Minnesota Physician August 2022

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MINNESOTA

AUGUST 2022

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXVI, No. 05

PHYSICIAN Care Coordination Improving patient satisfaction and engagement BY BONNIE LAPLANTE, PhD

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The Moral Law Within Care beyond medical services BY JULIA JOSEPH-DI CAPRIO, MD, MPH

are coordination has great potential to make a difference in the lives of Minnesotans. Many organizations have incorporated the care coordinator role within their business models with the purpose of bringing value and support to the people they serve. These individuals may be assigned to or contacted by a care coordinator (maybe with a different title but with the same purpose) from a variety of organizations connected to their medical or social services: public health, insurance companies or other support agencies. While the actions and work of care coordinators in each setting bring value to the patient, consistent communication and collaboration between all the individual’s care coordinators is a high priority to support them without confusion, reduce duplication of efforts and ultimately improve the patient’s health outcomes while keeping the individual at the center of care. Care Coordination to page 144

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significant part of each of our health is determined by what happens outside of a health care office or hospital. Some estimates suggest that as much as 80% of health status can be attributed to non-medical factors. This is why medical care alone is insufficient for achieving better health outcomes. I am a pediatrician and adolescent medicine specialist. From the time I started working in health care, I was always interested in the context in which the patients I served existed; how their health was affected by what would now be called the social drivers of health. While studying public health, I became interested in the health of populations and, again, the context in which they existed. Over the years, my approach to care has evolved. I began by trying The Moral Law Within to page 104


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55TH S ES SI O N

AUGUST 2022

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Publishing December 2022

Volume XXXVI, Number 05

COVER FEATURES The Moral Law Within

Care Coordination

Care beyond medical services By Julia Joseph-Di Caprio, MD, MPH

Improving patient satisfaction and engagement By Bonnie LaPlante, PhD

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Improving the Experience of Health Care Hilary Marden-Resnik, President and CEO

MEDICINE AND THE LAW............................................................. 14 The Interstate Medical Licensure Compact Commission Expanding your practice opportunities

By Marschall S. Smith ADMINISTRATION....................................................................... 20

CARE COORDINATION

The Minnesota Rare Disease Advisory Council

Improving Communication and Outcomes

A new resource for patients and clinicians

By Erica Barnes, MA, CCC-SLP HEALTH CARE POLICY.................................................................. 22 Physician Advocacy

BACKGROUND AND FOCUS: As health care faces rising costs, chronic workforce shortages and seemingly ever increasing administrative burdens, the pace of evo-

You are needed now

lution is unparalleled. One example is the emergence of care teams;

By Peter Dehnel, MD

many different licensed and unlicensed providers working together to the top of their training. While this offers benefits it also creates new challenges. The two most critical are ensuring every provider is aware of the care a patient receives and the patient is aware of, and adheres to, his or her individual treatment plan. The complexities of these task have given rise to a new part of the care team, the care coordinator.

OBJECTIVES: Our panel will examine the role of the care coordinator, how and why it is becoming an increasingly important part of health care delivery. When care coordination may be provided by clinic or health system staff, by third party payers, by private industry contracting out-of state employees, and even by state health agencies, utilization of this tool can present conflicts, confusion and frustration. We will look at the different aspects of care coordination and provide insight into how www.MPPUB.COM PUBLISHER

________________________________________________________________________

they work best in various practice settings. Mike Starnes, mstarnes@mppub.com

ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com

JOIN THE DISCUSSION We invite you to participate in the conference development process.

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.

If you have questions you would like to pose to the panel or have topics you would like the panel discuss, we welcome your input. Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

MINNESOTA PHYSICIAN AUGUST 2022

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CAPSULES

U of M Medical School Names First Female Department of Medicine Chair The University of Minnesota Medical School has recently announced Dr. Elizabeth Seaquist as the incoming chair of the Department of Medicine. As a 33-year, tenured faculty member of the U of M Medical School, Dr. Seaquist will lead from the intersection of patient care, research and education. “I am very honored to be asked to serve in this important role. Dr. Igarashi has done an outstanding job of building Medicine during his tenure and I look forward to continuing many of his plans to grow excellence in each of our mission areas,” said Seaquist, who also is an endocrinologist practicing at M Health Fairview. “This department has been my academic home for my entire career and I hope to provide all of our faculty the career development support that I

have experienced over the years.” She is an alumna of the University, where she completed both her residency in internal medicine and her fellowship in endocrinology. “As the first woman Chair of Medicine at the University of Minnesota Medical School, I am particularly interested in expanding the diversity of our faculty, students, trainees and staff,” Seaquist said. “I am grateful to Dean Tolar for giving me this wonderful opportunity and am excited to work with the faculty to build our success.” During her tenure at the University, Seaquist has helped to build systems to better link primary and specialty care as associate dean for medical specialties and primary care. She has also been a leader in multiple, groundbreaking interventional clinical trials for the treatment of diabetes, bringing in over 130 research grants, which total over $24 million. Many national institutions have recognized Dr. Seaquist for her leadership, mentorship and

unique abilities to care for patients, including the American Association of Physicians, the nation’s oldest medical honor society. “Dr. Seaquist is a superb physician-scientist who is highly respected by her patients and colleagues. She is an experienced and visionary addition to our leadership team, and we are fortunate to have her as the new chair of the Department of Medicine,” said Jakub Tolar, dean of the University’s medical school and vice president of clinical affairs.

Mayo Clinic Launches New Biomanufacturing Venture Mayo Clinic recently announced a new strategic collaboration in biomanufacturing to deliver novel biotherapeutics for rare and complex conditions. The collaboration brings together science, engineering and manufacturing to advance Mayo Clinic’s vision of delivering new cures to clinical care. The focus will be on therapies derived from

human sources known as biologics— cells, blood, enzymes, tissues, genes or genetically engineered cells—for use in medicines. Therapeutics based on biologics have the potential to target exact tissues needing repair. “Mayo is making significant investments in facilities to create the world’s most advanced and innovative ecosystem for the development, manufacture and delivery of biotherapeutics. We are seeking to build a community of innovators to explore ideas, develop new products and create thriving biotherapeutic companies,” said Julie Allickson, Ph.D., the Michael S. and Mary Sue Shannon Family Director of Mayo Clinic’s Center for Regenerative Medicine. “This nexus of entrepreneurs, startups and industry experts will help position Mayo Clinic as an authority in regenerative biotherapeutics.” Dr. Allickson is also the Otto Bremer Trust Director, Biomanufacturing and Product Development, Center for Regenerative Medicine.

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AUGUST 2022 MINNESOTA PHYSICIAN


CAPSULES

To support this new venture, Mayo Clinic has formed a strategic collaboration with National Resilience, Inc. to establish Rochester as a center for biomanufacturing regenerative technologies. “Mayo Clinic will advance regenerative technologies from discovery science to early phase clinical trials,” said Gregory Gores, M.D., Kinney Executive Dean of Research at Mayo Clinic. “Research in the emerging field of biotherapeutics lays the foundation to attract the scientific workforce of the future.” The collaboration has these areas of focus: • Process development expertise to advance Mayo Clinic biotherapeutics. • Working together to attract biotech companies interested in sponsoring clinical trials at Mayo Clinic for novel regenerative biotherapeutics. • Providing cell and gene products needed for biomanufacturing earlystage therapeutics. • Analytical testing and quality control required for manufacturing commercial grade biopharmaceuticals. Mayo’s goal in developing expertise in biomanufacturing new biologic-based medicines is to accelerate clinical care options that provide new hope for patients.

Sanford Breaks Ground on Virtual Health Center Sanford Health has recently broken ground on the state-of-the art Sanford Virtual Care Center, a 60,000 squarefoot facility that will change the way care is delivered to rural America and serve as a hub for a network of virtual clinics and telehealth services. Construction is underway with an anticipated opening date in 2024. “At Sanford Health, we take great pride in serving America’s heartland. It is part of our legacy and our identity.

Today, we take a critical step toward transforming the health care experience across rural America by breaking ground on the Sanford Virtual Care Center,” said Bill Gassen, president and CEO of Sanford Health. The new center will feature dedicated clinician workspaces equipped with the latest telemedicine technology and offer a variety of service lines, including on-demand urgent care, behavioral health care and primary care. The building will also house innovation, education and research initiatives to advance digital health care and workforce solutions for the future. “This flagship center will be the premier training ground to prepare medical students, residents and nurses for the next generation of care delivery,” said Brad Schipper, president of virtual care. “The innovation that takes place in this building will help us deliver on our promise to patients by leveraging the best of technology to provide high-quality, safe care with an emphasis on convenience and affordability.” In addition to the Sanford Virtual Care Center in Sioux Falls, South Dakota, five pilot satellite clinics will be placed where services are otherwise unavailable or diminishing, allowing high-tech, high-touch connectivity with Sanford clinicians. “A large contingency of the 1.5 million patients come to us from rural communities,” Bill Gassen said, defining rural community as a population of 50,000 or fewer. “It makes up a big part of what we do at Sanford Health. It’s part of our mission and at the core of what we do.” With virtual care, Sanford Health hopes to address: • Sustainability amid rising costs of delivering care.

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• Infrastructure limitations, such as challenges with connectivity and broadband internet access in many rural areas. • Health workforce challenges. • Health equity and access to care.

MINNESOTA PHYSICIAN AUGUST 2022

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CAPSULES

Gummies And Chews Now Available For Medical Cannabis Patients Effective August 1, patients registered in Minnesota’s Medical Cannabis Program became eligible to buy gummies and chews from the state’s medical cannabis dispensaries. Registered patients who are interested in these medical cannabis products can make an appointment for a consultation with a medical cannabis dispensary pharmacist. “The state’s medical cannabis program continues to respond to the needs of patients, and gummies and chews may be useful options for those who may have difficulty swallowing pills or tablets, do not want to smoke medical cannabis, or don’t like the taste of other forms of medicine,” said Minnesota Commissioner of Health Jan Malcolm. These medical cannabis gummies and chews are separate from the recently authorized hemp-derived edible cannabinoid

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products regulated by the Minnesota Board of Pharmacy. Under the guidelines of the state’s medical cannabis program, consultations are required when a patient changes the type of medical cannabis they receive. Both medical cannabis manufacturers are currently scheduling consultations. Patients should visit their dispensary’s website for details (see Green Goods or RISE dispensaries). The newest options for medical cannabis patients were approved last year during the Minnesota Department of Health’s annual petition and comment process to solicit public input on potential qualifying medical conditions and delivery methods of medicine for the Medical Cannabis Program. To become a patient in the Medical Cannabis Program, a person has to be certified by a participating health care practitioner for at least one of 17 qualifying medical conditions. More information on the enrollment process is available on the

AUGUST 2022 MINNESOTA PHYSICIAN

Office of Medical Cannabis website. Minnesota’s Medical Cannabis Program added dried flower as an option for patients 21 and older, effective March 1 this year. Enrollment in the program has steadily increased since the program was launched in 2015, according to the Minnesota Medical Cannabis Dashboard.

New MDH Study Shows $8B Impact of Excessive Drinking Excessive drinking cost Minnesotans nearly $8 billion in 2019, according to a new study from the Minnesota Department of Health (MDH) published recently in the American Journal of Preventive Medicine. The study found the greatest financial cost fell on those who drink excessively and their families, as well as government and health insurance providers. Other parts of society, including employers, were also found to experience

negative impacts from excessive drinking. “Excessive drinking can significantly affect individual health, but it also has a cost for families, communities and the health care system,” said Minnesota Commissioner of Health Jan Malcolm. “The financial burden is staggering, and of course there are additional psychological and societal impacts and harms in addition to those measured here. It’s important that we acknowledge these impacts and find ways to mitigate them.” The study shows excessive drinking cost Minnesotans $7.85 billion in 2019, through lost productivity, health care costs and other costs such as those related to criminal justice and motor vehicle crashes. The total financial cost equals $1,383 per Minnesota resident. Excessive drinking includes binge drinking (four or more drinks on an occasion for women, five or more drinks for men), heavy drinking (eight or more


CAPSULES

drinks per week for women, 15 or more drinks per week for men), or any drinking among pregnant people or people under age 21. Key findings of the report include: • Lost productivity accounted for almost three-quarters of the financial costs, including increased absenteeism, impaired productivity at work and at home, premature mortality and incarceration.

• Binge drinking contributed to 73% of the financial costs to society, or $5.7 billion. In addition to the economic costs, excessive drinking is linked to an increased risk of violence and injury, like traffic crashes and chronic health problems like liver disease, heart disease, high blood pressure and some cancers.

KRISTIN CHENOWETH

The 2021 Minnesota Legislature passed the Minnesota Telehealth Act, which among other things, extends existing reimbursement rates for telemedicine patient visits through June 30, 2023. The legislation also required Minnesota Department of Health (MDH) to conduct a study of the impact telehealth has on both the private health insurance industry and Minnesota Health Care Programs, including Medical Assistance and MinnesotaCare. The study is now underway, and will involve Minnesota residents, providers,

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State-Mandated Telehealth Survey Begins

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• For each alcoholic drink purchased, people in Minnesota experience an impact cost equivalent of $2.86.

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• About 3% of inpatient hospital treatments were attributable to alcohol, but these visits accounted for 35% of all inpatient health care costs.

and payer organizations by inviting them to participate in a survey with Wilder Research. Anyone may see if they are eligible to participate in the survey using this link to register: MDH Telehealth Screening- Providers (voxco.com). Eligible registrants will be contacted by Wilder Research with further details. If you have already provided telehealth care you will be eligible and your participation will help shape future reimbursement policies around these services. The MDH Telehealth Study will evaluate expansion of telehealth services and how this could impact future reimbursement policies. Several factors will be evaluated including access, quality of care, outcomes, patient satisfaction, value-based payments and innovation. It will weigh healthcare disparities and equitable access for underserved communities as well as healthcare costs and premiums. Also surveyed will be the impact on and availability of, in-person care, including specialty care, particularly in rural areas. The study will examine how payers ensure that telehealth services are appropriate to the patient’s needs and that patients may choose whether to seek or receive care via telehealth. It will measure whether audio-only communication supports equitable access to health care services, including behavioral health services, and whether it eliminates barriers to care for vulnerable and underserved populations without reducing the quality of care, worsening health outcomes, or decreasing patient satisfaction. Additionally surveyed is whether populations for which increased access to telehealth improves or negatively impacts health outcomes. The State welcomes all qualified participation in the survey.

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INTERVIEW

Improving the Experience of Health Care Hilary Marden-Resnik, President and CEO

During your time as interim president and

last few years, several new national, for-profit plan competitors entered our market, and that competition drives us to differentiate the value of being a regional, nonprofit health plan with strong community connections. This year UCare earned a 5-Star Medicare rating for quality, the highest possible rating. As a long-term Medicare Advantage plan with a loyal membership of over 116,000 members, we continue to see growth opportunity in this business line.

CEO, you led UCare through a period of considerable growth. What can you tell us about this?

I assumed the interim role when UCare was in a strong position as a leading Medicaid, Medicare and Individual and Family Health Plan provider. As a result of our successful 2020 RFP response to serve the Prepaid Medical Assistance Program and MinnesotaCare members in the sevencounty metro, we saw enrollment growth in these programs in 2021. We have a 46% market share of Individual and Family Plans sold through MNsure because of our well-priced and welldesigned plans. We continue to attract retirees to our high-value Medicare Advantage plans.

What were some of the UCare responses and lessons learned during this ongoing pandemic?

We learned how agile we can be to respond to a public health emergency. We pivoted quickly to keep employees safe by immediately transitioning them to work at home in March 2020, without disrupting our members and providers. As part of our mission to remove barriers to care, we developed a community response team to support our members’ ability to get needed care during the pandemic. They focused on contacting high-risk members first. As members’ use of telehealth services increased, we enhanced our support for those services. Our members also had access to our mental health hotline. We provided older, isolated members with iPads to help them stay connected. And we distributed more than 95,000 KN95 masks to the community. Before vaccines were available, we temporarily removed member copays for COVID testing, treatment and hospitalization,

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Medicare de-complicators. What are some of the most common things these people do?

We “...” want physicians to know how deeply we value their partnership in serving our members with quality care.

“...”

We also grew our workforce to keep pace with the increasing complexity of our business, to improve member and provider experience and to launch new capabilities in, for example, our equity and inclusion, community response and technology transformation work.

UCare offers the services of what you call

and we discounted premiums. Once vaccines were available, we helped members get their vaccines, hosting 85 vaccine clinics and arranging transportation and interpretation services. Please discuss the good and the bad of Medicare Advantage plans.

As a continuous Medicare Advantage plan provider since 1998, we believe firmly that such plans are among the best options for Medicare enrollees because they combine original Medicare with extras such as dental, prescriptions, OTC, vision, hearing, fitness and healthy food savings. These plans also offer care coordination for members who can benefit from it. And Medicare Advantage plans can be more affordable than supplement (Medigap) plans. Medicare Advantage plan enrollment has been growing nationally and locally because savvy seniors have picked up on the advantages of these all-in-one plans. Their popularity creates a crowded marketplace for consumers. Over the

This question cuts to the core of our mission to make health care more accessible for everyone. Our Medicare de-complicators are spread throughout UCare—from our sales and customer service representatives on the frontlines to our marketers, member experience, clinical and operational staff behind the scenes. The de-complicators simplify the complexities of health care and health coverage for our members and prospective members. Our sales team offers 1:1 consultation or community meetings to help shoppers find the plan that best fits their needs. We have a Say it Simple initiative that requires all communications to be written at an 8th grade reading level or lower. We define and explain insurance terms such as coinsurance, deductibles, out of pocket maximum, etc., in simple and relatable ways. We use infographics to illustrate concepts. We limit the number of words in each sentence. Health care can be so overwhelming, and we want to take the stress out of it by de-complicating it for our members and prospective members. What strategies do you have for diversity equity and inclusion issues?

These strategies are inspired by our goal of being an anti-racist organization. We focus on four dimensions of diversity, equity and inclusion— clinical, community, county and culture. We engage in clinical interventions to improve access, care and outcomes—especially in communities


with the greatest health care disparities. We provide community support to address social drivers of health, such as food insecurity and education gaps. We also support countless county public health initiatives. Internally, we’re focused on building on our already very strong and mission-driven culture through enhanced focus on diversity, equity and inclusion. Last year we hired our first VP of Equity and Inclusion to lead a new Department of Equity and Inclusion, and our board of directors has evolved its committee structure to ensure the board carries out its work with an even greater focus on equity. We’re also supporting the Minnesota Medical Association’s development of anti-racist cultures among Minnesota health care organizations, as well as the Minnesota Hospital Association (MHA) Workforce Development Roadmap initiative, addressing the workforce crisis and opportunities to diversify the workforce. What can you tell us about your plans to offer services in Iowa?

We submitted an RFP response in May to serve members of Iowa’s Medicaid programs and

expect to learn the results later this summer. Our plans to offer services in Iowa support our strategic growth goals. Iowa presents our first major expansion opportunity outside of Minnesota and Western Wisconsin. We are excited at the prospect of bringing our community-based, nonprofit approach to Iowa. Our strong midwestern values and long history of service and innovation for Medicaid members would make us a strong partner with Iowa if we are awarded a contract. Some examples of innovations are our Mobile Dental Clinic, drive-through vaccine and flu shot clinics and our Community Response Team. Care coordination is becoming an increasingly important issue. What kinds of services are you offering in this area?

Care coordination is a vital service we provide our members—particularly benefiting members with multiple and complex health needs. Care coordinators are our members’ allies and advocates. They stay in close contact with members to help them get connected to care. Care coordination helps ensure: member access to health care and community and waiver services,

improved member outcomes and the living arrangement of choice for our members. Care coordination at UCare is a collaborative process; it helps connect all the health care dots for our members through assessment, planning, facilitation and advocacy for options and services to meet our members’ needs. We help members receive access to care, social or community supports, a safe living environment and self-reliance. An important aspect of how we coordinate care is including awareness and sensitivity to culturally appropriate issues. Health care workforce shortage issues present a growing crisis. What are some potential solutions to these complex problems?

We are so grateful for the health care heroes who have provided care throughout the ongoing pandemic. Burnout and resignations continue to be a real concern, though. A potential solution includes providing more tuition support and Improving the Experience of Health Care to page 304

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.

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3The Moral Law Within from cover to understand the lives of my patients outside of the clinic room, changed to understanding and addressing social drivers, and now recognize that unless we address the root causes of social drivers, there will not be sustained improvement in the health of those we serve. For many diagnoses, we should consider societal and structural elements, what Dr. Rishi Manchanda, the CEO and founder of Health Begins, describes as community-wide social determinants of health and the causes of those social elements, the structural determinants of health. Examples would be supermarket redlining as a structural determinant of health and a food desert as a social determinant of health. The social risk factor that would then appear as a result of these is food insecurity. In order to be more effective clinicians, we must address the social risk factors. Further, sustainable improvement on the health of populations requires addressing the social and structural determinants of health. The business imperatives for this approach are clear—health care costs are reaching unsustainable levels. Nevertheless, the greatest reason to change is a moral one. I know little about philosophy, but I have thought a lot about Don Berwick’s 2020 Health Affairs Viewpoint, “The Moral Determinants of Health” that begins with a reference to the 18th century philosopher Immanuel Kant and the “moral law within.” What Dr. Berwick notes is that the research is clear on what is needed to improve health, but societies don’t invest in those things—for example, shunting more of health care spending to what will prevent illness, such as addressing the high rates of incarceration in Black and other diverse communities or supporting elders suffering from

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AUGUST 2022 MINNESOTA PHYSICIAN

loneliness, versus paying to repair the effects of a lack of investment and disinvestment in what is known to improve health. The pressures that ensure the status quo are powerful. But the more powerful force would be if more of us, including those of us working in health care, attended to the “moral law within,” advocating for what is right even if it is not immediately in our personal or organizational best interests. This approach would result in improved and equitable health outcomes.

A Framework for Better Care There are frameworks that can be used to improve the health of populations through the implementation of strategies beyond medical care and which can address health inequities. One I worked on with colleagues at the Alliance of Community Health Plans while I was a senior vice president and the chief medical officer for UCare recognizes that health inequities are due to a complex web of social and structural factors and is a framework that can be used by healthcare providers. The framework begins with identifying at least one equity issue to fully address, then using data and analytics to identify root causes—and solutions for those root causes that act at the individual, community and systemic levels. The individual level involves work within your immediate sphere of influence—your patients. An example might be addressing the issue of poor pregnancy outcomes by identifying pregnant people who are at risk for an adverse health outcome and reaching out to them to connect them to their health plan for care management support. At the community level, organizations work with others to make a community-wide impact. Using the same pregnancy outcome example, a health care organization may use philanthropy to support a community-based organization that provides doula services, which have been shown to improve health outcomes. At the systemic level, health care providers might choose to advocate for insurance coverage of doula care. As you assess your patients and determine that, in addition to providing medical care, they need other supports, there are many community-serving organizations you can access which can serve as resources for your patients. For example, the Wilder Foundation African American Babies Coalition has a number of initiatives to foster the healthy development of Twin Cities’ African American babies that include the Integrated Care and High Risk Pregnancy Initiative (ICHRP). This initiative connects parents and families to needed resources at NorthPoint Health & Wellness Center in Minneapolis, the Ramsey County Care Collaborative, and other resources in Ramsey County. ICHRP also trains others, including health care providers, on how to provide culturally relevant care to diverse communities. Another example of a Minnesota community-serving organization providers can support and refer patients to is Juniper. It is actually a network of organizations across Minnesota that offer evidence-based health promotion programs for adults that include falls prevention, fitness classes and programs that provide education on how to live well when aging or if living with a chronic health condition. Many of Juniper’s offerings are free, ask for a donation or in some cases are a covered insurance benefit. For example, Tai Ji Quan: Moving for Better Balance, is an evidence-based falls prevention program offered through Juniper. It is available online and in person at various sites across Minnesota. Many providers have changed how they practice and now determine whether patients need health promotion services similar to those Juniper provides. Also, providers are increasingly assessing patients for social drivers


of health in order to connect them to community-based resources that can address the social need. An example of this is asking about food insecurity by asking a patient or family if they worry their food will run out before they have the resources to buy more, then giving them information about available food shelves and where to get information about supplemental nutrition benefits.

Incorporating a New Approach Assessing for social drivers of health is integral to the work of Leap Pediatric and Adolescent Care, a St. Paul practice I recently started. We focus on advancing health equity and removing barriers to health and wellness, in part through collaborations with local county public health and communityserving organizations.

more likely to be hospitalized for their condition when compared to children living in an adjoining neighborhood. Access to care is challenging. There is very little to no pediatric/adolescent primary care in many areas of St. Paul, known as Health Services & Resources Administration Primary Care Health Professional Shortage areas. Leap Pediatric and Adolescent Care is located in one of these areas and commits to identifying and addressing social drivers of health.

We also commit to having a staff that represents the patients, families and communities Medical care alone is we serve. Studies have shown that patients from insufficient for achieving Black, Latino and Indigenous communities are better health outcomes. more likely to trust health care systems that have doctors and staff with similar cultural experiences. This trust can lead to improved health outcomes. Before the pandemic, families were resilient I’m one of the few Black doctors in Minnesota, even in the face of significant barriers; however the and over the years, families have said they brought pandemic has made it more difficult for them. I can their children and adolescents to me because I am Black. However, it is walk from my home in St. Paul to neighboring areas where many people have challenging and takes time to build trusting relationships with patients, no regular source of health care, including pediatric and adolescent care. even if you do have common cultural and social experiences. Many people St. Paul is diverse. Almost 50% of us are Black and/or of Indigenous in the U.S. distrust health care organizations and doctors. In fact, before the communities, Asian, or Hispanic. Twenty percent are foreign born, and 30% pandemic, one survey found that less that 60% of participants from the U.S speak a language other than English at home. Unfortunately, one in five St. said that doctors can be trusted. Fewer people from diverse communities Paul children live in families with incomes below the poverty level. Many trust doctors, and many report being treated unfairly by health care systems. children in St. Paul are behind on their well child visits and immunizations. The Moral Law Within to page 124 Children with chronic medical problems in some St. Paul neighborhoods are

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3The Moral Law Within from page 11 Building Trust

patients who want to incorporate traditional healing practices into their care plan and don’t know a good source of this care. She said she asks people in those communities for recommendations —– they know the best healers to recommend.

Trust with patients can be built. It requires consistently showing we care about them and will give them the time required to meet their needs. I remember The pandemic, our profound health disparities, the widespread a patient experience leader advising me to always lack of trust in health care—these all indicate ask a patient and family if there was anything the need to change how health care functions else I could do for them before I exited the exam in Minnesota and the U.S. This change is room. I have found that asking this question very necessary, so we are mandated to allocate rarely added significant time to the visit and gave more money and attention to the causes of Advocate for an approach to patients and their families a moment to make sure poor health and to the practices that promote health that is beyond and more we had discussed what was important to them. The wellness. Systems need to be built that address effective than medical care. same approach of asking how we can be of service the social drivers of health, connect patients to is useful if a provider or health care organization health promotion services, humbly partner with hopes to enter into a relationship with a community community-serving organization and build trust and community-serving organizations. with the communities we serve. Such systems are possible if we all attend to the “moral law We also build trust with patients and within” and advocate for an approach to health communities by providing culturally congruent that is beyond and more effective than medical care. care. Cultural congruence involves learning about the cultural beliefs and values of the individuals and communities being served and being open to integrating those beliefs and values into the care we provide. I recently spoke to a health care leader and mental health practitioner who asks patients whether they use or would like to incorporate traditional healing practices into their care. She has found some patients achieve better outcomes when traditional healing is used alongside our conventional mental health treatments. I asked her how she knows where to send

Julia Joseph-Di Caprio, MD, MPH, is president and founder of Leap Pediatric and Adolescent Care. She has also served as senior vice president and chief medical officer at UCare and held several physician leadership roles at Hennepin HealthCare.

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The impact of exceptional senior care The Good Samaritan Society is proud to provide comprehensive services to health care partners nationwide. With a commitment to quality, we believe that relationships, collaboration and human connection are essential in providing compassionate care.

Our expansive footprint ensures we have the expertise to provide residents and clients with a smooth transition through various levels of care. And as an affiliate of Sanford Health, a leading health care organization, we have access to a vast wealth of educational training and resources making us the right choice for health care providers and their patients. Our integrated approach means we’re improving the quality of life and wellbeing of our residents and clients and developing better standards of care across our communities. Services vary by location but may include: • Assisted living – Convenient, maintenance-free living with services, amenities and security features to help residents live vibrantly. • Home-based services – Customized, in-home medical or non-medical care within the comfort of a person’s home with extra support for meals, medications and more. • Long-term care – 24-hour care and services for those who need the assistance of licensed nursing or rehabilitative staff.

• Rehab therapy – Quality inpatient or outpatient services using physical, occupational and speech therapies to enhance recovery after a hospitalization, illness or injury.

The help your patient needs, when and where they need it. You can be assured that we will be there for your patient every step of the way, supporting their physical, emotional and spiritual well-being and safety. Learn more about each of our services below.

Assisted living When a person’s health and personal needs change, assisted living provides extra support, so they can have their needs met in a comfortable environment. Assisted living empowers residents to lead an active, social lifestyle in a community that offers safety and security with supportive services available should the need arise.

Home-based services Home-based services encompass a wide range of offerings from medical care and rehabilitation therapies to assistance with everyday household activities and shopping. These services are provided to people of all ages in their homes. Inpatient and outpatient rehab therapy Our rehabilitation services are for people of all ages who would benefit from additional therapy to enhance recovery after a hospitalization, illness or injury.

Our Medicare-certified inpatient and outpatient rehab programs feature therapy gyms and include physical, occupational and speech therapy. We offer tailored services to meet the patient’s needs. Long-term care We offer around-the-clock care that supports our residents and meets their needs. We help anyone in need of long-term care, including rehabilitation therapy or skilled nursing care. Our long-term care communities offer: • On-site licensed therapists

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All in one place Our goal is to provide the care and services our residents need to live their best life. We strive to deliver the highest quality of care to each resident and are dedicated to enhancing their lives by giving attention to the finer details of everyday life so they get the time and opportunities to focus on what matters most to them. For more information on the services we offer, and to learn how to refer a patient, visit our Health Care Partners page at good-sam.com.

All faiths or beliefs are welcome. © 2022 The Evangelical Lutheran Good Samaritan Society. All rights reserved.

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MEDICINE AND THE LAW

The Interstate Medical Licensure Compact Commission Expanding your practice opportunities BY MARSCHALL S. SMITH

T

he Interstate Medical Licensure Compact Commission (IMLCC) was born from an idea proposed at the April 2013 Federation of State Medical Boards’ meeting of the House of Delegates, when a resolution was adopted to formally explore the creation of a new physician licensure system. It was based on a simple question, with a complex answer: “What are the common standards of licensure that could be verified by one and accepted by many?” The IMLCC began accepting applications for the new process which answered that simple question in April 2017. Since that time over 13,000 physicians have used the process— submitting over 26,000 applications and receiving over 40,000 licenses. Minnesota physicians represent about 300 of the applications and 2,000 licenses—placing the Minnesota Board of Medical Practice squarely in the middle, volume wise, of the 39 member states processing applications. Information published by the Federation of State Medical Boards indicated that nationally about five percent to seven percent of all licensed physicians in the United States hold licenses and practice in more than one state. So far, the Compact’s processing numbers indicate that, on average, about two percent of those physicians used the Compact process to

obtain those multiple licenses. The processing information in Minnesota is reflective of these national trends. The Compact is generally a word-ofmouth organization, but we are working on a promotional video to provide information to hospital groups and physician organizations who can spread the word, driving the participation number up with the hope of doubling over the course of the next two to three years.

How it Works The IMLCC became a legal organization when, on April 15, 2015, the Governor of Alabama signed legislation authorizing establishment of the IMLCC in that state. With this action, Alabama became the seventh state to authorize the IMLCC, creating a legal threshold that made it possible for the implementation of the IMLCC to proceed. The 39 member jurisdictions are made up of 37 states, one territory and the District of Columbia. The remaining 13 states and three territories are in various stages of the joining process. There are currently three states with active legislation. And there has been interest expressed by six states and one territory about joining the Compact in the upcoming legislative season. We are actively working with medical boards, physician associations, hospital groups and patient advocacy organizations to close the loop with full participation. The COVID pandemic continues to impact the need for an expedited process for physicians to obtain licenses. It has highlighted the critical role played by the IMLCC and our member board staff in providing states with a safe, effective pathway to meeting that need. The expansion of telemedicine has played a critical role in providing the coverage, and the IMLCC has played a part in this expansion, but it remains one of the key reasons physicians use the IMLCC process. The others include regional licensure and locum tenens physicians, with a new use coming into play of hospital systems changing the way to provide post-treatment and inter-treatment care options. Generally, physicians prefer the Compact process over reciprocity recognition because the Compact process results in a full, unrestricted license that helps clarify issues about scope of practice, insurance billing and malpractice insurance concerns to name a few. Additionally, the Compact process is as quick as reciprocity recognition documentation that is required by many states with that option. Minnesota is the home to several major health care systems and nationally recognized centers of health care excellence—meaning that Minnesota physicians have use of the IMLCC process to critically impact the care provided to patients across the U.S.. A small but significant example is found by reviewing a map. The distance to concentrations of physicians, who are generally found in urban areas, in the upper sections of Wisconsin are closer to Minnesota than the urban areas of Wisconsin. Anecdotal reports from rural health care facilities in Wisconsin have noted that services and hours of operations have been expanded due to the increased pool of available physicians. The IMLCC is premised on the concept that medical licensing is state based, in part to ensure that each state can provide healthcare that is safe and

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meets its citizen’s expectations. In order to practice medicine, the physician must be licensed where the patient is receiving care. In many states, the IMLCC statute is the first time this premise was codified, which again helps to facilitate the effective, safe use of telemedicine as a treatment modality. So how does a physician use the Compact process to their advantage? The entire process is done using a single online application. The application is found at imlcc.org, which includes educational videos that can be viewed to understand the application process and documents required to complete the application. Once the application is started, it can be saved and completed at a later time. When completed and payment has been made, the State of Principal License (SPL) is notified of the application immediately. The key to the process is to establish eligibility. The first step is for a physician to establish a State of Principal License or SPL. The physician must hold a full, unrestricted license issued by the SPL, and either live or work in the SPL. This is the key to the expedited nature of the Compact process. The SPL has already gathered and holds the primary sourced information for the static data elements required by all member boards, i.e., medical school attended, USLME/COMPLEX attempts, GME training dates and completion information, etc. A physician using the Compact process must always maintain an SPL, and there are processes to change or “Redesignate” the SPL that can be done at any time without cost after the Letter of Qualification has been issued. Changing an SPL does not impact the Letter of Qualification. The next step is to pre-qualify yourself. There are nine questions asked that will be verified by a primary source by the SPL. The detailed descriptions

and requirements are found on the Compact webpage, in the educational videos and in the on-line application. A summary of these nine elements is: • Graduated from an accredited medical school. • Successfully completed ACGME or AOA accredited graduate medical education. • Passed each component of the USMLE or COMLEX-USA in no more than 3 three attempts for each component. • Hold board a current ABMS or AOABOS board certification. • Have no disciplinary actions reported to the National Practitioner Data Bank (NPDB). • A clean criminal history. • Have no actions taken against your controlled substance permission/license. • Not have any current or pending board investigations. • Submit to a fingerprint-based FBI background check. There is a non-refundable application fee of $700.00 to apply for the Compact process. The application fee is used to operationalize the single online application process and is quickly recouped by the ability to start work quicker. Additionally, it is more cost effective than applying for two or more state licenses when the costs related to obtaining the primary source data for each application are required by each state when using the traditional method. The Interstate Medical Licensure Compact Commission to page 164

Transforming Healthcare

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3The Interstate Medical Licensure Compact Commission from page 15 This first step generally takes about 30 to 45 days, with the majority of the processing time taken experienced in obtaining the results from the FBI fingerprint-based background check.

The Next Steps

range of $60.00 to a high of $817. The Nevada DO board has suspended license fees for 12 months starting in July 2022, so the cost for a license from that state is a nominal $0.01, which is refunded shortly after the license is obtained. The cost for renewals is not listed, as not all states have standardized renewal fees; however, the cost is the same as for traditionally obtained licenses.

Once the SPL has finalized its eligibility The top five specialties of physicians using the determination, the physician is notified via email Compact process are: Internal Medicine, Family that a Letter of Qualification has been issued. About Generally, all requested licenses Medicine, Psychiatry and Neurology, Radiology 9% of applications are determined not to meet the are issued in seven to ten days. and Emergency Medicine. Internal Medicine eligibility requirements, with the most common represents about 30% of the specialties. The reasons being not holding a current active board number of physicians who use the Compact fall certification or still in residency. The physician into three broad groups that are about equal in logs back into their account, selects the states from number: Locum Tenens physicians, telemedicine which they wish to obtain a license and pays the physicians and physicians extending their practice to a nearby state or region. licensing fee owed for that license (as determined by each state). Generally, all The most recent example of Compact process usage is found in situations requested licenses are issued in seven to ten days. The Letter of Qualification is where patients in need of highly specialized care or complex conditions valid for 365 days, which can be used at any time to obtain additional licenses. can now more readily receive coordinated post-treatment care with their The result is that a physician can obtain and hold 1 to 38 licenses, with a single local physician working remotely with their out-of-state treating physicians on-line application, in 37 to 55 days on average (processing times vary and licensed in the state where the patient resides. This helps the patient avoid depend on application completeness and member boards). costly travel expenses and increases the quality of care as it is coordinated The cost for a license from a state varies from state to state and board rather than handed off. to board. The cost to obtain a full unrestricted license is the same whether States who have joined the Compact have experienced an average of it is through the Compact or traditional path. In the “About” tab on the 10% to 15% increase in their physician workforce. Patients in rural, frontier Compact’s webpage, a list of the license costs by state are detailed, with a

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and medically underserved areas benefit by increasing the pool of available physicians through telemedicine provided by a physician licensed in their state. Hospitals in rural and frontier areas are able to keep their doors open and even expand hours due to the increased number of licensed physicians, many of whom can provide those services remotely.

Looking Ahead In a relatively short period of time, the IMLCC has achieved much to be proud of. Among the key highlights: • The Compact continues to grow. The Compact legislation has passed in 37 states, the Territory of Guam and the District of Columbia.

Compact process—a strong indicator that the process works and fills a need in the physician community. • The Compact is fiscally sound. The IMLCC’s operational functions are paid through a budget based on revenues generated from the application fees paid by physician applicants. The IMLCC annually reviews its fee schedule to ensure that it is appropriate.

License costs by state are detailed, with a range of $60.00 to a high of $817.

• The Compact has been a success. Applications received and processed have doubled each year since 2019. More than 8,000 applications have been received and processed between January 2022 and July 2022—more than the 6,995 received in the 12 months of 2021. • Physicians use the Compact. Between January 2022 and July 2022, more than 13,000 licenses have been issued using the

The Interstate Medical Licensure Compact Commission was created as an answer to the challenge of finding common standards verified by one and accepted by many. Through the hard work and dedication of the IMLCC commissioners, member board staff and IMLCC staff, the challenge was answered.

Check out the Compact on our webpage at imlcc. org. In addition to the application and educational videos, there is a FAQ section for physicians, publications and other information like the monthly update of the number of applications processed and licenses issued. Marschall S. Smith is the executive director of the Interstate Medical Licensure Compact Commission.

Inside the IMLCC Numbers Data Questions

April 2018 Results

April 2019 Results

April 2020 Results

April 2021 Results

April 2022 Results

Number of completed applications included in the data study

654

2,845

2,995

3,653

4,510

Average number of licenses obtain per applicant

3.0

3.0

1.6

4.0

4.0

Percentage who obtains one or two licenses

68

64

80

58

63

32

36

20

42

37

With 13% obtaining 7 or more licenses

With 13% obtaining 7 or more licenses

With 6% obtaining 7 or more licenses

With 14% obtaining 7 or more licenses

With 15% obtaining 7 or more licenses

Percentage of applications with a determination that the physician did not meet the eligibility requirements

11

10

16

9

9

Percentage of the applications which were additional license requests using the original Letter of Qualification but a separate application

11

20

26

This data field is no longer tracked by the IMLCC system.

This data field is no longer tracked by the IMLCC system.

Percentage who obtains three or more licenses

Average number of days from application received to Letter of Qualification (LOQ) issued Average number of days from the date an applicant is determined to be qualified to the date the requested licenses are issued

34

36

37

With 33% obtained in 15 days or less

With 32% obtained in 15 days or less

With 34% obtained in 15 days or less

50 With 33% obtained in 30 days or less (please note the change in our tracking mechanism)

52 With 35% obtained in 30 days or less

15

19

20

21

18

With 45% obtained in 7 days or less

With 51% obtained in 7 days or less

With 51% obtained in 7 days or less

With 53% obtained in 7 days or less

With 54% obtained in 7 days or less

MINNESOTA PHYSICIAN AUGUST 2022

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3Care Coordination from cover In Minnesota, patients receiving primary care services can work directly with a care coordinator in certified Health Care Homes. Minnesota Health Care Homes (HCH) are known nationally as patient-centered medical homes. Most Minnesota’s primary care clinics are certified through the Minnesota Department of Health as an HCH. Certified clinicians and their care teams are changing their way of providing care across the state. Using a care coordinator and a patient-and family-centered approach, they help patients access care in the right place at the right time, navigate through a complex care system, engage in their health care through active decision-making and goal setting and optimize health outcomes and overall population health. It is a proactive approach which contributes to a patient’s well-being. Care coordinators organize patient activities and share information with all members of the patient’s health care team to achieve safer and more effective care. Services are high touch and build a strong relationship between the patient, primary care clinicians and their care team. In Minnesota, certified primary care clinicians have embraced voluntary certification, combined with technical assistance and structured learning opportunities, to drive quality improvement (QI) and transformation in their clinics. The HCH approach shifts the clinic’s or health system’s focus from responding to patient’s needs to proactively engaging a population of patients and focusing on their health goals, needs and abilities to achieve desired health outcomes. The model encourages using the expertise of all members of the care team, including patients and their families.

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To be certified, a primary care clinic must demonstrate that it has met standards in the five domains of access and communication, registry and tracking, care coordination, care planning and performance reporting and quality improvement, each with specific criteria. Standards and criteria reflect the main goals of the program: to recognize individual patients and families as the most important part of the care delivery process and to put systems and processes into place to improve patients health outcomes. In primary care, care coordination needs vary among populations and individuals. Some care coordination processes are provided to the clinic’s entire attributed population by various members of the health care team, using appointment reminders, notification of gaps in care, transition of care support, coordination of specialty referrals, appointment follow-up support, and medication reconciliation. For emerging risk, high-risk and high-cost individual patients, one-on-one contact with a care coordinator provides “between visit” tracking, follow-up and coaching. This additional support to patients and families facilitates effective care management while allowing primary care providers to work at the top of their license. Intensive, oneon-one care coordinator patient support can improve health outcomes for individual patients with complex needs. Holistic and ongoing longitudinal support helps patients and/or their designated family member find the best approach to managing care needs, establish short term achievable goals to improve current health concerns, prevent worsening of health conditions and access health care at the right place at the right time. The care coordinator in primary care helps patients manage their conditions and navigate a complex medical care system. Care coordinators have strong knowledge of the entire care system and can simplify processes to guide and help a patient understand and make their way through a complex system. They communicate effectively with providers to ensure patients get the information they need to make informed decisions about their personal health care needs.

Engaging the Patient Developing a care plan and providing self-management education is particularly important for patients with chronic diseases and emerging modifiable risks. There are a variety of resources to meet patient needs, and one size does not fit all. The care plan starts with a comprehensive assessment that provides insight into the medical and non-medical needs of the patient. The assessment is used to inform the care plan with patient-centered goals that address health and wellness gaps. A patient-centered approach includes providing care that is respectful of and responsive to individual patient preferences, needs and values, while ensuring that patient values guide all clinical decisions. Using a patient-centered approach improves patient satisfaction and engagement.

Improving Patient Outcomes Care coordination in primary care is more effective when the patient is engaged and participating in their care. Care coordinators can help patients engage by understanding individual patient activation levels (knowledge, skills and confidence to manage one’s health) and meeting them where they are. Using evidence-based tools and techniques such as motivational interviewing, self-management education programs, setting patient-centered goals and tracking progress towards goal attainment—all foster individuals’ self-management of their medical conditions.

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Another potential benefit of effective care coordination is the facilitation of appropriate care within and across health care systems and the community.


Professional and workplace skills are often differentiated as soft skills or emotional intelligence in contrast with hard or technical skills. Technical or hard skills can be verified through certifications, degrees and work experiences. Soft skill elements are defined as the ability to connect and communicate, respect differences, work with teams and build relationships to effectively support Patients receiving intensive care coordination the needs of the patients served in the targeted care often need to see multiple health care providers and coordination population. Both skill types are very require various procedures. Some also have unmet valuable traits in providing care coordination. social needs. A care coordinator focuses on the Care coordination needs Evaluation is a critical tool for demonstrating a whole person since there are many factors outside vary among populations and care coordination program’s impact, assessing of a patient’s clinical condition which impact their individuals. effectiveness, determining return on investment, health and well-being. For patients with complex assessing patient satisfaction and identifying future medical and social needs, care coordinators can programmatic needs and opportunities. Primary help patients address social barriers such as food care organizations will want to institute a quality insecurity, access to transportation for medical improvement process to ensure program goals are appointments, affordability of medications, met and patient and program outcomes are evaluated. Quality improvement housing and insurance coverage by making and following up on referrals to should focus on both the patient as well as the care coordination processes, community organizations. considering what matters and to whom the changes will matter, such as Primary care providers are key collaborators in the care coordination clinicians, patients, staff or regulatory bodies. process. They facilitate warm hand-offs to the care coordinator, speak about Care coordination also benefits payer organizations. Payers benefit by the care coordinator as an extension of the care team, communicate with reducing fragmented care that results in additional costs and risks to complex patients in a way that aligns with the care plan and maintain close working patients and wasteful spending on things like unnecessary testing, duplicative relationships and effective communication with the care coordinator. procedures and emergency room visits for uncontrolled conditions. Care coordinators help patients, and their families access the system at the right time and right level of care before a higher level of care is required. Helping patients and their families to be successful in self-care and proactive care management can reduce the cost of care by preventing avoidable emergency room visits and hospitalizations.

Who Should be a Care Coordinator?

In Minnesota, individuals working in the role of care coordinator come from different backgrounds with variation in educational training, licensure, discipline and expertise. Successful care teams may have individuals with a variety of qualifications serving as a care coordinator. Care coordinators may be a Registered Nurse (RN), Licensed Practice Nurse (LPN), Certified Medical Assistant (CMA), Community Health Worker (CHW) or a Social Worker (SW). This variety of roles allows primary care organizations to tailor the composition of their team to meet the medical, social and cultural needs of the populations they serve. Variation of training and licensure within a care team can allow organizations to develop systems that optimize their resources, allowing care coordinators and other members of the team to function at the top of their licensure, supporting strong teamwork and improving the job satisfaction of each member of the team. Understanding the clinic’s target population provides the best solution to meeting patient needs and selection of a care coordinator. The care coordination scope of practice, training, tools and resources support the care coordination model best when matched to the breadth of responsibilities they will manage from a population perspective, creating an environment of success and improved outcomes for the patient. Understanding race, ethnicity and language, along with health complexity and disease prevalence through a Community Health Assessment, Community Health Improvement Plan, county rankings and/or utilization data can provide insight to the needs of the target population. For example, if a clinic has determined their target population has patients with mental health diagnosis and uncontrolled diabetes, they may be seeking an applicant or existing team member with experience and training in diabetes management and previous work experience in behavioral health.

Care Coordination to page 284

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ADMINISTRATION

The Minnesota Rare Disease Advisory Council A new resource for patients and clinicians BY ERICA BARNES, MA, CCC-SLP

T

he FDA defines a rare disease as “a disease or condition that affects less than 200,000 people in the United States.” When people hear the term a “rare disease,” they understandably assume that the disease affects only a small number of people. And while that is true for individual diseases, when the over 7,000 rare diseases are considered collectively, they affect a significant portion of the population. According to the National Institutes of Health (NIH), rare diseases affect between 25 and 30 million Americans. This equates to about 1 in 10 Americans living with a rare disease, or roughly 8-10% of the population. Despite this large collective number, rare diseases have historically been overlooked and underrepresented in our health care system, giving rise to the nickname “orphan diseases.” Abbey Meyers, founder of the National Organization for Rare Disorders (NORD), said “Families affected by rare diseases represent a medically disenfranchised population that falls through the cracks of every health care system in the world.”

Barriers to Care Rare diseases are incredibly heterogeneous in their etiology, despite the fact that the majority have a genetic basis. A rare disease may be neurological and

degenerative or vascular and stable. It may present in childhood or well into adulthood. But what is striking about rare diseases is how similar the barriers to care are for the majority of people eventually diagnosed. Dr. Paul Orchard, an expert on rare diseases with the University of Minnesota Medical School, said recently “Some of the diseases are genetic and the ability to treat them can be very difficult. If you have a gene that isn’t working correctly, it’s almost impossible with our current technology to cure every aspect of that disease. A small group of rare diseases have specific treatments, but many do not. In many cases, recognizing and curing the disease is not likely; the goal of treatment is to help provide a better quality of life.” Unfortunately, most rare diseases are characterized by an extreme delay in diagnosis. A 2013 impact report found that the average time to diagnosis for a rare disease patient is seven to eight years. Along the way patients are misdiagnosed two to three times, and many patients (especially those in rural communities) have limited access to a clinician with knowledge of a specific rare disease. When a rare disease patient is finally diagnosed, the short-lived relief is often replaced by the devastation of hearing the words from the medical community, “‘I’m sorry, there is nothing we can do.’” The grim fact this is that currently only roughly 5% of the 7,000 rare disease communities have an FDA approved treatment. When all of these factors are considered, it is not surprising that health quality of life measures for rare disease patients fall below even chronically ill patients diagnosed with more common diseases.

Responding to the Need In 2019, a grassroots coalition of 42 organizations led by rare disease patients and caregivers themselves recognized the urgent need to identify and address the common barriers to care at the state level in Minnesota. Due to their efforts, the state unanimously voted to create the Minnesota Rare Disease Advisory Council (the Council), and in July 2022, the Council transitioned to becoming its own state agency. The vision of the Council is to improve care for the rare disease community by ensuring that every Minnesota citizen living with a rare disease has access to a timely diagnosis and expert/coordinated care, as well as individualized treatment, management and support throughout the their lifespan. It realizes this vision through providing advice on research, diagnosis, treatment and education related to rare diseases. The Council has defined the following goals: • Be a comprehensive policy and informational resource for the state of Minnesota for all stakeholders who have engagement with the rare disease community. • Support and empower the rare disease patient community to advocate for improved quality of life. • Support and equip the medical community to better address the unique needs of the rare disease community in order to reduce health disparities. The work to diagnose and treat rare diseases is increasingly possible and other states have formed similar councils. Recently, the National Organization

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AUGUST 2022 MINNESOTA PHYSICIAN


for Rare Disorders (NORD) named M Health Fairview Masonic Children’s Hospital one of its initial cohort of institutions designated as Rare Disease Centers of Excellence. Each Center for Excellence was selected by NORD in a competitive application process requiring evidence of experience and expertise across multiple specialties to meet the needs of rare disease patients and a history of significant contributions to rare disease patient education, physician training and research. As a recognized national health care leader, these are important steps for Minnesota to be taking. Mayo Clinic recently announced a new strategic collaboration in biomanufacturing to deliver novel biotherapeutics for rare and complex conditions. The collaboration brings together science, engineering and manufacturing to advance Mayo Clinic’s vision of bringing new cures to clinical care. The focus will be on therapies derived from human sources known as biologics— cells, blood, enzymes, tissues, genes or genetically engineered cells—for use in medicines. Therapeutics based on biologics have the potential to target exact tissues needing repair. “Mayo is making significant investments in facilities to create the world’s most advanced and innovative ecosystem for the development, manufacture and delivery of biotherapeutics. We are seeking to build a community of innovators to explore ideas, develop new products and create thriving biotherapeutic companies,” says Julie Allickson, PhD, the Michael S. and Mary Sue Shannon Family Director of Mayo Clinic’s Center for Regenerative Medicine. “This nexus of entrepreneurs, startups and industry experts will help position Mayo Clinic as an authority in regenerative biotherapeutics.” Dr. Allickson is also the Otto Bremer Trust Director, Biomanufacturing and Product Development, Center for Regenerative Medicine. To support this new venture, Mayo Clinic has formed a strategic collaboration with National Resilience, Inc., to establish Rochester as a center for biomanufacturing regenerative technologies.” Mayo Clinic will advance regenerative technologies from discovery science to early phase clinical trials,” says Gregory Gores, M.D., Kinney Executive Dean of Research at Mayo Clinic. “Research in the emerging field of biotherapeutics lays the foundation to attract the scientific workforce of the future.” The collaboration has these areas of focus:

specified does it become, in principle, possible to know about its experiences of care, its health status and the per capita cost of caring for it.” If we are to make real progress, we must first acknowledge the community and challenge our own biases as a health care system. Perhaps one bias that has contributed to the delay in diagnosis is the medical school axiom, “when you hear hoofbeats look for horses and not zebras”. This well intentioned phrase may keep eager young medical students from misdiagnosing common diseases as rare, but it may also bias those same future clinicians from recognizing symptoms of a rare disease if and when they encounter them. Closing the gap in providing care will not be easy. There are many factors that cause inherent difficulties in making a timely diagnosis. Population heterogeneity means that no single clinician can learn all there is to know to provide care for all 7,000 rare diseases and even the low prevalence of individual rare diseases means that accumulating knowledge for a disease population is difficult. These challenges are even more pronounced in greater Minnesota due to the nature of complex care since it is often concentrated in urban and academic settings. This means that if a rare disease patient is going to receive care from a clinician knowledgeable about their disease they will have to travel or the knowledge will have to come to them. The last several years have demonstrated that telehealth is a practical tool for health care delivery. Far from simply a convenience, telehealth has opened up access to specialized care for some rare disease patients that they would have otherwise not been able to receive. Ensuring that telehealth is available on a permanent basis to rare disease patients is a significant step in the right direction. The Minnesota Rare Disease Advisory Council to page 264

• Process development expertise to advance Mayo Clinic biotherapeutics. • Working together to attract biotech companies interested in sponsoring clinical trials at Mayo Clinic for novel regenerative biotherapeutics. • Providing cell and gene products needed for biomanufacturing early-stage therapeutics. • Analytical testing and quality control required for manufacturing commercial grade biopharmaceuticals. Mayo’s goal in developing expertise in biomanufacturing new biologicbased medicines is to accelerate clinical care options that provide new hope for patients.

What to Know About Rare Disease The challenges in providing equitable care to the rare disease community are real. Indeed, even recognizing that the rare disease community is a subset of the health care population with unique barriers and collective challenges has only come in recent years. Donald Berwick, in his seminal work that established the triple aim of health care, said “Only when a population is

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CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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HEALTH CARE POLICY

Physician Advocacy You are needed now Advocacy: the act or process of supporting a cause or proposal (Merriam Webster Unabridged Dictionary – accessed August 2022) In health care: pleading or representation for a desired goal or interest group (Medical Dictionary, 2009)

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n the late 1990’s, the indoor air quality that we all experienced in public places was a much less favorable experience than it is today. Indoor cigarette smoking was freely allowed, with there being at most “smoking sections” that somehow magically expected secondhand smoke to stay within the boundaries of that section. It was aesthetically unappealing as well as being a significant health risk to those exposed to it, especially on a regular basis. That has obviously changed. Starting in the late 1990’s and continuing into the 2000’s, there was a concerted effort by a number of community organizations and public health groups, supported by a small cadre of local physicians and medical organizations, that began to campaign for the

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removal of smoking from indoor public places. While the bulk of the effort was carried out by these other groups, active physician involvement was essential to the success of this effort. As one Edina City Council member put it in 2003, “If secondhand smoke is such a big health issue, where are the physicians?” Thankfully, the effort was successful, and the Minnesota Clean Indoor Air Act went into effect on October 1, 2007. Indoor public places and venues are no longer permeated by secondhand smoke, which most people find as an improved experience. It is certainly a healthier environment, especially for those with risk factors such as heart disease, COPD, asthma and a number of other underlying health conditions. Considering this example, the following questions arise. What is physician advocacy and where is its place today? Where, as physicians, are we in this whole concept of advocacy; on behalf of our patients, our community and our profession? As with most complex topics, it will be helpful to break this down into specific components that are easier to “get your mind around.” There is certainly not a “one size fits all” answer to this very important topic. That said, the greater the number of physicians who get involved in advocacy efforts at some level, the greater the results will be in terms of better outcomes for our patients, our communities and our profession. Physicians are in a unique position of influence when it comes to healthrelated issues. This is certainly true with our patients when you are outlining a treatment plan of care or reviewing preventive health recommendations in a clinic or hospital setting. Physician opinions and testimony on healthrelated issues expressed in front of a city council or the state legislature also generally carry more weight than most other speakers. The usual challenge is getting physicians engaged, even on topics that they feel are important. Public advocacy is generally something that most physicians did not learn in medical school or residency, and it is easy to feel like a “fish out of water” the first time you appear before a city council or county commissioner meeting testifying about an important community initiative.

Opportunities for Advocacy A key first step is deciding that advocacy is in your “wheelhouse” as a physician and recognizing that this is actually an important aspect of your career and current role. In many ways you have likely been doing this with your patients since the very start of your training. What follows are some examples of how you can break this down into different levels of involvement and opportunity.

Patient Advocacy Advocating for important treatment and preventive health recommendations with your patients during clinic and hospital interactions is standard practice for physicians. Optimal diabetes control, blood pressure management, lipid reduction, colon cancer screening and immunization recommendations are important patient advocacy opportunities carried out several times a day


within patient interactions. COVID continues to present a unique and unprecedented issue for advocacy efforts within clinic settings. Enlisting the entire clinic staff–from the front desk to the medical assistants to the nurses–in these efforts will be far more effective than just individual physician effort.

in the issue. Also expect resistance, sometimes from very unexpected sources. There is a reason why the situation is what it is, and there are likely vested interests working hard to maintain the status quo. Finally, depending on the issue, you may be personally insulted if you are publicly advocating for a topic. Within the tobacco reduction work, this was especially true, and it would not be uncommon to hear comments like, “Wow, for a physician, she/he must not be very smart”.

Advocating on behalf of your patients takes on different sets of efforts. Working to help get patients into specialists in an accelerated manner can be critical There are many important issues and topics for the best outcome of that patient. Advocating on that will benefit from increased physician their behalf with insurance companies to receive Physicians are in a unique position of influence. engagement and involvement. These include a “second tier” treatments or medications can be number of direct health-related issues: obesity essential for them to receive the truly “best option” for reduction, diabetes prevention and prediabetes their particular diagnosis. Advocating on their behalf awareness, hypertension, dyslipidemia, heart for disability benefits or workers’ compensation may disease reduction, opioid awareness and reduction, be the only way for them to receive needed benefits. depression, suicide and mental health awareness, Again, it will be more effective and efficient to create access to needed health care services and patient safety deficiencies. an office environment where this can happen without excessive physician More recently added to this list are all of the health equity and social time and effort. An office-based case manager, likely a nurse, is one way to determinants of health opportunities. be more effective and efficient in this area. Finally, advocating for improvements that lead to a better community is something that will benefit your patients. Safe, walkable outdoor paths and play areas, accessible community centers with exercise facilities and local stores with healthy food options will all benefit the health trajectory of your patients and their families. This particular area does blend into the next topic.

Professional Advocacy Advocacy on behalf of physicians and this profession is extremely important, but like a number of other areas, uncommonly seen. It is important to emphasize that this is not stated from a self-serving position. The amount of Physician Advocacy to page 244

Community and Public Health Advocacy There are likely a large number of issues within your community (and Minnesota as a whole) that will benefit from your direct involvement as a physician. Reduction of secondhand smoke in public places was compelling, definable, actionable and received the support of a broad coalition of organizations. In many ways, it can serve as a template for how additional important health initiatives can be successfully addressed. A suggested approach is to find a topic or issue that is pertinent to you in your practice setting and affects your patients directly. You need to have a certain amount of “passion” or energy about this topic to have the staying power to get to at least an interim level of success. Do a brief information search on what can be done to address that particular topic. Find others locally who are also engaged in this topic, which will ideally include health systems, medical societies and/or public health-related entities (MDH, American Cancer Society, American Heart association and so forth). Find out what opportunities may exist to support their efforts. Then simply show up and work to create a successful outcome. This could include testifying in front of a city council or a committee of the state legislature. Easy, right? The answer to this last question is an unequivocal “NO”. Even health issues and public health problems that seem simple and straightforward are anything but that. To take the secondhand smoke issue again, there was a lot of resistance on many fronts opposed to reducing smoking in public and work places. This included hospitals and health systems, where the patients, staff and employees did not want their ability to smoke within their care and work environment to be limited in any way.

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3Physician Advocacy from page 23 time, effort, persistence and financial resources that go into training physicians develops a level of expertise in treating patients, developing medical policies, influencing systems of care and providing input on approval of protocols and treatment algorithms that cannot be duplicated or replaced by alternative resources, personnel or professionals. In general, patients do best when their physicians have the ability to implement a treatment plan that is tailored to their specific diagnosis or complex care situation. In general, physicians do best when they can prescribe the best plan of care with as few barriers as possible. Hospitals and health systems will do best when they have informed and engaged physicians helping guide the organization, establish medical policies and protocols, provide for quality of care review and establish initiatives that lead to better performance. Health plans will do best when they have significant informed physician input that leads to medical policy, formulary selections and coverage decisions. Communities will do best when they have engaged and informed physicians working within their borders and giving feedback to their community leaders. Finally, health policy at a state and national level will be best developed and implemented when it is informed by engaged and knowledgeable physician leadership. Advocacy designed to acknowledge and promote the unique role of physicians in these areas and activities is needed more today than in past times. Over time there has been significant erosion of physician independent decision-making and inf luence, unfortunately this seems to be accelerating. While physician advocacy for community issues and public health initiatives will likely enhance physician standing and respect, we still need an intentional effort of advocacy to support our professional standing and the unique role that we play in the delivery of health care services.

Cautions

Teaching Physician Advocacy University of Minnesota medical students are learning about the importance of advocacy early on in their careers through the Twin Cities Medical Society’s Dr. Pete Dehnel Public Health Advocacy Fellowship. Fall 2022 marks the program’s fifth year of teaching physician advocacy to University of Minnesota medical students on both the Twin Cities and Duluth campuses. Twin Cities Medical Society founded the fellowship as an experiential program for medical students to get hands-on, real-world training in advocacy. The fellowship is organized around skills training, personalized physician-mentor pairings and hands-on advocacy activities. Through small cohorts, connecting with like-minded peers and interacting with local leaders, students engage in the process of public policy, systemic change, and turning passion for a specific issue into action. The first group of cohorts in spring of 2018 included eleven student/mentor pairs. Since then, more than 115 student/mentor pairs have taken part in the program. During the application process, students are asked to identify an area of advocacy interest. Based on their interests, TCMS staff pair each accepted student with a physician-advocate to provide personalized mentorship. Areas of advocacy cover a range of issues including healthcare access, racial health inequities, environmental justice and reproductive health. Physician-advocates can be practicing or retired and are not exclusive to the U of M Medical School or TCMS membership. Current medical students can apply each spring to join the next cohort. Mentors are asked to connect with their student once each month and between TCMS-led activities and meetings, students typically spend three to six hours per month on fellowship activities. Learn more at: metrodoctors.com/fellowship.

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Physician advocacy is not a spectator sport, but does require real effort and a commitment of time to accomplish the important goals of improved patient care and better community health. It is also likely to be a slow process, with efforts extending over a number of years to accomplish the intended outcome. There may certainly be setbacks along the way. You may even get personally insulted through the process. This is truly hard work. At the end of the day, however, we are in the unique position to positively influence the lives and well- being of our patients and improve the health of our community. And that is a great outcome as a physician. Peter Dehnel, MD, is a pediatrician in the Twin Cities area. He has been working with the Twin Cities Medical Society since 2000 on a variety of health advocacy issues.

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3The Minnesota Rare Disease Advisory Council from page 21 the FDA has seen an unprecedented number of applications for drug approvals targeting rare diseases, most notably in the area of gene therapy. A large challenge ahead is implementing and integrating these advances into clinical care so that all patients can benefit. A number of institutions within the state of Minnesota are being recognized for the work they are doing in this regard.

Resources for Clinicians While the Council seeks to improve care for rare disease patients, it also exists to support the medical community. The rare disease journey is undeniably frustrating for rare disease patients, but clinicians seeking to provide the best care can also feel frustrated by the lack of effective treatments and difficulties getting their patients to the right provider quickly. The Council is actively identifying ways to both improve care for patients and reduce the burden of the diagnostic and management journey for physicians. In this regard, the Council recently conducted a state-wide survey of primary care clinicians to better understand these barriers to providing care to rare disease patients from their perspective and is using this information to increase resources for the medical community. One identified area of need for clinicians was the knowledge gap related to rare diseases between specialists and primary care clinicians, most notably in the area of transition of care. Over the last year, the Council has collaborated with Gillette Children’s and the Minnesota Medical Association to address this need in the medical community by hosting a roundtable to generate solutions. It has also participated in the creation of a Project ECHO program to better equip clinicians who are willing to take medically complex children into their case load. For more information or to participate in this program go to Minnesota Medical Association - Project ECHO (mnmed.org).

Speaking recently on rare disease issues, Dr. Orchard noted: The implications for society are huge. One recent study published an analysis of the cost implications of rare diseases in the United States. It found that the economic impact of rare disease each year is close to a trillion dollars. That stems from health care costs, productivity loss, caretaking and much more. Even if you’re not directly affected by a rare disease, it’s important for us to tackle these conditions as a society. The Minnesota Rare Disease Advisory Council is a new resource for the state of Minnesota, its medical community and rare disease patients themselves. In the next year, there will be opportunities for any medical professional who is interested in increasing their knowledge about rare diseases or supporting the Council to get involved. If you would like further information on the Council’s activities throughout 2022-23, you can visit the website at https://www.cbacraredisease.org/. Erica Barnes, MA CCC-SLP, is the executive director of the Minnesota Rare Disease Advisory Council. She also chairs the patient advocacy committee for

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3Care Coordination from page 19 Most payers require providers to demonstrate ongoing quality improvement, patient satisfaction and lower overall cost of care—all achievable goals with a strong care coordination structure. Care coordination at a primary clinic facilitates a strong and cohesive working relationship between all members of the primary care team, the physician and the patient. When all members of the team work together towards shared goals, patients feel engaged and valued. Their care is better understood, becoming

more effective and less fragmented. Using a patient-centered approach in turn leads to higher levels of patient wellness and improved health outcomes. It allows physicians and others to work at the top of their license, expands the physician’s reach to optimize a patient’s well-being and meets the goals and objectives of patients, providers and payers. Bonnie LaPlante, PhD, is the health care homes director at the Minnesota Department of Health.

HCH Patient Story

HCH Clinic Manager Comment

A care coordinator working with a patient experiencing early cognitive decline recognized the need for family involvement. She reached out to the patient’s son to fill him in on his mother’s condition, and he quickly helped to prioritize safety as their top concern. By working together with the patient and her son, the care coordinator located a home health agency that now sets up medications, takes her to appointments and provides other care during the week.

Collaborative care plans at Ridgeview took everything we were already doing and put the information down in one location for all the care team to see, including the patient. Finding out what was important to the patient changed our perspective on the care planning process.

HCH Patient Story Clinic staff had identified that a patient was needing to cancel appointments due to an inability to find transportation. Coordination staff worked with the family to understand and assess this barrier and learned that the patient was not able to navigate the process to access their medical transportation benefits due to a language barrier. Staff were able to provide instructions in the family’s own language and walk through the steps with them so that they could now do this for themselves.”

HCH Clinic Leadership Comment Despite the challenges of the pandemic, patients with care coordination at our clinic remained stable and received consistent care throughout COVID. “We are proud of that,” said a leader on the care coordination team. “Care coordination has been a steadying source for many patients when everything else has gone to heck.”

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3Improving the Experience of Health Care from page 9

leniency for students in medical school and allied professions, as well as forgiveness of student debt upon graduation. At UCare, we are invested in helping providers diversify their workforce so our members have access to trusted health care professionals from within their own communities. To address the shortage of mental health workers, we recently engaged in a cross-sector partnership with Alluma and the Amherst H. Wilder Foundation. This partnership will pay for clinical internships supporting prospective mental health professionals from underrepresented, underserved communications in both rural and urban Minnesota. We have joined the MHA on its Workforce Development Roadmap initiative addressing the workforce crisis, as well. What short and long-term goals do you have for UCare?

Short-term, our goals are to continue to be a market leader in Minnesota. Additionally, we hope to bring our Medicaid model—that puts

equity, community and the UCare values first—to the citizens of Iowa. Another goal is finalizing our technology transformation to be more efficient and effective in serving our members, partners and regulators. We look forward to county expansion opportunities, pending results of the most recent Minnesota Senior Health Options, Minnesota Senior Care Plus and Special Needs Plans RFPs. And we’re excited about our work with Lifespark to transform the experience of aging for Medicare members. Longer term, our goals are to continue to support members and providers through potential market changes, such as the resumption of Medicaid eligibility after the Public Health Emergency ends. We are committed to our goal of being an antiracist organization, implementing the next phase of equity and inclusion work to benefit employees, members and their communities. Another critical goal is to leverage opportunities to improve member and provider experience wherever we can.

Department of Family Medicine and Community Health 38 years ago, so we’ve always felt a strong bond with physicians and our provider partners. Although we have been an independent health plan for many years, we are proud of our history and we want physicians to know how deeply we value their partnership in serving our members with quality care. We want to make it easy to work with us to provide a path for our members’ best health. And we are always interested in supporting their outreach and innovations to improve health and racial equity, social drivers of health, child and maternal care, mental health, substance use disorder services and chronic conditions. We consider our extensive, highquality provider network to be a huge asset, and we are grateful every day for physicians’ tireless efforts to improve the health of our members and their patients. Hilary Marden-Resnik, is president and CEO of

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Pictured left to right: R. Scott Stayner, MD, PhD, David Schultz, MD, Peter Schultz, MD, MPH

If you have a patient struggling with chronic pain, Nura can help. Total pain management for simple to complex cases.

Your Partner in Chronic Pain Management Some physicians rely on Nura for assistance pinpointing the cause of the pain. Some look to us for specific treatments, while others turn to Nura for total pain management of complex cases. In every case, our message is the same: We’re here for the long-term, with the resources and commitment to make a genuine difference in the lives of patients.

Quick access to appointments for new patients. Nationally recognized as a center of excellence for implantable pain control.

Call our Provider Hotline to discuss a patient.

763-537-1000

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Holly Boyer, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

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