Senate Finance Subcommittee Issues Testimony From Essentia Health CEO Herman

WASHINGTON, May 29 -- The Senate Finance Subcommittee on Health Care issued the following written testimony by Essentia Health CEO David C. Herman involving a hearing on May 17, 2023, entitled "Improving Health Care Access in Rural Communities: Obstacles and Opportunities":

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Introduction and Background

Chairman Cardin, Ranking Member Daines, and members of the Senate Committee on Finance, Subcommittee on Health Care, thank you for the opportunity to testify at today's hearing: "Improving Health Care Access in Rural Communities: Obstacles and Opportunities." We are pleased the Subcommittee is interested in learning more on how to improve health care across rural communities and appreciate the invitation to tell you about our journey to value-based care.

Essentia Health is an integrated health system serving patients primarily in rural communities throughout Minnesota, Wisconsin, and North Dakota. Headquartered in Duluth, Minnesota, Essentia Health combines the strengths and talents of 15,000 employees, including 2,200 physicians and advanced practitioners, who serve our patients and communities through the mission of being called to make a healthy difference in people's lives. The organization lives out this mission with a patient-centered focus at 14 hospitals, 77 clinics, six long-term care facilities, six assisted and independent living facilities, seven ambulance services, 25 retail pharmacies, and a rural health research institute.

On behalf of Essentia Health, we are pleased to highlight our ongoing efforts to serve our patients and rural communities through value-based care models. Our experience has shown that delivering care through these models can be successful in rural communities. Our remarks will focus on:

* The unique challenges providing care in our rural communities.

* How we embarked on value-based care models.

* What we've learned along the way.

* How these models serve as a pathway for the future of rural health care.

Serving Rural Communities

Addressing the needs of our rural communities and the social determinants of health

Providing access to health care services across rural communities presents unique challenges in addressing the social determinants of health. Our rural patients across Minnesota, North Dakota, and Wisconsin tend to be older, bear greater burdens of chronic disease, experience higher levels of poverty and substance abuse, and have lower rates of education and insurance coverage compared to urban areas. 123 In these rural states, financial insecurity further perpetuates these challenges, as many of the counties we serve fall below statewide median income 4 (Appendix A).

Access to care is the largest, most complex issue currently facing rural health. Patients with access to a primary care physician spend less time in the hospital, have fewer visits to the emergency department, achieve better outcomes and have lower health care costs.56 But rural residents face significant barriers in simply accessing care. Patients across rural Minnesota face more challenges in securing appointments and establishing a patient-doctor relationship with primary care providers.7 Rural counties are more likely to face shortages of primary care doctors and mental health care providers.8 Over 40% of rural counties are underserved in primary care and over 80% of rural counties in America lack local access to behavioral health services.9 3 We are called to make a healthy difference in people's lives.

Residents in rural Minnesota need to travel greater distances to access inpatient services, particularly mental health and obstetrics.10 Furthermore, over 25% in Wisconsin11 and almost 20% in rural Minnesota12 lack reliable broadband internet for use in video visits, a barrier to accessing virtual services that were critical during the COVID-19 pandemic.

Rural hospitals and health care systems significantly impact their local communities, both on health and economic sustainability.13 As anchor institutions, rural hospitals and clinics play critical roles in the economic and social vitality of their communities.14 In 2022, Essentia Health invested $430.3 million in community contributions15 across our organization's geographic footprint.

Organizational Commitment from Volume to Value

Building an organizational culture and infrastructure to embrace value-based care Nationwide, health care spending grew to $4.3 trillion in 2021, accounting for 18.3% of the gross domestic product.16 This spending growth was fueled by the status-quo approach of paying for medical services based upon volume--an approach that is simply unsustainable. Traditional feefor-service (FFS) models pay for specific, itemized care delivered by clinicians. Adverse effects of the FFS approach include: - Rewarding the volume rather than the quality of care and outcomes.

* An emphasis on treatment at the expense of prevention and wellness.

* Providing no incentives for integrating and coordinating care.

* Discouraging practice transformation and clinician-driven innovation.

Recognizing the failure of volume-based reimbursement to meet the needs of patients, Essentia Health committed to transforming our care model to prioritize patient outcomes and overall value. Our volume-to-value journey started with the shared understanding of the need for strategic change, which helped create an environment and forward-thinking culture that embraces continuous improvement and innovation. Effective care transformation relies upon leadership support and engagement from physicians and providers, all aligned in agreement that a new model is required to best care for our patients and communities. At its core, value-based health care emphasizes prevention and wellness, in addition to treatment. This approach focuses on:

* Improving overall patient health.

* Connecting patients with the appropriate care at right time.

* Providing access to integrated care through the entire patient journey.

* Investing in practice transformation and quality improvement.

Value-based care is cost effective and improves care for all patients, particularly those with chronic illnesses, by improving patient outcomes, experience, and quality of life by:

* Limiting duplicative testing.

* Avoiding medication mistakes and overuse.

* Reducing avoidable emergency department visits and hospital admissions.

* Increasing patient engagement and adherence to care plans and medication.

As we face significant workforce challenges, value-based care supports our clinicians and care teams. Provider wellness has been at risk in our nation's health care system, and the pandemic heightened these challenges further. Implementing value-based care programs enhances the care clinicians can provide through care coordination and other services that connect patients with the resources they need to be healthy. A team-based approach to care allows clinicians to spend valuable time with their patients and to contribute their own innovations. Value-based care provides opportunities to make the delivery of health care more rewarding and fulfilling.

The model of care developed to improve outcomes in value-based programs leads to the implementation of best practices for all patients. Because it is neither practical nor proper to differentiate the way we care for patients based on whether they are enrolled in a value-based program, we are creating a best practice standard for all patients. It is the right thing to do for our communities to ensure that health care is sustainable. Simply put: Value-based care delivery is the best care model for all patients.

Essentia Health's commitment to engage in value-based programs and contracts has the added benefit of improving health care for our rural populations. That is why our organization entered into our first value-based payment contract in 2005, paving the way to make a substantial leap into value as an early adopter in the Accountable Care Organization (ACO) Medicare Shared Savings Program (MSSP). Embarking on a new way of measuring and providing care in partnership with the federal government was a challenging decision for our organization, yet it was a necessary step in moving away from a fee-for-service model. We advanced these efforts when the Minnesota Department of Human Services (DHS) launched a managed Medicaid program called Integrated Health Partnerships (IHPs) in 2013. In the IHP program, Minnesota DHS contracts with ACOs to achieve cost and quality targets. Essentia Health has remained in both of these programs, moving to dual sided risk-bearing models in 2016 for MSSP and 2018 for the IHP program. Today, we participate in 23 value-based care programs with more than 200,000 attributed members. Nearly 40% of our revenue flows through value-based programs.

How we did it: Analytics, Action, and Accountability

Create a model of care delivery that is as standard as possible and as unique as necessary to meet the needs of our patients and communities.

Our strategy for success focused on three "A's": Analytics, Action, and Accountability. Each of these helps to support a value-based care system with an emphasis on continuous improvement. Strategies for value-based care success include:

* Identifying the patients.

* Determining patients' care needs.

* Managing chronic illness.

* Providing care needs in a proactive and coordinated way.

* Driving appropriate utilization - lower health care spending.

* Addressing social determinants of health.

* Partnerships with government, private payers, and community organizations.

Analytics

Clinical and information technology infrastructure is a fundamental building block to invest in and maintain value-based care programs. Robust electronic health record (EHR) functionality and data collection systems are necessary to understanding patient populations and screening for the social determinants of health. Payer partnerships are also critical to the success of value-based programs. Payer and EMR data are integrated into clinical data registries to stratify the populations. The results of the analysis support the development of population-specific and actionable cost containment and health improvement strategies, such as:

* Risk stratification.

* The evaluation of utilization patterns.

* Care gap identification.

* Referral management.

Health is created through social, economic, and environmental factors in addition to health care access and individual health behaviors, and Essentia Health's social needs screening data collected over the past several years highlights the widespread barriers that have impacted inequities across the region. For example, in 2022, 144,000 Essentia Health patients completed a health-related social needs screening, with more than 20,000 (14%) patients identifying at least one social need related to food, housing, or transportation. The percentage of patients with social needs varies by clinic locations, with the highest-need communities having more than half (53%) of patients identifying at least one need. However, this need is not evenly distributed across race and ethnicity. We found that 22% of American Indian/Alaskan Native patients and 17% of Black or African American patients reported food insecurity compared to 7% of white patients and were also more likely to report financial strain and transportation barriers than white patients.

Actions: Implementation of the Strategies Informed by data on our populations, nurses, physicians, pharmacists, and community care associates work together to develop programs that address the needs of our patients. Clinical data registries are created to integrate EHR and payer data. The registries stratify the population, identifying those with the highest level of needs. Using this information, the team can engage with the patient to develop an individualized care management plan. As an example, through pharmacy care management, pharmacists review medications with patients to ensure they have the information needed to manage their medications and work with prescribers to identify the most cost-effective medication options. These efforts result in improved health outcomes, better patient experience, and lower overall utilization and cost.

The approaches used to serve patients have evolved along our journey. Changes in the population require new strategies, including:

* Use of alternative care delivery models, such as virtual care and remote monitoring.

* Improving transitions of care, such as after hospital discharge or when leaving the emergency department.

* Addressing social factors influencing health and well-being.

* Chronic illness management.

Patient-centered primary care encompasses strategies and services oriented around the patient to achieve their best health. Clinical and non-clinical experts support the care needs of the population working together in team-based care. Community care associates in rural areas are critically important to improve care outcomes by facilitating access, adding value to the health care team, and enriching the quality of life for their patients, including those who are poor, underserved, and in racial and ethnic minority communities.

At the core of patient-centered care is connection via the EHR. This critical tool allows providers to facilitate care with closed loop referral processes to ensure patients receive timely access to specialists and that the primary care provider remains involved in the patient's care throughout their journey. Several tools connected to the EHR support timely, efficient communication between patients and providers, including Essentia's online patient portal, our Nurse Care Line program, and Virtual Visits on Demand. This improves the patient's journey and engages them in the continuum of care. Care coordination identifies and supports patients with high-risk conditions by helping to arrange services and communicate with multiple providers while transitional care management services help patients transition between hospitalization and community setting.

While collecting data on social determinants of health helps to establish intervention plans, creating connections to community-based organizations is critical in addressing the social factors influencing health. Essentia Health has implemented the FindHelp platform, branded as Resourceful across our service area, and launched a campaign to encourage community organizations to input data and enable referrals. Having the information in a centralized location improves access for all patients and stakeholders. By building relationships with key community partners through outreach and engagement, we are facilitating stronger coordination between agencies and building a network of social care providers ready to help people in need across the region. Essentia Health has embedded access to the Resourceful platform in our EHR to enable providers, care managers, and community care associates to make direct referrals to communitybased organizations. Additionally, we also have the ability to determine if the patients received help from the community-based organization. In the two years since launching the program, there have been more than 10,000 referrals with 30% patients verified to have received services they need to support their health and well-being.17

Expansion to new partners and payers

Much like health care providers, government and commercial health plans are at varying levels of maturity in the value-based care journey. While through the years our government payer programs have been primarily in Medicare and Minnesota Medicaid, we are pleased that the North Dakota Department of Health and Human Services (ND HHS) has embarked on the journey to implement a value-based model to replace fee-for-service Medicaid. Being in full support of advancing value-based care, Essentia Health has engaged with ND HHS and the governor's office to promote the benefits of outcomes-based models. This new program starts out rewarding for process and engagement (pay for reporting) and ramps up over time toward rewarding health outcomes (pay for performance). We appreciate the partnership and willingness to seek input from providers to create a model with short-term and long-term goals.

While the government remains a key part of value-based payment strategy, private payer partnerships are just as fundamental to success. Essentia Health has established criteria to evaluate payer programs and determine alignment with system strategy through financial, systematic, and joint accountabilities. From a financial perspective, models with a glide path to increased risk/reward allow the payer and provider to create a long-term program together. Payer models that offer providers options on levels of risk allow the necessary time for providers to build the infrastructure needed to be successful. Access to timely data is part of the foundation of valuebased care. Payers that are engaged in advancing value-based care provide detailed membership and claims data to providers to support the analytics and care interventions needed. Finally, agreeing to fair terms and joint accountabilities will help ensure success with government programs and private payer plans as well.

Accountability

Oversight and accountability are key to advancing the journey from volume to value. We have developed a governance model with oversight committees with clinical and administrative leaders within Essentia Health and also with key payer partners to monitor performance. Through this governance structure we establish goals and provide oversight on performance.

Transparency on performance brings everyone together to identify improvement strategies that support the achievement of standard work through process and care design. We set targets for achievement that can measurably improve outcomes, and we have developed the tools needed to track progress. Examples include dashboards to monitor clinical quality metrics, surgical outcomes, and hospital inpatient length of stay.

Success in Value-based Care

From 2018 to 2021, Essentia Health removed over $102 million from the cost of care across all value-based programs, while being recognized as a top performer for quality, cost, and equity.

Value-based care is a continuous journey as we learn, evolve, and expand our efforts across our organization. Essentia Health has achieved success in both Medicaid and Medicare value-based programs, saving tax dollars while maintaining a high level of quality and patient satisfaction. We are pleased and proud of our achievements, yet we know we can do more.

Outcomes from our value-based care programs include:

* Medicare Shared Savings Program (MSSP) savings $42.4 million from 2018-2021.

* Minnesota Integrated Health Partnership (IHP) savings of $28 million from 2018-2021.

* Nearly 40% of our revenue flowing through value-based programs.

* Approximately 80% of value-based contracts having downside risk.

We have demonstrated our commitment to providing affordable, high-quality health care services for our patients and communities. As a participant in MSSP since 2013, Essentia Health transitioned from shared savings only into the risk-sharing track in 2016. Since then, we have demonstrated consistently high performance. In fact, our providers met 98% of the quality targets, earning full quality points for performance year 2021 and generated a 4% savings rate, or $13 million for the Medicare program. From 2018 through 2021, Essentia Health has generated cumulative savings to the federal government of over $42 million as an MSSP ACO (Appendix B). We have also demonstrated success in Minnesota's Integrated Health Partnership (IHP) as well. From 2018 through 2021, Essentia Health achieved savings of $28 million for the Minnesota state Medicaid program. Through this work, we have proven that investing into value-based care models can be successful and have brought forward a pathway to the future of providing care in rural areas. We must, however, continue to evolve the way we deliver care to ensure long-term sustainability for our patients and the communities we are privileged to serve.

Quality of care has not been comprised but enhanced in our journey. While focusing on care coordination, appropriate utilization, improving outcomes and lowering cost, our quality of care has continued to increase. This year, Essentia Health was named one of the top-performing health care systems in the state from Minnesota Community Measurement (MNCM), a statewide resource for timely, comparable information on health care quality, costs and equity. (Appendix C) 18 Essentia Health scored significantly above statewide averages on 13 of 21 eligible clinicalquality measures for 2021. We have continued to expand our value-based program portfolio with government and commercial payers with more than 200,000 attributed members in 23 programs with 53% in government programs and 47% are in commercial payer arrangements.

Learnings and Recommendations to Rural Health Care Providers

We have implemented a system and created a culture that supports value-based care to many communities and care sites that have joined Essentia Health during our journey.

To be successful in value-based care, it starts with a desire and commitment to start the journey and achieve the goals. A culture of teamwork and care management is key to building a valuebased care program. For small and rural practices, a foundation of EHR and other IS systems support likely cannot be implemented in small practices alone. Shared infrastructure that supports clinics, hospitals, and other sites of care will provide a network to reach populations across a region and coordinate across primary and specialty care services.

A common electronic health record with strong population health capabilities is necessary to understand social determinants of health and preventative care interventions. Health care providers must also be able to access measurement and data resources to track progress and develop local insights in care successes and care gaps to be addressed. They also benefit from tools for standardizing metrics across programs.

In rural areas, health systems must extend their capabilities by partnering with community resources to address local non-medical needs. Connecting to other social services is a critical part of population health improvement, including access to healthy food, transportation, and housing.

Other key learnings include:

* Set short-term goals that reward development and implementation of the infrastructure with a path to more complex models in later years.

* Align all payers within the same model redesign so rural value-based care participants do not have the burden of managing multiple different systems.

* Design models to accommodate lower patient volumes in rural settings to assist with setting benchmarks and targets and in the management of outlier cases.

Public Policy Recommendations

What policymakers can do to advance value-based care to the next level Policymakers play an important role in supporting value-based care. Essentia Health asks Congress to support critical resources for health care providers, reduce regulatory burden, and enhance the design of value-based payment models.

Continued support for critical resources

Extend the Bonus Payment for Advanced Alternative Payment Models (APMs)

Enacted in the Medicare Access and CHIP Reauthorization Act (MACRA), Congress provided a 5% incentive bonus for APMs with downside performance risk. This incentive payment has been important for Essentia Health to continuously invest in program management to participate in MSSP. Appropriate financial incentives will help attract providers to participate in these models to reduce cost and support their transition to value. We appreciated that Congress enacted an extension of 3.5% incentive bonus for 2023.19 We urge policymakers to reinstate a 5% Medicare bonus payment for new and existing advanced APM participants.

Protect the 340B Prescription Drug Discount Program

The 340B Prescription Drug Discount Program helps rural hospitals stretch limited federal resources and is used to support health services and programs throughout our communities.

Protecting this program is crucial for rural hospitals. The savings help provide essential services to their communities, but unfortunately the program is also coming under attack from drug manufacturers placing unlawful restrictions on covered entities, negatively impacting hospitals and the ability to acquire prescription drugs under the program.

Reduce regulatory burden

The COVID-19 pandemic brought unprecedented challenges and strain on Essentia Health and our nation's health care delivery system. However, the pandemic also provided a unique opportunity. Under the emergency, HHS invoked their authority and waived hundreds of regulatory requirements placed on health care providers. This alleviated barriers that resulted in rapid innovation to meet the challenges brought on by the pandemic.

Continue to remove regulatory barriers to improve access to telehealth

Throughout the pandemic, telehealth and virtual platforms has increased access and safely provided appropriate levels of care. Essentia Health strongly supports enhanced access to telehealth and digital health services and encourages Congress to alleviate regulatory barriers and enact policies to increase access to care through these modalities. Congress needs to consider ways to maximize access for patients, especially those who reside in rural and underserved areas. We thank Congress for enacting legislation to extend certain telehealth flexibilities issued during the public health emergency through 202420 and urge a comprehensive bill to permanently extend telehealth flexibilities made available during the pandemic.

Extend the 96-hour rule waiver for Critical Access Hospitals (CAH)

CAHs are required to maintain an average patient length-of-stay under 96 hours but was waived during the PHE. 21 With the PHE now expired, CAHs are faced with compliance risk of the 96-hour rule while continuing to provide services to patients that cannot be discharged in a timely manner. Essentia Health will face challenges to meet the 96-hour rule due to very tight health care system capacity driven by high acuity and lack of post-acute care discharge availability. Continued flexibility and stability will allow hospitals to provide access for their patients closer to home. Essentia Health recommends extending the 96-hour rule waiver through 2024 to align with the extension of various PHE telehealth waivers previously enacted by Congress.

Enhance value-based payment models

Enact the Value in Health Care Act

Introduced in the previous Congress, the Value in Health Care of 202122 would make a number of positive changes to the ACO program. The bill would modify risk adjustment criteria, improve benchmarking, alleviate barriers to program participation, and extend the advanced Alternative Payment Model (APM) bonus payment. We ask Congress to re-consider introducing and advancing this legislation to help providers nationwide move to value-based care.

Incentivize Participation in Alternative Payment Models (APMs)

To incentivize APM participation, it is essential to remove barriers and give additional flexibility and tools to innovate care. Specifically, Congress should remove distinctions that penalize safety net providers; improve financial methodologies so APM participants are not penalized for their own success; reduce regulatory burdens by offering increased flexibilities and waivers for clinicians moving to risk; and provide technical assistance for new participants.

Establish Alignment and Parity Between Alternative Payment Model (APM) and Medicare Advantage (MA) Program Requirements Overall, we support increased alignment between APMs and the MA program to ensure that APMs are not disadvantaged. This includes establishing parity between program flexibilities and network adequacy requirements including telehealth to reduce clinician burdens and improve patient access to care. Additionally, Congress should encourage more multi-payer value-based arrangements and examine how APM incentive payments and shared savings payments, which are incorporated into MA benchmarks, are equitably passed on to physicians and other clinicians.

Conclusion

On behalf of Essentia Health, we thank Chairman Cardin, Ranking Member Daines, and members of the Senate Committee on Finance, Subcommittee on Health Care, for the opportunity to testify on today's hearing: "Improving Health Care Access in Rural Communities: Obstacles and Opportunities." We are honored to share with members of the subcommittee our value-based care journey, which has significantly lowered health care spending while increasing the high quality of care and improving patient outcomes. Based on our journey, we hope our testimony today has demonstrated that value-based care is not only a possibility - it is a necessity to achieve health and vitality in rural areas of our country.

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Appendix A: Map of income and poverty levels in Minnesota and Wisconsin

Appendix B: Financial performance indicates savings achieved under benchmark while quality remained at a high level

Appendix C: Minneosta Community Measurement Results

We are called to make a healthy difference in people's lives.

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Notes

1 Minnesota Department of Health, Division of Health Policy. Rural Health Care in Minnesota: Data Highlights, 2022, https://www.health.state.mn.us/facilities/ruralhealth/docs/summaries/ruralhealthcb2022.pdf (accessed May 12, 2023).

2 University of North Dakota School of Medicine & Health Sciences Advisory Council. Health Issues for the State of North Dakota, Seventh Biennial Report, 2023, https://med.und.edu/about/publications/biennialreport/_files/docs/seventh-biennial-report.pdf (accessed May 10, 2023).

3 Sarina Schrager, "Rural Health in Wisconsin--Looking to the Future," Wisconsin Medical Journal, 117, no. 5 (2019), 192-193, https://wmjonline.org/117no5/schrager/ (accessed May 13, 2023).

4 Minnesota Department of Health, Division of Health Policy. Rural Health Care in Minnesota: Data Highlights, 2022, https://www.health.state.mn.us/facilities/ruralhealth/docs/summaries/ruralhealthcb2022.pdf (accessed May 12, 2023).

5 David P. Glass, Michael H. Kanter, Steven J. Jacobsen, and Paul M. Minardi, "The impact of improving access to primary care," Journal of Evaluation in Clinical Practice, 23, no. 6 (2017), 1451-1458, https://doi.org/10.1111%2Fjep.12821 (accessed May 12, 2023).

6 Barbara Starfield, Leiua Shi, and James Macinko, "Contribution of Primary Care to Health Systems and Health,"Milbank Quarterly, 83, no. 3 (2005), 457-502, https://doi.org/10.1111%2Fj.1468-0009.2005.00409.x (accessed May12, 2023).

7 Minnesota Department of Health, Rural Health Care in Minnesota.

8 Elizabeth A. Dobis and Jessica E. Todd. 2022. "The Most Rural Counties Have the Fewest Health Care Services Available." Amber Waves, The Economics of Food, Farming, Natural Resources, and Rural America, Economic Research Service, U.S. Department of Agriculture, August 1, 2022. https://www.ers.usda.gov/amberwaves/2022/august/the-most-rural-counties-have-the-fewest-health-care-services-available/

9 Dobis and Todd, The Most Rural Counties have Fewest Health Care Services Available.

10 Minnesota Department of Health, Division of Health Policy. Rural Health Care in Minnesota: Data Highlights, 2022, https://www.health.state.mn.us/facilities/ruralhealth/docs/summaries/ruralhealthcb2022.pdf (accessed May 12, 2023).

11 Danielle Kaeding, "Report: Rural Areas Of Wisconsin Suffer From Major Gaps In Broadband Access," Wisconsin Public Radio, January 4, 2021. https://www.wpr.org/report-rural-areas-wisconsin-suffer-major-gaps-broadbandaccess (accessed May 12, 2023).

12 Minnesota Department of Health, Division of Health Policy. Rural Health Care in Minnesota: Data Highlights, 2022, https://www.health.state.mn.us/facilities/ruralhealth/docs/summaries/ruralhealthcb2022.pdf (accessed May 12, 2023).

13 University of North Dakota School of Medicine & Health Sciences Advisory Council. Health Issues for the State of North Dakota, Seventh Biennial Report, 2023, https://med.und.edu/about/publications/biennialreport/_files/docs/seventh-biennial-report.pdf (accessed May 10, 2023).

14 "Leveraging Position as an Economic Anchor to Improve Health Equity," Rural Health Information Hub, Accessed May 13, 2023, https://www.ruralhealthinfo.org/toolkits/health-equity/2/organizational-capacity/economic-anchor

15 https://www.essentiahealth.org/about/facts-figures/

16 "NHE Fact Sheet, Historical HE, 2021," Centers for Medicare and Medicaid Services, National Health Expenditure Data, accessed May 15, 2023, https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-andreports/nationalhealthexpenddata/nhe-fact-sheet

17 Anthony Matt, "Essentia Health-supported program reaches 10,000 referrals for vital programs, services," Essentia Health Newsroom, April 12, 2023. https://www.essentiahealth.org/about/essentia healthnewsroom/essentia-supported-program-reaches-10000-referrals/ (accessed May 12, 2023).

18 Anthony Matt, "Essentia Health ties for first atop rankings of high-performing health care systems in Minnesota," Essentia Health Newsroom, January 12, 2023. https://www.essentiahealth.org/about/essentia-healthnewsroom/report-ranks-essentia-among-top-performing-health-care-systems/ (accessed May 12, 2023)

19 Consolidated Appropriations Act, 2023, Public Law No: 117-328, https://www.congress.gov/bill/117thcongress/house-bill/2617 (Accessed May 13, 2023).

20 Consolidated Appropriations Act, 2023.

21 Department of Health and Human Services, Changes to FY 2000 Hospital Inpatient Prospective Payment System (PPS) Policies As Required by the Medicare, Medicaid, and State-Child Health Insurance Program Balanced Budget Refinement Act of 1999 (BBRA), P.L. 106-113, Transmittal No. A-00-17, April 2000, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/A001760.pdf (Accessed May 15, 2023).

22 Value in Health Care Act of 2021, H.R. 4587, https://www.congress.gov/bill/117th-congress/house-bill/4587 (Accessed May 12, 2023). 23HDPulse, An Ecosystem of Minority Health and Health Disparities Resources, National Institute on Minority Health and Health Disparities, Created May 15, 2023. https://hdpulse.nimhd.nih.gov

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URL: Essentia Health

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Original text here: https://www.finance.senate.gov/imo/media/doc/Herman%20Written%20Testimony.pdf