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MINNESOTA

JULY 2021

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXV, No. 03

The Itasca Project Improving the First 1,000 Days of Brain Development BY JAKUB TOLAR, MD

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or the first time since 1918, the average U.S. life expectancy declined for four consecutive years. Just as our lifespan is shortening, so is our healthspan due to the earlier onset of chronic illnesses. Behavior and lifestyle choices contribute significantly to the decline in healthspan, but the risk for diseases— from heart disease and lung disorders to addiction and depression—can be reduced by optimizing brain development in the first 1,000 days of life, beginning at conception. A small investment during this time, as simple as better nutrition, parental education and community support, can reap huge benefits over a child’s life, something we all benefit from. As a broader community, we would be well served to better support parents and caregivers who are struggling.

Private Equity in Health Care A Growing Trend BY RANDAL SHULTZ, JD AND BEN PELTIER, JD

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ow more than ever, physician groups and other health care providers are looking for ways to work with private equity funds as an opportunity to grow their practice without selling it. Hospitals and national health care entities are acquiring physician practices at an extraordinary rate. But not all physicians want to sell to these organizations. Many physicians like owning their business and leading the changes occurring in health care. Private Equity in Health Care to page 104

The Itasca Project is a cross-sector alliance of Minneapolis-St. Paul-area employers who are drawn together by an interest in new and better ways to address regional issues that impact future economic The Itasca Project to page 124


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JULY 2021 MINNESOTA PHYSICIAN


53RD SESSION

JULY 2021

|

Publishing November 2021

Volume XXXV, Number 03

COVER FEATURES Private Equity in Health Care A Growing Trend

By Randal Shultz, JD and Ben Peltier, JD

The Itasca Project Improving the First 1,000 Days of Brain Development By Jakub Tolar, MD.

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 The Importance of Medical Associations

CLINICAL AND NON-CLINICAL CARE TEAMS Improving interoperability

Sarah Traxler, MD President Twin Cities Medical Society

TELEHEALTH................................................................................ 16 Maximizing Telemedicine Benefits Establishing work flow integration

BACKGROUND AND OBJECTIVES: As health care costs constantly rise, containment strategies involve care teams. Many individuals are now part of every physician-patient encoun-

By Elizabeth A. Krupinski, PhD PEDIATRICS................................................................................. 20 Understanding Developmental Trauma Its lifelong impact on health

By Norm Thibault, PhD, LMFT MEDICAL EDUCATION.................................................................. 22 Situational Judgment Testing Improving Medical School Selection Processes

By Mojca Remskar, MD, PhD, and Dimple Patel, MS

ter. Some are hands-on with the patient, some the patient never sees. New entities become part of care teams, offering services from chronic care management, to behavioral health screening, to care coordination, to coding, charting and much more. With goals of lowering costs, increasing reimbursement, and improving outcomes, clinics can customize teams to individual patient needs. Keeping up with this rapidly evolving landscape can exceed the capacity of many medical groups. Our remote panel of diverse stakeholder perspectives will examine the diversity of care teams and how they interact. We will explore benefits that could result from improved coordination of these care teams. We will identify the barriers to this improved communication, such as incompatible EHRs and data privacy issues, and ways around them. We will provide examples of successful integration of clinical and non-clinical care teams and a road map for adopting and scaling these models for all elements of our health care delivery system.

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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.

MINNESOTA PHYSICIAN JULY 2021

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New Executive Order Bans Conversion Therapy On July 15, Governor Tim Walz signed Executive Order 21-25, protecting Minnesotans from conversion therapy. Conversion therapy, also known as “reparative therapy,” refers to a counseling practice that seeks to change a patient’s gender or sexual orientation. Every leading medical and scientific association including the American Medical Association, American Academy of Pediatrics, and National Education Association have strongly rejected conversion therapy for minors, citing its harmful effects on the long-term mental health. “Our kids deserve to grow up in a state that values them for who they are – not one that tries to change them,” said Governor Walz. “This Executive Order aims to protect young and vulnerable Minnesotans from the cruel and discredited practice of conversion therapy and affirms that the

LGBTQ+ community is an integral part of One Minnesota.” The Executive Order restricts the practice of conversion therapy in Minnesota by directing state agencies in a number of ways including: • Requiring that HMOs and health plan companies do not cover conversion therapy • Pursuing administrative remedies against those companies that engage in unfair business practices related to conversion therapy. • Rulemaking as necessary to restrict coverage of conversion therapy. • Preparing a report on the public health impacts of conversion therapy. • Not paying for conversion therapy services through Minnesota Health Care Programs such as Medicaid

and pursuing recovery for payment of conversion therapy services. • Pursuing civil enforcement actions against health care providers who are engaged in discriminatory practices related to conversion therapy. Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children’s Minnesota, was invited to the signing to talk and said “Banning conversion therapy helps us send the message to LGBTQ kids that there isn’t anything wrong with who they are; that the way they love others and identify their genders isn’t’ something to be fixed or changed. But more than that, it gives us the opportunity to boldly step into a space of loving and celebrating LGBTQ kids and all of the ways that their ability to reimagine identity and relationships enhances the world for all of us,”.

U of M Study Highlights Disparities in Financing Medical Education A study just published in JAMA Network Open, a team including members of the HealthPartners Institute, former faculty and Arman Shahriar, Varun Sagi and Lorenzo Gonzalez, all fourth-year students at the University of Minnesota Medical School, found that nearly 40 percent of all funds used to pay for medical school are expected to come from family or personal sources and scholarships. The prevalence of these sources, however, varies widely by race and socioeconomic status. “Financing a four-year medical education requires upwards of a quarter-million dollars, and this amount has been rising faster than inflation since the 1960s. Prior to this study, little was known about how students pay for medical school, so we set out to shed light on this opaque subject,” Shahriar said. Using data from more

new 50 45 isforthe colon cancer screenings.

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than 29,000 medical students who responded to the 2017 to 2019 Association of American Medical Colleges (AAMC) Matriculating Student Questionnaire. The study found that: • Nearly 25 percent of all medical students come from the top five percent of household incomes (greater than $270,000 in 2019). For comparison, only three to four percent of students from the lowest three income quintiles rely primarily on family or personal funds. • Family or personal financing was more prevalent among Asian students and white students and was least prevalent among Black students. Black students graduate with the highest debt burden of any racial group.” • Between high- and low-income students, scholarships were distributed much more evenly than family or personal funds. The heavier reliance on loans among low-income students suggests an inadequacy of current scholarship amounts to offset the large deficit in family or personal funds. “Knowing that scholarship funds are finite, individual medical schools should work to ensure that scholarships are awarded through holistic review with ample consideration of economic background,” Shahriar said. “As medicine works toward improving its socioeconomic, racial and ethnic diversity, the last thing we want is for family wealth to be influencing educational quality.” Future work will better examine how financing methods have evolved over time for various subgroups, linking matriculant financing plans with debt at the time of graduation and beyond.

Program in Human Sexuality Rebrands as the Institute for Sexual and Gender Health Early this month, The Program in Human Sexuality (PHS) achieved the status of an Institute in the Department of Family Medicine and Community Health at the University of Minnesota Medical School. With this elevated status, PHS is announcing a rebranding and subsequent name change. The Program in Human Sexuality is now the Institute for Sexual and Gender Health (ISGH). This name change reflects the academic excellence and clinical growth built over the past 50 years. The Institute for Sexual and Gender Health’s clinical enterprise serves thousands of individuals, couples and families throughout the Midwest. Their research and educational endeavors influence international, national and local policy. Routinely collaborating with organizations, such as the World Health Organization, the World Association for Sexual Health and the Centers for Disease Control and Prevention, ISGH faculty work to raise awareness of sexual rights as an inherent part of universal human rights based on freedom, dignity and equality. Debuting with the new name is a symbol intended to highlight ISGH’s multidisciplinary approach to sexual and gender health: • Develop, provide and promote evidence-based best clinical care. • Advance groundbreaking discovery through biopsycho-social gender and sexuality research.

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• Advocate for sex and gender rights. “The elevation of the Institute for Sexual and Gender Health from a program to an institute is overdue,” said James Pacala, MD, MS, head of the Department of Family Medicine

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and Community Health. “This group has been at the forefront of progress on every significant issue regarding sexual and gender health for the past 50 years. The institute will advance its proud legacy into the next 50 years.”

Trellis Releases Report on Aging and Health Equity Issues Assessment on Access to Title III Services for Native Americans and Minority Older Adult Populations. Compiled by SDK Communications + Consulting the report provides a compelling snapshot of the ways different systems come together to create inequities for Black, Indigenous, and People of Color (BIPOC) elders aging in their communities. It looks at several key elements of health status, including nutrition, transportation, caregiver support services, special access needs and ability to obtain to

legal services. While the White population in Minnesota outnumbers all other ethnicities by an over three to one margin, the percentage of chronic and age related health concerns his much higher percentage wise in the, Black, Asian, Hispanic and Native American populations. The report concludes with several suggestions for addressing the core problems. As Minnesotans are aging and the population becoming more diverse, concerns addressed in the report will multiply over the next decade. By 2030, 15 percent of all older adults in the Twin Cities will be people of color. That’s almost 95,000 people in pure population numbers, and equivalent to half of the total Twin Cities older adult population in 2000. In total, this means that Trellis’ work to provide Title III funding in more equitable ways will happen as both the needs for aging services and the needs for elevating equity in the field of aging are accelerating, likely far beyond the pace of funding. The

Older Americans Act Title III funds that Trellis administers are intended to help low income and minority adults age in their communities. The results of this assessment show that broader inequities in income, health, housing and more make the work to fund Title III services a critical first step in helping BIPOC elders age in their communities – but only a first step. Part of this first step will be revising the Trellis Request for Proposals (RFP) process to be more transparent and accessible. A new RFP for some Title III services will be released next month.

Regions Expands Inpatient Mental Health Bed Capacity Early this month Regions Hospital announced plans to expand its inpatient mental health services by adding 20 beds to its current 100bed, on-campus inpatient mental health building. Regions is the east

metro’s largest provider of inpatient mental health services, serving 3,300 patients a year and operating at an average of 97 percent capacity. The project, which will entail converting existing shell space from a 2012 expansion, is expected to be completed by the end of the year and help serve an additional 600-plus patients annually. The additional capacity will allow mental health patients to receive treatment and recover more quickly in a supportive, healing environment while opening Regions Emergency Center beds for patients with various health care needs. “Many who experience a mental health crisis need the lifesaving care of a hospital and a safe place where they can receive intensive treatment,” said Christine Stanson, MD, medical director of inpatient mental health for HealthPartners. “Expanding inpatient mental health services at Regions will help us provide care to the growing number

WE’RE EXPANDING WAYS TO HELP YOUR PATIENTS Announcing new medical conditions accepted for Minnesota’s Medical Cannabis Program: • Sickle cell disease • Chronic motor or vocal tic disorder Patients with these conditions can be certified starting July 1. Visit mn.gov/medicalcannabis to view the full list of qualifying medical conditions.

SCAN TO GET STARTED

or visit mn.gov/medicalcannabis

Join Minnesota’s Medical Cannabis Program! As an approved health care practitioner*, you can certify patients to participate in the state’s Medical Cannabis Program. This program provides a treatment option for patients who are facing debilitating medical conditions, helping to improve their quality of life. *Health care practitioners eligible to participate are: Minnesota-licensed physicians, physician assistants and advanced practice registered nurses.

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of people experiencing crises.” In addition to a leading inpatient program for patients with suicidal ideation, Regions provides a wide range of comprehensive mental health programs. Other services include Regions Emergency Center, serving about 9,000 patients experiencing mental health crises each year, The Lee and Penny Anderson HeroCare Program, a specialized care program for veterans, military members and their families, DayBridge, a partial-hospitalization program for adults who need intensive therapy but can safely continue living in their communities and residential services such as Afton Place, Safe House and Hovander House. “Regions is a destination hospital for great care,” Regions President Megan Remark said. “Our community relies on us to be there when they need us, and to create an environment that fosters hope and healing. We are proud to continue to make investments to meet the needs of our community.”

Hennepin Healthcare Announces Reopening of East Lake Clinic In a joint statement with Hennepin County, plans were revealed for a phased reopening of the South Minneapolis Human Services Center at 2215 E Lake Street. The building had sustained damage during the George Floyd protests. One of the phases includes the renovation of 10,000 square feet on the sixth floor to become the new home of the East Lake Clinic, whose former building was much more significantly damaged in the protests and had been closed since. Tentatively starting in October 2021 and continuing throughout the year the building will reopen with services scheduled by appointment. “After a difficult year, reopening the Hennepin Healthcare East Lake Clinic will allow us to offer a trauma healing model of care, co-located with critical county

services and community support, to a neighborhood that we have been proud to serve for more than a decade and plan to serve for many years to come,” said Jennifer DeCubellis, CEO, Hennepin Healthcare. The Center had been a vital community asset providing a wide range of social services including access to health insurance; food and child care assistance, direct financial support and many related services. Tenants Briva Health and Seward Pharmacy will continue to operate in this space. Besides reopening the East Lake Clinic, new partnering organizations will be added to include the Office of Multicultural Services, a mental health center, and adult probation services. “The goals of the co-location are to provide efficient, effective service and care, create a safe and welcoming space for residents and provide easy access to services,” said Hennepin County Commissioner Angela Conley.

CDI Quality Institute Recognized by CMS CDI Quality Institute, a non-profit affiliate of RAYUS Radiology, has been qualified as a Provider-led entity (PLE) for the Medicare Appropriate Use Criteria (AUC) Program within CMS. PLE designation is granted to a select group of organizations nationwide tasked with providing real-time clinical guidance to treating physicians ordering diagnostic imaging procedures. Only 22 federally qualified organizations nationwide hold this designation. The Quality Institute is supported by more than 250 sub-specialty trained radiologists and top specialists within RAYUS’ nationwide network. Since its inception in 2003, the Quality Institute has helped define quality measures to ensure patients receive the right test at the right time, reduce unnecessary care – and lower costs.

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MINNESOTA PHYSICIAN JULY 2021

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INTERVIEW

The Importance of Medical Associations Sarah Traxler, MD President Twin Cities Medical Society What can you tell us about your recent decision to discontinue formal ties with the MMA?

What are some of the ways the Twin Cities Medical Society is addressing these issues?

One of the first steps in addressing these issues is acknowledging that the needs of physicians have changed. While issues like reimbursement and scope of practice will undoubtedly continue to be important, there is a growing hunger in today’s physicians to reclaim their roles as healers and create conditions in which their patients can have good health and live fulfilling lives. The need for good health extends far beyond the clinic walls, and TCMS provides physicians with an opportunity to effect the kind of societal change that will benefit patients’ health in a way that a hospital or clinic alone simply cannot facilitate.

This was not an easy decision by any means. Separating from the MMA, a strong and historic organization serving physician interests across the state, meant giving up some influence and support. In the end, we knew that to continue to advocate for all the relevant public health initiatives that our membership is passionate about, we needed to be able to move forward independently. This next phase will give our organization more freedom to evolve along with our profession and better support not only our physicians, but also our medical students who represent the next generation of public health leaders.

Medical associations and societies, and really every kind of professional association, have seen sharp membership declines. What are some of the reasons for this?

Historically, associations and societies in any industry were created to help members share best practices and collaborate on initiatives. The internet and social media have created environments where it’s much easier to find colleagues with similar interests, organize, and build momentum both online and in person. We believe to succeed well into the future, collaborative organizations like ours require a new strategy. Over the years, TCMS’s mission and work has become more and more focused on public health advocacy driven by physicians and supported by partners across the state and country. We want to reinforce and strengthen our support of our member physicians’ advocacy work in a way that is more adaptive and flexible. Uncoupling from our formal agreement with the MMA was just the beginning of a new strategy which will eventually become an innovative new model for TCMS that

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Physicians “...” are increasingly becoming more than just doctors who treat illness.

“...”

It’s important to note that the MMA continues to be an important partner of TCMS. While our formal relationship has changed, we are excited to continue to collaborate with the MMA in new ways in the future.

will benefit the health of our communities and support the work of our members. Why is it important for professional medical associations to continue?

While medical associations do need to evolve and adapt, they are still incredibly important for our profession and the healthcare industry as a whole. Physicians are increasingly becoming more than just doctors who treat illness. We are moving into the role of advocate not only for our patients’ health but the health of the community as well. Simply put, doctors are moving toward a role that is much more relational, rather than prescriptive. I’d like to think that instead of “fixing” things like disease and injury, we’re working to promote better health and proactively provide the resources and conditions that support health outside of the clinic walls. To be successful in this new healthcare landscape, we need to collaborate even more with our medical colleagues. An association like TCMS provides the structure and coordination to keep us moving forward toward these higher goals despite the demands of our daily jobs.

While I am incredibly grateful for the opportunity to provide care to my patients, I know I am not alone in feeling frustrated that I often provide treatment for preventable conditions. The frustration is rooted in the knowledge my patients don’t always have the resources to invest in their own health and my clinical-facing role will only go so far. TCMS is creating a space where physicians can work together to make real changes in the conditions that impact our patients’ health on a societal level. Creating a medical association wholly dedicated to advancing community health is a big shift, but we are confident that in doing so we will better meet the needs of our wider community and today’s physician. What should governance of a medical association in 2021 look like?

For decades, medical associations have used annual House of Delegates meetings as their method of legislation and policymaking. While the House of Delegates model has many strengths, the past year has highlighted the need for a nimbler form of governance that allows our organizations to be responsive to the rapidly changing needs of our community. In truth, I don’t think there is necessarily one right model for medical association governance.


Rather, I think we need to create new ways of governing that are grounded in democratic processes, that create space for those who haven’t been served by organized medicine in the past, and that have the flexibility to grow and change over time. Why is it important to keep partisan politics out of medical society policymaking and how can this be done?

I think if you look at the definition of “partisan” it means being prejudiced toward a particular cause. This goes against the nature of our work as physicians, and as scientists really. Our job is to remain objective and gather all the data to make the right diagnosis and choose the best treatment for our patients. That also includes ensuring individuals have access to the resources needed to make choices for their best health before they become ill. Being prejudiced or partisan toward anything just doesn’t fit in that scenario. Frankly, politics are a powerful tool to drive the right policies forward, but party agendas should never be a factor in deciding what’s “right” to begin with. Physicians have tremendous credibility when it comes to public opinion. It’s important for us

to use that power to influence public policy in the right direction. We are advocates of public health, and you cannot improve the health of the community without good, strong policies in place at the level of local, state, and national government. At TCMS we believe it is our responsibility to understand what drives good and poor health, to carefully evaluate the best science) available, and to create better laws when needed. Please tell us about how things are going with Honoring Choices Minnesota.

For over a decade, Honoring Choices Minnesota (HCM) has been a leading convener and connector - engaging both providers and the community in Advance Care Planning (ACP) conversations throughout Minnesota and nationally. ACP is a powerful tool for health equity which ensures that all individuals have a voice in their own healthcare decisions. Since 2017, we have been working to develop culturally specific ACP tools and resources, including with Volunteers of America, The Center of American Indian and Minority Health and most recently in partnership with the St. Cloud Somali community.

The significance of ACP became painfully obvious throughout the COVID-19 pandemic. In response, HCM developed a COVID-19 ACP Planning Guide and COVID-19 Treatment Preferences checklist for individuals to consider their care preferences if they contract COVID, and for providers to engage their patients in COVID-specific goals of care conversations. In addition to the need for a COVID ACP response, the pandemic also highlighted the growing need for greater accessibility to trained ACP facilitators. In April of 2020, in partnership with Riverwood Healthcare Clinic, we successfully piloted an ACP Helpline. This pilot became the foundation for a new multicommunity ACP Helpline pilot that will launch in September 2021 with the hope of extending this service statewide. Please tell us about your work with the Physicians Wellness Collaborative.

We are proud to build on Physicians Serving The Importance of Medical Associations to page 324

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.

MINNESOTA PHYSICIAN JULY 2021

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3Private Equity in Health Care from cover However, occasionally, outside financial resources are required to grow the practice. Fortunately, private equity can help physicians control their destiny and grow revenue through the “enterprise value” of their practice, in addition to earning technical and professional fees. Our firm, Lathrop GPM, represents physicians, hospitals and private equity firms so we see the differing perspectives from all sides of these transactions. This article focuses on the physician perspective. What are the benefits to physicians of partnering with private equity as an alternative to hospital acquisition?

The mechanics of a private equity transaction Financial firms in the equity space have developed financing strategies to enable physicians to make money from both the practice of medicine and from the business of medicine. The common structure of these arrangements is discussed in more detail below, but typically the equity fund injects cash into the practice to compensate the individual physician-owners, and the practice then agrees to retain a management company connected to the private equity firm. In many states, including Minnesota, the Corporate Practice of Medicine Doctrine prohibits for-profit entities from employing practicing physicians, so the practice continues its operations under the same legal structure. In addition to the up-front payment, the parties will typically establish a new compensation formula for the physicians and often identify new ancillaries to enhance revenues. The first question is why a private equity fund would buy a medical practice considering that there are no excess profits remaining after the payment of

CELEBRATING 30 YEARS OF PROVIDING CREATIVE PLANNING & DESIGN SOLUTIONS FOR EFFICIENT, PATIENTCENTERED HEALTHCARE ENVIRONMENTS

operating expenses and compensation to the providers. The answer is that private equity funds use the equity markets to create “enterprise value” for a medical practice. The equity fund promotes its ability to provide management expertise, savings through economies of scale, access to enhanced reimbursement rates through its managed care plans and a current (and future) liquidity event that will immediately place a large amount of cash in the physician’s pocket. A fundamental driver of the strategy that separates the equity fund from hospitals is that the equity fund can pay more to a medical practice for assets and services than can a hospital or other health care provider. Equity funds cannot make patient referrals so the amount paid by a fund is not restricted by the Stark Law, anti-kickback laws, or other health care regulatory limits. The financial strategy of the equity fund arrangement begins by paying the physicians an initial multiple of some factor (net cash flow or asset value for example) to acquire practice assets or equity. Then through the related management firm, it institutes corporate practices to make the physician group more profitable. Once the practice is more profitable, the equity fund will combine the practice assets with other assets and sell the combination to a larger equity fund. If the initial purchase is properly structured, the physician owners share in the proceeds of the sale of the combined group delivering a second cash payment at that time.

What is the equity fund financing strategy? The stock of many corporations is traded on a variety of stock platforms and exchanges (both public and private) and the trading value of those shares is often calculated at a multiple of a financial factor such as, asset value, revenue, a financial ratio or earnings before interest taxes depreciation and amortization (EBITDA). Over the last few years, the value of many medical practices has been calculated at a multiple of 5-12 times available cash flow or EBITDA, with a multiple of 7-9 being most common. Practices at the higher end of the multiple range tend to be larger, benefiting from demographic growth, or in a practice area that is expected to expand. The private equity fund’s strategy is to buy a medical practice’s cash flow or EBITDA at a base level multiple with the belief that if the fund can combine these attributes of multiple practices, the combined larger numbers will induce yet a higher multiple in the equity markets. Thus, the equity fund is often not looking to make its money on the daily operations of the medical practice but on this financing strategy. The equity fund is betting on the market’s ability to return large profits based upon selling the combined physician groups’ EBITDA at higher multiples than paid for the initial practice acquisitions. The strategy has been successful, and it is being used across the country for multiple types of physician groups.

How does it work technically?

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The answer to this question depends upon the nature of the equity fund and how it designs its financial model. State limits on “corporate practice of medicine” also limit the equity fund’s options for the structure of the practice after acquisition. In states with limits on ownership of a medical practice, the most common approach is for the equity fund to form a management company, have that management company acquire the assets of the medical practice, employ the non-professional personnel of the medical practice and enter into a management contract with the medical practice to control the cash flow and administrative aspects of the practice. Under this approach, the private equity fund will issue a Letter of Intent (LOI) to the medical practice describing the overall transaction structure. The


LOI will indicate that in exchange for the assets of the medical practice and a “to be determined” amount of regular cash flow from the practice paid to the management company (usually in the form of management fees), the equity fund will pay the physicians a large upfront payment based on the multiple.

collect the fee from the remaining physicians. This commitment term is another point subject to negotiation at the beginning of the relationship with the equity fund.

The equity fund will attempt to expand the revenues of the practice after the acquisition by increasing reimbursement rates, expanding ancillary/ The lump sum paid to each physician is typically provided in the form of technical services and adding new physicians. The part cash and part equity in either the management equity fund will want a portion of the incremental company or another entity owned by the equity gain, but the physicians should also be entitled to a fund. Frequently, the physicians will have a choice portion of the increase. Determining each party’s regarding how to allocate the cash portion of share of the gains is another important point of the purchase price and the equity portion of the The value of many medical practices has been calculated negotiation that should be determined up front. purchase price among the practice owners. Many at a multiple of 5-12 times The expanded revenue is also crucial to the equity transactions allow the physician owners to allocate available cash flow. fund’s goal of re-selling the practice to a larger the cash and equity according to the preferences of equity fund. That is why some physicians with a the individual owners, providing more flexibility lesser need for current cash will take more equity for each physician to determine how they want than cash up front, betting on the upside value of their payout. This means that one physician in the the subsequent “roll up” equity sale. group might want most of the purchase price in cash while another might want a greater portion of How do the physicians function/exist in the ongoing practice? the purchase price in equity. For physicians with a relatively short remaining medical career, the equity fund The next step is to negotiate an ongoing compensation formula for approach can create a once in a lifetime liquidity event. The practice environment each physician. The physician’s historical salary will be reduced to generate becomes almost irrelevant as the financial objectives are achieved and the longer the cash flow required to pay the “management fee” to the management view is less important. For the physician with a longer working timeline, the company. Typically, the fee paid to the management company will exist for 5-8 years. If a physician terminates employment or fails to generate Private Equity in Health Care to page 304 sufficient cash receipts to pay his or her share of the fee for each of those years, the equity fund will “claw back” part of the lump sum payment or

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3The Itasca Project from cover competitiveness and quality of life. The University of Minnesota Medical School is a member of the Itasca Project, and I am a co-chair of the First 1,000 Days task force. Roger Thurow, author of “The First 1,000 Days: A Crucial Time for Mothers and Children— And the World,” writes, “If we want to shape the future, to truly improve the world, we have 1,000 days to do it, mother by mother, child by child, for what happens in those 1,000 days through pregnancy to the second birthday determines, to a large extent, the course of a child’s life, his or her ability to grow, learn, work, succeed and by extension, the long term health, stability and prosperity of the society in which that child lives.”

As physicians, we know nutrition, healthcare, parenting and environmental safety, among other experiences, physically shape the connections in the brain, building the foundation for higher-level processing which happens later. Sensory functions start to develop before birth. Language development begins in the first year, followed soon after by higher cognitive functions. This progression requires providing the right conditions for development at the right times and avoiding conditions that hinder brain development.

During the first 1,000 days, the brain is very plastic, changing and rewiring itself.

Why we focus on the first 1,000 days The roots of malnutrition, disease, suboptimal academic development and inequality are often found in the first 1,000 days and unequal access to prenatal care. Failing to nourish strong beginnings results in persistent poverty and worsening inequality, as well as higher healthcare costs and weaker economies. Disparities across socioeconomic status first appear at just 18 months of age because when parents and families have to focus on basic needs, babies have less enriching environments. Health disparities are prominent and can form a life’s trajectory by age five.

During the first 1,000 days, the brain is very plastic, changing and rewiring itself, which is why this time period is a critical time for development, as well as intervention and treatment. Joint research by the University of Minnesota Medical School and the University of North Carolina is using advanced imaging technologies to develop the Baby Connectome—a specific map of neural connections and their evolution. The research shows that as children get older their brains become less plastic because many of the foundational pathways for vision, hearing, language, emotion and attention have already been laid down. By age four or five, there is still significant brain development to come, but it will be profoundly affected by the foundational architecture already established. Neuroscience research has shown that stress negatively affects brain development. Financial and food insecurity, housing instability, and exposure to violence are common sources of stress for children and families of low

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socioeconomic status that have a clear negative impact on brain development. These adverse childhood experiences can be found in nearly one in six adults and are linked directly to negative outcomes later in life, including an increased risk of obesity, heart disease and depression. According to the Centers for Disease Control and Prevention, researchers estimate that up to 1.9 million cases of heart disease and 21 million cases of depression could be avoided by preventing early adverse experiences. Lower socioeconomic status is also associated with lower total gray matter, which contains most of the brain’s neurotransmitters. Lower total gray matter volume is associated with behavioral problems such as rule breaking, excessive aggression and hyperactivity as early as age four. Later in life, lower gray matter is associated with higher risk for mental illnesses, such as depression and anxiety.

Building awareness and compassion around social determinants of health COVID-19 disproportionately impacted some of our communities of color, largely due to chronic health problems which have been created by lifetimes of inadequate access to healthy food, safe exercise and quality preventative care, as well as the stresses created by economic and other inequities. At our Broadway Family Medicine Clinic in North Minneapolis, care providers have long understood how communities are impacted by what we call social determinants of health. Led by faculty member Shailey Prasad MD, MPH, this clinic, its providers, staff and resident learners, created a space for ongoing conversations about social determinants of health and to connect resident physicians with partners and allies in health advocacy. In 2012,

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Prasad started the Community Health & Advocacy Talks or CHAT, monthly meetings to discuss everything related to health except clinical care. Over nearly 10 years, the group has engaged a broad range of speakers covering a diverse list of subjects, from then-mayor R.T. Rybak addressing the achievement gap in Minneapolis to former gang member John Turnipseed discussing the connection of generational violence and attention deficit disorder. Hanna Nedrud, MD, a current resident in the North Memorial Family Medicine Residency Program and CHAT participant and program manager said, “Medical training focuses largely on disease processes within the body and how we can address them within clinics and hospitals. Yet... in my practice, I need to pay attention to the environment outside the clinic, be informed about resources for my patients and use my power and privilege as a physician to advocate for positive change.” This and other initiatives teach us to develop close two-way relationships which position us not as experts teaching, but as a resource listening and responding to the needs of the community. Improving health equity will take all of us both in and outside of medicine—it will also require every one of us to do what we can to ensure healthy pregnancies and in turn healthy starts for children.

The Masonic Institute for the Developing Brain At the new Masonic Institute for the Developing Brain (MIDB), led by the Medical School and College of Education and Human Development, we are The Itasca Project to page 144

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3The Itasca Project from page 13

development and long-term outcomes. It has been 18 years since former Federal Reserve economist Art Rolnick released a report, “Early Childhood Development: Economic Development with a High Public Return,” sparking conversations around the globe about the economic return of early childhood development, specifically high-quality preschools.

bringing together researchers and clinicians across the University of Minnesota to focus on childhood brain development from many different areas of expertise and focusing on the needs brought by our community. We will use what we know and what we learn to help children by creating better assessment tools to identify neurobehavioral and mental health issues early in life, by developing interventions that target these early stages, by informing public policy, by educating Stress negatively affects our communities and by advocating for the millions brain development. of children who cannot speak for themselves. While MIDB will work with children of all ages, the institute will have a strong focus on the first 1,000 days. Research shows by intervening in the first 1,000 days, we can make an impact on each child’s potential for a healthy, happy and successful life. Yet too few parents, caregivers, educators, social workers and even some clinicians realize the critical effects of those early years and their lifelong impact on future health and education outcomes.

Defining the initiative Given the complexity of social determinants of health, focusing on the first 1,000 days needs to be a community-wide initiative. to ensure parents and caregivers have what they need in their children’s first 1,000 days. Minnesota’s business community has long been aware of the connection between early childhood

Neuroscience research tells us we need to start even sooner. In 2021, the Itasca Project released a report, “First 1,000 Days: Invest When It Matters Most,” to encourage employers to promote practices and policies that support optimal early experiences for children. The report defined four major factors in optimal brain development during the first 1,000 days that offer opportunities for intervention: health and wellness, knowledge and skills, community resources and support, and social determinants of health.

Health and wellness: Ensure all families have access to prenatal care, improve pregnant mother and infant nutrition, create conditions that encourage breastfeeding and expand support for family mental and emotional health. Knowledge and skills: Provide parent education and training, deploy electronic communication to reinforce good habits, and expand home visits with nurses and social workers. Most parents do not realize that the moments of connection and interactions in those first 1,000 days have a tremendous and lasting impact on their child’s future.

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Community resources and support: Increase available higher-quality childcare, funding for childcare scholarships and subsidies to expand affordability and elevate the early childhood education ecosystem. Before COVID-19, the Minneapolis-St. Paul region had a critical and growing shortfall of high-quality childcare—demand outpaced supply by 38%— and the cost of care ranked the third highest in the nation.

talking, playing, reading and singing with infants and toddlers for brain development. This work is being done in close partnership with the MIDB. Little Moments Count is a cross-sector collaboration of organizations focused on reaching parents across cultural communities with an aim to increase equity. The Itasca Project will lead the movement’s employerfocused engagement efforts.

Social determinants of health: Create jobs with family-sustaining wages, expand job training and placement for workers with low income, expand low-cost housing, ensure healthy food supply and encourage family-friendly practices in the workplace. Many non-clinical, environmental factors like stress on the family, ambient pollution and community safety play roles in stimulating or inhibiting brain development. Environment can even impact DNA, switching genetic factors “on” or “off.”

Conclusion

This fall, the Itasca Project is releasing a toolkit for employers to learn more about how they can support the first 1,000 days, including resources for parent and caregiver education. Employers are an often overlooked stakeholder in early childhood development. However, considering that 75% of mothers work outside of the home, employers are a critical partner to help improve the circumstances of children in those first 1,000 days of life.

A statewide social focus

Real change will come when we can collectively improve childhood experiences in the first 1,000 days of life and the early years of brain development. We need physicians and health systems to have access to meaningful resources for parents and children, as well as networks of non-profit organizations equipped to deal with the social determinants of health for families. Getting involved with Little Moments Count and the MIDB is a way to increase access to usable information for patients and families as they work to ensure their child has the best chance at success in life. We invite you to join us in making a difference and giving the next generation the best chance at a healthy, fulfilling life. Jakub Tolar, MD is Dean of the University of Minnesota Medical School and co-chair of the Itasca Project’s First 1,000 Days Initiative.

Through the First 1,000 Days Initiative, the Itasca Project is joining Little Moments Count, a Minnesota-based statewide movement to help parents, caregivers and the community understand the importance of

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TELEHEALTH

Maximizing Telemedicine Benefits Establishing work flow integration BY ELIZABETH A. KRUPINSKI, PHD

T

he United States and the world have seen a dramatic increase in the use of telemedicine since the inception of the COVID-19 public health emergency, due in most part to stay at home restrictions for both providers and patients. Prior to this, telemedicine was used in a wide variety of clinical and related patient care applications for at least 30 years, and had been seeing steady but not exponential growth. With the onset of the pandemic, in many cases programs were initiated quite rapidly using readily available and often low-cost equipment and tools, unless there was already an existing program and platform in place. The rapid uptake of telemedicine was facilitated at the state and federal levels by widespread waivers and measures to reduce barriers that were previously in place such as changes in reimbursements, requirements regarding patient and provider locations, cross-state licensure and privacy/security requirements. Those of us who have been in the field for a long time are hopeful that many of these measures will stay in place, but there are clearly some that will or already have expired. We are additionally hopeful that even though in-person practices are clearly coming back full-tilt, that everyone has seen and/or experienced the benefits of telemedicine and will continue to use it to some degree as feasible and appropriate with their patients.

Moving forward, providers will be faced with new challenges as they transition their pandemic generated telemedicine process to a new world of hybrid services. As noted, some things will still be allowed (e.g., certain billing codes) but others will likely return to pre-COVID status (e.g., use non-HIPAA-compliant devices and software platforms). In addition to finding the best software for future telemedicine applications, there are other things to consider when trying to maximize telemedicine benefits. From my perspective, although the technology is critical, telemedicine success has very little to do with the technology and everything to do with the people and the environment within which they practice. Thus, in order to maximize telemedicine, what follows are elements one should consider and focus on in addition to carefully selecting the most appropriate technology for your practice and providers.

Success requires planning First and foremost, the key to a successful telemedicine program is planning and figuring out exactly what role you expect telemedicine to play and how it fits in the mission and goals of your practice or institution. The use cases need to be clearly defined and must match an identified need. Then the who, what, where, why and when must be carefully delineated. Who needs to be involved (e.g., providers, billing, scheduling, IT, legal, administration), what clinical tasks can be accomplished via telemedicine, where will the technology and/or providers be located (e.g., clinic, home), where will the patients be (e.g., primary care provider office, home, work, school), why will telemedicine be offered as an option (e.g., lack of sub-specialty providers, patients need to travel long distances, no show rates are too high) and when will telemedicine be offered (e.g., certain days/times, any opening in the schedule)? All of this can be accomplished by plotting out in a workflow diagram what the current practice is and how it needs to be adjusted in order to integrate telemedicine into that workflow. Again, the expectation is that although some practices might remain essentially virtual, the majority are going to evolve into a hybrid practice – but such a hybrid will not happen overnight or automatically. Workflow integration is going to be just as critical as integrating telemedicine technologies into a practice – it really is all about the people, setting expectations and establishing standard operating procedures and protocols for everyone who is going to be involved. Another thing that can be done to maximize a telemedicine practice is to properly train everyone involved on standard operating procedures and protocols, especially the providers who will be interacting with the patients. Currently there are only a few states (e.g., Washington) that require providers to be trained in order to provide telemedicine services and oversee at the compliance aspect. For the most part training requirements are at the institutional level and are overseen by some sort of telemedicine oversight committee. For example, at Emory University a training program was developed by the Virtual Care Executive Team and all providers engaged in telemedicine are required to complete the on-line course before interacting with patients. It will be interesting to see what happens in the future as programs become more established. It is possible that insurance

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companies could start requiring and tracking training, as could the various medical boards. To date, however, there are no unified efforts on the near horizon so training and compliance will likely remain at the organizational level at least for now. To date there are very few training programs that formally incorporate telemedicine as part of the curriculum. A number of programs are increasingly exposing trainees to telemedicine if offered at their institution, but typically as an elective or chance encounter in the clinic. There are very few that require any sort of formal training in telemedicine, although this is very likely to change within the next few years as institutions evaluate their curricula and become aware of the need to train the next generations of providers in telemedicine.

Ethical practices and legal requirements for telehealth similarly do not expect everyone to be a lawyer but they should be able to describe local legal and privacy regulations, define components of informed consent, understand ethical challenges and professional requirements and assess potential conflicts of interest (e.g., interest in commercial products/services).

Success has very little to do with the technology and everything to do with the people.

Many of these skills can be acquired by those already in practice through attending the wide variety of courses and webinars available for telemedicine skill building. It is also highly recommended that before engaging with patients for the first time via telemedicine to engage in some simulated practice sessions – from start to finish practicing each skill and developing your “style” for interacting with patients via this virtual medium.

AAMC proposes telehealth core competencies

Assessing your program

There are a number of organizations that are working on developing and promoting telemedicine standards and one of them, the Association of American Medical Colleges (AAMC), recently developed a set of Core Competencies. Although specific to medical college trainees, they are comprehensive enough to cover nearly every other specialty/profession in many respects.

Finally, in order to maximize benefits you need to assess your program. This does not require a degree in statistics or setting up a complex experimental study. It really requires just two things – a set of metrics and a process. There are lots of metrics available and most have been studied in a wide variety of clinical applications so a good lit review will always help get you started. It is important to keep in mind that the things you measure need

Very briefly, the AAMC Telehealth Competencies consist of three tiers each with a set of explicit skills that increase in complexity and responsibility across three stages of practice: entering residency, entering practice and experienced faculty physician. The skills from each prior stage of training should carry over to the next phase as the provider becomes more expert and acquires additional skill sets. The competencies are organized across the following six domains: patient safety and appropriate use of telehealth, access and equity in telehealth, communication via telehealth, data collection and assessment via telehealth, technology for telehealth; and ethical practices and legal requirements for telehealth. Patient safety and appropriate use of telehealth includes four skill sets ranging from being able to explain to patients and caregivers the benefits and limitations of telemedicine to knowing when a patient is at risk and how/when to escalate care (e.g., convert to in-person) during an encounter. Access and equity in telehealth has three skill sets, including knowing your biases and implications when considering healthcare, how telehealth can mitigate or amplify access to care gaps, and taking into account all potential cultural, social, physical and other factors when considering telemedicine. Communication via telehealth has three skills covering establishing rapport with patients, creating the right environment (e.g., lighting, sound) and knowing how to incorporate a patient’s social support into an encounter. Data collection and assessment via telehealth covers how to obtain a patient history, how to conduct an appropriate remote exam, and how to deal with patient-generated data. Technology for telehealth does not expect everyone to be an engineer or IT expert, but they should be able to explain equipment requirements for a visit, explain limitations and minimum requirements, and explain risks of technology failure and how to respond to them.

Maximizing Telemedicine Benefits to page 184

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3Maximizing Telemedicine Benefits from page 17 to reflect your goals/mission for using telemedicine, the bottom line of making a profit is not always the most appropriate metric to use. There are many relevant metrics and a good starting place is the article by Shore et al. “A lexicon of assessment and outcome measures for telemental health” is a great source to get some ideas. Although developed for the telemental health community, the metrics provided apply quite well to nearly any specialty or practice. The metrics include such things as patient/provider satisfaction, no shows, symptom outcomes, completion of treatment, wait times, number of services, cultural access, cost avoidance and patient safety. Once you decide on metrics that are appropriate for your practice (recommend starting with 2-3, then add more as your practice grows) there is a very easy, straight-forward process for getting to outcomes. First, consider a given measure an indicator – these are concrete activities, products, etc., that can be measured readily (e.g., from the patient record). For example, you could measure A1C levels in patients as a function of being enrolled in a telenutrition program. The next step is to set performance targets – these are concrete goals that are time limited and based on the indicator metrics. For example, you would like to see a 25% reduction in A1C levels in at least 50% of patients enrolled in the telenutrition course at six months post-baseline. Finally, you will have quantifiable outcomes (without fancy statistics) at the end of your set time period – if you meet your 25% reduction goal in 50% of patients, great. If not, then maybe reassess the program or whether your goals were realistic. In any case, you now have concrete outcomes of

your program demonstrating its benefits that you can provide to funders, administration, your care team and even patients and the community. In order to maximize telemedicine benefits you need to get the word out about its availability and its effectiveness!

Looking forward The world has changed for physicians and whether you are a solo practitioner, in a small independent practice, or part of a large heath system, whether rural or metro or specialist or generalist, we will all be increasingly impacted by telehealth. As best practice guidelines are developed and integrated we have an opportunity to help shape that future. The nature of telehealth is very collaboration-friendly and the opportunities it presents for improved outcomes (and lower costs) are significant. It can and will shape medical decision making and it is up to us all to be sure it is done in the most positive ways. Elizabeth A. Krupinski, PhD, FSPIE, FSIIM, FATA, FAIMBE, is Professor and Vice-Chair of Research at Emory University in the Department of Radiology. She is Associate Director of Evaluation for the Arizona Telemedicine Program and Co-Director of the Southwest Telehealth Resource Center. She is Past President of American Telemedicine Association, Past Chair of Society for Imaging Informatics in Medicine, and President of the Medical Image Perception Society. She is Editor of Telemedicine Reports.

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PEDIATRICS

Understanding Developmental Trauma Its lifelong impact on health BY NORM THIBAULT, PHD, LMFT

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here is a very small window in the early life of humans to learn to trust the world around us. The process of bonding to caregivers – attachment - is our most important task during this time, and one that will have a resonating impact throughout our life. The sensitive period for attachment, when our brains are most malleable, begins in pregnancy and continues up to about 24 months post-birth. Prenatally, epigenetic research is helping us understand how the environment of the birth mother and experiences of the birth father can shape the way that genes are expressed later in life. During this time of development, significant events happen neurologically as sensory, language and higher cognitive function pathways are formed in the brain. At the outset of life, infants have one significant survival task: to determine if the world is safe or dangerous. When the world is safe, infants will strive towards social engagement. When the world is unsafe they will be defensive in nature and learn to not trust their environment, nor those around them. These two systems, social engagement and social defense, are impacted by the caregiving the infant receives. When caregiving is appropriate, responsive, and timely, the infant learns to trust and becomes

more willing to socially engage. Significant research posits that “early experiences with sensitive, nurturing caregivers promotes a pattern of brain development supportive of emotional resilience, empathy and cognitive flexibility.” When caregiving is lacking, misinterpreted or abusive, the infant’s social defensive system will engage in an effort to protect and survive, thus showing up as hypervigilance, being slow to trust and quick to become defensive. Ultimately, children develop neurologically in the context of relationships, yet most trauma begins at home – the vast majority of people responsible for child maltreatment are the children’s own parents. We know what happens when children are programmed to explore their world in a healthy environment. When a toddler strays away from a caregiver and then becomes frightened or hurt, it returns to the caregiver for safety, comfort and reassurance. But, what if the caregiver is the one who is frightening or harmful? Who or where does a toddler turn to for safety or comfort? When caregivers are not in tune with the needs of their child or when they are abusive to their children, it may create a situation wherein the children involved become distressed. This type of anxiety can reach a point that a child loses trust in the ability of others to care for them or to provide relief. These children cannot regulate their own emotional states, and consequently learn that they cannot depend on others to assist them when in emotional distress.

Developing emotional responses

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Neurologically speaking, the amygdala seeks to protect us from harm. In children who have experienced caregiver abuse or neglect, it is typically overactive. The neural substrate between the amygdala and the lower prefrontal cortex is not engaged in a way that inhibits reactivity or impulsivity. Therefore, children respond to situations in ways that are interpreted as anti-social or inattentive; they demonstrate significant levels of anxiety or anger, which typically lead to unhealthy or socially inappropriate responses. There is no space to learn or apply experience because they transition so quickly from stimulus to response. Oftentimes these children are then given pejorative labels, such as “Oppositionaldefiant” or “Conduct-disordered.” Simultaneously, they are frequently diagnosed with Attention-Deficit Hyperactivity Disorder, when in fact, they are simply demonstrating hypervigilance in order to stay safe, as dictated by their amygdala. This dichotomy between caregivers as “guardians” and as “abusers” creates a confusing predicament for the child in regard to caregiver loyalty. This may ultimately manifest itself as behaviors designed to keep the child safe, and at the same time, keep the family intact. Ironically, a child cannot remove itself from a home in order to protect itself, and it typically does not want to see its family separated, either. When these children are then compared to normative standards of behavior, they fall short and their coping mechanisms are often misinterpreted by professionals in a deleterious way.


This lack of an appropriate interpretation is of significant concern because emotional state), is destined to failure because such compliance is contrary vital concepts around chronic interpersonal trauma are not taught to mental to their instinct to social defensiveness and ultimate safety. Children who health students in most graduate schools. A 2013 study on enhancing adoptionhave suffered developmental trauma are at a significant disadvantage when competence among mental health professionals determined that less than 25% compared to peers, because the very behaviors that they have incorporated of adoptive families found that their mental health to stay safe and survive are considered anti-social professional was adoption-competent. Further, and rebellious in nature. This shows up in social, some reported that experiences with clinicians educational and clinical environments where the who were uneducated in these important concepts child is punished and shamed for trying to cope actually damaged their families. Most important in the only way it knows. The vast majority of people among these findings is that treatment without an Making matters more difficult is the proclivity responsible for child maltreatment appropriate diagnosis ultimately leads to an incorrect to prescribe medications to inhibit these behaviors. are the children’s own parents. or incomplete diagnosis, and thus, an incorrect or With neurological damage comes a need for incomplete treatment plan. neurological healing, which involves dampening

Development trauma disorder In 2009, Bessel van der Kolk, MD, and Robert S. Pynoos, MD, submitted a paper to the American Psychiatric Association which introduced a new diagnosis by addressing “the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma.” Their hope was that this new diagnosis – Developmental Trauma Disorder (DTD) - would be incorporated in the DSM-V. Diagnoses in the DSM-IV were far from perfect in diagnosing children who have problems resulting from child abuse, neglect, death of loved ones or traumatic medical experiences. Most of the common disorders used in the DSM-IV to identify symptoms associated with interpersonal trauma fail to adequately conceptualize the impact of development in the context of ongoing danger, maltreatment, and inadequate caregiving systems. For example: • Reactive Attachment Disorder (RAD) is limited to early childhood and occurs in the context of “pathogenic care.” However, many children adopted at birth have symptoms of RAD yet have never struggled with pathogenic care.

the defensive amygdala and healing the social engagement system. This happens primarily through safe and trusting relationships, not medication. The most reliable healing mechanism we know of is engagement with people we can trust and attach with. Dr. Stephen Porge’s seminal research on Polyvagal Theory provides an excellent lens to view the importance of safety in relationships in regard to healing. According to Dr. Porges, social behaviors are neural exercises that promote neurophysiological states supporting mental and physical health. Trauma and abuse lower the threshold to trigger defensive behaviors that Understanding Developmental Trauma to page 264

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• PTSD, which began as “Battle Fatigue” in World War I, captures the fearfulness, worry and avoidance involved with trauma, but not the emotional liability and disorganized attachment beliefs of DTD. • Oppositional Defiant Disorder and Conduct Disorder involve anger, distrust and conflict, but don’t address guilt, shame, anxiety, dissociation and depressed mood seen in DTD. Drs. van der Kolk and Pynoos’ efforts were ultimately rejected by the American Psychiatric Association for inclusion in the DSM-V. This was a missed opportunity.

Borrowing serenity One of the major concerns about diagnosing and treating developmental trauma involves its contrast with traditional, behavioral methods of parenting and treatment. Many parents, teachers and providers utilize behavioral means, which are based on principles of loss. When the child makes a mistake, they lose something, such as a privilege or activity. When they do well, they gain privileges or rewards. Behavioral methods typically do not work with children who have suffered developmental trauma, because losing something only serves to reinforce that authority figures cannot be trusted. If a teacher or practitioner is focused on behavioral compliance in the home or classroom, the child (who cannot regulate its

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MEDICAL EDUCATION

Situational Judgment Testing Improving Medical School Selection Processes BY MOJCA REMSKAR, MD, PHD, AND DIMPLE PATEL, MS

S

ituational Judgment Testing (SJT) is a tool generally recognized as having been invented by the psychologist Alfred J. Craddall around 1942, as a way to predict appropriate action by employees in the workplace. Administered through a series of questions, SJT presents several potential solutions to specific workplace scenarios.

Why is there a need for consideration of a tool like SJT? Let’s admit it—the institutional student selection processes in medicine favor specific groups of people over others. As argued in a recent article in Annals of Internal Medicine, medical schools, professional organizations, academic departments and private practices are racialized organizations, which to a large extent, continue to use structures and processes that promote certain groups. Traditionally, we have relied heavily on the use of academic measures, such as cognitive tests, as a leading factor in our decision-making. It is welldocumented that using these measures disadvantages certain populations of applicants. In evidence-based medicine, it seems counterintuitive and hard for us to admit, but studies show that “good looks’’ and being thin improve your chance of being selected into a residency program. Being Black, Asian or obese is a disadvantage, according to various studies. Practice of individual,

one-on-one interviews with faculty, no matter how unbiased and openminded faculty are, leads to acceptance of “the best fit” candidates, who often reflect the leadership structure/image, which in medicine still predominantly consists of white, heterosexual, cisgender males.

Changing a paradigm In recent years, we have seen a significant emphasis being given to non-cognitive domains related to interpersonal communication and professionalism, with the intent to counter the above-mentioned trend within medical schools, professional medical institutions and hospitals. To support the need for non-cognitive competencies to be included in the selection process, there is evidence that competencies, such as teamwork and accountability, correlate with improved patient outcomes, patient satisfaction and adherence to treatment plans. The AAMC and the Accreditation Council for Graduate Medical Education (ACGME) both emphasize professionalism and communication skills as essential components of a well-rounded physician by including them into their assessment frameworks. However, at present time, we do not routinely use reproducible, validated, easy-to-use tools to measure the professionalism and communication domains in our interview processes. Instead, we rely on one-on-one interviews as the most important way to assess applicants’ interpersonal and communication skills, maturity, interest in the field, dependability and honesty. This process is not standardized and lacks inter-rater reliability, and therefore, its outcomes are biased by personal preferences of interviewers. The SJT can measure non-cognitive skills, such as those related to professionalism and attributes of an individual that mimic actual real-life events related to specific professions. Its ability to objectively measure interpersonally oriented skills is what makes it attractive for the selection processes.

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Development of the SJT starts with analysis of professional critical events that present specific constructs or domains relevant to the profession. Experts and non-experts are asked to develop a list of best, worst and in-between responses or approaches to address different situations and incidents. In the final step, a scoring key is developed based on the ability of specific responses to differentiate between experts and novices and the correlation with job performance in specific domains. The administration of SJT is relatively simple. It comes in a series of online scenarios for which the candidate is asked to rank the responses from the best to the worst. It can be administered as a written test, a video or a cartoon. As mentioned previously, AAMC has developed its own SJT which measures eight pre-professional competencies relevant to medical school applicants – service orientation, social skills, cultural competencies, teamwork, ethical responsibility to self and others, reliability and dependability, resilience and adaptability and capacity for improvement. Understanding the importance of the inclusion of the professionalism domains into candidate selection, the SJT presents around 30 scenarios with multiple responses required to each one. Test takers select a response most closely related to how they would handle that situation. The entire test takes about 75 minutes to complete. Since SJT requests individuals to


respond to the questions to the best of their ability, there is a possibility that the individual will respond with the option they feel will satisfy the exam, and not necessarily respond as they would act in the situation. This has been studied and the impact of fakability has been determined to be relatively small.

Creating a holistic review The University of Minnesota Medical School is one medical school with two campuses. The mission of the Medical School states that it seeks to enroll and educate skilled, compassionate and socially responsible physicians. Furthermore, the school is looking to educate individuals who appreciate working in diverse communities with an interdisciplinary focus and within inter-professional teams. The aforementioned attributes and others are being screened for in the current admissions process, but using a valid and reliable assessment tool that can accurately identify these non-cognitive attributes in applicants is a necessary tool for holistic review. There are both opportunities and challenges to including a non-cognitive assessment. The challenges include the added cost to taking an examination on top of an already expensive endeavor. There are no fees in this initial year for taking the test, though the AAMC plans to add them moving forward. Exactly how they will be charged is undetermined at this point. It already costs on average $1,400 for an applicant to apply to medical school. Furthermore, applicants would need to spend additional time preparing on top of the many hours of academic coursework and co-curricular activities. Adding another requirement could cause additional stress and anxiety to an already demanding process. It will also require committee members to take additional time to learn a new tool, and some might feel unwilling to embrace new and unproven methodologies.

The opportunities, however, outweigh the challenges in the long run. A non-cognitive assessment directly compliments holistic review and fits with the mission of many medical schools. Implementing an assessment like the SJT has the potential to make medical education more accessible to a wider audience. There is already plenty of data showing that lower MCAT scores keep under-represented in medicine (UIM) populations out of medical education in greater numbers. The holistic review process takes a great deal of time and involves many people. A non-cognitive assessment could help make the review process more efficient for the institution and potentially free up time for an already highly committed group of people. Finally, and maybe most importantly, could a non-cognitive assessment like the SJT be as highly valued as the MCAT? It would be worth figuring out, so that when we are speaking about applicant access and medical student failure and success, our first question is something other than “What is the candidate’s MCAT score?”

Improving resident selection In parallel to the efforts by the U of M Medical School, U of M Graduate Medical Education Office, under the leadership of Drs. John Andrews and Michael Cullen, has also developed SJT geared towards resident selection. The model includes the following dimensions of professionalism – conscientiousness, aspiring to excellence, integrity, accountability, teamwork, patient centered care and stress tolerance. The resident-specific

Situational Judgment Testing to page 244

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3Situational Judgment Testing from page 23 SJT has been shown to predict overall ACGME milestone performance and multisource professionalism assessment performance. In the resident selection process, any given department generally receives about 1,000 applications each year. The screening process frequently includes scores on a cognitive test as the primary filter due to the simplicity of using a number. This is combined with review of application packets, which include the applicant’s medical school transcripts, AOA membership, letters of recommendation, personal statement and description of their research activities, work experiences and volunteer activities. Based on these, the final decision is made to interview about one-tenth of the applicants. In the actual interview process, we have used United States Medical Licensing Exam scores and assessment of applicants by faculty as the most important components of applicant selection. As discussed earlier, this is a flawed process, which selects a specific population of applicants and more often than not can work against minority applicants. In the recent few years, the U of M anesthesiology residency program has worked on standardization of the interview process to minimize subjectivity. Several factors have led our residency program to look for opportunities to incorporate new measures of applicant non-cognitive domains into our process. Most importantly, our residency program is making a structured effort to increase the ratio of UIM applicants in our program. As part of this transition, we have started using standardized questions in our interview process in 201617. And in 2018, we have added SJT as part of the applicant interview process.

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JULY 2021 MINNESOTA PHYSICIAN

Unanswered questions A lot remains to be investigated to inform the best use of a tool like SJT. We have yet to define what an appropriate weight of all the different new measures is in the decision-making process about applicants. Longitudinal studies of how inclusion of situational judgment tests change our successful applicant pools are not well described. We have yet to answer questions about how new measures correlate with medical student, resident and attending work performance. However, at the U of M Medical School, we believe a standardized holistic process that relies less on traditional academic performance measures and emphasizes interpersonal and professionalism dimensions of individual applicants can diversify our medical population to better reflect population statistics. We believe medicine as a whole has to find ways to diversify the physician population to better represent the U.S. population. A tool like SJT is a move in the right direction toward a more balanced physician pool in the future. Mojca Remskar, MD, PhD, MACM, is a professor and the Executive Vice Chair in the Department of Anesthesiology at the University of Minnesota Medical School.

Dimple Patel, MS, is the Associate Dean of Admissions at the University of Minnesota Medical School.


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3Understanding Developmental Trauma from page 21 the Positive Care of Children, these problems include alcoholism, depression, disrupt connectedness and the ability to co-regulate. Ultimately, it is our drug abuse, eating disorders, obesity, high-risk sexual behaviors, smoking, quest for safety that determines our physiological state. At birth for mammals, suicide and certain chronic diseases. A number of research studies have the bidirectional neural communication between found a correlation between childhood abuse and the face and the heart forms the core of the social diagnosed mental health disorders in adulthood. engagement system with the primary caregiver. The occurrence of emotional, sexual and physical This involves variables such as prosody, gaze, facial child abuse is found to be a leading risk factor for expressivity, mood and affect, posture during the development of depression. Sexual child abuse social engagement, emotional state regulation, and and family violence were found to be significant risk A child cannot remove itself from a sound hypersensitivities. These assist in creating factors for anxiety disorders. Strong correlations home in order to protect itself. a co-regulation between the child and parent have also been found between family violence in which a caregiver can transmit safety to the or physical neglect and later substance abuse. In child and allow the child to then relax into the summary, much of the care that physicians provide comfort and influence of that parent, even after to adults today can be attributed to the care that having experienced trauma and abuse. I call this patient received as an infant. “borrowing serenity.” Developmental trauma is pervasive. Fully two-thirds of children in the United States report at least one traumatic event by age 16. In 2013, the national average of child abuse and neglect victims was 679,000 children, or 9.1 victims per 1,000 children. Developmental trauma crosses socioeconomic status, race, gender and all other social boundaries. Its impact is lifelong. Those who have grown up with Developmental Trauma are at higher risk for significant health problems as adults. According to the American Society for

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Treatment for developmental trauma involves education, awareness and safety. All caregivers and treatment team members need education to understand the unique features of developmental trauma so that behaviors and effect can be correctly interpreted. What is seen as anti-social in a typical environment actually makes sense in the context for which it was created. There is a reason for this behavior and the feelings supporting it, and rarely does it have to do with wanting to be difficult or oppositional. It is about coping and surviving, and the professional’s task is to make a correct interpretation of the context that created and shaped these behaviors. Writing a prescription is insufficient treatment. While it might dull the effect, it does little to assist in facilitating co-regulation between a parent and child - the mechanism that most promotes neural healing. Psychotherapists and caregivers should be educated in modalities and interventions specific to the unique needs of these children, such as Hope for Healing through ATTACh.org, Dyadic Developmental Psychotherapy, Trust-Based Relational Intervention, Occupational Therapy Sensory Interventions and others. It is imperative that all professionals who work with children understand the deleterious impact of developmental trauma. For too many children, their responses to perceived danger have created outcomes that have made their conditions worse because of a lack of understanding on the part of a treating professional. It is our task to assess the full context of the behaviors, as well as the detailed history of the children and parents with whom we work. Only then are we best able to assist them in their complete healing and a promising future. Norm Thibault, PhD, LMFT, is the current President of the Association for

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3The Importance of Medical Associations from page 9

Physicians 30+ year legacy of providing confidential support for physicians experiencing substance use disorders by launching a new initiative aimed at expanding our wellness offerings called the Physicians Wellness Collaborative (PWC) in 2020. PWC provides eight confidential, free counseling sessions for physicians, residents, medical students and their immediate family members. We’ve seen an incredible response to our work over the past year and a half. We have recently extended our free counseling services for our Advance Practice Providers colleagues. We have also partnered with the Metro Minnesota Council on Graduate Medical Education on two innovative new programs: setting up proactive wellness appointments with licensed mental health professionals for residents as they enter into their program and a pilot program using a mobile app, PWC PeerConnect, which is confidential space for residents to connect with recent residency graduates and practicing physicians who are passionate about supporting residents as Peer Support Mentors.

We are also dedicated to continuing to address systemic barriers to physician wellness, including partnering with other organizations to change medical licensure language which prevents many Minnesota physicians from accessing mental health services. How are you addressing institutional or systemic racism in health care?

The depth and urgency of the need to combat systemic racism has been reinforced over the past year, and we have seen strong leadership around health care system change from local physician and medical associations. TCMS will continue to focus on how systemic racism creates conditions outside the clinic that lead to ill health. Public health advocacy around menthol and other flavored tobacco – a key driver in racial disparities in tobacco use and ultimately tobaccorelated death and disease—will continue to be an emphasis of our organization’s work. Additionally, we are committed to continuing our work to address the harm of sugary drinks which, like tobacco, are disproportionately and aggressively marketed toward Black and Latino children. We are actively working

to extend our model of physician education and advocacy to support communities working on other pressing health issues like universal school meals, a living wage and new models of public safety. What would you like physicians to know about the Twin Cities Medical Society?

Twin Cities Medical Society has provided me with opportunities to advocate on issues that are close to my heart, to mentor the next generation of physician-advocates, and to connect with an incredible community of physician activists. I warmly invite you to attend one of the engagement opportunities we will be hosting this Fall, and join us in working to create real change for the health of our community! Sarah Traxler, MD, serves as Chief Medical Officer of Planned Parenthood North Central States and is President of Twin Cities Medical Society. She is a board-certified obstetrician gynecologist. Dr. Traxler has special interests in reproductive health policy and healthcare for the underserved.

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

U

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. 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.

Physician/employer direct contracting

CAR T-cell therapy to page 144

BY MICK HANNAFIN

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

• •

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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Conclusion

3Private Equity in Health Care from page 11

An equity fund/physician practice transaction can lead to many benefits for a practicing physician. Enhanced management expertise, savings through economies of scale and access to enhanced reimbursement rates can result in more financial resources for the practice of medicine and enhanced compensation for physicians. But the arrangements must be properly structured to protect the physician owners’ financial and practice interests. In considering such a transaction, it is important for physicians to work with legal experts with This type of transaction industry knowledge. Legal issues related to health and practice structure care regulatory compliance, tax, ERISA, and is not without risk. securities law all must be fully considered when entering into such a deal.

reviews are mixed. In the best situations, the physicians have no further business or regulatory responsibility, and see patients as they walk through the door. The physician relies upon the management company to assure everything is profitable and that the physician will always have a job. The equity fund has the incentive to increase every physician’s compensation so the physician can ignore the business side of the medical environment.

But this type of transaction and practice structure is not without risk. If the arrangement is not properly structured, some physicians feel oppressed and part of a corporate machine focused upon maximizing profits to the detriment of patient care. There may also be reduced ability to spend the time with a patient that the patient needs. Finally, joining a larger corporate structure may reduce physician autonomy and entrepreneurial spirit. The practice becomes a job instead of a profession. Most significantly, if the management company fails (as has happened frequently in the past), the physician’s practice may be forced to close requiring the physician to find a new practice setting. Physicians may also be subject to “clawbacks” of the original payments if practice liabilities are higher than originally expected. These may include regulatory non-compliance, billing errors and issues, or other unanticipated liabilities.

Randal Schultz, JD is a health care attorney at Lathrop GPM who counsels health care organizations of all types across the country for the development of business/financial structures, entity formation, program/product creation and regulatory compliance.

Ben Peltier, JD, is a health care attorney at Lathrop GPM who focuses his practice on a wide range of transactional matters including contracting, mergers and acquisitions, regulatory guidance, governance and compliance.

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Sofia Lyford-Pike, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

mphysicians.org

Profile for Minnesota Physician Publishing

Minnesota Physician July 2021  

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