Minnesota’s journey toward universal coverage

Notes from the Council’s early years show how people who believe in human wellbeing can come together to make progress. Through decades of change, reform and reaction, managed care is still a force for good in Minnesota — not just because it’s a practical idea. It’s the human caring and expertise of Minnesota’s nonprofit health insurers that matters most.

Find out about the early history of managed care, MinnesotaCare and more from the people who helped make it happen.


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The Courage to Innovate: Hennepin Health

Addiction is on the rise, and one doctor is determined to stop it. How a small grant from a health insurer gave a physician the time and help she needed to save more lives at Hennepin County Medical Center.

An epidemic of poisoning
In 2016, opioids killed 153 people in Hennepin County. That year deaths from cocaine and amphetamines rose dramatically too, and 84 county residents died after what the sheriff calls “acute alcohol intoxication.”

Those startling figures don’t even account for the many, many more Hennepin County residents killed by addiction in subtler ways: by drug-related violence, in accidents caused by people too impaired to walk or drive, by cirrhosis or hepatitis C, by despair and suicide.

Even Minnesota, nationally renowned for treatment centers and a thriving culture of recovery, addiction is killing more and more of us all the time. Many people see the epidemic of substance addiction as a moral and social crisis. But addiction might also be something much simpler — and maybe much easier to remedy.

Dr. JoAn Laes

JoAn Laes, M.D., is an addiction medicine specialist, and she was frustrated. At Hennepin County Medical Center (HCMC), where she works in the addiction medicine department, she’d see patients come into the hospital after an overdose of alcohol, opiates or some other mood-altering substance. She and her colleagues would treat the acute poisoning, then the patient would leave — usually without getting any help for the underlying addiction.

“People would show up with a drug overdose,” Dr. Laes recalls, “and there wasn’t much we could do. Maybe there was a drug and alcohol counselor available to talk to them, but probably not — there were only two counselors for our 500-bed hospital. So we basically had to give these patients lists of phone numbers for treatment options and tell them, ‘Follow up on your own.’” Needless to say, that approach didn’t work very well. “We’d see many of these patients multiple times, after multiple overdoses,” Dr. Laes says.

For an addictionologist, little could be more distressing than to watch people get poisoned, again and again, by the same deadly chemicals. Worse yet, Dr. Laes knew she could help change the course of many patients’ addiction, by writing a prescription for drugs like naltrexone or acamprosate that work by diminishing the power of addictive craving in the brain.

“These medications aren’t new, but our health system doesn’t yet use them very widely,” Dr. Laes explains. “Our counselors, who knew a lot about behavioral addiction treatment, weren’t trained to talk to patients about these other therapies. Most patients didn’t even know they had medical options.” And so the epidemic of poisoning continued.

In frustration, Dr. Laes came up with an idea: What if she and her colleagues could not only treat patients for overdoses, but also for the underlying chemical dependency? To make that more aggressive outreach work, she thought, HCMC would need more help — maybe another Licensed Drug and Alcohol Counselor (LADC), a physician assistant or nurse practitioner, maybe time to consult with other physicians. They’d definitely need to bring the LADCs they had under the umbrella of addiction medicine, so they could coordinate their work with the addiction medicine specialists and other clinical staff.

“I just want to do inpatient consultations with patients who have addictions,” she told an HCMC colleague one day. “How can I get this started?”

Well, her colleague told her, there was actually a program especially designed to get just such ideas off the ground — grants to support experiments aimed at improving the health of people in Hennepin County. Dr. Laes applied for a grant for her idea, and she got it. The work began in October 2015. Two years later, HCMC hasn’t treated addiction the same way since.

The courage to innovate
The money to fund Dr. Laes’s idea came from Hennepin Health, the county-owned health insurer that provides care for people with Medical Assistance insurance. Ross Owen, health strategy director for Hennepin County, smiles when he remembers Dr. Laes’s application for funding. “She’s a doctor who realized that people admitted to HCMC weren’t being treated for addiction,” he says. That’s a little crazy, he adds, “since the people we care for are deeply affected by addiction.” When her proposal came in, it sounded like exactly the kind of experiment Hennepin Health wanted to encourage.

Where does this money come from? “After we’ve paid for our members’ medical bills and operated our health plan, we take resources that are left over and share them with our partner organizations that work with us to care for county residents — HCMC, NorthPoint Health Center, Hennepin County,” Ross explains. “And some of that money funds what we call reinvestment initiatives. We solicit proposals for improving how we care for people. Every year, we fund a few projects, from six to ten or so. We measure the impact of those projects and bring that information back into the work we do. It’s a way for us to try new ideas, to take risks, to see what new practices might work — and to shore up infrastructure and plan for the long term to create better health for people in Hennepin County.”

“It’s intentional,” says Amy Harris-Overby, director of HCMC’s population health program. “With these grants, Hennepin Health is intentionally taking the value that’s been created in the health plan and creating public benefit by testing new ideas.” The best thing about the reinvestment grants, she says, is simple: “They give us the courage to innovate. Every project we approve has merit, and we give it a chance. Sometimes they work beautifully; other times, we have to admit they don’t, and learn from the failure.”

Amy Harris-Overby and Ross Owen

What does failure look like? Amy and Ross chuckle as they reel off a list of promising reinvestment projects that just didn’t turn out to work. Their favorite example was the time when Hennepin Health got into the business of renting apartments. “Up to half of our members don’t have housing they can count on,” Ross says, “and our teams of social workers hustle all day to help people who are sick find a safe place to stay. The idea was, why not just rent a block of apartments ourselves, so we wouldn’t have to deal with landlords?” It was a radical and brilliant idea — and testing it out showed conclusively that it didn’t work. “Instructive failure,” as Amy calls it, is actually success. By funding small, promising projects, measuring them and learning from them, Hennepin Health behaves more like a startup than like an old-fashioned HMO. They move fast, they learn each experiment, they jettison what fails and double down on demonstrated success.

“We already pay”
For a county-operated insurer like Hennepin Health, success means a measurably better life for county residents — less expensive health care, better experiences for patients, more effective medical care and prevention. But beyond the usual horizon of health care, Hennepin Health and its partners think of their work in the broadest possible terms. “As a part of Hennepin County,” Ross says, “we are the people who bear the cost of inequities and poor health, outside our role as a health plan.”

The connections between medical care and overall community health are sometimes hard to understand, and Ross and Amy take every opportunity to explain them. People in Hennepin County who get health insurance throughMedicaid — many whom are Hennepin Health members — account for more than half of the county’s corrections budget, Ross explains, and more than half of visits to emergency shelters. “If we can’t keep our people well,” he adds, “everyone in Hennepin County is going to pay for the care they need, in one way or another. We already pay — in the criminal-justice system, in public safety, in the foster-care system.”
The only question is whether public resources would be better spent getting people well than in locking them up, policing them or taking away their children. That’s what reinvestment grants are designed to find out.

An antidote for hopelessness
With their grant funding, Dr. Laes and her colleagues hired a new LADC to counsel people who come to HCMC with substance problems. They hired a new advanced practice provider to talk to people while they are in a hospital bed recovering. Even more importantly, she says, “the Hennepin Health grant allowed us to take a team approach. The counselors have better connections to me and my colleagues, and we work together to make sure that each patient has the best long-term care plan possible. We meet all the time, we talk about our patients, and we coordinate between what happens in the hospital and where they go next.”

The long-term plan is just as important as the inpatient consultation. “The LADCs are integral to the work we do,” says Dr. Laes. “They know the entire community network of treatment options, help make appointments for patients and help them access funding for treatment. Physicians and physician assistants like me get people with opiate use disorder hooked up with our addiction medicine program, which uses medication-assisted treatments like methadone or buprenorphine. We have an outpatient clinic, where we follow up with people to continue any medications we start in the hospital.”

The evidence Dr. Laes amassed during the grant period made a compelling case for the work they were doing. In a three-month period, the LADC worked with 333 HCMC patients, and the physician and advanced practice provider consulted with 72. The need for their help was clear: tree out of four of those patients said they were currently using alcohol, 28 percent said they were using stimulants, 22 percent reported using opioids. But the big news, for Dr. Laes and Hennepin Health, was what those consultations accomplished. “We found a 4.4% decrease in 90-day readmissions for patients with substance use diagnoses,” Dr. Laes reports, “and a 2.5% decrease for patients with alcohol.”

Beyond readmission metrics, the payoff of Dr. Laes’s work happens right there at the bedside of a patient who’s suffering. “Most of the time, my patients haven’t heard of the medications we can offer them to treat their addiction,” she says. “They tell me, ‘I’ve been through 28-day treatment 20 times, and then I fall back into my old habits. I’ve learned what treatment programs have to teach me. I just can’t change.’” To people who’ve felt it, that hopelessness is the most toxic poison of all.

“Then I tell them about naltrexone or acamprosate, and we get it started right there while they’re still in the hospital.” She pauses for a second, then smiles: “It’s generally a pretty good visit.” ☤


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ACOs build toward the future

What happens when you realize doctors and insurers, patients and employers are all on the same side? Great care that’s less expensive.


Read how an ACO pioneer is reinventing care for Minnesotans.


Taking health care personally
When you ask an insurance company vice president about the benefits of accountable care organizations, or ACOs, you expect to hear talking points and impressive figures. But Christine Finn, vice president of sales communications at Medica, says something unexpected. “I belong to an ACO,” she says. “When I go to the doctor, all my records are in one place — I don’t have to say the same thing over and over.” If you’ve ever filled out the same form in a new doctor’s office for the umpteenth time — and chances are you have — you’ll understand why simply not repeating yourself makes such a huge difference.

Chris Finn, Medica

Ken Horstman, University of Minnesota

Lisa Span, Medica


Chris has responsibility for sales communications at Medica, but she talks about her ACO from a patient’s perspective. That’s as it should be, she explains. “The accountability in ‘accountable care’ is something we take personally,” says Chris. “Medica, with our health care provider partners, takes accountability for driving improvements in health care that affect our members. Including me.”

Today, nearly 50,000 receive their health care through one of six ACO networks and eight leading health systems — Altru, Essentia Health, HealthEast, Fairview, Mayo Clinic Health System, North Memorial, Park Nicollet and Ridgeview Community Network.


Starting from common ground
The basic principles of accountable care organizations, like Medica’s, are easy to understand. First, ACOs assume that insurers, employers, medical professionals and patients can and do want to achieve better medical results at lower prices. With that fundamental agreement in mind, ACOs set up payment structures that reward quality and efficient care — then pass any resulting savings on to everybody involved.
“Medica was the first health plan in the region to align with a health system to develop an ACO,” says Chris. Back in 2012, Medica’s partnership with Fairview Health Services was innovative and market-leading. Medica’s partnership with Fairview was so successful that the insurer decided to double down on the collaborative model.
“By now,” Chris says, “we’ve had ACOs in place long enough to prove they’re delivering meaningful improvements.” Members enrolled in ACOs average:

  • a 12 percent increase in the use of preventative services
  • nearly 14 percent fewer ER visits
  • 16 percent fewer hospital admissions
  • increased use of affordable generic medications

“We’re not just giving lip service to efficiency. With our ACO partners, we’re keeping people healthier, for less.” How much less?


Employers who choose ACOs are spending up to 15 percent less than they would with broad-network plans and employees enroll year-after-year. That’s how ACOs quickly became one of Medica’s most popular health insurance options.


Better care for less
Better care for less sounded like a very good bargain to large employers, for whom health insurance is a massive and growing expense. The University of Minnesota, one of the best research institutions in the nation and the world, is also the state’s sixth-largest employer.


“When ACOs came along a few years ago, we saw them as a way to address care and cost all in one package,” says Ken Horstman, the university’s senior director for total compensation.


But the ACO model could be a challenge for University employees to accept. Like many other Minnesotans, U of M employees had been accustomed to “open-access” policies, which let them see any doctor or hospital they preferred, and enrolling in an ACO plan would mean choosing from a smaller selection of in-network care providers. “We did not know what the first-year experience would be,” Ken says, “but 95 percent of the employees who chose the ACO plan stayed in it the next year.”
Employees liked it, and the University did too. “After the first year,” Ken recalls, “we looked at the utilization experience, risk reduction and average medical cost for employees and families who’d switched into an ACO and compared it with their experience from the year before, under a broad-network plan. The same employees, on average, had lower costs with the ACO.”


With results like those, Ken and his colleagues decided to encourage even more university employees to join ACOs. “We’ve made a commitment that we’re going to support more of the overall premium for our employees who choose ACO plans,” he says, “in the belief that members’ experience with the ACO will continue to be positive and that their overall health will be supported.” This year, about 15 percent of the 38,000 people insured through the University are enrolled in ACO networks, and Ken anticipates that more will make the leap as time goes by.


Like Chris Finn, Ken knows the benefits of ACOs from personal experience. “I took my family into the ACO this year,” he says. “I got a call from my clinic and from an ACO representative to encourage us to stay in touch if we had questions. My son got a call from them saying that they’d noticed a gap in care for his asthma, and offered to help him get that taken care of.” Before joining the ACO, Ken observes with delight, “the only time we ever got a call from a clinic ever at our house, it was from our dog’s vet! This was the first time I’d ever received a call from a medical provider without asking for it.”


The benefits of partnership
Why are Medica’s ACO partnerships working so well? Better health care happens when you start from the assumption that everybody — employees and their employers, doctors and nurses, hospitals and insurers — is on the side of wellbeing. For insurers and health care providers, traditionally at odds, that shift to agreement has been particularly fruitful.
“I love this work because we’re coming at it with a new mentality,” says Lisa Spann, Medica’s director of market and product efficiencies. “We’re not going into it with our traditional mindset. Instead of looking at health care from an insurer’s perspective, we sit down together with providers. By having these conversations together, the dialogue shifts. We start asking, ‘How would our members experience this? What really matters to them?’ The ACO is more than just a new model for reimbursing providers,” she adds. “It enables real creativity.”


Lisa’s work brings her into contact with Medica’s six ACO partners every day, so she understands the difficulties — and the rewards — of crossing old institutional boundaries to put wellbeing first. When she thinks about the future of health care in Minnesota and beyond, she sees challenges. “There’s a long way to go,” Lisa admits. “But we’re tackling the first step. We’re creating infrastructure between payer and provider, and establishing real trust. Once we’ve got that, we can tackle any problem.”

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Depression, race, opportunity for health, explorer Bancroft all at upcoming conference

Where can you find conversations about mental health, equal opportunity for health and using data in exploration and more all in one place? At the MN Community Measurement Annual Conference. Join the conversations 8:15 to 5 p.m., Sept. 15, at the Earle Brown Heritage Center in Brooklyn Center.
Ann Bancroft, one of the world’s preeminent polar explorers and internationally recognized leader, will start the day off with her stories of discovery, pioneering, exploration and using measurement and data to help her and others navigate expeditions.
In the afternoon, Stephen Nelson, M.D, director of the Sickle Cell Clinic at Children’s of Minnesota, will speak about race, racism and how we can all give Minnesotans the opportunity for health and well-being.
Topics throughout the day include adolescent depression and mental health, medical expenses and what we can do to improve the care Minnesotans get.
Find out more and register at MN Community Measurement.

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Patients rate knee, back surgeries

Thousands of Minnesotans have surgeries on their knees and back. How do they feel after the surgery compared to before? MN Community Measurement asked. Here’s what patients reported.

The details are here and you’ll see the amount of improvement varies by where the patient went for surgery.

Minnesota is the first state in the nation to collect and publicly release results for three orthopedic surgeries: total knee replacement and back surgeries. Back surgeries in this report are lumbar fusion, which joins vertebrae in the lower back so they heal into a single bone, and herniated disc, removing all or part of the damaged disc that is causing problems.
Note when you look at the report, the back surgeries rated on a 100-point scale, measure how much pain, function and mobility improved. The knee surgery rating is a 48-point scale; the higher the score the better the knee worked.

“It is important to understand the effectiveness of these surgeries because the demand for them is growing.” – Ed Ehlinger, M.D., commissioner, Minnesota department of health

Detailed information on each type of surgery is available here. And you can find out more from the Minnesota Department of Health.

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Minnesota’s clinics rated in Consumer Reports magazine

In the May issue of Consumer Reports, a special insert includes ratings on 500 primary care clinics across the state. The ratings, which reflect the same data as what is currently on MNHealthScores.org, provide Minnesotans with objective information on the quality of care for colon cancer screening, diabetes care and vascular care. Clinics were included in the insert if they had enough data to report on at least two of the three measure areas.

These ratings give Minnesotans a window into how their doctors compare. Known as the Doctor Project, the effort was funded by the Robert Wood Johnson Foundation and was led in Minnesota by our colleagues at MN Community Measurement.


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