden of CKD. Organ procurement organizations throughout the country should be accountable and monitored with more consistent metrics. Public awareness campaigns can encourage and educate high risk populations to monitor their blood pressure, blood sugar, and kidney function through blood and urine tests, leading to earlier detection. These efforts will decrease costs and

help patients manage their health, awareness, and choices.

Conclusion A positive interplay between Medicare payment incentives and improved quality of dialysis care is the desired outcome. It’s been a long and winding dialysis journey since the introduction of ESRD Medicare coverage in 1972. Dialysis is a lifeline for ESRD patients. More locations for in-center dialysis clinics and/or the option of home hemodialysis expands patient choices. Yet, the skyrocketing costs of the ESRD program, and cost control measures throughout the decades, can become entangled with unintended consequences impacting quality care. The recently enacted Advancing American Kidney Health Initiative’s new payment incentives intend to align with patient outcomes. Increased dialysis industry competition and the innovative focus of Kidney X also fuels promise for improved kidney health. Time will tell if the intended consequences yield intended results. The 37 million Americans estimated to have kidney disease and every U.S. taxpayer stand to benefit from a successful outcome. Jennifer Cramer-Miller serves on the Board of Directors for the National Kidney Foundation Serving Minnesota, is a Donate Life Ambassador, and is an ESRD Patient who has been a two-time in-center hemodialysis patient, one-time home hemodialysis patient, and four-time kidney transplant recipient.

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3Integrated Health Partnerships from page 15 further engagement with providers and patients who benefit from this program. In addition to demonstrated lower cost of care, anecdotal evidence of improved care delivery is strong, but we want to hear more directly from providers and our public health program enrollees who are served by IHPs. Additional considerations are to continue to assess the incentives within the accountability framework, including those that address social determinants of health, and to facilitate a greater exchange of information between the IHP health care delivery systems.

and hosting a farmers’ market during the growing season. Partners include the local public health department; a community/technical college; University of Minnesota Extension; a hunger relief organization; several local growers; a local food hub that connects farmers, wholesale buyers, and shoppers; and a Twin Cities non-profit that breaks down barriers between locally grown food and those who need it. Since the inception of the program, ED visits have decreased, and A1C measures for diabetic food-share enrollees have improved.

Providers interested in learning more about the Integrated Health Partnership program should visit DHS’s IHP Overview webpage, located at https://tinyurl.com/mp-ihp-overview.

The third is a large integrated pediatric delivery system that established an intervention aimed at helping mitigate the barriers faced by children and families in accessing support for complex socio-economic needs by utilizing a team of multi-lingual staff and community partners to support families. Once identified through a screening or referral process, this system works to connect families to on-site services and/or external resources. Staff follow up with families and community agencies to determine the effectiveness of the referrals and support and ensure that the families’ needs are met or that the family no longer requests support. In addition to the full-time employees used to staff this program, this system’s partners include legal services, hunger relief organizations, transportation providers, housing programs, early childhood development and education organizations, other community organizations, and benefits for which they qualify.

Mathew Spaan, MPA, manages the Care Delivery and Payment Reform section of the Health Care Administration within the Minnesota Department of Human Services. He holds a master’s degree in Public Administration. He can be reached at Mathew.Spaan@state.mn.us.

Sara Bonneville, MS, MPP, is a senior policy analyst in the Care Delivery and Payment Reform Section of the Health Care Administration within the Minnesota Department of Human Services. She holds master’s degrees in Health Services Research, Policy & Administration and in Public Policy. She can

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be reached at Sara.Bonneville@state.mn.us.

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Helping physicians communicate with physicians for over 30 years. MINNESOTA

AUGUST 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 05

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.

Physician/employer direct contracting

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

Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: •

Exploring new potential BY MICK HANNAFIN

ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

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Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

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Share new diagnostic and therapeutic advances Develop and enhance referral networks Recruit a new physician associate

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with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Apply online at www.mankatoclinic.com MINNESOTA PHYSICIAN MARCH 2020

Jon Thomas, MD, served on the Minnesota Board of Medical Practice for

3Improving access to care from page 13

16 years. He was appointed by Independent, Republican, and Democratic

enables expedited disciplinary action by member states, based on another state’s action. Lastly, there has been confusion regarding the type of license that is issued under the expedited process. The license obtained via the Compact process is the same license that is obtained via the traditional process. Think of it as similar to TSA PreCheck or CLEAR at airport security checkpoints. Once you are properly vetted, you have access to the expedited process. And like TSA PreCheck or CLEAR, access to the expedited process expires after one year.

Governors. As Chair of the Federation of State Medical Boards (FSMB), he led the effort to develop the Interstate Medical Licensure Compact. His tenure with the Minnesota Board of Medical Practice culminated with a gubernatorial appointment to the newly formed Interstate Medical Licensure Compact Commission. He was elected Chair of the

The FBI raised concerns that Minnesota law enabled sharing of criminal history record information.

With the FBI’s approval of recent legislative changes, Minnesota immediately began issuing Letters of Qualification to its licensees. The Board is delighted that Minnesota physicians finally have the opportunity to fully participate in the Compact process. Visit the Interstate Medical Licensure Compact Commission website for additional information: https://imlcc.org/ Minnesota is grateful to its legislative authors, particularly Sen. Carla Nelson and Rep. Tina Liebling, and to the Minnesota Medical Association for their continuous support of and advocacy for the Interstate Medical Licensure Compact.

Commission and oversaw the development of the IT platform and presided over the start of the multistate licensure process.

Ruth M. Martinez, MA, is Executive Director of the Minnesota Board of Medical Practice. She has been actively involved with development and implementation of collaborative initiatives, programs and policies, and technological advancements that expand portability for licensees and expand access to quality health care for consumers. Ms. Martinez is serving her third term as an appointee to the Interstate Medical Licensure Compact Commission IMLCC). She currently serves on the Executive Committee as chair of the IMLCC Rules and Administrative Procedures Committee.

Minnesota Physician digital access now available Never miss an issue · New reader-friendly format · Instant access anywhere · Read back issues

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MINNESOTA PHYSICIAN MARCH 2019

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

SHARE YOUR INSPIRATION. POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic)

On the U.S. Army health care team, you will enjoy the satisfaction of providing quality care to Soldiers and their families, in a setting with innovative technologies, robust resources and a dedicated, supportive team.

• Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available

Learn more at healthcare.goarmy.com/nz72

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

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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

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www.minneapolis.va.gov MINNESOTA PHYSICIAN MARCH 2020

3Surprise billing from page 11 balance billing for that service after the fact …. [Congress] should require truth in advertising … [and] impose penalties on insurers … who represent themselves as being in-network, if those facilities permit physicians to balance bill for services.” One Minnesota proposal could similarly eliminate surprise billings for elective treatment through prepayment by an individual for an agreed-upon itemized bundled procedure price that is binding on the provider. For example, a Minnesota statute could expand on the previous mandate to post the price of individual services, which unfortunately makes it impossible for an individual to add up a total cost. Instead the statute could mandate that providers (surgery centers, hospitals, clinics) post their customary prices for their 25 most common bundled procedures involving multiple providers (including anesthesia, radiology, laboratory, etc.) and not to include insuring post-procedure hospitalization costs. Specific procedures might vary from a colonoscopy or annual diabetic care or might involve a complex of bundled services for a radical prostatectomy or hip replacement. Such a statute would have to mandate that an itemized bundle procedure price requested by an individual patient must be based on the published customary bundle price and must include what is covered and not covered. The itemized price must also be allowed to reflect the severity of the patient’s condition and health and to allow provider refusal to make a contract with the patient. Bundled price contracting for a procedure is not new. It is already the norm for many outpatient procedures in surgery center-insurer private contracts.

A proposal for mandated customary bundled price publication could be useful price transparency for all patients, not only for a small group of patients with Health Savings Accounts seeking a cash price for an elective procedure. For example, if one clinic and/or hospital system publishes a low bundled procedure price, it is predictable that competitors will lose business. That happened to hospitals once unpublished low-cost surgery centers dotted the landscape. For providers it could be publish or perish.

Conclusion Surprise billings are a symptom generated by federal Medicare “observation” regulation, hospitals gaming the regulations, and by inadequate personnel levels in carrier-run network facilities. Statutory fixes for surprise billings should consider that insurance carrier hospitals with inadequate personnel to cover their services ought to pay the fees of non-network providers. Further, pretreatment contracts for common elective bundled procedures would preclude surprise billings. Mandated transparent prices without surprise billings might mushroom into a patientfriendly competitive marketplace for all. Other states or even Congress, the administration, and doctors may notice that a statutory surprise billing fix is possible without futile price-fixing. Robert W. Geist, MD, is a retired urologist. Board-certified by the American Board of Urology, he has served in leadership roles on multiple professional associations, and is a past president of the Ramsey County Medical Society, United Hospital Medical Staff, and the Minnesota Urologic Society.

Experts at integrating food prescriptions into care for patients with type 2 diabetes and other illnesses Research shows that food prescriptions, like those filled by FOODRx, can lower HbA1c scores and the total costs of caring for patients with type 2 diabetes. FOODRx brings healthy food directly into health care settings, removing common barriers to nutrition and creating a cost effective, simplified prescription for wellness. “We need to take off our blinders and start learning new ways to address the real-life circumstances that make our patients sick. FOODRx creates the partnerships we need to do this work. We’ve got some real ‘Ah-ha’ moments ahead of us.“ —Dr. Diana Cutts, Hennepin Healthcare To learn more, contact us at 651.282.0887 or at foodrx@2harvest.org

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MARCH 2020 MINNESOTA PHYSICIAN

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MINNESOTA PHYSICIAN MARCH 2020

Sofia Lyford-Pike, MD

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