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Community-clinics leader would like to see more incentives for patients to improve their health

The 40-year-old Fremont Community Clinics system in Minneapolis has seen a 30 percent increase in new patients each month since the recession hit, says Executive Director Steve Knutson.

Best hopes, worst fears for health reform

But it’s not the type of growth that results in the ongoing preventive care Knutson would like to see patients receive as part of national health-care reform.

“They come in with pretty complex issues and want to be cared for and treated in one visit because they don’t plan on coming back anytime soon,” he said. “I think it’s just born out of the sheer economic anxiety that many of the patients who are coming to our clinic sites are experiencing.”

Fremont, which has three locations in north and northeast Minneapolis, served 9,000 patients in 2008 — 40 percent of them uninsured.

Knutson, who became executive director in April, has an unusual background for a community-health-clinic leader. His 30-year career includes stints as vice president of provider relations for Medica and vice president of operations for HealthEast Clinics. He also has served on Fremont’s board of directors.

In this installment of MinnPost’s “Best hopes, worst fears for health reform” series, Knutson says he would like to see more incentives for patients to improve their health. “We can have providers do wonderful things and intervene early, but if we don’t have a willing patient on the other side of the table we’re not going to get to an endpoint,” he says. 

This transcript has been edited for length.

MinnPost: How have your views about health-care policy changed in the course of working for an insurer, a private clinic system and now a community clinic?

Steve Knutson
Fremont Community Clinics
Steve Knutson

Steve Knutson: I think the varied background I have gives me a little bit of a unique perspective because I’ve seen how the system relates to one another and to each segment. I’ve certainly been able to look behind the veil, so to speak, and through actual experience, at how providers relate to payers, how payers relate to providers and at a lot of information, I guess, about the very unique and very complex relationships that exist.

MP: How would you describe the pace and clientele at the Fremont clinics since the recession hit? 

We’ve had a tremendous increase in new patient visits at our three locations. We are seeing upwards of 30 percent new patients per month. That sounds pretty impressive, but actually we’re seeing … what I like to call “one and done.” Patients are waiting as long as they possibly can, and in some cases longer than they should, to get medical care.

They come in with pretty complex issues and want to be cared for and treated in one visit because they don’t plan on coming back anytime soon. That’s a huge, huge concern that we have for their safety and well being. Once they come here, we try to explain to them that they have some potentially lower cost options to access their care at a community health center. It still doesn’t really result in them necessarily coming back.

So, it’s a real unique set of circumstances, I think, where on the one hand you have the tremendous increase in patient visits, but that doesn’t translate to ongoing care. And I think it’s just born out of the sheer economic anxiety that many of the patients who are coming to our clinic sites are experiencing.

MP: Any idea how many of the people you’re seeing had health insurance but they lost their jobs or couldn’t afford COBRA?

That’s not a piece of information that we track. Anecdotally, we are seeing many of these new patients who heretofore have never accessed care at the county hospital or tried to access charity care or tried to obtain services at a community health center such as ours. So, the anecdotal information is pretty clear that there are a lot of patients who are finding themselves in a completely new circumstance and feel like they cannot continue to pay for care wherever they were receiving it previously.

MP: What are the key pieces of reform legislation that will have the biggest impact on the Fremont Clinic and others?

That’s actually really hard to answer because the various reform proposals are such a moving target. I can certainly speak more broadly — and it is a personal point of view. I think that the No. 1 issue that reform has to address is the cost factor, and until we adequately bend that cost curve a lot, all of the other stuff we’re talking about is nothing but window dressing, quite frankly.

You don’t even have to look on a national level. Look at the state level and what is happening to our state budget and the percentage that is being eaten up by our public health programs. It’s like this huge machine just gobbling up greater and greater percentages of our state budget, and the managed care methods and the reforms to date really haven’t made that much of a bend in that curve. That rate of increase just continues to way outpace anything else in that budget.

So, from my point of view, until that cost factor gets adequately addressed, I’m just having a hard time understanding how significant reform can really take hold.

The second thing I see as vital is some insurance … revisions — pre-existing conditions, individual policy denials for health conditions, coverage portability from plan to plan. They don’t affect widespread portions of our population, but they incredibly impact selected groups of our population in really a very adverse fashion. They may not be touching widespread numbers of our society but the ones they do touch — it’s just so onerous for them.

What I’m talking about is for a patient who has a pre-existing condition and as a result can’t get insured for service to treat that condition, they’re left on their own. They’re uninsured for that particular condition. Uninsured isn’t quite the right term; I probably should say self-insured because they have to cover it — they’re not going to get an insurance benefit to help them out with that. Likewise, when somebody’s applying for some type of coverage and they’re getting refused or excluded because of their health history.

So, they’re not just getting refused or excluded for the treatment of the particular condition that’s in question. They’re just getting rejected outright — ‘we’re not going to insure you because you have this condition.’ So that means they can’t get coverage for obviously that particular condition but then any other things that might come up that they need coverage for.

MP: What are your best hopes and worst fears for health-care reform?

Clearly, my worst fear is that the various reforms do not lead to meaningful cost reduction. Bar none, that is my biggest fear. I hear a lot of talk about the savings that electronic medical records are going to generate for the system. I don’t believe them. I see the impact of electronic medical records in clinic organizations all over town. We’re in the process of implementing one. But how that will translate to cost savings, I think, is extremely questionable at this point.

If the reformers are sitting back believing that they can rely on the spread of electronic medical records to drive significant and meaningful cost savings, I just don’t buy that. I don’t buy that at all.

Second, there is so much payment-rate reform that needs to occur. We’ve got situations here in at least some of the Upper Midwest where we have pretty efficient medical care, relative to rest of the nation, and yet our reimbursement models currently penalize us for that efficiency. We could provide the same service down in Florida or New York and get paid dramatically more for it. So, I hope that reform addresses those steps; my fear is that they may not because, again, there’s a lot of politics wrapped up in it.

MP: I’ve been intrigued by the same question of how electronic medical records (EMR) are supposed to save money. It looks like there’s a huge front-end cost to getting all that set up. Is that what you’re referring to?

Absolutely. It’s not just front end. I’m right in the middle of an implementation right now, so I can’t speak firsthand from this location. But I know enough about what’s happened with EMR implementations at other medical providers where it has permanently affected the pace and the efficiency with which providers can treat patients.

Don’t get me wrong. I may come off sounding negative about EMR. I am not; in fact, I believe that the clinical quality enhancements that can occur way outpace the negatives associated with how it affects patient flow in the clinic and how long it takes providers to become proficient with the system.

So it is a very valuable tool; I think it’s especially valuable for a community health center such as ours, because we will use that system to reach out to patients and improve care. Certainly, over time, I think you can at least hypothesize that that improved care will cause a corresponding benefit in the cost equation as well.

Everyone says quality costs less. Well, I think that remains to be demonstrated successfully. But when I hear people talk about EMR as the primary means of doing it, I don’t know. That return is way out there as far as I’m concerned — if it’s there at all.

I’d be completely remiss if I didn’t say that my greatest hope is that, through whatever set of reforms takes place, that it encourages patients to establish care with a primary care provider because I am convinced that more regular visits and treatment of chronic medical conditions can ultimately have a reduction in costs. In other words, if you spend a little now to try to keep problems in check, they don’t become really big problems that down the road can only be dealt with by a hospital admission and some type of expensive intervention.

The other hope I have is that whatever the outcome that there is some motivating factor that relates to patient involvement and patient accountability. In other words, that individuals or patients have an incentive to improve whatever lifestyle contributors might be negatively impacting their health. We can have providers do wonderful things and intervene early, but if we don’t have a willing patient on the other side of the table we’re not going to get to an endpoint. I really haven’t heard too much of that yet in the dialogue and that’s one thing I think is pretty important.

MP: Is there anything you want to tell me that I haven’t asked you?

The opportunity to give our organization some exposure — that we are a very viable alternative for people who are in need of medical care and really can’t rely on the general system … because of their economic circumstances.

Patients have a variety of options here that they don’t have at hospital emergency rooms or private clinics. We have staff dedicated to helping patients get enrolled in state public programs — and even if they aren’t eligible, we have alternatives for patients.

In general, I think our community health center network flies under the radar screen. We certainly are not viewed as one of the mainstream provider alternatives. So many of these patients who find themselves in economic difficulty turn to Hennepin County Medical Center, and I’m here to tell you, and I think they [HCMC] would agree, for many conditions the hospital ER is the least cost-effective place for those types of treatments.

The hospital ER has to be staffed and set up to take on the biggest train wrecks, and there’s a big, big overhead price attached to that. So, when you’re not a train wreck, you just have a bad cold, or you’re trying to get your diabetes managed correctly or your asthma is out of control, that’s about the most expensive setting you can have providing care to that patient.

There are very effective alternatives, and patients need to recognize that a community clinic offers a very welcoming setting. They don’t have to expect to sit in an ER waiting room for a couple of hours to let all those train-wreck cases get ahead of them. They can come in and be seen almost immediately. We have more than a dozen community-clinic alternatives in our metropolitan area.

MP: I’ve been wondering how your clinic might feel the impact down the line if Congress increases Medicaid eligibility to 150 percent of federal poverty guidelines.

It would be dramatic. Most medical providers would look at Medicaid as not a very good payer — we actually look at it as one of our better payers.

MP: How will the scheduled expiration of the state’s General Assistance Medical Care program for poor adults affect your clinic?

That’s a very, very good question, and we’ve obviously looked at that quite a bit. Oddly enough, and quite frankly surprisingly enough, we do not have a big GAMC population. I’m not really sure what the reason for that is, so it’s not going to impact us directly. However, I am very concerned. My expectation is that those patients will try to obtain care where they always have — which, at least in Hennepin County, is probably Hennepin County Medical Center.

Either the medical center is going to have to be prepared to accept them as a charity case of some type or they’re going to redirect them to someplace and those ‘someplaces’ might include community clinics. Then we would be faced with having to treat them without any reimbursement, and quite frankly that’s not a sustainable model.

Casey Selix, a news editor and staff writer for, can be reached at cselix[at] Follow her on Twitter.

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Comments (1)

  1. Submitted by Nancy Hokkanen on 11/05/2009 - 12:19 pm.

    I don’t understand why insurance compensation is severely limited or disallowed for basic nutritional supplements such as vitamins and minerals, especially given so much discussion over Vitamin D deficiency (see remarks by Dr. Gregory Plotnikoff at the U of M).

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