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MPPA Meeting: September 25, 2018

Friday, September 28th, 2018

MPPA Meeting Wednesday September 25, 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, Neil Shah MD, , Wayne Zuehlke CPA, Steve Burgeson (new Fellow), and Matt Flanders. It’s of interest the we had 25 responses to the meeting announcement. Last-minute illnesses of some, the active political campaigns, and a very busy group of people reduced attendance to eight from the scheduled 16! Two sent remarks regarding their experiences in Canada’s Medicare system, which I read at the meeting.

A fruitful meeting attested to by the long length of these minutes. Please note that my comments are in [brackets]. We had excellent open discussions of all issues! Read on…

Minutes of the May 23, 2018 meeting were circulated to all before the meeting and were not discussed further.

1. Election issues—Single payer panaceas [Favored by 26% of physicians 2018 survey.]
• Bob Geist described the two Medicare-for-all bills now in congress including BernieCare and another from the Physicians for a National Health Plan—neither has a CBO fiscal note. Bob then discussed the Mercator Center (George Mason U) 10-year cost analysis of BernieCare at $ 32 Trillion (with a T) and found near the same cost as the end result of implementing the ObamaCare cartel-like program now in progress. BernieCare advocates claim that it will be $2T cheaper. The problem is that these are two socialized programs with the same catastrophic result albeit one is to be run by the feds (B’Care), and the other by a government-backed (i.e. crony) HMO-ACO industry (O’Care).
• Dave Feinwachs described the MN MNCare buy-in (DaytonCare) proposed by the DFL—MNCare is a state program linked to Medicaid. The opinion was that this is a state supported premium for an expensive poor product. His estimates are that it would save a family buyer $69/mo., or about $800/year with the same high price (hidden with tax-payer props) and poor benefits plus access problems due to poor pay rates for clinics. The same HMO-ACO industry will run the program—a middleman expense of what was described as enormous, as is already evident in the MN Medicaid program. In the discussion, one suggestion was for a real FFS alternative of 80% state major med insurance and 20% individual insurance and cash payments [I hope this is an accurate recounting of the idea, It’s of interest this mixed concept is favored by a significant 35.5% of physicians: 2018 survey RWG] In regard to the election, hanging in part on the DFL DaytonCare proposal, absentee ballots, pre-filled out, have been sent to all registered Democrats for early mailing—the GOP has no such program as far as is known. Re-constituting a MN high risk pool (the successful old MCHA program killed by Obamacare) was discussed. It was pointed out that merger mania continues with the Blues outsourcing back office work to Anthem. Finally, the Office of Legislature Auditor (OLA) claimed it could not find an independent auditor for MN Medicaid as required by law and would do the audit itself—this is a highly suspect excuse and a continuing story.
• Critiques of SP panaceas. I read two brief letters from two ex-pat Canadian doctors regarding problem with the Canadian Medicare system. Its attributes are that it’s free open access, It’s problems are that the appearance of free care generates unlimited demand too often met with harsh rationing of care measures resulting in a rotting infrastructure of equipment and available clinicians plus long queues for the ill paying a high price in lost wages, morbidity and occasional mortality. The burden of triage for an interventional radiologist recounted wait-times of 7 months for a CAT scan and 13 months for an MRI. In one case the doctor had only the typical 2-line limited clinical history on the referral; a triage to the end of queue resulted in a preventable death—the doctor could no longer in good conscience practice in such a harried poorly funded system. He moved to the US to practice good patient care rather than impossible bureaucratic care. He wrote: “I quickly realized that the moralistic Canadian system is not really about providing care, but about providing an illusion of care.”
• Free-market Alternatives.
o Bob Geist described the Family Medical Account (FMA) Medicaid program, which funds an enrollee-owned debit card for outpatient care. The simplicity of onsite payments eliminating the expensive HMO middleman function ought to meet the state goal of lowering Medicaid costs much as has happened after Conn. fired all its Medicaid HMOs. Would lack of independent primary care docs be a problem? [Probably not the way the program is constructed; details on request.]
o Cash only practice was discussed, and in some detail, both the CCHF “Wedge” program and concierge practice.
o It was noted that Denmark will run a large trial using the Medibid program.
o We have in the past discussed at length expanded and reformed HSAs—p. 6-7
2. Sen. Scott Jensen’s priorities for the 2019 session were discussed. These are appended to the minutes (see p. 4) including SF numbers. Please note that these priorities mimic almost all of the MPPA initiatives discussed in part #3 of these minutes. The exceptions are MOC reform and the possibility of a state legislative Resolution to a) repeal of 2011 federal waivers of patient protection laws and b) amend 2015 MACRA franchising law (i.e., payments for services exclusive to providers underwriting-insuring population costs). Repeal and amending federal law would eliminate coercing providers into underwriting (insuring) the risk coercion population costs and mandate that clinics have freedom to contract for underwriting or not. Scott has just completed a new AWP bill—more on that later.
3. Legislative Patient-Clinic Protection Issues.
• Freedom to choose Any Willing Provider (AWP). Neil Shah noted that since insurance is vital for clinic survival, patients ought to have freedom to escape a network for care paid at least the same rates as are providers in the network. Balance billing is a non-starter. A SD state referendum approved freedom to choose by > 60%–a freedom to choose bill was promptly passed by the legislature, Other states (e.g., Utah) have passed similar bills, but some state laws are more limited in scope.
• Clinic Fair Care bill would mandate payments for deductible services by the insurance corporation holding the patient’s deductible money, which the patient ought to be able to spend as they please.
• Clinic Fair Contract Act would eliminate state mandated quality reports, would require any entity wanting clinic data to pay for it, would mandate that a clinic be free to contract or not. It would require that patients opt-in to reporting their clinic data to 3rd parties even, if the clinic contracts to report data to a 3rd party.
• A patient financial bill of right would require itemization in plain English, never receive a surprise bill, and 7 other common-sense requirements including price transparency (see P. 5).
• Transparency bill amendments would eliminate gag clauses, include all providers, make sure that facility fees are posted up-front before a service is provided, pre-care estimates of all (4 possible) fees, and truth in pharmacy pricing.
• Amend MN CON law to eliminate requirement of no overnight stays.
4. Matt Flanders briefly discussed the CCHF Wedge program and Twila Brase’s new book, Big Brother in the Waiting Room. I personally give it highest praise—a book that for the next few years will be a necessary reference for any healthcare activist. It’s #1 in sales in its category; going like hot cakes. A second printing is pending—only four more at the Amazon warehouse as I write, but more coming. My recommendation: Buy it on-line now!!
5. A MN Legislative Resolution to repeal waivers of patient protection laws was discussed. This will be sent to the Fellowship when completed,
We are again grateful for Dr. Crutchfield’s gracious hospitality for use of his conference room.
The next meeting date is to be determined.
Respectfully submitted,
Robert W, Geist MD

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