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Volume XXXV, No. 07



ealth care in the United States is incredibly complex and fragmented. Patients are often assessed, treated and monitored by multiple clinicians in multiple facilities which can result in a rushed and complicated episode of care that includes many players and interactions. A study by Coverys (a medical professional liability insurer) using closed claims data shows that while care transitions—in and of themselves—are not a major primary allegation in malpractice claims, they are more likely to result in indemnity payments and significant patient harm than many other types of events that trigger claims. Because health care often involves care transitions, it stands to reason that many malpractice claims that allege other primary causes (e.g., medication, diagnostic or surgical error) also have a component of risk related to one or more care transitions.

CMS Reimbursement Cuts Congress wants your money BY CHRISTOPHER CRANCER AND ZACHARY BRUNNERT


ike the plot of Groundhog Day replaying itself year after year, physicians once again need to rally together to convince Congress and Centers for Medicare and Medicaid Services (CMS) that cuts, in some cases exceeding 9.75% to Medicare reimbursement, are not beneficial, particularly at a time when so much is asked of our health care system. For some provider types, 9.75% is the tip of the iceberg: the newest Medicare Physician CMS Reimbursement Cuts to page 124

Care Transitions to page 144

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Publishing April 2021

Volume XXXV, Number 07

COVER FEATURES CMS Reimbursement Cuts Congress wants your money

By Christopher Crancer and Zachary Brunnert

Care Transitions Identifying & Reducing Risks By Robert Hanscom, JD; Marryann Small, MBA; Ann Fiala, RN, BSN, CPHRM, CHC, CHPC; Patricia Bennett, RN; Barba Ricci, BS, AIC

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Improving Early Detection and Intervention Michael Georgieff, MD Co-director of Masonic Institute for the Developing Brain

BEHAVIORAL HEALTH.................................................................. 20 Accessing Mental Health Care


Reasons people don’t seek help

By Todd Archbold, LSW, MBA ENGINEERING............................................................................ 22 Engineering in Health Care Facility Design Understanding an important role

Improving the safety net BACKGROUND AND OBJECTIVES:

By Brent Wavra, PE – Mechanical Engineer

When a patient leaves the hospital and returns to an assisted living facility, or home, they experience a care transition. This term is also used when a patient goes from one physician to another. It can also refer to entering rehabilitation programs or treatment of a condition diagnosed by a physician and then transferred to another type of health care provider. As the spectrum of care teams expands, the number and type of care transitions also expands. Cumulatively these transitions are a leading cause of medical malpractice claims, most of which are easily preventable. Our expert panel will define and explain the most common problems in care transitions. We will examine the negative outcomes that arise from these issues and propose simplesystemic solutions. We will discuss best practice standards that have already been established around these concerns, why they are not more widely followed, and how they can be implemented. We will review technology, which in some cases creates problems, that can be used to reduce them.



Mike Starnes,

ART DIRECTOR______________________________________________________ Scotty Town, Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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




New Partnership Addresses Equity in Connecting Community Care Stratis Health, in partnership with Collective Action Lab, has been commissioned by a local private funder to facilitate the co-creation of an initiative to support and facilitate referrals addressing social needs across multiple sectors in Minnesota. An open invitation to participate will launch the collaborative design of a sustainable shared solution for connecting people through culturally responsive methods with community resources such as health care, food, transportation, and housing. “We recently completed the first phase of this project to gauge interest across community, health care, payer, and state agency organizations for exchanging social needs referrals,” said Jennifer Lundblad, Stratis Health president & CEO. “We are very encouraged that

more than 90% of respondents are interested and willing to participate in designing a common approach to optimize technology for the good of individuals and communities.” The new initiative will enable organizations to screen for and identify a range of needs and electronically refer them to responsive services. An added and powerful benefit is a “closed-loop” feedback mechanism to track how specific referrals are addressed and utilized. “Very often, initiative design and change of this nature is directed and designed by only one part of the overall system, and it is usually the part with money and power,” said Olivia Mastry from Collective Action Lab. “This project is exciting in that it embeds equity in the process itself by creating conditions and agency for all who are impacted by the changes to shape and drive the recommended solution.” The process for co-creating a common social needs resource will

include convening stakeholders to identify the operational, financial, and other “must-haves” from all perspectives. The first step is to establish a Guiding Council selected by and composed of members from a wide variety of stakeholders. Organizations involved in the earlier development process will be included in this next phase of the work, as well as other interested organizations. It is a “bring-a-friend” effort. If your organization was not involved in the first phase and would like to be going forward, contact Senka Hadzic (

Hudson Hospital Announces Expansion Plans Hudson Hospital & Clinic, a part of HealthPartners, has announced plans to expand primary care services to meet growing demand in the community. The project is expected to be completed in May.

The addition of family medicine and pediatrics to the primary care clinic brings more physician services to the nearly 200,000-squarefoot campus. This further provides the Hudson community with access to board-certified physicians in 15 primary and specialty care services, and a single location with one comprehensive medical record to meet all of the area’s health care needs. Hudson Hospital & Clinic is the largest provider of care in the region with primary care, urgent care, specialty services, 24/7 emergency medicine (11,000 annual emergency department visits on average) and inpatient services, as well as the city’s only full-service multispecialty clinic. The clinic also recently added options for extended hours, video visits, mobile check-in and online scheduling for a more convenient patient experience. “Continuing to expand our primary and specialty care services in Hudson is

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an important priority to keep care local and fully meet the needs of our community,” Hudson Hospital & Clinic President Tom Borowski said. “We know patients receive better, more coordinated care when they stay within a system, and we’re excited about this opportunity for the Hudson community to experience our primary care, medical and surgical services close to home.” Hudson Hospital has been serving the community since the 1950s. Since 1999, together with HealthPartners, Hudson has made significant investments to keep high-quality hospital and specialty care close to home for patients. “We always look for opportunities to improve the health and well-being of our community, whether it’s by expanding the health care services we offer or partnering with other groups in our community to address factors of health beyond our hospital and clinic walls,” Borowski said. Current community-focused initiatives include PowerUp, which encourages kids and families to eat healthier and move more, the Make It OK campaign to reduce the stigma of mental illnesses, and a wide variety of local, community-based organizations and events in which Hudson Hospital & Clinic proudly sponsors, supports and participates.

Southdale Hospital Adds 52 Single Occupancy Rooms M Health Fairview Southdale Hospital has completed construction on two new floors of private patient rooms above the Carl N. Platou Emergency Center, adding approximately 38,000 square feet of space to the building. The new rooms are designed to be easily reconfigured for various needs–including both intermediate and intensive care. The expansion adds 52 new single-occupancy rooms, offering greater privacy and a better experience for

patients and their families. The construction project began in 2020 and is part of a larger transformation process. The new rooms will provide improved privacy and comfort for patients throughout the hospital and allow the hospital to better adapt as community needs change. Every new room is designed to be easily reconfigured for different levels of care. These include intensive and intermediate care, which provides ongoing monitoring and specific supports. The rooms will also be available for medical/surgical use. This type of care provides support for patients before and after an operation, as well as for a variety of other medical conditions. “At M Health Fairview, we’re always looking for new ways to make compassionate individualized care accessible and more enjoyable for all,” said Jeoff Will, chief operating officer, acute care hospitals. “Sometimes, that’s as simple as giving our patients and their families more privacy during their stay.” Increasing the number of single-occupancy rooms will also improve infection prevention practices and decrease the potential for the spread of illness. “Our plans for this project have always been centered on improving the experience our patients have when they are in our care. We want patients to be comfortable and safe, and to know that they are getting the best care.” said Joe Knowles, director of nursing at Southdale Hospital.

MDH Opens Twin Cities Area Monoclonal Antibody Clinic The Minnesota Department of Health (MDH) recently opened a new clinic in St. Paul to expand access to monoclonal antibody COVID-19 treatment in the Twin Cities metro area. COVID-19 monoclonal antibody treatment can help qualifying patients get better faster. It is an outpatient treatment

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for patients with mild to moderate symptoms that started within the past 10 days, and who are at high risk of their illness leading to hospitalization or death. “This clinic will strengthen the existing capacity of providers in the Twin Cities to give this life-saving treatment,” said Minnesota Commissioner of Health Jan Malcolm. “Patients and their providers seeking monoclonal antibody treatments can make an appointment at this clinic and other locations by using the state’s online tool, the Minnesota Resource Allocation Platform.” To receive this treatment, people who have tested positive for COVID-19 should contact their health care provider or visit the Minnesota Resource Allocation Platform (MNRAP) to request an appointment. The newly opened site is not a walk-in clinic. MNRAP is an online scheduling tool the state created during the pandemic to

facilitate equitable access to monoclonal treatments. Patients or their caregivers can access MNRAP to find out if they qualify for treatment. The website will also refer them to the nearest site with an available appointment, including the new St. Paul clinic. MDH is partnering with Matrix Medical Network to operate the medical clinic, located near Interstate 35E and Arlington Avenue West.

Allina CEO Announces Retirement at Year End Dr. Penny Wheeler has announced her plan to retire at the end of 2021 after a career at Allina Health spanning decades as a physician, President of the Abbott Northwestern medical staff, Chief Medical Officer and finally as CEO since 2014. Wheeler will remain on the Board of Directors after she transitions

out of the CEO role. The Board of Directors named Lisa Shannon, currently serving as the President and Chief Operating Officer, as Wheeler’s successor. “The community, countless patients and families, and Allina Health have benefited in innumerable ways from the passion, commitment and servant leadership of Dr. Penny Wheeler,” said Deb Schoneman, Chair of the Allina Health Board of Directors. “We thank her for her decades of incredible service and contributions to Allina Health. Penny leaves an indelible mark on our organization and her legacy of leading systemic changes to better support whole person care, diversity, equity and inclusion, as well as payment model reform, will continue to benefit the communities we serve well into the future. We are grateful she will remain engaged with the organization on the Board of Directors.”

Wheeler plans to fully transition CEO leadership duties at the end of 2021. Lisa Shannon assumed the President title in 2020 and the two will continue their close partnership and collaboration throughout the transition. “My journey has been inextricably linked with Allina Health since the day I was born at Abbott Northwestern Hospital,” said Wheeler. “It has been the ride of a lifetime and I am filled with tremendous gratitude and pride for what we have collectively been able to accomplish in service of others over the years. Allina Health has enabled me to fulfill my purpose to improve the lives of others as both a physician and as a leader. Along the way, I have collected countless stories from those who I have been so privileged to meet. It is those stories that I will miss the most, but the timing is right for me to step away. I have tremendous gratitude

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and optimism for the future of Allina Health under Lisa Shannon’s incredible leadership.”

BC/BSMN Adds Community Health Services to Benefit Set Becoming the first non-public insurance company in the state to provide free access to community healthy care workers, Blue Cross and Blue Shield of Minnesota (Blue Cross) announced it will begin offering these benefits to commercial health plan enrollees. As part of a continuing effort to improve the health of members by addressing the societal factors that impact health, effective January 1, 2022, regardless of specific plan renewal dates, Blue Cross will cover services delivered by community health workers across all fully insured commercial health plans. These include Individual and Family plans − both on and off MNsure − in addition to small and large fully insured employer groups (plans in which Blue Cross designs the benefit structure and pays for covered health care costs). Commercial plans in which employers design their own health benefits and pay for their own health care costs − known as self-insured plans − will also have this new benefit available for 2022. Community health worker programs focus on culturally appropriate assistance and education provided by front-line public health professionals who work in conjunction with primary care providers. Additionally, community health workers serve as liaisons between individuals, the health care system, health insurers and social service agencies. Through community outreach, social support and patient advocacy, community health workers are key to bridging gaps in communication and improving health outcomes in communities with cultural and language barriers. “Navigating the complexities of the

health care ecosystem is even more challenging when facing cultural, language, and other sociodemographic barriers that affect our members’ health,” said Dr. Mark Steffen, chief medical officer at Blue Cross. “Community health workers play a crucial role in advancing health outcomes and reducing inequities that disproportionally affect BIPOC (Black, Indigenous, and people of color) communities.” “Community health workers have been instrumental in helping our Medicaid members achieve their optimal health for more than a decade,” said Paul Valley, vice president of commercial sales. “By expanding this benefit to our commercial member population, Blue Cross is taking a significant step toward making health care more equitable, sustainable and affordable for all.”

New CPT Code for COVID-19 Booster The American Medical Association (AMA) has recently announced that the Current Procedural Terminology (CPT®) code set has been updated to include a new code for booster doses of COVID-19 vaccine created by Johnson & Johnson. The new CPT code for the booster dose of the Janssen COVID-19 vaccine joins unique CPT codes previously issued to COVID-19 vaccine booster doses from Moderna and Pfizer. The CPT codes for reporting COVID-19 vaccine boosters from Janssen and Moderna are effective for use as of Oct. 20. The CPT codes for the Pfizer boosters were made effective on Sept. 22. As with all the CPT codes related to COVID-19 vaccines, the effective dates coincide with the emergency use authorization issued by the FDA. For quick reference, the new code assigned to the Janssen booster for the COVID19 vaccine is: 0034A.


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Improving Early Detection and Intervention Michael Georgieff, MD Co-director of Masonic Institute for the Developing Brain Please tell us about the mission of the Masonic Institute for the Developing Brain.

showed that early life events set the brain on a life-long trajectory.

The mission of the Masonic Institute for the Developing Brain (MIDB) is to develop an innovative neurodevelopmental research, educational and clinical intervention institute in a single setting. As a shared facility, it will bring together clinical and academic experts from three entities, including: M Health Fairview Masonic Children’s Hospital and pediatric specialty clinics (M Health Fairview), the University of Minnesota College of Education and Human Development (College of Education and Human Development) and the University of Minnesota Medical School (Medical School).

About five years ago, as part of the growth of CNBD, Professor Frank Symons, Associate Dean for Research in the College of Education and Human Development, and I approached Dr. Jakub Tolar, then head of the Stem Cell Institute, about the potential role of stem cell therapies in neurodevelopmental disorders. When Dr. Tolar became Dean of the Medical School, he and Dean Emeritus Quam were captivated by the idea of a larger institute that would integrate the research performed at CNBD, the education and policy initiatives at the Institute on Community Integration (ICI) and our M Health Fairview clinics that provided neurobehavioral care. They, in partnership with the University of Minnesota Foundation, rapidly secured a site for the MIDB along East River Road and major philanthropic support from Minnesota Masonic Charities and the Lynne and Andrew Redleaf Foundation. The effort was capped by the recruitment of Professor Damien Fair from Oregon Health Sciences University to co-found and co-direct the MIDB.

The understanding of these developmental processes ranges from basic biologic underpinnings of brain development to clinical and policy interventions. The MIDB is based on the science that the brain is most responsive to interventions and environmental conditions during its periods of most rapid growth: the first 1,000 days postconception with a second peak during adolescence. Thus, our programs focus on the best ways to identify risks to the brain, promote the most healthy brain growth possible and bring new and novel interventions and knowledge to the clinical, educational and policy arenas. The MIDB facilitates this process by having researchers, educators, policy makers and clinicians under one roof where they can collaborate.



Brain “...”health is an investment in society going forward.


The MIDB’s basic tenet is that investment in early childhood brain health is an investment in society going forward. The MIDB is unique in that it is not dedicated to any one neurobehavioral disorder, but instead seeks to discover basic processes by which the brain develops. This in turn informs us about many neurobehavioral disorders and helps clinicians bring responsive treatments to patients. In addition to being a leading-edge research facility, M Health Fairview is relocating the majority of its outpatient behavioral, developmental and mental health care to the facility—making it easier for clinicians and researchers to collaborate and for patients to get the care they need in one location.

What can you share about how and why the Institute was founded?

The MIDB was the brainchild of Dean Jakub Tolar of the Medical School and Dean Emeritus Jean Quam of the College of Education and Human Development, both of whom put in an enormous amount of energy and monetary investment for the MIDB to be established. The original seeds of the MIDB date back about 20 years with the founding of the Center for Neurobehavioral Development (CNBD) under the watch of President Robert Bruininks. CNBD was part of the birth of a new field at the time called neurobehavioral development. Its goal was to bring together researchers from basic science through policy to engage in collaborative interdisciplinary approaches in understanding neurobehavioral development, as well as solving or preventing neurobehavioral problems. The emphasis on early brain development reflected an emerging concept called “The Developmental Origins of Adult Health and Disease,” which

What is your role there and what does it entail?

I co-direct the MIDB with Professor Damien Fair, who brings his own remarkable research to the U of M. In our role as co-directors, we set the scientific and clinical agenda for the MIDB. We ensure that the pipeline of scientific information generated by the researchers reaches the clinics, the educators and the policy makers in a much more rapid time frame than has traditionally been possible. We do this through creating and overseeing core services that are designed to assist researchers and clinicians to facilitate their work. In Dean Tolar’s words, we are there to ensure that “collisions” happen among all the people participating in the MIDB so that everyone is aware of new knowledge that is coming down the pipeline as soon as it becomes available. This information may be in the form of novel therapies, new learning modules or new scientific concepts. Professor

Fair and I have remarked that we are “the hosts at the party.” It is our job to make sure everyone knows what everyone else is doing and to foster new, productive collaborative teams to move the field forward faster and more efficiently. What does the vision for collaboration outside the medical community include?

The ICI is a major partner for the MIDB programs and within the MIDB building. They are dedicated to educational and policy agendas as these relate to individuals with disabilities and have been recognized for their work in this non-medical space for over 40 years. Their leader, Dr. Amy Hewitt, has been instrumental in promoting the MIDB agenda, and ICI will also play a role in shaping clinical care within the MIDB. For example, we know that autism spectrum disorder (ASD) diagnoses and the number of families seeking care are increasing nationwide. Researchers from ICI are working with M Health Fairview providers to develop telehealth interventions that families can start with their children at home even while awaiting diagnosis. One of the MIDB cores I mentioned previously is the Community Engagement and

Education Core, led by Dr. Anita Randolph, a research neuroscientist, community organizer and educator, who was recruited to the U of M to lead the core. The goals of this core are also to ensure that critical supports are available for early intervention and treatment and to engage children and adolescents in programs that foster brain development. The MIDB engages with U of M Extension Services, multiple community programs, the Itasca Project’s First 1,000 Days Initiative and potentially with the legislature. We recently published an article about the Itasca Project. What role does the MIDB play in this work?

The MIDB provides neuroscience expertise and community engagement information to the Itasca Project (Itasca) through biweekly meetings with representatives. From a neuroscience perspective, we think it is important that the arguments set forward by Itasca to support early childhood—the first 1,000 days—efforts be grounded in sound neuroscience principles. These principles prove early life environment, including stress reduction, nutrition and supportive environments, set developing brains

on a positive life course trajectory and prevent later neurobehavioral problems. Itasca’s First 1,000 Days Initiative gives us the opportunity to share the science with Itasca partners across the state who play a role in early childhood education, legislative policy, employment policies and more. Together, our ultimate goal is to make Minnesota a destination for excellent early childhood brain development. What can you share about your work with Neuromodulation?

I am involved in research that plans to use neuromodulation to treat infants after brain injury at birth, specifically newborn strokes. Based on the work of former MIDB member Dr. Bernadette Gillick, neuromodulation appears effective in improving physical outcomes when applied to older children, aged 8-16-years old, who had strokes at birth. Arguably, the therapy would be more effective if applied during the period of maximal brain plasticity shortly after birth. This ground-breaking work continues in collaboration Improving Early Detection and Intervention to page 104

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3Improving Early Detection and Intervention from page 9

with Dr. Gillick at UW-Madison. Our research group thinks that ultimately the combination of neuromodulation and cellular replacement therapy may work the best. This therapy has also been prototyped as an option for neonatal brain injury. Neuromodulation is a great example of one of multiple innovative therapies being developed at the U of M to treat the developing brain. At the MIDB, we’ll have the capacity to translate this research into future patient care at established clinics devoted to supporting children with neurodevelopmental concerns through their first 1,000 days. For example, the M Health Fairview Birth to Three Program will relocate to the the MIDB when it opens to patients Nov. 1. Please tell us about the work with Human Phenotyping.

The Measurement and Human Phenotyping (MAP) core is at the heart of the clinical research program. It plays a vital role in making sure that the researchers in the MIDB are using the most precise and current assessment tools in their

studies. One can assess the developing brain in multiple ways, including anatomically and functionally. Of course, ultimately families are most interested in function, i.e., behavior, but the period of maximum plasticity for the developing brain is characterized by infants and children who have a very limited behavioral repertoire. The challenge is to find ways to assess the health of the brain and its functionality early enough that any interventions will have their greatest impact. Some ways we do that is by using an MRI to assess how well the brain looks anatomically and how it is hooked up, using connect to me techniques. We can record high density EEG output by the brain to assess responses to tasks that we have children perform even if they are too young to respond behaviorally or verbally. We can use eye-tracking to assess preautism social interactions in at-risk children well before the typical age for the diagnosis of autism. We are developing biomarkers— nutritional, stress and brain functionality—that can be measured in the urine, saliva or blood and tell us about an individual’s brain status. Finally, we develop and use new behavioral assessment tools that can give us early readouts of very specific areas of the brain,

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rather than relying on more generalized behavioral testing. The MAP advises researchers and physically assists investigators on the use of these tools. The tools can detect early neurodevelopmental problems well prior to clinical symptoms and can monitor response to interventional therapies. With our multidisciplinary clinicians and researchers working side-by-side, families will have easy access to both clinical care and the latest research, such as human phenotyping. Our goal is to improve both early detection capabilities and early intervention for patients. What are you doing in the area of Translational Neuroscience?

One of our missions is to shorten the timeline from when fundamental developmental neuroscience discoveries are made in the laboratory, then go into clinical trials and ultimately clinical care. We have a group of about 20 researchers representing multiple departments on the U of M Twin Cities campus who are researching the biological underpinnings of typical and atypical neurodevelopment. Their Improving Early Detection and Intervention to page 304

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3CMS Reimbursement Cuts from cover

Each year CMS issues their MPFS, which provides for the payment of over 10,000 physician services and sets the Relative Value Units (RVU). Fee Schedule (MPFS), coupled with the expiration of previous Congressional In formulating reimbursement, CMS calculates a geographical practice relief, is set to slash payments to radiology providers by 11.75, and in some cost index (GPCI) for every payment locality, the Resource-Based Relative cases, nearly 20%. Serious work is now immediately required to educate Value Scale (RBRVS) and the Conversion Factor. The RBRVS is calculated lawmakers on the consequences of mortgaging for each CPT code based on physician work, safety net programs like Medicare. As the nation’s practice experience and malpractice insurance health care system is tested like never before, these costs. Using the geographically adjusted RVU, proposed reductions threaten timely access to the Conversion Factor is used as a multiplier to vital health services at a time when there should determine the Medicare-allowed reimbursement be continued investment. rate. These annual calculations are bound Delays in care can be by budget neutrality requirements, meaning a matter of life or death. Setting the Stage increases in certain codes must be offset by Providers have seen unprecedented challenges reductions in others. through the COVID-19 pandemic, including In July, CMS issued the calendar year (CY) executive orders prohibiting elective procedures 2022 MPFS proposed rule, which is set to become and restrictions on their ability to diagnose and effective on January 1, 2022. Contained in this rule treat patients. These government-mandated is the finalization of provisions previously outlined restrictions caused patient volumes to severely in the CY2020 and the conversion factor set at $33.58, a $1.30 decrease from drop, mammography screenings nearly ceased at a 90% reduction, providers the previous fee schedule. The latest iteration of the MPFS is not the only were forced to furlough large numbers of employees, and in many cases, close threat to reimbursement coming into the new year; the potential for double facilities entirely. It is estimated that over 10 million breast, colorectal and digit cuts is essentially made up of four different reduction mechanisms. prostate cancer screenings were canceled or delayed over the past year. These In addition to the 2% stemming from the 2022 MPFS, the expiration of delays in care have continued to contribute to disparities in health care equity. last year’s Congressional relief and statutory pay-as-you-go (PAYGO) As providers are now working to see patients whose care has been delayed, they requirements portend a drastic cut to essential components of the nation’s are again facing nearly 13% reductions to reimbursement. health care delivery system. As a result of direct clinician engagement, Congress infused nearly $3 billion into last year’s MPFS, increasing the conversion factor by 3.75%. This assistance is set to expire at the end of this calendar year, and advocacy groups are asking Congress to extend this relief through 2022 or 2023. Additionally, stemming from the 2013 Budget Control Act, providers have been subjected to a 2% across the board reduction to Medicare rates each year. These reductions were delayed by Congress in an effort to help providers through the end of 2021. This assistance is also set to expire at the end of this calendar year, and advocacy groups are asking Congress to extend this relief through 2022 or 2023. If Congress does renew the so-called “moratorium on sequestration,” these mandatory spending restrictions will go back into effect at the beginning of 2022 and will only further compound the financial stress clinicians face.




Furthermore, other budgetary rules threaten an automatic 4% reduction to certain agencies, including the Medicare program. PAYGO outlines that new legislation must “pay for” increases in spending over 5-year and 10-year windows; otherwise mandatory spending must be sequestered. In the Medicare program, that spending is set at 4% across the board reductions. Unfortunately, when Congress passed COVID relief bills, they did so without dedicated funding and Medicare became the default program for borrowing.






This myriad of factors all culminate in representing a significant cliff effect in payment for essential health services, totaling a minimum cut of 9.75%.

Impacts to Providers and Patients It’s important to remember that decreased Medicare rates will not be the only form of payment to providers that will be impacted. Many states use



these CMS rates as a factor in determining their fee-for-service Medicaid rates; some even directly set rates to a specific percentage of the MPFS. These forces exacerbate issues around health care equity and threaten access to record numbers of Americans covered by Medicaid, topping out at almost 75 million lives, of which nearly an additional 10 million lives were added during the pandemic. Additionally, many states utilize a managed care delivery system for their Medicaid beneficiaries, which operates on capitated per member per month payments. These rates are required to be actuarially sound and are often set by just a handful of large actuary firms, most of whom heavily weigh Medicare rates in making their determinations. These proposed reductions will result in continued downward pressure on provider contracts with private payers as insurers consider government reimbursement rates in contract negotiations. Slashing payments to vulnerable specialty providers will also threaten access for patients, including those who are not direct Medicare beneficiaries. These reductions perpetuate the climate in which small providers increasingly struggle to keep their doors open. Market forces, paired with a pandemic, and decreased reimbursement have all resulted in some community-based providers closing up shop. Many outpatient imaging centers and radiology groups have been forced to consolidate operations, leaving many patients in regions lacking a proximity to care. Further reductions to reimbursement will only worsen this problem.

an agile and impactful network, the RPAN will meld traditional lobbying strategies with a campaign-like public affairs arm to amplify messaging from its members to directly engage policy makers.

In Closing This discussion sets up more than support for clinicians pertaining to payment for services rendered. Potential double-digit cuts to providers and a Congress that continually borrows against our most vital safety net programs mean that public engagement is more important than ever. Please visit the website, www., now to add your name to the growing list of clinicians and patients opposing drastic rate reductions. Ask Congress to act now to extend the 3.75% conversion factor relief and extend the sequestration moratorium (PAYGO & sequester relief) to prevent over $5 billion in payment reductions for vital health services. Christopher Crancer is SVP of Radiologist Partnerships & Policy, also the Executive Director of the RAYUS Quality Institute.

Zachary Brunnert is the Director of State Legeslative Policy for RAYUS Radiology.

As we have seen in the nursing home industry, reduced reimbursement has led to the limiting of government payer exposure by providers. As rates fall, and providers face increasing employment costs, they often have no choice but to limit their contact with payers that do not reimburse at cost. This risks a growing segment of the population facing fewer options when seeking health care services. As it pertains to diagnostic imaging, when patients are often seeking timely answers to their health, delays in care can be a matter of life or death.

A New Vision for Advocacy Based on a Winning Formula The Radiology Business Management Association (RBMA) and RAYUS Radiology have newly organized a consortium of radiology practices and organizations. This group advocates on federal and state legislative and regulatory policy to advance clinical and business initiatives on behalf of radiology patients, practices and physicians. As a result of the 2020 success at mitigating large scale payment reductions, the Radiology Patient Advocacy Network (RPAN) is set to formalize a broad advocacy structure to address the immediate crisis of proposed 11.75% cuts to radiology. Furthermore, this group also aims to change the conversation around payment with the goal of leading efforts to move out of the cycle of working to prevent disruptive cuts. RPAN will do this through deploying a full scale public affairs strategy that changes the conversation to position groups able to achieve growth and success through innovative public policy. Last year, the coalition behind these efforts set up a forum for clinicians to directly contact policy makers. Through a sign-on, the website had over 5,000 signatures. Providers and patients of all types are welcome to engage via this format. This new facilitator’s success will be driven by a highly active and engaged membership, whose grassroots strategies, which have already proven successful, will be the fuel that drives the organization’s influence. As

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3Care Transitions from cover Each time a patient is wheeled from one hospital department to another, is referred from a primary care physician to a specialist, is discharged from the emergency department to their home or is sent from an acute care environment to a nursing home or other post-acute care setting, they are participating in what is known as a “transition in care.” These distinct moments of patient handoff are laden with risk; a notable study found that 80% of serious medical errors are caused by ineffective care transitions. Care transitions involve situations where: • Multiple providers and influencers must collaborate, coordinate and communicate fully and effectively on behalf of their shared patient. • Differing cultures (among hospital departments, between different facilities or practices and between patient and provider) can result in miscommunication with negative consequences. • Resources can be stretched thin during periods of emergency or high volume and during shift changes. • Reliance upon electronic medical records can pose complications and increase risk. • Discharge decisions can be rushed or incomplete. • The patient’s ability to understand the process and treatment, as well as their functional capability, is vital. In an era of productivity and profitability, physicians and their support teams are challenged to do more with less time—more procedures, more patients,


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more billing codes, more diagnostic mysteries to solve and more specialists to consult. These pressures can have patient-safety consequences. Some clear themes related to care transitions that emerged from the data include: The patient and their family can be crucial to outcomes. Sometimes the strongest predictor of patient outcomes is an accurate assessment of the patient’s functional readiness to care for themselves or convey crucial information to other medical providers. When health care practitioners hand off a patient without fully understanding whether the patient understands their next steps, adverse events are more likely to follow. When discharging patients to home, patients and family members become caregivers, and when discharging to a post-acute care facility, nursing home or other doctor’s office, the patient is often the only single person who traveled the entire medical journey. If the patient and/or their family are not offered the conversations, written discharge instructions and other resources needed for ideal outcomes, even good communication and documentation to other providers might not be enough. Communication is imperative (and verbal is not enough). As demands on health care providers increase, delivery of care can become rushed. For example, complicated home care instructions are offered verbally to a nodding and anxious patient but are not confirmed via a teach-back or reinforced with detailed written instructions, or prescriptions for expensive medications are written without confirming whether the patient can afford to fill them. It’s not just good communication with patients that matters, as communication happens at multiple levels: provider to patient and provider to provider. One study estimated that 80% of serious medical errors involve miscommunication during the handoff between medical providers. Communication was the third-most frequent risk issue during transitionrelated events that triggered malpractice claims in the analysis. Accountability saves lives. With patients receiving their care from multiple providers across separate, sometimes disconnected health care systems, even the most experienced provider or the most lucid and savvy patient may be left wondering, “Who’s in charge?” It’s vitally important for there to be clarity about who’s coordinating the care and what comes next. Shared accountability among multiple individuals and groups can be imperative to ensuring good outcomes. “Let me check that with the nursing team” or “I’d like to have a conversation with the radiologist before your appointment” or “Please confirm this suspicion with the patient and then circle back with me” can be simple moments of shared accountability and confirmation that can help reduce injury to the patient. Failure to follow up or improper follow-up is the secondmost frequent risk issue in care transition events, according to the study. Fragmented environments are ripe for structured improvement. It has been estimated that at a single academic medical center, more than 4,000 care transitions happen each day. It’s safe to assume that kind of frequency of handoffs is the norm at other types of hospitals and health systems. With patients transferring from medical centers to nursing homes to rehabilitation centers to doctors’ offices to their own homes, the complexity of caring for even a single somewhat-stable condition can be daunting. Implementing a proven care-transition model and being diligent about internal processes, communication, documentation, discharge planning and patient assessment and education are key factors for successful care transitions. Some patient populations are at higher risk than others. We know from the data that elderly patients, cancer patients, patients who come to the doctor or the hospital unaccompanied and those who have language, health literacy or cultural barriers are at much higher risk during or after a

care transition, and when sharing vital patient information with your transition in care. Providers and organizations that take this into account medical colleagues and collaborators, doing it “the same way every day” and work to identify and assess at-risk patient populations can help level can improve safety and outcomes. Adopt one of several handoff mnemonics the opportunity for good outcomes. Systematizing the use of social workers to help you ensure a thorough conversation and/or written document, and interpreters and having access to language translation services for develop meaningful checklists and ensure they are discharge instructions is also important. Patientused and consider implementing a proven carecentered care is all about remembering to meet transitions model that has worked well at similar the patient where they are—not simply treating organizations or in service to similar patient the disease or condition. Systematizing the use of populations as yours. Routine and rigor are vitally social workers and interpreters and having access Clinical decision-making important because delivering health care is highly to language translation services for discharge is the heart of optimal complex and full of variability. instructions is also important. Proactivity and health care delivery. thorough assessment can identify gaps and create Patients may be pressed for time or face opportunities. No two healthcare facilities are challenges in paying for their care. If the care exactly alike, but they can all be assessed through transition plan is not executed in the context of common filters to determine areas of vulnerability your patient’s reality, it is more likely to result in and opportunity when it comes to care transitions. patient harm. Some questions to consider: Does Taking the time to look at your practices can help identify where the patient work full-time while raising children alone and therefore might improvements are needed. Assessment tools are available through medical have to go weeks or months before following up with the primary care professional liability companies, and you can engage consultants to help you doctor or specialist you are referring to? Is a co-pay for an MRI something improve your culture of accountability, communication and safety when it they can afford or might the promise to pursue additional diagnostics be comes to care transitions. You should also regularly analyze your outcomes the patient’s way of maintaining their pride in the face of a medical request data (e.g., readmissions, completed referrals, patient complaints and patient they know they can’t fulfill? Is it possible that a discharge to home, while it morbidity and mortality statistics). might be situationally sensitive for a patient who doesn’t have coverage for Standardization and practice contribute to successful outcomes. When communicating with a patient about their condition and their upcoming

Care Transitions to page 164

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3Care Transitions from page 15 rehabilitation services, isn’t in the patient’s best interests if they don’t have the functional capacity to manage medications or daily activities?

Unique Issues That Impact Patient Handoffs Clinical referrals can be difficult. Patient discharge instructions can be difficult. Even transferring a patient from one unit of a hospital to another can be difficult. Much of that difficulty arises because of one or several unique but predictable factors: • As health care organizations seek to be optimally productive and fiscally responsible, patient loads per provider can be heavy and burdensome. When you don’t have much time to spend with a patient, it can be very difficult to ensure thorough handoffs. • Effective care transitions require some level of teamwork and rapport among clinicians and their patients, but cultural divides (even differences in how the cardiology department and the emergency department function and speak) can create unintended consequences. In serving their patients, health care providers must often rely on colleagues with whom they have little synergy and perhaps no relationship. • The EMR has, for better or for worse, come to replace word-ofmouth information and the over-reliance on these records causes many transition-in-care issues, from the assumption that the EMR is complete despite some crucial notes or test results not having been dictated yet, to the common occurrence of a patient having records

for the same condition and care journey in multiple EMRs at multiple facilities with no interconnectivity to one another. • A stable patient can become unstable in a short period of time, and when a handoff takes too long, the entire situation can quickly go from “under control” to perilous. • Since the advent of the hospitalist model and the ever-increasing trend for many U.S. patients not to have a primary care physician, there is often no single source of relationship or information about a patient’s health. And unless the patient is an incredibly capable communicator, much can slip through the cracks.

The Patient’s Role in Care Transitions Transition-related events involve a certain degree of patient involvement or a lack of buy-in—cases where a stronger focus on shared decision-making and a shared mental model between provider and patient might have led to better outcomes. Take, for example, a patient who nods, smiles, or verbally confirms that they understand the prescribed next steps (e.g., referrals, home care) but doesn’t truly understand. Clinicians may not be aware of the patient’s confusion or ensuing decision-making that results in poor outcomes until they hear from their malpractice insurance carrier. Think also about patients who don’t have a primary care physician (PCP) or haven’t seen their PCP in many years. When you treat a patient and discharge them to a PCP who doesn’t exist or with whom there is no maintained or trusted doctor-patient relationship, the care transition becomes immediately vulnerable.

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A patient’s functional status—their ability to walk, their cognitive abilities, and their ability to perform daily activities—are important considerations. Something as simple as relying on a patient to use eye drops or change a bandage can be imperiled by a misunderstanding about what the patient is truly capable of managing on their own.

are several ways to double check that families are prepared and clear about what to do next and that it’s a provider’s responsibility to educate families and patients through verbal and written means that can improve the health literacy of these stakeholders.

Patients often fail to make or keep critical follow-up appointments. The Agency for Healthcare Quality and Research (AHRQ) reports that more than one-third of patients with an inpatient status who were discharged from hospitals requiring more care ultimately failed to get that care. Such absent care contributes to hospital readmissions and poor outcomes.

Managing a patient’s medications is a complex endeavor, even in the absence of multiple care transitions. Coverys analyzed more than 10,000 closed medical malpractice claims in 2017 and found that medication-related issues were the fourth-leading claim allegation. Medication issues were the secondmost frequent allegation in care-transition events. Similarly, medicationrelated events that involved the highest levels of injury severity (including death) were those that involved an alleged failure to properly monitor a patient’s condition during and after a transition. It is understandable how the continuation of or management of medications, as well as the ongoing monitoring of patient vitals, can be difficult during swift, complicated, or disorganized care transitions. These important details can slip through the cracks when one provider assumes another provider is keeping tabs on them.

One of the primary measurements of ineffective care transitions is hospital readmission. For events where care started in an inpatient setting, 38% resulted in the patient being readmitted to the hospital, and these cases accounted for 47% of indemnity paid for care transition events. The most frequent readmissions occurred within 30 days. Improved patient engagement during transitions can help. Medical practices and hospitals that have lower than-average transition-in-care risk are typically those that have systematized phone, text and email follow-up (with patients and receivers alike) to ensure that referrals are completed as advised. Health care providers rely upon patients to act in their own best interests and often count on families and caregivers to help ensure optimal outcomes. The National Transitions in Care Coalition (NTCC) offers Patient and Family Engagement/Education as one of their seven essential intervention categories. They suggest having families and patients explain the details of their care plan in their own words. The NTCC reminds providers that there

Monitoring and Medication Management Issues

Diagnostic Issues and Clinical Decision-Making Before a patient experiences a transition in care, they nearly always receive a diagnosis, even if only preliminarily. So a discussion of care transitions must include a review of the diagnostic process and the degree to which diagnostic accuracy is a precursor to the quality of a patient’s care transitions. In a 2018 review of 10,618 closed claims over a five-year period, Coverys found that Care Transitions to page 184

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3Care Transitions from page 17 diagnostic-related errors were the leading root cause of medical malpractice claims—33% were diagnosis-related, and 47% of indemnity paid over a five-year period was for diagnosis-related claims. Even when a diagnosis is accurate and timely, arriving at it often triggers the need for one or more care transitions—referrals to specialists, transfer to different hospital units, transition to radiology or other diagnostics or discharge to home or nursing facility. And referral management is complex and full of risk; 9% of all diagnosis-related claims alleged an issue with referral management. When making a diagnosis and preparing a patient for a transition to another provider or care environment, strong clinical decision-making is key. In the review of 3,466 closed claims with diagnosis-related allegations, 53% were determined to have an issue with clinical decision-making. Thoughtful, big-picture clinical decision-making is vital before, during and after care transitions. Sending a patient to the wrong location, at a premature time, or without proper safety nets in place creates vulnerability to patient harm. In examining the 210 transitions-in-care events that form the basis of the report, two of the largest indemnity payments ($3M and $5M) involved allegations of a failure to diagnose and treat conditions that caused serious injury or death. Clinical decision-making is the heart of optimal health care delivery. Of the myriad risk issues at play (563 risk factors across 210 patient events), a failure in clinical decision-making accounted for 29% of those risk issues. The most common types of clinical decision-making issues were failure to



obtain a full family or personal history, negligent post-operative monitoring and treatment, failure to obtain a specialty consult or referral, inadequate or inappropriate testing, narrow diagnostic focus and failure to rescue.

Technology, Tools, and Best Practices While the stories and statistics about what can go wrong during patient transitions warrant serious attention and concern, there is also cause for optimism about improving patient outcomes through the implementation of new systems, technologies, tools, models and protocols. Fine-tuning an organization’s care transition practices is inherently difficult because process changes can be difficult to sustain over time, and care transitions are highly human in nature. The good news is that doing something (anything) to bring structure, safety nets and additional thoughtfulness to patient handoffs can and will have a positive impact. There are several areas you might examine to get started improving care transitions, including: • Conduct a formal, thorough assessment of your practice or facility as it relates to care-transition processes and behaviors. • Reconsider the design and utilization of your EMR, knowing that it is a key component of transition-related communications. EMR systems can be prepopulated with clinical referral templates and other helpful tools to ensure good patient outcomes. • Audit your current discharge protocols and identify ways to improve them. • Consider ways in which you can categorize patients into different populations based on transition risk. Then provide additional

layers of support and safety for those who are most vulnerable to harm during a transition. • Rethink older technologies that your team could be using more effectively, like telephone, email and your practice’s portal, to ensure timely communication with other providers and patients alike. • Closely examine the way in which you interact with radiology. When it comes to care transitions, the role of radiology is crucial and in need of attention. While claims involving radiology occur infrequently, they often result in high indemnity payments.

can require return visits or hospital readmission, ultimately costing patients, providers and hospitals more time in the episode of care and a higher likelihood of poor patient outcomes.

Discharge is not a medical term for goodbye. Discharge or referral should be thought of as a beginning and not an end. Discharge to home, rehab, post-acute care facility, nursing home, or hospice is the beginning of the next phase of the patient’s treatment or healing. Providers who pass a patient along to the next step in Health care providers a medical journey should be immediately thinking and administrators face about when and how they will follow up and check a daunting daily task. in—with other providers, with caregivers, and with the patient.

Managing Risk and Improving Patient Safety This article provides data driven recommendations for reducing risk and improving outcomes related to the transition of patients from one provider or one setting to another. Following is a final list of recommendations that apply broadly to care transitions. What you save through speed may cost you in patient harm. A great deal of transition-related adverse events involve brief interactions where time pressures can make it difficult for adequate discharge instructions or referral information to be clearly conveyed and patient questions thoroughly addressed. When one appointment or admission is handled sub-optimally, it

Functional teams, safer patients. Effective teamwork has long been a focus of surgical departments and other high-risk medical environments. It is equally important that teams of providers—across departments in hospitals and health systems and between providers who refer patients to one another—prioritize ways to improve their interdependent processes and communications to ensure improved patient safety. Collaboration and community at the core. Excellent patient care involves a “we” mindset from providers and caregivers, who should always be thinking about “our patient” and “what we can do to support them,” Care Transitions to page 284

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Accessing Mental Health Care Reasons people don’t seek help BY TODD ARCHBOLD, LSW, MBA


tudies consistently show nearly one out of five people will experience diagnosable symptoms of a mental illness in their lifetime, and less than half of them will ever seek the treatment they need.

According to polls from organizations like the American Psychiatric Association (APA) and National Alliance on Mental Illness (NAMI), a majority of adults reported increased symptoms of anxiety and depression throughout the pandemic, adversely impacting their daily lives. Parents are now reporting more worry and anxiety related to their children’s health. The necessary safety restrictions, such as social distancing, have exacerbated social stressors including financial distress, job instability and food insecurity. These subsequent stressors have disproportionately impacted our BIPOC communities. More people are feeling isolated and disconnected as mental health providers are overwhelmed with referrals. With mental illnesses so prevalent, why don’t more people get help? Nearly one in 13 people suffer from asthma and nearly one in 10 from diabetes; almost all get care or help managing their symptoms. Nearly one

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in 10 people suffer from depression, and more alarmingly, nearly one in five adults suffer from some form of anxiety, yet less than half will get professional care. At least half of all cases of mental illness onset before age 14, meaning many people struggle with symptoms from a very early age. Comparatively speaking, most people will never experience the breathing difficulties associated with asthma or the tingling hands and feet that diabetes may cause. Yet everyone knows what it is like to feel depressed and anxious. It is when these feelings begin to impact our daily functioning that we need to get professional help. An acquaintance recently shared with me that she wanted to get involved in mental health advocacy, but had a hard time relating since she did not know anyone with a mental illness. I simply told her, “Yes, you do actually know several people with a mental illness; you may just not know they have an illness.” Many people may be effectively managing their symptoms, but sadly, many are not getting any help at all and are not talking about it. There are three main reasons people don’t get the mental health care they need, when they need it.

Access Barriers These are real, often tangible barriers that prevent someone from getting help. They can range from such things as financial barriers, lack of reliable transportation, geographical isolation, poor internet and more. Some of these barriers can be more easily overcome than others, but in general they only add to functional impairment and create more frustration. Some access barriers may simply be not knowing who to call or where to go. Sadly, many individuals access care only through a crisis with an emergency room as their entry point. Across the nation, we estimate that there is one mental health professional for every 378 people. This includes psychiatrists, psychologists, psychotherapists, advance practice nurses and drug and alcohol counselors. Of course, many of these are specialists and not trained to treat all conditions. Some specialties may focus on treating certain age range or certain conditions, while some are focused on research and may not care for patients directly. On average, psychotherapists carry caseloads of 40 to 60 patients, while psychiatrists carry caseloads closer to 400 and even upwards of 1,000 patients. Minnesota ranks in the middle of the nation, with an average of one mental health professional for every 365 people. Minnesota also ranks above the national average in alcohol and drug abuse, as well as racial inequities. Furthermore, our state has comparatively vast rural areas endearingly referred to as greater Minnesota. In these rural areas, the ratio of mental health providers to the population is close to one for every 1,500 people. Many people in these regions will struggle to find the right mental health provider, if any at all. While telehealth services have been extremely successful in many places, it requires reliable internet and tech-savvy patients. Unlike other health care providers, mental health providers are more likely to be out-of-network with insurance plans as a result of poor reimbursement rates. Many people report being underinsured, so the costs of care become a barrier. It is estimated that nearly one of four psychotherapists do not accept insurance plans, and even fewer psychiatrists are in-network. Paying

out-of-pocket for regular health care is a luxury that very few can afford. Financial insecurity can only exacerbate feelings of depression or anxiety about financial matters. In addition, poverty and low income are risk factors for mental illness. This inequity is widening a gap in our communities, disproportionately impacting BIPOC individuals.

more normal for them. When we don’t engage in these conversations, we lack the revelation that others may also feel this way and it can be different for us.

Stigma and Fear

While we have made significant progress in debunking myths of mental illness that have contributed to stigma, this is still a significant factor that prevents many from talking about mental health and getting treatment. Stigma can lead to discrimination resulting in barriers to care, confusion/frustration, physical harm and We can all become advocates worsening symptoms. In some cases, stigma may and speak out against stigma. stem from misunderstanding, misinformation or lack of education in our communities.

Accessing some services, such as residential treatment or substance use disorder (SUD) treatment, can require extra steps for approval and are subject to scrutiny of utilization throughout treatment. At the end of 2020, a monumental lawsuit found one of the nation’s most profitable insurance companies was intentionally and methodically denying coverage for psychiatric services. The investigation revealed denials for care led to people dying as a result of an identified, but untreated mental illness. There is little oversight of mental health parity laws, and the behavior of insurance companies to ensure comparable coverage between medical and mental health services is discriminatory at best. A large part of the access problem is that insurance companies pay so poorly for mental health care that many providers cannot afford to be in-network.

Life as Usual For many, we just feel the way we feel, and that is normal for us. The symptoms of a mental illness or deterioration of mental health may be something we don’t realize is different. We just get used to the mild but chronic pain in our hip or we learn to cope with dry skin in the winter. Just as easily, we may struggle to get out of bed each morning or we may fear meeting new people, and we assume that is just life as usual. We can tolerate these things for at least a short while, and often we are not aware that effective treatments exist. Studies have shown that upwards of 20%50% of the population experience symptoms of a mental illness in a given year, but never identify it as such. This can be due to lack of information or educational resources. It can also be cultural or a familial tradition. We may not talk about feeling depressed, we just deal with it. This is different than stigma which is rooted in fear or shame. In these instances, people simply are unaware that things can be different. Some may be aware of their mental health struggles, but be unaware that help is available. There are a variety of treatment methods for all conditions, ranging from psychotherapy and medication management to transcranial magnetic stimulation (TMS), equestrian programs, and more homeopathic approaches. More than 75% of individuals receiving psychotherapy report improved symptoms. The APA cites numerous studies that have identified brain changes in people with mental illness (including depression, panic disorder, PTSD and other conditions) as a result of undergoing psychotherapy. In most cases, the brain changes resulting from psychotherapy were similar to changes resulting from medication. We can combat this by normalizing conversations about mental health and feelings so we can gain deeper perspectives about our own. Studies have shown younger generations are more apt to talk about mental health and subsequently find treatment. The APA published a report showing that members of Generation Z were more likely to receive treatment or therapy than any other generation, and nearly twice as likely as Baby Boomers. This is largely due to increased awareness and because these kinds of conversations are

While stigma is often seen as an external factor or public force, some create their own selfdoubt and shame that is equally as harmful. They may feel that mental illness is a sign of weakness or something they are unable to control. It is important for people not to become isolated and to connect with others who may also be experiencing similar feelings or symptoms. Primary care providers, school counselors and even human resource departments can help connect people with resources and care they need. This may include support groups and even trusted online forums. Learning to accept our condition is a powerful first step in allowing us to access care. Accessing Mental Health Care to page 264

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Engineering in Health Care Facility Design Understanding an important role BY BRENT WAVRA, PE – MECHANICAL ENGINEER


o help understand engineering in health care, it’s helpful to compare it to the human body. Each health care facility has a skeletal system which is the building structure, internal organs are like the mechanical / plumbing system, nervous system is comparable to the electrical / IT systems, and think of the skin as the walls that hold it all inside. The consulting engineer’s responsibility is to ensure that all systems are designed to allow the building to become alive after construction is complete. Just like every person is unique, each health care facility is unique. Strong communication skills are the key to success when it comes to designing a new building or remodeling an existing health care space.

Engineering in Health Care We start with the end in mind–each health care facility operates with its own idiosyncrasies that make up its unique nature and culture. As consulting engineers, it’s imperative we understand from the start what the stakeholders’ needs are when it comes to the day-to-day operations of their facility. We must also discuss the facility’s operational goals, energy use, care team function and overall patient satisfaction objectives.

Input from facility staff and stakeholders is valuable information as we start to lay out our system designs. Architects provide detailed renderings of different areas of the building, e.g., layouts of patient rooms, operating rooms and lobbies based on heavy input from the stakeholder group. Mechanical, electrical and plumbing (MEP) consulting engineers need similar guidance. For example, we need to know how the medical gases will be arranged on the headwall within a patient room, the preferred location of a med gas alarm panel, the optimal temperature setting in an operating room, emergency power needs for outlets, preferred equipment manufacturers–all of which make the workspace tailored to the needs of staff for an efficient and functional environment. The character of a health care space is typically determined by what you see and physically identify within the facility. Elements like window locations, wall color, artwork and space layout tend to be the items that influence perception of the facility by patients and health care workers. However, nearly 40% of the building is located behind the walls, above the ceiling or in hidden utility spaces that have a higher impact on care, but have a less tangible impact on a person’s perception of the facility. The mechanical and electrical systems determine temperature, humidity, air

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filtration, infection control, water, medical gases, lighting, power, data, nurse call, way finding and other items. Many things play a significant role within the space without the users directly identifying them. The bricks and mortar of a facility are static and visibly noticeable; however, the mechanical and electrical systems are alive within the building, if unseen.

team and owner understand the financial implications associated with these systems. For example, MEP systems can range from $50-$150 per square foot. Applying that to a 400,000 square feet replacement hospital means the systems cost can range from $30 million to $70 million. Having an early understanding of MEP systems needs for present and future use helps provide clarity into the project budget from the start and avoids the need to cut costs later. Communication during design is the path to success.

It is never too early to start understanding the MEP needs of a health care facility with the finished project in mind. Many MEP systems drive overall The cost for MEP generally design decisions. For starters, the engineers need Engineers role on the Design Team accounts for nearly 40% to understand and coordinate space requirements As health care engineers, we know the value we of the cost of construction. for MEP systems, because most of the equipment can provide from the start and our work with is located above the ceiling and determines the our architectural partners is a part of the process. height of the building. In some hospitals, separate Our goal is to be an integral part of the design floors route the MEP infrastructure throughout team and bring a thorough understanding of how the building. Another significant consideration is early design decisions can affect the engineering incorporating serviceability of the MEP infrastructure and the cost of doing systems’ design and implementation for the project. so. It’s important to remember each square inch of building costs money and Understanding the goals, timeline and budget of a construction project additional space to service equipment does not turn revenue like a patient is valuable information used early on during design of a new project. Each of room. Taking time to coordinate with facility personnel, the architectural these components is used to determine the correct type of heating, ventilation design team and the construction manager will find the best solution and and air conditioning (HVAC) to coordinate with these criteria. For example, the right price, both of which are crucial for a successful project. if the goal of the project is to provide an energy-efficient mechanical Secondly, MEP systems and supporting infrastructure are expensive. The cost for MEP generally accounts for nearly 40% of the cost of construction. Knowing the MEP needs of the facility early on helps the entire project Engineering in Health Care Facility Design to page 244



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3Engineering in Health Care Facility Design from page 23 can work with the architectural design team, other consulting engineers and system, then a geothermal system might be considered. Coordinating a specialty consultants. We can effectively see how our design works within location of the geothermal well field with the civil engineer is a hurdle to the space before it’s built, saving time and money during the construction work through, but possible when both parties are process. Another benefit to 3D technology use brought to the table early on. Another example within our industry is the ability to use virtual is a project’s compressed construction timeline, reality so an owner can see their project before it’s which determines manufacturing lead times of built. In the past, owners would try to imagine how mechanical and electrical equipment and may a project would aesthetically look, feel and function Net Zero means providing drive the system selection. based on the 2D design drawings. Now, they can

renewable energy solutions along

“walk through” a project before it’s built and make There are hundreds of scenarios like these, with onsite energy generation. design decisions based on what they are seeing in which if discussed at the beginning of the project real time versus getting through construction and with a consulting engineer, keeps the design wishing they had made different decisions. From process moving forward from the beginning. If an engineering perspective, the locations of wall not, there is the possibility of going backward to switches, lights, sinks, medical gas outlets or light redesign parts of the project to accommodate the levels are now easily seen and understood. This is useful for medical staff correct MEP system that fits the building needs. This can result in slowing involved in the design process–they can see how they could work within the down the design process and jeopardizing the construction schedule. space and suggest changes to help improve their ability to provide better care. Knowing the best way to communicate our designs and the effects of Not all mechanical and electrical systems are as obvious as lighting, design decisions to people outside of the design and construction community domestic water, and room temperature, but they are the backbone within is an important part of our job. As consulting engineers, we prepare our design a health care facility that make the building function. Systems like central on 2D set plan drawings for the constructors to construct. We also work with utility plant–heating, air conditioning, steam, and power–along with the design team within 3D models to better understand how our designs terminal devices like air handling units for creature comfort and filtration affect the overall project outcome. Working within this 3D modeling medium for infection control. These unseen systems play a signification role for is called Building Information Modeling (BIM). BIM has changed how we

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the life of the building and need to be discussed early during the design process. They don’t have the awe factor like other building components such as a grand lobby or granite counters, but they provide a safe, healthy, and functional environment for all. To provide the best solution, bringing in an MEP engineer in at the beginning of the process allows time for the MEP systems to be appropriately incorporated into the building. The required footprint of the MEP systems takes valuable real estate within the facility and the sooner this is accounted for the better it is hidden within the building and allows the beauty of the building shine through.

Benefits of Engineering in Health Care – Inside and Out of Your Building Engineers contribute to many benefits within the facility for your patients and staff. We contribute to a healthy and safe working environment, as well as clean and healing spaces for your patients. We can be resources for your facilities teams to keep your building functioning at its best. But we also look beyond the ways we can provide benefit inside the building. As good stewards of the earth, the MEP industry is working towards more energy efficiency solutions when designing buildings–including health care facilities. The term Net Zero is a buzzword right now but is often misunderstood. Net Zero means providing renewable energy solutions along with onsite energy generation to offset what the facility is consuming. Net Zero does not mean having zero energy consumption or being off the grid. The first step in working toward Net Zero is reducing the building energy consumption to limit the cost of renewable and onsite generation. Many health care facilities have energy/water conservation goals outlined in

their long term Environmental, Social, and Governance (ESG) plan, which sets conservation goals of the health care provider. Health care facilities have one of the highest Energy Usage Indexes (EUI) of commercial spaces. The high EUI is due to 24/7 operation and high concentration of outside air and power consuming devices, but there is still an opportunity for energy saving design solutions. Systems that provide the greatest energy reduction include optimizing the chilled water plant used for air conditioning, using airside energy recovery, fine-tuning the HVAC control sequencing, implementing daylight harvesting and collecting rainwater for irrigation. But energy conservation does not sit solely on the shoulders of the MEP engineers. For example, the orientation of the building on the site in relation to the sun, the number and locations of windows and wall and roof insulation values all go into quantity of energy the building uses.

In Conclusion Finally, the MEP systems are a critical element in the operations of a health care facility. These unseen systems play a significant role for the life of the building and need to be considered at the very beginning of and throughout the design process. It is important to discuss and set energy conservation goals as early as possible so the entire design team can find effective solutions. Brent Wavra, PE is a Mechanical Engineer and Director of Business Development for Obernel Engineering.

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3Accessing Mental Health Care from page 21 Similar to how younger generations have helped to normalize conversations about mental health, their outward advocacy and openness have made talking about mental health more of a strength than a weakness, as it used to be seen. This has been helped by social media and online apps designed to build resiliency, diagnose and even treat mental illnesses. We can all become advocates and speak out against stigma. This will help support all of those around us and provide a safe conversation if we need support ourselves.

Helping Your Patients All health care systems and providers have a responsibility to respond to mental health needs of patients. This requires more training in mental health, including identification of symptoms, crisis management, and providing basic care to those experiencing symptoms. This also means awareness of the reasons people don’t access care when they need it. It is estimated that nearly 50%-70% of primary care visits involve a mental health concern, but it is rarely discovered. Some providers hesitate to hear the story because connecting their patients with mental health resources can be difficult. This is a systemic issue–our network of mental health resources is not broken, because it has not yet been built. When we don’t listen to the patient’s story, we erode engagement in care and we miss things. It is estimated that nearly 70% of people with a chronic health condition also struggle with their mental health. These conditions are almost always treated separately, and the referral follow-through to a mental health provider is about 50%. This drives up costs and decreases the quality of care. For example, one common comorbidity is diabetes and depression. If treated separately, the costs

of care could be three times more than if they were treated at the same time. Diet, exercise and insulin are all critical factors for both conditions, but absence of the other’s treatment plan results in different independent recommendations. Failure to effectively care for diabetes can exacerbate depressive symptoms, and increased depression can lead to worse follow-through on medical recommendations for diabetes. We need to treat them together. Local integrated health care models have shown to increase patient follow-through by 52%. In some cases, co-located therapists were able to care for 250% more patients in the integrated setting than in a stand-alone clinic by themselves. Minnesota offers a Psychiatric Assistance Line (PAL) for any health care provider seeking consultation on a specific case. This free on-demand service is managed by clinical social workers and staffed by board-certified psychiatrists. This helps alleviate numerous access barriers and helps primary care providers treat psychiatric conditions directly in their own care setting. While this list is not exhaustive or detailed, it helps to summarize the main factors that prevent many from getting mental health treatment when they need it. We can help connect people with service by advocating for parity and fairness in access and by talking about the signs and prevalence of mental illness. This will help to increase awareness and the likelihood that someone will get help when struggling.

Todd Archbold, LSW, MBA, is a licensed social worker and the Chief Executive Officer at PrairieCare.

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3Care Transitions from page 19 rather than the default mindset of “that other provider has taken over at this point.” True collaboration keeps the patient as the core focus at every step and in the mind of every provider. Documentation is not paperwork but an extension of care. Imagine what the U.S. healthcare experience would look like if providers thought about transition documentation as the book version of the movie— the whole story, just in written form. If you value the readers and decision-makers who reference the EMR and other handoff or discharge documentation as customers who need the whole story, how might patient outcomes be improved for the better? A balance of listening, speaking and written instructions is needed. For a provider to insist that “I’m more of a talker than a writer” or “I answered all the patient’s questions, so I didn’t think it necessary to outline a full transition plan” or “They were given written instructions—that’s all they should need” is simply not adequate. Ensuring clarity in communication requires a thoughtful balance of listening, speaking and written instructions.

interoperability. So while it’s true that broader ecosystems are sometimes at fault for individual cases of patient harm, the stitching together of process gaps, dysfunctional teams, or siloed systems happens one provider and one leader at a time. It begins with you.

Conclusion Every day in the United States, millions of care transitions take place for patients in hospital, out-patient and continuing-care settings, most without major incidents but all with inherent risk for poor outcomes. In this article, we have identified key factors that can contribute to poor care transitions and ways to mitigate these factors. We also recognize that relationship building, partnerships, and effective communication belong to all stakeholders— health care professionals, patients and families, as well as communities. Robert Hanscom, JD, Vice President of Risk Management & Analytics. Maryann Small, MBA, Senior Director, Risk Analytics. Ann Fiala, RN, Senior Risk Specialist.

Mindset matters. Perhaps the most common phrase heard during a hospital morbidity and mortality review or during a deposition or trial in the wake of a malpractice lawsuit is “I didn’t think that” or “I assumed that.” Our perspectives, frames of reference, assumptions and mindsets matter when it comes to patient care—sometimes to a life-and-death degree.

Patricia Bennett, RN, CPC, Senior Manager, Clinical Coding.

Stitching together a fragmented health care environment begins with you. Health care providers and administrators face a daunting daily task— serving patients optimally in a system that often fails when it comes to

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Barbara Ricci, BS, AIC, Senior Analyst. This article is excerpted from a report published by Coverys—Care Transitions: the Coverys Knowledge Center at or link to:

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With more than 35 specialties, Olmsted Medical Center is known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

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3Improving Early Detection and Intervention from page 10

research areas span the developmental topics like nutrition, stress, obesity, infection, toxins, addiction, autism and schizophrenia. Because their laboratories are not located on the MIDB campus, their interaction with clinical researchers and clinicians is facilitated by the Translational Neuroscience Core. This core is responsible for putting together research teams of pre-clinical and clinical researchers around the developmental topics noted above. This powerful interdisciplinary approach allows us to pinpoint the important biological factors that underlie the diagnosis and treatment of many neurodevelopmental disorders. Providing biological plausibility and proof is key to sharpening our approaches to treating neurodevelopmental disorders. It is key because we can be more specific in our therapies and the timing of those therapies when we know the biology. Many of our M Health Fairview clinicians at the MIDB are also researchers and educators at the U of M . They’re immersed in these discoveries, and we hope the Translational Neuroscience Core will even further expand collaboration across university departments and into medical care.

What are some of the longer term goals

involved with the MIDB?

for the MIDB?

It is estimated that up to 50% of physician visits for children involve discussion, diagnosis and treatment of behavioral issues. When primary care physicians need additional consultation, there are multiple subspecialties which assess and potentially treat neurodevelopmental issues: pediatric neurologists, neuropsychologists, developmental pediatricians and child and adolescent psychiatrists. Yet fundamentally all of these subspecialists are assessing brain health and function. The MIDB brings all of these disciplines together in a single setting with a concise approach so that each child can potentially be evaluated by team members from all of these disciplines. From that intake, an individualized plan can be crafted to address a child’s needs, fueled by new knowledge and innovative approaches. Long term we hope to be a learning resource for physicians in Minnesota so they can leverage the knowledge generated by and tested in the MIDB in their own practices.

The most important goals are to shorten the timeline from discovery to intervention and to engage the community in brain development activities. As Dr. Fair has pointed out, the discovery to intervention process can take as long as 17 years, and that is simply unacceptable for our rapidly growing and developing children. We believe that the new efficiency of putting the researchers, educators, policy makers and clinicians in a single setting will facilitate speeding up that timeline. Ultimately, we want to learn from every patient’s experience to make our approaches better for the next patient who comes along. From a community perspective, engaging underrepresented individuals in neuroscience and helping those patients with difficulty in accessing consistent, effective and individualized neurobehavioral services are main focal points. Building these programs will take time, but will pay off in the long run because ultimately prevention of mental health problems through early detection and intervention far outweighs the cost of diagnosing and treating them later in life. What would you like physicians in Minnesota to know about how they can become

Michael Georgieff, MD, is the co-director of Masonic Institute for the Developing Brain and a professor at the U of M Medical School and College of Education and Human Development. He is a neonatologist at M Health Fairview Masonic Children’s Hospital.

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Volume XXXII, No. 05

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


niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting

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

Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: •

Exploring new potential BY MICK HANNAFIN


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

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

Share new diagnostic and therapeutic advances Develop and enhance referral networks Recruit a new physician associate




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Sofia Lyford-Pike, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

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