Minnesota Physician cover stories

September 2017

Past MP cover stories

Reducing failure to diagnose claims

What to do when patients decline cancer screening


By Ginny Adams, RN, BSN, MPH, CPHRM


Diagnostic error is the most frequent allegation in medical professional liability (MPL) claims involving death, according to the National Patient Safety Foundation in 2014. It is the number one cause of MPL claims for all primary care specialties, radiology, and emergency medicine. Claims alleging a failure to diagnose cancer are among the most numerous and most costly examples of diagnostic error. Several issues underlie many of these cancer claims, including the failure to offer or provide appropriate cancer screening.


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A better way to treat chronic pain

Alternatives to opioids


By Nima Adimi MD, MS


Chronic pain is one of the biggest medical problems facing the world today. As medicine advances and people live longer the incidence and prevalence of chronic pain will only increase given the inevitable degeneration of our bodies. Chronic pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage for at least three months. As a physician I have always been interested in statistics. Numbers put things into perspective for me so here are some alarming statistics regarding chronic pain:


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The value of Medicaid

A safety net for children


By Kelly Wolfe


Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.


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Opioid Prescribing Improvement Project

A safety net for children


By Kelly Wolfe


Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.


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Quality reporting

The importance of accounting for social conditions


By Paul Kleeberg, MD, and Phil Deering, BA


Like many Minnesota physicians, Dr. Lynne Ogawa first saw her Minnesota Statewide Quality Reporting and Measurement System (SQRMS) outcomes toward the end of the last decade. At the time, the family practice doctor saw patients at the Fremont Clinic, located in the heart of North Minneapolis.


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Why just retire?

Consider physician emeritus


By Michael J. Weber, JD, and Nancy Lee Nelson, JD, MPH, RN


If you are like many other Minnesota-licensed physicians, you might be unaware of the option to retire as a “physician emeritus.” To retire as a physician emeritus, a physician has to complete a short application with the Minnesota Board of Medical Practice.


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Regenerative Medicine Minnesota

Transforming the future of health care


By Jakub Tolar, MD, PhD, and Andre Terzic, MD, PhD, FAHA


We have grown accustomed to the medical miracles—antibiotics to combat infection; transplantation to replace failed organs; and biologics to control high cholesterol, rheumatoid arthritis, or psoriasis—that have transformed patient care. Despite remarkable advances, many serious health problems resist conventional medicine and surgery, causing suffering and shortening lives.


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The Minnesota Adult Abuse Reporting Center

Protecting the vulnerable


By Commissioner Emily Piper, JD


An older adult woman living in northern Minnesota was at her most vulnerable—recovering from surgery after a stroke—when she became the victim of financial exploitation by her own daughter.


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The CARES Model

A way to engage your patients


By Archelle Georgiou, MD


Sixty-two percent of Americans say they want to deliberate with their physician about their treatment options. And, to help make the right choices, consumers have been armed with an array of health information sites, symptom checkers, cost calculators, and provider quality scores and report cards.


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Minnesota Prescription Monitoring Program

Important updates responding to an epidemic


By Barbara A. Carter


In a recent survey conducted by the American Medical Association, in which 44 of the 49 state prescription drug monitoring programs (PDMP/PMP) responded there was a 180 percent increase, between 2014 and 2016, in the number of physicians’ and other health care professionals that had registered for an account with a PDMP/PMP.


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the opioid epidemic:

Complex problems, complex solutions

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Thursday, April 26, 2018, 1-4 pm

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Recognizing Minnesota physician volunteers

Quality reporting

The importance of accounting for social conditions


By Paul Kleeberg, MD, and Phil Deering, BA


Like many Minnesota physicians, Dr. Lynne Ogawa first saw her Minnesota Statewide Quality Reporting and Measurement System (SQRMS) outcomes toward the end of the last decade. At the time, the family practice doctor saw patients at the Fremont Clinic, located in the heart of North Minneapolis. The clinic, now part of Neighborhood HealthSource, is a Federally-Qualified Healthcare Center (FQHC). More than 80 percent of the patients she served had incomes at or below the federal poverty level (currently set at $24,600 for a family of four). Further, nearly 40 percent had no insurance, and the great majority of those insured (over 45 percent) were covered by forms of public insurance.


The SQRM numbers she saw weren’t good: Fremont Clinic, like most Minnesota community clinics, scored in the bottom 10 percent for D5, the diabetes care measures. Dr. Ogawa and her colleagues at Fremont agreed that all the elements of the D5 (A1C, blood pressure control, cholesterol control, smoking status, and daily aspirin) were important, and they did their best to ensure that their patients understood the importance of taking their medicine, eating right, and quitting smoking. Despite their best efforts, the clinic’s scores remained well below average when compared to other clinics in the state.


Then in 2007, Dr. Ogawa left Fremont and started working at Fairview’s Hiawatha Clinic, where most patients had private insurance and were above the poverty level. That year, her SQRMS measures jumped—from the bottom 10 percent to above average. In 2010, Dr. Ogawa shifted jobs again. She returned to serving low-income patients, this time at East Side Family Clinic, in the Payne Phalen neighborhood of St. Paul. Here, like at Fremont, over 85 percent of her patients have no insurance or are covered by public insurance (Medicaid, CHIP, etc.). Most patients are either Asian (many Hmong and other Southeast Asian refugees and their families) or Hispanic. Once again Dr. Ogawa saw a big change in her SQRMS numbers—East Side Family Clinic’s numbers fell into the bottom 10 percent.


The fairness of quality scores

Dr. Ogawa’s quality score rollercoaster ride from low to high back to low represents only one case, but it illustrates a persistent and troubling truth. She sees it this way: “When I treat patients, who live in stable neighborhoods, have stable incomes, and speak English as a primary language, I’m scored as an above average physician. But when I serve those who live in unstable neighborhoods, are below the poverty level, and struggle with English, the quality scores indicate I’m not doing my job as well as I should. But of course I’m the same doctor practicing medicine in the same way. What’s different is the reality of my patients’ lives.”


Her experience is not unique. Across the nation, as in Minnesota, clinics that serve populations that are more affluent and whiter tend to score well on quality measures, while those that serve low income, non-white, non-English speaking populations tend to score poorly on quality measures.

In an era where compensation is increasingly tied to quality measurement, this contradiction has powerful implications. A report prepared by the National Academy of Sciences titled Accounting for Social Risk Factors in Medicare Payment states: “…current VBP design generally does not account for the role of social risk factors in producing health care outcomes. This has led to concerns that the trend toward VBP could result in certain adverse consequences for socially at-risk populations, such as leading providers and health plans to avoid patients with social risk factors, underpayment of providers disproportionately serving socially at-risk populations (e.g., safety net providers), and thus exacerbating health disparities.”


How value-based payments affect community clinics

The Minnesota Department of Human Services (DHS) is the largest payer to clinics that serve low-income Minnesotans. Since 2013, DHS has encouraged clinics and networks to participate in Integrated Health Partnerships (IHPs). Under IHPs, “Participating providers enter into an arrangement with DHS, by which they are held accountable for the costs and quality of care their Medicaid patients receive. Providers showing an overall savings across their population, while maintaining or improving the quality of care, receive a portion of the savings. Providers who cost more over time may be required to pay back a portion of the losses.”


One of the first IHPs was the Federally Qualified Health Center Urban Health Network (FUHN). The FUHN network includes 10 of 12 FQHCs in the Minneapolis/St. Paul metro area. If the total cost of care for patients attributed to FUHN is lower than the predicted cost, DHS splits the savings with FUHN. However, these shared savings are at risk depending on quality and patient satisfaction benchmarks. Over the first three years, FUHN generated over $16 million in savings for DHS, and thus was entitled to more than $8 million in payments. However, in year three of the contract, changes made to quality measures by MN Community Measurement (MNCM), resulted in FUHN not achieving all quality benchmarks. The result? FUHN’s gains of more than $8 million were reduced by almost $400,000.


Currently, none of the SQRMS measures takes the patient population served into account, i.e., Hennepin Health Care for the Homeless clinic reports the same measures and is scored the same way as the Park Nicollet Clinic in a more affluent community like Golden Valley. This is troubling to Steve Knutson, CEO of Neighborhood HealthSource and chair of the FUHN Board of Directors, who said, “The Minnesota Community Measurement compares clinics with patient populations like ours to clinics that serve patients from wealthy communities like Edina or Minnetonka, strikes us as unfair and unscientific. We’d even be satisfied with an adequate footnote in the MNCM Report that highlights the difficulty in serving these patients, and the data complications that exist when attempting to compare provider quality. But to date, MNCM has remained essentially silent on the inaccuracies involved with such comparisons. The playing field is clearly not level.”


The effect of social risk factors

The reality that Dr. Ogawa experienced with the SQRMS rollercoaster persists. A comparison of top-performing clinics in the D5 measures to clinics serving populations with patients with Medicaid or no insurance paints a stark picture: clinics serving the neediest patients are clustered at the bottom of the report.


At the root of this tilted field is the phenomenon broadly defined by the term social determinants of health. The National Academy of Sciences report cited earlier identifies five domains of social risk factors that contribute to health:


  1. Socioeconomic position
  2. Race, ethnicity, and cultural context
  3. Gender
  4. Social relationships
  5. Residential and community context—factors that are associated with health care outcomes independent of quality of care


Numerous studies document the effects of these risk factors on patient health. Perhaps differences in life expectancy provide the starkest example of the impact of social determinants: “Life expectancy of 40-year-old men in the poorest 1% of the income distribution is 14.6 years shorter than for men in the richest 1%, and for women, the difference is 10.1 years (Chetty et al., JAMA, 2016). Data indicates that Minnesota’s perennial status in the “Top Five Healthiest States” lists does not exclude us from these glaring disparities: People in some neighborhoods of the Twin Cities have a life expectancy of greater than 83 years. But according to James Allen, PhD, at the University of Minnesota Duluth, within three miles of those affluent ZIP codes, life expectancy can drop by more than 13 years.


Attempts have been made to quantify how social determinants affect one’s health and health outcomes. In his seminal 2007 article: We Can Do Better, Stephen Schroeder estimated that health care activities contribute to 10 percent of a person’s health. Dr. David Satin, a University of Minnesota Medical School assistant professor who studies bioethics, quality improvement, and pay-for performance issues says, “It’s somewhere between 10 and 30 percent.” The percentages may be argued; however, there is general agreement that Figure 1 reflects the relatively small percentage controlled by health care providers.

Figure 1. Determinants of Health Factors that contribute to the social patterning of health, disease, and illness

Source: Kate Erickson, MSW (reprinted with permission)


How providers who serve the underserved view quality measures

The safety net providers we talked to agreed that measuring quality is an essential aspect of medicine. “Of course I need to know my diabetic patients’ A1Cs and all their D5 measures,” says Dr. Christopher Reif, a family physician who has spent more than 40 years in community clinics. “But if I have 15 minutes with a Somali patient who doesn’t speak English, and who is also dealing with depression, should I spend my time trying to convince him to quit smoking? My job as a physician is to help people lead healthy lives, where they contribute to their families and communities, maintain friendships and have a bit of joy. SQRMS doesn’t measure health. For me, it’s a daily balancing act, trying to improve our patient’s health but also realizing the financial well-being of our clinic is increasingly based on hitting the numbers required by the quality measures.”


Discussing the same issue, Dr. Ogawa brings up another wrinkle. First, like Dr. Reif, she makes it clear she supports evidence-based medicine and quality measures. “We focus on numbers because they are quantifiable and backed up by evidence. We know the evidence shows patients with A1Cs lower than 8 have a reduced risk of complications. But, I serve a lot of Hmong people and other Southeast Asians,” she says. “Many Hmong patients report to me that they feel better and are more active with community and family when their A1Cs are at 9. So, if I get them to a number (9.0) that seems to be optimal for their health, am I a bad doctor? Maybe I’m a bad doctor if I get them all down to the SQRMS goal of 8.0, where they report feeling less healthy.”


Another issue with the SQRMS measure is that many are pass/fail, based on reaching a single number, rather than rewarding an amount of improvement. Since safety net clinic patients often delay care (due to factors that include: lack of insurance, refugee status, unstable housing, and low or no income) they are often sicker than the average Minnesotan when they present at the clinic. Dr. Ogawa feels that she and other providers at her clinic don’t get credit for the very real improvements their patients achieve. “If my patient has an A1C of 12, and by the way, it’s not unusual for me to see numbers that high, and over time we get that down to 8.5, that’s real improvement. But with SQRMS, I don’t get credit for that work. On the other hand, when I worked at Fairview’s Hiawatha Clinic, and patients went from an A1C of 8.7 to 7.9, we were rewarded for achieving the SQRMS measure.”


What’s being done?

There is some good news for safety net providers who are struggling with quality measures that don’t acknowledge the burdens of poverty, race, and ethnicity, neighborhood, etc. Nationally, CMS has commissioned the National Academy of Science report cited earlier with the following recommendation (emphasis added): “The committee supports four goals of accounting for social risk factors in Medicare payment programs: reducing disparities in access, quality and outcomes; improving quality and efficient care delivery for all patients; fair and accurate reporting; and compensating health plans and providers fairly. These goals would best be achieved through payment based on performance measure scores adjusted for social risk factors (or adjusting payment directly for these risk factors) when combined with public reporting stratified by patient characteristics within reporting units.”


For Minnesota providers and patients, 2017 legislation positions our state to lead efforts to resolve issues that arise from quality measures that don’t account for social determinants of health. According to a report by MS Strategies, a non-profit consulting group (http://www.msstrat.com/), some of the key changes include:


  • Authorizing the Minnesota Department of Health to collect data on race, ethnicity, preferred language, country of origin, and other sociodemographic factors.... as required for stratification or risk adjustment of quality measures.
  • Requiring Minnesota’s DHS to adjust quality metrics appropriately for providers who primarily serve socioeconomically complex patients who ask to be scored on additional measures beyond those mandated for statewide quality measurement.
  • For IHPs, DHS is now required to risk-adjust payments for different levels of service intensity needed to address social determinants of health for some patients including those with limited English skills, cultural differences, homelessness, health disparities, and other barriers to care.
  • Finally, requiring that DHS’s new quality strategy for managed care organizations include a plan to identify, evaluate, and reduce health disparities based on an enrollee’s age, race, ethnicity, sex, primary language, or disability status.



Minnesota health care providers, policy makers, payers, and those who develop quality measures acknowledge that if quality measures are to be used to determine payment, measurement and payment methods and systems must account for patients’ social conditions. Dr. Satin recommends a three-part approach:


  • Developing alternative measures that reflect the realities of the patients being served. For example, a measure of taking stock and beginning to address the mental health, chemical dependency, or social determinants of health for diabetic patients with chronically poor blood sugar control.
  • Implementing fee schedules that compensate physicians and clinics for the complexity of serving patients from disadvantaged communities. For example, paying more for visits with complex patients who require interpreters, or who suffer from mental illness or chemical dependency, etc.
  • Applying risk-adjustment methods for the current measures to account for social determinants of health. For example, using census block data to identify disadvantaged neighborhoods and adjusting scores appropriately.


Whether Dr. Satin’s recommendations will be followed, or other methods to level the field will be implemented remains to be seen. Clearly, the cost of maintaining the status quo is too high to justify inaction.


Paul Kleeberg, MD, is a regional medical director for Aledade, Inc., a company that assists small independent primary care practices to collaborate to form MSSP ACOs and participate in commercial shared savings programs.


Phil Deering, BA, is a consultant who has worked extensively with both rural health centers and Federally Qualified Health Centers on the use of electronic health records and other technology to improve care and lower cost.

Minnesota Physician Publishing Inc. © 2017