OB & GYN CARE

For All Stages Of Life

Low- and high-risk obstetrics, including advanced maternal age.

Certified nurse midwifery. Gynecologic care, including well-woman screenings and in-office procedures

Gynecologic surgeries, including minimally invasive surgeries and robotics for conditions such as endometriosis and pelvic organ prolapse

Menopause Clinic, including management of peri-menopause

Center for Urinary and Pelvic Health, including urodynamics.

Nutrition and wellness consultations.

Infertility evaluation and treatment.

FSARS-CoV-2—the virus that causes COVID-19—was initially framed as a respiratory pathogen, but has been shown to directly or indirectly impact nearly every organ system of the body. Theoretical mechanisms include that the virus damages the lining of small blood vessels, causes micro-clots, persists in viral reservoirs, reactivates other latent viruses, spurs ongoing inflammation, triggers autoimmune-like conditions and other possible pathological processes we’re only beginning to grasp. There may be subtypes or multiple diseases grouped under the umbrella term of long COVID.

The symptoms of long COVID vary from person to person. They can range in severity from mildly annoying to outright debilitating, with extreme fatigue, dizziness, cognitive dysfunction (“brain fog”), shortness of breath and other symptoms intense enough to prompt a visit to the emergency room. In a subset of cases, long COVID can seriously disrupt work, school, mental health, family life and daily activities.

Onset and duration of symptoms can be highly variable. They might persist from the acute infection or they can manifest some weeks after apparent recovery, presenting as a new chronic condition. For others, symptoms are more episodic, improving for a time only to re-emerge after physical or mental exertion, stress, illness or other “triggers.” People with severe long COVID may meet diagnosis criteria for conditions like dysautonomia, postural orthostatic tachycardia syndrome (POTS) or myalgic encephalomyelitis, also known as chronic fatigue syndrome or ME/CFS. Because the symptoms and timelines are so varied, there is not yet an agreed-upon clinical case definition for long COVID, and existing definitions from the Centers for Disease Control and Prevention (CDC) and World Health Organization are purposely broad.

Although severe illness and certain pre-existing conditions increase the risk of long-term complications after acute COVID-19, many people with long COVID were previously healthy and/or had only a mild acute infection. Vaccination appears to reduce the chances of developing long COVID, but it may still follow breakthrough infections. Similarly, milder variants and increased population immunity have lowered but not eliminated the occurrence of long-term symptoms. While use of certain medications during the acute infection are showing promise for reducing long COVID, more study is needed. Just as COVID-19 is not going away, long COVID is also unlikely to go away.

Beyond the obvious impacts on the health and well-being of individuals, the burden of long COVID has implications for the health care system, the workforce and the economy. It’s estimated that up to four million Americans have left the workforce because of long COVID so far, with many yet to return. Associated job loss and reduced hours may account for 15 percent of the labor shortage. Medical costs for patients can soar as they seek tests and specialists not covered by insurance.

The far-reaching toll of long COVID also appears to follow the disproportionate impacts that COVID-19 has had across populations and communities, further exacerbating the health inequities that predated the pandemic. Rural and low-income areas, Minnesotans of color, Native Americans, the LGBTQ community and people with disabilities and chronic conditions will bear the largest burden. People in higher-risk occupations during the height of the pandemic, such as health care, education, service industries and other jobs that required in-person work have been shown to experience higher rates of long COVID as well.

Likely Underdiagnosed

Given the myriad presentations of long COVID and lack of standardized definitions or protocols, it’s not surprising that many providers have struggled to identify, diagnose and manage post-COVID conditions—even if they’re aware of them. The ICD-10 code (U09.9: Post-COVID-19 condition, unspecified) scarcely shows up in medical records, despite the likely high prevalence.

A lack of public awareness compounds the problem: people with long COVID might recognize that they have lost some degree of health or function, but fail to make the connection to a recent infection with COVID-19. The complexity, uncertainty and evolving knowledge around postCOVID conditions make communications and messaging around long COVID a challenge for both health care and public health personnel.

Stigma may also play a role. Patients with similar post-infection conditions like ME/CFS and chronic Lyme disease have been dismissed for decades, and long COVID may be written off as simply anxiety or a deficit in healthy living habits. While studies have indicated that many patients with long COVID experienced increased anxiety and depression, the impacts on mental health often stem from the loss of normalcy, stability and identity felt by those who are facing a new chronic illness or disability.

The dearth of sufficient diagnostic tools can perpetuate this dismissal, as most routine tests—as well as expensive, specialized imaging—may fail to show any abnormalities. Many providers order tests to exclude or understand overlapping chronic conditions, but stop short of making a long COVID diagnosis.

Potential Treatments, Management and Support

While there is not yet a cure for long COVID, symptoms can often be reduced or managed with help from a health care team. Care guidance varies and continues to evolve, but many patients make progress with different combinations of physical and occupational therapies, medications, coordinated care and strict pacing regimens. Rehabilitation specialists may be able to apply treatments and therapies for known conditions that are similar to or overlap with long COVID, such as POTS, mast cell activation syndrome, and traumatic brain injury. The general approach is often to target the most pervasive symptoms and focus on regain of function or adaptation to a “new normal.” Mental health professionals can assist patients in psychosocial adaptation. Referral to social services may help ease the stress of lost wages and alleviate concerns around household bills and food insecurity.

Peer support, such as online patient groups, can be a literal lifeline, although unmoderated forums can also harbor misinformation and suicidal

Long COVID to page 124 ideation. Still, validation and solidarity can be very helpful, particularly for people with long COVID who have faced stigma, loss of employment, mounting medical bills, new disability or strain on relationships. Caregivers may also benefit from peer support. A handful of health systems have launched their own forums and group therapies, which could serve as a model for others.

Many patients get better on their own after several months, while others get worse, progressing toward disability. We are still learning why. Even people who gradually recover from long COVID may need support for several months, such as assistance with daily tasks, social services or accommodations at work or school. As of July 2021, long COVID and post-COVID conditions can qualify as a disability under the Americans with Disabilities Act (ADA). Documentation from providers is crucial for connecting long COVID patients to the accommodations and support they need to stay employed, improve recovery and live their fullest life.

Efforts Underway, but More Work Needed

Researchers in Minnesota and around the world are investigating the potential etiologies, subtypes, treatments and prevention for postCOVID conditions. The White House has pledged an “accelerated, whole-of-government effort” to address long COVID, and in 2021, the National Institutes of Health (NIH) launched a billion-dollar initiative to study risk factors and run clinical trials. Yet progress is slow, and awareness and resources are lacking. The NIH trials have struggled with mistrust and lack of participation from patients.

Meanwhile, many clinics and hospitals have set up their own approaches to serving long COVID patients. Some have identified a small team to coordinate care and services, while others have stood up comprehensive long COVID specialty clinics. Various interim care guidance has been published.

However, the lack of consensus around diagnosis and treatment, variation in awareness and divergent resources available across providers can trickle down to the patient experience. Specialty clinics may not be accessible, and rigorous schedules of follow-up appointments impractical. For those without insurance or a regular provider, it may be nearly impossible to find a clinician they trust who can identify and provide care for long COVID, particularly in the space of a primary care visit.

Recognizing these disparities, MDH began efforts to understand how and where patients are receiving care for long COVID across Minnesota. Clinicians have expressed that there is little communication among providers who see long COVID patients and that a coordinated learning network would increase access to care and the quality of the care that is provided.

The Long COVID Guiding Council of Minnesota Clinicians

MDH began recruiting Guiding Council members in late 2022, in partnership with Stratis Health and consultants from the former Institute for Clinical Systems Improvement (ICSI). We recognized the importance of bringing a small but diverse group of clinicians to the table with representation from primary and specialty care. In addition to experience with long COVID patients, areas of expertise include physical medicine and rehabilitation, infectious disease, pulmonology, traumatic brain injury, post-viral illness, rural health care, pediatrics, geriatrics and long-term care. It was also crucial to include not just the big health systems with specialty clinics and research teams, but also Federally Qualified Health Centers and community clinics, rural hospital systems, the Veterans Administration and many others. We are also gathering input from people with long COVID, caregivers, support services, community leaders and other health care practitioners.

The Guiding Council began convening in January 2023 and will meet monthly through at least early summer. Participants are enthusiastic about sustaining this learning network for many months or years to come, as guidance and treatments evolve. This infrastructure can aid in rapid dissemination of new evidence and best practices, as well as support implementation in different health systems serving diverse communities across the state. The group has discussed existing definitions and guidance, tools and education for providers and systems-level approaches to improving care and access. Outcomes will be summarized and posted on the MDH website at a future date at this site: www.health.state.mn.us/diseases/ longcovid/providers.html

To better understand the lasting effects of COVID-19 on the lives of Minnesotans, MDH is also conducting a statewide phone survey over the next few months among people who have had laboratory-confirmed COVID19. Results will be used to identify and guide future activities to address long COVID. We have prioritized partnerships throughout our work, engaging with communities, employers, schools, local public health, other state agencies and national workgroups. Currently the MDH long COVID program is funded by a CDC COVID and Health Equity grant grant through June of 2023. A proposal to extend MDH’s long COVID work has been recommended by Governor Tim Walz and Lieutenant Governor Peggy Flanagan. The proposal builds on the foundation and partnerships MDH has fostered since 2020 and provides a sustained and equitable public health response to long COVID throughout Minnesota. It also includes resources for vital capacity-building for communities and local public health, enabling more tailored messaging and approaches and bolstering patient-led support.

A Call to Action

Long COVID will continue to challenge patients and providers for years to come. As the urgency around COVID-19 recedes, we must acknowledge that while COVID-19 may be a limited respiratory illness for many, it can also result in unpredictable, long-term, life-altering symptoms for others.

The impacts on health and well-being, communities, health care systems, the workforce and the economy cannot be ignored.

There is also hope: new clues and success stories are emerging every day. As knowledge about long COVID grows, health care practitioners can educate themselves and their patients. They can explore what their system or clinic is doing to address long COVID, watch for evolving care guidance and share patient resources. And when confronted with a patient struggling to recover from a COVID-19 infection, they can consider: Could this be long COVID?

Guidance for providers, resources for patients and much more can be found at www.health.mn.gov/ longcovid. If you would like to provide input about your experience with long COVID in the clinical setting, please fill out the brief survey at https://survey. alchemer.com/s3/7147319/Long-COVID-Survey

Kate Murray, MPH, is the program manager for Long COVID and Post-COVID Conditions at the Minnesota Department of Health. She also holds a Master of Public Health degree in administration and policy.

Ruth Lynfield, MD, is the state epidemiologist and medical director for the Minnesota Department of Health, as well as a board-certified pediatric infectious disease specialist.

How do we explain the insurance industry’s eagerness to participate in Medicare and Medicaid when Congress enacted those programs precisely because the insurance industry didn’t want to insure the elderly and the poor? Answer: The insurance companies are being overpaid.

Congress has been notified dozens of times over the last forty years that Medicare pays more to insure Medicare beneficiaries through insurance companies than it does to insure beneficiaries in the traditional (or original) Medicare program. In its March 2022 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) stated, “The MA [Medicare Advantage] program has been expected to reduce Medicare spending since its inception … but private plans in the aggregate have never produced savings for Medicare…”

Measuring Overpayments

MedPAC and other observers are able to measure the overpayments to insurance companies in Medicare because they have a handy yardstick with which to make such measurements—the original fee-for-service (FFS) unprivatized portion of Medicare. Half the enrollees in the Medicare program remain in the original program. Those enrollees are roughly comparable to the half that are insured through Medicare Advantage plans. By comparing the per capita cost of the original program with the per capita cost of the Medicare Advantage program, analysts can get a rough measure of how much the Medicare Advantage plans are overpaid. (The comparison is rough because healthier Medicare beneficiaries enroll in Medicare

Advantage plans, and the algorithm that MedPAC and others use to adjust costs to reflect health status is crude.)

Unfortunately, the research on the impact of privatization on Minnesota’s public health insurance programs is not as rigorous. The legislature failed to conduct research prior to 1983, which is when the legislature began the privatization process, to determine whether HMOs could save money. In 1983, it passed a law authorizing the Department of Public Welfare (DPW) to participate in a “demonstration” promoted by the Reagan administration, in which Medicaid recipients would be forced into HMOs in two counties (Hennepin and Dakota). DPW was so unsure of the claims made for HMOs that it wrote into its application to the federal government a requirement that HMOs receive subsidies and be allowed to offer worse coverage than the MA program offered. By 1996, the legislature still had no evidence that HMOs could save MA money. That was the year the legislature authorized DPW’s successor, the Department of Human Services (DHS), to force MA and MinnesotaCare recipients throughout the state into “managed care organizations,” (MCOs), as insurance companies that employed managed care tactics were being called by then.

Zombie Programs

Since 1996 the privatized versions of MA and MinnesotaCare have been on autopilot. They have become zombie programs: hey don’t deliver the savings they were supposed to deliver, but they won’t die because the legislature refuses to ask whether they are saving money. And now that the great majority of MA and MinnesotaCare recipients are in HMOs, there is no comparable population in a FFS, unprivatized program against which to compare the costs incurred by the MCOs. And so we must look to other types of evidence to determine whether Minnesota’s grand privatization experiment worked.

For starters, we know privatization raised Medicare’s costs by driving up administrative costs. In the private sector, insurance companies incur overhead costs equal to about twenty percent of their revenues; their overhead is about fifteen percent when they participate in a public program like Medicare. How are they supposed to cut utilization sufficiently to pay for that fifteen percent overhead? They don’t have the ability to do that without harming patients.

Privatization has the same effect on Medicaid. According to research published by the Lewin Group, a subsidiary of UnitedHealth Group, insurance companies that participate in Medicaid generate the same level of overhead costs—about fifteen percent. As the Lewin Group put it, “MCOs must typically achieve roughly a fifteen percent savings on overall medical costs vis-à-vis the FFS setting simply to break even.” Other experts agree. In a 2006 article, the Wall Street Journal reported, “[A]ccording to Martha Roherty, director of the National Association of State Medicaid Directors, …. [a]t Medicaid HMOs, only eighty percent to eighty-five percent of premium dollars generally go for medical costs.”

A small body of research indicates Medicaid privatization not only forces taxpayers to pay for insurance industry overhead, but it drives up the administrative costs of the state agencies that run Medicaid (DHS in Minnesota’s case). Several experts who observed the Medicaid privatization fad as it spread across the nation in the late 1980s and early 1990s have commented on the additional burden that supervising MCOs places on state agencies. “Medicaid managed care programs have proven enormously taxing for state Medicaid agencies to put into operation and then manage effectively,” reported Freund and Hurley in a 1987 evaluation of the earliest Medicaid privatization demonstrations. Michael Sparer, a nationally recognized expert on Medicaid, wrote in 1998: “Medicaid managed care actually increases the state’s regulatory role. State Medicaid officials need to select health plans, determine capitation rates (and struggle with risk adjustment), supervise the marketing and enrollment process, ensure quality of care, consider whether to adopt special programs to protect safety-net providers during the transition to managed care, and so on.

Inside the Numbers

The research suggests DHS’s administrative costs doubled during the 1990s, from 4-5 percent of expenditures (the pre-privatization level cited by the 1991 report of the Minnesota Health Care Access Commission) to 10 percent, as DHS pushed MA and MinnesotaCare recipients in all counties into MCOs. The total increase in the cost of Minnesota’s Medicaid program caused by additional administrative costs might be on the order of twenty-fifteen percent MCO overhead that the taxpayer didn’t have to pay for prior to privatization, plus another 5 percent added on to DHS’s overhead. And this doesn’t take into account the increase in the administrative costs inflicted on providers. If we assume the MCOs cut utilization (both necessary and unnecessary) by 5 percent, the net increase to the taxpayer would be fifteen percent.

Is fifteen percent the correct number? It’s a reasonable estimate, but we don’t know for sure. It wasn’t supposed to be this way. When DPW applied to the Health Care Financing Administration (HCFA) in 1981 for permission to experiment with HMOs within the MA program in Hennepin and Dakota counties, DPW promised HCFA it would conduct a rigorous study of the effect of HMOs on utilization and costs. DPW promised to “provide HCFA with adequate data to evaluate the demonstration’s effectiveness in increasing enrollment, impacting cost savings, and enhancing health care competition.” DPW said it would collect utilization data from the HMOs in the “experimental counties” (Hennepin and Dakota), collect utilization data in several adjacent control counties, and compare aggregate expenditures in the experimental and control counties. On the basis of these assurances, HCFA granted DPW permission to run its proposed demonstration over a three-year period, December 31, 1985 to December 31, 1988.

Soon after the demonstration began, the HMOs refused to provide the necessary data to DPW. DPW asked HCFA for an extension of the study period, but in September 1987 HCFA refused. Congress and the Minnesota legislature took DHS and the HMOs off the hook by enacting bills that permitted DPW/DHS not only to continue its privatization “experiment” but to expand it into all Minnesota counties even though the rigorous examination DPW had promised had not been done.

In 1993, a DHS employee, Steven Foldes, made the last known attempt to conduct the study DPW had promised HCFA. He sought to compare the quality and cost of care for MA recipients in Hennepin and Dakota counties with the quality and cost of care provided to MA recipients by doctors paid FFS in five other metropolitan counties that had not yet been privatized. He compared 1991 utilization rates for 121,402 FFS MA recipients with 98,578 MA HMO recipients enrolled in one of four HMOs—Group Health, Medica, Metropolitan Health Plan, and UCare. Again, the HMOs refused to deliver to DHS the necessary data. In his final report, Foldes noted the HMOs’ failure to deliver usable data and called for more research.

Foldes was, however, able to draw firm conclusions about two preventive services— mammography and Pap smears. “[T]he health plans had a comparatively 5 percent higher rate of Pap smear use,” he wrote, “but the fee-for-service setting had a comparatively 35 thirty-five percent higher rate of mammogram use.” Because HMOs claimed they were much better than FFS doctors at delivering preventive services, these findings were embarrassing to the HMOs. They persuaded DHS to conceal the study from the public. But someone leaked the study to the Star Tribune, which published a front-page article about it on March 13, 1994. Under the headline, “Study shelved after HMOs complained,” the article opened with these sentences:

“Minnesota officials suppressed a study raising questions about HMO care for poor people...The study was the first attempt by the Minnesota Department of Human Services to see whether the state was saving money by sending Medical Assistance patients to health maintenance organizations…”

Deaf Ears

Neither the legislature, then in the hands of Democrats, nor then-governor Arne Carlson, a Republican, called for hearings into the HMOs’ conduct, nor did they demand that DHS take appropriate steps to force the HMOs to cooperate. DHS, which had abolished Foldes’ position when it shelved his study, did not initiate a follow-up study.

In the summer of 2004, a half-dozen members of the Minnesota Universal Health Care Coalition and I asked House minority leader Rep. Matt Entenza for help extracting from DHS a statement on whether the insertion of MCOs into MA and MinnesotaCare had saved money. In December 2004, DHS Commissioner Kevin Goodno replied to a letter from Rep. Entenza with this statement:

“There no longer remains a credible comparison group of fee-for-service recipients against whom to compare the groups now enrolled in managed care. We do not have a methodology that could accurately assess whether managed care has cost us more or less than fee-for-service.”

That is where we stand today. Minnesota law still describes MA and MinnesotaCare privatization as a demonstration even though the rigorous study of the “demo” promised by DPW four decades ago never occurred. And it still describes the privatized counties as the “experimental” counties. Some experiments never die.

Legislative Response

Two bills introduced this year in the Minnesota legislature might, just might, trigger a discussion of the impact the grand privatization “experiment” has had on the cost of MinnesotaCare and MA. One is HF 96/SF49, the MinnesotaCare “buy in” or “public option” bill supported by Governor Tim Walz. This bill would eliminate the income eligibility ceiling on MinnesotaCare. That provision in the bill has been widely reported. A section near the end of the bill that has not been widely discussed would require DHS to prepare an estimate of alternative “models” of MinnesotaCare, one of which has to be a deprivatized MinnesotaCare.

Another bill that could trigger a good discussion (if not a review) of the “experiment” is SF404/HF816. This bill, authored by DFL Senator

Privatized Medicaid and MinnesotaCare to page 304