QUARTERLY - SUMMER 2016
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Photo from Penny Hatcher, MN
Our work in the Office of Rural Health and Primary Care takes place at the intersection of health care and community development. The health care mission of rural and inner city hospitals and clinics, community health centers and other safety net providers is of course paramount. Many leaders also perceive the value of the safety net as a major employer and community economic engine. Looking at some key historical developments illustrates this convergence and points to the role of the safety net in achieving health equity.
Hospitals in the United States emerged from institutions such as almshouses that provided care and custody for the ailing poor. Rooted in this tradition of charity, hospitals trace their ancestry to the development of community efforts to shelter and care for the chronically ill, deprived, and disabled.
Philadelphia´s Pennsylvania Hospital is an example. Founded in 1751 by Benjamin Franklin, it´s the oldest hospital in the United States. One of its early physicians was Benjamin Rush, who signed the Declaration of Independence and served as Surgeon General in the Continental Army. Rush was a civic leader in Philadelphia, where he was a physician, politician, social reformer, educator and humanitarian, as well as the founder of Dickinson College. A leader of the American Enlightenment, he opposed slavery, advocated free public schools, and sought improved education for women and a more enlightened penal system.
U.S. hospitals arose from a holistic worldview that embraced what we now call the social determinants of health. The development of modern medical tools like anesthesia in the 1880s and antibiotics in the 1920s and 30s began the scientific era of medicine we´re familiar with today, and institutions adjusted accordingly.
The Economic Opportunity Act of 1964, which initiated federal support for community health centers, has a similar foundation in social determinants. In addition to funding neighborhood clinics, the law directed the federal government to focus its efforts for low income people on employment, health, housing and other educational assistance.
Recent developments to turn the U.S. health care system toward what´s called a value-based payment approach resonate with these historical roots of the health care system. To meet expectations that they improve the health of their patients and do so efficiently, more and more healthcare institutions are returning to their roots as instruments of broad community improvement. The most innovative are tackling issues such as mental health and chemical dependency, housing, employment and environmental factors that contribute to diseases like asthma.
Benjamin Rush probably wouldn't recognize the medical system of today - in his time bloodletting was a common treatment for yellow fever and other diseases - but he might see some similarities between his Revolutionary era and today´s growing appreciation for a comprehensive approach to individual and community health.
Mental Health Payment Reform
Recently, a pair of relatively quiet reforms in the mental health payment system have been moving forward very quickly. They deserve to be less quiet. In fact, the combined effect of what are called Behavioral Health Homes (BHHs), and Certified Community Behavioral Health Clinics (CCBHCs) has the potential to redesign the landscape in mental health delivery across the state. By using new payment models to create incentives for broader access and integration with other providers—particularly primary care—communities with mental health clinics can expect a new push towards coordinating care across sectors.
Behavioral Health Homes
The idea for the BHHs came out of the Affordable Care Act, which allowed states to create an optional “health home” benefit for Medicaid enrollees. Since Minnesota already had our Health Care Homes clinical model in place, the state decided to focus this new benefit on behavioral health services for people with serious mental illnesses which nearly everyone recognizes deserve better coordination of services.
After input from stakeholders, the Minnesota Department of Human Services (DHS) came up with a list of services that are required to become a BHH. In addition to the services already covered, BHHs must provide:
To provide all of these services, participating clinics must have the right staff in place. The BHH model defines three distinct roles for a clinic to qualify, all of whom must be engaged in the care of clients:
Finally, the clinic must coordinate closely with primary care. In fact, a primary care clinic can become a BHH as long as it meets all the criteria.
BHHs will be paid a per member / per month fee, based on the complexity of the needs for each client.
The BHH model is rolling out this summer, with early adopters already working on their internal structures and processes in order to become certified. There are 14 clinics in the Metro Area working towards certification, and 13 in Greater Minnesota. For Medicaid enrollees with serious mental illnesses, the BHH model creates more muscle to support coordination of care, and increase recovery.
For more details, visit the DHS BHH Services webpage.
Certified Community Behavioral Health Clinic Model
The second, perhaps more transformational mental health reform is coming online on an even faster timeline, and offers participating mental health clinics the opportunity of cost–based reimbursement. The Certified Community Behavioral Health Clinic model also stems from federal legislation—in this case the Excellence in Mental Health Act of 2014—which included the guidelines for states to build CCBHCs and federal planning money. DHS applied for a planning grant and received almost a million dollars, which is pushing this project forward quickly.
In essence, the CCBHC model is the Federally Qualified Health Center model for mental health clinics. In exchange for providing a comprehensive set of mental and chemical health services, clinics are reimbursed at cost. Participating clinics must also be governed by a community board, and they must implement care coordination agreements with other health care providers such as hospitals and clinics.
For CCBHCs, the required services are:
If a clinic cannot provide all of these services themselves, they are allowed to contract out for them in order to be certified, and all providers under contract will be reimbursed at cost.
The CCBHC model is transformational for participating clinics, and for some communities, it offers the hope of sustainable financing for a broad range of mental and chemical health services. And while CCBHC payment is also limited to Medicaid enrollees, reimbursement is not limited to a subset of the mental health population.
Just this last session, the Legislature passed over $8.5 million in funding over the next three years to continue the development of CCBHCs. Six clinics are already working on becoming CCBHC pilot sites, and three of them are rural. These “first implementers” will be able to apply for certification in July.
As these two new models progress simultaneously, the increased emphasis on better access to services and coordination across sectors should help strengthen the health care safety net. In fact, one clinic is planning to be certified as both a BHH and a CCBHC. It will be fascinating to see how the two models work in tandem to improve care.
Finally, most of the mental health community already knows these reforms are underway. For providers not familiar with these changes, it may be a good time to reach out to the mental health providers in your area—chances are, they may be reaching out to you in the near future.
For more information on these grants, please contact Primary Care Financial & Technical Assistance Programs Manager Will Wilson at 651-201-3842.
Health Workforce Planning & Analysis
Unit Supervisor Nitika Moibi
Senior Research Analyst
The Graying of Minnesota's Psychiatry and Psychology Workforce
There have been systemic and ongoing concerns about our capacity to meet our citizens’ need for mental health services. As the Affordable Care Act and mental health parity regulations have expanded access to care, the pressure on an already-strained mental health system has only grown. Much of the discussion has focused on the workforce: Minnesota employers report extreme difficulty recruiting mental health professionals, particularly those at the highest levels of education. In 2013, state legislation created a steering committee to investigate mental health workforce shortages. With membership from state agencies, educational institutions, and professional associations, that group’s efforts resulted in a number of legislative changes that will open up the pipeline to make it easier for people to enter these professions.
As important as these efforts are, will they be enough? Here, we take a look at the quiet but considerable demographic shift in two key mental health professions: psychiatry and psychology. The median age of Minnesota psychiatrists and psychologists is 55 and 57, respectively, making these two of the grayest health care professions in the state. (For comparison, the median age of Minnesota’s workforce is 41.) As shown below, more than half of licensed psychologists, and just under half of licensed psychiatrists, are age 55 or older in Minnesota.
Age of Minnesota Psychologists and Psychiatrists
Source: MDH analysis of data from the Boards of Psychology (February, 2016) and Medical Practice (November, 2015).
The vast majority of psychologists and psychiatrists over the age of 55 are still working, as shown below. Additional analyses (not shown) revealed that most of these professionals are not just working—they’re working at or near full–time. Approximately 47 percent of psychologists and 61 percent of psychiatrists age 65 and over are still working at least 30 hours per week.
Share of psychiatrists and psychologists who are still working in the profession, ages 55+
Source: MDH Physician Survey (2015) and Psychology Survey (2016).
However, these older professionals won’t keep working forever. Substantial portions of them report that they plan to leave the profession within the next five years, as shown below. Shortages and impending retirements among psychiatrists have been a concern for some time, but these data show that the loss of retiring psychologists will only exacerbate existing shortages, making it even more challenging for Minnesotans with complex and persistent mental illness to access the services of mental health professionals.
Share of psychiatrists and psychologists that plan to leave the profession within the next five years, ages 55+
Source: MDH Physician Survey (2015) and Psychology Survey (2016).
These changes will have ripple effects on Minnesota’s mental health system as a whole. Both psychiatrists and psychologists occupy special niches in the system. Psychiatrists (along with psychiatric advanced practice nurses) can prescribe medications, and psychologists alone are trained to conduct formal psychological assessments. Some psychiatric and psychological services may be assumed by others in the healthcare system, including primary care physicians and/or other licensed therapists. However, these workers are already in short supply as well. Welcome investments in Minnesota’s mental health system—such as the latest $48 million injection of new funding including $20 million to increase staffing—will help address the challenge of ensuring an adequate workforce in the years to come.
Dr. Michael Zakula
Please tell us about your professional life
I grew up in Buhl, the epicenter of Minnesota’s Iron Range, in the 1960’s and early 70’s. When you grow up in a town of 700 people, you learn a lot about your neighbors and their way of life. It shapes who you are and it most definitely impacted where I went and what I have done in life.
After finishing High School in Buhl, attended to Hibbing Junior College and completed my pre-dental studies there. On the Iron Range, parents and grandparents wanted their children and grandchildren to have the opportunity to branch out from mining and quality education was extremely important to the community. We didn’t have a four year college but our Junior Colleges were excellent and the level of teaching was outstanding.
Right after graduating from Junior College, I was accepted into the University of Minnesota School of Dentistry, which was one of the best, if not the best, dental schools in the country. Its curriculum was very clinically oriented which meant I was given the opportunity to develop proficiency through hands-on dental procedures. Some schools base their curriculum on the time you spend in the clinic. Ours was based on the number of procedures we did, (fillings, dentures, extractions, etc.). I was in the last class to attend classes in the School of Dentistry’s original Owre Hall and in the first class to use the new Moos Health Sciences Tower which was a state of the art facility and yet another example of how our state has always supported first class dental education.
I was fortunate to participate in the School of Dentistry’s first rural dentistry program and in between my Junior and Senior year, I went to Montevideo to spend the summer with Dr. Paul Thompson as my mentor. When you’re in dental school, you get one patient in the morning and one in the afternoon. When I showed up my first Monday morning with Dr. Thompson, he had six patients lined up for me in the morning and 6 patients in afternoon. Although I had already done my pediatric rotation, I hadn’t done any oral surgery yet. Dr. Thompson said, “no problem, I’ll teach you,” and he did. He showed me how to fix my own equipment, e.g., how to keep my compressor, running, because in rural Minnesota it might be days before a technician can reach you. He taught me how to run a business. He helped me hone my skills on hundreds of patients and build up my self-confidence. I learned how to be a jack-of-all trades because that’s what a rural dentist is. By the end of the summer, I knew I wanted to practice rural dentistry when I graduated. When I returned for my Senior year of dental school, it was a breeze.
During my last year of school, I was selected to receive an Army Health Professions Scholarship and upon graduation spent two years in the service in Fort Leonard Wood in Missouri as a Captain. I found out that the quality of education in Minnesota was second to none. There were six of us, all dentists fresh out of school, and from a clinical standpoint I had the most experience. In fact, I ended up taking the place of one of the oral surgeons for the better part of a year. When my service ended, I looked for an orthodontic residency that emphasized a clinical rather than a research curriculum. I chose Emory University School of Dentistry in Atlanta for that reason.
By the time I was done with my residency, I knew I wanted to work in a rural setting. I had recently gotten married and we decided we wanted to be near family. We settled on Hibbing just down the road from where I was born and I opened my practice there. In some health professions, you may only see a patient once. An orthodontist is committed to seeing that patient on a monthly basis for the next two years so it’s much more difficult to pick up and move. There’s never a good time to leave. What began as a 5 year-plan ended up being a “35-years later” plan! And I have to say I enjoyed every bit of it. When you are a rural dentist you have to figure out, as my previous mentor Dr. Thompson demonstrated, how to take the initiative and solve problems within your own community. Over the course of my career, I have had many opportunities to get involved with issues that mattered to me. In rural communities, get something done in one area often has a ripple affect of improvement throughout the rest of the community which is incredibly satisfying. That reliance on each other creates deep roots and resilience.
After a number of years in private practice, I began to see some gaps in available dental services on the Iron Range. One such service was treatment for temporomandibular disorders (TMJ or TMD). At the time, the only consistent option for treatment was to send people to the University of Minnesota. This is was one of those “jack-of-all-trades” moments. I decided to enroll in post graduate TMJ courses from the Medical College of Georgia and at the University of Minnesota so I could treat these patients. In the end, there were so many people with TMD that all I could really do was make them more comfortable. I finally had to limit what my scope of practice to treating TMD as it presented in my orthodontic patients. I trained other dentists in the area to do splint therapy so they could in turn treat their own patients.
Another area of dental services that we lacked on the Range was for cleft lip and palate. At the time, Dr. George Dinham was the only one treating patients for the condition, but he was nearing retirement and he didn’t want to quit until he found someone to replace him on the Facial Dental Clinic Team sponsored by the State of Minnesota. One Friday a month, I drove down to Duluth and served as the orthodontic consultant for the Facial Dental Team. As it turned out, the reimbursement rate for the Medicaid kids was so low and the paperwork was so time consuming that our office decided to keep treating cleft lip and palate patients but all on a pro bono basis along with the help of another couple of orthodontists in Duluth. Being able to help these kids was worth the effort and it was marvelous how our dental community came together to get it done.
About that time, the State of Minnesota was looking at combining the Hibbing Technical College, which had its own Dental Assistant Program, and the Hibbing Junior College, my alma mater. While serving on the college advisory board, it occurred to me that if they were going to reorganize the Dental Assistant Program at the college anyway, why not add a clinic so that other dental students could have access to rural patients as well? It could be a win/win for both students and patients. I got the Dean at the University of Minnesota School of Dentistry, Michael Till, and the President of Hibbing Community College, Tony Kuznik, together to talk about the idea. It took two to three years of looking for funding but those two men made it happen. It would have been so easy for each of them to throw up their hands but they were committed to working it out because it would benefit the significant dental and economic needs of local residents. Since 2002, there have been 1,000 dental students who have rotated through what is now the Hibbing Community College Dental Clinic (HCC). It is operated as a joint venture between the University of Minnesota and the HCC. The population served is primarily underserved families of St. Louis, Lake, Cook, and Carlton Counties. Dental students assigned to this clinic do at least a two week rotation here and gain experience in rural dentistry. It has become the prototype for other outreach programs around the state such as the Rice Regional Dental Clinic program.
The opportunity to become involved in solutions to problems has been extremely rewarding for me and it is all a part of what it means to practice dentistry in a rural setting. Many of us practicing on the Iron Range have become concerned that newly graduating students are not replacing dentists nearing retirement. Dental students nowadays have so much debt coming out of school (the average amount being $250,000) and the thought of setting up a private practice all by oneself can be daunting. I approached Northern Minnesota Dental, a group of us dentists who live and serve on the Range, and suggested we come up with a scholarship fund to attract young dentists to our area. I was so appreciate of the work that Dr. Till had done for the HCC that we called it the Michael J. Till - Northern Minnesota Dental Scholarship. The annual award provides financial assistance to promising dental students from rural Minnesota with the goal of having them return to practice in Greater Minnesota when they are done.
For a number of years, I had been adding my voice to those trying to convince Legislators on Dental Day at the Minnesota State Capital that we needed to address the growing shortage of dentists in the state. When Minnesota Representative Tom Rukavina’s mother was having trouble getting dental care in a Virginia nursing home, we got a dentist into the facility to see her. That opened up an opportunity to present our concerns for the future of dentistry in Minnesota in a very personal way.
I was able to make a presentation to the Iron Range Resources & Rehabilitation Board (IRRRB) who agreed to create a Dental Education Loan Forgiveness Program to attract three dentists to the Iron Range. Those three dentists came back to the Range and all three built their own new practices and eventually hired other dentists. It was such a positive investment into the community that the IRRRB provided funding for 2 more dentists. Dentists are often uniquely vested in their community. They often are their own business owners, build/rent their own office space, and hire their own staff. Once they settle, it is likely that they’ll stay. When I checked back with those first dentists funded by the IRRRB, the first one had been there for five years already. I did some quick calculations on the number of patients a dentist typically sees and how many are typically on Medicaid. I included business taxes, hiring, the financial impact in the community and I discovered that the return on the original scholarship investment was 50 to 1 on the dollar. Perhaps much higher.
In 2010, it was a natural next step to help work on the legislation that established a loan forgiveness program to attract dentists to the Taconite Assistance Area (TAA). The Minnesota Dental Foundation Board administers the program and it is named the Martha Mordini Rukavina Loan Forgiveness Program in honor of former Representative Rukavina’s late mother.
I was just finishing serving as President of the Minnesota Dental Association and participating in my first Minnesota Mission of Mercy, funded in large part by Delta Dental of Minnesota Foundation, when Rodney Young, President and CEO of Delta Dental of Minnesota and President of the Delta Dental of Minnesota Foundation, suggested I submit our loan forgiveness data and impact statement to their Foundation Board. In 2015, Delta Dental of Minnesota Foundation along with the Minnesota Dental Foundation committed $2,000,000 to the Dedicated to Minnesota Dentists (DMD) Program. The purpose is to increase Minnesotans’ access to dental care by attracting qualified dentists to the parts of Greater Minnesota and the Twin Cities that are underserved. This funding will help with dental student’s debt burdens.
In a rural setting, you might find yourself trying to find solutions that solve your immediate problem, but it is so clear that one solution will lead to others in ways you can’t predict; benefits are shared; opportunities become available. Looking back on it, it is amazing to me to see how far we’ve come in solving some of our local workforce issues.
What do you think are the most important issues facing rural health and what would make a difference; or what changes would help address those issues?
At this stage of my career, I love being involved in the Minnesota Rural Health Advisory Committee because it gives me a broader picture of how all healthcare, including oral health is changing. These workforce issues span across all the health professions. It is so refreshing to see such a committed group of people genuinely concerned about rural health coming together to advise the Commissioner of Health.
It has been extremely rewarding to discuss and research creative ideas and strategies for the future. We can’t use old solutions. We have to think outside the box and consider how best to proceed for the future. I am very optimistic when I see the passion and dedication on RHAC. It has pushed me to the next level in terms of seeing rural health as a statewide and national issue and it has made me want to stay involved and contribute what I can.
And your life away from work?
I am now retired which means more hunting, fishing, kayaking and mountain biking around Lake Vermillion. I was recently awarded the 2015 University of Minnesota Alumni Service Award and the University of Minnesota School of Dentistry Distinguished Dental Alumnus Award. Receiving this recognition was beyond my wildest dreams. When presented with the awards, I said, “It’s pretty unusual when you get to do what you love to do and then you get recognized for it.” I’ve been blessed with a wonderful profession. There’s nowhere else that I’d rather live. What I’ve been able to contribute has been hinged on what rural life has given me.
My chosen profession has not only afforded me a full and very blessed life, but I’ve been given so many opportunities to become involved in the greater community because of it. The choice to practice in rural Minnesota has been rewarding beyond my expectations.
Dr. Michael Zakula, Hibbing, is the current Licensed Health Care Professional Representative on the Rural Health Advisory Committee.
|MISSION: To promote access to quality health care for all Minnesotans. We work as partners with policymakers, providers, and rural and underserved urban communities to ensure a continuum of core health services throughout the state.|