INTERVIEW

In 2019, the University of Minnesota, Fairview Health Services, and University of Minnesota Physicians began a new partnership known as M Health Fairview. This brand encompasses all the facilities and services in our joint clinical enterprise, including those acquired by Fairview when they purchased HealthEast in 2017.

M Health Fairview is the brand we use to help the public understand who we are. It represents the powerful combination of academic medicine at the Medical School and University of Minnesota Physicians and the operational strength and reach of Fairview Health Services.

The Medical School and M Physicians are the “M Health” in M Health Fairview. We bring research capabilities, innovative care models, and multi-specialty expertise, and we train the next generation of medical professionals.

The pandemic clearly demonstrated the power of academic medicine. Our physicians were in communication with colleagues around the world in late 2019. We knew what was coming and we knew we’d have to prepare—pivoting research and clinical care resources to address the disease and the community impact. Our commitment to saving lives sends us in to overdrive during times like these. I have seen collaboration across specialties and disciplines like never before, a willingness to do things differently for the sake of our patients and the communities we serve. I am hearing a strong desire to continue this momentum to help conquer other challenges in health care today, including health disparities and access to care.

We have learned that virtual care is a real option for many kinds of visits. It opens up access—not only for patients far from our metro area, but also for those who are closer. The emergency orders in place during the first months

of the pandemic paved the way for us to provide care to patients in some other states. Now we face licensing barriers to provide broader virtual care across state lines. We are consulting with other health care providers to address these issues and share best practices at an operational level.

We decided early on that we could provide the best care by creating “cohorts” of COVID patients. This meant keeping patients on dedicated units to improve efficiencies and to improve care. My colleague at Fairview, Mark Welton, MD, floated the idea: What if we make all of Bethesda a COVID hospital? In just over two weeks, our physicians stood up Bethesda to care for COVID patients— the first in the state and one of the first in the nation.

We have since demonstrated great outcomes, with higher survival rates than in other metropolitan centers, and an extremely low rate of infections among health care workers. Brad Benson, MD, FACP, FAAP, chief academic officer, Tim Schacker, MD, vice dean for research, and their teams have led a number of clinical trials that demonstrate how our academic physicians are advancing the standard of care.

One recent example stemmed from the concern that we would run out of ventilators during the COVID-19 crisis. Anesthesiologist Stephen Richardson, in partnership with the University’s Earl E. Bakken Medical Devices Center, worked with Boston Scientific, Medtronic, and UnitedHealth Group to develop the Coventor, a low-cost, simple-to-produce ventilator. These companies used their expertise to refine the ventilator and help get rapid FDA approval.

Many of our clinicians are involved daily in addressing health disparities. For example, research funded by the Medical School is helping physicians and learners in our family medicine clinics tackle access barriers faced by our Somali, Hmong, and Karen communities.

Our Broadway Family Medicine Clinic has been serving the North Minneapolis community for more than 40 years. Tanner Nissly, DO, Kacey Justesen, MD, and their team partner in unique ways to improve both health and health care. Dr. Renée Crichlow’s Ladder Program helps kids from underrepresented populations pursue health care careers. They have also partnered with Second Harvest Heartland to address food insecurity and a lack of education regarding nutrition. They are currently relocating the clinic to a larger site and, with the help of a University grant, are partnering with the College of Design to create an innovative, community-focused clinical space.

Through our partnership with Fairview, we recently launched the Healing, Opportunity,

People, and Equity (HOPE) Commission. Our physicians, Taj Mustapha, MD, and Christopher Warlick, MD, PhD, are part of this commission and focused on dismantling the structural racism that impacts health outcomes and health care.

Our leadership will soon include a vice president of diversity, equity, and inclusion to ensure comprehensive focus on any issues of racism or bias in our organization. This new leader will partner with Ana Núñez, MD, FACP, who recently joined the Medical School as its inaugural vice dean for diversity, equity, and inclusion.

To respond to the needs of our employees, we have established internal working groups comprised of physicians and staff to address themes from listening sessions we held earlier this summer. I have also asked each of our Board committees to add a goal to their charter statement that relates to diversity, equity, and inclusion.

Hearing loss profoundly impacts health and quality of life across the lifespan. Hearing is important for learning and forging social connections, and for maintaining brain health as we age. Prevention of hearing loss is an important public health goal, and we also need better treatment options to restore hearing for the millions of individuals who have already suffered loss.

The University of Minnesota is on the forefront of hearing technology development. We have a leading-edge, high-volume cochlear implant program. A team of scientists, engineers, and surgeons, led by Hubert Lim, PhD, Meredith Adams, MD, MS, and Andrew Oxenham, PhD, is conducting a multi-national project funded by the National Institutes of Health to develop the world’s first auditory nerve implant, which will bypass the diseased inner ear to send electrical signals directly to the hearing nerve and on to the brain.

Our researchers are also developing novel hearing aid technologies, such as an ultra-hearing device that transmits low-level ultrasound signals non-invasively but directly to the cochlea, so the brain that does not need to compete with distorted sounds coming through damaged middle and inner ear structures. We are also developing technology to treat tinnitus with multimodal neuromodulation.

The crisis of health care affordability is a national conversation and we feel the effects acutely in Minnesota. Health care systems are feeling the cost pressures of providing high quality care and an excellent patient experience, even as reimbursements fail to rise at the same rate. Addressing access issues and health disparities in our communities requires long-term investments that do not see an immediate return.

The University of Minnesota Medical School has been a center for solutions in the past, and we are in the best position to find solutions now. Our faculty members are doing some truly amazing things that will change the standard of care. Through science and better health system organization, we will find answers.

Bevan Yueh, MD, MPH, interim CEO at University of Minnesota Physicians, also holds leadership positions in the Medical School as vice dean for clinical affairs and as the department head for the Department of Otolaryngology/Head & Neck Surgery.

Just as your patients trust you, you can trust MNGI for the best adult and pediatric GI care possible. Our dedicated, caring team of specialists are uniquely qualified to meet the special GI needs of all your patients–big and small. With clinics throughout the metro and telehealth visits, MNGI offers the appointment access your patients deserve. MNGI–the smartest choice in GI care.

3 Recalibrating Medicare reimbursement from cover

over the current fee schedule. Unfortunately, due to a statutory provision requiring “budget neutrality,” any reimbursement increase to one type of clinician essentially requires a decrease to another provider type. In the case of the newest CMS fee schedule, some medical specialists are set to see their Medicare payments slashed by as much 11%. In good times, an 11% cut would be difficult to swallow, but in the current health emergency it’s not unsustainable.

COVID-19 has already created substantial challenges for health care providers. For the first time, clinicians faced government-mandated restrictions on their ability to care for patients. As restrictions on elective procedures blanketed the country and patient volumes dropped precipitously, mammography screenings nearly ceased with a 90% reduction, most clinics were forced to furlough large swaths of employees, and, in many cases, close facilities entirely. Now, as specialty providers gear up to treat the backlog of patients whose care had been delayed, they face potential double-digit reimbursement reductions from CMS that will have clear implications on other forms of reimbursement.

Annually, CMS issues their MPFS, which provides for the payment of over 10,000 physician/licensed clinician services and sets the Relative Value Units (RVU). In formulating reimbursement, CMS calculates a geographical practice cost index (GPCI) for every payment locality, the Resource-Based Relative Value Scale (RBRVS), and the Conversion Factor. The RBRVS is

calculated for each CPT code based on physician work, practice experience, and malpractice insurance costs. Using the geographically adjusted RVU, the Conversion Factor is used as a multiplier to determine the Medicareallowed reimbursement rate. These annual calculations are bound by budget neutrality requirements, meaning increases in certain codes must be offset by reductions in others. The proposed CMS rule states that if revisions to the RVUs cause expenditures for the year to change by more than $20 million, adjustments shall be made to ensure that expenditures do not increase or decrease by more than $20 million. Typically, large-scale payment methodology changes receive significant scrutiny by providers, but with clinicians working to address a backlog and treat patients during a pandemic, these significant reimbursement changes seem to be flying under the radar.

During the rule-making process last year, CMS signaled their intention to move forward with the adoption of a new reimbursement methodology and coding structure, increasing payments for evaluation and management codes (E/M) while reducing payments to specialists like radiologists by 8%. This change set out to eliminate the blended payments for certain levels of E/M codes, and to break them out for each of the five levels.

At the beginning of August 2020, CMS issued the calendar year 2021 MPFS proposed rule, which is set to become effective on Jan. 1, 2021. Contained in this rule is the finalization of provisions previously outlined in the CY 2020 MPFS and sets the conversion factor at $32.2605, a $3.83 or 10.6% decrease from the previous fee schedule. This is estimated to reduce payments to radiology by 11%, interventional radiology by 9%, cardiac surgery by 9%, physical therapy by 9%, and radiation oncology and radiation therapy by 6%. Others, mainly specialties that focus heavily on office visits, are set to see rates boosted substantially.

Adding complexity and confusion is the efforts by CMS to also bundle some types of payment codes. This is requiring extreme process and treatment changes for many who are also affected by the budget neutrality rate cuts.

These unsustainable reductions come at a time when all health care providers are under extreme financial stress. Coupled with elective procedure restrictions and fear that COVID-19 will impact volumes, these proposed reductions to Medicare reimbursement will not just cause ripples through the health care system, but disruptive waves that will impact the stability of the health care system for providers and patients alike and likely cause further consolidation of the health care system.

Decreased Medicare rates will not be the only form of payment to providers that will be impacted. Many states across the country use these CMS rates as a factor in determining their fee-for-service rates, and some even directly peg to a specific percentage of the MPFS. Additionally, many states have moved to a managed care delivery system for their Medicaid beneficiaries, utilizing capitated per member per month payments. These rates are required to be actuarially sound, often set by just a handful of large actuary firms, most of whom heavily weight Medicare rates in making their determinations. Furthermore, these proposed reductions will result in continued downward pressure on provider contracts with commercial payers, as insurers consider government payer rates in contract negotiations.

Slashing payments to vulnerable specialty providers will also threaten American College of Emergency Physicians, and many others continue to access for patients, including those who are not direct Medicare beneficiaries. press CMS to prevent rate reductions, and to ask Congress to waive budget These reductions perpetuate the climate in which small physician offices neutrality requirements for the latest fee schedule. This would allow for increasingly struggle to keep their doors open. Market forces, paired with primary care and others to receive a much-needed reimbursement increase a pandemic and decreased reimbursement, have all resulted in communitywhile also ensuring that specialists don’t have to endure draconian cuts. based providers closing up shop. Many outpatient While large industry organizations have imaging centers and radiology groups have been engaged lobbying groups and consultants, these forced to consolidate operations, leaving many efforts are only as effective as their ability to activate patients with an absence in choice. Further a grassroots network of professionals and directly reductions to reimbursement will only exacerbate engage policymakers. This is where you come in. this problem. Additionally, as we have seen in the nursing All health care providers are under extreme financial stress. Health care clinicians lending their voice to an industry advocacy movement is immensely helpful, home industry, reduced reimbursement in some greatly impacting the trajectory of the campaign states can lead to limiting of low-paying payer to prevent draconian reimbursement reductions. exposure by providers. As rates fall, and providers As groups of surgeons, radiologists, social workers, face increasing employment costs, many have pathologists, and other specialties come together, no choice but to limit their contact with payers there are some simple steps clinicians can take to that do not reimburse at cost. This risks a growing better ensure the success of this growing effort. segment of the population having fewer options when seeking health care services. As it pertains to many specialist services, when patients are often First steps include: seeking timely answers or treatments, delays in care equate to denial in care. • Finding out if the medical specialty or professional association Making an impact points” for use with Minnesota’s congressional delegation; Across the spectrum of specialty providers, a large grassroots effort is emerging as various coalitions are forming to prevent drastic cuts to reimbursement. retains a lobbyist or industry representative to provide “talking Advocacy groups such as the American Medical Association (AMA), Recalibrating Medicare reimbursement to page 344

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3 A dual pandemic from cover

it were available today. The simple act of wearing a mask is seen in some quarters as a partisan not “just the flu.” Data from the MDH shows that since that first case in

Even the youngest age groups are not safe—as cases of COVIDworst calls the entire disease a hoax. False medical information has spread known as multisystem inflammatory syndrome (MIS-C) in children. online with other outbreaks of infectious disease—2009 H1N1, Ebola, There have been 24 confirmed cases of MIS-C since the pandemic began, Zika, measles—but COVID-19, along with the all of whom have required hospitalization and, resulting public health guidance, has become in some cases, prolonged stays in intensive uniquely politically divisive and suspect. care. There is growing evidence of long-term Institutions such as the CDC and the FDA health consequences to SARS-CoV-2 infection, are no longer seen as neutral and independent. including myocardial damage, pulmonary Nearly half of all Americans say they definitely or COVID-19 is absolutely not scarring, and strokes. probably would not get a COVID-19 vaccine if “just the flu.” Finally, when researchers from the political declaration instead of a basic public COVID-19 mortality, the excess mortality seen health measure to slow the spread of the virus. in communities of color, particularly Native

We must be clear: COVID-19 is absolutely racial disparities in the effect of this pandemic. 19 increase, we are seeing more cases of the rare but severe complication University of Minnesota examined age-adjusted Americans and Black people, shows significant March, over 7,100 patients have been hospitalized, including 2,000 who Countering misinformation were treated in the ICU and 2,000 who have died. It is important to note How do we begin to address these dual pandemics: the real virus, and that severe illness and deaths have occurred in every age group, even those the fake news? To start with, despite claims in the media, relying on herd with no underlying conditions. One of the first cases in Minnesota was an immunity through natural infection is not the answer. Herd immunity is the Ironman triathlete in his 30s who ended up on ECMO (extracorporeal epidemiologic principle that when a sufficient proportion of the population membrane oxygenation). While he survived, his case offered proof of the has immunity to a disease, through prior infection or vaccination, the risk posed by SARS-CoV-2 to younger, healthier people as well as those aged likelihood of disease transmission to susceptible individuals is reduced. 50 and older. Simply allowing herd immunity to develop by waiting for infections to occur in enough of the population is not an appropriate strategy for COVID-19.

The current seroprevalence rate in Minnesota is unknown (though a study is underway), but in early spring a nationwide study reported in JAMA estimated it at only 2.4% overall in the Minnesota metropolitan area. While the rate is almost certainly higher than that now, we are still very far away from the threshold necessary for herd immunity, estimated to be about 50% to 70%. The cost of herd immunity through natural infections will be even more cases, more illness, and more death. Also, while the duration of natural immunity remains unclear, so far infection does not appear to provide life-long immunity, as proven by several cases of re-infection. Rather than relying on natural immunity, vaccination of the population will be necessary to manage the spread of COVID-19.

While we wait for a safe and effective vaccine, testing, contact tracing, isolation, physical distancing, and masking are the pillars of our control strategy for COVID-19. The practice of isolation and quarantine in the management of infectious disease outbreaks goes back at least to the Middle Ages and probably longer, and is key to beating back COVID-19. Anyone with symptoms of illness should be counseled to stay home and be tested, with positive cases advised to isolate. The benefit of testing, apart from diagnosing those who are ill, is that it allows the identification and quarantine of presymptomatic contacts, who are believed to be responsible for 50% of viral transmission. Everyone should be encouraged to comply with requests from the health department to identify contacts for contact tracing, and it should be emphasized repeatedly that even if you have an asymptomatic or mild infection, you may still transmit to others who may be more vulnerable.

When isolating and quarantining an entire population is not realistic, we must rely on other measures, specifically limiting the size of gatherings, maintaining physical distance from others, and wearing a face covering. An

David Schultz, MD Chief Executive Officer Nura Pain Clinics Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers

Although the COVID-19 pandemic has captured the headlines, chronic pain does not relent. According to the CDC, high-impact chronic pain (pain that interferes with work or life most days or every day) affects approximately 20 million U.S. adults.

According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability off ered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn off their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we offer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.

If you have a patient struggling with chronic pain and you’d like to discuss the case, please call our Provider Hotline at 763-537-1000. If the situation is urgent, we will do our very best to see your patient the same or next day.

MDH review of COVID-19 community outbreaks in Minnesota found that lockdown fatigue that so many people are experiencing and the desire to they are invariably tied to events where people are gathering in large groups, visit and socialize with our friends and loved ones, but we must not forget not social distancing and not wearing masks. A compelling example of the the risk that these gatherings pose. impact of not following this guidance was a wedding held in southwest The issue of therapies for COVID-19 has also been affected Minnesota at the end of August. Two-hundred by politicization and misinformation. and seventy-five individuals (over the executive Hydroxychloroquine was touted as a miracle order’s limit of 250) celebrated indoors in a therapy by some before definitive data emerged crowded restaurant without social distancing or showing its lack of efficacy. This misinformation masking. At the time of this writing, 77 cases and one hospitalization have been linked to this event. These cases have included health care workers and teachers, further illustrating how Your patients need to hear from you that this is a real and urgent concern. even led to the death of a man in Arizona who ingested fish tank cleaner in the misguided belief that it would work as prophylaxis. Other theories about dubious, unproven, or flat-out dangerous the ripple effects from a single event spread out to treatments have circulated, including bleach, affect other settings like health care and schools. UV light, cow urine, colloidal silver, and the We understand that early messaging about dietary supplement oleandrin. In August, when masking from public health was contradictory to the FDA issued an emergency use approval for the current guidance; however, this early recommendation was made before convalescent plasma over the objections of leading scientists from the NIH there was clear evidence of the risk of asymptomatic and pre-symptomatic that the evidence for its efficacy simply was not there, it was widely seen as spread and when concerns about the lack of PPE for front-line health care having bowed to political pressure, raising major concerns about the vaccine workers were at a peak. approval process.

We do not have the space here to debunk all of the myriad myths about mask-wearing that have popped up on social media and beyond; suffice it to say that we have not seen epidemics of mask-related illness in health care workers who wear them for hours to do their job. We also understand the

The good news is that in the midst of the storm, treatment for COVID-19 has drastically improved. Alternative management strategies for acute hypoxic respiratory failure such as high-flow oxygen and prone positioning can avoid the need for intubation and invasive ventilation. The groundbreaking

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RECOVERY (Randomised Evaluation of COVID-19 Therapy) trials in months ago will result in evolving data and evidence. We understand that this the United Kingdom showed that dexamethasone significantly reduces is how science works, but our patients may not. Above all, your patients need to mortality in patients with severe illness, and it is now part of standard hear from you that this is a real and urgent concern; you are a trusted source of recommended therapy. information, and your words and opinions have more power than you think. It

The investigational antiviral drug remdesivir is vitally important that you continue to reinforce has shown moderate efficacy in clinical trials, and the important messages of testing and contact after an initial period of scarcity in Minnesota tracing; staying home when ill or waiting for test when the drug needed to be allocated to patients results; and following measures such as masking based on clinical priority, is now widely available. Wearing a mask is seen in and social distancing. Be prepared to discuss the value and worth of vaccines (including flu shots)

Finally, initial reports of monoclonal some quarters as a partisan in anticipation of an eventual vaccine approval. antibody therapies have been promising. All political declaration. Your front-line efforts make a difference! of this is a far cry from the early days of the pandemic, when clinicians had little to offer patients other than supportive care and a grab Kristen R. Ehresmann, MPH, RN, is an bag of potential experimental therapies. epidemiologist and director of the Infectious Disease Epidemiology, Prevention and Control Speaking to patients Division at the Minnesota Department of Health. Ms. Ehresmann has led So what can we do? All of us in the health field are on the front lines of fighting numerous outbreak investigations, published in peer-reviewed journals, and these dual epidemics, whether we are caring for patients or working behind been an invited speaker at national meetings. She currently oversees the the scenes in the laboratory or in public health. If we do not provide accurate epidemiologic response for COVID-19. information, conspiracy theories and fringe views will fill the void. It is important that we all reinforce science-based messaging as well as the evolving nature of the pandemic. We are continuing to learn more about how this virus Sarah Lim, MBBCh, is a board-certified infectious disease physician who spreads and how it affects the human body, and as we learn, we adapt our was previously an assistant professor in the Department of Infectious Diseases guidance. Changing guidance may be frustrating for both physicians and the at the University of Vermont. She is now working as a medical specialist at the public, but of course the study of a novel virus that was unknown to science nine Minnesota Department of Health on the COVID-19 response.