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. There were 3 last minute cancelations.
The result was an excellent conference with two quality presentation. As Dave Racer wrote early this morning, “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 a place, where American families are kings in the medical free-market place. A place where prices guide decisions on quantity and quantity of services to buy, where everyone has money for medical care whether from a wage, savings, or a safety-net, 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) Agenda. Independent Practice, Problems and Solutions was the discussion focus of some of our local medical scene heroes, MPPA Fellows Merlin Brown, Mark Holder, Doug Smith, and Carolyn McClain led by Dr. Lee Beecher.
Doug Smith led-off recounting his migration from a part-time to a full-time solo cash only family practice. A model he agreed would be difficult for a new med school graduate to emulate; he had the advantage of long history in practice from which time many patients returned. [BTW, Doug was the originator of Minute Clinics, a book author, and excellent speaker, who I used more than once for the TCMS forum—rwg]
Mark Holder recounted his development of a solo family practice in a concierge model with a set monthly fee: free clinic visits; no copays of surprise bills; free telemedicine sessions; no insurance problems; and accepts HSA payments.
Merlin Brown, an internist in solo practice, followed by describing a new model of gathering associated independent clinics (not necessarily cash only) and including all specialties linked by a TPA (Third Party Administrator) paying the bills funded by employers. The typical employer is self-insured. The model has 2 tiers: first is a cash only transparent group of clinics with transparent prices paid 100% by the employer (no copays or deductibles). Tier 2 is a temporary PPO to not interrupt patient access. Why is this attractive? The prices paid the clinics are up to 80% less than in the commercial medical market! For those interested in this innovative concept of independent practice, contact Merlin at http://www.solartehealth.com/ or 952-999-4049. A number of our physicians voiced interest in this link. See the attached Solarte handout from Dr. Brown—very interesting!
Carolyn McClain, an ER doc, recounted her trip to the Washington DC mecca to object to various bills ostensibly aimed to control surprise billings, but which would end up in control of the current insurance titans and the private investment firms (PIFs) buying up medical practices grouping up to 15,000 physicians—yes, that’s real negotiating power. But the PIFs use a bait and switch tactics. High original pay is continually lowered, as they walk off with increasing profits from negotiations with MCOs. Another problem is that the legislation allows arbitration only for fees > $1,200; since most fees (e.g., radiology) are mostly < 1/10th of that, there is no arbitration. Further the PIFs control the clinician payments and Insurance corporations are using “surprise billings” as a trojan horse to fix prices. There is a better way: “baseball-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, both Rs and Ds want to fix surprise billings. Carolyn found lots of docs in DC, 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 profit-driven to ration care for those > age 65 and Democrats to laud “single-payer” MCO cartels profit-driven to ration care for those < age 65—[i.e., “for all”—rwg].
2) Agenda. ACO mercenary manipulations and Pre-RX Bundled prices. [Rep, Gruenhagen was out of town for an important family affair—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. Details page 4.
Bob then noted the MN House staff were 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 un-bundled 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—again see the attached Solarte Health handout. Details on page 5.
Bob then noted the Family Medical Account (FMA) Medicaid reform bill (HF 2873). Details on page 6.
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, but not yet going 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.
Bob Geist, secretary pro tem
ACO Disclosure and Liability (patient protection) bill:
Rationale: This is scary!
• ACO kickbacks contingent on profit-driven rationing of care access are a threat to patient interests, to professional medicine’s covenant of exclusive loyalty to patients, and to the integrity of nation’s medical system, when lubricated by profit-driven rationing of care
• ACOs require federal waivers of patient protection laws, because ACOs are profit-driven mini-insurance corporations without a license, practicing medicine without a license
• The ACO insurance corporation covets the professional appearance and legal attributes of large integrated clinics. Clinics earn, and split monies paid, for delivering services. In contrast, an ACO insurance corporation needs a waiver “license” to split premium profits earned from clinicians rationing services.
• Patient and Professional Integrity Protection: https://www.jpands.org/vol24no3/geist.pdf
o “(1) Where clinician pay is contingent on the volume of referrals ordered, malpractice culpability at minimum ought to be shared lest the ACO abandon clinicians in court.
o (2) Clinician pay contingent on rationing of care metrics ought to be subject to full disclosure for every ACO patient and caregiver.”
HF # pending
• Section 1 requires providers and health plan companies to disclose to enrollees, specific information about the reimbursement methodology the health plan company uses.
• Section 2 requires a health plan company to make available to a provider, a description of reimbursement conditions in the provider’s contract with the health plan company that may limit or restrict health care services provided.
• Section 3 amends the duties of the ombudsperson for public managed health care programs, to include helping public health care program recipients understand the reimbursement methodology used by the recipient’s prepaid health plan.
• Section 4 provides for health carrier liability if a health carrier compensates a provider and conditions the amount of compensation on limiting the amount of services provided, and the patient is injured by a delay or denial of care that was a consequence of the limit.
• the disclosures required by this law may not be claimed as proprietary or trade secrets.
RWG 651-485-5933 [c] Posting pre-treatment pricing of common bundled services for individuals.
• We have an un-bundled bill problem. Hospitals are gaming the CMS transparency mandate. CMS’s transparency doesn’t work—ex-post care unusable endless coding prices, upcoding, and surprise billings of marked up service prices.
• NYT article Jan 13, 2019 re: failure of the CMS post treatment transparency mandate. https://www.nytimes.com/2019/01/13/us/politics/hospital-prices-online.html?action=click&module=Top+Stories&pgtype=Homepage&stream=top&utm_campaign=newsletter_axiosvitals&utm_medium=email&utm_source=newsletter
• It is one thing for ACOs-HMOs to insure a “bundle” of various comprehensive services for a population with a global (capitation fee) budget. It is quite another thing for 2 or more providers to offer a bundle price to an individual for comprehensive services such as for heart surgery, a total knee, diabetes care for a year, endoscopy and other services, etc.
• A bundle bill for individuals would obviate gaming (massive unusable un-bundled reports) and ‘surprise’ billings for marked-up prices, for which the administration (Trump Calls for Cracking Down on Surprise Medical Bills) and a bipartisan group of Senators and House Reps hope to deliver bills
o Oct 5, 2019 op-ed regarding low priced Walmart Super (health care) Centers.
HF bill # pending
a) Require all providers, Clinics. Hospitals, Pharmacies, whether in or out of an insurance company network to publish and display the usual ex-ante price of 50 common bundled services for individuals;
b) to include an estimated good-faith price, which may include risk adjustment for the individual’s health;
c) to include making a binding contract;
d) to include the lowest cash price bundle to be applied for emergency care of an unconscious patient,
e) to include the lowest cash price bundle for emergency care of acute trauma, cardio-vascular mishaps, acute complications of illnesses such as epilepsy, diabetes, etc.
f) to include an offer of a lowest cash price for the un-insured patient.
g) to include ability of insurance corporations to contract prices for individual enrollees in similar manner as can individual patients.
RWG 651-485-5933 [c]
Family Medical Accounts (FMAs) for Medicaid reform: HF 2873
• Problem: unrelenting cost inflation of the MN Medicaid program
• FMA Program: Each enrollee would have a debit card (cash) to pay for outpatient services; use restricted to Medicaid approved medical expenses.
o FMA savings. Debit card electronic transactions for services eliminates 3rd party middleman overhead costs and unnecessary pre-authorization barriers to care.
• 2012-2016 Connecticut dropped its Medicaid program overhead from 12% to 5.2% after firing its Medicaid HMOs.
• 1990 pre-HMO MN Medicaid overhead costs of 4-5%.
• Free choice of Medicaid program. At times of enrollment each enrollee in two categories families with children (n= 705,400 in 2017) and adults without children (n=199,950) would have free choice of the FMA program or of the standard HMO program.
• Free choice of provider. Enrollees with money on a debit card have free choice of providers and no unnecessary nuisance barriers to care.
o With good luck in health and a minimum of prudence there is a chance that enrollees can roll over significant un-spent money for future health care costs—a potential bridge out of Medicaid.
• Funding the FMA debit card. 50% of 2016 Federal annual costs of enrollees: $1,500 per child and about $2,500 per adult the first year—
o FMA funding is near twice as much as the $1,305/yr. spent by a non-Medicaid healthy young adult.
o Any out-patient charge over $300 is considered a major-medical expense and covered by Medicad.
• Other States. FMA program far less complex: no cash copays for services; no “policy contributions” (premiums); no punishments for non-payment (e.g., loss of eye and dental care); and a real possibility of roll over money.
o MN Medicaid overhead expenses might be reduced to low 1990 levels of 4-5%3 much like that in Connecticut without HMOs of 5.2%.1
• The FMA Goal: “Ownership of resources is the path to a decent life free of poverty and dependency: a goal for all Americans.”