Physician Patient

Archive for February, 2018

MPPA Meeting Thursday February 22, 2018 at 6-8 PM in the conference room at Crutchfield Dermatology, Egan MN

Wednesday, February 28th, 2018

Those present: President Lee Beecher MD, Bob Geist MD, Dave Racer MLitt, Carl Burkland MD, Dave Feinwachs JD, PhD, Phil Raines MBA, Rep. Glenn Gruenhagen, Charles Crutchfield III MD, Mike Ainslie ND, Dave Kunz, Neil Shah MD, Doug Smith MD, Darrin Rosha JD, Lyle Swenson MD, KIP SULLIVAN JD, RUSS WELCH MD, ERIC BECKEN MD, AND REP. BOB LOONAN.

1. Minutes of the January 18, 2018 were circulated to all before the meeting and were not discussed further.
2. Private practice: Ready for a Resurgence—a presentation by Dr, Neil Shah. Dr. Shah noted that health care consolidation caused by permissive CMS regulations doesn’t pay off for patients (fewer lemonade stands = more expensive lemonade) and creates barriers to entry. He noted that narrow networks payoff for insurance corporations in lower premiums, that there is a large variation in hospital costs—large systems have significantly higher prices, that burnout in these systems is a very real problem thanks to poor management of doctors. Doctors ought to be left alone to do their work through reducing unnecessary regulation, work-loads, and data entry clerking, Health insurance marketplace disempowers patients as stewards of their healthcare dollars. The solution is in the attributes of private practice for cost-reduction through Quality, Self-determination, and Agility. He noted local individual clinics have high quality ratings. The serious problem for medicine is the triple increase of insurance premiums from 1999 to 2017 ($6K to $18K). He is opening a new practice this March: Premier Dermatology (
• This excellent presentation was followed by numerous questions and comments from an approving audience. One noted that medical schools did not teach the business of medicine. One question not asked was regarding the alleged usefulness of report cards—something that has not worked in particular with state cardiac surgery report cards.

3. Fairness for patients, means that they ought to be able to spend their own money (for deductibles) where they want and not be foiled by insurance corporations. David Feinwachs, Rep. Bob Loonan, and Rep. Glenn Gruenhagen discussed the problem of constraints—Rep. Gruenhagen has 30 co-sponsors on a bill to treat this problem. in the discussion it was asked how much spending was for deductibles. [I once roughly calculated this at about 50% of all expenditures were for affordable low-cost care. Maybe 25% was for major elective care and surgery, and that documented were catastrophic care expenditures of 24.4% including transplantations, CABG, ICU, neo-natal ICU, dialysis, end of life care, etc. (based on findings of UMN Reinhard Priester for the Citizens League’s an old “Prescription for Care” study). BTW, end of life care has been found stable for decades—RWG.] Another interesting comment was that the “Plans” pay more in-net-work than out!

4. Patient Freedom to Choose their Doctor was discussed by Dr. Charles Crutchfield. IA serious problem is that the Jensen Senate bill is limited to Primary Care doctors only. If it passes, the HMO PR minions may rapturously describe “choice”, which they control, not patients. [I do not add personal comments at meetings I run: IMO the Senate bill would likely kill real patient choice of doctor for our life time. The last time AWP was barely defeated by the HMOs was in 1998. It should also not be forgot that the HMO-ACO corporations cannot transfer insurance risk to independent doctors, which is what will be happening to in-house network gatekeepers paid contingent on how many corporate dollars they “spend”—aka “value pay”. A Patient Choice bill that includes only primary care doctors would further enlarge corporation profits and power, not patient interests. A weak “passable” bill is a fantasy that would ill serve MN patients—RWG.]

5. Transparency legislation. “Show me the price” bills were reviewed by Dave Racer, Rep. Loonan and Rep. Gruenhagen. The House and Senate bills have only a few areas of disagreement—in general there are four prices that must be published and be given to the patient at time of service: reimbursement paid by Medicare, Medicaid, a health plan, and the “retail” price of a provider.
• [A notable absence was specific transparency of facility fees, which often more than double the cost of ordinary office visits and procedures.]. The Senate bill excludes hospital and outpatient surgery—something that would bury facility fee transparency.
• Proposed MN legislation (see pp. 3-5 for comparison table and a House bill).
• At the meeting January 18th it was noted that:
i. HMOs oppose transparency claiming contracts can’t be re-done.
ii. The cost of care problem is not, as often alleged clinician or patient cost culprits but that HMO-ACO corporations may be the cost culprits. What’s happened to raise prices? Facility fees, as noted, can more than double prices.
iii. HMOs are TPAs spending MN state Medicaid money, yet claim that what is spent is a “trade secret” even though the state has the insurance risk without state oversight.
• Earlier at this meeting it was again noted that the Office of the Legislature Auditor (OLA) has yet to report where MN spends its public sector medical money. There is a letter circulating at the legislature with specific questions that the OLA is asked to answer.

6. There was no time fore the second half of the program! including
Single payer: Medicaid and Medicare.
• Dealing with “Warren Buffet’s tape worm” (with AM, BRK, JPMC).
• DHS “Next Gen IHP”, i.e., ACO Medicaid contracting.
• FMA sanity vs. the HMO status quo.
• Medicare for all.
• MNCare for all (Dayton)
MN legislature resolution to repeal HMO-ACO waivers of patient protection laws:
• Repeal FTC anti-trust waivers and CMS anti-fee-splitting and (Stark) anti-kickback waivers
• Mandate MACRA clinic freedom to contract or not for payments contingent on volume of orders for care—the Poltergeist strategy.

The attendees again applauded Dr. Crutchfield’s gracious hospitality in the use of his conference room.
The next meeting date is to be determined
Respectfully submitted,
Robert W, Geist MD, Secretary pro tem

Side-by-side comparison of two transparency bills

By Dave Racer, MLitt

Transparency bill. [House bill]
A bill for an act
1.2 relating to health; requiring transparency in health care costs; proposing coding
1.3 for new law in Minnesota Statutes, chapter 62J.
1.5 Section 1. [62J.815] HEALTH CARE PRICE DISCLOSURE.
1.6 Subdivision 1. Program requirements. (a) In order to facilitate price transparency in
1.7 health care costs, the commissioner of health shall establish the health care price disclosure
1.8 program. Notwithstanding any nondisclosure agreement or contractual obligation, all 1.9 individuals and business entities, including hospitals, physicians, nurses, pharmacies, 1.10 pharmaceutical manufacturers, dentists, and any other health care related provider that
1.11 furnishes health care related items, products, services, or procedures for sale to consumers
1.12 shall disclose the price for each item, product, service, or procedure. The price disclosure
1.13 must be made to a consumer at the time of service or sale of a product and must include the
1.14 provider billed amount, the health plan reimbursement rate for the provider’s highest-volume
1.15 health plan payor, and, if they apply, the Medicaid and Medicare allowable reimbursement
1.16 price the individual or business entity accepts as payment for each item, product, service,
1.17 or procedure.
1.18 (b) The disclosure of price and provider billed amount required under this section shall
1.19 not be considered a violation of any confidentiality obligation contained in any binding
1.20 contractual agreement. 1.21
Subd. 2. Information on costs. The individual or business entity specified in subdivision 1.22 1 must provide continuous, ongoing price disclosures to the commissioner. The price of
1.23 each item, product, service, or procedure must be made available on the individual’s or
1 Section 1.
business entity’s Web site and must include all wholesale, retail, subsidized, discounted, or
2.2 other price the individual or business entity accepts as payment. The information on the
2.3 Web site must be continuously updated. If the individual does not have a Web site, then the 2.4 price disclosure must be made through the group practice the individual is associated with.
2.5 The commissioner shall maintain a Web site for the health care price disclosure program
2.6 and shall post reported prices from each individual and business entity specified in
2.7 subdivision 1. The program Web site must be updated continuously.
2.8 Subd. 3. Penalty. A person who intentionally or repeatedly violates a provision of this
2.9 section is guilty of a petty misdemeanor, and may be fined not more than $300 for each
2.10 failure to disclose prices under this section.
2 Section 1.

Addressing the Opioid Death Crisis

Thursday, February 1st, 2018

The hospital emergency department (ED) is not the proper setting to do an in depth assessment of a patient’s future needs and provision of ongoing medical or psychiatric or addictions care. This is particularly true for assessing the diagnosis, impact and treatment of chronic pain conditions. And the ED is certainly not the preferred venue for establishing a trusting doctor-patient relationship; at best, it may be a start. But it takes two to tango. And what is the next step? Emergency Medicine in the Age of Managed Care has, for various reasons, become the default “provider” for many too many medical assessments. The ED doc is in the necessary business of triage.

EHRs are no panacea. Calls for alerts and stops on the electronic chart may be OK, but they often lead to CYA (defensive medicine) and patient abandonment. Limiting ER dispensing to ten opioid pills might help, but the real question is what happens to the patient next. Followup? Stigmatizing patients and doctors is not the answer. Crying wolf and putting Prince on a plane? Yes, patients do have rights, I know. But as all parents know, sometimes intervention is necessary.

The Minnesota Prescription Monitoring Program is a valuable tool. Its use should be enthusiastically promoted. In my addictions practice I’d use it as a tool to put data on the table and discuss plans with the patient. PMP registry is a recent requirement for Minnesota medical  licensure. This is good.

Opioid deaths in Minnesota continue to rise.  Obviously this bad situation has both supply and demand dimensions. But physicians and pharmacists are being blamed inordinately. Drug advertising is ubiquitous. And of course pot (both medicinal and recreational) is viewed in the media as a a different matter. We need a lot of education and common sense. And patients and families are key in endorsing (or not) all drug using behaviors.

Two Minnesota experts on effective primary care relationships with patients understand its value for pain management, and also the limited ability of the ED in reversing the current “opioid epidemic.”

Dr. Scott Jensen ( ) and Dr. Wayne Liebhard are two physician authorities on the marginalization of Minnesota primary care, and they authoritatively write about it. They wear both the hat of a primary care physician who espouses professional relationships and alliances with his/her patients and also (in recent years) emergency room physician. Many well trained primary care doctors have become ED doctors due in large part to the lack of administrative support and payment for relationship-based primary care services in Minnesota’s managed care clinic and health insurance systems. Dr. Wayne Liebhard wrote  The Vortex Effect and Elephants in the Examining Room

Below are two articles (perhaps) linking opioid prescriptions (for pain) to Medicaid funding. The argument goes that economically challenged patients on Medicaid have a heightened incentive to sell their prescription opioids on the street. And criminal drug dealers entice them to do so. yet, rich, white suburbanites are dying at high rates. See:


Prescribers allow too many (opioid) pills before individual patients are properly evaluated and treated.  And as a condition of further treatment. The ED is not the best venue to do such evaluations. Funding for addictions treatment is insufficient in Medicaid and other third party pay, almost always program-based rather than patient-centered, programs funded by Medicaid are not properly evaluated and compared for their effectiveness (cost-effectiveness), and demonstrated continuity of relationship-based, patient-centered pain and addiction care with qualified personnel is not currently the key to funding care by third parties.

Pain clinic physicians have been unfairly targeted as opioid enablers.

Opioids will be a political issue in 2018. We should empower patients with money, information, and sound health care choices. I had a lot of Medicaid people who paid cash to see me and get on track reversing opioid dependency. Carfentanyl Law enforcement? Yes. Yes.

Both supply of and demand for opioids must be addressed.