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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)
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.

MPPA Meeting Thursday September 14, 2017 at 6 PM in Central Medical Building, St. Paul.

Thursday, September 14th, 2017

Those present: President Lee Beecher, Bob Geist, Dave Racer, Hannelore Brucker, Carl Burkland, Don Gehrig, Wayne Zuehlke, Mike Ainslie, Dave Feinwachs, Tim Herman, and Doug Smith.

1. Minutes of the May 16, 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 discussed by RWG. The committee Chair, Sen. Scott found himself unable to get to the meeting and sent his regrets.
3. 2018 Legislature. David Racer and Feinwachs led the discussion.
• It was noted that the Reinsurance bill passed this session had some serious problems, especially since MCHA was not revived—MCHA ought to be a priority.
• The fate of the Health Care Access fund (and provider tax) remains problematic.
• The new option for discounted fist dollar care coverage (by Golden Rule and UHC corporation) was briefly discussed—catastrophic insurance would be needed.
• It was noted that with Guaranteed Issue (GI) and Community Rating (CR) there is no true insurance underwriting—the corporations are on the public-private dole. One person observed that the ObamaCare promise was that, if you back the bill, we’ll give you all the patients and the money—the result is the corporations complain that they don’t get enough money with all the patients. Trump so far is not coughing up the dollars; if the mandate is not enforced, the “plans will collapse.” [IMO, maybe. But we got what was a medical system handed to government protected HMO-ACO cartels as a path to UHI—this time to commercial corporation health services or corporate socialism (aka “privatization”) unlike to national socialized NHSs as done abroad—RWG.] The corporations are looking at a bipartisan Congressional recue at this moment.
• The HMOs make their money in Medicaid. [The expensive disabled are steered into the FFS sector (run by DHS); the well are steered to the Medicaid HMOs (aka “cherry picking”). Confirmation came from DHS, this morning: “MA recipients with a disabled basis of eligibility are excluded from this requirement (to enroll in HMOs) and largely served under fee-for-service.”
• A problem has occurred to those age >55 no Medicaid. They are finding out that their homes are being owned by the government with liens based on how much premiums would have cost; not on how much was spent on their care—if they had no Medicaid expenses, they could still lose their house. Apparently, folks have found out and are dropping out of Medicaid. The legislature has not corrected the problem.
• The problem with MN Medicaid is that the HMOs are spending state money but claim that how it is spent is a “trade secret” (i.e., proprietary information). 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 data ought to be mandated.
• The Hi-Lex vs. Michigan Blues was brought up because Medicaid is a self-insurance program akin to a private company ERISA self-insurance program—Hi-Lex is one of thousands of such ERISA companies using HMOs as TPAs. Medicaid uses HMOs as 3rd party administrators (TPAs). The MN HMOs would have us believe they are “at risk” insurance companies yet they tell the state what was spent and the state “believes” it and pays up—without an audit! Hi-Lex won the suit in 2015 with the result that the Blues illegal fraud cases have jumped to > 200 all of which the Court said shall be paid without question. [There remain efforts to open-up Medicaid HMO books to see, if MN (and CMS) Medicaid has been similarly defrauded. No state audits have been done!
• Action item for Dave Feinwachs: It was suggested that members co-sign a letter to the Office of the Legislative Auditor (OLA) to obtain paid claims data—many agreed; Dave Feinwachs will arrange.]
4. Family Medical Account bill. RWG discussed his testimony to the Senate Select Committee last week. A copy of the FMA briefing letter was handed out and was previously attached to the emailed agenda. FMA program is basically a method of FFS payment for Medicaid enrollees in categories families with children and childless adults. Mike Ainslie wondered if this could be used for the disabled—this is not in the bill but ought to be considered for a separate bill for a program of Personal Health Budgets for high need patients. [Pilot studies have begun in the UK NHS of all places—RWG. See O’Shea L, Bindman AB. Personal Health Budgets for Patients with Complex Needs. N Eng J Med. 2016;375(19):1815-1817.]
• Action item for RWG. I hope to get hearings on the FMA bill when the legislature re-convenes.
5. Other legislative items.
• Tax-free insurance equity for those not in employer-based insurance is a federal, not State issue.
• Out-of-pocket expenses credited to deductibles (the Fairness bill) for out of network care failed in the legislature so far.
• “Up to 50% of EHR data entry clerking” is an unpaid expense for un-paid data collection mandated by state law. It was suggested that using the VAH system (a public free EHR system) cold break the strangle hold on the IT involved.
1. Action item for Smith Racer, RWG: [All members were sent an email this morning regarding the IT problem and it ramifications thanks to the work of Doug Smith and Dave Racer—please note the recommendations of how to deal with the problem using legislation to negate a bad law—RWG].
6. MPPA. It was pointed out that MPPA is an excellent irritant of importance stimulating political action thanks to the synergy of the group and its wide-spread connections. No one is alone, as long as MPPA exists and our many Fellows freely discuss the issues of political malpractice, which continues to threaten patients, professional integrity ( the covenant of loyalty to patients first), and has already resulted in toxic financial results for families and the nation.

6. The meeting adjourned at 8 PM—with the usual post meeting confabulations!

7. The next meeting will be sometime before the legislature re-convenes. Congressional acts may determine the MN 2018 legislative session activities. During this summer and fall, there has been and will be continuous member activity regarding the next legislative session.

Respectfully submitted,
Robert W. Geist MD,
Secretary pro-tem