UCare: A Growing Force in MN Health Care

It has been another great year for UCare, the nonprofit health plan established 30 years ago by the University of Minnesota Department of Family Medicine and Community Health. Membership for the plan grew by 20% over the last year and more than 100% over the last five years. While those percentages are astounding, they’re not surprising. UCare has been a dynamic force in Minnesota’s health care landscape since its formation.

The plan was originally created as a means to improve access to care for the underserved and increase the number of patients seen in University of Minnesota family medicine residency clinics. UCare President and CEO Nancy Feldman told the Star Tribune in a recent feature (published December 21, 2013) that the health plan has “a unique role in the market, bringing health care to those who have challenges getting it.” She continued, “We have always stayed focused on that mission.”

Until recently, UCare’s business has been government-funded programs, like Medicare, Medical Assistance, and Special Needs BasicCare (disability programs). UCare reports that it currently serves more people from diverse cultures and more people with disabilities enrolled in Medical Assistance than any other health plan in Minnesota.

In 2013, the plan joined Minnesota’s health insurance exchange MNsure, launching its first individual commercial products, dubbed UCare Choices. UCare saw this as an opportunity to provide continuity in coverage for individuals who may move between UCare’s government-funded and commercial plans, like members who lose eligibility for state Medical Assistance programs but are still lower income or early retirees who are not yet receiving Medicare.

UCare’s Medicare plan (UCare for Seniors) is available statewide and in 26 counties in western Wisconsin. Availability of its Medical Assistance and UCare Choices products varies by county, but more than 80% of Minnesota counties now offer more than one of UCare’s products. That’s a long way from the health plan’s initial offerings in just Hennepin and Dakota counties.

Since its beginnings, UCare has believed that primary care delivery plays an important role in the health of its members. UCare was investing in coordinating care long before it became a national movement. University of Minnesota Department of Family Medicine and Community Health head Macaran Baird, MD, MS, chairs the UCare Board of Directors; and, the department and UCare have remained connected through the years.

Ghita Worcester, UCare senior vice president of public affairs and marketing, remarked, “University of Minnesota family medicine residency clinics benefit from our members. And, UCare benefits from having a relationship with those who are on the ground serving our members and contributing to the education of the next generation of primary care providers.”

As of February 2014, UCare’s membership hit 377,000. The plan is on track to reach (and exceed) its 400,000-member milestone this year. UCare’s growth can only be described as explosive and encouraging.

Baird said, “We have enjoyed watching UCare grow and make a significant impact on underserved communities in Minnesota. We’re proud of our role in UCare’s beginnings, proud to be connected to a health plan that believes their members matter and desires to invest in quality and access of care.”

Medical Students Experience Urban Medicine

Recently retired UMN faculty Barbara Leone, MD, left,
precepts with a med student at Broadway Family
Medicine Clinic, located in an underserved area
of Minneapolis.

The following story, written by Minneapolis-based writer and editor Barbara Knox, first appeared on the University of Minnesota Foundation website in August 2013. This story has been edited and was shared with permission in our latest newsletter.

Fact: When the Affordable Care Act (ACA) is fully implemented next year, there will be a dearth of primary care doctors awaiting the onslaught of newly insured patients.

Consider the numbers: In 2011, only seven percent of medical school graduates nationally chose a primary care career, despite the fact that more than half of patient visits are to primary care doctors. Fifty years ago, more than half of America’s doctors practiced primary care; today, fewer than one in three are primary practitioners, and many of those doctors are nearing retirement.

The problem only gets worse in urban settings, where common health disorders—high blood pressure, obesity, diabetes—are prevalent and primary care doctors scarce.

Not surprisingly, medical schools across the country are looking for ways to bring students face-to-face with what they call the “underserved” urban population. Often such exposure encourages students to consider a career in primary care.

“Primary care is known to be the most effective, most efficient way of delivering health care,” says Chris Reif, MD, MPH, one of three co-directors of the Urban Community Ambulatory Medicine (UCAM) clerkship. UCAM allows 12 students per year to spend a three-month rotation at an urban family medicine clinic in Minneapolis or St. Paul.

“Most of our training in medical school is devoted to health and disease in individuals,” says Reif. “But UCAM asks, ‘How do we promote the health of the community in places where the burden of disease is heaviest?’”

The Power of UCAM

When alum Elizabeth Beckman, MD, started medical school at the University of Minnesota, she already had a passion for working with an urban population struggling with mental illness. She naturally looked for opportunities to build her experience with that patient group. When she discovered UCAM, her interest only grew.

“UCAM was far and away the best experience I had in medical school,” says Beckman, who recently graduated and began a combined family medicine/psychiatry residency at the University of Cincinnati. “The time I spent in a family medicine clinic taught me how essential it is to help patients improve their health in the context of their community, instead of just within the context of the medical system.”

UCAM is a forerunner to the Metropolitan Physician Associate Program or MetroPAP. Both urban programs owe their existence to the University of Minnesota’s renowned Rural Physician Associate Program or RPAP.

Established in the 1970s, RPAP was the first program of its kind to offer a clerkship that sent medical students into rural settings to work in family medicine clinics. RPAP was so successful that it has served as a model for other medical schools around the world looking to launch similar programs.

In the early ’90s, it also inspired a group of second-year medical students to launch UCAM.

UCAM Beginnings

In 1993, Joanna Perkins, MD, MS, then a medical student, and a couple of her classmates were regular attendees at the American Medical Women’s Association meetings on campus.

“Several of us in the group started talking about what we’d be doing for clerkships,” recalls Perkins, who is now medical director of outreach and a staff physician in pediatric cancer and blood disorders at Children’s Hospitals and Clinics of Minnesota. “Several people were interested in RPAP, but a few of us were more interested in working in an urban setting. So we went to the RPAP administrator and asked what we’d have to do to set up a similar program in the city.”

Perkins, along with Anne Edwards, MD, and Colleen Townsend, MD, did the legwork, and UCAM was officially launched in 1994.

“I worked at the Bloomington Lake Clinic in South Minneapolis [since relocated after a fire],” says Perkins, “and while I ultimately chose to work in pediatric oncology, I knew I wanted to continue to serve in that same community.”

UCAM not only immersed the students in the clinic setting but also exposed them to the cultural realities of the neighborhoods in which they served.

“We met with Hmong shamans and Native American healers,” Perkins explains. “We went to community advocacy group meetings and sat in on neighborhood focus groups. We wanted to complement the medical experience with supplemental cultural learning.”

Why It Works

UCAM director David Power, MD, right, with a patient.

UCAM clearly met a need, and students responded enthusiastically—and still do today: The clerkship is already filled for the next two years with students eager to get hands-on experience at sites like Broadway Family Medicine Clinic in North Minneapolis (the clinical arm of the University of Minnesota North Memorial Hospital Family Medicine Residency) and La Clinica in West St. Paul.

“UCAM gives students exposure to the very real and practical side of medicine,” says David Power, MD, MPH, UCAM co-director. “They learn not just about the illnesses so prevalent in these communities—depression, chemical dependency, diabetes—but how to fill out disability paperwork or how patients qualify for Medical Assistance. Nowhere else in the Medical School curriculum is there information on these sorts of real-world problems.”

It’s very common, Power adds, to hear students say that UCAM was a life-changing experience. Besides gaining clinic experience, the students spend time with their mentors, co-directors Reif and Timothy Rumsey, MD, a family physician who works at United Family Medicine Residency and runs a clinic one day a week at the Dorothy Day Center in St. Paul.

According to Power, UCAM has been overwhelmingly successful in encouraging students to consider a family medicine career: About two-thirds of UCAM students go on to work in primary care. That’s significant today, as medical schools struggle to meet the growing demand for primary care doctors.

This Is Primary Care

The following editorial was written by University of Minnesota Family Medicine and Community Health faculty Shailey Prasad, MD, MPH. It appeared in our fall 2013 newsletter, the Family Medicine Connection, and was originally shared on the Primary Care Progress blog. 

---

Shailey Prasad, MD, MPH

Inspired by a campaign that identified the work of public health, faculty Shailey Prasad MD, MPH, hopes the work of primary care will one day be identifiable in our communities, outside clinic walls.  

By Shailey Prasad, MD, MPH 

I recently saw a sticker on a bus shelter. It was an arrow about 10 inches long and 6 inches wide. It seemed to be pointing to the bus map. “This Is Public Health,” it said. The sticker, part of a larger campaign, gave me pause. Sure, a bus stop is public health because it’s a marker of mass transportation; it symbolizes improved access and decreased pollution from individual cars. Looking around, I saw a lot of places that would be appropriate for that sticker.

Later, I had the opportunity to talk with a few students who had participated in the campaign. They were thrilled with the neat places they had labeled, such as a bike path, a farmers market, and a park. And they were particularly happy that the exercise had led them to a clearer understanding of public health—that it is pervasive and promotes healthy choices.

Labeling Primary Care

Given a sticker that reads, “This Is Primary Care,” I wonder where I would put it. How would I define primary care? For a long time, primary care doctors were derisively called “just generalists.” Our discipline was the fallback for medical students who couldn’t get into another specialty. We were also the least understood discipline since we address such a wide range of health issues.

I’ve read essays from pre-medical students who wanted to go into medicine in order to understand and serve the human condition. Idealism is a strong component of the drive to go into medicine. And then, as we’ve all heard someone say before, “medical school beats it out of them.” One way or another, career choices are skewed away from primary care during medical school.

Primary care has a marketing problem. We need “This Is Primary Care” labels to stick in diverse places around our towns.

Primary care has the unique ability to keep one foot in clinical medicine and one in public health. But we lean toward the clinical side and need to explore the wide world of public health. Restrictive payment models combined with the enormity of public health work and our lack of familiarity with it have kept us in the clinical realm. We need to counterbalance the pull and top heaviness of “sickness care” with a move to public-health-focused “wellness care.” It would be more productive and complete the holistic approach that most of us crave.  

Merging Primary Care and Public Health

 

I’m not alone in my thinking. The Institute of Medicine has challenged our field to better integrate primary care and public health in the context of improving population health. Merging the here-and-now of clinical medicine with the long-term horizon of public health brings with it challenges and opportunities. But it is in this particular niche area that we can thrive. Keeping individuals in mind, aiming for community-wide impact, and shaping the future of larger swathes of society should be the goals of the primary care physician of the future.

Merging public health and primary care would close the loop on issues identified in clinics with input from homes and communities. It would put into context environmental factors that worsen a child’s asthma and would link community groups who would then be partners in developing means to address those factors. Well-child visits would include college preparation activities. Activities that start with the immediacy of a clinical encounter would lead to activities that make a broader community impact. For example, a clinical encounter dealing with domestic abuse would lead to building or strengthening shelters for battered women. It would add out-of-clinic population management activities to our current in-clinic encounters, such as creating walking groups for people with peripheral vascular disease.

Besides improving population health, I believe this approach would help address physician burnout. Could a move to a more holistic approach to care and wellness decrease the existential angst of dealing with emotionally draining clinical scenarios one at a time?

Moving from the Clinic to the Community 

 

The Affordable Care Act calls for more preventive services and requires not-for-profit hospitals to develop community assessment and create community assistance funds, bringing opportunities to change our current care delivery models. We need to embrace these opportunities to move out of traditional clinical settings, go into the communities that we serve, and understand and function in the manner that communities want. The newer models of care, such as patient-centered medical homes and accountable care organizations, provide us with a rubric for population management. Moving out of traditional settings and into the community will empower us to better use our skills.

And as we do this, migrating from the current restrictions within the four walls of the clinic to the communities that we work in, we will be able to place labels all over our communities that read, “This Is Primary Care.”