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Minnesota Independent Medical Practice and Consumer-directed Health Care Policy

Tuesday, November 5th, 2019

MPPA Meeting Wednesday October 23, 2019 at 6-8 PM in the conference room at Crutchfield Dermatology, Egan MN.

Those present: President Lee Beecher MD, Bob Geist MD (RWG), Lyle Swenson MD, Wayne Zuehlke CPA, Dave Feinwachs JD, PhD, Carl Burkland MD, Mark Holder MD, Carolyn McClain MD, Mike Ainslie MD, Neil Shah MD, Merlin Brown MD, Doug Smith MD, Matt Flanders, and Dave Racer.

The result was an excellent conference with quality presentations. As Dave Racer wrote, As one of the laymen in the room last night I’d call the gathering a great success. For what we learned about individual initiative, entrepreneurism, and hope. For being faced with stark realities as a result of the furtherance of factory medicine, for the love of practicing medicine heard around the table.” [As Dave noted, there may be no single fix for the medical system, but all the small things we do (the meeting was a good example) are aimed at a single goal: empowering American patients and families. That would be where American families are kings in a medical free-market place. A place where prices guide decisions on quantity and quality of services to buy, where everyone has money for medical care — whether from a wage, savings, or a safety-net program, and where insurance is for financial catastrophe, not for prepayment of care “promised” by colluding profiteering political-corporate cartel barons holding all the money—rwg] Please note: my comments are in [brackets]

 

Minutes of the May 16, 2019 meeting were circulated to all before the meeting.

 

1) Independent Practice, Challenges and Solutions was the focus of an outstanding meeting featuring four outstanding Minnesota physicians: MPPA Fellows: Doctors Doug Smith, Mark Holder, and Merlin Brown who were joined by Dr. Carolyn McClain. The discussion was led by MPPA President Dr. Lee Beecher www.leebeecher.com

 

Dr. Doug Smith https://www.oronofamilymedicine.com/ led-off the discussion by recounting his journey from a part-time to (currently) a full-time solo cash-only family practice. Doug’s practice model, he agreed, would be difficult for a newly minted medical specialty resident to jump into; Doug has the advantage of a long history in family practice gaining experience with patients earning a fine reputation in the community for which satisfied patients seek him out. [BTW, Dr. Smith was the originator of MinuteClinic, is a book author, an excellent speaker, and a member of the CCHF Wedge of Freedom https://www.cchfreedom.org/cchf.php/1183 ]

 

Dr. Mark Holder http://mperialhealth.com/physician/ recounted development of his growing and thriving solo family practice within a concierge (retainer fee) structure featuring a set monthly fee, open-ended as-needed clinic access, no co-pays or surprise billing to patients for his professional services, no insurance hassles for him, and (encouraged) acceptance of direct payments from a patient’s HSA.

 

Dr. Merlin Brown https://health.usnews.com/doctors/merlin-brown-137904, is a practicing internist (now in solo practice) who described creating SolarteHealth https://angel.co/company/solarte-health-1 , a new practice networking model for associated independent clinics (which are not necessarily cash-only) linked together by Solate as a TPA (Third Party Administrator) as an alternative to an insurance company and managed care. The Solarte TPA model is appealing to employers who are self-funded who want cost-effective alternatives to expensive and administratively driven HMOs and closed-panel provider networks. The typical employer client for Solarte is self-insured. The model has 2 tiers: Tier 1 is a group of cash practices with transparent fees to patients (posted prices) which is paid 100% by the employer (no co-pays or deductibles for employees!). Tier 2 includes a preferred provider organization (PPO) which in today’s market is needed to allow greater patient access to and choice of specialty care. Merlin hopes the PPO option will lose importance in the future as more physicians join up. The Solarte TPA model is proving to be attractive to employers and individual consumers (patients and families). Payments to clinics for equivalent medical services are up to 80% less than in the current commercial managed care medical market. [For those who are interested in this innovative concept of independent practice, contact Merlin Brown at http://www.solartehealth.com/ or 952-999-4049.

Dr. Carolyn McClain 

https://constellationmutual.com/bio/dr-carolyn-mcclain/

 

An ER doc and clinic leader, Carolyn reported on her recent trip to Washington DC (on her own dime) to scrutinize and meet with Minnesota policymakers about current legislative bills  ostensibly designed to eliminate or control “surprise billings” after the fact to unsuspecting patients. Who should control or arbitrate these unexpected bills from out-of-network anesthesiologists or other professionals? She explained that proposed legislation to curb surprise billing if enacted will empower insurance titans and private investment firms (PIFs) which are responsible for (exponentially) buying up remaining independent medical practices in the US.

Also, current legislative activity on surprise billing will accelerate the demise of independent medical practices. And the argument she heard from our policymakers is that large organizations are needed to control the independent medical practice outliers. Meanwhile, private investment firms (PIF) are investing in ever-larger insurance-provider controlling organizations. And PIFs are cashing in on bait and switch tactics used by healthcare investment oligopolies which as a business practice offer signing bonuses to independent physicians and clinics (bribes) followed by loss of their professional practice autonomy and incrementally lowering salaries contributing to physician burnout. Private investment firms bet on and profit from healthcare mergers and acquisitions which feed the big players. And “surprise billing arbitrations affect only for fees greater than $1,200. But since most medical procedure fees (e.g., routine radiology) are much lees than $1200 (for example, an ER visit). So there is no arbitration for most “surprise bills.”  Furthermore, the MCOs which control the clinician payments are using “surprise billings” as a Trojan horse issue to actually fix prices upwards to their advantage.

There is a better way: By usingbaseball-style” independent dispute arbitration (IDR) pegged at 80% of median prices determined through an independent database, such as the FAIR Health Database. Patients are taken out of the middle of disputes and physicians still retain some leverage in negotiations. [Is 80% detrimental price fixing for clinicians? Why not 100%—rwg] Apparently, a NY model does work. Will anything pass? PIFs don’t want any bill, but both Republicans and Democrats want to “fix” surprise billings. Carolyn found that lots of docs in DC are worried about the same issues for which she went to Washington.

One commentator asked, what happened to Anti-corporate practice of medicine laws? Dave Feinwachs noted that these laws are functionally dead, and quipped that this allows Republicans to laud Medicare Advantage (HMO) plans which are profit-driven to ration care for those > age 65 and Democrats to laud “single-payer” MCO cartels which are profit-driven to ration care for those < age 65.

2) Agenda. ACO mercenary manipulations and Pre-RX Bundled prices. [Rep Glenn Gruenhagen was not present at this meeting–rwg].

Bob Geist briefed everyone on a bill: to mandate ACO disclosure to enrollees and providers of payments contingent on the volume of referrals (aka “value pay”). This makes ACO-HMO corporations liable for lawsuits alleging delay and denial of care, if the clinicians are paid bonuses contingent on the volume of referrals (aka “value pay”). Disclosures required by this law may not be claimed as proprietary or trade secrets.

 

Bob then noted the MN House staff is writing a bill requiring the posting of Pre-treatment pricing of common bundled services for individuals (not populations) to halt “surprise” billings including contracted transparency for 50 common elective procedures (from complex heart surgery to OP colonoscopy) before services are delivered. We have an unbundled post-care billing problem. Hospitals are gaming the CMS transparency mandate. It doesn’t work—there are unusable endless coding prices, surprises! Dr. Brown noted that this is what’s going-on with independent practice pricing.

 

Bob then noted the Family Medical Account (FMA) Medicaid reform bill (HF 2873).

 

3) Reference-based Pricing (RBP).

 

Dave Racer gave us a brief update. He and Greg Datillio are publishing a book, Health Care 2020: Connecting the Dots. Apparently RBP does work elsewhere in the Us, but has not gotten going as yet in MN.

 

4) Next meeting to be announced.

 

Again, our thanks to Dr. Charles Crutchfield for his kindness in lending his office meeting room and for the wonderful help of his staff: Kelly and Allison.

 

Respectfully submitted,

 

Bob Geist, MPPA Secretary

MPPA Meeting Minutes: May 16, 2019

Tuesday, May 21st, 2019

Those present: President Lee Beecher MD, Bob Geist MD (RWG), Carl Burkland MD, Wayne Zuehlke CPA, Rick Morris MD, John Tyler, Tim Herman, Dave Feinwachs JD, PhD, and Lyle Swenson, MD.

Please note: my comments are in [brackets]

 

Minutes of the Feb 26, 2019 meeting were circulated to all before the meeting.

MPPA website update www.physician-patient.org recommended by president Lee Beecher. The group approved $750 to revise the site. Lee will coordinate efforts with MPPA webmaster Kevin Hauge in consultation with the MPPA Board of Directors (see the tab “Who We Are”). We want to make our MPPA website a user-friendly and accurate resource for patients and families (health care consumers), professionals, employers, politicians, and the media interested in health care competition in Minnesota, informed patient and family (consumer) choices, and price transparency for services and products. The site will : 1. Include online links to Minnesota independent medical practices and consumer-directed health care insurance products. 2.  Highlight current health care policy discussions and opinion/inputs from contributors to the MPPA Listserv.

 

1. Reference-based pricing of services and related insurance—Dave Racer.

 Here is the link to a video of Dave Racer’s presentation—https://meedah.org/physicians. Just below the website picture, you see on the left the video—hit the start button >. I think you will find this in person presentation far more intriguing and informative than my too brief summary:

  • Legislation to approve RBP can be found in MN Revisor’s web site; see SF 2814. [The bill is blessedly brief—an easy read so look it over—RWG]
  • The reference price is the Medicare price, since it is ubiquitous with regional (state) and academic rate adjustments.
  • The related insurance products look like indemnity insurance—subd. 4 (c). Levels of insurance can vary widely. Racer gives examples, but “real time” plans in theory could be 100% to 300% or more of Medicare – although most likely they would be more like 175% for physician services, and 225% for facility charges or some such combination.
  • “Balance billing would be ideal”. [Let’s hope it is included, since clinics or hospitals will be subject to real open (free) market competition on price. Unfortunately, in Subd. 3(d)line 2.8 balance billing appears to be prohibited—RWG].
  • Clinic option is to accept insurance payment vs. assignment of benefits to the patient. The Racer version would accommodate balanced billing as the concept rests on patients and physicians dealing directly without interference. No MN insurance company allows assignment of benefits now.
  • Video highlights
  • Video highlights
    • 15:05—re reference-Based Pricing (RBP)
    • 17:55—4 hospital and 4 clinics examples.
    • 21:41—Insurance plan design.
    • 24:06—pricing insurance plans
    • 26:12—balance billing.
    • 30—assignment of benefits or not
    • 29:30—for doctors
    • 1300good for the nation

2. A Legislative issue for 2020: HF 2639, SF 3601 Mr. John Tyler. [This is a big bill that is not easy to summarize—RWG.]

 

  1. a) Health insurance underwriting, renewability, and benefit requirements modified; Minnesota health risk pool program created; unified personal health premium account creation allowed; Minnesota health contribution program created; health plan market rules eliminated; and waivers requested. [This is the Revisor’s summary—RWG].
  2. b) House File 2639/SF 3601 Bill Summary [The following is John Tyler’s summary—RWG.]

Introduction:  The Affordable Care Act has imposed narrow open enrollment periods for privately-owned coverage and federal mandates for coverage and tax penalties through 2018.  The purpose of this bill is to reintroduce fundamentally sound underwriting and basic insurance principals that allow for premium affordability, enhanced coverage tailored to the consumer’s needs and a more stable market at all fully insured levels.  “A formula for affordability” for all fully insured plans in Minnesota.

 

  1. Privately-Owned, Affordable Individual Coverage: Lines 11.26 – 26.5, Article 2.  Re-invents the Minnesota Comprehensive Health Association with the (MHRA).  Not a reinsurance plan – a high-risk pool.  Cedes adverse risk to the new MHRA at time of application.  Underwriting is restored allowing for standard and preferred-risk rating for those that qualify, estimated 70% to 75% of applicants.  Rating +25% or – 25% off-of standard rating.  Guaranteed-issue with underwriting to establish preferred-risk rates for applicants.
  2. Small Employer Groups (2 – 49 covered employee lives) Affordable Coverage Restoration:
  • Mid-Sized Employer Group (50 – 100 covered employee-lives) Affordable Coverage Implementation:
  1. Re-establishes Pre-existing Condition Clause Penalty for Those W/O Previous Coverage Only: Lines 6.5 – 6.13, Lines 7.27 – 8.6, Lines 4.18 – 6.13. All fully-insured contracts for those applying for coverage without prior coverage – meaning does not apply to individuals that have maintained coverage without a break of 63 days or longer.  Motivates maintaining continuous coverage without imposing penalties that are a disincentive to becoming insured.  Conditions diagnosed during prior 6 months of the start of coverage are not covered for the next 12 months of active coverage.  All other conditions covered.  and large groups and short-term individual plans and all government plan coverages qualify as “prior coverage.”  Motivates maintaining continuous coverage without a break.
  2. Defines the Sole Purpose of the Health Care Access Fund to be the funding of Minnesota Health Risk Association (MCHA 2.0). 20
  3. Defines the Funding of the MN Health Risk Association and Transfers from the Health Care Access Fund:

Reinstates the Healthy Minnesota Defined Contribution Program:  Lines 29.6 – 30.22.  Once passed into MN Law, it uses a choice of private individual policies with a government subsidy for those MNCare income earners at 200% of federal poverty and up.

 

  1. Legislative 2019 wrap-up and 2020 speculation[cancelled since legislature entanglements prevent Sen. Scott Jensen from attending, while Rep Glenn Gruenhagen was going on TV at the time of the meeting—RWG].

 

  1. MPPA legislative patient-clinic protection issues: These issues are not on this May 16 agenda—.
    • Free market alternatives,
    • Threats to kill Stark law—so far, only at federal level.
    • MN Legislature Resolution to repeal 2011 ACO-HMO waivers of patient protection laws including legalized bedside kickbacks (bribes) for rationing care.
    • FMAs for Medicaid briefing—HF 2873, Gruenhagen
    • AWP and patient freedom to choose providers
    • Patient financial bill of rights.
    • Models of national health insurance: the Scandinavian experience, US single payer proposals, and Medicare overhead vs. private insurance
  • SF 399 provider tax
    • Matt Flander’s article analyzing the 2% provider tax.
  • a preliminary briefing on the April 17 MN Supreme Court Decision on Warren v Dinter—the MMA position on the liability of a corporate ‘team physician’ employee.
    • Transparency amendments;
    • “Analyzing The House E&C Committee’s Bipartisan Surprise Out-Of-Network Billing Proposal.” Paul B. Ginsburg, Mark Hall, Erin Trish. The Trump administration has set the goal of transparency in pricing to avoid ‘surprise’

o   Apropos is the proposed MN bill: Mandate posting of pre-ante pricing of common bundled services for individuals. We have an unbundled problem. Hospitals are gaming the CMS transparency mandate. CMS’s transparency doesn’t work—unusable endless coding prices, surprise billings post care. https://www.washingtonexaminer.com/policy/healthcare/after-trumps-blessing-house-rolls-out-plan-to-end-surprise-medical-bills

 

  1. Next meeting to be announced.

 

Again, our thanks to Dr. Charles Crutchfield for his kindness in lending his office meeting room and for the wonderful help of his staff: Kelly and Allison.

 

Robert W. Geist, Secretary