This MPPA Meeting (in its 25th year) was held, Wednesday, June 8, 2022, at 6 PM on Zoom with a few in-person volunteers; an attempt to see if a Hybrid-Zoom meeting would work in the future. There were glitches (a real nightmare at times) using the computer at the Shoreview Community Center. I hope these will be worked-out before the meeting this fall in October.
Present were Robert Geist MD, Robert Koshnick MD, Wayne Zuehlke CPA, Marie Casey Olseth MD, Peter Nelson JD. Dave Feinwachs JD/PhD, Lee Beecher MD, Dave Racer MLitt, guest speaker John Diehl JD, Darrin Rosha JD, and Scott Jensen MD.
- A total of twenty-six replied, 12 attended; there were numerous last-minute cancelations.
- 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 and Fixing Medicine’s Dystopias.
- Gubernatorial Candidate Discussion. We had a discussion with MPPA fellow Scott Jensen. He joined us via Zoom from his campaign trail. Our key issues might be medicine, but all agreed that this time it is not true of the electorate.
Our able discussion leaders, Peter Nelson, Dave Feinwachs, and Dave Racer, agreed with Scott that voters primary concerns are inflation safety, abortion, and crime—medicine comes in 3rd or 4th.
Scott agreed that Medicaid enrollees using the FFS system might work, that some sort of new MN risk pool for the uninsurable was needed [the MN successful MCHA program was destroyed by Obamacare–rwg]. Scott also discussed the mistakes made by state and fed in addressing the covid-19 pandemic and in particular his personal investigation by the Board of Medical Practice. He doubted the veracity of various state and federal dictates and means of counting co-19 illness and mortality. [It was common for government policy makers and party hacks to persecute those, who dissented from federal and state dictates and machinations; our MN Board should not have participated in such an obvious political assault. Indeed, The MN Board never charged Scott. He was in time exonerated as results of faulty government “science” and policies became evident—rwg].
Scott also discussed the merit of American family access to Direct Primary Care, the inflated cost of Medicaid that ought to be subject to an independent audit, and the oppressive regulations governing medicine.
A UMN regent noted his concern regarding loss of MN clinicians to other states compared to the numbers of those coming to MN from elsewhere.
Discussion leader Dave Racer, briefly reviewed Scott’s gubernatorial campaign, thanked him for graciously sharing his limited time with us, and wished him good luck on the campaign trail.
- November Election Speculations.
Bob Geist first reviewed the published speculations of retired Stanford CA Professor, Victor Davis Hanson (VDH). Hanson thinks that the party campaigns will be heavily influenced by their internal schisms.
For example, the Democrats will make spectacles of being “centrists” and talking “tough on crime.” The Left is now a “reactionary schism: Confederate in its racial obsessions, separatism, worship of bicoastal monopolies of big money, and “nullification of federal (immigration) law.” [This is scary. The news media reports that our wide-open border has overwhelmed security forces not only by unprecedented large numbers (representing dozens of nations and not confined to tropical America) but are faced with many drug smugglers, “coyotes,” gang members, criminals formerly expelled, and have found a number of terrorists. Meanwhile, the administration and congressional House democrats are being accused of totalitarian-like persecution of former presidential advisors and even congressional members of the republican party—rwg.]
VDH notes that the Republican party schism has “transmogrified into the upper middle-class small businessperson, the middle-class working men and women, and the lower middle-classes emerging out of subsidization.” Why? Because the new party members “did not really need capital gains cuts but did need tax cuts and were less in need of government free money. They had no intrinsic reason to think whites were their enemies.” Most candidates will be running on MAGA and ecumenical middle-class policies. “The Right is now in radical schism in its casting off traditions and conformity, through questioning every past cannon of Republican governance, “as it absorbs minorities and middle-class whites, who the clueless new-left Democrats despised and drove away.”
Our discussion leaders, ably led by Peter Nelson, Dave Racer, and Dave Feinwachs, noted that recent voter uprisings against VA democrats as they voted into office a Republican, as well as school boards and lawless AGs in some CA cities. Might moderate progressives’ campaign efforts wake up Republican campaigns? In MN, they thought that the 2-party’s electoral popularity made the local election too close to call, albeit this may not be the Democrats year. A curiosity mentioned was that the MN Med Assoc is taking a position regarding the SCOTUS threat to the existence of the old Roe v Wade decision. Election integrity was thought to be a potential genuine issue.
- John Diehl, JD, gave us an eloquent review of his book, Medicine! To Make Our Health Care System Well–The Origin, Evolution and Future of the American Health Care System.
The system emerged over 100 years ago with the scientific method, was loosely organized, later exploded in specialization, and the public interest was assured by professional ethics. The broadest strokes were the 1948 Hill-Burton Act (it funded a massive expansion of medicine’s facilities), and 1965 Medicare and Medicaid insurance coverage of the old and indigent. [I have mostly used John’s slides for paraphrasing these minutes, because I was unable to show his slides—on of the meeting glitches. He did a remarkable and excellent off the cuff presentation in 20 minutes! The highlight emphases are his—rwg.]
The financing mechanism soon developed as the center of attention. The doctor was the clinical decision-maker; the expansion of insurance meant that the patient had to agree but had only a very indirect connection between the decision to consume and the amount paid. Thus, there were no moderating economic forces in the medical care transaction. The “insurers” prices (premiums) were driven almost entirely by medical care consumption and were out of its control. An insurer’s only recourse was underwriting, benefit limits and exclusions of certain services; these tools were ineffective (especially in light of statutory benefit mandates). Added possible fraud and abuse resulted in medical system inflation. Attempts at management have resulted in massive system costs.
One private model developed in the 1920’s was the prepaid group practice
model [for Kaiser dam workers—rwg.] In the late 1960’s this model was seized upon as the solution. It transitioned to a more generic managed care model. The financing agents required [and acquired—rwg] enormous political power. This model exploded after 1975. By 1985 the concept had evolved from “prepaid health care” to “managed care;” in the 1990’s this was the dominant model. Subsequently, Medicaid and now Medicare have moved to adopt this model. Diehl discussed various aspects of the system: accessibility, quality, altruism, choices, privacy, and patient/physician autonomy. “SOME OF THESE ELEMENTS ARE VIRTUALLY NONEXISTENT; ALL ARE AT LEAST AT RISK.” [author’s emphasis—rwg.]
Diehl enumerated the many issues involved (including Stark anti-referral collusion law, fraud, tort, licensure, ethics, anti-trust, and so forth) and the pervasive electronic access and communications. These create easy access, but their enormous value in data presents a constant serious threat.
The GOOD NEWS: Quality and Individual Autonomy are strong. Thanks to Hill-Burton and the “Critical Access Hospital” concept, there is good geographic accessibility of service locations. Improvement is needed in: Financial accessibility (surprisingly); in timely availability; Altruism; Choices; and Information privacy.
There might also be unwelcome news: We have now finalized the establishment of one, monolithic system with: a tight hold on providers’ participation; burdensome regulation and expensive capital-intense operational requirements; absurd, monolithic payment regimes; no underwriting; high premiums and burdensome, costly “risk adjustment;” and fragmented, disorganized, payment-oriented care.
Remedies? He thought: an improved financing system is necessary–broaden types of permitted financing by adding cash, episodic debt, and “catastrophic” insurance; retain broad array of mandated benefits/coverage; retain “insurance” price regulation through loss-ratio regulation; return to underwriting . . . with a twist (regulation of underwriting standards to assure fair competition and fair treatment of customers); adopt the “risk pool” methodology; and a premium safety net to assure affordable coverage and more stable risk. He noted the shortage of qualified personnel, the need to expand the supply of physicians, to expand “team” model accountable to a physician, physician accountability for system performance, no payment for limiting/rationing care, and no compensation for historically voluntary system/patients’ support.
He continued to advocate reducing barriers for qualified professionals to engage in
private practice (support; regulatory relief) in the entire range of models; barriers to participation in financing arrangements; and regulatory operating burdens.
He advocated: establishing safeguards against anti-competitive forces in reimbursement and access by patients; the right of privacy; the ethical duty of confidentiality; and a fundamental constructive doctor-patient relationship. HIPAA should revert to its original terms: a patient authorization for any release or external use. There ought to be a private right of action, minimum scheduled damages, plus attorneys’ fees for any improper use/disclosure. We ought to establish a system of data collection, “cleansing,” and storage to provide de-identified data for research, underwriting, planning, ad actuarial use.
In the open discussion period, Diehl was asked about the problem that corporations are our masters. He agreed and went on to elaborate what he thought were some of the problems of pre 1970s medicine, namely access, public accountability, and quality as well as the problem created by development of large group practices. He thought return of power to patients and small group practices a good goal. One person noted that the “system” had dumbed down to 19th century apprenticeship models creating distrust in the system when the ‘team’ member is unidentified. He wants to see an MD for care.
John Diehl gave us a comprehensive view of medicine’s various evolutions in its many complex aspects. One may not agree with all his opinions for fixing these various dystopias from which we all suffer, but he deserves accolades for a job well done! I look forward to reading the final edition of this excellent book—I am grateful that I have had the chance to read an early version.
- The agenda for an October meeting and date are pending.
- Before opening to the public, the new website needs additional re-formatting and the addition of various publications by members. I hope it will be ready this summer.
The meeting adjourned at 8 PM.
Robert W. Geist MD, secretary pro tem
651-485-5933 [c] email@example.com
June 24, 2022