Minnesota Physician • January 2022

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Volume XXXV, No. 10

PHYSICIAN Medicare Advantage Overpayments An unsustainable future BY KIP SULLIVAN, JD


Health Care Supply Chain Dynamics Finding room for improvement BY LUIS VALADEZ


he concept of supply chain management is relatively new, first appearing in 1983. Prior to the industrial revolution, manufacture of nearly everything was local and relied on local resources. Greater production capacities brought greater supply chain needs, but they were constrained by simple exigencies such as delivery options. The internal combustion engine and trucks changed delivery options from boats and trains, Health Care Supply Chain Dynamics to page 104

his year marks the 50th anniversary of a law that permitted health insurance companies to participate in Medicare. The law, known as the Social Security Amendments of 1972, permitted what was then a new form of health insurance, the health maintenance organization, to enroll Medicare beneficiaries. The law explicitly stated that HMOs could not be paid more per enrollee than Medicare would have paid if the enrollee had remained in the traditional Medicare program. In fact, Congress expected HMOs to reduce Medicare costs because, unlike traditional insurance companies, HMOs used managed care tactics to reduce utilization of medical services.

Medicare Advantage Overpayments to page 124

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Publishing April 2022

Volume XXXV, Number 09

COVER FEATURES Health Care Supply Chain Dynamics

Medicare Advantage Overpayments

Finding room for improvement

An unsustainable future

By Luis Valadez

By Kip Sullivan, JD

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Improving the Health of All People Lisa Shannon CEO, Allina Health

PRACTICE MANAGEMENT............................................................ 16 Clinical Service Lines Which model is right for you?

By Daniel K. Zismer, PHD, Gary S. Schwartz, MD, MHA PEDIATRICS................................................................................. 18

CARE TRANSITIONS Improving the safety net

Treating Pediatric Injuries What happens in the ice and snow

By Allyce Fisk, PA-C, MMS, Rebecca Rouse, PT, DPT MEN’S HEALTH........................................................................... 22 Circumcision

BACKGROUND AND OBJECTIVES: When a patient leaves the hospital and returns to an assisted living facility, or home, they experience a care transition. This term is also used when a patient goes from one physician to another. It can also refer to entering rehabilitation programs or treatment of a condition diagnosed by a physician and then transferred to another type of health care provider. As the spectrum of care teams expands, the number and type of care transitions also expands. Cumulatively these transitions are a leading cause of medical malpractice claims, most of which are easily preventable.

The debate of medical necessity

By Duong Tu, MD

Our expert panel will define and explain the most common problems in care transitions. We will examine the negative outcomes that arise from these issues and propose simplesystemic solutions. We will discuss best practice standards that have already been established around these concerns, why they are not more widely followed, and how they can be implemented. We will review technology, which in some cases creates problems, that can be used to reduce them.



Mike Starnes, mstarnes@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.

As we transition to a post-pandemic business world, health care will lead the way in terms of new policies, procedures and readiness. The Minnesota Health Care Roundtable has adjusted to these dynamics. We now invite our readers to participate in this now remote conference process. If you have questions you would like to pose to the panel, or have topics you would like the panel to address, we welcome your input. Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.




Allina Health Launches Comprehensive Cancer Institute Allina Health has recently announced the launch of the Allina Health Cancer Institute (AHCI), a regionally differentiated cancer program that redefines how cancer care is delivered by providing comprehensive, expert, person-centric cancer care from diagnosis to survivorship. “We know a cancer diagnosis can be overwhelming for patients and their loved ones and fragmentation in care can add to the burden - and we recognize that needs to change,” said Allina Health President and Chief Operating Officer Lisa Shannon. Over the last 18 months, substantial resources were committed to launch a novel organization construct, which includes new and expanded facilities, like the previously announced new, comprehensive radiation oncology center within the United Hospital campus; as well as

the recruitment of top physicians, management and caregivers. Badrinath Konety, MD, who most recently served as, Dean of Rush University Medical College and Senior Vice President for Clinical Affairs at Rush University System for Health in Chicago, joins the team as the AHCI President. “Our goal is to provide expert cancer care that is easily accessible and convenient to the patient,” said Dr. Konety. “We have numerous sites across a wide geographic area. The AHCI creates a network, everyone working together, to deliver comprehensive cancer care that fits the lives of our patients and their families. This model of connected care is one of the most important features of the services we can provide.” The “Institute” model of care offers an expanded suite of oncology services and reflects the commitment to prevention and detection, clinical innovation and research partnership, substantial emphasis on tumor-specific specialization, the importance

of physician alignment with a strong focus on a multidisciplinary team of providers and processes needed to deliver whole person cancer care. “Our communities may notice a change to the look and name or our locations, but the real change comes from within the system,” said AHCI Vice President Michael Koroscik. “We will passionately strive for our patients and families to fully experience this reimagined commitment to care during every level of their cancer journey.”

Fairview Begins New Portable MRI Machine Trial M Health Fairview has recently begun a trial of a new portable MRI machine – the Hyperfine® Swoop® Portable MR Imaging System™. This technology uses artificial intelligence (AI) to convert the signals detected by the MRI into detailed pictures of the brain. Traditional MRI units can weigh five tons or

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability? Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.



more and generate strong magnetic fields that require special medical suites for safe use. The use of AI with MRI technology allows meaningful images to be extracted from weaker signals. Because of this, an accurate scan can be performed with a smaller magnet and weaker magnetic field – which means the MRI machine can safely travel around the hospital and to a patient’s bedside. M Health Fairview is the only health system in Minnesota, and one of only a handful nationwide to trial this leading-edge technology. The fact that traditional MRI machines need to be in specialized suites limits who can receive scans. “Many patients are too sick to transport at times that an MRI is needed. Even for healthier patients, transport poses risks,” said M Health Fairview Neurosurgeon Clark C. Chen, MD, PhD. During traditional MRI scans, patients are also alone in a suite without the support of their friends or family. With the new


portable MRI, patients can have their support system in the room during a scan, which can be especially helpful for young patients. So far, portable MRI scans have been performed in various hospital settings – including the emergency department, intensive care unit, post-anesthesia area, and the neurology/neurosurgery inpatient unit. Patients who receive a scan from the portable MRI during our trial also receive a scan from our traditional MRI machine. This way, clinicians can compare the results. “We are carefully evaluating the images from this portable unit and comparing them to traditional MRI and computerized tomography (CT) scans to ensure that patient care is not compromised,” said Chen. “Continued development of this technology means that someday clinicians could bring a portable MRI machine to wherever an MRI scan is needed.” The portable MRI will be trialed at M Health Fairview University of Minnesota Medical Center and M Health Fairview Masonic Children’s Hospital for a six-month period.

UCare and Leading Edge Partner to Assist Rural Minnesota Seniors The UCare Foundation has partnered with the LeadingAge MN Foundation (LAMF), to bring a visionary new model of integrated care to aging adults living in rural communities in west central Minnesota. Through separate funding, LAMF has awarded Connected Communities for Healthy Aging pilot grants of $800,000 each to two LeadingAge Minnesota members – Knute Nelson in Alexandria, Minnesota and Perham Health in Perham. The UCare Foundation contributed an additional $100,000 to each organization to support program design and implementation through year-end 2022. With the goal of helping older adults experience healthier aging, the

pilots will coordinate and deliver an inter-connected continuum of community-based supports (socialization, meals, transportation); preventive and primary care; acute, post-acute and long-term care; and other services to support and enhance older adults’ quality of life. Key objectives are: • Convene and advance a local and collaborative whole-system, whole-person approach to serving seniors • Improve care of Medicare Advantage members in a local health plan in coordination with providers of primary care, acute- and postacute care, home care and community-based services • Connect consumers to local resources for healthier aging • Implement effective workforce strategies to support this collaborative model “For too many older Minnesotans – especially those living in remote rural communities – the prospect of healthy aging diminishes when they reach their older years,” said Ghita Worcester, Senior Vice President of Public Affairs and Chief Marketing Officer. “Through these pilot projects in west central Minnesota, we will create integrated hubs of essential resources that will help people recapture their sense of a life well-lived.” “The Connected Communities for Healthy Aging pilots will show there is a better way to age. We will leverage recent changes in Medicare Advantage reimbursements, implement learnings from previous rural pilot projects, and design coordinated systems of care that support all dimensions of health for people in all the places they call home,” added Gayle Kvenvold, President and CEO of LeadingAge Minnesota.

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Avera Marshall and RCHI Partner to Create Access Health Marshall In a collaborative agreement, Avera Marshall Regional Medical Center and Rural Health Care, Inc. (RHCI) have opened a new primary care clinic in Marshall as a Federally Qualified Health Center (FQHC). This collaboration permits existing Avera Medical Group Marshall’s primary care services to return to the Carlson Street campus at 1521 Carlson St., and operate as Access Health Marshall. Available services will include behavioral health, family medicine, pediatrics, obstetrics/gynecology, internal medicine and urgent care. Limited lab and imaging services will also be available. The clinic is now open. Patients will continue to receive the same high level of quality health care from providers and staff they know and trust in Marshall. Through a lease agreement with

RHCI, physicians, advanced practice professionals and staff will continue to be employed by Avera. Avera Marshall Regional President and CEO Debbie Streier said returning primary care to the Carlson Street campus in collaboration with RHCI and remodeling the Bruce Street campus offers wins for patients, the community and Avera Marshall. In addition to high-quality health care, benefits of an FQHC include a sliding-fee discount program and discounted pharmacy program for financially qualified individuals. “This collaboration expands access to high-quality care in rural communities, including those individuals and families who fall into lower income categories,” Streier said. “Avera and Rural Health Care, Inc. have partnered successfully for more than seven years in several communities. Created in 1991 under federal law, FQHCs are “safety net” health care providers. RHCI accepts

all major insurances and provides services to all individuals, regardless of ability to pay, by providing a sliding scale based on family income and size. RHCI operates 12 other community-based health centers in South Dakota and Minnesota and has its headquarters in Fort Pierre, S.D. The location combines RHCI’s knowledge and experience in community health center operations and Avera’s expertise and technology. Jim Hardwick, CEO of Rural Health Care, Inc., said, “Avera’s willingness and enthusiasm to collaborate with RHCI will allow the Marshall clinic to reach more individuals in need of quality health care. In today’s health care climate, increasing access to high-quality, cost-effective health care is the goal. This collaborative delivery model has a long history of reducing barriers while enhancing and expanding access to care in rural locations.”

RAYUS Radiology Opens Two New Imaging Centers RAYUS Radiology, formerly Center for Diagnostic Imaging, has announced the expansion of its growing network of high-quality, high-value diagnostic imaging centers throughout the Twin Cities with the opening of two new outpatient-based advanced diagnostic imaging centers in Otsego and Shakopee. RAYUS operates 17 other outpatient-based diagnostic imaging centers in the Twin Cities, and in Eau Claire and La Crosse, Wisconsin. The new Otsego center provides a full-range of diagnostic imaging services that feature a high-field MRI, CT, diagnostic and therapeutic injections, 3D mammography, ultrasound and X-ray, while the new Shakopee center offers 3T MRI, CT, diagnostic and therapeutic injections, ultrasound and X-ray. “We are thrilled to continue our growth in Minnesota and further increase access to diagnostics and imaging to physicians and their patients in the Otsego and Shakopee areas,” says Dr. James

new 50 45 isforthe colon cancer screenings.

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• Hypertension, 29% and 63%, respectively.

Dima Slobodeniouk, conductor Baiba Skride, violin

• Hyperlipidemia, 29% and 33%, respectively. • Diabetes, 5% and 19%, respectively. • Smoking, 17% and 13%, respectively.

Send us your news comments@mppub.com



Regarding health beliefs, 99% of all participants agreed that their actions could affect health and cardiovascular disease prevention, which was important to them. Also, 83% reported trust in their health care provider and 39% had a perception that their risk of a cardiovascular event was high. “The higher prevalence of risk factors and the corresponding burden of cardiovascular disease in African Americans in Minnesota are stark, but I am encouraged by the high level of trust in clinicians that this analysis revealed. Our community-based research FAITH Program (FAITH stands for Fostering African American Improvement in Total Health) will use these findings to continue working to improve cardiovascular disease risk factors in this population in community and clinical settings,” says Dr. Brewer.


Minnesota has the lowest age-adjusted heart disease mortality in the U.S.; yet, African American adults 35 to 63 have nearly double the rate of death from cardiovascular disease, compared to their white counterparts. Findings of a new study show that basic health beliefs and demographics, such as age, sex, marital status and level of education attained, were associated with the risk factors for cardiovascular disease. Of the study group, the prevalence of common risk factors were hypertension, 68%; hyperlipidemia, 47%; diabetes, 34%; and current cigarette smoking, 25%. Also, 18% of participants had cardiovascular disease, and the pervasiveness increased by 30% or greater with three or more risk factors. “The increased risk factors and prevalence of cardiovascular disease stands out because our findings are significantly higher than found in previously documented studies,” says senior study author LaPrincess Brewer, M.D., a preventive cardiologist at Mayo

Upcoming Concerts


Mayo Study Addresses Higher Rates of Cardiovascular Disease in African Americans in Minnesota

Clinic. In comparison to Minnesota Heart Health Program findings, the Minnesota Heart Survey recorded only a 4% proportion of cardiovascular disease and the Atherosclerosis Risk in Community study found 13%. The incidence of common cardiovascular disease risk factors varied widely across similar studies, as well. Compared to those in the Minnesota Heart Health Program study, the Minnesota Heart Survey and the Jackson Heart Study, respectively, showed lower prevalence of:


Sullivan, Medical Director of the Twin Cities for RAYUS Radiology. “These new centers will offer multi-modality solutions for physicians and their patients to obtain the highest level of diagnostic imaging care in a timely manner.” RAYUS’ ongoing expansion in Minnesota, as well as the opening of a new location in Maine, are the latest efforts in the medical provider’s national growth strategy that accelerated in 2021 following Wellspring Capital Management’s 2019 acquisition and subsequent investment in expanding the network and physician and patient services. With these new locations, RAYUS has added 21 centers in 2021 to increase its nationwide network to 150 locations.

CANELLAKIS CONDUCTS DON QUIXOTE FEB 25–26 Karina Canellakis, conductor Jean-Guihen Queyras, cello

TCHAIKOVSKY’S PATHÉTIQUE SYMPHONY MAR 3–5 Nathalie Stutzmann, conductor Tobias Feldmann, violin

minnesotaorchestra.org #mnorch 612-371-5656 | All artists, programs, dates and prices subject to change. PHOTOS Skride: Marco Borggreve; Steves: Rick Zagreb; Canellakis: Mathias Bothor; Stutzmann: Simon Fowler.




Improving the Health of All People Lisa Shannon, CEO, Allina Health

Taking over from Penny Wheeler are some big shoes to fill. What can you tell us about how she has helped you to continue her legacy?

have come together and rallied to continue caring for our community in the most challenging of circumstances–we quickly pivoted to virtual care, found new ways to connect patients to their loved ones during times when we couldn’t have them at the bedside and quickly implemented important safety measures as part of our Safe Care Commitment to assure our patients it was safe to receive the in-person care they need, whenever they needed it.

I feel an incredible pride and honor to be able to lead Allina Health at this time following Dr. Penny Wheeler, who is a tremendous leader for our organization and who brought me to the organization. I am privileged to have been able to work alongside Penny for the last four years. She has been an exceptional leader, mentor and friend and I am grateful she is extending her service as a member of our Board of Directors.

What can you share about how the Allina Health Aetna partnership has developed?

“...” to all voices Listening is critical to providing the highest quality, compassionate care. “...”

As I look to the future, I hope to accelerate the foundation we have laid as an organization to ensure every part of our system works in coordination to provide a seamless experience for our patients, while continuing our momentum to change how health care is delivered to serve all patients and create more access and greater affordability.

I’m inspired by our entire team because it is truly extraordinary to watch the compassionate work that everyone is involved in, not only in the pandemic, but prior to COVID-19 and for countless other care needs that our community has.

Allina Health/Aetna was developed as a way to bring together two health care organizations with proven reputations for caring for the community with a goal of delivering an expert, cost-effective, personal and more comprehensive approach to health and wellness. Some examples of how we are delivering value-based care to patients are alignment on incentives and motivations to optimize patient health, sharing of real time clinical data to ensure holistic and personalized care and creating a streamlined patient experience by cross collaboration of our customer experience teams.

We recognize that cancer care can be complex and overwhelming–that’s why we’ve set out to reimagine cancer care by taking the right steps to ensure that every part of our system works in coordination to create an effortless care experience that fits the lives of our patients and their families. We believe a seamless cancer care experience is one of the most important services we can provide.

Please tell us about the new Allina Health

Our teams are 100% committed to caring for the communities we serve. They are not only dedicated to providing high-quality, compassionate care to our patients; they are deeply dedicated to each other. Our teams set a high bar for themselves, and they consistently strive to be best at what they do.

Cancer Institute?

The Allina Health Cancer Institute redefines how cancer care is delivered by providing comprehensive, expert cancer care that puts patients at the center and surrounds them with dedicated and compassionate caregivers, who work as a coordinated team to provide treatment and remove stress and inconvenience, allowing our patients to focus on healing.



The unprecedented challenges of COVID-19 are now echoed by the Omicron variant. What stands out in your mind around how Allina has reacted to the ongoing pandemic?

The resiliency and humanity I have witnessed, despite how fatigued and challenged our teams have felt, is nothing short of remarkable. Our teams

Another challenge that has become front and center is health care equity/social disparities in health care. How has Allina addressed these issues?

For our organization, the interlocking crises of a global pandemic, economic inequality and systemic racism have led us to an inflection point in how we seek to understand our role as a health care provider—to facilitate change for those we are privileged to employ and serve across Minnesota and the region. We are committed to eliminating racial disparities and inequities in care for all. As an organization, we have implemented a DE&I council that I lead, created an operations committee that includes representatives from teams such as human resources and community partnerships and we’ve developed employee resource groups to empower employees at every level to become advocates. Our DE&I goal is to improve the health of all people in our communities by using our collective strength as a care provider, employer, purchaser and community partner to eliminate systemic inequities and racism. We acknowledge this is a long-term journey, and as an institution we have much to learn. Please tell us about the Allina Integrated Medical (AIM) Network.

The Allina Integrated Medical Network brings together physicians and Allina Health to

provide market-leading quality and efficiency in patient care by ensuring patients have easy access to quality, affordable health care. The network is positioned to support the achievement of better collaboration and integration across the continuum of care through technology, contracts and support services. Allina is very active in the field of medical research. While there are too many outstanding projects to cite which ones come to mind first?

work to deliver on our caring mission. Each of us–employees, patients and community–members have a role to play in creating health care that works for all of us.

Physician burnout has been on the minds of many health care organizations. While clearly it is even more important now, what are some of ways Allina is dealing with these issues?

This is more important now than ever as we navigate through some of the most challenging times that health care has faced in decades. And yet, these same challenges present us with opportunities to learn and adjust how we can better provide more seamless, affordable, accessible quality care. I believe that listening to all voices is critical to providing the highest quality, compassionate care for the communities we serve.

We respect and value the important contributions of all our employees, and we recognize it is a very challenging time and our caregivers are weary mentally and physically. We are focused on supporting our entire team through mental health and well-being programs, benefits, pay, career development and more. We are and will continue to listen to what’s most important to our employees. Bringing Whole Person Care to life for those who serve is an important part of our ongoing commitment and one of my highest priorities. What are the biggest challenges you see in the future for Allina and health

Lisa Shannon, is president and chief executive officer of Allina Health. Prior to her appointment as CEO she served as president and chief operating officer. Before joining Allina Health, she held the roles of chief operating officer and president of health system delivery, for KentuckyOne Health, the largest integrated health system in Kentucky.

care delivery as a whole?

Throughout my entire career, I have remained passionate about quality care and elevating the voices and expertise of those who are doing the

Transforming Healthcare

One of the most important clinical trials we conducted was the ENSEMBLE study. Allina Health was the only clinical trial site in Minnesota to participate in Janssen Pharmaceutical’s (part of Johnson & Johnson) COVID-19 vaccine study, during phase 3 of its clinical trial. Our commitment to clinical research has remained steadfast during the unprecedented challenges of the COVID-19 pandemic. The Allina Health Research team was well-positioned to meet the rapidly evolving COVID-19 research needs in support of our employees and the communities we serve. Through our partnerships with other organizations and the robust research infrastructure

built over many years, we have been able to quickly pivot to a research team focused on understanding COVID-19 treatments, protocols and safety, while safely continuing our many other areas of research.




3Health Care Supply Chain Dynamics from cover

While it is a tangible commodity and subject to more measurement than any other industry sector, through more different lenses and metrics, it can but it was the life or death demands of World War II that brought supply chain also be extremely subjective, employing concepts such as quality-adjusted management to its next level. Simple innovations like the invention of pallets, years of life. Health care supply chain dynamics are further complicated by storage systems and supply warehouses ushered in the use of computers for radical variation in how and where the care is provided. The supply chain tracking, projections and inventory control. Today, concerns of a two-physician primary care office supply chain management involves a globalized are just as legitimate as those of the Mayo Clinic, network that leverages artificial intelligence and but the scale and challenges are very different. As highly trained industry professionals who utilize a teaching hospital serving many of the counties an ever-expanding array of delivery methods and most underserved, Hennepin Healthcare System We saw prices increase vehicles. Two years ago, the COVID pandemic (HHS) has different demands than systems such by 100%-200% where turned the fledgling global industry of supply as Allina Health or M Health Fairview, but there we had to utilize third chain management upside down. are also many base line similarities. party local distributors.. Health care delivery is unique from other business sectors for many reasons, so it is not surprising that supply chain concerns are unique. The pandemic brought the acute shortage and inability to deliver PPE, ventilators, vaccines, etc., to the fore. As fast as these problems were solved, new ones arose. The more people who were trying to fix things, such as mandates concerning access to health care services, the more new problems arose. The rapid development and subsequent deployment of the MRNA vaccine stretched the borders of supply chain management, as does the delivery of booster doses. One of the things that makes health care unique in terms of supply chain considerations is that we are in the business of manufacturing health.

OB & GYN CARE FOR ALL STAGES OF LIFE Low- and high-risk obstetrics,

Menopause Clinic, including

including advanced maternal age.

management of peri-menopause

Certified nurse midwifery.

Center for Urinary and Pelvic Health, including urodynamics.

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

Nutrition and wellness consultations.

Infertility evaluation and


Early, late, and Saturday appointments



M A P L E G R O V E • B L A I N E • P LY M O U T H • C R Y S T A L



Assessing the challenges To address the difficulties of being certain our providers have the tools necessary to deliver the best possible care for our patients, HHS has spent many years developing a department of supply chain management. To get where we are today took a methodical approach to our maturity progression spanning over five years. The mindset and determined needs are embraced by everyone on the team, and it ensures we are all in this together. We evaluated our maturity in three areas: people, process and technology.

People We needed to make sure we had top talent that embraced change. Leadership was a key factor in this progression, as we needed to make sure we kept the team engaged and involved in the decision making process. We therefore created a sense of ownership with team members. Another key factor was mindful hiring. As staff moved on to other positions, we made sure we brought in top talent to help progress the maturity journey. We looked for talent that was good fit with our existing leadership structure, as well as candidates who had forward thinking ideas about improving and committing to operational excellence and employee engagement.

Process As we evaluated the operations as a whole, the one factor that stood out was the daily inconsistency of the work we performed. Everybody had their own way of performing a task or running a report. This led to gaps in service and information that adversely affected the reliabilty of business decisions. An example is the way we reviewed our contracts. Each individual had their own style of review and timeline. We brought the group together for a working session to discuss possible improvement tactics, which resulted in an increase in completion on time from 50% to 98%. This practice is still maintained and is monitored bi-weekly. We also looked at our logistics, procurement and sterile processing departments and decided to go back to the basics. We therefore developed standard operating procedures (SOPs), as well as updating our departmental policies to reflect the future state of supply chain. Once all our SOPs were updated, the next phase was to train all staff to the new standards. This enabled us to feel confident that the continued improvement of our processes would drive efficiencies across the board and not for just one individual or shift. In addition, when asked to present data or opportunities to our executives, we knew the information was accurate and everyone was now running the same reports. Technology In order for technology to work, you need the people and processes working in sync. Technology is meant to enhance your people and

clinically approved substitutions up front, we didn’t have to go through the rigor of tying up critical resources at critical times.

processes. If they aren’t working together, technology will be impaired. This was by far the most challenging area to drive maturity as capital funding was limited. Our approach was to inventory our existing system instead of going out to the market to find the best of the best. What we found was we already had what we needed to create a maturity path in this area. We looked at our reporting process and how we could make our customers understand the data a bit more easily. We used Power BI (Business Intelligence) to help provide a clear, one screen visual of what our reports were meant to convey. By using Power BI, rather than Excel spreadsheets, we eliminated the potential for confusion.

As we look to the future of supply chain, we learned a lot over these two years. Previously, we relied heavily on driving business and value through one distributor; diversification among distributors will help driving standardization across our organization. In the future, we want to be as flexible as possible, so we have not put all of our eggs in one basket. Neither just-in-time inventory or lean inventory will be sustainable methodologies with all product lines, as these practices will now lead to shortages and stockouts as lead times have lengthened. Another way we are rethinking future supply chain is by looking at offshore versus onshore manufacturing and distribution. Offshore will help cut down lead times and increase product reliability. However, we need to realize this new supply chain comes at a cost. Managing cost will be the biggest challenge as health systems already have narrow margins. We saw our transportation costs double, we saw our prices increase by 25% where there were raw material shortages and we saw prices increase by 100%-200% where we had to utilize third party local distributors. This will challenge health care supply chains as we continue to mature and drive non-value-added cost out of our system to accommodate the new norm. But by having your people, processes and technologies in place, it’s achievable.

Enter the pandemic When our people, processes and technology were in place with positive results realized daily, the pandemic hit. It was stressful at first because we didn’t know the length or impact it would have on our organization. However, by having processes and systems in place, we were able to pivot and create new processes to accommodate this new normal. We seemed to have a grasp on the demand until our manufacturers and vendors weren’t able to keep up with demand and product was dried up. Our driving force was to ensure our patients and staff had what they needed to feel safe. We had multiple command centers open (system wide and supply chain) to keep the communication fluid. Our supply chain command center sometimes met three times per day to determine where we were able to source hospital-grade personal protective equipment (PPE) and other vital supplies and equipment. We looked at our backorders daily and worked to identify third party smaller trusted distributors from whom we could source product. This helped us grow our vendor relationships, which we would need to ensure we were prioritized for future procurement. We also quickly realized the need for updated days on hand (DOH) of our inventory to send to our hospital incident command center (HICS), as well as our departments across the hospital, to facilitate understanding of their inventory levels. We established a visual stop light dashboard (red for < 14 DOH, yellow for 14 through 29 DOH, and green for > 29 DOH). This enabled everyone within our health care system to easily identify our PPE status. By redefining and standardizing our processes we were able to pull reliable data quickly and efficiently when needed.

Luis Valadez is Senior Director, Supply Chain Administration at Hennepin Healthcare.

Rethinking the future By having our people, process, and technology in line, we were able to come together as a team to understand the situation at hand and implement systems and processes adapted to the pandemic. As we come up on two years of the pandemic and our PPE distributors are now healthy with their inventory, we are seeing a shift in supply chain shortages which have been more disruptive than those at the onset of the pandemic. We are seeing our supply and equipment shortages move from a couple dozen items to now several hundred at any given time. Whether longer lead times to items held at ports, lack of cargo containers to transport product, lack of trains and trucks due to worker shortages, or just a sheer lack of raw material to manufacture goods, we are not seeing a pattern of specific categories being affected; rather this shortage is showing all across the board. The challenge seems to be a new backorder every day our team needs to addres.









Early on in our maturity journey we identified an opportunity to use product substitutions in the event we couldn’t obtain the original product. This initiative took several years and is still ongoing to this day. By placing



3Medicare Advantage Overpayments from cover These tactics includes incentives to order fewer services, limiting patient choice of doctor and hospital and micromanaging doctors. But the introduction of HMOs (and after 1997, all types of insurance companies) into Medicare did not cut Medicare’s costs. Throughout the half century during which insurance companies have participated in Medicare, they have raised Medicare’s costs. They have been paid more, at times much more, to insure their enrollees than if those enrollees had remained in the original Medicare program.

The Medicare Advantage program Not surprisingly, the large overpayments have facilitated enormous growth in the Medicare Advantage program, the current name of the Medicare program in which insurance companies participate. Today, 46% of all Medicare beneficiaries in the country, and 56% of beneficiaries in Minnesota, are enrolled in one of the Medicare Advantage insurance companies. Minnesota’s rate is second only to the 57% rate for Hawaii. Ten giant insurance companies, led by UHC Healthcare, Humana and CVS Health Corporation, account for four-fifths of the enrollment in Medicare Advantage plans. How did this happen? Medicare was enacted, after all, because the insurance industry did not want to insure the elderly. And HMOs were allowed into Medicare only because they were expected to lower Medicare’s costs. Why has Medicare overpaid insurance companies for half a century?

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We can eliminate one explanation immediately: that Congress didn’t know about the overpayments. Beginning in 1980, analysts inside and outside the federal government regularly published research demonstrating that Medicare was overpaying HMOs. Note that the phrase fee-for-service (FFS) refers to the traditional Medicare program in which doctors and hospitals are paid a fee only after they render a service. In contrast, Medicare Advantage insurance companies are paid a lump sum per enrollee in advance. In a 1995 report to Congress entitled “Growing Enrollment Adds Urgency to Fixing HMO Payment Problem,” the US General Accounting Office (GAO) stated, “Medicare has paid HMOs more than it would have paid for the same patients’ care by fee-for-service providers.” In a 2005 report entitled “Payments Exceed Cost of Fee-for-Service Benefits, Adding Billions to Spending,” the GAO stated, “It is largely . . . excess payments, not managed care efficiencies, that enable plans to attract beneficiaries by offering a benefit package that is more comprehensive than the one available to FFS beneficiaries, while charging modest or no premiums. Nearly all of the 210 plans in our study received payments in 1998 that exceeded expected FFS costs….” The explanation for the overpayments is two-fold: the insurance companies have always enrolled healthier beneficiaries (a problem known as favorable selection), but they have been paid as if they attracted beneficiaries of average health. For example, if the average annual cost of insuring a beneficiary in the traditional Medicare program was $10,000 and United Healthcare (UHC) enrolled healthier beneficiaries whose average cost was $9,000, it could be said UHC enjoyed favorable selection. If the Centers for Medicare and Medicaid Services (CMS, the current name of the agency that runs Medicare) were to pay United $10,000 for each enrollee, the overpayment would equal $1,000 per enrollee. The obvious solution would be for CMS to pay UHC a premium commensurate with the health status of its enrollees – in this case, $9,000. But CMS has never been able to reduce its payments to insurance companies to match the lower cost of the healthier beneficiaries they enroll. There is no solution to either problem. The favorable selection problem will persist as long as a Medicare Advantage program exists alongside the traditional program. CMS’s effort to improve the accuracy of its payments to Medicare Advantage plans only made the problem worse.

Favorable selection Medicare beneficiaries and Medicare Advantage plans both contribute to the favorable selection problem. Medicare beneficiaries contribute because they vary in their willingness to give up choice of provider (doctor and hospital) in exchange for the extra services the Medicare Advantage plans can afford to offer (because they are overpaid). Sicker beneficiaries are less likely to want to join an HMO or any other type of insurance company that limits choice and attempts to influence physician-patient decisions.


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The insurance companies aggravate favorable selection by their advertising and recruiting tactics (cherry-picking) and their treatment of the sicker enrollees they cannot avoid (lemon-dropping). Medicare Advantage plans are not allowed to refuse to enroll applicants, but they can encourage healthier beneficiaries to apply by their marketing tactics (where they market, what they say in their advertisements and what they cover at little or no expense to the enrollee), and they can encourage sicker enrollees to disenroll and return to traditional Medicare by denying or delaying services.

Dozens of studies published over the last half century have shown that insurance companies that participate in Medicare have enjoyed favorable selection. Here are five examples spanning the last 40 years.

their enrollment in HMOs, the HMO enrollees had a rate of hospital admissions that was two-thirds the rate in the fee-for-service group.The members of the HMO-disenrollment group had a substantially higher rate of [hospital] admissions than the fee-for-service beneficiaries…” The title of this article was, appropriately enough, “The Medicare-HMO revolving door: The healthy go in and the sick go out.”

A study published by Paul Egger in 1980 concluded that beneficiaries who joined Group Health Cooperative of Puget Sound (one of the nation’s oldest HMOs) “had a rate of hospital inpatient use over 50% below the comparison group” consisting of beneficiaries in traditional Medicare. The money currently spent A 1988 report to the Health Care Financing Administration (the former name of the agency that runs Medicare) stated that the beneficiaries who enrolled in Medicare HMOs cost 21% less than those who stayed in traditional Medicare.

on insurance companies’ overhead could be used to raise reimbursements to doctors.

A study published in “Medical Research and Review” in 1997 concluded “in the six months prior to their enrollment, new HMO enrollees use on average 37% fewer services than do beneficiaries in traditional fee-for-service Medicare. Furthermore, HMO disenrollees use 60% more services in the six months after disenrollment than do fee-forservice beneficiaries.” A study published in the “New England Journal of Medicine” in 1997 found HMO enrollees were much healthier than traditional Medicare beneficiaries when they signed up with HMOs, and those that later disenrolled from HMOs were much sicker. The authors reported, “Before

A study published by the Kaiser Family Foundation in 2019 found that Medicare beneficiaries who enrolled in a Medicare Advantage plan were 13% less expensive than the average cost of a traditional Medicare enrollee. In 2016, beneficiaries who stayed in traditional Medicare incurred Part A (hospital) and B (physician) medical expenses of $9,362 on average, while those who signed up with a Medicare Advantage

plan cost just $8,109.

Risk adjusting premiums accurately is impossible If favorable selection and the overpayments have been obvious for four decades, why hasn’t CMS eliminated the overpayments? Why doesn’t CMS just reduce the premiums down to a level commensurate with the better health–the lower cost–of the insurance companies’ enrollees?

Medicare Advantage Overpayments to page 144

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3Medicare Advantage Overpayments from page 13 Answer: because CMS sets the premiums prior to the year for which the beneficiaries are enrolled, and predicting what each insurance company’s pool of enrollees will cost the next year is a primitive science.

cost 1.5 times as much as the average beneficiary; beneficiaries with a cancer diagnosis cost 1.7 times as much. CMS spent the next seven years preparing a new risk adjuster called the Hierarchical Condition Categories (HCC) risk adjuster. To the four demographic factors, CMS added 3,000 codes for diagnoses.

Between 1973 and 2004, CMS (and The addition of all those codes greatly its predecessor, the Health Care Financing improved the accuracy of the risk adjuster. The Administration) tried to risk adjust premiums new HCC could predict 11%, and within a few downward using four factors: age, sex, Medicaid years, 12% of the variation in spending between Medicare has paid HMOs status and nursing home status. Although each of individual beneficiaries. But 12% is still more than it would have paid these factors is correlated with medical spending for the same patients’ care by negligible. To return to our United Healthcare (80-year-olds typically cost more than 65-yearfee-for-service providers. example, now CMS can reduce UHC’s olds, for example), the correlation between these overpayment by 12% from $1,000 to $880. The demographic factors and spending is very weak. overpayment is still immense. Twelve percent They only predict one percent of the variation in is obviously 12 times better than one percent, spending. To explain what that means, let’s go but it still gives Medicare Advantage plans an back to the United Healthcare example. If UHC was overpaid by $1,000, enormous incentive to continue cherry-picking and lemon-dropping. CMS’s demographic risk adjuster would only call for reducing UHC Another way to illustrate the crudeness of the HCC risk adjuster is to premium payments by one percent, or $10, from $10,000 to $9,990. demonstrate its disparate impact on the healthy and the sick. According to the UHC would still be overpaid by $990. Medicare Payment Advisory Commission (MedPAC, an agency created by In the Balanced Budget Act of 1997, Congress instructed CMS to the Balanced Budget Act of 1997 to advise Congress on Medicare), the HCC improve the risk adjuster by adding diagnoses to the four demographic results in huge overpayments for the healthiest beneficiaries and enormous factors. It’s easy to see the logic in that proposal: People diagnosed with underpayments for the sickest. For example, looking at the healthiest 20% of diseases and conditions cost more than people with no diagnoses, and beneficiaries; it overpays by 62% but for the sickest one percent, it underpays people with serious diagnoses cost more than those with mild or temporary by 29%. MedPAC and researchers at CMS who were hired to develop the diseases or conditions. Medicare beneficiaries with diabetes, for example, HCC have made it clear that for both technical and financial reasons it is not possible to improve the HCC by even a small amount.

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The HCC was implemented between 2004 and 2007. It backfired immediately. It gave the insurance companies an incentive to make sure every disease and condition is listed in patients’ medical records (which is legal), as well as an incentive to add diagnoses to medical records that are inaccurate (they overstate the seriousness of the condition), inappropriate (the diagnosis was made by someone not authorized to make the diagnosis) or flat out fraudulent. Adding inappropriate or fraudulent codes is called upcoding. Both behaviors–more thorough listing of legitimate diagnoses and upcoding– increased CMS’s payments to the Medicare Advantage plans more than the increased accuracy of the HCC reduced them. This conclusion is supported by the Medicare Advantage plans’ behavior following the implementation of the HCC. Medicare Advantage plans began to advertise richer benefits for lower premiums, and that in turn caused enrollment to soar–from 13% of all beneficiaries in 2005 to 46% in 2020. Congress has tried to address the upcoding issue by instructing CMS to reduce plan payments by a few percentage points each year, but that approach has not stopped upcoding or overpayments. Over the last several years, federal prosecutors have sued several of the larger Medicare Advantage plans for defrauding Medicare–UHC, Anthem and Kaiser Permanente (Kaiser)–for example. A complaint filed by the US Department of Justice against Kaiser last August stated that each additional diagnosis was worth $3,000 to Kaiser.

How much is enough? Insurance companies cannot make a profit off Medicare beneficiaries if they are paid no more than what those beneficiaries would have cost had they remained in traditional Medicare. The reason is their high overhead.

UHC and all other Medicare Advantage plans incur administrative costs equal to about 15% of their total Parts A and B expenditures on average. Those costs include the cost of advertising, creating networks of providers that enrollees must use, influencing and overruling doctors, lobbying and profit. Profit constitutes a quarter to a third of that 15% figure. But insurance companies cannot cut spending on hospitals and clinics by 15%. Experts guesstimate they can only cut medical spending by about five percent. Research on how much Medicare Advantage plans reduce utilization of medical services is sparse and inaccurate because plans do not publish information on how they allocate their revenues. This means insurance companies must be overpaid by at least 10% in order to induce them to participate in Medicare Advantage. And since insurance companies need additional overpayments to finance the extra benefits, e.g., dental care, eye glasses, hearing aids, that lure beneficiaries out of the traditional program into Medicare Advantage, the overpayments must be even higher than 10%. Bruce Vladeck, who administered CMS during Bill Clinton’s presidency, discussed this issue in an article he co-authored two decades ago for the journal “Health Affairs.” Managed care plans do not have to be just more efficient than FFS Medicare,” he wrote, “they have to be a lot more efficient. With administrative expenses in the range of 8 to 25%, [plans] have to incur medical expenditures 10 to 20 % less than FFS…just to break even. In most markets…plans cannot attract enrollees unless they offer additional benefits, which also cost money…” The subtitle of Vladeck’s article was “Theory meets reality, and reality wins.” That accurately sums up the problem: the theory that insurance

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companies could save Medicare money was always inconsistent with reality. It was based on hype, not evidence. If it wasn’t inconsistent with reality, why did Congress need to enact Medicare in the first place? Congress enacted Medicare because the insurance industry did not want to insure the elderly (or the disabled, who were added to Medicare in 1972). Overpayment is the reason 46% of all Medicare beneficiaries are insured by health insurance companies today, 50 years after Congress first allowed HMOs into Medicare. If they were paid no more than CMS pays for traditional beneficiaries–a requirement Congress wrote into the original 1972 law allowing HMOs into Medicare–they would not participate.

A deadline looms Payments to Medicare Advantage plans (including the overpayments) are financed directly by taxpayers and indirectly by lower reimbursements to doctors and hospitals that treat Medicare patients. Taxpayers include: people of all ages who pay the Medicare payroll tax that funds Medicare’s Part A trust fund, all Americans who pay federal taxes and all Medicare beneficiaries who pay what are called Medicare Part B premiums. Thus, virtually all health care professionals and all Americans have a stake in terminating the Medicare Advantage overpayments. It is true that people who enroll in Medicare Advantage plans are getting some of the benefit of the overpayments in the form of coverage for services they couldn’t get if they remained in traditional Medicare. But those services are being purchased by the taxpayer at an unnecessarily high price. Medicare Advantage Overpayments to page 284

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Clinical Service Lines Which model is right for you? BY DANIEL K. ZISMER, PHD, GARY S. SCHWARTZ, MD, MHA


he U.S health care marketplace is at an interesting inflection point, and this time it more specifically implicates career decisions for certain physician subspecialties, especially clinical specialties that operate primarily in the ambulatory care arenas. Particularly implicated are specifically identified clinical service lines (CSLs) that are not wholly dependent upon referring physicians for patients. Successful CSLs operate with effective brand positioning strategies which strive to predetermine patient choice, e.g., the patient has made up their mind where to go for care before the need arises, e.g., “If I get cancer, I’m going to the [xyz] cancer center.” Practical experience demonstrates that referring physicians are not likely to persuade patients to do something other than their expressed choice for specialty care.

Clinical service lines (CSLs) Before moving forward with the central theme of this article, CSL model decision-making for clinical specialists, it’s useful to begin with a common definition and understanding of a CSL. A clinical service line is a grouping of related clinical services and programs dedicated to an identified constellation of related diagnoses and conditions,

designed to produce and deliver a superior course of care, over time, based upon evidenced-based best practices for defined clinical populations. Now, back to the inflection point discussion. Specialty CSLs are at the top of the strategies list for three very different models of delivery. Examples of CSL getting the most attention and investment dollars include: orthopedics, cancer care, eye care, heart care, wellness, sophisticated urgent care, behavioral health, industrial medicine, dental care and oral surgery, GI, ENT, urology, a range of pediatric subspecialties and primary care networks. Are there common denominators here? There are a few that make sense, at least when looking through the lens of strategy and finance. All these generate most of earned revenue in the outpatient arenas. The anatomy of the grouped revenue streams include: professional services, imaging diagnostics, interventional procedures and some forms of retail products and services sales. Demographic trends favor future growth in service demand. Moreover, the operating economics available lend well to effective productivity management and targeted strategic investment strategies.

Three types of CSL organizational designs The three types of organizational designs operating in and competing for the CSL markets and related rewards include: • Larger, integrated community health systems. • Academic health centers.

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• Specialized, independent physician groups that consolidate and aggregate subspecialty providers to achieve sufficient size, scale, scope and geographic reach and to attract required levels of investment capital.

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All three models can succeed with capable leadership, focus and commitment. The question for the physician specialist is “which model is right for me?” The balance of this article presents a framework for practice option decision-making. First, we consider a brief comparison of the three organizational designs.

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Typically, the IHS will identify and aggregate a number of related physician specialties and related clinical programming under the system brand; independent and employed providers may be involved in the brand strategy. The IHS typically owns the CSL, including the larger portion of the associated revenue streams. It capitalizes the start-up, and IHS senior leadership oversees operations and performance. Most typically, the IHS operates as a not-for-profit organization under the U.S. Internal Revenue Code. Independent physician groups may become affiliated with the strategy and practice alongside providers employed by the health system. Independent physicians may also enter into for-profit partnerships and joint ventures with IHS service lines, ambulatory surgery centers, for example.

The academic health center (AHC) www.mppub.com 16


The AHC is usually, but not always, university affiliated. They exist to serve a three-pronged mission strategy: teaching, research and clinical care. They

may rely upon grant funding for a considerable portion of their total mission budget. Leadership, management and operations financing can be more or less centralized, and interests of clinical departmental leaders can be tipped variously to any one of the three mission paths and related strategies.

The pure play physician model The pure play model is typically focused on more easily identified and understood brand and mindshare strategies aimed at specific patient markets and clinical services programming, such as orthopedics, cancer care and comprehensive eye care. The organizational and business model is often physician owned and controlled. The pure play models can be wholly capitalized by the physicians who own them, or investment capital can be pooled with for-profit sophisticated investors, private equity players, for example.

Questions to Ask So how does the specialty physician find the suitable CSL home (i.e., “which model is best for me”?). The issues that follow will provide insight into this question. Consideration of these issues will require some soul-searching, a bit of research and discussion with experienced peers. • I practice in a specialty that has the potential to take a brand strategy directly to the end user (the patient). Provider referrals are important but are not likely to comprise the larger portion of new patient flow over the course of my career. • Hands-on physician decision-making control is important to me, i.e., direct physician control over organizational governance, leadership, management, strategy and patient care. • My specialty requires a close relationship with deep, complex hospital service capabilities, including their ability to make significant investments in clinical technologies and specialized facilities.

Characteristics of successful CSLs Whether delivered by way of any model described above, successful CSLs share common characteristics. The characteristics described here derive, in-part, from the specialty physician decision-making framework described above. Characteristics of successful CSLs include: • The brand strategy clearly and effectively positions and differentiates the range of services and CSL value propositions in the mind’s eye of the target end-users: patients, families, referral sources, related community agencies, and targeted market social media communities. Clear, crisp brand strategies emove any market confusion around the “business” the CSL it is in. • All who serve the CSL (providers and staff) understand the mission of the CSL (its reason to exist), its vision (where the CSL is going and why), along with its strategy the path to achieve stated goals, i.e., how we expect to execute on the mission. • There is a common and well-known CSL performance scorecard: one available for all providers and staff to see, understand and learn from, especially metrics pertaining to the patient and referring provider experience. • There is a clear, accessible “front door”, meaning the potential user knows how to effect that first contact, whether as a patient, a family representative or a referring provider. • Care navigation begins with the first contact. The CSL reaches out, invites the patient in and begins the care management process with the first contact. Clinical Service Lines to page 264

• The economics of the payer mix for my specialty must be financially supported by a broader and diverse clinical service portfolio and business model – one that integrates what I do with other more profitable specialty services. In other words, the economics of my specialty are not as favorable as a “stand-alone” CSL • I am willing to put my own money at risk in the model, i.e., take personal financial risk in hopes of reaping greater financial reward over time. • In addition to being a clinician, I am interested in a career path that includes freedoms to pursue a range of professional interests: leadership, research, entrepreneurial innovation, teaching or deeper sub-specialization. In other words, my career plans permit me to evolve my career within the model I select. • I want to help build a business that creates equity for me, i.e, my ownership that has real future financial value potential beyond the compensation I earn. • The model selected will lend well to the continued recruiting of other high quality providers and staff, even as competition for the best professionals increases. • Future market-place, reimbursement and operating economic trends portends more positively or negatively for my specialty. • Well-capitalized competitors will be investing heavily in the services delivered by my specialty, including select related ancillary services opportunities. MINNESOTA PHYSICIAN JANUARY 2022



Treating Pediatric Injuries What happens in the ice and snow BY ALLYCE FISK, PA-C, MMS, REBECCA ROUSE, PT, DPT


t every age, kids play sports seriously and don’t want to be sidelined by an injury. The winter weather season in Minnesota creates new challenges. Winter sports and activities often bring new injuries that can cause significant issues for our patients and their families. The common winter sports in our region, such as basketball, skiing, snowboarding, figure skating and hockey, in addition to all the recreational activities like ice fishing, sledding, skating and snowmobiling can cause a wide array of injuries in children. Some of these injuries will result in quick trip to the ER, where the pathway to a pediatric orthopedist is clear. However, few parents have a pediatric orthopedist in their speed dial or even know what one does. When the symptoms of an injury persist, the most likely remedy will be a trip to their regular medical home, and this is when it is important to remember that, regardless of the severity of injury, we are here to help. While many common injuries may be safely diagnosed and treated absent the advanced training and diagnostic skills we offer, there are important matters to keep in mind. For example, if a patient has suspected growth plate injuries, missing


the growth plate injury diagnosis or mistreating it can cause malformation of the bone or complete arrest of the growth plate, causing a difference in limb length which can lead to lifelong diminished capacity. The most common injuries in the winter range from mild sprains to significant fractures that require surgery. It is important to remember that pediatric orthopedic specialists are best equipped to evaluate, diagnose and treat pediatric injuries, as there are special considerations when evaluating and treating pediatric patients. Children are not small adults, and the developing skeletal system responds to trauma differently than that of the adult. The same mechanism of injury that may cause a sprain or strain in an adult, or even a teenager who is skeletally mature, may cause a growth plate injury in a child who has not reached skeletal maturity. This is because of actively growing bone at the epiphysis, metaphysis and apophysis, collectively referred to as the growth plates. This area of developing bone creates an area of instability that can be more easily injured in children, and providers who do not commonly treat pediatrics may not be able to recognize these injuries or treat them appropriately

Common injuries Common injuries resulting from walking in slippery conditions caused by Minnesota ice and snow include wrist injuries. These often occur due to a fall on an outstretched hand (also known as a FOOSH). This type of fall can result in buckle fractures of the ulna or radius at the wrist or throughout the forearm. Nondisplaced fractures may be treated with casting. More severe fractures to the wrist, forearm or elbow may also occur secondary to a slip on the ice and may require operative treatment. Clavicle fractures are often caused from activities such as sledding or falls directly on the shoulder. The majority of clavicle fractures are treated with immobilization in a sling. Shoveling heavy snow is another common cause of injury during Minnesota winters. Adolescent patients may occasionally come in for care due to muscle strains in their back. Other common spine diagnoses in adolescent athletes include spondylolysis or spondylolisthesis; these are diagnosed most often in gymnasts and figure skaters, but may be exacerbated by activities requiring twisting while carrying a load just like shoveling.

Spondylolysis vs. spondylolisthesis

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Spondylolysis is a stress fracture in the lower back. Children and teens who participate in sports that put repetitive stress on the lower back, such as gymnastics, basketball, skiing, figure skating and weightlifting, are at highest risk. As the athlete’s muscles become overly fatigued, the stress of the workload is transferred to their bones. Over time, the continued pressure can cause stress fractures in the lower back. Some children are born with a genetic tendency to develop spondylolysis even if they do not participate in sports; the risk of spondylolysis is higher during growth spurts. If left untreated, spondylolysis can progress to spondylolisthesis, a condition in which a vertebra, weakened by fracture, slips out of alignment with the rest of the spine.

Athletes with either condition can usually return to sports after several months of rest and physical therapy. Patients may need to wear a back brace as part of their recovery, which will be custom-made for them in our orthotics department. In rare situations, if a vertebra is severely out of alignment or if a child remains in pain after other forms of treatment, spinal fusion surgery may be needed from one of our skilled, experienced physicians.

Knee and ankle injuries From a sports medicine perspective, the most common winter sports injuries generally involve the knee and ankle joints. Ankle sprains and fractures occur commonly in basketball players or from a fall on the ice, and ligamentous knee injuries are common in both basketball and hockey players.

examination tests to further evaluate the patient for multiple injuries and determine the most appropriate diagnostic tests to ensure no injury is missed. If an ACL tear or meniscal pathology is suspected, we will send the patient for an MRI of their knee to evaluate for these injuries. Should an ACL tear be noted, the patient will require surgical intervention in the form of an arthroscopy with ACL reconstruction. The specific surgical method of ACL reconstruction will depend on the patient’s age and activity level.

Missing the growth plate injury diagnosis or mistreating it can cause malformation of the bone.

Anterior cruciate ligament (ACL) tears are always a hot topic of conversation when it comes to pediatric injuries, and our team is well-trained to accurately diagnose and treat this injury. Treatment for a child’s ACL injury will depend on the severity of the injury, and all options will be discussed at a child’s first appointment. ACL injuries generally occur in teenage athletes and are less common in younger children. Depending on the mechanism of injury, there may be concomitant injuries to the knee, such as a meniscus tear or collateral ligament injury. The possibility of these injuries is why we perform specialized

Non-surgical treatment for ACL sprains or less severe knee injuries include avoiding activity and potentially using a knee brace. We rely heavily on our rehabilitation team to help these patients get back to play or sport. Physical therapy is an important treatment for all sports injuries, especially ACL tears. Our on-site physical therapists work with patients and families to create custom rehabilitation plans and goals. Physical therapy and occupational therapy can be utilized for both surgical and non-surgical patients. Many high impact injuries that we see can occur with activities like skiing and snowboarding. Such injuries may include tibial shaft fractures due to ski boots, metaphyseal fractures due to falls, or intense axial loads Treating Pediatric Injuries to page 204

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3Treating Pediatric Injuries from page 19 EOS imaging

during snowboarding. Again, the treatment for these injuries depends on We use EOS imaging for many of the X-rays we take. EOS is a medical imaging the severity of injury. If an ankle sprain is suspected, we may use an ankle system that provides 360-degree images while limiting the X-ray dose absorbed brace and physical therapy to help a patient return by the patient, who is either sitting or standing. to their activities. For a nondisplaced tibial shaft EOS offers a number of advantages over fracture, we may treat the patient with a cast, more traditional X-ray units, including fast, using crutches to remain non-weightbearing stress-free, low-dose radiation exams for children to the affected extremity. Unfortunately, if the with hip, knee and spine conditions. It is ideal fracture is significantly displaced, these injuries EOS is a medical imaging system for children with conditions that require multiple may require surgical intervention. For all that provides 360-degree images. X-rays. Studies have shown that using low-dose pediatric patients, the growth plate is a special EOS imaging can reduce the radiation dose consideration. Therefore, in the event of concern by 55% compared with digital and computed that the patient’s growth plate has been affected radiography (standard X-ray technologies) without during an injury, we will typically follow the compromising image quality. most conservative treatment plan to ensure we are protecting the growth plate.

Radiology Our new state-of-the-art facility offers in-house radiology for X-ray imaging prior to the patient’s appointment with an orthopedic provider, which means no time is lost scheduling another appointment or driving somewhere else. X-rays expose children to radiation in low doses, and we take additional steps to reduce this exposure. When performing X-rays on children, we make sure we use the lowest possible radiation dose, described as ALARA (As Low As Reasonably Achievable).



EOS scans are also easier for children that may have a fear of X-rays. These scans, which take six seconds or less with a total exam time of 3-4 minutes, capture both front and side views of a child’s body and can be taken with the child sitting or standing in a natural, weight-bearing position. There is no need for them to lie down or turn over, as they often do for traditional X-ray.

Rehabilitation Our team of physical and occupational therapists are highly trained in addressing a multitude of different diagnoses. With regard to non-operative and post-operative management of injuries, we are able to tailor our treatment

strategies to the patient and their needs–whether it be using crutches to get around at school or progressing back to playing a high-level sport. We use the most current evidenced-based practice when utilizing modalities and strengthening techniques following injury or surgery and work closely with the medical providers to make sure the patient is making progress and meeting their goals as expected. Specializing in treating pediatrics also gives us a clear lens of how treating a young athlete differs from treating a high school athlete and the importance of using high-level training when appropriate. Our therapists have additional experience treating athletes who may use a wheelchair to play basketball, a sled to play hockey or a prosthesis to go snowboarding. It is crucial to consider all aspects of an athlete’s life and not just their performance on the court or the ice, but how their rehab will affect their ability to engage in their everyday activities.

In conclusion Unfortunately, it is impossible to eradicate all risks our Minnesota winters or winter sports pose. However, ensuring proper protection during sports is one way to reduce the risk of injury to athletes. Wearing a helmet to ski or snowboard or full pads to play a hockey game is important to provide the maximum protection to our athletes. Wearing good winter attire and using a broad-based stance to walk on the ice and snow can help to reduce the risks of falls when out and about on slippery sidewalks and driveways. Shriners Children’s is one of the world’s greatest philanthropies and has evolved into an international health care system for children, able to

treat many health care issues including orthopedic conditions, spinal cord injuries, burns and cleft lip and palate. All children receive care regardless of the families’ ability to pay. Our centers vary regionally in terms of the range of conditions they treat. Shriners Children’s Twin Cities is a specialty clinic focused on the diagnosis and treatment of pediatric orthopedic impairments and injuries. Initially we served a six-state region providing care for some of the most difficult congenital deformity cases, such as children born with their feet facing the wrong way. Some of our patients required over a dozen major surgeries before they were 18. As time went on, we have expanded the range of services we offer to include common injuries. We recently relocated to a new facility in Woodbury where, under one roof, we have a skilled and knowledgeable medical team consisting of orthopedic surgeons and physician assistants, physical and occupational therapists, prosthetic and orthotic providers, radiology technicians, child life specialists and licensed social workers. This collaborative approach allows us to treat a wide spectrum of patients with diagnoses ranging from cerebral palsy to ankle sprains. Please think of us as a resource and partner when you have patients who may benefit from these services and skills. Allyce Fisk, PA-C, MMS, is an orthopedic physician assistant at Shriners Children’s in Woodbury.

Rebecca Rouse, PT, DPT, is a physical therapist at Shriners Children’s in Woodbury.

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Circumcision The debate of medical necessity BY DUONG TU, MD


ircumcision, derived from the Latin circum- + caedere, meaning “to cut around,” is an apt description for the actual technique of removing the foreskin from around the glans, the head of the penis. It is the oldest documented elective surgical procedure performed in on humans. The technique of cutting around the glans has varied in the tools, anesthesia and timing. There are two broad categories of the modern method of circumcision: • Newborn circumcision using a nondisposable clamp such as the Mogen, Gomco or Plastibell under local anesthesia. • Circumcision in older infants, children and adults, which is performed under local or general anesthesia and usually is done as a surgical procedure.

Religious and social factors Circumcision originated in different parts of the world and dates back to ancient Egypt, 2400 BCE and biblical times. Circumcision throughout the ages may have been perpetuated in various cultures as a religious mark, status symbol or rite of initiation, as well as scorned as a social stigma, depending


on the group or particular time in history. This deep connection to global spiritual history and cultural identity is one of the reasons why assessing its legitimacy in the modern world is not a straightforward proposition. One can see there is not just a medical side to this discourse, but also an emotional and spiritual one. Although the covenant of circumcision described in Genesis has been paramount to Jewish and Muslim identity, it is not a tenet of most Christian beliefs, with exceptions such as the Coptics. It is clear that circumcision was maintained in many Christian societies for puritanical reasons rather than religious beliefs. The “medicalization” of circumcision began in Victorian England, where infant circumcision was established due to inaccurate associations with sexual activity, especially masturbation, and venereal disease, as well as blindness, tuberculosis and psychiatric illness. Victorians erroneously believed the removal of the sensitive foreskin would serve as a deterrent to masturbation and promiscuity. However, the availability of circumcision remained limited, and it was reserved for the upper class. Similar parallels were made in the United States when circumcision miraculously cured a young boy’s paralysis in 1870. After that, routine circumcision spread like wildfire as surgical prophylaxis against all sorts of seemingly unrelated diseases. It became so prevalent in the United States that it morphed from a health measure to a symbol of American citizenship. According to a journal article from “Urology”: • “It became a mark of distinction, separating those who were born in the United States from those who were not, those who were clean and well bred from those who were poor, foreign, and unhygienic.” • Ironically, perhaps due to the wide scale availability of newborn circumcision in the US, even the poor and foreign now have access to the procedure. This prevalence withstood the test of time even when the historical rationales for circumcision were either forgotten or refuted. The issues of circumcision and its relationship to health promote ongoing debate regarding the role of circumcision, especially as societies and cultures evolve, leading toward re-evaluation and skepticism. This is healthy; when you close off the discussion, you stifle progress.

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Economics From a financial perspective, newborn circumcision is roughly ten times less expensive than the cost of adolescent or adult circumcision, mainly due to the added cost of general anesthesia in the latter group. If that group opted for local anesthesia, the cost discrepancy would be greatly minimized. For example, a clinic in California that offers circumcision under local anesthesia over the full range of ages charges an estimated cost difference of $700 for clients age one and older. These clinics provide the service to a population not typically covered by health insurance programs (ages greater than 1), albeit sometimes at a premium, and demonstrate the actual feasibility of circumcision under local anesthesia past the newborn phase.

Medical benefits

Preventing STI and HIV

In the discourse of the medical benefits of circumcision, three primary arguments are decreasing: 1) risk of urinary tract infection (UTI), 2) risk of penile cancer and 3) risk of transmission of sexually transmitted infection (STI), especially HIV.

Three randomized controlled trials were performed in Sub-Saharan Africa to validate the global HIV/AIDS crisis response, and the results are indisputable. In an area of a generalized epidemic (high HIV prevalence in the general population) and low circumcision prevalence, adolescent and adult circumcision cuts the risk of HIV acquisition in half. This sounds very specific, and that specificity has relevance.

Preventing UTI The risk of UTI for boys is the highest in the first year of life. This risk is significantly higher in uncircumcised boys, but this trend begins normalizing after six months to a similar risk after one year. The risk is attributed to the natural history of colonization of the foreskin and progressive resolution of physiologic phimosis, i.e., the very normal inability to fully retract the foreskin in early life.

Assessing its legitimacy in the modern world is not a straightforward proposition.

Studies have demonstrated this increased risk, but most of these studies are observational studies. Moreover, a significant number of them poorly define their method of urine collection and include bagged urine specimens, notorious for their inaccuracy in diagnosing UTI. The high false-positive rate is attributed to foreskin colonization inevitably sampled by a bagged specimen, thus skewing the risk of uncircumcised boys. However, that increased risk is likely genuine even if the magnitude of the increase is in question. The risk is even higher for boys with another risk factor, such as an underlying urologic abnormality, i.e., vesicoureteral reflux (VUR) or a history of recurrent UTI. UTI risk stems from phimosis. Recent studies reveal that treating phimosis with steroid cream significantly decreases UTI risk to that of circumcised boys. Therefore, treat the phimosis; decrease the risk.

Aside from the discourse regarding whether the studies performed in Africa were ethical from a research perspective, many have questioned the applicability of this finding for areas without a generalized epidemic, e.g., North America, Europe, Australia, etc., and whether you can relate that benefit to newborn circumcisions in these respective environments. In fact, studies have surfaced illustrating a significant attenuation if not the absence of the risk reduction in these Western populations. The posited reasons for these results are numerous and essentially relate to differences in transmission patterns of HIV and the availability of antiretroviral therapy (ART). The World Health Organization (WHO) acknowledges the utility of male circumcision in preventing transmission of HIV only in the context Circumcision to page 244

Preventing penile cancer A case-controlled study from Washington State revealed a higher risk of invasive penile cancer (odds ratio of 2.3) in individuals who were not circumcised as newborns, and the highest risk among those with a history of phimosis (odds risk of 11.4). Two findings from this study: 1) “late” circumcision did not decrease the risk, and 2) there was no increased risk when phimosis, or more precisely penile tear resulting from phimosis, was not present. A systematic review and meta-analysis confirmed these results. Why is only newborn circumcision protective? Given the prevalence of newborn circumcision in the US, there are many more circumcisions performed later in life for various medical indications usually related to infection, inflammation, scarring or pathological phimosis–risk factors for penile cancer themselves. Performing the circumcision after those risk factors have already occurred will not remove the risk. The mechanism is underlying and already underway. As an alternative to routine circumcision, perhaps a more cost-effective way to mitigate risk would be education towards recognition of these risk factors and the natural history of foreskin retraction. It is not simply the presence of the foreskin that conveys risk; it is what can happen when the foreskin is unretractable. In addition, penile cancer is rare in the U.S. as well as inNorthern Europe, where most men are uncircumcised. There is nothing magical about newborn circumcision and penile cancer; the circumcision is another way to treat phimosis. Therefore, treat the phimosis; decrease the risk. MINNESOTA PHYSICIAN JANUARY 2022


3Circumcision from page 23 of high HIV incidence and existing low circumcision rates, such as in the African countries where the three major randomized trials took place. In Africa, circumcision as HIV prevention was directed toward the at-risk population, in this case the general population. That same strategy can be recommended to at-risk people in other locations. The newborn in a place like the US is not among them. What about the other sexually transmitted infections? Circumcision reduces the risk for chancroid (haemophilus ducreyi) infection. There is conflicting evidence regarding herpes simplex virus 2 (HSV-2). Circumcision decreases the risk of syphilis, but this finding was also drawn from the data collected in Africa. This correlation seems to exist in populations at-risk for acquiring STIs in general. A systematic review and meta-analysis of the literature revealed no significant impact of circumcision on non-ulcerative STIs such as gonorrhea, chlamydia, trichomonas and human papilloma virus (HPV). The risk of STI is grounded in behaviors (multiple sexual partners, inconsistent condom use, transactional sex) occurring after sexual debut. They are conscious–and hopefully informed–decisions made when the person can exercise some level of autonomy. For example, if an adult male wants a circumcision to prevent HIV, he can choose to do so after being informed that it is never a substitute for safe sex practices. Therefore, with regard to STI, it can wait.

Mutilation With regard to circumcision, there exists a double standard. For a boy, the procedure is rooted in tradition, religion and history. For many, now and likely for a long time, it is acceptable to perform circumcisions routinely. One can argue that male circumcision has health benefits, whereas female genital mutilation does not. However, as discussed, the health benefits of male circumcision are conflicting, particular to a population, can be delayed or can be replaced with viable and less invasive alternatives. To force adults to undergo circumcision for potential benefit would be a coercive public health strategy, but for the newborn boy, it is legitimized.

Malpractice claims A recent review of a legal database from the University of California - San Francisco revealed only 77 cases from 1939 to 2021. The most common reason for litigation was negligent surgical performance, and the top three cases reported regarding complications were dissatisfaction with appearance, pain and impaired sexual function. Most verdicts favored the physician, especially when negligent informed consent was alleged.

The physician’s role Parents rely on us for our expertise and knowledge. Therefore, we should do our best to deliver the best evidence-based care possible and maintain as much objectivity as possible; we should lay out the facts and share in Circumcision to page 304

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3Clinical Service Lines from page 17 • Leaders decide, define, deploy and direct the expected culture of the organization Patients, families and referral sources will gauge the quality of care and the patient experience, as much by the performance of the perceived culture as the clinical outcomes derived. • The patient identifies with a care team and feels the value of the team regardless of location or service accessed, e.g., the patient is recognized, known and welcomed by staff across sites. Members behave as a cohesive, dedicated, integrated team. • Services that compose the CSL portfolio are managed to create the financial performance required to achieve the vision and growth strategy defined, including sufficient financial “staying power”. • The CSL is sufficiently connected to other providers, as needed, to complete the service capabilities and experience promised to the end users. • Leadership is in a constant state of staff and organizational development in service to the mission.

Putting it into practice There is a lot of good news here for the clinical specialty providers looking for the right practice platform and environment, providing they pay attention to the market dynamics around them and are prepared to evaluate where they best fit. The risk here is the proverbial square peg in the round hole, i.e., right physician in the wrong model.

The market dynamics that portend CSL strategies can be seen coming. They include: provider-side market consolidation, specialty-related practice acquisitions, mergers and private equity investors acquiring and aggregating specific clinical care provider groups, e.g., orthopedists, cancer specialists, ophthalmologists, etc. Also watch for emerging specialty-based brand positioning strategies in the media and examine organizational recruiting strategies, especially for organizations with known brands, health systems for example. Pay attention to compensation and benefits plans floated by those doing the recruiting, sharp increases, for example. Look for signs of increasing local and regional competition for providers and specialized staff. Finally, use the decision-making framework provided as a guide to determine where you might best fit. Then as you start down the path to deciding with whom or which model type to affiliate, use the list of CSL success factors as a guide as you interview the candidates for your next position. Daniel K. Zismer, PhD is Co-Chair and CEO of Associated Eye Care Partners, LLC. He is also Professor Emeritus, Endowed Scholar and Past Chair, School of Public Health, University of Minnesota.

Gary S. Schwartz, MD, MHA is Co-Chair and Executive Medical Director of Associated Eye Care Partners, LLC. He is also President of Associated Eye Care Holdings, LLP and Associate Professor, Department of Ophthalmology. University of Minnesota.

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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

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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.

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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3Medicare Advantage Overpayments from page 15

is not represented by well-heeled organizations. But physicians and hospitals do have trade associations with a long history of representing Money spent on insurance company administrative costs would be far better their members in Congress. The American Medical Association, the spent extending coverage for those same services–dental, vision, hearing, etc.–to American Hospital Association and the numerous other organizations the 38 million beneficiaries in traditional Medicare. After all, those 38 million that represent the professionals and institutions people paid the same taxes the Medicare Advantage which treat patients insured by Medicare should enrollees paid to finance Medicare. Why shouldn’t speak out now in favor of terminating the they enjoy the same coverage? Alternatively, the overpayments to Medicare Advantage plans. money currently spent on insurance companies’ They should also promote legislation that Payments Exceed Cost of overhead could be used to raise reimbursements ensures that all Medicare enrollees have access Fee-for-Service Benefits, to doctors and hospitals or could be added back to the extra benefits Medicare Advantage plans Adding Billions to Spending. to Medicare’s trust funds to lower costs for future offer now, thanks to their overpayments. Doing taxpayers and Medicare beneficiaries. so would undermine the counterargument we can expect from the insurance industry: That Congress will soon have an opportunity to ending the overpayments means ending the debate the overpayments. Medicare’s trustees extra services the overpayments finance. Change predict that the Part A trust fund (the one that happens only when Congress feels pressure for funds hospital services) will run short of revenues beginning in 2026. Part change. The public and providers must let Congress know they want the A is financed by a payroll tax paid half by employers (1.45%) and half by overpayments stopped. employees (1.45%). Congress will be under great pressure to raise that tax as 2026 approaches. Medicare Advantage plans will probably not lobby Congress to raise the payroll tax (at least not openly), but we can be sure they will tell Congress not to reduce their overpayments.

Kip Sullivan, JD, is a member of the Health Care for All Minnesota Advisory

Next steps

Medicine, Health Affairs, and other peer-reviewed journals.

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Taxpayers of all ages should let members of Congress know how they feel about the overpayments. Unfortunately, the American taxpayer

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3Circumcision from page 24

In Conclusion

Today, our task was to shed light on only some controversies surrounding circumcision. It will likely be a long time before we come to a consensus. It is an immense task to ask for sweeping change, but people are working on it. These people include bioethicists, those involved in the medical humanities and providers striving to produce evidence to deliver optimal care. In the meantime, we should meet in the middle and focus on harm reduction rather than prohibition. The American Academy of Pediatrics’ Committee Circumcision is often performed on a small on Bioethics suggests that 14 years is a good age for an When you close off the person, but the impact can be far-reaching and discussion, you stifle progress. individual to meaningfully provide input for informed broad. Providers performing circumcisions need consent. It is far easier to perform a circumcision later to be appropriately trained in the technique and in life when informed consent can be obtained than their results audited. Informed consent should not to reverse a circumcision performed as a newborn. be restricted to only potential physical trauma. A deeper dive into the ethics of circumcision One can expect that inclusion of potential mental is beyond the scope of this discussion, and trauma in the effort of full disclosure would make anyone take pause. notably missing is a discussion of the complications that play into the risk/ Complications should come back to the provider in full accountability; benefit ratio of the procedure. Many providers reading this will already only then can the process improve. know the likely complications, but some will not see the morbidity and mortality associated with such a routine procedure. Its complications can Duong Tu, MD, is is a pediatric urologist at the University of Minnesota be as catastrophic as penile loss or amputation, along with sepsis from Medical School. infection and death. Therefore, the procedure cannot and should not ever be taken lightly. the decision. We should construct an environment for non-judgmental discussion and recognize personal biases. An addition to that discussion would be allowing their children to decide for themselves when they can understand the stakes. For some, this can take the burden off them and at the same time empower their children.

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