MPPA Meeting Minutes – 02/09/22

This MPPA Meeting (in its 25^th year) was held, Wednesday, Feb 9, 2022, at 6 PM on Zoom,

Present were Robert Geist MD, Robert Koshnick MD, Wayne Zuehlke CPA, Marie Casey Olseth MD, Peter Nelson JD. Dave Feinwachs JD/PhD, Don Gehrig MD, Doug Smith MD, Carolyn McClaim MD, Natasha Chernyavsky, Kip Sullivan JD, Pam Cole PT, and Wayne Liebhard MD.

• I forgot to record this Zoom meeting. Sorry!
• Once again please note that my own opinions in these minutes are always enclosed in [brackets—rwg]

The Meeting Focus was Politics 101. We addressed the primordial issues of Medicine: Medicine’s Professional Integrity and Cost, Access, Quality. Of the latter, are we still plagued with HMO dilemma of “pick any two?”^[[1]]

• Three MPPA Fellows climbed up on a soapbox in our public square to address these issues.
• First, Kip Sullivan analyzed overpayments in the national panacea program, Medicare Advantage.
• Next Bob Geist and Glenn Gruenhagen reviewed 3 bills in the legislative hopper. These are a Medicaid Reform (FMA) bill (HF 1984) and 2 bills regarding threats to the moral integrity of medicine, namely, ACO clinician kickbacks for rationing care (HF 2796) and a MN Resolution to Restore Federal Patient protection laws (HF 2781). It is difficult to address federal law malpractice from the state level. We did not have time to address a 4^th price transparency bill (HF 2795).
• Bob mentioned that the spade work on these four bills has been done. What he needs are volunteers to carry-on the battle for them! Senate sponsors are being sought.

The reason these House bills were tacked onto this meeting is that Bob will have to scale back his activities and is looking for help—age has finally wrought some finishing touches. Two revered colleagues once noted a truth that is not to be ignored: “Times corrosive dew drops doth nibble the mighty warrior.” Bob is no mighty warrior, but like them he is all too human. He needs some mighty young warriors to carry the load. Young Rep. Glenn Gruenhagen and other MPPA warriors are doing their part to counter political medical malpractice. Please see Appendix A at the end of these minutes for Bob’s analysis of what FMA Medicaid Reform and the other bills might accomplish for MN; they might even act as paradigms for other state’s legislative actions.

Presentation I. Kip Sullivan on Medicare Advantage Overpayments.

Kip noted that “[M]anaged care plans do not have to be just more efficient than FFS Medicare, they have to be a lot more efficient. To begin with, the administrative costs of Medicare’s FFS program are small; …[W]ith administrative expenses in the range of 8–25% – [HMOs] have to incur medical expenditures 10–20% less than FFS … just to break even. In most markets, capitated plans cannot attract enrollees unless they offer additional benefits, which also cost money….” “Although many employers believe, in principle, managed care plans save money, little empirical evidence exists on the cost savings of managed care.…”

• “Our review of studies on risk selection shows that because most HMOs benefit from favorable selection (the healthier individuals typically enroll in HMOs), Medicare has paid HMOs more than it would have paid for the same patients’ care by fee-for-service providers. Estimates of the excess payments range from almost 6 percent to 28 percent.” (U.S. General Accounting Office, Growing Enrollment Adds Urgency to Fixing HMO Payment Problem, November 1995, 9)…
• From 1972 to 2004, overpayment occurred primarily because (a) Medicare Advantage plans enrolled healthier people and (b) CMS’s “demographic” risk adjuster did not reduce the premium payments sufficiently to prevent overpayment. Since 2004, additional overpayments have occurred for Medicare Advantage plans upcoding. From 1972 to 2004, overpayment occurred primarily because (a) Medicare Advantage plans enrolled healthier people and (b) CMS’s “demographic” risk adjuster did not reduce the premium payments sufficiently to prevent overpayment. Since 2004, additional overpayments occurred from Medicare Advantage plans [mercenary!— rwg] upcoding. CMS’s “demographic” risk adjuster was grossly inaccurate using only four factors: Age, Sex, Medicaid status, and Institutional status.
• In conclusion, Kip said that Congress set a trap for future congresses when it inserted HMOs into Medicare. 1) HMOs, and after 1997, insurance companies of all types raised Medicare costs because they attracted the healthy and were paid as if they attracted beneficiaries in average health [once known as “cherry picking” and “lemon dropping”—rwg]. 2) when Congress and CMS sought to improve CMS’s risk adjuster by adding diagnoses, the improvement was minimal and worse, it gave the insurance companies a new way to cheat – upcoding. 3) There is no effective solution to this problem other than setting Medicare Advantage rates substantially below the average cost of insuring traditional Medicare enrollees or terminating the MA program. A) Risk adjustment cannot be improved. B) Battling upcoding is expensive. [Emphasis added—rwg.]

Discussion of Medicare Advantage Overpayment

There was a good deal of discussion regarding risk adjustment which Kip summed up at the end of his presentation. He also noted that upcoding is worse in the private market than in the public. One discussion leader noted that the latest up-code strategy is a promise to improve the health of populations [this has always been the “health maintenance” sales-pitch. It will be interesting to see if this very old managed care utopia-pitch will be bought again—rwg] One clinician noted that his ACO had periodic staff “upcoding parties” and used RNs for well-paid [“preventive”] annual Medicare H and P exams. One doctor noted that upcoding brought more pay. [This is part of problemed ACO-HMO “value pay” or “bonus opportunity” kickbacks; fed-speak,[[2]] not mine—rwg]. Kickbacks are addressed later in the meeting. The independent practicing clinicians present said that they opted out of Medicare because of such system dysfunctions.

Presentation II.

Bob Geist and Rep. Glenn Gruenhagen presented 3 MN House bills.

The FMA Medicaid Reform bill HF 1984.

• The family medical account program is cash on a debit card for OP care. The state is the HDHP insurance carrier insuring catastrophic expense, i.e., any OP encounter > $300 or hospitalization. The essence of the program is that we can distribute medical care with money or distribute it with politics; the latter empowers crony (government franchised) corporate cartels to profitably ration care for “cost control”.
• The FMA program distributes OP care with money in the hands of patients—a revolutionary defined contribution program for a public program with defined benefits.
• Outlined were the elements of the bill: who is eligible, how much money to fund the debit card, how the program works (“follow the money”), and the benefits to patients, the profession, and populace when, “Ownership of resources is the path to a decent life free of poverty and dependency: a goal for all Americans.”^[[3]]
• The FMA bill 1) Empowers patients with money instead of empowering corporate bureaucrats; 2) it puts OP care money for the enrollees on debit cards instead of giving it all to corporate cartels—where all the money for care disappears at the end of the year; and 3) onsite payments eliminate the need for high-cost HMO-ACOs or their continuing corporate profit-driven high pricing, up-coding, and rationing of care (aka, profiteering when hidden).
• In MN-speak the FMA bill is a 3-goal hat trick compared to the Medicaid MCO corporate penalty box forever.

Discussion FMA Medicaid Reform bill HF 1984.

There seemed to be general agreement that the concept of this Medicaid Reform was good. [Last year two nationally famous UMN economists were presented the FMA program; they thought it could work—rwg.] A practicing doctor noted that it is a FFS program, “just like my cash only practice”. Another clinician thought it a great idea for her particular specialty. A physician thought the ability of enrollees to save significant money would be very effective; it gives the chance of real savings for an enrollee lucky in health, prudent in use, as well as a financial bridge out of Medicaid for medical care. It would eliminate the need for expensive 3^rd party “payers”.

Bob wondered if it would be wise to fire all the Medicaid ACO-HMOs as did Conn. in 2009. Conn. program overhead dropped from near 12% to 5.2%^{[[4],[5],[6]]}–much the same as the 4-5% overhead in 1990 MN before HMOs reigned.^[[7]] The group correctly thought that dropping HMOs from Medicaid impossible in MN. [Maybe something that another state might consider when installing an FMA program?—rwg.]

Bob hoped that, if some other state could implement the FMA program of economic sanity instead of continuing perpetual rationing cost control failure and scams, a national paradigm could be set for emulation by all states. Rep. Glenn Gruenhagen pointed out that the FMA Medicaid Reform created an option to the current HMO only program—Bob described the latter as the “HMO box” where Medicaid funds and patient care encounter data disappears. Glenn noted that Medicaid HMO program high costs are not sustainable and could eventually eat up all MN state tax revenue!

One clinician had practiced in a county where 23% of the population was on Medicaid—”there was much abuse”. [In recent weeks we have seen reported in the news that improper (fraudulent?) Medicaid payments have increased from 5.8% in 2013 to near 21.7% in 2021.^[[8]] This follows Medicaid expansion to childless adults in 2014—rwg].

Please continue reading about the FMA bill in Appendix A.

Presentation III. ACO disclosure and liability HF 2796

Bob Geist and Rep. Glenn Gruenhagen presented 2 bills dealing with the successful attacks on medicine’s >2000-year covenant of exclusive loyalty to the interests of the patient and public weal.

The ACO disclosure and liability bill (HF 2796) deals with the nature of ACOs; they are often “joint ventured” with HMOs;^[[9]] sophistry to hide violation of old anti-trust law. ACOs are “insurance corporations without a license practicing medicine without a license”.^[[10]] Contracted clinicians and clinics are a professional façade for an insurance business. ACOs are “licensed” through 2011 FTC^[[11]] and CMS^[[12]] regulatory waivers of both federal anti-trust and patient protection laws—about which more below. They balance fixed budgets through profiteering from rationing care access (payment contingent on the volume of care),² upcoding, and raising prices.

The case of Warren v Dinter was presented.¹⁰ Diabetic patient Warren’s hospital admission requested by a neighboring clinic NP was refused by hospitalist, Dinter, without being seen; 3 days later she was found dead from staph septicemia—the case is still pending in district court. In my opinion, it is doubtful that Dr. Dinter had any mercenary intent—I argue that the decision was due to the current political corporate cost control mindset.

For example, many years ago, a complaining patient was deemed sick and needing care until proven well. But decades of political-corporate cost control to “preserve society’s scarce resources” has been the mindset that reversed the old professional Samaritan, who cared that patients always hurt in both body and mind. They are not only carbon machines.^[[13]]

In contrast, it is not uncommon for many pundits and for MCO corporations needing to balance fixed budgets to view patients as self-indulgent cost culprits or merely a “consumer” or “case”; thus, managers calculate a case to be physically well before proven physically sick. It can lead to delay of treatment rationalized by the statistical fact that most people “get well anyway”, a self- serving rationalization at best. This mindset can be a potent artificially created danger to patients where ACO-HMO staff have been imbued with calculating physical health alone (a temperature under 102 F does not warrant an ER visit—“go to the clinic in the morning”. A mindset that can lead to an unconscious decision that it is safer to foster the corporations duty to guard society’s “scarce resources” rather to open the gate to another potential cost culprit “consumer”.

I speculate that lack of insight from a mindset the calculates a new patient is well until proven otherwise is unwitting; it probably sent patient Warren home instead of into the hospital. The worried clinic NP saw a sick patient; the hospitalist heard only about a case: a diabetic with a high wbc.

There was a similar case years ago in Portland OR. A distraught Spanish-speaking mother knew she had a sick baby despite a normal temperature—the child’s plight for 2 days lacked even simple HMO clinic investigation until the sudden appearance of four blackened arms and legs was found to be caused by pneumonic septic shock. [Don’t ask me for details—I would cry.]

A gatekeeper mindset that unconsciously calculates relative patient/“consumer” risk vs corporate/“society” financial risk is a potential systematic risk for ACO-HMO patients “well” before proven sick. HF 2796 is weak in that it only gives transparency to a corrupt system of rationing care where pay is calculated on the volume care ordered—more pay for ordering less care (a “bonus opportunity”) and less pay for ordering “too much” use of corporate money (a “negative payment adjustment”); fed-speak^[2] for “value pay” which is in fact volume pay. [How did we arrive at a system of powerful crony cartels rationing care? Bob examined this progression in a paper published a few years ago: A History Political Malpractice—From Good Intentions to Cartels^[[14]]

Discussion ACO disclosure and liability HF 2796

A discussion leader noted that 1997 Texas law made HMO corporations liable to law suits if there was harm done. [The federal court stated that federal ERISA law, “…preempts all state laws that “relate to” any employee benefit plan… Under a hold harmless clause in this context, only providers, and not managed care entities, could be held liable for the result of treatment even if the treatment was determined by what the managed care company, and not the provider, determined to be medically necessary.”^[[15]]–rwg.]

In 2001 SCOTUS reviewed the case of Herdrich v Pegram.^[[16]] Herdrich claimed that delay in ordering an abdominal CT scan led to morbidity from a ruptured appendix. The Court found that HMOs were not liable because Congress saw the need to control costs—of necessity doctors “wore two fiduciary hats”; this means that under HMO and ERISA law that a harmed patient can only recover the cost of a neglected procedure (a CT scan in this case). I railed against of the insanity of fiduciaries with “two hats” that created a unanimous opinion written by Justice Souter.¹⁶

One discussion leader stated that ACOs were indeed practicing medicine. [They lack meaningful liability. The only remedies I see presently are the transparency mandated in this bill and the MN Resolution to restore federal patient portion laws; we examine this next—rwg.]

Presentation IV. A MN Resolution to Restore Federal Patient Protection Laws HF 2781.

Bob Geist pointed out that the problem was Corporate profiteering through hidden clinician payments for delay and denial of care (incented by “value pay” kickbacks).^[[17]] The solution is to restore federal patient protection laws. Although it is difficult to deal with legalized federal regulatory and Congressional medical malpractice, this bill attempts to do so. Specifically:

• Resolved that Congress and the administration restore patient protection laws through:

1. Repeal FTC waivers of anti-trust laws for ACOs and HMOs:^[[18]] and
2. Repeal CMMS waivers of anti-kickback (anti-fee splitting) and anti-self-referral (Stark) laws for ACOs and HMOs;^[[19]] and
3. Amend MACRA to mandate clinic freedom to contract or not for payments contingent on volume of orders for care (aka “value pay” incentives);^[[20]] and
4. Send this petition to Congress and all pertinent executes agencies.

Discussion A MN Resolution to restore federal patient protection laws HF 2781.

There was general support of the Resolution’s intent. It was pointed out that Resolutions are weak by their nature. [Too true, but how else can one deal with federal medical political malpractice from the state level and simultaneously avoid a hostile governor’s veto?—rwg.] One discussion leader thought that a better means would be to make public all data of those entities to which the government has outsourced (franchised) its functions of insuring and producing medical care—it was estimated that such public data would chase scammers out of public programs. [The FMA bill does that by mandating all (redacted) expenditure-encounter data be public; cash payments on site; this also eliminates the need of expensive 3^rd parties—rwg.]

The meeting adjourned at 8 PM.

Respectfully submitted,

Robert W. Geist MD, secretary pro tem
651-485-5933 [c] rgeistmd@comcast.net  

The Spring meeting is tentatively scheduled for Wed., June 8^th. The agenda is already very full.

• The agenda focus is: 2022 Election Preview https://victorhanson.com/what-will-the-2022-midterms-look-like-part-one/ Proposed Discussion leaders are Dave Feinwachs, Peter Nelson, Doug Smith and all assembled.
• We hope to include a discussion with our MPPA Gubernatorial candidates—Scott Jensen and Neil Shah; that will depend on their busy schedules. Proposed discussion leaders: Dave Feinwachs, Peter Nelson, Doug Smith; John Diehl JD
• 2022 MN legislative session review. Proposed discussion leaders: Feinwachs, Nelson, and Koshnick
• Book review, Medicine: To Make Our Health Care System Well, by John Diehl JD
• Final new website review.

The fall October meeting date has not been set. Tentatively the focus is: “Factory Medicine: Pitfalls and Climbing Out” led by Mike Ainslie. I hope to add a book review by an MPPA Fellow with an interesting-nationalized program to support a primary care clinic for all American families.

Appendix A, by RW Geist MD

The 4 MN bills discussed at this MPPA meeting are the beginning of a beginning. The aim is to address medicine’s primordial problems of ethical integrity as well as its cost, access, and quality problems created by federal regulatory and Congressional law. It is not easy to overcome federal level malpractice from a state level—one has to begin somewhere.

For example, I think that the FMA Medicaid Reform bill could become a paradigm for states to emulate nationally. The bill is a means to get out from under perpetual MCO (ACO-HMO) Medicaid cost inflation and profiteering through hidden upcoding, fixing high prices, and rationing of care scams. The other bills might also be paradigms for action in other states.

FMA Medicaid Reform bill, HF 1984.

Background. Perpetual cost-price inflation after 1965 only faltered once—from 2004 to 2009 inexpensive HSA-HDHP insurance competition resulted in expensive HMO insurance carriers peddling (the much idolized) “full coverage” were failing despite the power to ration care. That episode and Greg Scandlen’s thoughtful essay on HSAs for Medicare,^[[21]] stimulated my interest in developing the HSA-like FMA Medicaid Reform program championed by Rep. Glenn Gruenhagen.

Rationing Care. Rationing of care access to control costs began in both private and public sector medicine in 1973. The HMO Act of 1973 gave HMOs the perverse power to control the benefits they insure^[[22]]—something illegal for all other casualty insurance companies. HMO Corporate power to ration care for cost control was created because of the post 1965 onset of “7%” demand inflation.^[[23]] Inflation had arrived abruptly for the first time in 90 years after 1965,^[[24]] when 85% of the population ended up on welfare funded by tax-subsidized medical insurance (employed workers in 1942 and the official old, poor, and disabled after 1965.) Care appeared “free” because “the boss [government] paid for it”. Most all of us are on welfare.

Profit-driven rationing of care to balance fixed corporate budgets has failed to control costs and yet rationing has been the only means considered for cost control for near 50 years! Hidden profit-driven rationing (profiteering) may now include bedside clinicians; this is a danger to patients, the medical profession’s covenant of exclusive loyalty to patients, and the public weal,^[[25],[26]] not loyalty to the state, corporations, or cartels.

Ethical Failure. It remains the moral/ethical failure of US politicians, who outsourced to commercial corporations the job of profit-driven rationing of care to fix the problem of demand inflation that the politicians themselves created. The cost of underserving patients (underutilization; queuing) follows in both non-profit NHSs abroad (Canada)^[[27]] and in mercenary corporate rationing of care in the US. The politically created MCO industry commercial medical market place is where caveat emptor rules; populations of government and HMO corporations (“payers”) are auctioned to “providers” for servicing.^[[28],[29]] The nation’s and individual’s cost has been high, when the politically created cost inflation “fix” is outsourced to legalized collusive crony (politically favored) corporate cartel cost control police.^{2,10, 11,12,14,17}

Microeconomic Sectors. The nation must act on an alternative to the commercial medical market place driven by caveat emptor. Buyer beware is condoned for commercial market places where goods and services are bought and sold. These are private microeconomic sectors where millions of transactions take place daily between millions of people with different goals works better than any managed microeconomic sector.^[[30]]

The medical microeconomic sector is different from a commercial; it deal deals with human life and death not commodities or “populations” auctioned by 3^rd parties for servicing.^28,29 The professional market place is where patients were protected through a > 2000-year covenant of exclusive loyalty to the patient backed by over 100 years of State Medical Practice Statutes. The professional marketplace was displaced by the politically created commercial after 1973 that condones profit-driven rationing of care. Both 1973 federal²² and 1973 MN^[[31]] HMO Acts overwrite state laws prohibiting referral fees (aka, splitting fees) through controlling the use of insured benefits. The result is medicine’s multiple commercial dystopias that threaten patients, the medical profession’s covenant of exclusive patient loyalty, and our nation’s ethical integrity, while additional hidden profiteering from upcoding and high price-fixing threatens the nation’s financial integrity.

FMA Bill. Until patients, not government or corporate bureaucrats, are again king in the medical marketplace, the nation will suffer from queuing that transfers the cost of care to patients through lost wages, morbidity and even mortality.²⁷ Instead of American families controlling their own medical budget, the state now controls a nationalized budget of taxed dollars; nationalized budgets create crony cartels rationing care: NHSs abroad (Canadian or UK style) or more in the USA, crony corporate health service (CHS) big box “Medical Home” (ACO-HMO). If not changed, this US system of crony cartels will continue to impoverish the nation financially and the medical sector ethically.

The FMA bill represents an alternative to costly HMO rationing of Medicaid patient care—3^rd parties are eliminated when patients have cash (on a debit card) for mundane OP care expenses. “Ownership of resources is the path to a decent life free of poverty and dependency: a goal for all Americans.”[32]

Conclusion. The insanity of 3^rd party rationing care police and profiteering scams^{[10,13,14,15,16,18,21]} can be fixed.

The FMA Medicaid Reform bill is a fix for Medicaid enrollees: they would control use of the money for onsite payment of mundane OP care expenses; this eliminates unnecessary 3^rd party expense.

If medical account programs work when unfettered in private sector markets, why not in the public sector too?

RWG 2-12-22

[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.

[2] 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

[3]. Kennedy JV. Introduction ix, and Chap. 7, Affordable health care: In: Ending Poverty. Rowan & Littlefield Publishers Inc. Lanham, MD. 2008

[4] McCue M. Financial Performance of Health Plans in Medicaid Managed Care Mike McCue, https://www.cms.gov/mmrr/Downloads/MMRR2012_002_02_A07.pdf [see Exhibit 1]

[5] Beck M. Connecticut Moves Away From Private Insurers to Administer Medicaid Program. file:///C:/Users/Geist/Documents/Connecticut%20Moves%20Away%20From%20Private%20Insurers%20to%20Administer%20Medicaid%20Program%20-%20WSJ%202016.html

[6] A Précis of the Connecticut Medicaid Program. http://www.ct.gov/dss/lib/dss/powerpoint/MAPOC101014.pdf [see p. 1]

[7] The Minnesota Health Care Access Commission Final Report to the Legislature. https://www.leg.state.mn.us/docs/pre2003/mandated/910163.pdf [MN HCAC report 1991 Medicaid overhead p.78]

[8] Dublois H, Ingram J. Ineligible Medicaid enrollees are costing taxpayers billions.| January 23rd, 2022

https://thefga.org/paper/ineligible-medicaid-enrollees-costing-taxpayers-billions/

[9] Brill J. Competition in health care markets. Keynote Address, Federal Trade Commission Hal White Antitrust Conference, Washington, D.C., Jun 9, 2014. Available at: https://www.ftc.gov/system/files/documents/public_statements/314861/140609halwhite.pdf.

[10] Geist RW. ACO Kickbacks in the News and Gatekeeping in the Courts. J Am Phys Surg 2019;24(3):90-91. Accessed 9-1-19. Available at https://www.jpands.org/vol24no3/geist.pdf

[11] 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

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

[13] Powsner S. “Manufacturing vs. Repair” in Health Care. JAMA. 2005;294:2580.

[14] 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

[15] Kasprak J. RE: Texas HMO Liability Lawsuit; October 1, 1998 98-R-1185

https://www.cga.ct.gov/PS98/rpt%5Colr%5Chtm/98-R-1185.htm

[16] Geist RW. Pegram v. Herdrich. A recent U.S. Supreme Court decision threatens patients and physicians. Minnesota Medicine 2002;85(7):6,58-59.

[17] Verma S. Pathways To Success: A New Start For Medicare’s Accountable Care Organizations. Health Affairs Blog, August 9, 2018. https://www.healthaffairs.org/do/10.1377/hblog20180809.12285/full/.

[18] FTC 67026 Federal Register / Vol. 76, No. 209 / Friday, October 28, 2011 / Notices

[19] CMS 67992 Federal Register / Vol. 76, No. 212 / Wednesday, November 2, 2011 / rules and Regulations

[20] 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

 

[21] Scandlen G. Bringing health saving account to Medicare. CHCC, 9-28-05; http://www.cahi.org/cahi_contents/consumerinfo/pdf/chccHSAmedicare.pdf [This file is no longer available on line—ask me if you want a reprint.]

[22] HMO Act of 1973. US Code chapter 42 sec. 300e (b) (1,2,3,4,5) and (c) 2D. http://www.harp.org/300e.htm#a {accessed 11-23-15). [“incentives”]

[23] 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. The Brookings Institution; Washington D.C.;1982:442-446 and 477-488.

[24] Anderson OW. Part One, Chap. V. The mixing of the private and public sectors. In: Health Care: Can There Be Equity? New York: John Wiley & Sons, 1972:70.

[25] Sulmasy DP. What is an oath and why should a physician swear one? Theor Med Bioeth. 1999;20:329-346.

[26] Sulmasy DL, Bloche G, Mitchell JM, Hadley J. Physicians’ Ethical Beliefs About Cost-Control Arrangements. Arch Intern Med. 2000; 160:649-657.

[27] Danzon, Patricia, M. “Hidden Overhead Costs: Is Canada’s System Really Less Expensive?” Health Affairs. 1992;11(1):21-43.

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

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

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

[31] Mn HMO Act 1973: 62D.12 subd.9(c).

[32]. Kennedy JV. Introduction ix, and Chap. 7, Affordable health care: In: Ending Poverty. Rowan & Littlefield Publishers Inc. Lanham, MD. 2008.