Lauren Gilchrist, Special
Advisor to the Governor for Health Reform
An Interview with The Civic
2104 Girard Avenue South,
Notes of the Discussion
Broden, Janis Clay, Rick Dornfeld, Lauren Gilchrist, Paul Gilje
(coordinator), Curt Johnson, Randy Johnson, Verne Johnson (chair), Sallie
Kemper, Ted Kolderie, Dan Loritz (vice chair), Walt McClure, Wayne Popham,
Dana Schroeder, Clarence Shallbetter.
Summary of Discussion: Lauren
Gilchrist, Special Advisor to the Governor for Health Reform,
distinguishes between three main healthcare issues: access to health care,
quality of health care, and management of health factors external to the
health care system. She cites the difficult challenges of increasing
numbers of uninsured, variation in quality of care, and rising costs. The
administration advocates a "triple aim" of better care, better health and
lower costs. That goal will be advanced, she believes, both through the
continued development of the state's health exchange and with enactment of
several key recommendations of the Governor's health reform task force.
Those recommendations include measures to increase access, support
accountable care organizations and prevention efforts, broaden the use of
electronic healthcare records, make more effective use of all levels of
health care professionals and increase the ranks of primary care
Introduction of the
Gilchrist is Special Advisor to the Governor for Health Reform. In this
role, Gilchrist works with governor
Dayton, state agencies and
other public and private stakeholders to implement health reform
Gilchrist previously served as health
policy advisor to US Senator Al Franken and received the Congressional
Staff of the Year award from the American Diabetes Association for her
work on the Affordable Care Act. She also served on the US Senate Health,
Education, Labor & Pensions committee as a public health policy fellow for
Chairman Edward Kennedy and contributed to the framing of the Affordable
Prior to her work in Washington
DC, Gilchrist was Outreach Director
for the U of M Powell Center for Women's Health and worked in direct
service with women and at-risk youth. She holds a Master's degree in
Public Health in Maternal Child Health and Epidemiology from the
University of Minnesota.
Lauren Gilchrist asserts that the broad
term "health care" is best understood as a continuum of health-related
issues. The problems encountered in "health care" are best defined if we
separately consider the issues unique to three different parts of that
There is the process of getting the care
that people need. That's the access and insurance coverage part of the
problem: How do people get to the care they need?
There is the quality of the care itself
once people have accessed the health care system: How do we make sure
people get the best care possible?
There are health matters that arise
outside of the health care system. Up to 70 percent or more of our
health is determined by factors outside of health care: how much
education we have; where we live; what kind of work we do. We can't
ignore that 70 percent, she said. The problem becomes: How do we
support health outside of the health care system?
Gilchrist said Minnesota is currently
sixth in the nation in overall health indicators, a drop from first place
in 2005.Some of that decline, she said, is attributable to trends in the
Increase in number of uninsured.
In 2001, about six percent of Minnesotans were uninsured; we're now at
nine percent and have been holding steady there. We need to be sure
we're getting people access to the care they need.
Large variation in the quality of health
care. Gilchrist said
Minnesota is unique in having a very strong health measurement
infrastructure, so we know where the variation is. Most states don't
have this type of information.
She gave the example of best practices for optimal diabetes care. "We
have pockets of the state where the majority of people with diabetes are
getting the ideal care for diabetes," she said. "We have other parts of
the state, such as northeastern Minnesota, where maybe 10 or 15 percent
of people are getting optimal diabetes care. We have a really broad
range in quality of care. Overall, Minnesota has 20 percent of people
getting optimal care for diabetes."
Rising health costs.
Gilchrist said health care costs per capita are on an unsustainable
trajectory, with seven to eight percent cost growth each year in
Fourteen percent of the state economy is
health care and that's just at the beginning of the baby boomers retiring.
She noted that by 2030, there will be 165,000 Minnesotans over 85 and
health care spending increases with age.
"It's sobering to look at those numbers," Gilchrist said. "This is really
a potential crisis."
Minnesota must look at the triple aim:
better care, better health and lower cost. Gilchrist said Minnesota
Governor Mark Dayton put forth a vision of health care reform based on
achieving better care, better health and lower cost all together. Those
three goals together are called the "triple aim."
The Minnesota Health Care Reform Task
Force, appointed last November by Gov. Dayton, is charged with providing
leadership and advice on how Minnesota should move forward on the triple
aim. The task force will develop recommendations to the governor and the
legislature by Nov. 30, 2012.
The task force, which has 17 members,
includes legislators, commissioners and representatives across the
spectrum of health care-public health and prevention all the way to
long-term care. "We need to be talking about these things all at the same
table," Gilchrist said. "We've been able to create a forum where there has
been substantive and civil discussion around some really tough issues."
The task force has developed the following
principles to guide its work:
The outcome of health reform should be
to maximize health and functioning for all Minnesotans at a cost that is
sustainable for our economy.
All Minnesotans should have affordable
and portable health care coverage and accessible, high-quality services
at predictable costs.
We must create and restructure health
delivery services and payment approaches to support high-value care that
centers on the needs of all Minnesotans.
Minnesotans should be engaged in their
own health and health care, including awareness of the costs, risks and
benefits of health services and health behaviors.
Health reform should take into
consideration that other areas, such as education, economic development,
housing and transportation, have powerful influences on health outcomes.
Prevention of avoidable health problems
and complications should be central to health reform efforts. For
example, it would be better if we prevented diabetes, rather than having
optimal care for those who have it, Gilchrist said. "We need to look at
primary prevention-preventing disease before it occurs."
We must reduce health disparities and
increase health equity through all efforts. One of Minnesota's weaker
points, she said, is variability in health care quality. We are one of
the healthiest states overall, but if we compare the healthiest
Minnesotans to the least healthy Minnesotans, we have one of largest
gaps in the country. We need to close the gap by bringing up the lowest
Minnesotans need to prepare for
decisions and needs they will face as they age. We must ensure that our
systems of care and financing-acute and long-term care, health care and
community-based services-are prepared to meet these needs. Gilchrist
said we must have discussions and education, through programs like
Honoring Choices, so people understand what decisions and choices
individuals and families will face.
We must make the best use of existing
resources and build on what's working in the current system. We have to
be thinking about how to provide better care at lower costs.
Recommendations of working
Health Care Reform Task Force has four work groups, which began meeting
last year: access; care integration/payment reform; prevention/public
health; and health workforce. Each of the groups has presented its
recommendations to the full task force over the past few months and the
task force now has draft recommendations. Final recommendations are due to
the governor and the legislature by the end of the year. Gilchrist
discussed some proposals of the various work groups under consideration by
the full task force and the Exchange Advisory Task Force.
Exchange Advisory Task
Move forward on a Minnesota-made health
The Exchange Advisory Task
Force is a separate group that is considering options for how to best
build a Minnesota-made exchange. Gilchrist said the health exchange
continues to be controversial. One perspective is that we shouldn't create
the exchange, because that's meddling and is creating unnecessary
infrastructure. That view says we should just let the market be, let
private insurance run as is and create more competition within the
However, finding good,
affordable health insurance is very challenging for many individuals,
families and small businesses. The exchange presents the opportunity for
consumers to access health insurance in a more organized, user-friendly
way, and receive tax credits or Medicaid, if they are eligible.
Even among those who want to
have an exchange, there is controversy over what the exchange should look
like, who should run it and what the role of the state should be.
Gilchrist said some states are creating exchanges within their high-risk
pools; some are creating them as new state agencies; some as private
entities; and some as public-private partnerships.
The Minnesota Exchange
Advisory Task Force has provided preliminary recommendations regarding a
state-based exchange, including support for operating the exchange as a
Governor's Health Reform
1. Access Work Group:
Make health insurance affordable for
low-income Minnesotans by eliminating premiums and co-pays for
individuals and families with incomes up to 150 percent of poverty.
This would include many people currently in MinnesotaCare.
Nine percent of Minnesotans
are uninsured. Sixty percent of the uninsured are eligible for public
programs like Medical Assistance or MinnesotaCare, but they're not
enrolled. Barriers to enrollment include complexity and cost of enrolling
in programs. Gilchrist said even MinnesotaCare premiums are currently
enough of a barrier for the lowest-income people that they may choose not
to have insurance.
2. Care Integration and
Payment Reform Work Group:
Organize the care delivery and payment
systems around the patient, not administrative systems that do not
While Minnesota has one of
the best health care systems in the world, Gilchrist said we still have
fragmentation and division in how we fund health care, which drives
fragmentation at the patient level and the care level. We end up with
redundancies and inefficiencies that don't serve the patient. About 50
percent of health care is paid for through public programs
(Medicaid/Medicare) and about 50 percent through commercial insurance and
employers. Initiatives such as health care homes help address these issues
across public and private payers in Minnesota.
Support accountable-care organizations
as a new way of paying for health care services.
organizations provide incentives for providers to meet certain outcomes
and then share savings with providers if health outcome and cost targets
are met. These shared-savings models are evolving to "shared-risk" models
that hold providers financially accountable if they do not meet
agreed-upon outcomes. These models focus on improving health while also
Support Minnesota providers' use of
electronic health records.
In 2007/2008, Minnesota made
it a goal to have all hospitals and health care providers using electronic
health records by 2015. Federal stimulus funds were available to help
build electronic records for many health care providers and Gilchrist said
most larger health care systems now have such records. However, many
smaller providers, long-term care providers and mental health providers
haven't received the resources to make the change.
3. Prevention and Public
Health Work Group:
Invest public health funds upstream in
An example of upstream
prevention that Gilchrist mentioned is a diabetes prevention program that
focuses on people who are pre-diabetic. It offers information about
nutrition and exercise in a group setting over 13 to 16 weeks. The program
has decreased the risk of participants developing diabetes by 60 percent.
4. Health Workforce Work
Look at student loan forgiveness for
primary care providers.
Primary care providers who
focus upstream and on prevention are really an important area of emphasis,
Gilchrist said. We want to make sure we have specialists, but our primary
care workforce has been weakening over the years, since their salaries and
reimbursements are lower. This has occurred while demand for their
services is increasing and will continue to increase.
Create an interprofessional health care
team that allows everyone to work at the top of their license, including
investment in health care providers who provide the most value for the
Having an adequate health
workforce requires us to be making some investments in the pipeline now,
which is hard to do in this budget environment, Gilchrist said. In
Minnesota we have some unique models of new professions that are
developing, such as community health workers, community paramedics and
We also need to be using
nurses, nurse practitioners and physician's assistants to the top of their
license. Then we can use community health workers and dental therapists
for services like education and help navigating the health care system. "
It's not just about having more people in our workforce," she said. "It's
about using the people we have more effectively."
Health Care Reform Task
Force must prioritize.
In response to a question, Gilchrist said the task force will have to
prioritize its proposals. The goal of the group is to have some level of
consensus on the recommendations. But, she said, "It's unlikely that every
recommendation currently under consideration will move forward."
The governor and the
legislature will decide which ideas to move forward. Many of the
recommendations do require legislation and funding, but some can be done
administratively, she said.
Citizen Solutions: Look
beyond the triple aim.
From April to July 2012,
Citizen Solutions-a project of the Bush Foundation and the Citizens
League-held 40 community meetings across the state with 1,100 Minnesotans
to discuss how to make our state healthier and our health care system work
better. According to the Citizens Solution report, participants agreed
that the health care system's triple aim of better health, better care and
lower cost does not go far enough. They believe that those objectives are
essential, but not sufficient, to truly achieve health.
determined three principles for action:
Empower Minnesotans to be co-creators
and co-managers of their health.
Equip Minnesotans to make healthy
choices within the health care system.
Encourage the redesign of institutions
and the creation of environments that help reinforce health daily
These principles are
intended to help guide future health and health care policies in
Minnesota, including proposals of the Health Care Reform Task Force.
Updating Medicaid and
MinnesotaCare systems is a major part of the cost of developing the health
In response to a question about the cost of developing the health
insurance exchange, Gilchrist said the reason we need significant
investment in Minnesota is that we are now running our Medicaid and
MinnesotaCare systems on "legacy systems-really, really outdated
eligibility and enrollment programs." Part of the reason it's so difficult
for people to navigate these programs is because we have such arcane
infrastructure, she said. Just modernizing those public programs requires
a fair amount of investment and provides a high return on investment.
We're getting federal money to do that.
She noted that Minnesota is
not spending more on the exchange than other states and is, in fact,
spending quite a bit less than some states.
People must take a greater
role in their own health care.
A questioner asked how people can be encouraged to take a greater role in
their own health care. Gilchrist said some employers are now making
greater investments in employee wellness programs to make sure the work
environment supports better health. Target and Best Buy have been leaders
in providing health incentives to encourage their employees to be
healthier. We also need to support community health with programs like the
Statewide Health Improvement Program, including what kind of food and how
much physical activity kids are getting at school.
We also need to be looking
at how to bring that focus on prevention to our public programs, such as
the diabetes prevention program being run with the Medicaid population.
She said the state has a role as payer to encourage prevention in schools,
housing and transportation by making the "healthy choice, the easy choice"
and building physical activity and better nutrition into our communities.
People need a better
understanding of the cost and quality of health care. Gilchrist
said some national physician groups are outlining the top overused
procedures in various fields, such as cardiology. This information is
available at www.choosingwisely.org. "Physicians should be discussing the
full range of options with patients and patients should be asking about
these procedures to make sure they're not getting unnecessary care," she
"We need to give patients
those types of tools. We often don't know which questions to ask or what
the cost is. We have to be increasing the transparency in order to make
consumers capable of having more responsibility in the system."
In response to a comment
that some insurers and providers seem to think they've made a lot of
progress on cost and quality, Gilchrist said
is a national leader in these areas and also has the foundation to be
doing a much better job on the triple aim. We have a measurement
infrastructure, nonprofit health care systems and nonprofit health
insurers. Also, we have a culture of collaboration, she said. "In most
other states, health care providers and insurers won't sit at the same
table. In Minnesota
they sit at the same table all the time."
"It's the task force's role
to say that Minnesota has the foundation to be the healthiest state, but
if we look at the trajectory we're on, we can still do more to lower cost
and improve quality," Gilchrist continued. "We have to be doing more.
We've done a lot and we've got a lot of tools, but if you look at the
numbers, we're not doing enough."