MPPA Meeting Minutes – 02/26/19

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MPPA Meeting Tuesday, February 26, 2019 at 6-8 PM in the conference room at Crutchfield Dermatology, Egan MN.

Those present: President Lee Beecher MD, Bob Geist MD (RWG), Carl Burkland MD, Wayne Zuehlke CPA, Vince Hunt MD, Mike Ainslie MD, Sen, Scott Jensen MD, and Mark Holder MD (a new member) was warmly welcomed. It’s of interest the we had 23 responses to the meeting announcement; 13 to attend, but last-minute illnesses, political activities, and some unexpected cancellations (snow, ice, and cold?) reduced the group to 8. The result was an excellent conference with Sen. Scott Jensen. One person sent questions for Scott about two bills.

Please note: my comments are in [brackets] and see the 3 attachments (pp. 3-5)

  1. Minutes of the Sept. 23-2018 meeting were circulated to all before the meeting.
  2. 2. Legislative issues were discussed with Sen. Scott Jensen
    1. a)     [277] DPC establishing direct primary care service agreements between patient and physician. Makes clear that agreements are not insurance and not under jurisdiction of the insurance commissioner. No discrimination in fees [risk adjustment] allowed for health reasons—one price for each patient services. Effect on concierge practice was discussed.
    2. b)    [SF 354] requiring health carriers to offer one​ health plan that is an any willing provider (AWP) option. Neil Shah thought that restricting payment to 120% of health plan price was too low and ought to be 160% for primary care and 180% for specialists—Scott agreed.
    3. c)    [SF 278] PBM regulation requiring licensure, increasing transparency on prices and rebates, disclosing any conflicts of interest, and requiring an expansion of pharmacy networks so patients have more options to fill a prescription. Imposes fiduciary duty to Plans and patients. Transparency gag clause removed. Channel 11 PBM program broadcast planned for this Wed, 2-27, at 10 PM.
    4. d)   SF 353] “Affordability” of drugs. Set’s ceiling prices by an independent commission with no end date. Based on Canadian system [sounds like the UK’s NICE program of allowable annual expense for care and drugs ] with review of annual cost over $30,000, or any large $10K annual increase, or of any 10% immediate increase. [Allows MD dispensing meds]. Discussion worried about possible future system fraud. [This is a price-fixing bill for drugs. We did not discuss the ramifications of price fixing in general].
    5. e)     [SF 03] Providing best value for care [through patient action]
  • a “right to shop act” requiring health plan companies to develop and implement
    a shared savings incentive program. This is a very complex bill aimed at incenting patients to shop for the least expensive elective referral for care. “Savings” will be shard 50/50 by patient and plan—the discussion was that this was ridiculous, since the Plan saved the money, not the patient.
  • Ln 5.19 specifies that the administrative expense is “a medical expense”! [Which seems equally ridiculous and nothing more than a profiteering center for the insurance corporations at the patient’s expense.]
  1. [SF 349] eliminating the State mandate for interoperable electronic health​ records (EHRs) ​ At Senate Committee hearing today it passed with only 2 negative votes!
  2. Protecting access to care for patients with pre-existing conditions has been inserted into the PBM bill, SF 278.
  3. The following Senate bills were briefly discussed: SF 350 prohibits non-compete clauses—opposed by hospitals; SF 351 requires uniform rates for primary care services located within a certain geographic area [ln 1.71—concern with mandated utilization and referral requirements were not discussed]; SF352 establishes a refundable tax credit for premium support—former MCHA program was a prospective cost program and this bill is a retrospective cost program, wherein the state reinsures 80% of cost > $50K to $200K and insurance company picks up coverage of >$200K. Thus, corporate insurance risk minimized.
  4. Provider Tax—Scott said that the state doesn’t want to lose the revenue. [Complex bad policy forever looms again!]
  5. Bill to allow pricing of bundled care for individuals briefing by RWG. The current CMS mandated transparency for billings (usually post-ante care) are a failure of un-bundled unreadable complexity. Posting pre-ante costs of 25 or 50 common bundled services would have a similar purpose as did the popular transparency Act last year. Scott thought this had merit.
  6. Patient and clinic protection issues.

a)      HF pending Medicaid Reform FMA bill, which would fund enrollee-owned debit cards for outpatient care, was briefly outlined by RWG.

  1. MN legislature resolution briefing by RWG about repeal of FTC and CMS regulatory waivers of patient protection laws including amending MACRA law to allow clinics to take underwriting risk or not; no authors as yet—attachment 3.

c)     Patient financial bill of rights (Rosenthal) was thought inappropriate at this time by Scott.

d)   [HF 3] The MN Comprehensive Health Act MNCare buy-in. [Acronym, MCHA, is cleverly stolen from our successful MCHA program for the uninsurable that was killed by ObamaCare]. BTW, there is no audit clause. [We need the original MCHA program!]

e)     [Clinic Fair Contract Act has been dropped—it is Fed reporting requirements that are a problem and not state mandates at this time; more information form more clinics needed to proceed—RWG.]

  1. Future MPPA Directions.
  2. Lee Beecher eloquently discussed future needs to involve patient and doctors in re-establishing patient-centered care—this was warmly received.
  3. A new proposal for reference-pricing insurance by Dave Racer and Greg Datillo was discussed. It includes an interesting means of having virtual discussion-action groups. I will ask Dave to consider giving a presentation of the idea at a future meeting.
  4. Mark Holder thought that it would be good to explore a cash-only group of primary and specialty clinics, which could be city, state, or nation-wide. [I will ask Matt Flanders to forward to him the CCHF Wedge cash-practice program details.
  5. The nature of MPPA, as a think tank, was briefly discussed. Basically, we are a conversation group of 83 members with incredible talents available for actions proposed by individual Fellows. A briefing is attached,4
  6. Former Representative Steve Gottwalt sent us an interesting message, which we did not have time to discuss—attached 5.

We are again grateful for Dr. Crutchfield’s gracious hospitality for use of his conference room.

The next meeting date is to be determined.

Respectfully submitted, Robert W, Geist MD, Secretary pro tem

MN Legislature RESOLUTION: Repealing FTC waivers of anti-trust law and CMS waivers of anti-fee splitting kick-back and Stark anti-self-referral kick-back laws and amending MACRA law to mandate clinic freedom to contract or not for payment contingent on volume of orders for care (aka “value pay”) would eliminate coercing providers into underwriting (insuring) population costs.

  1. WHEREAS, FTC waivers of anti-trust laws [[1]] legalize creation of government protected corporate cartels (“payers”) through mergers of competitors and;
  2. WHEREAS, CMS waivers of anti-fee-splitting and anti-self-referral (Stark) laws [[2]] legalize shifting cartel underwriting financial risk and profit driven gatekeeping functions onto the providers of the services (aka “value-purchasing” contracts); and
  3. WHEREAS, HMO insurance corporation and Government agency (aka “mega-payers”) profitable cost controls require transfer of underwriting risk to provider ACO corporations and their bedside providers for the cost of servicing the clientele (populations) of the mega “payer” government agencies and MCO corporations; and
  4. WHEREAS, waivers legalizing collusive “payer” behavior payments is how patients can lose the protection of anti-trust, anti-fee-splitting laws, and exclusive professional loyalty of their bedside physicians paid “bonus rewards” to ration care in the role of corporate gatekeepers; and
  5. WHEREAS, in violation of anti-trust law, mergers (“joint venture”) are formed for the purpose of cartel collusion in fixing capitation fee rate bids at auctions of “payer” populations for servicing, and;
  6. WHEREAS, in violation of anti-fee-splitting and anti-self-referral (Stark) laws provider corporations can profiteer through collusion to split capitation fee profits from rationing care (aka “gainsharing”) amongst provider insurance corporations and mega “payers”; and
  7. WHEREAS, profiteering through denial and delay of care is how professionals at the bedside and professional organizations can lose their claim of exclusive patient and public loyalty and is how the integrity of America’s health care system is endangered, when laws create a double legal standard for physician behavior through legalizing ACO split fee payments contingent on volume of referrals (aka “value pay”) something that are illegal bribes under state Medical Practice and federal statutes; and
  8. WHEREAS, Multiple cost control experiments have failed using pay contingent on volume of care referrals ordered (aka, “value contracting”, “P4P”, “value pay”, “bonus rewards”, “negative payment adjustments”, etc.) [[3],[4],[5]]; and
  9. WHEREAS, Federal waivers legalize ACO violations of anti-trust and of anti-fee splitting, and anti-self-referral (Stark) laws[6]; now therefore, be it

Resolved that Congress and the administration repeal waivers of patient protection laws through:

  1. Repeal FTC waivers of anti-trust laws for ACOs and HMOs:[1] and
  2. Repeal CMMS waivers of anti-kickback (anti-fee splitting) and anti-self-referral (Stark) laws for ACOs and HMOs;[2] and
  3. Amend MACRA to mandate clinic freedom to contract or not for payments contingent on volume of orders for care (aka behavior pay or “value pay”); and
  4. Send this petition to: United States congress members, appropriate congressional committees, Minnesota members of Congress, and to appropriate officers in the Executive Branch of the U.S. government.

What is MPPA and Why Meetings?

  1. MPPA is a think tank inclusive of many different opinions. It is based on the proposition that we are for Empowering patients and physicians to make informed health care decisions. The motto may not be as succinct as E pluribus Unum, or L’Etoile du nord, or Liberté, égalité, fraternité, or Sovereignty in each barrel (ND Mandan tribe in drilling its 4th well). But our motto is nonetheless good; a basis for our conversations.
  2. You are not alone with a home in MPPA—we’re a kaleidoscopic group devoted to analysis of public policy and political malpractice. We are not a policy making group with policy making meetings run by Rules of Order and a staff to collect dues and to carry out policy with lobbyists at the legislature—in other words we are not a mini-MMA. We are rather a place where your ideas, not you, can be freely critiqued in a civil manner.
  3. MPPA is the of a few medical policy organizations in MN not acting like a trade association and without ties to commercial industry or political party agenda. That is, I think, our strength and the reason we have steadily grown. There are 4 (of 83) currently on the roster, who have specifically asked to not be involved in the usual email loops—I send them meeting notices, minutes and important announcements such as publication of op-eds, letters to the editor, published books, and so forth. The email loops are spontaneous—lots of issue opinions and ideas there!
  4. Meetings per Greg Plotnikoff are a great opportunity for:

1) Community: to connect with colleagues with similar concerns, beliefs. You are not alone.

2) Conversation: to exchange, deepen and strengthen one’s thoughts. Your insights are important to share. We are all teachers and we are all learners.

3) Catching Up: to learn of what has happened and what is pending relevant to health care policy and funding. You need to know what is not in the media and important issues that float under the political radar.

4) Consensus: to identify key leverage points and deadlines. Together, we need to know what is possible and when actions are most needed.

5) Coordination: to sequence, prioritize and coordinate efforts to optimize key leverage points. There is strength in our numbers and there is power in our synergy.

6) Convener: to discuss HC re-design, changes, future trends, etc.—RWG.

RWG ver. 3-18-18

Emails 2-22-19

Sorry I cannot make it — Great agenda!

One other thing you might want to discuss: The persistent drum beat of DHS taking over health care in Minnesota (i.e., ultimate single payer).

The language is laced through several bills this session. While many are frustrated with the HMOs, replacing them with DHS would be a disaster.

Thanks for all you and MPPA do for common sense health care reform!

Steve Gottwalt
952.923.5265
steve@gottwaltconsulting.com

 [1] Federal Trade Commission. Statement of antitrust enforcement policy regarding accountable care organizations participating in the Medicare Shared Savings Program. Federal Register 2011;76(209):67026-67032. Available at: www.gpo.gov/fdsys/pkg/FR-2011-10-28/pdf/2011-27944.pdf. Accessed Dec 6, 2015

[2] Centers for Medicare and Medicaid Services. Medicare program; final waivers in connection with the Shared Savings Program. Federal Register 2011;76(212):67992-68010. Available at: www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27460.pdf . Accessed Dec 6, 2015.

[3] 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 [There was no difference—RWG]

[4] Lewis VA et al. Explaining sluggish savings under Accountable Care. N Eng J Med. 2017;377(19):1809-1811. http://www.nejm.org/doi/full/10.1056/NEJMp1709197 [“Value Pay” kickback experiments don’t work—RWG]

[5] House Committees on Energy & Commerce and Ways & Means and the Senate Committee on Finance Staff. SGR Repeal and Medicare Provider Payment Modernization Act. February 6, 2014. http://www.ppsv.com/assets/attachments/D0517215.PDF [No longer available on line—ask me for a copy—RWG]

[6] Kanter GP, Pauly MV. Coordination of care or conflict of interest? Exempting ACOs from Stark law. N Engl J Med 2019;380:410-411.

By Minnesota Physician-Patient Alliance February 26, 2019