Larry Jacobs: >> [BACKGROUND]
Good afternoon. I want

to welcome you to

this public conversation
that's been convened

by the Center for the Study
of politics and governance.

At the Humphrey School
of Public Affairs.

This is part of an ongoing
series that we've been

doing on healthcare
and other issues.

And my name is Larry Jacobs.

I'm a faculty member at

the University of Minnesota and

at the Humphrey School
of Public Affairs.

I want to welcome you to
this conversation and

also to participate
in this conversation.

You'll see at the
bottom of your screen,

there's a Q&A button.

Please, please
give us questions.

We'll get to as many
as we possibly can.

And uh we'd welcome that.

I'm very excited about
today's program.

It's on maybe the most
important issue of our time,

which is the coronavirus.

We're going to talk about the
horror of the coronavirus.

I'm sure that's going
to come up in terms

of illness and of course,

there's the economic impacts,

and we've been talking
about that since March.

Today, we're going to
take a slightly well,

a quite different take on it.

We're going to look possibility

that the coronavirus is
actually producing innovation,

innovation in our
healthcare system.

We've got a terrific panel,

and I'm very excited about this.

First, we have Craig Samitt,

who's the President and

CEO of Blue Cross Blue
Shield of Minnesota.

And with a lot of
our guests today,

they're multi talented
in a lot of ways.

Dr. Samitt is also a physician,

and he got his medical degree at

Columbia University
in New York City,

which happens to be
where I got my PhDs.

We've got that bond.

Thank you very much, Dr.
Samitt, for being with us.

We have two Minnesota
legislators who are

big players in the
healthcare area

and are quite involved
in healthcare.

Senator Michelle Benson is

the deputy majority leader.
She is a Republican.

She represents the North part of

the Twin Cities suburbs
in District 31.

She's also chair of

the Health and Human
Services Committee.

Also joining us is
Senator Matt Klein.

He represents the
Southeast Twin Cities

of the Metro area
and District five.

He also serves on
the minority side,

that's a Democrat on

the Health and Human
Services Committee.

In addition, Senator
Klein is a physician,

and he serves at the Hennepin
County Medical Center,

which is a level
one trauma center.

It is also the
Safety Net hospital

here in the Twin Cities,

in many ways, is the bedrock
of healthcare in Minnesota.

I want to thank all three

of you for joining us
today. Thank you very much.

Let me start with
the big issue here.

If you go back in
history and you look

at major crises and challenges,

whether it's a war
or it's a pandemic,

we have seen innovation.

The last pandemic back in 1918,

and other healthcare
crisis in other countries,

we've seen tremendous
investment in infrastructure.

We've seen public
health breakthroughs.

During war times,

we've seen breakthroughs
in terms of

emergency room care and

other sorts of
medical treatments.

Today, we're faced with

another set of challenges that

the coronavirus has brought to

us and there's a
conversation going

on that this experience
or horror that

we've been going through
may produce changes in

healthcare delivery and also in

the system of reimbursement
for healthcare.

Dr. Klein, I want
to start with you.

You're in the front lines

in treating
coronavirus patients,

as well as being
a public official

in the Minnesota Senate.

How do you assess where we

are in terms of
potential innovation?

Matt Klein: >> Professor,
thank you for having me on.

I think the most dramatic
and telling one,

which my colleagues
will speak to, I think,

is telemedicine, and
I'll leave it to

them to describe some of the
innovations in that area.

But one of the first things
I noticed in the hospital

shortly after the
pandemic hit was that

our occupancy rates for
hospitalizations went way

down dramatically and suddenly

and there were a lot
of reasons for that.

But one of the most
significant was that

we providers realized
that the safest place

for our patients to be was
not in an institution.

It was in the privacy
of their own homes,

if possible, sequestered
as they could.

I think that drive to

keep people safe and keep
them healthy outside

of hospitals may turn out to be

a significant shift
in our thinking.

Aligned with that, Professor

is reimbursement systems that

would reward that type of thing.

Reimbursement systems that don't

incentivize hospitals to
get people into beds,

but rather incentivize
us providers,

to keep people healthy and
keep them out of hospitals..

If we're able to we've

known for years that
we have to do that,

and we've made some baby
steps in that regard.

But this may be the
seminal event in

our lifetimes that drives us to

that in a more progressive way.

Larry Jacobs: >> Thank
you. Senator Benson,

you made a comment
in an event we did

about a month ago
that said we really

ought to be talking about
not just the heart,

but also opportunities for

innovation that led
to today's event.

I'm curious what your current
thinking is about what we

might learn or carry forward
from where we are today.

Michelle Benson: >> Well
I think, first of all,

documenting the new ideas
that are coming forward.

We talk about telemedicine.

But for example, the
Department of Human Services

has moved from word
signature to e signature.

They would have
not done that had

it not been for COVID
forcing that to change.

It might have taken years
and a lot of study,

but now what the finance
industry is doing as far as

signatures for compliance are
being done electronically.

I look at what's going to happen

in the medical device in the
pharmaceutical industry.

Now that the FDA has found a way

to move things really quickly,

we're going to have to go

back to something
a little slower.

Not everybody's going to work
in panic mode all the time.

But how do we move faster?

What needs to be done

versus what's going
to sit for a while.

I think our thinking in

government processes like that

is going to
fundamentally change,

and there's a lot of
government in healthcare.

I think I'm paying attention
and bringing that over,

I talked to a man who

worked on ventilators
because of this,

pushed forward and got
through FDA approval,

a ventilator that just
requires a gas canister.

What does that do for
healthcare in remote areas

and third world countries

where electricity
might not be reliable?

We look at ECMO that was on
the battlefield now being

completely incorporated

into our hospital
operating system.

We accelerated a
lot of innovation.

I think it's important to
recognize it documented and

not lose track of the learning,

especially for regulators.

Larry Jacobs: >> Dr.
Samitt, be curious.

Do you see a new normal

maybe emerging or at
least the outlines of it?

Craig Samitt: >> I struggle with

the terms old normal
and new normal,

and I think the term I'd

prefer to use is
a better normal.

I echo the Senator's comments.

I've long been a believer
that healthcare has been

ripe for a reinvention
and ripe for innovation.

I would venture to say

that I would not have
predicted that it would

have been 100 year
pandemic that would really

force us to really
stare honestly

at the system that
we've created,

whether the mechanism
of reimbursement,

the lack of
coordination of care,

the very facility centric
model that we've built.

The fact that care isn't as

convenient or frankly
patient centric or

service centric as we'd
like or the care that

isn't affordable on the
trajectory that it's on.

I think there will
be a better normal,

and I think that we should focus

on the better normal
as what patients want,

what our communities need.

It frankly goes beyond the
model that we've used before.

I think the model
needs to evolve,

and I very much predict that it

will take a totally
different form.

Matt Klein: >>
Professor, you give us.

Larry Jacobs: >> Senator Klein.

Matt Klein: >> Sorry to
interrupt. I just wanted to

add two other things
that I really think will

emerge out of our
changed behavior

surrounding healthcare
delivery during this time.

One is the rapid and
universal acceptance

of careful PPEs and
hygienics between patients,

which we've become adept
at fully gowning and

gloving and maintaining

sterile procedure
between patients.

Probably something that
we should be doing

every year during
flu season anyway,

preventing illness in
that fashion could really

transform the volume of

illness that we see
on a seasonal basis.

Also, this is, I
think, as you know,

has brought into high relief

the balance between physical
and spiritual health.

We've had to do some things

in terms of isolating patients.

We don't let guests
into the hospital.

We don't let guests into
congregate care facilities.

We've realized that
while that may

decrease mortality
and morbidity,

it has its own very real impact

on emotional and
spiritual health,

and trying to find
that balance is

something that's going to be

brought to the fore
by this illness.

Larry Jacobs: >> Dr. Samitt.

Craig Samitt: >> Professor,

what I would also add
to double down on

Senator Klein's comments is

the addition of social health
and health inequities.

I think we tend to think of

health care very unilaterally
as just clinical health,

but if we think about
it as clinical health,

emotional health
and social health,

we need to focus on
the intertwining of

those three as equally
important and the COVID crisis,

as well as the crisis of
racial injustice has very much

exposed an opportunity for us to

get stronger in the health of

the community by
focusing on all three.

Larry Jacobs: >> I
definitely want to come into

the question about
racial disparities.

Before we do though, I want
to make sure everyone's

following along here
on the big themes.

Dr. Klein could you give us

some very concrete examples

about how telemedicine
is being used?

I saw a study,

I think it was by
the AMA that had

asked primary care
physicians and

specialists about their level of

confidence in
telemedicine last year.

Not so high. There were a lot of

doctors who weren't
that confident in it,

and obviously,
things are changing.

We're seeing all sorts of

billing information coming
forward that shows,

as you said,
hospitals are empty,

doctors' offices are empty,

and we are much more
reliant on telemedicine.

What precisely is telemedicine?

Matt Klein: >> You bet.
Well, and this is, again,

something that we've
known we should

be doing for generations and

culture is almost impossible

to change unless it's forced.

This is forcing to change.

Physicians like me, were

trained to bring people
into the office,

make them take a
half day off work,

drive downtown, pay for
parking, come upstairs,

sit in your office
for 15 minutes,

and then leave and get a bill.

For a lot of reasons it's

pretty apparent why that's not

the best way to
deliver medicine.

If you can do it while someone

stays at work and
reports their symptoms,

tells you their temperature, and

then you treat appropriately.

Here in the hospital
where I work,

we're using it as
COVID follow ups.

You know, one of
the manifestations

of this illness is that people

may seem to be getting
better and then at

around 14 days get worse.

We arrange a televisit at

various periods after discharge

to ensure people are
still breathing well.

We send them home with an
oximeter where they can check

their oxygen level
obviously much better care

than somebody returning
in a crisis to

the hospital 14 days
later, better for them.

Physically and health wise,

but also just
better for resource

allocation in this entire field.

Larry Jacobs: >> You've
mentioned several ways in which

telemedicine could be
used, prescreening.

Do you have coronavirus?

Do you need to come
to the hospital?

Let's have a teleappointment
and look into that.

Secondly, follow up care.

Someone was in the hospital,

they've been released.
How are they doing?

Let's make sure that it's not
coming back with a surge.

There's also been
talk about using

telemedicine in the
hospital to monitor,

using advanced technology,
how patients are doing.

You might have nurses
within 10 feet,

but if you've got
monitoring of patients,

you might be able to pick up

severe incidents that are

just around the corner that
might not be apparent.

Is that also something
that you've seen?

Matt Klein: Absolutely.
We do telemetry.

We do continuous
cardiac monitoring,

continuous oxygen monitoring.

One of the things that
we've developed during

COVID is iPad visits.

Every time you enter
a patient's room,

it expands a certain amount

in personal
protective equipment,

a mask, a gown, a gloves,

a laundry bill, and so forth.

It exposes that person

entering the room to a
certain level of risk.

We've started sending
an iPad into the room

or leaving a sterilized
iPad in the room,

and people who maybe don't

clinically need to
be at the bedside,

somebody who's arranging
billing information

or follow-up demographics
or so forth,

dietary preferences,
they'll visit via

an iPad visit rather than
a direct in-person visit.

Larry Jacobs: Senator
Benson, you've talked for

a number of years
about the challenge of

providing medical care in

Minnesota with our,
what, 67 counties.

People don't think of us as
a particularly large state,

but we are, and a lot

of healthcare is concentrated
in the twin cities.

Do you see benefits to
telemedicine in terms of reaching

potentially underserved areas or

rural areas that are not
near a clinic or a hospital?

Michelle Benson: I
see an opportunity

for improved compliance
in those areas.

For example, diabetes follow-up,

really important to
have those check-ins.

I talked to physical

therapist and physical
therapy assistants

doing some telecheck-ins,

even if they can't physically
monitor the exercise,

have found much better
compliance with PT follow up.

I think that increases

accessibility for the folks
in Greater Minnesota,

but also for people who might be

home restricted in
the Metro area.

Definitely improves
the access to

specialists for people
who are distanced,

and I don't want to get into

necessarily a network
adequacy conversation,

but we want to be
cautious that we don't

reduce the physical presence of

some specialist because
that physical presence

is important as folks need.

There's nothing to
replace direct contact,

as Senator Dr. Klein talked
about, the humanness,

the spiritualness of
medical treatment,

that you can do
check-ins with a doctor,

but there are times you need to

see that professional
face to face.

I think as a supplement
to physical presence

to improve compliance,
improve follow-on care,

not just for COVID,

but if you have a surgery and

they want to check
your range of motion,

how much of that can
you do via telemed and

decide if you actually need that

physical in-person
therapy appointment.

I think those are all emerging

and are going to be
really important.

One of the things that I think

is going to come out of COVID,

with people working at home,

and this isn't just
related to health care.

But as we come out of COVID,

people have realized they
don't need to be physically in

the same place all the time
to get their work done.

I think we're going
to see people

accessing the quality of life in

Greater Minnesota and
having good healthcare

there is going to be an important
part of their decision.

Larry Jacobs: Senator
Benson, I'm curious, though,

are you worried that the
popularity of telemedicine and

perhaps it's longevity after

we get control over
the coronavirus?

That it may actually
reduce clinics and

hospitals in rural and
underserved areas.

We are seeing a significant drop

in patients, in revenue.

There is a crisis that

appears to be emerging
in those settings.

Michelle Benson:
Particularly for

Greater Minnesota hospitals,

there were, I think,

27 that were underwater
last year, financially,

and then the removal of

elective procedures threatens
their very existence.

We're going to see consolidation

of some of those
rural hospitals,

I have no doubt.

But the people are still
there who need care,

so we're going to need
a different model for

providing care to
those individuals.

Yes, there will be reduced
physical clinic space,

just as there's going to
be reduced office space.

As we do more things from

home and do more
things virtually,

just the physical
presence will reduce.

It is a concern, but again,

the focus needs to be on the
quality and availability,

and if that can be
accomplished with a lower cost

and greater ease
in mental health,

in particular,
chemical dependency,

they're seeing really
emerging success

by having someone
checking in instead of,

"I couldn't get there because

my car had a flat tire or
I couldn't get a ride."

If they can do compliance via

check-in with a medical
professional through a device,

that actually improves the
quality of their outcomes,

even if the building
they need to go

to isn't accessible
at this point.

With every change, there
is going to be disruption,

the invention of the automobile

put the buggy industry
out of business,

and we keep going back
to things like that.

But evolution is
going to happen,

innovation is going to happen,

and so not restraining it,

but perhaps directing it
is the best public policy.

Larry Jacobs: Dr. Samitt,
here we are in July,

there are certainly folks
who are worried about

the convergence of a second
wave of the coronavirus,

perhaps at the same time that
the flu season picks up.

Push us ahead a little bit.

What are the questions we
should be asking today about

how to move forward the
innovations we're already seeing?

What is it that we should
be preparing for in

July that we may need

in October and
November and December?

Craig Samitt: I think
the first thing that we

all need to think about is,

let's do what we can to really

prevent an additional surge

or a further expansion

of patients who are
COVID positive.

I think a lot of it
is more of the same.

I think in this period when
we're continuing to see

the reduction in utilization
in facilities, and, frankly,

what concerns us even more

are those patients who are
at home that don't have

COVID that are not having

the opportunity to come in and
to have preventative care.

I think we worry about
underutilization.

We very much have been
thinking about what

we're calling a day
after tomorrow,

which is when the
COVID pandemic passes,

when the economic crisis passes,

when the racial and
justice concerns

pass or are improved,

what does care look like?

For us, it's building out

an infrastructure of a
better care delivery future.

I would couple the
Senator's comments

about the expansion
of telehealth.

We very much believe that
telehealth is here to stay.

It may not be at the magnitude
that it's at here in July.

I suspect it will come

back closer to baseline,
but not completely.

But I think the other
prediction that

we may see as we think about

care delivery reinvented is
we may see the return of,

I guess, what I would call
the modern house call.

I thought I should
share some stats,

which I thought were
pretty remarkable.

In 2019, we had,

at Blue Cross, 65,000

telehealth claims
for the entire year.

In the last three months alone,

we've processed over a
million telehealth claims.

The math would suggest it's
nearly 100-fold increase.

If we think about
care previously,

care historically may have been

99% face to face in clinics,

hospitals, doctors'
offices, and 1% virtual.

But perhaps the future
will be 50% face to face

and 20% telehealth
and 30% in-home care.

I think it's those types of
models that we very much

want to and need to think
about preparing for.

Larry Jacobs: Dr. Klein,
what is it that you

would recommend
that we think about

today so that you're
in a better position

come November or December

if there is a second
wave of the coronavirus?

Matt Klein: Thank you for
that question, Larry.

The hospitalizations from
the beginning have been

the pinch point in how

a society and how a state
can care for this the best.

I appreciate that the
governor has let out

front on that by

shutting down and during

that time building up
our hospital capacity.

We have reserve capacity
at our hospitals.

Hospitals across Minnesota
are ready to amp

up intensive care unit
staffing as needed.

What we've looked for
at the legislature,

and I've partnered
with Senator Benson

and will continue to
work with her on,

is some form of temporary
medical liability.

What we may find as this surges,

which it will, is
that we are going to

ask people to practice out of

their usual scope of practice.

We're going to ask nurses
who would typically work in

an allergy clinic to come into

the hospital and help with
ventilator management.

We're going to ask family
practice docs who maybe

don't practice that
much in the hospital to

come in and do ER

work because it's simply
going to be volume issues,

and our existing staff
will become ill as well.

We have a precedent in

Minnesota when we
want to encourage

caregivers to step into

a situation where they
might be a little unsteady.

We have a good Samaritan
law that says,

listen, just go out there and
do the very best you can,

and we're going to
give you immunity

from medical liability

temporarily for
that circumstance

because we want you to dive in.

I've been working with
Senator Benson on trying to

get something like
that surrounding

COVID so that our
caregivers can feel

confident stepping
into a situation

which is not entirely
familiar to them.

Larry Jacobs: Senator Benson,
I heard your name mentioned.

Michelle Benson: There
are a lot of challenges

our healthcare system
is going to face.

I'm glad to hear
it spoken out loud

that there will be
a surge this fall.

I think there has been a level,

deaths are low,
hospitalizations are low,

ICU usage is well
within capacity.

But the reality that this is

an ever present problem for

the foreseeable future and
that as we go into fall,

we re-enter our
homes and schools,

if that becomes the case,

but we are closer together.

Viruses move very well
in those environments,

and then influenza
is going to come.

The medical liability
is about staffing,

having enough people to

care for a likely
surge in the fall.

New York Presbyterian Hospital

had respiratory therapists,

and the doctors will
correct me, normally,

respiratory therapists see
10 vent patients in a shift.

They were at 80 at

one point because they

couldn't get enough
respiratory therapists in.

Those are the things that

our healthcare system has

had the opportunity
to look at and

being able to bring in

skilled medical
professionals from

other practices in other states

is what Senator
Klein is working on.

We've learned PPE, and so I've

started checking
in with hospitals.

Are you keeping a 30-day supply?

And do you get worried when
it gets down to 30 days?

And what are the protocols
for pulling back on

PPE management if we
start to see a surge and,

for example, if the
Chinese start messing with

our supply chain
for some reason.

Those are the things we need to

look forward to in the fall.

The things that we had to
emergently deal with in March,

PPE, staffing, access to
ventilators and beds,

we just need to keep checking to

make sure that we've got a plan,

and our hospital systems

in the regions throughout
the state have been

really good at working
together to do best practices.

But the same problems
we faced in March need

to be evaluated for November
and December and forward.

Larry Jacobs: This is going
to be a big debate at

the Capitol and because
I'm certain there'll

be lawyers and patient
groups who want to

weigh in about this issue.

But it's always nice to see

a Democrat and
Republican talking

together and on the same page

and identifying similar issues,

so I applaud you for that and
look forward to the debate.

I want to pick up
on another issue.

It's actually well-framed
by a question.

How can we ensure telemedicine
makes healthcare more

affordable if you're
required to pay,

you being the insurer,

is required to pay
providers the same

for procedures done at home as

done at a hospital or a clinic?

This is known as parity.

There's a debate on
this, of course.

Dr. Samitt, what's
your view about that?

Craig Samitt: I think that
one of the ways that we would

want to think about

an opportunity to
reinvent care delivery,

and this may very much tie to

a discussion about the way that

we reimburse for outcomes

in population health
versus volume,

is we need to think
through the lens of

prevention and
wellness and avoidance

and the use of virtual care and

telehealth services for
that predominant purpose.

I think if we think about,

and Senator Klein
mentioned this,

when we think about the
way that patients have

historically
constructed a visit,

and when they arrive in
the doctor's office,

not only do they have that
visit with the doctor,

but they're more than likely
to have an imaging study,

a lab test, perhaps
a prescription,

some of which are not
necessarily needed.

When we look at the
evidence about the things

that we collectively do when
people come in face to face,

some of them are low
value and they don't

necessarily improve the quality
outcome for that patient.

Obviously with a
telehealth visit,

even if parity is the same

for the physician
component of that visit,

I think we would
think a bit more

carefully about whether all of

those supplemental charges or

supplemental expenses
would occur.

The same would be
true of urgent care.

If there's an
opportunity to bring

care into the home or care into

the community as opposed to in

an emergency room or in
an urgent care facility,

there's a likelihood that the
patient wants to stay home,

that the care can be equally
effective in the home,

and that a resulting
hospitalization wouldn't be needed.

I think in all of those ways,

telehealth could very
well be steeped in

a much more prevention
and well-oriented model

that would reduce

and eliminate some of

the unnecessary low value
downstream services.

Larry Jacobs: You've
raised a number of issues,

but I just want to focus
in on what I think are

two dimensions for the
conversation we've

been having about telemedicine.

>> One dimension is care
and we've just been

talking about prescreening
and follow up,

and the use of IT techniques

in a hospital to
monitor patients.

The other issue is
affordability and our spending.

Obviously, the healthcare
industry is huge,

it's approaching four
trillion dollars a year.

These things are not trivial
and I think, Dr. Samat,

what you're saying is,

we need to look at both of

them and prevention is
certainly part of that,

looking at ways
to move away from

simply paying for volume
of discrete services

which is known as pay for
service and move towards

a more value based
approach to reimbursement,

where you would say, pay for

someone is getting
a hip replacement.

For the hip replacement with

a penalty if that patient
has to go back into

the hospital because of

a complication that should
have been prevented.

Looking at the
affordability issue,

do you think telemedicine
is a way to save money?

Craig Samitt: >> I wouldn't
necessarily put it as

telemedicine is a
way to save money.

I think the way that
we should think about

optimizing care delivery is,

what is the right
care delivery site?

What is the right procedure?

What is the right modality
that we should use to care for

people that maximizes
their outcomes

and that is most affordable?

The challenge that we've got,

even when we think about

paying for a
telehealth visit the

same that we're paying
for a face to face visit,

maybe we're thinking
about payment all wrong.

Maybe, in essence,
what we should say is,

let's pay to ensure

that a patient is getting
exceptional care,

high levels of service,

and we'll pay a
primary care physician

a certain amount of

money totally for all the care

that they would want to
provide to a patient.

Then let the health plan
get out of the way in

terms of where's the right
site and how should we pay?

The provider then
gets to decide,

is this service best
performed in the home,

in the Cloud,

in my office, in the hospital?

I think if we changed
payment and we focus

on rewarding better
care at a lower cost,

the entire care
delivery model shifts.

Larry Jacobs: >> I take it
from what you've said that

the parity law is

not something that you
think is a great idea?

Craig Samitt: >> Well, I think
the parity law is based upon

the existing fee for

service volume based
reimbursement model.

If we believe that the
world should pivot

more to a population health
reimbursement model,

then the parity law is
somewhat less material,

it becomes a bit

irrelevant when the
reimbursement model changes.

Larry Jacobs: >> Dr. Klein, parity
law relevant. Do you agree?

Matt Klein: >> Only as a way
to shift our culture away

from in person visits
to televisits.

But professor, exactly
as Dr. Samat said,

your question about parity
presumes that we're going to

continue to reimburse
per encounter.

If that's the case,
and we do that,

no matter what you
reimburse a televisit for,

an enterprising
provider will double

their encounters to make
more money and will

continue to incentivize volume.

I agree that we need to
shift conceptually away from

those perverse
incentives towards

global health in the hospital
setting where I work,

I've advocated for
global budgets.

You give an
institution like mine,

Henpin Healthcare X
number of dollars,

$10 million for this year to
care for your population and

then you entach
quality incentives,

population based incentives.

If the vaccination rate in

your community is above
X percent next year,

you'll get an additional amount.

That would steer us
away from trying to

fill beds and order

more X rays and more towards
trying to make sure that

the people in our community
are healthy and satisfied.

Larry Jacobs: >> Senator
Benson. I think of you

as a doctor of policy.

Michelle Benson: >> I
would have to go through

your program and actually

produce thesis on that.

Larry Jacobs: >> Senator
Benson, what are your thoughts

about the parity laws?

Is this something that
we needed to jump

start telemedicine and now
should be pulling back on?

Michelle Benson: >> There was
quite a fight. Julie Rosen

actually carried this bill,

and I remember the
debate quite vociferous.

From the payer community,

why should we pay when it

doesn't cost the doctor as much?

They don't have to have as
much square footage, etc.

That's why I like to go to
and almost completely the

opposite of the two
gentlemen on the call.

I would love to see individuals

subscribe not government say,

this is how much we're going
to pay your hospital system.

But to see individuals, say,

this is how much you have for

primary care per month and
we're going to pay doctors.

Dr. Jensen introduced something

called direct primary care
which is allowed in Minnesota.

Actually, Omaha has done

a really good job of coupling

this with access to a hospital.

You subscribe and
you get what you

need and you can

leave that doctor if you
don't like that doctor.

But where they match
up really well,

and this is where good ideas
can come from all places,

if a doctor says, you know what?

I'm going to need to
see you in the office

as a follow up for that surgery,

or let me do a prescreen

at home and let's see if
you need the follow up,

that increases quality
for the patient.

It reduces wasted time for
the healthcare system.

But if we only pay for
an in office encounter,

then we've defeated
the purpose of

trying to innovate,
have minimal contact,

have the patient and doctor

be at the center of
the conversation,

and it becomes about
checking a bunch of boxes.

If we can think of it as
a subscriber service,

and maybe for public programs,

we set an amount
which we have done in

many cases and both

of my colleagues are
familiar with it.

But what if an individual

can use their money to
subscribe to a clinic and

a hospital and then
have major medical

for all of the things
that are at the top 5%?

Larry Jacobs: >> Dr. Samat,
does that sound workable

to you? You're muted.

Craig Samitt: >> Excuse me. The
model of direct primary care

and really the notion
of allowing a patient

to really select the
services that they

want and really not
have the incentives

for the physician to generate

volume based utilization has

really been in existence
for quite some time.

I very much am an advocate

for alternative primary care

and stronger primary
care models.

It certainly focuses
on what we're trying

to achieve which is
more service oriented,

higher quality, and more
affordable care models.

When we talk about care

reinvented and we talk
about payment reinvented,

I think everything needs to
be on the table as long as

the incentives that we create

reward outcomes, reward quality,

reward efficiency,

reward following of
the medical evidence,

rewarding the things
that really do

translate into a
healthier community.

We should not be rewarding
for the things that

don't generate better outcomes.

We should be creating
incentive models that

reward better care at

a lower cost for the
people we serve.

I think everything should be on

the table as we think
about those models.

Larry Jacobs: >> Senator Benson.

Michelle Benson: >> It
brought up before. We have

annual renewals for
insurance every year.

Nobody does that for their
homeowners or auto insurance.

What incentive is there for

a care system or

an insurance company
to say, you know what?

We're going to work on
your overall health.

In public programs,
there's not a lot of

incentive for saying
we're going to

work on your overall health.

We're going to have a
discussion about disparities.

If we look at disparities,

high blood pressure,

diabetes or type 2
diabetes in particular,

those seem to be more

common in some of our
minority communities which is

contributing to overall
them being less

successful in a healthcare
system that was

largely designed not
to meet their needs.

How do we start moving

towards an overall evaluation
of health instead of,

your cholesterol's high,
let's give you a drug?

Because right now,
we reward the doctor

for the 15 minute office visit

and then the scripts paid for,

and then Pharma gets therapies.

But nobody says, you know what?

You have the ability to

control some of this
on your own and it's

going to have this
much broader impact

in the overall
quality of your life.

Larry Jacobs: >> That fits
into the broad theme at least,

of value based care where
prevention would be part of it,

behavioral health
would be part of it,

as well as reimbursement
of doctors and

hospitals with the
bundling of payments.

Senator Klein, I'm going to
ask you about a theme that

your colleague just raised

which is about
racial disparities.

One of the most striking and
even shocking revelation

has been the fact that people of

color are dying and
getting sick because of

the coronavirus at much
higher rates than are whites.

What are you seeing in terms of

your practice and what concerns
you about this pattern?

Matt Klein: >> Well,
thank you for questions.

As with everything in society,

the coronavirus seems to have

brought this into high
relief as we know,

morbidity and mortality levels

for people of color are
much higher than they are

for white people in our
country with coronavirus.

To put myself in context,
I'm 52-years-old.

I went to medical
school in the '90s.

We did not learn anything about

racial disparities in
outcomes, healthcare outcomes.

Although now that it
has seen the light,

it's clear that that is a a
severe healthcare emergency

and a societal failure.

It's caused me to study myself,

study my practice and the way

I and my colleagues and the
people around us as part of

our support team have
treated patients for

the last 30 years and what
systemic racism really means.

If you were to ask me
if I'm a racist person,

I would say I personally
I'm not racist at all.

Have I participated in a system

that is guilty of
systemic racism?

Yes, absolutely.

I'll give you a concrete
example, Professor,

I began examining,
let's say we had

two identical patients come into

the emergency department and

I was going to care for them.

One was a white woman
from Golden Valley,

45-years-old with
abdominal pain and

one was an African American
woman from North Minneapolis,

45-years-old with
abdominal pain.

I began to examine

how much time would get spent

with each of those patients.

How much symptom
validation would they get?

How quick would
their pain relief

be treated and aggressively?

What studies would be
ordered and how quickly?

What would their
discharge plan be?

It becomes apparent I
think for any provider,

once you start asking those
questions and looking at

your own encounters
that people of color

have a different experience
in our healthcare system

which I think in
large part accounts

for the differences
in their outcomes.

It's something that
we really need

to dig deep individually
in terms of

our own practices to plumb

the depths of how this has

been allowed to
fester for so long.

Larry Jacobs: >>
Dr. Samat, what can

the insurance industry do to
address racial disparities?

Craig Samitt: >> Well,
I think that one of

the challenges with the
healthcare industry

is we've been forced to

stay in our lanes that

health insurance is supposedly

all about networks
and claim payment.

When in all reality,

I think that there's a role
that health plans can play,

especially given our desire
to improve outcomes for

populations that we should be

in the racial and
equity business,

the social disparities business.

Even beyond what
Senator Klein said,

even if those two
patients came into

the hospital and were
treated identically,

their outcomes may not have
been identical because

their underlying
personal circumstances

back at home or in
their communities,

whether it's housing
instability or food insecurity,

or loneliness or the
inability to see

a primary care physician

easily because of
transportation barriers,

that's the whole
notion with equity.

Equity is not treating
everyone the same,

equity is expecting that

everyone will have
identical outcomes,

that everyone has
the opportunity for

equally high quality
healthcare in our community.

From our point of view,

why can we not get into

the social determinants of

health business or the health
and equities business?

We very much believe
that we should

be in the food and
security business.

There are examples of systems in

our state that are creating

food pharmacies and what
they're finding is that

when they assure that

their community members are
getting access to food,

they see a significant reduction

in emergency room utilization.

If we believe in
improving outcomes,

why would we not be in

the food distribution business
in partnership with others

throughout the
state just to make

sure that the communities
that we serve are healthier?

I think the lines will get
blurred and that we will play

a role in helping to

support social health,
not just clinical health.

Larry Jacobs: >> Senator
Klein, I want to come back to

you on this question because I

listen to Dr. Samat and I

think about the politics
of legislature,

does this feed into

a fairly progressive agenda

about getting into
the food industry,

getting into social
determinants which is basically

the economic and social
factors that drive healthcare.

It's not always your doctor.

It's, do you have
adequate housing?

Are you living in a
community in which you

feel intense economic
stress and violence?

Is this basically a
progressive agenda?

Matt Klein: >> Well, I
suppose it's historically

been called a
progressive agenda.

Although to the extent that it

saves government
payers a lot of money,

I think it's fairly
conservative.

Again, if we had
reimbursement systems

that rewarded outcomes like

decreased racial disparities in

childbirth or improved
vaccination rates

in a community and
decreased hospitalizations,

that ends up saving

public and private payers
quite a bit of money,

and it's simply a matter
of shifting direction

from filling hospital
beds to having

caregivers in that setting
when they're with a patient

figuring out how best to take

care of the community
that they serve.

Yeah, addressing
things as healthcare,

calling things healthcare,
which traditionally have

not been called healthcare
like food insecurity,

housing instability,
addiction, poverty,

I guess gets labeled as
a progressive agenda,

but I think it has some
conservative appeal.

Craig Samitt: >> Professor,

one of the things
that I would add,

we often use the adage that

an ounce of prevention is
worth a pound of cure.

The reality is that's not
how our healthcare industry

has historically worked or
in the sickness business.

If we were truly to
invest in the ounce,

I would argue that racial
inequities, social disparities,

social determinants of
health are in that ounce,

along with many other
things that we could

do that would prevent, protect,

avoid illness so
that we don't have

all of the downstream
negative effects,

sickness, and mortality

that come with lack
of prevention.

Larry Jacobs: >>
Senator Benson, I

can anticipate some
of your comments.

Let me move to the
positive question.

Do you think there is space for

a positive bipartisan agenda
that would take the lead of

Senator Klein about
looking at moving

more to a value based
reimbursement system so

that the spending
that was going on was

focused on these broader
determinants of health?

Michelle Benson: >> I think
it's really interesting

to hear an executive from

an insurance company talking
about global budgets.

>> As I look at it, what

we've got now,

county caseworkers who
see food and housing,

and they've got all
these silos and piles.

Then in a separate lane,

we have insurance
companies under PMAP.

They're actually going
out for procurement now,

and social
determinants of health

are probably part
of that contract.

We've siloed our system.

I went down to Powderhorn Park,

and the day that I visited,

there were actually 47 or 50,

I can't remember which
day I looked at,

open slots for women
and children housing.

Why were they disconnected?

Why are we pushing all these
resources into spaces,

and bureaucracies
are in the way?

Child protection system
impacts minority communities

much harder than it impacts
our majority White community.

The destruction of families'

chemical dependency is treated

differently depending
on geographically,

actually, where
you're located has

a pretty big impact

on your access to
chemical dependency.

Siloing of our system
is problematic.

I'd like to look at
how we reduce silos.

We're going into a pretty
tough budget year,

so tough sledding, if you say,

we want to increase
payments overall,

but how do we reduce silos?

Put the individual at
the center and say,

here are the resources
that we have

available and for this audience,

this might be a stretch.

In the disability community,

and Senator Klein has sat in
on many of these hearings.

For the disability community,

our first decision used to be,

how are they safe?

They were institutionalized and

now it has taken a long time,

but we're moving to how do

they get to live the
life that they choose?

Then we make sure that there

is support and safety available.

Maybe some of the paradigm of if

someone has multiple
complex health issues,

maybe it's not about

all the individual
silos that serve them,

but how do they make choices
that have good outcomes over

a number of years instead of the

immediate 60-day,
90-day turnaround?

That innovation, I think,

is always going to be welcome.

I think it's a little tough to

find money for everything,

but if we can break down silos,

resources can be more flexible.

Larry Jacobs: >> Time is
running down, so I want

to raise a couple issues.

Dr. Samitt, a question

from one of the folks
who's listening in.

Should Minnesota medical
licensing requirements

be adjusted to allow

providers to virtually see
patients across state lines?

Craig Samitt: >>
The challenge with

credentialing and
licensing is to assure

that there is a mechanism to
guarantee qualifications,

capabilities, and
high-quality outcomes.

I think that has often
been reserved to

either specific institutions
like health plans or

hospitals where
delegation exists

or with state boundaries.

I think if we were
to think about

extending licensing and
credentialing more broadly,

we would all likely want

some assurances that the
care that I'm receiving

virtually is not
by a provider that

hasn't been held to
the same level of

scrutiny that my state
would be held to.

I don't mean to
hedge your question,

but I think that as long
as a mechanism could be

created that there's
universality,

the highest possible bar

to assure that
credentialing is done

accurately and correctly
to check for quality,

then we could potentially
see extension

of those rules
beyond state lines.

But I'd very much be

interested in my colleague's
point of view on that.

Larry Jacobs: >>
Well, this is one of

the most political
issues out there,

and I want to give you an A plus

for very agilely handling it.

It's one of the ideas that

Republican lawmakers
in Washington,

around the country have

talked about as a
way to lower cost.

We're not going to go into
it because I want to ask

a different question
to Senator Klein.

We're seeing and this
conversation is a good example of

the focus on biological,
physiological health.

We've talked a bit
about prevention,

but we have not talked about

the infrastructure
for public health.

I think the assumption of

this conversation
is the next step,

the yesterday that Dr.
Samitt has referred to,

is going to be looking
at the biological,

physiological side
of healthcare.

Are you concerned that
we are not now talking

about and planning for the
tomorrow public health system?

Matt Klein: >> Well, that's
a really good point.

Public health was the
red-headed stepchild

of healthcare all along,

and all of a sudden it's got

the spotlight on it
and we're figuring out

what happens when you wash

your hands and when you

socially distance
and wear a mask.

Virtually everybody is a
public health expert now,

if you go on the Internet.

It's got a lot of attention
that it never had before.

No, I'm not concerned.

I think similar to your
opening question to

this forum is this is

one of the things that maybe we

should have been
doing 10 years ago,

talking about public health,

talking about prevention,

and now it's got a
big spotlight on it,

so here's our moment to

fortify it and become
educated about it

and realize why it's a
more important thing than

just going into

the emergency department
when you have a finger cut.

Larry Jacobs: >> Senator
Benson, could you envision

the next session legislature,

meaning starting in 2021,

major legislation in
Minnesota to improve

our public health system that
would encompass testing,

contact tracing,
just really prepare

us for the next pandemic
that might come through?

Michelle Benson: >>
Well, most people aren't

aware we've always done testing,

tracing, and tracking.

We did it for syphilis.

We've done it for TV,
we've done it for

measles. They're big three.

Really uncomfortable to
be in a conversation with

the governor talking about
a syphilis outbreak,

but we do this.

What happened?

Global pandemics come
once every hundred years,

and we couldn't flex
up fast enough.

Our systems were antiquated.

Yes, there needs to
be some improvements.

But one of the warnings

that we need to take in
government is not to overreact.

Let's look at what we're

going to realistically need
over the next five years.

Influenza comes every year.

We try to do testing, tracking,

and tracing for influenza.

What is a stable but flex
up structure look like?

We talked about
the pandemic 1918,

the pandemic now,

we have had SARS,

we had H1N1,

and we did Ebola response.

Do folks remember what
we did for Ebola?

It was amazing.

It was one of my first
introductions to

the importance of public health.

How do we build a system
that's stronger than it

was before COVID without
being oversized,

but can flex up?

What's a five year need look

like and do continuing
evaluations and improvements?

We're going to get some
best practices out of this.

Pay attention to those,

put away the things
that didn't work.

But being cautious about
a level of overreaction.

We don't have resources to build

a pandemic level response

that is a permanent
infrastructure.

Larry Jacobs: >> Thank
you, Dr. Samitt,

I've got a very unfair question.

We've run out of time,

but I can't leave it
without raising it.

We've seen the Federal
Drug Administration

expedite its review and

approval of treatments and

vaccines because of the
coronavirus crisis.

Does that strike
you as an area for

careful examination in terms of

the yesterday that you
were referring to?

Craig Samitt: >> I think that

it's yet another
complicated question,

and I wouldn't say
it's necessarily

unfair because on the one hand,

we certainly want to expedite

the availability of
treatments that work.

On the other hand,

are we giving it ample
time to understand

whether those drugs do work
and whether they're safe?

What we may very
well need to see,

and I think that this was in
development pre COVID was,

is there a way to think

about testing and trials
of drugs a little

bit differently
through the lens of

real world experience or

real world evidence
that essentially says,

can we bring things
to market sooner,

but then continue

the comparative testing
afterwards with populations

to understand after
they come to market

whether they are as effective

as they were presumed to be?

The question is, is there a
model that is a bit more of

a balance of speed and efficacy?

We've been overly
cautious in approvals.

I think that is for good reason,

but it has slowed down

the development and
the introduction

to market of new drugs.

That being said,

we then need to find an
alternative way to make sure

that they work and

that they're safe for
people who take them.

Larry Jacobs: >> It's a
very well crafted answer.

Just to fill out a little
bit on the timeline,

I think the average now is
well above seven years in

terms of the initial filing
to when there's a decision.

It's not either or,
as you've said,

we've had periods where

drugs have been
approved quickly,

and then there have been
horrific consequences

that dominate
congressional hearings

and lead to

some really just horrific
health complications,

birth defects, deaths,

heart attacks. It's a misery.

Craig Samitt: >> Maybe the
thing is that we need to

understand safety first
and maybe efficacy second.

I know that seems odd for a
health plan executive to say.

But the most important
thing is safety first.

But then if something is safe,

but it isn't effective and most

certainly if it's
very high cost,

then we need to keep re-evaluating
those drugs and then

take them off the market or

move them to other alternatives.

Frankly, they're not delivering

the results that were
predicted or expected.

Larry Jacobs: >> Just for
folks who are wondering

this terminology of
efficacy and safety,

that is the framework that
the FDA works within,

and there's been
debate about this for

just about six decades,
fairly intense nature.

But I think the way you
put it about re-examining.

We are out of time, and I
want to respect your time.

I'm going to just do
a couple last things

first for folks who've
enjoyed this program,

I want to give you a heads
up, what we've got coming up.

The Center for the
Study of Politics and

Governance is one
of the leading,

training areas for
election administration.

If you're interested in
either entering the area of

election administration and
working for our democracy,

you might be interested in this.

We've got information
session coming up on Monday.

It'll be at noon Central Time.

You'll have alumni.

There'll be information about

this remarkable
programs now turning

out nonpartisan professional
election officials.

Coming up next Wednesday is
one of my favorite program.

It's on American conservatism,

and our focus is from Ronald
Reagan to Donald Trump.

We've got some
terrific panelists,

including Peter Wehner,

who is a Reagan
administration official

and a rock solid conservative.

That'll be a terrific program.

Then we've got a program
coming up in mid August,

August 13th on
election security.

We're going to get into issues

about the threats that we
are now seeing from Russia,

Iran, China,

how they're being handled.

Unlike 2016, we have seen

a massive ramp up of
efforts on security with

a terrific partnership
between Washington and

the US Department of
Homeland Security,

as well as the states
and the counties.

It's a great story that's
coming up August 13th.

I want to thank you
for joining us.

I also want to thank Blue
Cross and Blue Shield of

Minnesota who sponsored
today's programs,

and I think it's seven years

of programs that we've
been doing in partnership.

I want to thank my good
friend and partner,

Scott Keefer, who's been

integral to all of this

and a good personal
friend of mine.

If you're interested
in this program,

you can catch the recording,

which we'll be
distributing by tomorrow.

I want to thank Mike Cary,

who handled all the IT stuff.

He's really the producer of
this program. Thank you.

Kate Cimino, who is

the Assistant Director of

the Center and the
master of all.

Thank you very much
for joining us.

I want to thank our
guests who are terrific.

I promised a great panel,

and I think you all
over delivered.

Thank you, Senator
Benson, Senator Klein,

Dr. Samitt illuminating,

and I think we can go
on for two more hours.

Have a good day.
Thank you very much.

Michelle Benson: >> Thank you.

Matt Klein: >> Thank you.