Report: Exploring Professional Worker Unionization in a Corporate Practice of Medicine Milieu

A MN Physician-Patient Alliance Report, 2024

Editor: Robert W. Geist MD
MPPA Chief Librarian[1]

Table of Contents

• Report: Exploring Professional Worker Unionization in a Corporate Practice of Medicine Milieu  1
• A MN Physician-Patient Alliance Report, 2024. 1
• Table of Contents. 2
• Report Executive Summary. 4
• Forward to this Report. 5
• Cost-price Inflation. 5
• The ACO Hospital Corporation/Worker Dilemma. 7
• Chapter 1. Unions vs. the Corporate Practice of Medicine. 9
• Chapter 2. Legal Ramifications. 10
• The Corporate practice of Medicine. John E. Diehl JD[] 10
• Prohibition of corporate practice of medicine laws is crucial. 10
• Medical professionalism. 10
• The Corporate Practice of Medicine Prohibition – Guidance for the Future. 11
• Private Equity (PE) in medicine. David Feinwachs, JD, PhD, 12
• Private Equity (PE) firm financial engineering of medicine is focused on Return On Investment (ROI). 12
• Chapter 3. Economic Future and Speculation. 13
• Prof. Stephen Parente, PhD. 13
• “The market needs to move to work directly with patients and the community.” 13
• RWG. Do unions and ACO corporations have a common enemy?. 13
• De-industrialize?. 14
• Retail Marketplace?. 14
• 1973 Transition from a Professional to a Commercial Medical Marketplace. 14
• Chapter 4. Prof. Robert G. Kennedy, PhD Four Ethical Considerations and End Game. 16
• What might be the union end game?. 17
• Chapter 5. Curtailing Corporate Practice of Medicine (CPOM) 18
• Prohibit the Corporate Practice of Medicine. 18
• A Retail Mainstreet Medical Marketplace needs Policy Maker Attention. 18
• Chapter 6. A Retail Medical Marketplace? Editorial 19
• The Nature of Microeconomic Retail Sectors. 19
• The Nature of a Macroeconomic Marketplace and Fatal Flaw. 20
• The Nature of a Restored Retail Medical Marketplace. 21
• Chapter 7. Individual Meeting Commentary. 23
• Chapter 8. Summary of Oct. 17, 2024, MPPA Meeting. 25
• Meeting High points. David Feinwachs JD, PhD. 25
• Editor’s Postscript. Professional Medicine’s Link to its Past Cut by the CPOM.. 25
• Appendix A. Oct 17, 2024, Meeting agenda. 26
• Title: Unionization of Medical Workers vs. ACO Corporate Management: Why Unions? Why Not?​  26
• Appendix B. Oct. 17, 2024, MPPA meeting minutes. 28
• Preamble: 28
• Meeting Minutes: 28
• Unionization of professional clinicians in America’s Hospital Corporations. 28
• Summary. 32
• [Meeting Postscript 32
• Appendix C.. 33
• Corporate Practice of Medicine Prohibitions, John Diehl JD. 33

Report Executive Summary

The Corporate practice of Medicine problem (CPOM) is the essence of this story. (see App. C.)

On Oct 17, 2024, MN Physician P Alliance (MPPA [[2]]) conducted a meeting to discuss unionization of the medical staff of a local Accountable Care Organization (ACO) hospital corporation. How did we end up with a corporate medical factory model where corporate managers legally control use of patient money and can thus make medical decisions to produce or not produce patient care in the interests of the corporation? [[3] ][[4]] The financial conflict of interest with patients is obvious. The corporate practice of medicine problems encountered and its alternatives are the subject of this meeting Report.

The hope is that this meeting report can be used for in-depth academic and community discussions that translate into medical system political action reforms for elimination of the corporate practice of medicine factory model.

 A summary of this report:

1. The plight of the unionizing professionals in a legalized corporate practice of medicine milieu is explored including physician burnout and moral injury, when the professional covenant of exclusive loyalty to patients is broken by the corporation practicing medicine.
2. The legal aspects of the corporate practice of medicine are recounted by lawyers, John Diehl and Dave Feinwachs. Corporate vs. union “bargaining is warfare,” the antithesis of a professional workplace, and a system “tragedy.” Private Equity (PE) is only about financial return on investment (ROI).
3. The economic market ramifications for the corporate practice of medicine were noted by Prof. Stephen Parente, UMN Calson School of Management, “The market needs to move to work directly with patients” helped by a “back to the future” cell phone information app for prices and clinic locations. Dr. Geist noted the problem of ACO corporation capitation underfunding wrought by federal and HMO industry mega-payers; this is the means of transferring insurance risk to the mini-ACO hospital corporations servicing large mega-payer populations.
4. The ethical issues analysis of unionization by Prof, Robert Kennedy, STU dept of theology and business, said, “I have long been skeptical about unions for professionals…There are always trade-offs, e.g., the turn to contract employees, to mechanizing many functions…[or] to transferring functions to non-professionals.”
5. Alternatives to the corporate practice of medicine might consist of empowering patients with control of their own money for primary care according to Dr. Robert Koshnick. Dr. Geist sees restoration of a retail Mainstreet medical marketplace as achievable first through reform of public programs that empower enrollees with HSA-like money on a debit card for OP care. He thinks the private sector of necessity will similarly revert to the affordable 2004-2009 era of HSA-HDHP real insurance programs instead of costly pre-paid corporate care.
6. Summary: David Feinwachs, JD, PhD, recounted the meeting’s high points: 1) prohibit corporate practice of medicine. 2) eliminate the parasitic 3^rd party middleman. 3) medical decisions ought to be made by patients with the advice of their professional providers.
7. Postscript: The link to medicine’s Professional Past cut by the Corporate Practice of Medicine.
8. Appendix A: Oct 17, 2024, MPPA meeting agenda and speakers. Appendix B: Meeting minutes. Appendix C: Corporate Practice of Medicine Prohibitions essay by John Diehl, JD.

Forward to this Report.

This October 17, 2024, meeting report is a story of the unionization of a professional corporate workforce attempt to recapture the professional practice of medicine in a commercial corporate practice of medicine milieu. A place where corporate administrators make medical decisions and not the patient and their doctor; the doctor can become a professionalism facade of the corporate practice of medicine.

The unionizing medical professionals at the meeting eloquently expressed their feeling of entrapment in a system that violates their professional covenant of exclusive loyalty to their patients’ interests. In other words, that is “what happens when your insurer is your doctor.”[³]

Cost-price Inflation.

This story did not begin recently. It began after 1965, when U.S. cost-price inflation occurred abruptly for the first time in 90 years following passage of Medicare and Medicaid laws.[[5]] This was a tipping point in time: 85% of the populace (employed workers since 1942 plus the 1965 added official old, poor, and disabled). They suddenly had inexpensive tax-subsidized insurance[[6]]—a piecemeal U.S. version of National Health Insurance (NHI) passed with good intentions, but without a National Health Service (NHS) for control of tax-subsidized “free” stuff.

The good US intentions behind using tax subsidies to artificially decrease the price of insurance meant that untaxed insurance dollars were preferentially used to pre-pay even affordable and expected medical care; the “original sin” of political economic malpractice.[[7]] As care appeared “free” (“the boss or government paid for it”), unrelenting demand for services was met by a rise in prices to expand the then relative weak supply of both clinic and hospital services. When no one asked the price of care, wealth was transferred to medical sector expansion from other economic sectors—the market worked.

Since repealing popular tax subsidies was considered political suicide, culprit economic sloganeering was invoked. “Market failure” was allegedly due to ignorant patients in the hands of profligate providers practicing in an inefficient “cottage industry” doing “sick care” instead of “well care”.

Response to Inflation. The next political move to control politically induced demand inflation was not to repeal subsidies for popular “free” care, but instead to ration access to care. The US delayed rationing of “free” care ended in 1973 with passage of the Health Maintenance Organization Act (HMO) of 1973. [[8]] The hype was that inflation would be controlled via corporate efficiency profit-driven to maintain health. Of more practical importance, could pre-paid HMO corporations halt inflation by emulating the successful delay and denial regulatory strategies of socialized pre-paid National Health Service (NHS) managed care organizations abroad? HMO corporate and later cartel managers were given the mandate to control costs of politically created demand, a near impossible job without Draconian rationing of care.

Nationalizing industry was a political anathema in the 1970s, The alleged efficiency of profit-driven corporations was palatable compared to using the presumed inherent inefficiencies of any nonprofit socialist system of managed care rationing. Health insurance corporation stocks sold on Wall Street gave a reassuring patina of free-market capitalism to HMO socialist-like rationing controls akin to those abroad in NHSs. These powerful controls legalized by the HMO Act gave medical insurers the perverse power to control the use of the benefits they insured [[9]]—something not-allowed any other casualty insurance company.

Auctions, Failure to Control Costs, Cartels, and Scandal. Following passage of the U.S. HMO Act of 1973 there was an accelerating transition from a professional medical marketplace, in which services were sold to patients, to a commercial marketplace in which populations (“covered lives”) of HMO insurance corporations and government agencies (the mega “payers”) were sold at auction to providers for servicing [[10]][[11]]—the essence of Managed Care.

Auctions of patients for services at capitation fee rates administered at progressively lower prices; negotiations were often “our way or the highway”; [[12]] HMO prices mimicked low government public sector service prices. Auctions of patient populations through capitation fees[[13]] transferred to many clinics the insurance risk of caring for a mega-corporation’s clientele—many capitated “at risk” clinics in CA went broke.

By the late 1990s regulatory cost control panaceas had failed. [[14]] Draconian HMO rationing of care tried in the early 1990s, such as drive-by deliveries and mastectomies, was a dramatic financial success as premium inflation rates dropped from 18% in 1988 to 0.8% in 1996.[[15]] Yet Draconian rationing was a corporate political bust. HMOs were seen to wear the black hat of rationing. The dilemma of managed care on a fixed budget was exposed: “Cost, access, quality—pick any two.”[[16]] The cost of exploding managed care bureaucracy of 3,200% from 1970 to 2010 (mostly after the early 1990s) compared to a physician increase of only 150%, created an internal medical inflation never calculated and rarely considered.[[17]]

After decades of HMO Industry failure to control costs through legalized corporate profiteering from rationing care, 2010 Obamacare created a new more powerful cartel-like system of price controls and franchising. 2011 federal regulations legalized merged national mega-“Payer” corporations and local mini-merged hospital-staff “Provider” corporations to service mega-payer populations at capitation rates fix legalized by the federal CMS and MCO industry mega-payers.[[18]][[19]] Despite its power, the crony government-backed cartel system has failed.[[20]]

The scandal is the political legalization of a more powerful corrupt system of profiteering and collusion to reach the golden goal of cost control. And now the December scandal of murder of the CEO of UHG, leader of a corporation given the impossible job of rationing care to control the costs of tax-subsidized “free” care created by political economic malpractice 5 decades ago.

The ACO Hospital Corporation/Worker Dilemma. This cartel-like system means that the mini-ACO hospital corporations have no control over their income. To make ends meet, they must of necessity profiteer from rationing care or be bankrupted. Therin lies the dilemma of the Hospital ACO and its workers. The ACO corporation may opt out of servicing mega-payer populations as a bargaining tool, [[21]] yet in the long run must have populations to service with no other place to go than to the mega-payers.

Where once patients paid doctors for services, mega-payers corporations now pay mini-hospital ACO corporation providers to ration care: a system of profiteering contingent on the volume of care bedside doctors prescribe masquerading as “value contracting” and “value pay””. The corporate practice of medicine in action.

A fix? Those present at the October 17, 2024, meeting felt it necessary to restore medical decision making to the patient-clinician relationship. Is this possible without eliminating the corporations practicing medicine? Could we restore or create a new retail-like “main street” medical system where the patient is boss as is true in all other microeconomic sectors where goods and services are sold without the need of any 3^rd party actions or interference?

David Feinwachs, JD, PhD, recounted the meeting’s high points: 1) prohibit corporate practice of medicine. 2) eliminate the parasitic 3^rd party middleman. 3) medical decisions ought to be made by patients with the advice of their professional providers. Can these become realistic goals?

Is unionization of professionals a beginning to return decision making to the lowest possible level, i.e., subsidiarity (decentralization) or decision making by the patient-clinician relationship where the patient is the boss, not the corporation managers? [[22]][[23]] We’ll see these questions explored in this meeting Report.

RWG
Editor
12-14-24

Chapter 1. Unions vs. the Corporate Practice of Medicine

Unionist testimony. Lisa Schweiger MD, Nick VenOsdel MD [[24]]

“Over the past 15 years, healthcare in the U.S. has transformed from a physician-led, patient-centered model into one dominated by large corporate entities. Initially, physicians were promised a symbiotic relationship, relief from administrative burdens, greater financial stability, and more time with patients while protecting their autonomy. However, these promises were not upheld and very quickly physicians found they had traded autonomy for corporate structures that quickly prioritized profitability over patient care, leading to a fundamental shift in the doctor-patient relationship. Instead of the promised partnership, doctors became sidelined, increasingly seen as employees rather than decision-makers in both clinical and systemic settings.

As corporations took over, physicians were burdened with excessive documentation, unpaid clerical work, and pressure to meet payer-driven metrics. The focus on financial gains by healthcare administrators, many of whom were not practicing physicians, led to widespread interference in the physician-patient relationship, patient autonomy, service line shutdowns, hospital closures, and reductions in critical care, particularly in rural and underserved areas. Nonprofit healthcare systems, which were expected to focus on patient welfare, increasingly have adopted aggressive for-profit behaviors. Rural communities faced disproportionate harm: closures of mother-baby units, pediatric programs, and mental health services, forcing patients to travel long distances for essential care.

The erosion of physician leadership in decision-making has contributed to growing burnout, moral injury (where someone who holds legitimate authority has betrayed what is morally right), and epidemic rates of depression and suicide among physicians. As they struggle to adapt to this profit-driven environment, career longevity in the field has significantly diminished and it has become clear that adaptation and increased resilience is not a solution. In response, some physicians have begun organizing through unions to regain their voice in healthcare decisions. Unionization efforts have already led to positive changes in the Allina health care system, including stronger collaborations amongst healthcare professionals, protection and advocacy for patient care, protections for patients with medical debt and legislative advancements that hold healthcare systems accountable for service cuts.

This movement underscores the urgent need for physicians to reclaim their role in healthcare leadership. Unionization is a powerful tool to accomplish this, providing physicians and other health care providers the resources and legal protection they need to advocate for their patients at the system and legislative level. Without reasserting their influence, patient care and the future of the medical profession in the United States will continue its pattern of deterioration and dysfunction.”

Chapter 2. Legal Ramifications.

The Corporate practice of Medicine. John E. Diehl JD[[25]]

Prohibition of corporate practice of medicine laws is crucial.

MN court decisions since 1933 dictated that the doctors’ duty to the patient was exclusive; there is no place for a middleman. Diehl went into the details of later court exceptions. [See Appendix C.] His personal belief is that corporate vs. union “bargaining is warfare,” the antithesis of a professional workplace, and a system “tragedy.”

In Diehl’s expanded commentary:

Medical professionalism.

“The public expects health care to be guided by medical professionals, and that was the origin and development of our system. Byron Starns’ work on professionalism reminds us that the characteristics of a professional are:

• Mastery of a complex body of knowledge and set of skills,
• a sense of purpose (a calling), and
• autonomy.

“In the medical profession the calling is to apply one’s knowledge and skills for the benefit of the patient, and the doctor is expected by the medical profession and the law to fulfill that duty undeterred by any other force; a doctor must put the patient’s interest first. Doctors are legally accountable to their patients and the state for a failure to fulfill these duties.

“The Corporate Practice of Medicine Historic Roots. The strict legal prohibition of the corporate practice of medicine, in Minnesota a common law doctrine established by the Minnesota Supreme Court in 1933 (Granger v. Adson, 190 Minn.23 (1933)) is intended to protect professionalism and thus foster high quality, patient-focused medicine. In establishing this legal doctrine the Supreme Court stated:

“It is improper and contrary to statute and public policy for a corporation or layman to practice medicine. * * * What the law intends is that the patient shall be the patient ofthe licensed physician not of a corporation or layman. The obligations and duties ofthe physician demand no less. There is no place for a middleman.

“The middleman is the issue! In the Granger case the middleman was a business corporation that, under the law and in practice, operated to maximize profits for its shareholder(s). In a practice owned or controlled by a non-physician actually, anyone not responsible to the patients the physician owes primary allegiance to that entity’s mission, and that creates an irreconcilable conflict with the physician’s duties to those patients.

“Over the years the corporate practice prohibition was found to prohibit various proposed insurance arrangements in which doctors would be employed by an insurance type arrangement to see patients that had purchased that insurance, but some70 years ago, courts in various states began to allow new medical service arrangements when there were explicit safeguards to protect against the health plan interfering with doctors’ duties to their patients. In 1955 this new approach was recognized in Minnesota by allowing a non-profit “middleman” with explicit prohibitions against interfering with the doctors’ autonomy. The new approach recognized that new organizational models can be beneficial if there are safeguards against interference with the doctors’ duties to the patient and the doctors’ autonomy.

“Just as most of the patient protection features of the initial HMO laws have been cast aside in favor of “managed care” arranged through unregulated ERISA plans, with the passage of time the protections of doctors, patients, and the doctor-patient relationship under the 1955 ruling and, later, The HMO model, were forgotten. With this the stage was set for sloppy thinking on these important issues leading to the subordination of the values that controlled the delivery of medical services.

“Conversely, however, the decisions that allowed new structures in financing and delivering medical services did not discredit or reject the sound policy reasons upon which the corporate practice prohibition is based. The principles underlying the corporate practice prohibition are still recognized, but by 2000, federal regulations dominated the system (both in terms of Medicare and Medicaid, and the federal pre-emption of state regulation of employer-based employee health benefit plans) and in essence we deregulated the entire system; there are protections in securing insurance and the scope of coverage, but what patients actually get under those arrangements is laissez faire.

The Corporate Practice of Medicine Prohibition – Guidance for the Future.

“The modem challenge is to reestablish the doctor-patient relationship and professionalism, relegating the financing tool to a subordinate role. This can be achieved if medicine and lay leaders insist that it happen and if medicine sincerely embraces the doctor’s ethical duties to patients and society.

“The essence of the corporate practice prohibition is the recognition and protection of a doctor’s duties to his/her patient and the illegality of arrangements that have even the potential to interfere with that. The antithesis to the control/interference that is prohibited in the corporate practice doctrine is professional autonomy. Professional autonomy is essential to altruism. Altruism is the central quality of professionalism. Selfless service.

 “When exceptions to the corporate practice prohibition were first allowed, we looked at the key characteristics of the practice of medicine and found ways to allow new structures and relationships while [we thought] protecting the essential features of the doctor-patient relationship. Over time, those safeguards were lost.

“Today we should take the same approach. We should focus on the features that are essential to an autonomous professional and work to protect or re-establish those features. We must identify practices that, while currently permitted, lead to the corruption of our system and the destruction of the doctor-patient relationship.

“What are these destructive practices? The bill of particulars must be developed, but there are some obvious candidates. Ubiquitous third-party payment terms that incentivize payor treatment protocols and deny payment for any other approach. Physician scheduling algorithms that limit access and leave no time for real attention to the patient and her/his problems. Payment prerequisites that require the collection and reporting of patient data requirements that divert time and attention from the patient to support payors’ data harvesting businesses. Anything that is a “middleman” that alters the doctor’s performance of his/her duties to the patient is the evil that the corporate practice is aimed at preventing.

“The best course forward is legislation that would “refresh” and broadly apply the corporate practice of medicine prohibition. The result would be applicable to all, and it would happen more swiftly than a case-by-case, state-by-state, litigation or a collective bargaining approach; it would be in place when the law is passed.”

4914-7573-9652, v. 1

Private Equity (PE) in medicine. David Feinwachs, JD, PhD,

Private Equity (PE) firm financial engineering of medicine is focused on Return On Investment (ROI).

Feinwachs believes unionization is a credible health care worker response to corporate power and may help to protect patients. He described in detail the recent arrival of Private Equity (PE) firm financial engineering of medicine focused on ROI, rather than on patient care needs. [PE profit motives sound a bit like corporate cartel goals on steroids; a potential for added financial chaos—rwg.] PEs cut staff; cut patient safety; their hospital infection rates and falls increase. An intolerable situation that “cries out for collective action”: a need to “crumble the system” and for the FTC to stop bad mergers.

Chapter 3. Economic Future and Speculation

Prof. Stephen Parente, PhD

“The market needs to move to work directly with patients and the community.”

While he worked in the Trump administration, all organizations were mandated to post prices. The Biden administration then published guidelines for downloading price information. The complexity makes it difficult for public use. The response to complexity at the UMN Carlson School of Management is an IPhone application of the top 74 disease codes that allow an individual to search for places of services and for monthly updated prices.

The app, My Med Vita (my medical life), is also capable of recording and controlling health information. Parente said, that this might be “back to the future using modern means.”

[In other words, could this app work best in a retail main street medical marketplace where real prices help guide patient choice of professional provider? RWG]

Robert W. Geist, MD, asked,

RWG. Do unions and ACO corporations have a common enemy?

1st. Do Allina and their medical workers have a common enemy? Yes! It’s the corporate mega “Payers”, i.e., the federal Center of Medicare and Medicaid Services (CMS) and the HMO industry (generically, Managed Care Organization or MCO). These mega “Payers” hold and control most of the nation’s health care money and populations. At auctions of mega Payer populations to mini-ACO Provider servicing corporations for servicing, financial risk is transferred to mini-ACO provider corporations through capitation rates dictated by the mega-Payers. An ACO hospital “Provider” producing care has no control of its income on a fixed (ever decreasing) dictated capitation rate; the provider ACO corporations must of necessity profiteer from rationing care or die financially.

2^nd. Can we do away with MCO industry huge bureaucracy and its overhead?[¹⁷] This large bureaucracy and its profiteering from rationing access to care are internal drivers of medical inflation, and yet rarely questioned despite decades of cost control failure.[[26]][¹⁴]

The US is caught in a powerful politically created industrialized corporate system of pre-paid “coverage” perversely combined with legalized corporate control of “covered” benefits use and kickbacks for rationing care. [⁴][[27]] A place where “What Happens When Your Insurer is your Doctor [[28]]? A system that leads to high 3^rd party costs and can lead to corporate vs. union strife.

De-industrialize?

Why not de-industrialize/de-corporatize medicine to solve the problem? Why not restore American families/patients as kings in a retail medical marketplace, which works in all other microeconomic sectors, [[29]] Geist said, “We don’t need grandiose costly political-corporate baronial controls of the nation’s family medical budgets!” How can we reverse the corporate centralized control system to American family control?

Retail Marketplace?

The retail marketplace works in every other microeconomic (“Mainstreet”) sector where there is no corporate cartel profiteering from rationing provision of groceries, cars, shirts, or refrigerators. Recently, a retail medical marketplace worked in the US from 2004-2009, i.e., the brief era of HSA-HDHPs. A time of affordable service and insurance prices, when patients controlled the money. A time when high priced HMO “comprehensive care industry” almost went broke by 2009! Why not go with this proven retail medical marketplace again? [^[30]][^[31]]

1973 Transition from a Professional to a Commercial Medical Marketplace.

In 1973, there was a transition from a professional medical marketplace in which services were sold to patients. The HMO Act of 1973 created a commercial medical marketplace in which patient populations are auctioned to providers for servicing. [[32]] [[33]]

Industrialized corporate system of cost control is itself costly. It requires a huge bureaucracy and has failed cost control goals despite 50 years of legal power to profiteer from rationing care. Incented “pay for performance” profiteering [e.g., “value pay” contingent on the volume of care ordered] does not bring quality results.[[34]] Meanwhile, the quality of the current powerful corporate cartel model of network cages and profiteering from rationing care system erodes medicine’s moral and financial integrity.

If the principle of subsidiarity is not followed, i.e., empowerment of American families in a retail medical marketplace, we go broke subsidizing the enormously expensive crony corporate cartels profiteering from rationing care.

Medicine before 1965 was once a retail market where patients bought services and insurance, which was recently replicated (2004-2009) and proven to be affordable without costly managed care.[¹⁵] Would this be better than the costs of corporate-union strife. Ought we to try it again?

Addendum of Incendiary Words

“Now comes corporate medicine stripping “of its halo every occupation hitherto honored and looked up to in reverent awe. It has converted the physicians . . . into its paid wage laborers”‘ and “patients into commodities bought and sold.” [[35]] 

Chapter 4. Prof. Robert G. Kennedy, PhD Four Ethical Considerations and End Game

Prof. Robert G Kennedy, PhD, (University of St Thomas, MN)

First of all, the experience of physicians parallels the experience of other professionals. This experience includes the curtailing of professional autonomy (which is really the suppression if not dismissal of professional judgment), the struggle with persistent budgetary constraints (at the same time as institutions manage huge flows of money), the imposition of non-professional duties that compete with the professionals time and energy, the remarkable growth of non-professional staff (which may draw away resources or even compete with professional activities), and so on. All of this is replicated in so many areas of life as a consequence of our new abilities to manage massive amounts of information which in turn leads directly to the corporatization and centralization of so many aspects of our lives.

Second, the medical profession is a victim of its own success. Medicine today is able to do routinely what was almost unimaginable a generation or two ago. Medical advertising has created a non-finite market for professional medical care in all of its manifestations and encouraged the conviction that no one should be unable to access care on account of financial inability. With these two in place, the opportunity was created for a staggering amount of money (government + private investment) to be diverted to medical care. The metrics of success quietly but irresistibly have shifted away from what we professionals imagine is important to the preferences of investors (which is ROI in one form or another).

Third, the fact of the matter is that younger professionals today have mostly made their peace with the new situation. The sorts of laments that we older professionals make strike our younger colleagues as quaint but not reasons for action. They see their challenge to be navigating the new environment to craft the best professional and personal life they can. Indeed, I think that in many cases they cannot imagine any possibility of returning to what we recognize as lost. Furthermore, in both medicine and education, we professionals take part of our compensation in the benefits of the resources available to us. We have traded our professional freedoms for access to technology and more pleasant physical working environments. I think we have been bought cheaply but our younger colleagues are probably reluctant to risk giving up what they have for what they never experienced.

Fourth, I have long been skeptical about unions for professionals. There are always trade-offs.

Many unions in history were formed out of conflict as a defense against the burdens imposed by management. This may work for a time, but it also prompts management to seek new strategies. The new strategies often focus on directing resources to mollify the presenting complaints while temporarily taking resources from other areas. The longer-term strategy is generally to develop new structures to suppress the problems. The situations can be very complicated but do note the turn to contract employees, to mechanizing many functions or sending them offshore, to transferring functions to non-professionals, and so on. All this and more has already begun in medicine and unionization is like to encourage its acceleration.

Professional unions also create internal conflicts that proponents often do not recognize in the beginning. Nurses’ unions can be an example for physicians. They can attempt to bargain collectively but there is little they can do in the face of management intransigence except engage in work stoppages. This may work but the optics for nurses, to say nothing of the personal costs, are terrible. How would physicians fare better?

What might be the union end game?

Further, I do wonder, in connection with proposals for physicians’ unions, what the end game might be? Professionals in every area confront conflicts of interest. Why do you think that unions would be a suitable instrument for addressing your concerns in this area? And any consideration of the end game must consider the costs associated with success. What would physicians be willing to sacrifice to diminish the tensions of these conflicts of interest?

RGK

Chapter 5. Curtailing Corporate Practice of Medicine (CPOM)

Prohibit the Corporate Practice of Medicine.

Dr Robert Koshnick noted that PE invasion of medicine constituted a further serious risk to professional clinical autonomy. He recommended that the best way to combat the corporatization of medicine and its foibles is to prohibit the corporate practice of medicine. Physicians should have some business training in medical schools, so they have the skills to set up independent practices. It would be simple to set up direct primary and specialty care clinics to avoid the costs of third parties. Non-compete clauses should be legislatively eliminated to allow the freedom to opt out of corporate medicine. HSAs should be freed from their present restrictive regulations. See my upcoming November op-ed in the Heartland Health Care News on “Empowerment Accounts Can Fix Restrictive HSAs”: https://heartlanddailynews.com/2024/10/empowerment-accounts-can-fix-restrictive-hsas-commentary/

A Retail Mainstreet Medical Marketplace needs Policy Maker Attention.

Robert W. Geist MD recommended analyzing and a trial of a new intriguing concept to rebuild/restore a retail main street medical marketplace. [[36]][[37]] Can today’s US average $25,572 annual cost of medical insurance [[38]] someday be reduced to near the retail main street average automobile insurance rate of $2,388? [[39]] A retail marketplace place is where American families (patients) are king, not the barons of either a crony monopoly National Health Service (NHS) cartel or a crony oligopoly of US Corporate (CHS) cartels. A retail main street medical marketplace is an alternative worthy of policy maker attention.

Obama reformulation of the HMO industry into a powerful massively merged crony collusive corporate cartel system of price fixing and franchising has failed to control costs, despite profiteering from rationing care masquerading as “value contracting”, For many, it remains the only political/corporate vision of the future. A failed system of political social engineering degraded quality and efficiency with a financial conflict of interest between corporation interests and patient interests and needs.

Without a change of direction from the corporate practice of medicine (CPOM), a threat remains to patient health, the professionalism of medicine, solvency of many ACO hospital corporations, and the solvency of American families and the nation. A restored retail medical marketplace without crowd-out by politically favored CPOM factories could give the US patient-centered care a chance for medicine to restore its professional quality and affordability.

[See Chapter 6 for details of a retail medical marketplace.]

Chapter 6. A Retail Medical Marketplace? Editorial

A new intriguing concept is to rebuild and restore a retail main street medical marketplace. [[40]^{,[41],[42],[43]}] Can today’s US average $ $25,572 annual cost of medical insurance someday be reduced to near the main street average automobile insurance rate of $2,388? [²⁰][²¹]

A retail marketplace place is where American families (patients) are king, not the barons of either a crony monopoly NHS cartel abroad or a crony oligopoly of US corporation cartels. A retail main street medical marketplace is an alternative worthy of policy maker attention. It would restore the umbilical cord link to medicine’s past covenant of exclusive loyalty to patient interests, an umbilical cord cut by the corporate practice of medicine for corporate interest in its own solvency on a fixed budget. The question is how to get there, but first what is the nature of a microeconomic retail “main street” sector like medicine?

The Nature of Microeconomic Retail Sectors.

A retail marketplace is a place where families would control their own budget for medical care and its insurance against catastrophic financial loss; a microeconomic marketplace place akin to where we buy groceries, autos, refrigerators, houses, and shoes. A complex place where millions of transactions take place daily between millions of people with millions of goals guided by market prices for service and insurance. A place where families control their own medical budgets, as they do in every other microeconomic main street private sector. The individual family budget may be inflexible, but the aggregate of millions of family budgets is flexible.

Medicine is a complex microeconomic sector of millions of people forced into a government macroeconomic mold of politically fixed budgets for “cost control.” [⁴][[44]][[45]] Can this US medical system be reformed and become affordable? Can medicine be affordable if the cost of internal inflation from massive merger expansion of a parasitical cartel bureaucracy and their profiteering from ratioing care are eliminated?

There were two retail eras of medical system affordability. The first was a 90-year time from 1875 to 1965 when the medical and consumer price indices (CPI) were the same. [[46]] Then after 1965 government subsidies for medical insurance gave 85% of the population (employed workers since 1942 and the added official old, poor, and disabled) the appearance that care was “free”; “the boss or the government paid for it.”

The second retail era of medical system affordability was from 2004 to 2009 when real insurance, HSA-HDHPs, became available—their low competitive price for protection against catastrophic financial loss nearly broke the HMO Industry’s pricey pre-paid comprehensive “Plan” businesses. Competition rapidly dropped all medical premium rates from 13.9% to 6.1% by 2007. [[47]][[48]] Common sense retail economics works; social engineered managed care system of apparent free (pre-paid) stuff does not.

Can a retail mainstream medical marketplace be restored? Why not? Absent crowd-out by politically created and favored pre-paid managed corporate rationing of care for “cost control”, the spontaneous re-creation of a retail medical marketplace would require no social engineering legislation. Why?

The Nature of a Macroeconomic Marketplace and Fatal Flaw.

Let’s first look at the nature of corporate cartel rationing systems. Public medical care program cartels differ in each nation. Current US public medical programs, Medicaid and Medicare, are funded by a single payer (Medicaid has both federal and state payers) of comprehensive benefits at State fixed prices for pre-paid services. The US cartel version franchises multiple surrogate corporations to manage care at fixed capitation rates to provide care for official poor, old, and disabled. Nations abroad are single payer programs with comprehensive benefits. They differ from the US model in that they have franchised a single monopoly NHS cartel to provide and manage the money and care of all citizens. The US model for Medicare has a high overhead.[[49]] It seems probable that NHS overhead is similarly high and hidden in national budgets.

Nations abroad seemed trapped forever in NHS monopoly cartels to manage pre-paid care for all citizens. For example, the UK’s NHS was exempted when all other socialized microeconomic sectors were deregulated after 1980.[[50]] Woe comes to any politician threatening elimination of ever-popular “free” care. Few realize that “free” care is paid by their taxes; there’s no free lunch.

The UK’s NHS was not deregulated and suffers periodic NHS cartel managed dystopias. The fatal error of government managed microeconomics sectors, to paraphrase the economist John Cassidy, is that no central authority, however brilliant [or well-intentioned], can accomplish the functions of freely determined prices for the allocation of labor, capital, and human ingenuity.[[51]]

The Nature of a Restored Retail Medical Marketplace.

What would happen if the US eliminated the public sector single payer oligopoly model of corporate cartel management of medical money and care? Can we assume that a microeconomic retail medical model would spontaneously appear? Looking abroad, it is probable. After the UK’s socialized microeconomic sectors were deregulated in 1980, the general economy blossomed when the government went “out of business”.

What would happen if the US government did go out of the medical business of using surrogate pre-paid managed care corporations to service the old, poor, and disabled? Is there a feasible means to fund individual enrollees to manage their myriad services instead of funding corporate cartel mangers? Why not? How would this work? And what would be the advantages?

For example, a MN program to deregulate and reform Medicaid would create a mini retail OP marketplace for enrollees. [[52]] Enrollees would be given funds for OP care on a debit card. They would have a free choice of provider. Clinic fee rates would be increased to Medicare rates (about a 25% increase), would have onsite payments, and no clinic account receivables.

Enrollees can judge the quality of patient-centered care, i.e., its personalization, timeliness, continuity of care, and trust in access to expertise even when the prices of pre-paid services are fixed. The single-payer state would insure each enrollee against unexpected financial catastrophe from ill health. A mini-retail OP marketplace of financially empowered patients means that corporate cartel management and profiteering from rationing care of enrollees in no-choice network cages are unnecessary for care or for service payment. The state would insure catastrophic expenses as it did before the mid-1990s at which time MN Medicaid overhead was only 4-5%. [[53]]. We don’t need a 3^rd party to be your doctor or to pay bills. State contracted electronic payment of OP and IP services is inexpensive.

An example is Connecticut. CT successfully reformed their Medicaid program by firing its HMOs. HMO program overhead was reduced from 12% to state management 5.2%. [[54]] Fee rates were increased to Medicare rates; private clinics could afford to be open for enrollees (a 22.7% opening increase.). ER visits plummeted 22.7%, and hospital admission rates fell 43.9%.

The difference from pending MN legislation is that the MN Medicaid FMA Reform program is simpler. Enrollees would be empowered with debit-card money, clinic account receivable would be eliminated by on-site debit card payment, and if the enrollee is lucky in health and avoids frivolous ER visits, he or she could accrue savings making it financially possible to afford leaving medical assistance for a job in the private sector.

Is a retail main street medical marketplace achievable in Medicaid? Why not? Could it be a paradigm for other states and tailored for Medicare? Again, why not? Connecticut did it.

Advantage? A barrier-free market absent centralized administrative controls is how microeconomic market sectors work smoothly.[⁵¹]

RWG

Chapter 7. Individual Meeting Commentary

Wayne Liebhard:

I applaud the efforts of any action that can strengthen/restore the doctor-patient relationship, including unionizing efforts. The Mn. Physician article by doctors Schweiger and Venosdel appropriately and correctly points out the “ethically precarious position” that physicians now find themselves in as employees of corporate medicine (now around 80% of all physicians).

The “moral and ethical dilemma” is real, and unionizing efforts are born thereof. I found myself somewhat surprised in doing my research for “Walking The Tightrope-Trusting Your Life To Telemedicine,” that these days there is a relative dearth of ethics education in medical schools, though interestingly, pre-meds seem to have an interest (I’m working with St. John’s University to teach a course there).

A strong ethics base is a MUST for today’s physicians as a guide to protecting the sanctity of the doctor-patient relationship, and an area where we must remain vigilant. Corporate Practice of Medicine (CPOM) doctrine and laws were supposed to help shield us from undue doctor-patient interference, but those laws are useless without teeth for enforcement (including Minnesota’s CPM laws

Don Gehrig: system diagnosis and recommendation

De-contract and ‘opt out’ of Medicare/Medical Assistance, as true healthcare is one Dr, one license, thousands of patients. Then hang your shingle and be a physician, not a provider.

Keep it small, one patient at a time, in a direct pay model. Small independent community hospitals and procedure centers must be restarted locally, and valued in a direct pay model, as well.

Big MCO or private equity owned medicine is for manufacturing like outcomes to profiteer off the system and its evolved, corrupted tangled rules and regulations that make good healthcare impossible and injure participants, rather than take good care of patients and allow Drs to properly do that.

Real healthcare is one unique patient at a time, in a local small venue, whose outcome always is what transpires after a true Dr-patient relationship is restored and then is privately and confidentially practiced.

Then you measure outcomes. Keep the delivery and payment system simple as taking care of individual patients is complex enough!

“Build it and they will come.”

Paul Schanfield [“happily retired”]

I very much sympathized with the Allina primary care docs having to unionize. It appears that Allina just ghosted them – i.e., just stopped communicating with them. Hopefully unionization of physicians [I hate the term “providers”] is not the long-term solution for physicians – who have lost control of healthcare delivery.

The dissatisfaction of many patients [not consumers, clients] may allow an opening to shed the failed concept of corporate medicine -maybe.

Unfortunately, many current physicians are satisfied with the current system. They are perfectly happy to collect a paycheck, perfectly happy with either work in the clinic or the hospital full time, perfectly happy to allow others to attend leadership meetings and make decisions and are pleased with their current work life balance – even though it jeopardizes patient care.

Corporate medicine places physicians in an unwinnable conflict of interest position, adds an expensive and extensive bureaucracy and heaps unnecessary administrative duties and book work upon them. Private equity control of medicine would be even worse!

I do not think the opt-out approach is workable for the majority of physicians.

I loved the vocabulary that was used in the discussion; these terms are right on the money:

• – medical factories
• – mega payers
• – corporate medicine
• – medical control profiteering

Finally, we did not discuss the role of electronic medical records. While the EMR does have benefits [like My Chart] it sucks time away from direct physician-patient interaction time and allows for easy oversight by the government and other payers. If something is not in the EMR, “it did not happen.”

What a mess.

John Wust MD, CPOM experience

“The corporatization of medicine is resulting in decreased access to Obstetrical Services across Minnesota based on non-transparent business ROI or profitability calculations. These business decisions are often covertly discriminatory, violate the ethical principles of health equity, and reinforce systemic racism. In addition, decreasing access is not patient safety centric and may be contributing to worsening maternal morbidity and mortality outcomes across Minnesota.” 

Chapter 8. Summary of Oct. 17, 2024, MPPA Meeting

Meeting High points. David Feinwachs JD, PhD

David Feinwachs recounted the meeting’s high points: 1) prohibit corporate practice of medicine. 2) eliminate the parasitic 3^rd party middleman. 3) medical decisions ought to be made by patients with the advice of their professional providers.

Editor’s Postscript. Professional Medicine’s Link to its Past Cut by the CPOM

We have now addressed for the first time in MN medical history the many ramifications and possible pitfalls that might arise from the unionization of a hospital corporation’s professional staff. The purpose is to break the ice with this briefing that we hope will lead to in-depth community and political re-consideration of today’s politically created and failed corporate attempts to quell medicine’s inflationary costs through profiteering from rationing care.

The corporate factory model of medicine has led to medical staff unionization. Why? The Corporate Practice Of Medicine (CPOM) model of profiteering from rationing care for “cost control” remains a threat to the quality of patient care, to the integrity of medical professionals, to the profession itself, and yes, to the integrity of family and national solvency. We can do better. It’s time leave the CPOM, a failed fatally flawed nightmare, and move on.^[51]

Would a retail medical marketplace restore the umbilical cord connection to medicine’s past covenant for exclusive loyalty to the patient interests, an umbilical cord cut by the corporate practice of medicine? It ought to be considered and tried again. We can start in the public sector.

It’s predictable that the private sector will of necessity revert to the successful HSA-HDHP insurance model of 2004-2009 through repealing pertinent IRS regulations. A model that was killed by Obama regulations.^[[55]][[56]] We can easily try it again in the public sector starting with MN Medicaid Reform If this MN Medicaid Reform becomes a paradigm adopted by other states, it would be possible to achieve cost control in public sector programs and later the paradigm can be tailored for Medicare.^[[57]]

Is it possible to achieve affordable private and public sector medical care and insurance in a retail medical marketplace. Why not? A path to solvency for all players.

Respectively submitted, Editor: Robert W. Geist MD, Chief Librarian MPPA,

https://physician-patient.org/ . registmd@comcast.net

Appendix A. Oct 17, 2024, Meeting agenda

Title: Unionization of Medical Workers vs. ACO Corporate Management: Why Unions? Why Not?​

Place: Zoom, Oct .17, 2024, at 7-9 PM

See speaker bios. P. 2

Introduction: Brainstorming: problem solving RWG 5 min

Format: Serial presentations (70 min), later open discussion (30-40 min)

Posing the Problem: Why Unions? Why not?

From corporate industrialization of medicine to worker unionization RWG 5 min

1. Why a medical worker union?

Professional experience in an industrial corporate cartel marketplace

Lisa Schweiger MD, Mike VenOsdel MD, [[58]] 15 min

Corporate response ACO spokesperson. 5 min [No response by 9-23]

2. Medical legal aspects:

Unionization vs. Corporate practice of medicine. Restoration? John Deal JD; 5 min

Invasion by Private Equity (PE). Dave Feinwachs JD PhD 5 min

3. Medical Econ 101

What direction will medicine take? Any alternative scenarios? Prof. Steve Parente 5 min

Unions-ACO hospital corporations; do they have common enemy? Bob Geist MD 5 min

4. Professionalism ethics and unions

Verbatim summary of Prof. Robert Kennedy’s observations, 5 min

5. Alternative to medical industrial strife (the principal subsidiarity).

National Hoover institute program Bob Koshnick MD 5 min

MN Medicaid Reform program. A retail “Mainstreet” medical marketplace? RWG 5 min

6. Speaker audience discussion. 30-40 min
7. 7^th inning stretch: Summary Dave Feinwachs. 5 min

See speaker bios.

RWG secretary pro tem

Our speakers include:

Moderator:

• Posing the Problem:” Why Physician Unions? Why not?”

Robert Geist MD
Retired, MN Urology,
MPPA Chief Librarian https://physician-patient.org/

2) Union Response:

Lisa M Schweiger MD, FAAP
Pediatrician, author
Allina Health Cambridge Medical Center since 2004

Union Response:

Nick VenOsdel, MD, FAAP
Pediatrician, author
Allina Health Hastings Clinic

• Legal issues:

John Diehl JD

Larkin Hoffman law firm
Special Assistant Attorney General, State of Minnesota, 1969 – 1972
Chief, Minnesota Department of Health, HMO Unit, 1973 – 1975
General Counsel, University of Minnesota Hospitals and Clinics, 1975 – 1983

Dave Feinwachs, MA, MBA, JD, PhD, 

Former General counsel Minnesota Hospital Association (MHA) 1981-2010
Attorney, St. Paul, MN

• Economic issues and industrial strife:

Prof. Stephan Parente, PhD

Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis, MN Minnesota Insurance Industry Chair of Health Finance.

Robert Geist MD

• Ethical issues verbatim commentary by Robert Geist MD for:

Prof. Robert G Kennedy, PhD, MBA, is professor and former chair in the Department of Catholic Studies at the University of St Thomas (MN). He was formerly professor of Management and sometime chair of the Faculty in the Opus College of Business at UST. University of St. Thomas | stthomas.edu. St. Paul, MN.

• Alternative to industrial medicine strife:

Robert Koshnick MD

Family practice, ret.; author
Detroit Lakes, MN

Robert Geist MD

• Summary:

Dave Feinwachs JD PhD

8)Editor’s postscript.

Robert W, Geist MD

Appendix B. Oct. 17, 2024, MPPA meeting minutes

ver 10-25-24

Unionization of professional clinicians in America’s Hospital Corporations

MPPA Zoom meeting minutes Oct. 17, 2024, Thursday 7-9 PM https://physician-patient.org/

[Note: my comments are few and in brackets—rwg.]

Preamble:

[How has it happened that a hospital medical staff sought unionization? Has the nature of hospitals changed? If so, why?

These unprecedented questions were the subject of an historic MPPA meeting [[59]] Oct 17, 2024. To seek answers the meeting gathered experts in medical law, economics, and professional ethics. The grievances of the medical staff clinicians were heard first. Hearing their plight made it obvious that the nature of hospitals had changed. Hospitals, once community institutions with an independent medical staff, have become mini-insurance corporations servicing the medical care of large populations on fixed budgets dictated by others. Are they not thus forced to ration care to survive financially? How did this happen?

These questions are explored in the meeting minutes. See Appendix B]

===================

Meeting Minutes:

Unionization of professional clinicians in America’s Hospital Corporations

Those Present:

Lisa Schweiger MD, Nick VenOsdel MD, John Diehl JD, David Feinwachs JD, PhD, Prof. Stephan Parente PhD (UMN Carlson School of Management), Prof. Robert G. Kennedy PhD (St. Thomas U), Robert Koshnick MD, Robert W. Geist MD, Paul Schanfield MD, John Wust MD, Hannelore Brucker MD, Wane Zuehlke CPA, Wayne Liebhard MD, and Donld Gehrig MD

Introduction

Dr. Geist described the meeting format: a brainstorming briefing about unionization of professional clinicians and its legal, economic, and ethical ramifications. How did the nation get to this potential for industrial corporate vs. union strife? He presented slides showing the post 1965 origin of medical demand inflation for the first time in 90 years and the political attempt to fix the early 1970s inflation “crisis” rate of 7% through passing the HMO Act of 1973. HMO pre-paid Plans were given the perverse power to control use of the benefits they covered. [[60]] This system of Managed care (MC 1.0) rationing of care did not work, cost-price inflation continued. By 1988 premium rates rose to 18% annually, a real crisis. Business leaders throughout the nation decided to try the promises of the HMO industry to control costs. It worked. By 1996 HMO Draconian rationing reduced premium inflation rate to nearly 1%! The public anger over delay and denial of care and drive-by mastectomies and deliveries resulted in states passing patient bill of rights laws. The HMOs sensed that wearing the black hat meant political danger. Draconian rationing of care was cut back. By 2003, premium rate increases reached 15%. In 2003 Congress passed a law permitting sale of HSA-HDHP insurance policies to afford protection against unexpected financial catastrophe. By 2007 the competitive price of insuring against catastrophic financial loss from ill health dropped premium rates for HMO comprehensive coverage to 3.5%. The Plans almost foundered. In 2009 Obama regulations killed the HSA-HDHP competition to clear the path for 2010 ObamaCare’s powerful cartel-like managed care corporations to control costs allegedly through increased corporate quality and efficiency.

Union Doctor Testimony.

Over the past 15 years, healthcare in the U.S. has transformed from a physician-led, patient-centered model into one dominated by large corporate entities. Initially, physicians were promised a symbiotic relationship, relief from administrative burdens, greater financial stability, and more time with patients while protecting their autonomy. However, these promises were not upheld and very quickly physicians found they had traded autonomy for corporate structures that quickly prioritized profitability over patient care, leading to a fundamental shift in the doctor-patient relationship. Instead of the promised partnership, doctors became sidelined, increasingly seen as employees rather than decision-makers in both clinical and systemic settings.

As corporations took over, physicians were burdened with excessive documentation, unpaid clerical work, and pressure to meet payer-driven metrics. The focus on financial gains by healthcare administrators, many of whom were not practicing physicians, led to widespread interference in the physician-patient relationship, patient autonomy, service line shutdowns, hospital closures, and reductions in critical care, particularly in rural and underserved areas. Nonprofit healthcare systems, which were expected to focus on patient welfare, increasingly have adopted aggressive for-profit behaviors. Rural communities faced disproportionate harm: closures of mother-baby units, pediatric programs, and mental health services, forcing patients to travel long distances for essential care.

The erosion of physician leadership in decision-making has contributed to growing burnout, moral injury (where someone who holds legitimate authority has betrayed what is morally right), and epidemic rates of depression and suicide among physicians. As they struggle to adapt to this profit-driven environment, career longevity in the field has significantly diminished and it has become clear that adaptation and increased resilience is not a solution. In response, some physicians have begun organizing through unions to regain their voice in healthcare decisions. Unionization efforts have already led to positive changes in the Allina health care system, including stronger collaborations amongst healthcare professionals, protection and advocacy for patient care, protections for patients with medical debt and legislative advancements that hold healthcare systems accountable for service cuts.

This movement underscores the urgent need for physicians to reclaim their role in healthcare leadership. Unionization is a powerful tool to accomplish this, providing physicians and other health care providers the resources and legal protection they need to advocate for their patients at the system and legislative level. Without reasserting their influence, patient care, and the future of the medical profession in the United States will continue its pattern of deterioration and dysfunction.

Legal Issues.

John Diehl, JD, thought that restoring prohibition of corporate practice of medicine laws is crucial. MN court decisions since 1933 dictated that the doctors’ duty to the patient was exclusive; there is no place for a middleman. Diehl went into the details of later court exceptions. His personal belief is that corporate vs. union “bargaining is warfare,” the antithesis of a professional workplace, and a system “tragedy.”

David Feinwachs, JD PhD, believes unionization is a credible health care worker response to corporate power and may help to protect patients. He described in detail the recent arrival of Private Equity (PE) firm financial engineering of medicine focused on Return On Investment (ROI), rather than on patient care needs. [PE profit motives sound a bit like corporate cartel goals on steroids; a potential for added financial chaos—rwg.] PEs cut staff; cut patient safety; their hospital infection rates and falls increase. An intolerable situation that “cries out for collective action”: a need to “crumble the system” and for the FTC to stop bad mergers.

Economic Factors. Professor Stephan Parente, PhD, was in China but left us an intriguing video. He said the market needs to move to work directly with patients and the community. While he worked in the Trump administration, all organizations were mandated to post prices. The Biden administration then published guidelines for downloading price information. The complexity makes it difficult for public use. The response to complexity at the UMN Carlson School of Management is an IPhone application of the top 74 disease codes that allow an individual to search for places of services and for monthly updated prices. The app, My Med Vita (my medical life), is also capable of recording and controlling health information. This might be “back to the future using modern means.”

Dr Geist claimed that the hospital ACO corporation and its workers had a common enemy: CMS hegemony in the public sector and the HMO Industry near hegemony in private and now public sectors. Geist said that the logical conclusion is for hospitals and workers to cooperate in defrocking the corporation factories model where they have no real control of their income; they are nothing more than politically created factory machines oiled by hidden profiteering from rationing of care scams for “cost control”. Is it possible to eliminate the corporate model at least in the public sector? He thought, why not?

The current corporate cartel model of medicine itself is an enormously expensive system due to the expense of internal bureaucracy inflation and the inherent inefficiency of adjudicating claims. It has failed to control cost-price inflation for American families or the nation while in corporate network cages quality has deteriorated. PE’s recent invasion of medicine has made corporate practice of medicine more frightful. Profiteering from rationing care erodes the integrity of medicine and the integrity of nation’s attempt to control cost inflation, a frightful problem.

Once hidden profiteering is fully exposed the whole system of mini corporate ACO factories practicing medicine is vulnerable to extinction. A spontaneous retail medical marketplace of empowered American families is a replacement that would require no political social engineering in the private sector. Of necessity businesses will have to revert to proven affordability of HSA-HDHP real catastrophic insurance. Public sector reforms will require legislation. Legislation for Medicaid reform is pending in the MN.

Ethical issues.

Dr. Geist read a verbatim message from Prof. Robert Kennedy, a professionalism scholar at STU. Kennedy’s four points are: 1) Physicians’ experience parallels the experience of other professionals including education. Professional autonomy is curtailed, even suppressed, and non-professional duties are imposed. New abilities to handle massive amounts of data directly leads to corporate centralization. 2) The medical profession is a victim of its success. Medical advertising has created a near infinite market now coupled with the conviction that no one should be unable to access care because of financial constraint. The metrics of success quietly but irresistibly shift from what professionals imagine to be important to the preference of investors for profits (again, ROI). 3) Younger professionals have mostly made their peace with their new situation. The laments of older professionals strike younger colleagues as quaint and with no reason for action. We have traded professional freedoms for access to technology and pleasant physical working conditions. “I think we have been bought cheaply.” 4) He is skeptical of unions for professionals. The results may be mechanizing services, sending them offshore, and transferring work to non-professionals. Unionization may encourage corporate acceleration of these cost cutting means.

How would physicians fare better then nurse unions? They can engage in work stoppages, but the optics [of strikes] and personal costs are terrible. The end game? Proponents may think unions would be a suitable instrument of addressing professional concerns. The end game costs might be willingness to diminish tensions and that physicians would be willing to sacrifice to diminish the intolerable tensions of conflict. [Are professional covenants of exclusive patient loyalty and autonomy thus imperiled? —rwg.]

Alternatives to corporate-union strife—account-based insurance

Dr Koshnick noted that PE invasion of medicine constituted a further serious risk to professional clinical autonomy. He recommended that the best way to combat the corporatization of medicine and its foibles is to prohibit the corporate practice of medicine. Physicians should have some business training in medical schools, so they have the skills to set up independent practices. It would be simple to set up direct primary and specialty care clinics to avoid the costs of third parties. Non-compete clauses should be legislatively eliminated to allow the freedom to opt out of corporate medicine. HSA regulations should be freed from their present restrictive regulations. See my upcoming November op-ed in the Heartland Health Care News on “Empowerment Accounts Can Fix Restrictive HSAs:: https://heartlanddailynews.com/2024/10/empowerment-accounts-can-fix-restrictive-hsas-commentary/.

Dr. Geist’s slides showed the alternatives to corporate factory medicine through MN Medicaid Reform. HMO Medicaid hegemony would be broken by a pending bill: a Family Medical Account (FMA) program, SF 2287. The senate and companion house bill will be re-introduced in the 2025 session. It empowers enrollees with money for OP care on a debit card (funding is about 40% of total annual individual cost). If an enrollee does not use an ER for sore throats and is lucky in health, they can pocket unused debit card money in a state bank for future health care needs. The next year begins repeat debit card funding. If the enrollees suffer a catastrophic expense (usually in-hospital care), Medicaid pays the bill. The new version of the FMA reform bill will make it the default Medicaid program and will raise fee rates to Medicare rates (about a 25% increase). The results: a TPA linked to a debit card is a low transaction cost (about 1/5^th of an HMO’s); patient choice of Any Willing Provider (AWP) access for care; and on-site provider payment (which makes 3^rd party HMOs irrelevant.) When eliminated by irrelevancy, the HMO/ACO cartel-like 3^rd party profiteering from rationing care is gone. Empowered families entrusted with money for medical care means as patients they not only have free choice of place for care and are no longer welfare supplicants; they are families with money at the clinic door like their richer cousins. In the future, expansion of the FMA concept might be considered for the complex needs of the disabled or chronically ill (e.g., the successful CMS Cash and counseling and other programs ^[[61],[62]]) and for MNCare.

Q and A.

Emphasized again was corporate usurpation of clinical decisions. One person thought unions are only a 4^th party, not likely to help to fix medicine’s dystopias. An obstetrician recounted his experience of Medicaid pay too low to sustain his private clinic, which necessitated becoming a corporate worker. The problem in the corporation are cuts in local OB care endangering patient-centered quality of care; and the corporation says not to order fertility studies. It is predictable that unionization of a hospital corporation’s professional staff locally is only an inkling of what will soon happen nationally.

The meeting’s purpose is a briefing that we hope will lead to in-depth community re-consideration of today’s corporate troublesome means to quell medicine’s inflationary costs; corporate action has resulted in a unionization response of its professional workers. Can we do better than this?

Summary

David Feinwachs recounted the meeting high points: 1) prohibit corporate practice of medicine [the MN Medicaid Reform can be a 1^st step; if it is a paradigm adopted by other states and later tailored for Medicare—rwg.]. This is a chance to end corporate factory medical practice. [IMO, the private sector will of necessity revert of the successful HSA-HDHP model of 2004-2009 through repealing pertinent IRS regulations]. 2) eliminate the parasitic 3^rd party middleman. 3) medical decisions ought to be made by patients with the advice of their professional providers.

Those present kept talking until 9:15 PM. The discussion was too fascinating to leave! Enthusiasm is typical of a meeting where everyone gets a chance to talk. [It is my hope that a booklet (or in digital form) of this meeting will be created; a template for community action—rwg.]

[Meeting Postscript

We have now addressed for the first time in MN medical history the many ramifications and possible pitfalls that might arise from the unionization of a hospital corporation’s professional staff. The meeting’s purpose was to break the ice; a briefing that we hope will lead to in-depth community and political re-consideration of today’s failed corporate attempts to quell medicine’s inflationary costs at too high a cost. Corporate factory model of medicine has led to medical staff unionization. The model remains a threat to the quality of patient care, to the integrity of medical professionals and to the profession itself, and to the integrity of family and national solvency. We can do better—rwg.]

Respectfully submitted,

Robert W. Geist MD, secretary Pro Tempore and Chief MPPA Librarian, https://physician-patient.org/
rgeistmd@comcast.net
11/8/24

Appendix C

Corporate Practice of Medicine Prohibitions, John Diehl JD

Historic Roots and Guidance for the Future

John E. Diehl – October 11, 2023

The strict legal prohibition of the corporate practice of medicine is intended to foster high quality, patient-focused medicine. This prohibition is widespread and is as old as modern medicine in the United States. Many states have statutes that prohibit or restrict the corporate practice, and this doctrine emerged in Minnesota (and elsewhere) as a common-law doctrine, i.e., recognized and enforced by judicial precedents.

1. The corporate practice doctrine was first addressed by the Minnesota Supreme Court in 1930 in a case where a for-profit corporation, a bank, was selling the legal services of an employed lawyer. The lawyer was compensated as an employee and the bank charged, collected, and retained as bank income all of the fees for professional legal services. In finding the bank guilty of the unlawful practice of law and the lawyer guilty of professional misconduct, the Supreme Court wrote:

[N]either a corporation nor a layman, not admitted to practice, can practice law, nor indirectly practice law by hiring a licensed attorney to practice law for others for the benefit or profit of such hirer. In re Otterness, 181 Minn. 254 (1930)

Three years later the Minnesota Supreme Court applied this doctrine to the medical profession. Granger v Adson, 190 Minn. 23 (1933). This case involved an individual businessman, John Granger, whose business was to sell subscriptions for “health audits” for an annual feed. Subscribers would submit specimens for lab analysis, and they would receive back from Mr. Granger the finding of the lab analysis, the possible maladies indicated thereby, and lifestyle changes that could mitigate these problems. All of these findings and recommendations were then conveyed by Mr. Granger to his subscriber.

In order to accomplish this, Granger hired a well-qualified, licensed physician (a pathologist) to undertake diagnostic laboratory tests and formulate advice on exercise and diet to improve the subscriber’s health. Granger hired the doctor, and then sold these services to patients who paid Granger.

The Minnesota Supreme Court held that the involved services constitute the practice of medicine and, citing the Otterness ruling, stated:

It is improper and contrary to statute and public policy for a corporation or layman to practice medicine . . . . The obligation of Dr. Grave under his contract was to . . . Granger not to the subscribers. Plaintiff might engage anyone to perform these analyses. What the law intends is that the patient shall be the patient of the licensed physician not of a corporation or layman.

2. The obligations and duties of the physician demand no less. There is no place for a middleman.

Accordingly, for many years the Minnesota Attorney General, in advising state agencies or in taking law enforcement action, held the position that the corporate practice of medicine doctrine prohibited fraternal orders and insurance companies, including mutual (policy-holder-owned) insurers, from hiring professionals to provide medical services to “members,” i.e., people who paid the insurer for the services that they would receive.

Then, in 1955, following more lenient court decisions in other states applicable to certain nonprofit corporations, the Minnesota Attorney General advised the state that Minnesota should, under certain circumstances, allow individuals seeking to arrange for medical care for themselves and their families to form a nonprofit corporation for that purpose. Op. Atty. Gen. 92-B-11, October 5, 1955. Pursuant to that ruling, Group Health Plan, Inc., now known as HealthPartners, was formed.

Accordingly, we came to understand that there is a broad non-profit corporation exception to the prohibition, and in some states, there are statutory exceptions to the doctrine in the case of hospitals employing doctors. In the former, that exception is not as broad as many think; as to hospitals I speculate that such an exception was not thought to be a problem because, historically, patient care in a hospital was controlled by the members of the medical staff (not by board members or managers) so it would be assumed that a hospital would not interfere with sound medical judgment.

In this context, please note the observations highlighted by the Attorney General in recognizing the non-profit exception:

Factually, the stated corporate purpose of Group Health Plan, Inc. was:

• To provide a means for corporate members and their families to secure comprehensive medical and dental care and thus make comprehensive service available to all who pay for membership without regard to individual economic status.
• To raise the standards of medical care and increase availability of services in the community.
• Subject to this prohibition in its Articles of Incorporation: In any event the corporation shall not intervene in any manner in the professional relationship between the doctors of medicine or dentistry and their respective patients and shall have the power to make only such contracts as relate to the economic aspect of the medical and dental care secured and provided pursuant to such contracts.
• In the early Minnesota cases the Court was clearly concerned with the exploitation of a profession for the profit of a private corporation and interference by the corporation with the professional relationship involved.

3.

• In an earlier Minnesota Attorney General Opinion ruling against a proposed medical plan, the doctor and the osteopath were subject to the control of the corporation, and the opinion states, “The corporation stands between the patient and the doctors.” . . . [it] appears that upon the facts stated in the formed opinion cited, the organization involved was profiting substantially by the rendition of medical services to its members and was interfering with the professional relationship between the doctors and patients. Upon the facts there presented, that opinion was undoubtedly correct.
• In a 1938 California decision in which the court prohibited a commercial medical service plan, it distinguished that plan from “benevolent organizations” that were allowed to operate. In doing so, the court noted the principal evils attendant upon corporate practice of medicine spring from the conflict between the professional standards and obligations of the doctors and the profit motive of the corporate employer. It may well be concluded that the objections of policy do not apply to nonprofit institutes.
• In the facts of a 1939 federal court decision from Washington D.C., the court observed that the corporate members were organizing for their mutual benefit and not for profit, and the plan they were establishing did not in any way undertake to control the manner in which . . .[the doctors] attend or prescribe for their patients. . . .[The plan] in no way tends to commercialize the practice of medicine.
• In a 1954 California case the court commented: None of the activities of the group health plan is harmful, injurious, or inimical to the public health or welfare. None of them tends to demoralize the medical profession. . . .None of them does or will prevent the establishment and maintenance of adequate or reasonable standards. None of them does or will lower the standards of the medical profession or degrade the practice of medicine, to the detriment of health or anyone.

In the 1955 Minnesota ruling Attorney General Miles Lord summarized all of this, as follows: The objectionable features of the “corporate practice of medicine,” or of any other profession, as stated by the Minnesota Supreme Court in the cases cited above, and by the numerous other courts that have considered the problem, are that the exploitation of the profession leads to abuses and that the employment of the doctor by a business corporation interposes a middleman between the doctor and the patient and interferes with the professional responsibility of the doctor to the patient. The corporation considered here would be nonprofit and has a provision in its articles of incorporation prohibiting the corporation from intervening in the professional relationship between the doctors and the member-patients and confining the corporate activities to the economic aspects of medical and dental care.

4.

These decisions do not discredit or reject the sound policy reasons upon which the corporate practice prohibition is based. They look at the underlying evil and recognize that new organizational models can be beneficial if there are safeguards against those evils.

In this context we note that some 55 years ago . . . shortly after Medicare began . . . the federal government, private employers, and indemnity health insurance companies (each for their own reasons) started to explore the prepaid group practice model as a public policy strategy. Medicare triggered enormous inflation in health care and people were searching for relief.

The theory was that the expansion of prepaid group practice would mitigate the temptation in the third-party-payor setting to order and provide unneeded services, and would create financial incentives for preventive care and early diagnosis. This was thought to foster better outcomes and less intense (and less costly) treatment. As this discussion developed it became apparent that there were legal barriers to this strategy that needed to be addressed.

The HMO legislation in 1973 and succeeding years was the tool to remove these barriers. Fifty years later the broad objectives of the HMO concept have been forgotten and the “managed care” remnants present all of the evils of the corporate practice. The health plans may not employ the doctors, but their monolithic payment model and ubiquitous presence controls the patient care setting and professional decision-making as certainly as if everyone were an employee. This is the corporate practice of medicine. We need an intervention to fix the fix.

The modern challenge is to reestablish the doctor-patient relationship, relegating the financing tool to its subordinate role. This can be achieved if medicine and lay leaders insist that it happen and if medicine sincerely embraces the doctor’s ethical duties to patients and society.

The essence of the corporate practice prohibition is the recognition and protection of a doctor’s duties to his/her patient and the illegality of a structure that has even the potential to interfere with that. The antithesis to the control/interference that is prohibited in the corporate practice doctrine is professional autonomy. Professional autonomy is very important if not essential to altruism. Altruism is the central quality of professionalism. Selfless service.

Behavioral psychology and behavioral economics teach us that our best performance is in the context of autonomous actions with a sense of purpose and a sense of mastery . . . doing what we do for the sake of the mission, not because we are forced to, or paid to, but because it is our calling. Fostering these factors will restore the energy, creativity, and dedication in medicine. The characteristic of the corporate practice seems to intentionally defeat autonomy, purpose, and mastery.

The future of the profession depends on the rescue of these qualities.

John Diehl, JD
4876-5457-3702, v.

[1] https://physician-patient.org/

[2] MPPA web site. https://physician-patient.org/

[3] Wainer D. What Happens When Your Insurer Is Also Your Doctor. WSJ. 6-13-24. https://www.wsj.com/health/healthcare/what-happens-when-your-insurer-is-also-your-doctor-and-your-pharmacist-8df727af

[4] HMO Act of 1973. US Code chapter 42 sec. 300e (b) (1,2,3,4,5) and (c) 2D. https://www.law.cornell.edu/uscode/text/42/300e

[5] Anderson OW. Part One, Chap. III. The liberal-democratic political and economic matrix. In: Health Care: Can There Be Equity? New York: John Wiley & Sons, 1972:32.

[6] Geist, RW. A History of Political Malpractice: From Good Intentions to Cartels. MNPhysician. October 2015. http://issuu.com/mppub/docs/minnesota_physician_oct_2015?e=2538202/30749083

[7] Phelps CE, Parente ST. The economics of US health care policy. Rutledge, NY and London.2018:wiii, 1-2.

[8] Brown LD. Chap. 9. Policy analysis and disembodied incentives: HMOs as idea and as strategy. In: Politics and Health Care Organization: HMOs as Federal Policy. Washington, DC: The Brookings Institution, 1983:477-478.

[9] HMO Act of 1973. US Code chapter 42 sec. 300e (b) (1,2,3,4,5) and (c) 2D.

[10] Woolhandler S, Himmelstein DU. Annotation: patients on the auction block. Am J Public Health.1996;86:1699-1700

[11] Alok Gupta, Stephen T Parente, Pallab Sanyal. Competitive bidding for health insurance contracts: Lessons from the online HMO auctions. UMN Carlson School MIS Quarterly. Dec 2012. https://experts.umn.edu/en/publications/competitive-bidding-for-health-insurance-contracts-lessons-from-t

[12] Jacob JA. “Doctors told: take risk or take a walk”. AMNews. Nov. 8, 1999, p. 13, 16

[13] Woolhandler S, Himmelstein DU. Annotation: patients on the auction block. Am J Public Health.1996;86:1699-1700.

[14] Iglehart J. Changing health insurance trends. N Eng J Med..2002;347(12):956-962. https://www.nejm.org/doi/full/10.1056/NEJMhpr022143

[15] KFF/HRET Employer Health Benefits Survey.2007:33;Exhibit 1.1 https://www.kff.org/wp-content/uploads/2013/04/76723.pdf

[16] Bodenheimer T. The Oregon health plan—lessons for the nation. Parts 1 and 2. N Engl J Med. 1997;337:651-655, 720-723.

[17]Cantlupe J. Athena Health Expert Forum: How hospital admin boom could reduce burnout 11-7-2017. [See graph].

https://www.athenahealth.com/resources/blog/expert-forum-rise-and-rise-healthcare-administrator

[18] FTC 67026 Federal Register / Vol. 76, No. 209 / Friday, October 28, 2011 / Notices Rules and Regulations http://www.gpo.gov/fdsys/pkg/FR-2011-10-28/pdf/2011-27944.pdf ;

[19] CMS 67992 Federal Register / Vol. 76, No. 212 / Wednesday, November 2, 2011 / Rules and Regulations http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27460.pdf

[20] Rakshit S, Wager E, Hughes-Cromwick P, Cox C, Amin K. How does medical inflation compare to inflation in the rest of the economy? Peterson KFF health system tracker, August 24, 2024.

https://www.healthsystemtracker.org/brief/how-does-medical-inflation-compare-to-inflation-in-the-rest-of-the-economy/#Cumulative%20percent%20change%20in%20Consumer%20Price%20Index%20for%20All%20Urban%20Consumers%20(CPI-U)%20for%20medical%20care%20and%20for%20all%20goods%20and%20services,%20January%202000%20-%20June%202024

[21] Blake S. Hospitals Leave Medicare Advantage Networks as Problems Plague Coverage. Newsweek. Jul 24, 2024 https://www.newsweek.com/hospitals-leave-medicare-advantage-networks-problems-coverage-1929855

[22] Subsidiarity. Cambridge English Dictionary https://dictionary.cambridge.org/us/dictionary/english/subsidiarity

[23] Kennedy R G. Subsidiarity and the Management of Associations. 13th German-American Colloquium Wildbad Kreuth, Germany. 22 July 2014.

[24] Schweiger L, Venosdel N. Health Care at the Crossroads Securing the future of patient care. MN Physician. July 2024;xxxxvIII(4):1. https://www.mnphy.com/0724-cover-one-lisa-schweiger-nick-vanosdel

[25] Diehl J. CORPORATE PRACTICE OF MEDICINE PROHIBITIONS. October 11, 2023. See Appendix C.

[26] Cantlupe J. Athena Health Expert Forum: How hospital admin boom could reduce burnout 11-7-2017. [See graph].

https://www.athenahealth.com/resources/blog/expert-forum-rise-and-rise-healthcare-administrator

[27] SGR Repeal and Medicare Provider Payment Modernization Act. Prepared by the House Committees on Energy & Commerce and Ways & Means; Mar 15, 2015. https://www.entnet.org/wp-content/uploads/files/SGR-Legislation-Section-by-Section-2-14-2014.pdf

[28] Wainer D. What Happens When Your Insurer Is Also Your Doctor. WSJ. 6-13-24. https://www.wsj.com/health/healthcare/what-happens-when-your-insurer-is-also-your-doctor-and-your-pharmacist-8df727af

[29] Hyman DA. Health Insurance Coverage—Is Broader Always Better? JAMA Internal Medicine. 2024;184(3):233-234. https://jamanetwork.com/journals/jamainternalmedicine/issue/184/3

[30] Silver C, Hyman D. You Aren’t as Sick as Government Claims; Give Medicare money directly to patients to solve ‘upcoding.’ WSJ. Sept. 4, 2024 https://www.wsj.com/opinion/you-arent-as-sick-as-government-claims-medicare-upcoding-fraud-6c08eb35

[31] Silver C, Hyman DA. Overcharged: why Americans pay too much for health care. Cato institute, 2018:331-335.

[32] HMO Act of 1973. US Code chapter 42 sec. 300e (b) (1,2,3,4,5) and (c) 2D. https://www.law.cornell.edu/uscode/text/42/300e

[33] Alok Gupta, Stephen T Parente, Pallab Sanyal. Competitive bidding for health insurance contracts: Lessons from the online HMO auctions. UMN Carlson School MIS Quarterly. Dec 2012. https://experts.umn.edu/en/publications/competitive-bidding-for-health-insurance-contracts-lessons-from-t

[34] Jose F Figueroa, Yusuke Tsugawa, Jie Zheng, E John Orav, Ashish K Jha. Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ 2016;353:i2214. http://dx.doi.org/10.1136/bmj.i2214;

[35] Woolhandler S, Himmelstein DU. Annotation: patients on the auction block. Am J Public Health.1996;86:1699-1700. https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.86.12.1699

[36] Hyman DA. Health Insurance Coverage—Is Broader Always Better? JAMA Internal Medicine. 2024;184(3):233-234. https://jamanetwork.com/journals/jamainternalmedicine/issue/184/3

[37] Hyman DA, Silver C. Leveraging Medicaid expansion. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4588044

[38] KFF 2024 Employer Health Benefits Survey 2024. Section 1: Cost of Health Insurance.

https://www.kff.org/report-section/ehbs-2024-section-1-cost-of-health-insurance/#:~:text=The%20average%20annual%20health%20insurance,$25%2C572

[39] Bank Rate. https://www.bankrate.com/insurance/car/average-cost-of-car-insurance/

[40] Hyman DA, Silver C. Leveraging Medicaid expansion. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4588044

[41]Hyman DA. Health Insurance Coverage—Is Broader Always Better? JAMA Internal Medicine. 2024;184(3):233-234. https://jamanetwork.com/journals/jamainternalmedicine/issue/184/3

[42] Silver C, Hyman DA. Overcharged: why Americans pay too much for health care. Cato institute, 2018:331

[43] Silver C, Hyman D. You Aren’t as Sick as Government Claims.Give Medicare money directly to patients to solve ‘upcoding.’ WSJ. Sept. 4, 2024 https://www.wsj.com/opinion/you-arent-as-sick-as-government-claims-medicare-upcoding-fraud-6c08eb35

[44] FTC 67026 Federal Register / Vol. 76, No. 209 / Friday, October 28, 2011 / Notices Rules and Regulations http://www.gpo.gov/fdsys/pkg/FR-2011-10-28/pdf/2011-27944.pdf ;

[45] CMS 67992 Federal Register / Vol. 76, No. 212 / Wednesday, November 2, 2011 / Rules and Regulations http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27460.pdf

[46] Anderson OW. Part One, Chap. III. The liberal-democratic political and economic matrix. In: Health Care: Can There Be Equity? New York: John Wiley & Sons, 1972:33

[47] KFF/HRET Employer Health Benefits Survey.2007:33;Exhibit 1.1 https://www.kff.org/wp-content/uploads/2013/04/76723.pdf

[48] KFF 2024 Employer Health Benefits Chart Pack. Fig.2. https://www.kff.org/slideshow/2024-employer-health-benefits-chart-pack/

[49] Litow M. Medicare versus Private Health Insurance: The Cost of Administration. Health watch newsletter;2004(52):28-30. https://www.soa.org/globalassets/assets/library/newsletters/health-watch-newsletter/2006/may/hwn-2006-iss52-litow.pdf

[50] Yergin, D, and Stanislaw J. In: The Commanding Heights. New York, NY: A Touchstone Book. Simon and Schuster; 1998:128-129, 137, 222-232.

[51] Cassidy J. The price prophet. The New Yorker. February 7, 2000:44-51.)

[52] MN SF 25-00263.

[53] The Minnesota Health Care Access Commission Final Report to the Legislature, January 1991 https://www.leg.state.mn.us/docs/pre2003/mandated/910163.pdf p.78 [site gone]

[54] Connecticut Huskey report 2016.

https://www.cga.ct.gov/hs/related/20160219_Informational%20forum%20on%20Connecticut’s%20Medicaid%20Expenditures,%20Initiatives%20and%20Long p.2

[55] Rosendale MM. Letter to Werfel D. IRS Commissioner April 3, 2024. DPCs are Health Plans. https://www.taxnotes.com/research/federal/legislative-documents/congressional-tax-correspondence/irs-hindering-health-savings-account-use-rosendale-says/7jdfg

[56] HSA regulations 2009. https://www.irs.gov/pub/irs-prior/p969–2009.pdf

[57] Scandlen S, Gausewitz L, Bringing Health Savings Accounts to Medicare. Consumers for Health Care Choices. 9-25-05. [No longer available online. Ask me for a copy. RWG]

[58] Schweiger L. Venosdel N. “Health Care at the Crossroads” https://www.mnphy.com/0724-cover-one-lisa-schweiger-nick-vanosdel

[59] MPPA https://physician-patient.org/

[60] HMO Act of 1973. US Code chapter 42 sec. 300e (b) (1,2,3,4,5) and (c) 2D. https://www.law.cornell.edu/uscode/text/42/300e

[61] O’Shea L, Bindman AB. Personal Health Budgets for Patients with Complex Needs. N Eng J Med.

2016;375(19):1815-1817 https://www.nejm.org/doi/full/10.1056/NEJMp1606040

[62] Paying for senior care. https://www.payingforseniorcare.com/paid-caregiver/cash-and-counseling-program