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MPPA Meeting, Feb 19, 2020: Discussing 2020 MN Legislation

Saturday, February 22nd, 2020

MPPA Meeting Wednesday February 19, 2020, 6-8 PM in the conference room at Crutchfield Dermatology, Eagan MN.

Those present: President Lee Beecher MD, Bob Geist MD (RWG), Wayne Zuehlke CPA, Dave Feinwachs JD, PhD, Carl Burkland MD, Mike Ainslie MD, Neil Shah MD,  Dave Racer, and Noel Collis MD.

Please note: My comments are in [brackets]

Minutes of the October 2019 meeting were circulated before the meeting.

Part I—MN Patient Protection bills 2020. RWG

 

  1. Observation billFeinwachs [HF and SF pending introduction]
  2. A 2-day observation status means a patient is not technically admitted to a hospital. Patients are being billed for care as outpatients. This can also happen to people who are working after age 65, even though they have Part A Medicare (hospital) coverage automatically, but not Part B (outpatient) insurance. The bill says that the patient must be informed that being place in an “observation” bed means she may be billed for outpatient care, is technically not admitted to the hospital, and if not told and formally consenting to this, the hospital cannot balance bill the patient.

 

  1. The bill also gives the MN Commissioner of insurance regulatory power over private Medicare supplement plans— to prevent seniors being enrolled in into Medicare (HMO) Advantage plans through advertising and promotions—they ought to know that Medicare Advantage is in fact private HMO-like coverage; they are they are no longer covered by traditional Medicare and its rules.
  2. Hearings on this bill will probably occur next year.

 

  1. Q: is there a right to refuse observation status in a hospital? A: Yes. And, to request formal admission to the hospital. (DF)

 

  1. ACO disclosure and liability billRWG (for Rep. Gruenhagen and Sen. Jensen)
  2. The MN case of Warren (a patient of a nurse practitioner who died after not being admitted to a hospital) v Dinter (a gatekeeper physician who denied authorization for hospital admission) [https://www.jpands.org/vol24no3/geist.pdf] The MN Supreme Court in 2019 ruled that a jury must adjudicate this case of alleged medical malpractice by Dr. Dintner. And, importantly, the fact that Dr. Dintner did not himself personally exam the patient is not a denial of a doctor-patient responsibility. He or she can be sued for malpractice even if a physician does not personally examine a patient.

 

  1. The bill is intended to require the disclosure of risks that Accountable Care Organizations (ACO) pose to the access or quality a patient’s care and a physician’s professional integrity [HF and SF introduction pending], if and when financial kickbacks are expected or paid to physicians contingent on their rationing of corporate dollars — such as receiving increased salary or bonuses when they order no or less expensive care and “negative payment adjustments” when they obligate “too much” of ACO dollars.

 

  1. CMS’s program of ACO “double sided” (insurance) risk depends on kickbacks to ACOs contingent on bedside clinicians rationing medical care to patients. This form of government care rationing has not worked to either save money or improve care in over a decade of federal (CMS) ACO pilot experiments. And ACO managers will not sign up for losses when bidding on insuring the cost of a population’s care. [That includes MN, where to the best of my knowledge there are no kickbacks going on.]. However, the power and reach of the federal CMS may force all states to use the ACO double-risk kickback formula for medical care cost control.

 

  1. This ACO disclosure and liability bill if enacted will help educate and protect patients and medical professionals alike — by requiring transparency of kickback payments to medical care  “providers” at the time of patient enrollment and specify the the tort liability of ACOs.

 

  1. Posting of pre-treatment prices for elective bundles of OP and In-patient services—RWG (for Rep. Gruenhagen. [HF pending introduction].

The rationale for the bill: Merely posting prices for (long and detailed) listings of coded medical treatments present with an unwieldy, complex, and often unusable challenge to medical care consumers (patients and families). Pre-treatment bundle pricing by itemizing what is covered and not covered in an episode of surgery including anesthesia for a hip replacement procedure, for example, binds the provider to the bundled price. By so doing, “surprise” billings will not, or will rarely, occur. And “providers’ have an incentive to compete based on expected care rendered. Patient friendly price transparency usual bundles of expected care will benefit all parties.

 

  1. Medicaid reform (FMA bill) bill to empower patients and reduce costs of care by-passing (administratively expensive) 3rd party rationing of care. Creating the ability of Medical Assistance patients to use onsite debit card payments for the outpatient services of the patient’s choice —RWG for Rep. Gruenhagen [HF 2873]

 

Part II—Other issues RWG moderator

 

  1. Hospitals are now selling identifiable patient data—Feinwachs
  2. In 2020 many businesses including hospitals and health systems are selling access to personal patient medical data to Google. They claim freedom to sell and buy data using the HIPPA “privacy” law which allows them to do so. Moreover, these companies want to change Minnesota’s stringent medical data privacy law which protects a patient’s right and need to consent to medical data sharing.

 

  1. Parenthetically, it was noted that EHR companies (such as Epic) want to continue selling unconnected data patches and thus not allow system connections. We advise patient ownership of their own data and patient-control of enhanced data-sharing connectivity.

 

  1. Up-date Gov. Walz’s MNCare “buy-in” proposals—Feinwachs
  2. Polls are clear that the US in 2020 is not supportive of “Medicare for All.” Over 170,000,000 citizens on private insurance fear losing their current medical care insurance, and unions (who have negotiated benefits for their members) do not support it.

 

  1. The “Public Option” in Minnesota would be a government subsidized Medicaid-like program. There is opposition to expanding Medicaid. Families, who never used Medicaid prior to its expansion under the ACA have been billed (through liens on their homes) for “premiums they never paid or knew anything about, despite never having used any medical services! MN has repealed this threat. But theoretically, the feds could re-institute the lien business in a Public Option program. Further, subsidy money for the Buy-in premiums go to the administering insurance company, not the family or program recipients.

 

  1. Parenthetically, this brought up a discussion of three MN physician legislators who’ve announced their recommendation to create a public utility-like commission to advise on drug prices.

 

  1. Neil Shah pointed out that “there are modest proposals that would help educate the public in order to lay the groundwork for reducing drug prices for consumers. First would be mandatory disclosure of drug price kickbacks other than to consumers. Disclose the lowest cash-payer price and the patient’s Out-of-pocket (OOP) insurance price to the consumer at the pharmacy. The patient can then choose which price they’d like to pay – cash or insurance-allowed (see: GoodRx). Second, mandatory disclosure of rebates – both to PBMs and to insurers – on a per drug basis publicly reported online. Again, the public (consumers) – and most companies who pay for commercial health insurance (employers) – do not understand how badly they are being fleeced.

 

  1. Up-date from DC and MN for 2020—Dave Racer discussion
    1. “The MN GOP Healthcare Task Force (RHCTF) bill is called the Minnesota Patients’ Medical Care Affordability and Quality Act (MNMCAQ). The bill is a comprehensive proposal for reforming the MN insurance system. It includes a new internal to coverage version of  Minnesota’s successful (1976-2013) Minnesota’s Comprehensive Health Association (MCHA) covering expensive pre-existing medical conditions. The bill was not further discussed.
    2. An important new book: The Manual: Health care 2020: Connecting the Dots by Greg Dattilo and Dave Racer was discussed. [http://themanualhealthcare2020.com/  click on “order a copy”].
    3. After passing MN 2018 laws (62J.81 ff) mandating the posting of clinic prices (including Medicare, Medicaid, Insurance-carrier, and billed prices, the authors were able to explain and “connect the data” dots about the use and value of medical care and insurance (third party) price disclosure for Minnesota clinics and hospital systems.
    4. The spread between Medicare and posted prices shows that the mean price for care in Minnesota was 201% of Medicare allowable rates with a high of 282% and low of 109%. [see attached email file table from the book]. The Racer-Dattilo charts include, among other things, the insurance company’s discounted rates for services/procedures reported as well.
    5. Neil Shah noted that “the Reference Based Price (RBP) tables are an easy way to compare prices across clinics. This is very useful information for HR directors, employers, and medical care consumers (patients and families) who take the time to choose their physicians and clinics. Most consumers in 2020 are new to this, but it will be beneficial to those who want to know what their care costs and how much their commercial or government coverage will and will not pay.”
    6. Dave Racer identified many inaccuracies in current MN clinic postings and absence of Medicare prices for comparison.
    7. Read pp. 79ff to see a sampling of the impact of hospital chargemaster prices. [These are usually closely guarded secrets, and they are very often grossly inflated over the actual costs of providing care to patients.]
    8. The authors recommend that all physicians, medical professionals, hospitals, clinics, and providers should disclose their Medicare-Percent  – the percent of Medicare they actually accept as full payment. All regular Medicare providers must accept ehat the government will allow. If public information, this allows patients to evaluate a physician or clinic’s prices in a simple manner. and make price-informed decisions accordingly.
    9. Chapter 15 discusses Reference Based Pricing Insurance (RBP) Plans. These allow employers or individual consumers (patients) to buy coverage that would pay up to a certain percentage of Medicare allowable payments, and allow patients to seek care from any willing medical professional or facility who posts its prices. The reference price use would allow “providers” to establish their own prices for what they do, and would make comparison shopping for medical care much more possible.
    10. Racer and Dattilo visited Washington, DC in January and met with Peter Nelson, aides to Representatives Tom Emmer, Mark Meadows, Sen. Tim Scott and Sen. Todd Young. They also met with Representative Gary Palmer, R-Alabama, and Jim Banks, R-Indiana. Their trip included a meeting with two staff aides to Vice President Mike Pence. The RBP pricing concept as Medicare-Percent Disclosure was well-received [RBP].

 

4) Next meeting to be announced.

 

Thanks to Dr. Charles Crutchfield for lending his office meeting room and for the wonderful help of his staff: Kelly and Allison.

 

Respectfully submitted,

 

Bob Geist, MPPA Secretary

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 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