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

Saturday, May 26th, 2018

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

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 (
• 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]
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.