MPPA Meeting Wednesday February 19- 2020 at 6-8 PM in the conference room at Crutchfield Dermatology, Eagan MN.

Focus: legislative issues.

Those present: President Lee Beecher MD, Bob Geist MD (RWG), Wayne Zuehlke CPA, Dave Feinwachs JD, PhD, Carl Burkland MD, Mike Ainslie MD, Neil Shah MD, Dave Racer, and Noel Collis MD. There were 3 last minute cancelations.

Please note: my comments are in [brackets]

Minutes of the October 2019 meeting were circulated to all before the meeting.

Part I—MN Patient Protection bills 2020. RWG (~30-45 minutes)

Observation bill—Feinwachs [HF and SF pending introduction]
Dave explained how 2-day observation means not in the hospital. It can also happen to people who kept working after age 65; they got Part A (hospital) automatically, but not Part B (medical) insurance. The bill says that if “observation” means the patient was not in the hospital and if not told, that the hospital cannot balance bill.

The bill also gives the MN Commissioner of insurance regulatory power over private Medicare supplement plans—the object is to prevent seniors being shoved into Medicare (HMO) Advantage plans through false promotions—they ought to know that MA means that they are no longer in Medicare, but a ward of the HMO corporation.
Hearings will probably not be heard until next year.

Q: is there a right to refuse observation? A: Yes (DF)

ACO disclosure and liability bill—RWG (for Rep. Gruenhagen and Sen. Jensen)
The MN case of Warren (the dead patient) v Dinter (the gatekeeper) case was recalled pertinent to an analysis published in Sep 2019 [https://www.jpands.org/vol24no3/geist.pdf] The MN Supreme Court ruled that a jury must adjudicate the case of alleged malpractice.]

The bill is intended to expose the risks that ACOs pose to patient care and professional integrity [HF and SF pending introduction], if and when kickbacks are paid bedside gatekeepers contingent on rationing use of corporate dollars or not, i.e., bonuses for ordering less care and “negative payment adjustments” for ordering “too much” use of ACO dollars.

CMS’s program of ACO “double sided” (insurance) risk depends on kickbacks for bedside clinicians rationing care profitable for the ACO and CMS. The Taxpayer’s problem is that such draconian means of rationing did not work in over a decade of CMS experimentation with ACO double-sided risk—[program expansion is insane]. And current ACO managers are not dumb—they are not signing up for losses when insuring the cost of population care. [That includes MN, where to the best of my knowledge there are no kickbacks going on.]. However, the might of CMS may force all states to use the ACO “double-risk” and its kickback formula “for cost control”.

This ACO disclosure and liability bill would help protect both patients through transparency of kickback payment at enrollment and clinicians, whose gatekeeper conflict of interest liability would be shared by the ACO.

Posting of pre-treatment prices for elective bundles of OP and In-patient services—RWG (for Rep. Gruenhagen. [HF pending introduction].

The rationales for the bill are that mere transparency of long lists of coded treatments have proved indecipherable and thus unusable, and that pre-treatment bundle pricing (itemized what is covered and not covered) when prepaid binds the provider to the price—“surprise” billings do not occur! Patient friendly price competition may well result for everyone.

Medicaid reform (FMA bill) bill to reduce costs through elimination of expensive 3^rd party rationing of care and through onsite debit card payment for OP services of patient’s choice —RWG for Rep. Gruenhagen [HF 2873]

Part II—Other issues RWG moderator

Privacy vs. hospitals selling identifiable patient data—Feinwachs discussion.
Many businesses including hospitals, data sellers, etc. have a buyer, Google. They want freedom to sell and buy data using the old federal loose loop-holed HIPPA “privacy” law to replace the MN more stringent privacy law. There would be no privacy remaining for MN citizens, if the data sellers win open electronic access. Opposition is in place.

Parenthetically, it was noted that EHR firms want to continue selling unconnected data patches and thus not allow system connections much less patient ownership of their own data.

Up-date Gov. Walz MNCare “buy-in” proposals—Feinwachs discussion.
The nation is not ready for “Medicare for all” from fear of losing current insurance and unions hate it.

The “Public Option” into a subsidized Medicaid-like premium program has opposition. Families, who never used Medicaid were billed (through liens on their homes) for “premiums they never paid or knew anything about and despite never having used any medical services! MN repealed this threat. Theoretically, the feds could resume the lien business in a Public Option program. Further, the subsidy money for the premiums go to the insurance company, not the family.

Parenthetically, this brought up a discussion of the four MN physician legislators, who announced their intent to create a public utility like commission to drug prices.

Dr. Neil Shah pointed out that “there are modest proposals that would help educate the public in order to lay the groundwork for reduced drug pricing. First would be mandatory disclosure of drug price kickbacks. Show the lowest cash-payer price and show the patient’s OOP price. The patient can choose which price they’d like to pay. Second mandatory disclosure of rebates – both paid to PBMs and to insurers – on a per drug basis reported publicly once per year. Again, the public – and most companies who pay for commercial health insurance – do not understand how badly they are being fleeced. Even if bills addressing these issues die, the on-record commentary from the drug runners (provided they can get a hearing) would be priceless”

Up-date from DC and MN for 2020—Dave Racer discussion
- “The MN GOP HealthCare Task Force bill is comprehensive, with each part dependent on the other. It includes restoring a new, better form of MN MCHA (named differently) to provide a person easy access to a high-risk pool program. There are many other provisions, but these were not discussed.
- A new book was distributed. “The Manual: Health care 2020: Connecting the Dots” written by Greg Dattilo and Dave Racer. [Something everybody should read. To get a copy open http://themanualhealthcare2020.com/ then click “order a copy”].
- After the MN 2018 laws (62J.81 ff) mandating the posting of clinic prices (including Medicare, Medicaid, Insurance-carrier, and billed prices, the authors were able to connect the data dots for many clinics and hospital systems.
- The spread between Medicare and posted prices revealed that the mean price for care in Minnesota was 201% of Medicare with a high of 282% and low of 109%. [see attached email file table from the book]. The Racer-Dattilo charts include, among other things, the insurance company discount rates for reported services as well.”
- Dr. Neil Shah noted that “the Reference Based Price (RBP) tables represent an easy way to compare prices across clinics for HR directors and consumers who have the time/ability to choose their physicians. Most consumers may not avail themselves of this, but it will be beneficial to those purchasing commercial health insurance.”
- “Racer identified many inaccuracies in clinic postings and sometimes no Medicare price for comparison.
- You will have to read pp. 79ff to see a sampling of the impact of hospital chargemaster prices. [These are closely guarded secrets and very often grossly inflated over the actual cost of care.]
- The authors recommend that all physicians, medical professionals, hospitals, clinics, and providers must disclose their Medicare-Percent – the percent of Medicare they accept as full payment. This would be public information and allow patients to judge physician’s prices in a simple manner.
- Chapter 15 discusses Reference Based Pricing Insurance Plans. These would allow patients to buy coverage that would pay up to a certain percentage of Medicare, and allow patients to seek care from any willing medical professional or facility. The reference price use could preclude balance billing, would allow each provider to establish their own price, and would make comparison shopping possible.
- Racer and Dattilo visited Washington, DC in January and met with Peter Nelson, aides to Representatives Tom Emmer, Mark Meadows, Sen. Tim Scott and Sen. Todd Young. They also met with Representative Gary Palmer, R-Alabama, and Jim Banks, R-Indiana. Their trip included a meeting with two staff aides to Vice President Pence. They report that the Medicare-Percent Disclosure was well-received [RBP].”

4) Next meeting to be announced.

Again, our thanks to Dr. Charles Crutchfield for his kindness in lending his office meeting room and for the wonderful help of his staff: Kelly and Allison.

Respectfully submitted,

Bob Geist, secretary pro tem