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Archive for the ‘Minutes of MPPA Meetings’ Category

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 (PremierSkinMD.com)
• 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]
1/12/18
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.
1.4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
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.
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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.
REVISORSGS/EP18-5223
01/12/18

MPPA Meeting Thursday January 18, 2018 at 6-8 PM in the conference room at Crutchfield Dermatology, Egan MN

Thursday, January 18th, 2018

Those present: President Lee Beecher MD, Bob Geist MD, Dave Racer MLitt, Hannelore Brucker MD, Carl Burkland MD, Wayne Zuehlke CPA, Dave Feinwachs JD, PhD, Marie Olseth MD, Phil Raines MBA, Sen. Scott Jensen MD, Rep. Glenn Gruenhagen, Jon Thomas MD, Greg Plotnikoff MD, Charles Crutchfield III MD, Chris Foley MD, and Comfort Anyieh MD (triple boarded in IM and introduced by Dr. Plotnikoff) [4 members canceled at the last moment because of illness or unexpected travel plans—RWG]

1. Minutes of the Sept. 14, 2017 meeting had been circulated to all before the meeting and were not discussed further.
2. 2017 Senate Select Committee on Access and Cost was reviewed by Sen. Jensen, the chair of the committee. He recounted the issues that he hoped to introduce in the legislature regarding Transparency (more on that below), drug mark-ups, gag-orders, any-willing provider to preserve the patient-physician relationship, equal 3rd party payments for equal work, HIPPA law problems, and HMO audits. Facility fees were briefly discussed later.
• Transparency legislation. 4 state bills were reviewed. Discussion with Sen Jensen was led by Dave Feinwachs, Dave Race, Marie Olseth, and Phil Raines,
• Proposed MN legislation was discussed at length (see the bill in appendix p 3-4). The rationale for the bill was brought out in commentary by the discussion leaders and all those present:
• BCBS does not reveal fees prices for services. Contract prices depend on size/power of group. Everyone except providers has access to “all-payer” prices.
• HMOs oppose Transparency: claim that contracts are already done and can’t be re-done.
• The cost of care problem is not alleged clinician or patient cost culprits but rather the self-serving insurance industry accounting methodology (NIAC) hiding where state money is spent. For example, NIAC does not detect the lack of connection between encounter and payment unlike generally accepted accounting principles (GAAP) used everywhere else. What’s happened to raise prices?
i. Facility fees
ii. The problem with MN Medicaid is that the HMOs are spending state money. claim that how it is spent is a “trade secret” (i.e., proprietary information), and self-report need for state money without state oversight of where the money goes.
iii. DHS thus has no idea how money is spent on enrollees [with exception that a childless adult cost $7,992/person in 2016—RWG]. If federal block grants happen, full disclosure of encounter-payment data might be mandated.
• It was 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 needs to answer.
• Is the OLA capable of doing an audit? It was suggested that the answer was no! Another opinion is that OLA did a good job on MNSure and special education audits. [The problem apparently is in MN HMO audit bookkeeping methodology separating encounter and payment, which makes a forensic audit impossible]
• Sen Jensen noted that this bill is a first step. Patients want the best price and have nowhere to find it.
• A question now regards transfer of BCBS Medicaid money to its new a for-profit joint-venture partner, Anthem corporation.
• Quality metrics used to determine payments was noted. Balance billing ought to be allowed [Current federal Medicare regs and state Medicaid regs would have to be repealed to do this for public programs—RWG]
3. Maintenance of Certification (MOC) discussion was led by Dr. Jon Thomas, former long-time chair of the MN Board of Medical Practice. Protests over the American Board of Medical Specialists (ABMS includes 24 societies) handling of exams and their cost has resulted in ABMS Board rancor and hopes for progress. The problem with periodic exams is that they have not been shown to be effective and yet are a required mandate by insurance corporations and hospitals. Dr, Thomas favors continuous learning through the state CME program; a program method that he thinks needs to be strengthened. The coercive nature of the MOC program continues to be a problem, [I am told that MN legislation is being considered to deal with periodic MOC exams, the common irrelevancy to medical practice, and coercion problems—RWG].
4. Buy-in to MnCare proposal of Gov, Dayton. Discussion was led by Dave Racer, Rep. Gruenhagen, and Drs. Beecher and RWG. It was pointed out that poor pay public program force clinics out of practice. They have apparently been ruinous to rural physicians where the population of public program recipients is large. Expanding this proposal would be a state financial disaster. [This maybe a big item at the legislature. Another public Medicaid program of more serious nature had just come to my attention since the MPPA meeting. The is the MN DHS agency’s “New Gen IHP” proposal—I’ll be emailing the fellowship an analysis done by one of our regular correspondents— RWG]
5. The attendees applauded Dr. Crutchfield’s gracious hospitality in the use of his splendid conference room.
6. We did not get to all items on the agenda. This includes a briefing on Medicaid proposals (of which the most serious might be DHS’s Next Gen IHP (aka ACO) initiative and EHR problems and possible solutions if entities wanting clinical reports were mandated to pay for them by contracting directly with willing clinics—the state’s mandate reports are a free-loader’s tax on clinics.
7. The next meeting is on Feb. 22 and focused on Independent Practice led by Dr. Neil Shah.
Respectfully submitted,
Robert W, geist MD
Secretary pro tem


Transparency bill. (Sen. Scott Jensen and Rep. Bob Loonan)
1/12/18
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.
1.4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
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.
REVISORSGS/EP18-5223
01/12/182.1
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.
REVISORSGS/EP18-5223
01/12/18