By: Chuck Sawyer, DC Northwestern Health Sciences University

The Minnesota health care landscape is changing at an unprecedented rate. In today’s political and policy climate, just about everything is affecting patients, employers, payers (both public and private) and health care providers. And although many of the changes we’re experiencing in health care pre-date the Affordable Care Act (ACA), the rate of change has quickened and your outlook on the current landscape could rely on your ideology, according to HealthBasics research. There are bright spots in the emerging health care landscape, but also some continuing challenges.

Underinsured Minnesotans

Many more Minnesotan’s now have insurance coverage – especially in the Medical Assistance (Minnesota’s version of Medicaid) and Minnesota Care programs – as a result of MNsure, and the federal premium subsidies available through the ACA. That’s a big step forward because it means that lower income individuals and families have better access to health care, the uncompensated care burden for hospitals is dropping and patients living with chronic disease are generally better able to get the care they need. Increasing access to quality care is a significant goal but, while we’ve made some headway, the ultimate aspiration of universal access to affordable care is still unrealized.

That’s because we have a growing underinsurance problem due to the cost shifting that many individuals and families are experiencing as a result of high deductible insurance plans. While these plans do provide what amounts to be catastrophic protection, more patients are delaying getting the care they need or worse yet, forgoing visits to health care providers altogether.

The Affordable Care Act also prevents plans from denying coverage (or dropping existing policies) due to a pre-existing condition, charging women higher insurance premiums than men and allows children up to the age of 26 to stay on their parent’s policies.

Health Equity

We also have a health equity challenge. The various contributing factors were detailed in a 2014 report to the legislature from the Minnesota Department of Health. One highlight includes the overuse of opioid medication in the treatment of chronic pain, which has a high-cost and a large risk of addiction.

New Thinking About Health Care Teams

Another landscape consideration that’s getting attention lately is the health care workforce itself. Some policy experts are predicting a looming physician shortage. However, there are other professionals who are filling the primary care gap including nurse practitioners and physician’s assistants. Health coaches are also playing an increasingly important role, as are physical therapists and pharmacists.

These highly-skilled professionals are becoming more important in the health care system, especially as care coordination comes into sharper focus within health care homes and accountable care organizations. But aside from non-physician professionals who are commonly recognized as being on the health care “team” there are others providing care to patients with greater frequency, but who work predominately outside large health systems and other traditional medical settings.

I’m specifically referring to those who are often referred to as “complementary and alternative” providers, although that label is fortunately falling out of favor. Among them are chiropractic doctors whose training – absent the graduate residency experience – is comparable to medical physicians.

They are especially skilled and the primary care they provide is highly effective when they see patients with acute or chronic back pain, which is now well recognized as a major cause of disability. In fact, there is growing evidence that when back pain patients see chiropractors first, there is a reduced need for injections, surgery, and other more expensive and less effective treatment approaches. Chiropractors also care for patients with many other health conditions by virtue of both their training and scope-of-practice.

The evidence for a greater role for well-trained massage therapists is also growing. Where these providers practice spans the entire continuum from part-time, solo practices, to health systems, hospitals and the Mayo Clinic.

And finally, there is also rapidly growing interest in acupuncture and Chinese medicine practitioners. Although the health benefits that come about when patients see these providers often extends beyond pain, given the narcotic medication problem that is now so prevalent, acupuncture is a safe and often effective treatment option.

Broader Collaboration to Promote Best Outcomes

But we also have a challenge here as well, and that’s to leverage their value so that all health care professionals work more collaboratively together in ways that lead to the best outcomes for patients. Although the integration of alternative health care services into primary care settings is happening, there are opportunities to do more and some obstacles to overcome.

For example, while more ambulatory care settings would benefit from the care that chiropractic doctors can provide to patients with musculoskeletal problems, lower insurance reimbursement is a significant impediment. Payment parity between chiropractors and other primary care providers, or a shift to value-based reimbursement will help open up more opportunities for both DCs and the primary care clinics who would otherwise desire to add them to the care team. Reimbursement for acupuncture and massage therapy services is even more restricted.

But I believe the most important obstacle to greater inclusion is the lack of familiarity that medical physicians have with health professionals who receive their training outside of large academic health centers. Nurses, physical therapists, physician’s assistants and others like them are generally better accepted because more of their training occurs in essentially the same settings as that of medical students. However, even preparing professionals for interdisciplinary practice who do train in university academic health centers is an ongoing challenge, hence the focus of attention in the National Center for Interprofessional Practice and Education based at the University of Minnesota.

Training together, working together, and the will and skill required to develop new professional relationships among and between provider groups will be necessary for the advancement of true integrative care delivery.

Among a host of other factors, an aging population, the high cost of conventional medical care and the need for better patient access to primary care – and those who can provide some or all of it – should cause us to find better ways to leverage the value of the entire health care workforce. Too much is at stake for the patients we all serve in Minnesota.

Join us Nov. 17 for a discussion on the future of health care at Northwestern Health Sciences University. For more information and to register, visit