Physician Patient

May 23, 2018 MPPA Meeting: ACO Economics Update; Price Transparency Bills Pass MN Legislature; July 11, 2018 Health Care 2020 Conference

MPPA Meeting Wednesday May 23, 2018 at 6-8 PM in the conference room at Crutchfield Dermatology, Egan MN.

Those present: President Lee Beecher MD, Bob Geist MD, Carl Burkland MD, Dave Feinwachs JD, PhD, Phil Raines MBA, Mike Ainslie ND, Neil Shah MD, Kip Sullivan JD, Jeff Taylor DDS, Vince Hunt MD, Wayne Zuehlke CPA, Hannelore Brucker MD, guest Mark Braake MD, Melissa Larson MBA, guest speaker. There were 8, who canceled in the AM—four for health reasons.

Please note that my comments are in [brackets].

Minutes of the February 22, 2018 were circulated to all before the meeting and were not discussed further.

ACOs and Independent Practice Private practice was the meeting focus—
Melissa Larson MBA, the CEO of Integrity Health Network (IHN) LLC, Duluth presented the experience of its ACO version of the CMS Medicare Shared Savings Program (MSSP)—A program with only upside financial risk are paid for good results, not bad financial results (aka downside risk). Their first efforts were begun in 2013with the help of a KY consulting firm and later developed into a geographically dispersed group of MN and WI private clinics consisting of 66 MDs and 93 mid-level providers. The ACO insures >5000 lives (the minimum allowable), but it found enrollment decreasing as patients shifted into Medicare Advantage Plans. Since their quality and other bench marks were already high and continued to be so, the upside bonuses were not earned in any of the 3 years of the plan’s existence from 2014-2016. There were financial losses in every year. They found coding one of the most important factors in earning income—it took up much of the ACO resources. If the IHN ACO is to be resumed/continued, unsustainable losses would need to be addressed. Using other consultant vendors with an expansion of clinics may be considered. [Will the future involve becoming part of a large hospital system? RWG]
Kip Sullivan (see his full ACO report in Appendix I) then briefed the meeting regarding the origin and rationale for ACOs (a term not coined until 2006) and the performance of CMS experiments. The 1st began in 2005-2010; it failed as costs increased. Two later experiments were begun in 2012 as directed by Obamacare law. {Implementation needed to be legalized through 2011 FTC and CMS waivers of patient protection laws—RWG]. The Pioneer ACO program (with both upside and downside financial risk) and the MSSP ACO program (upside risk only) failed to control costs and did not include the significant cost of start-up ACO costs. In the follow-up open discussion, the experience of clinicians at the meeting was that ACOs lost money, that upcoding was the only way to make ends meet, and that there was a financial conflict with patients in ordering care. The basic problem identified was that ACOs were a transfer of financial risk clinics; the bedside conflict of financial interest with a patient was considered a probable element in increased physician burnout. One retired physician found that he was unable to get out of the ACO to which he was assigned. It was also pointed out that clinics providing care in poor neighborhoods were getting the short end of the CMS financial stick. Dave Feinwachs summarized the discussion by giving his impression that ACOs were upcoding scams. [Of interest, a UHG whistleblower case that was unsealed by a federal judge in 2017, would corroborate this opinion of a scam: Three of 6 DOJ-CMS claims were dismissed by a federal judge in early 2018, but 3 remain open for possible action.—RWG]
The group was then asked to discuss the future of ACOs. The consensus was that ACOs don’t control costs and are causing problems for ACO clinicians where the corporate focus is increasing upcoding revenues rather than patient care. It was thought that once the downside risk was enforced, that there would be a cascade of ACO drop outs. [A contrary opinion might consider that ACO implementation backed by powerful government, industry, and academic PR could succeed in final demolition of the medical market place leaving government cartels in total control—a corporate form of a “single” payer system. Cartels function and thrive through price fixing insurance rates and service prices, franchising delivery of care to cartel (“at risk”) joint ventures and imbedding a system of rationing of care kickback bonuses at the ACO bedside—”value pay” for corporate-cartel profits—RWG].
The fate of MPPA bills of interest at MN state legislation discussion was led by Phil Raines MBA. Patient Freedom to Choose clinics and Fairness in applying self payments for services to deductibles died in the house. The Step-therapy Override bill passed as did the transparency bill including disclosure of facility fees—we can thank the efforts of many MPPA fellows and legislators as well as Sen. Draheim who carried the Transparency bill. The bill to gut MN’s strong privacy legislation was defeated (the “HIIPA conformity” bill).
Patient and clinic protection issues were discussed.
The July 11 HealthCare 20/20 seminar described in detail by its MIPA organizers Phil Raines and Neil Shah (who also spoke for the temporarily disabled Dave Racer). The heavy hitters on the program are a bipartisan group of medical and legislative leaders (Appendix II). The morning session will be about: The Healthcare Blueprint in 2020. The afternoon session will be: Political leaders responding to the 2020 Blueprint.
The last 15 minutes delved into means to override the government-backed managed care cartel industry hegemony in the public and private medical sector [I am not calling it a medical marketplace because IMO cartels per se destroy a free market—RWG]. These items were not discussed due to lack of time but can be addressed in detail at a later meeting. Each can be seen in the appendices:
A patient financial bill of rights (Appendix III)
The Family Medical Account Medicaid proposal (Appendix IV)
A Clinic Fair Contract bill mandating payments for quality reports (Appendix V)
A MN legislative resolution to repeal 2011 regulatory waivers of patient protection laws and amendment of 2015 MACRA law to make underwriting risk contracts voluntary. (Appendix VI).

The fellows and guests in attendance expressed their gratitude for Melissa Larson’s excellent presentation and help in discussing various aspects of ACO implementation.


We are again grateful for Dr. Crutchfield’s gracious hospitality in the use of his conference room.

The next meeting date is to be determined—probably in September with: a Focus on Health Care re-design and on Legislative items of importance.

Respectfully submitted,

Robert W, Geist MD, Secretary

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