MPPA Board

The players in this History are an eclectic group; they vary in their perspectives and their actions sometimes did shape the world in which we live. A Fellow may not agree with other MPPA Fellows—but that is the way discussions work in an open public square. We are in an open forum of ideas. MPPA does not possess nor enforce any orthodoxy. There is no other organization like it.

Current officers

Doug Smith, MD
PRESIDENT
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Wayne Zuehlke, CPA
TREASURER
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Robert Koshnick, M.D., FAAFP
PROGRAM DIRECTOR
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Tim Herman
SECRETARY [ read bio ]

Don Gehrig, MD
COMMUNICATIONS DIRECTOR
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Robert W. Geist, MD
CHIEF LIBRARIAN
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Board Members

David Feinwachs, JD, PhD
[ read bio ]

Hannelore Brucker, MD
[ read bio ]

Lee Kurisko, MD
[ read bio ]

Lyle Swenson, MD
[ read bio ]

Mike Ainslie
[ read bio ]

Gregory A. Plotnikoff, MD, MTS, FACP
[ read bio ]

Pamela Cole, MSPT, CWS
[ read bio ]

I grew up in MN on a small farm up by Scandia MN. My bachelor’s degree was in Agronomy and I spent a 9-month stint as an agronomist. After my first 3 months, I realized I did not want to do this for a living and took the MCAT and applied to the UMD School of Medicine and was accepted for entry in the 1983 School of Medicine class.

In Medical School I could not find anything that I liked better than all of medicine, so I went to residency in Family Medicine.

While in Residency, my director, Richard Bick, suggested that as a family doctor, the most satisfying (both medically and financially) was to make sure I had “MSI” (multiple sources of income). Therefore, I spent a lot of time in Residency and my early years in practice in ER, Urgent Care, and Administrative medicine. I also continued to have a thriving practice.

It was the combination of Peer review/administrative medicine and clinical practice that I found my niche. I enjoyed seeing how other physicians practiced and would take some of the data I read about and reviewed in administrative medicine and put it into my own practice.

I became very interested in the efficient delivery of care and with a patient of mine. In 1999, I started working on developing MinuteClinic, providing a limited scope of practice run by mid-level providers, audited by me, to see patients in large volume areas. Our first clinics were in Cub food. Ultimately that business was sold in 2006 to CVS pharmacies. 2000: MinuteClinic https://www.forbes.com/2007/08/31/christensen-disruption-kodak-pf-guru_in_cc_0904christensen_inl_slide.html#3815e0626ad3

From the start, MinuteClinic’s low-cost health care clinics were highly disruptive. It placed its kiosks in drugstores and made the simple diagnosis of a number of common conditions lower-cost and more convenient. Quick diagnosis, prescriptions, and no appointments. By reducing the cost of treating the most common maladies, insurers were quick to embrace MinuteClinic’s offering. CVS Caremark acquired the company in 2006.

I was then out of the business and did not have an active practice. I continued in administrative medicine for a few years until in 2007 decided to start up a non-insurance billing practice what came to be known as a “direct care practice”. I have practiced that since that time.

I also became involved in another start up practice, a telemedicine practice out of Miami Beach, that ultimately sold to Teladoc.

For that reason, in 2012. I became interested and joined MPPA and medical politics. I did NOT find that the organized medicine groups spoke for either my patients or me. I have found MPPA to be a chance to communicate with like-minded people, to hear about other ideas and to put forth a concerted effort to keep the patient first in medicine.

It all started in Mankato, MN, in 1956. There, I was born into a family that would produce seven children; I was the middle child. Producing those children was the extent of my father’s involvement. My mother endured severe abuse and neglect at his hands and was left to rear her children by herself. That meant that I was a welfare child and was at the mercy of government assistance, including for health care. Even as a young person, I hated being on public assistance.

Attended the U of M, then graduated from Mankato as an accountant. Early accounting stints included IRS, GELCO, Inc., and General Mills. Entered the investment business and succeeded financially. Made first missions trip in 1996 to Ukraine and never stopped. Made it a passion, formed our own 501(c)3 to build youth community centers in Ukraine and traveled there 60 times or so. Exited the investment business in 2003 and have worked with various non-profits since then. Plus, I stay connected to young people by coaching basketball: BOYS in high school and GIRLS in AAU.

Spent my life thinking there was nothing I could do to affect politics in any way, specifically around health care; actually, no reason to worry about it, until health insurance became more expensive and more onerous and less helpful.

A few years ago, a mutual friend introduced me to Twila Brase and her ‘CCHF’ organization. I agreed to come aboard and help her raise some money and – wow – what an education! Figured out that I care passionately about taking health care out of the control of third-party payers and putting it more back into the hands of the individual on a free-market basis as much as possible. Through that gig, I met the good folks at MPPA and also John Tyler and the RHCTF (Republican Health Care Task Force) and became more involved.

Connections made in the last few years resulted in my getting mixed up in actual politics, namely Doug Wardlow’s campaign for Attorney General in 2018. We lost. But, this year, I’m helping Tyler Kistner try to unseat Angie Craig in the 2nd Congressional District and am hopeful of success.

There’s so much to know in health care; continually, I find myself playing catch-up. But somebody has to do something to keep the pressure on for more free-market health care, restoration of the patient-doctor relationship, protection of privacy, and the efficiency and cost-savings all those things would encourage. And, to stave off total government control of our health care, which would carry ample negative ramifications to make it an absolute catastrophe.

I believe this is where MPPA could serve a purpose or mission.
And, to that extent and in my own limited way, I am all in.

Wending a Path Through Years of Medical System Cost Control Panaceas. I started walking this path of managed care cost control panaceas in 1973. I saw reported in the St. Paul Pioneer Press that the legislature was going to pass an HMO bill. I later found out that it would mimic a Congressional HMO bill.

Policy makers were responding to the abrupt onset of a first ever medical cost-price inflation in 90 years. These 1973 HMO bills passed but did not pass the sniff test. They made it legal for corporations to control the benefits they insured—a perverse gatekeeper power allowed no other casualty insurance company.

The fall-out over many decades was that physicians, once employed by patients, gradually sank into hospital and other 3^rd party employment—the paradox of unintended consequences for many professional associations, which had adopted the “inevitable” necessity of rationing care policed by managed care corporations to control costs. Doctors were to be the police!

I thought that publishing papers on the perils of commercial corporations controlling medicine might help stop futile public policy and prevent the destruction of patient (“consumer”) control of the medical market place. Naïve? Yes.

Behavior Pay. In 1974, I published a piece (N Engl J Med. 1974;291:1306-1308) pointing out that “incentive payments” contingent on behavior in reducing the volume of orders for care was double-speak for 3^rd party bribes (“money or favor given or promised to a person in a position of trust to influence his judgment or conduct” (Webster 10^th ed.). “Incentives” became popular after medicine caught physics-envy flu—if you can’t really measure quality or motives you could measure the outcomes of behavior “incentivized” by money rewards and/or punishments contingent on behavior in the volume of care ordered, i.e., of government or HMO money used for care. More pay for fewer referrals; less pay for ordering too much care.

Commercial vs. Professional Enterprise. In 1978, I wrote that commercial and professional enterprises have different primary goals and are controlled by different laws (N Engl J Med. 1978;299:483-486). Commercial enterprise deals with buying and selling goods and services with the primary goal to serve the economic interests of the entrepreneur or the enterprise. Indeed, caveat emptor works best in ordinary microeconomic market sectors where refrigerators, shoes, thumb drives, autos, and most services, are sold.

In contrast, professional enterprise has the primary goal of serving the interests of patients (or the clients of the law profession). Physicians are professionals not because of some salable expertise but rather by “professing” to exclusively serve their patients’ interests first. For practical implementation of this policy, from early in the 1900s to 1970s state laws and AMA ethics limited a practicing physician’s economic gain to reimbursement for the services that he or she rendered. In 1981, all that changed. The FTC had sued the AMA and won in court—suddenly, Judicial Council Opinions were antitrust violations. A new set of AMA Opinions were devised: “III. A physician shall respect the law …” The law was the HMO Act of 1973, which meant that commercial caveat emptor ethics ruled, not professional ethics. Kickbacks and bribes, i.e., behavior pay, to bedside clinicians for rationing care, became legal. The covenant of exclusive patient loyalty was reversed to corporate financial loyalty of playing the dual role of care giver and insurance underwriter.

Physicians found themselves powerless, when no longer patient employees. In 2010, clinicians were offered alternative power through being gatekeepers in “Accountable Care Organization” (ACO)—in a 2015 Opinion, the AMA called this “stewardship” of the nation’s scarce resources, i.e., money.

Why Play Medical Politics? I finally understood that I was an Econ 101 and Professionalism 101 missionary preaching against theological-like beliefs in managed care’s specious and futile illusions of cost control through rationing care masquerading as pay-for-performance, which morphed later into sugarcoated “value” pay double-speak. The social engineer managed care theologians continue to win yelling “a right to medical care”, while they create profiteering schemes to take it away.

Political Lessons. Doing politics is demanded, when a profession (and a dedicated highly trained professional medical workforce at all levels) is speciously demonized as practicing “avaricious poor care”. For this reason alone, I would do politics again—justice demands it.

There is a path to a professional medical market place where American families are king, not corporate or government bureaucrats. That is a path to affordable universal health insurance and delivery of quality patient-centered services. That goal is achievable; a topic for another time.

In MPPA, I found brilliant physician and lay leaders willing and very able to discuss in a civil manner the vagaries of Econ 101 and Professionalism 101 and their remedies. All were interested in patient protection and in good patient care unlike the commercial insurance corporations that dominate medicine today in which the choices are: “cost, access, and quality; pick any two”.[1] I never felt alone once the sparkling discussions of MPPA peers began; a place for sharing ideas and remedies for medicine’s economic and ethical problems in a collegial manner.[2]

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

I was born in Germany and studied medicine in Tübingen, Duesseldorf and Freiburg. At the time students were allowed to study at different universities but I did all my examinations in Tübingen at the Eberhard Karl’s University founded by Eberhard I., Duke of Wuerttemberg in 1477.
After finishing my medical studies, I would have been a general practitioner, but I decided to stop working at the hospital as I saw my first child mainly sleeping while I finished the residency with grueling hours. Germany did not have a childcare system at the time. I decided to do minor medical work and keep studying for myself. My husband, who I married right after graduating from the university, and I did both the ECFMG exam for foreign medical graduates but our planned move to the United States had to wait until 1975.

After arriving in the US, I had to adjust my daughter and son to the change in our lives. One year later I started an internship in internal medicine in Dearborn, Michigan at Oakwood Hospital. (At the time it was hard for foreign medical graduates to find an internship at the large hospitals, no matter what the credentials were). I was proud that I passed my Flex exam on the first try after my break of all those years as many foreign graduates failed, sometimes more than once. I finished my internal medicine training at Hennepin County Medical Center after our move from Michigan to Minnesota in 1978 and passed my board exam in Internal Medicine.

There was another break in my career as I was expecting twins. Both identical girls had a ventricular septum defect of the heart; in one girl it closed by itself and the other girl needed open heart surgery at age one. Fortunately, both are well, and all my children are quite successful!

My husband told me in 1983 that he needed me in the allergy office. Being a brilliant physician, he became my mentor. I joined MPPA as a practicing allergist. At the time I was a solo practitioner as my husband and my partner of 20 years in the allergy office had died in 2003.

The idea of an organization furthering cooperation between patients and their physicians was extremely attractive to me. Through recommendation of Mike Starnes I asked David Allen to assist me in the overall business management of the office. David suggested to me to join MPPA which I did, if remembered correctly, in 2005 as the first female member. My first impression was the comfort of Dr. Lee Beecher’s office as meeting place, surrounded by art and books and talking to people with different relations to the healthcare field including a number of physicians. The atmosphere was friendly with lively and passionate discussions of different temperaments but always with the goal to help physicians and patients to keep their relationship. We were all aware of the Oath of Hippocrates (460 – 377 BCE) that the over-abundant regulations seemed to destroy.

MPPA’s environment was especially consoling when I felt bombarded with Minnesota Community Measurements (MNCM). The 2008 Health Reform Law (Minnesota Statutes, Section 62U.02) mandated that the Minnesota Health Department (MDH) establish a statewide measurement for the Pay for Performance Program (P4P). The MDH used as its contractor the MNCM that became the report card manufacturer. I remember working for 3 months to fulfill the MNCM requirements for asthma measurements and incorporating them in a format that could be accomplished during regular patient visits. The absurdity of this law was fully visible to me when I learned that I was actually ahead of the measurements. I was the second physician after Mayo Clinic’s Pulmonary Department to use the newly available nitrous oxide measurement for lung function. As I was my own boss, I could decide to use this new device, even though I did it with a financial loss.

Then the commissioners of the MNCM told me they would not use this new measurement as not everybody had it available. So, they were behind the progress and now this measurement is used the world over by pulmonary and allergy specialists as measurement for lung function. Although I never dared, as other physicians in the group did, to change my office to a private pay praxis, I followed the ideal to give every patient the time and care that they needed, regardless of my income.

Sometimes I wished the MPPA would have had more influence on our legislators, but the group never failed to try. In addition, I learned much about the inner workings and politics of insurers and the operation of Medicare and Medicaid. I admire the relentless efforts on improving the system.

Now, that I have given my office to another allergy group, I am still pursuing my love for research and was allowed to give talks at the Annual Meeting of the American College for Allergy, Asthma & Immunology. My love for medicine will never end. For the rest of my life, however, I will be grateful for the support I received from MPPA and hope that I have contributed to the goal of this organization.