November/December - Health Care Reform

Nov/December 2015

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

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NICOTINE

MORE HARMFUL THAN YOU THINK

NO AMOUNT IS SAFE FOR YOUTH

It’s highly addictive.

It harms fetal health during pregnancy.

It may harm adolescent brain development.

IT’S TOXIC IN HIGH DOSES • E-cigarettes and e-liquids contain nicotine.

• Kids are ingesting e-liquids left unattended.

• Poisonings are up for 0-5 year olds in MN.

80

E-cigarette Poisonings

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TAKE STEPS TO PROTECT YOUTH www Keep harmful products out of reach.

Call 1-800-222-1222 for Learn more online at poison emergencies. health.mn.gov/nicotine.

CONTENTS VOLUME 17, NO.6

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NOVEMBER/DECEMBER 2015

IN THIS ISSUE

How Do We Fix Our Flawed Health Care System?

By Robert R. Neal, Jr., M.D.

4

PRESIDENT’S MESSAGE

Reflections

By Kenneth N. Kephart, M.D.

5

TCMS IN ACTION

By Sue Schettle, CEO

Page 32

Page 25

Page 5

6

HEALTH CARE REFORM

•

Single Payer Systems Around the World

By Lynn A. Blewett, Ph.D.

9

•

Why the ACA is Good for Minnesota and America

By Congresswoman Betty McCollum

11

•

A Health Care System that Works for Patients

By Congressman Erik Paulsen

13

•

Colleague Interview: A Conversation with Stephen T. Parente, Ph.D., MPH, MS

16

•

Single Payer Momentum Builds with PNHP

By Dave Dvorak, M.D., MPH

18

•

The Patient—Honoring Choices

By Dave Racer, MLitt and Lee Beecher, M.D., DLFAPA, FASAM

20

•

Health Care Reform in Minnesota: Progress, Problems and Possibilities

By Tyler Winkelman, M.D.

23

•

What is Single Payer and Why Should Obstetrician-Gynecologists Care?

By Carrie Ann Terrell, M.D., FACOG

25

•

Understanding MNsure Today

By Kathryn Duevel, M.D.

27

•

Competitive Bidding for State Managed Care Contracts Benefits Patients, Taxpayers

By Nathan Moracco, Assistant Commissioner

29 30

In Memoriam New Members Career Opportunities

32

LUMINARY OF TWIN CITIES MEDICINE

Frank J. Indihar, M.D.

Page 5 MetroDoctors

The Journal of the Twin Cities Medical Society

On the Cover: Health Care Reform — a challenging topic with much passion on all sides of the issue. Articles begin on page 6.

November/December 2015

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Andrea Westmoreland MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

November/December Index to Advertisers TCMS Officers

President: Kenneth N. Kephart, M.D. President-elect: Carolyn McClain, M.D. Secretary: Thomas E. Kottke, M.D. Treasurer: Matthew Hunt, M.D. Past President: Lisa R. Mattson, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Emily Johnson, Marketing and Communications Coordinator (612) 623-2885 ejohnson@metrodoctors.com Ellie Parker, Project Coordinator Physician Advocacy Network (612) 362-3706 eparker@metrodoctors.com Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704 kpeterson@metrodoctors.com

Allina Health.......................................................31 American Lung Association ................................

Inside Front Cover Coldwell Banker Burnet..................................14 Crutchfield Dermatology.................................. 2 Dermatology Consultants....................................

Outside Back Cover Entira Family Clinics .......................................30 Fairview Health Services .................................31 Healthcare Billing Resources, Inc. ...............10 Lakeview Clinic .................................................31 PrairieCare PAL .................................................22 Saint Therese.......................................................10 Senior LinkAge Line........................................... 8 St. Cloud VA Medical Center ............................

Inside Back Cover St. David Center ................................................12 Uptown Dermatology & SkinSpa................28

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For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.

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November/December 2015

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The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

How Do We Fix Our Flawed Health Care System?

I

n this issue of MetroDoctors, we have asked for articles on improving our health care delivery system. Our intention is not to promote any particular models, but rather to educate and to stimulate discussion as we move toward solving a growing health care problem in this country. Here in the Twin Cities we are blessed with health care as good as anywhere in the world. Unfortunately, despite the fact that we spend 2X the amount per capita as other comparable countries, our national health care delivery and outcomes are below most other developed countries according to a 2014 Commonwealth Fund study of international health care systems. These ratings are based on quality, efficiency, access, equity and healthy people. The United States was rated last out of the 11 countries studied, and the UK was first. The U.S. spends 16.9 percent of GDP on health care or $8,745/capita, while the UK spends 9.3 percent of GDP or $3,289/capita. The U.S. has problems other than cost — we still have 10 percent of our population or about 32 million people uninsured and our life expectancy is shorter than most comparable countries. It is imperative that we come together to overhaul our system.

Our fist article by Lynn Blewitt nicely outlines the health care systems of several major countries. These health care models should provide useful ideas for health care reform in this country. We asked two of our local congressional representatives, Betty McCollum, DFL, and Erik Paulsen, GOP, to provide their perspectives on the health care problem. Our colleague interview is with Stephen Parente, Ph.D, a health care economist who is Health Finance Chair at the Carlson School of Management at the University of Minnesota. His comments include the difficulty in measuring the quality of health care management and the benefits of health care services, payer mechanisms, and health care disparity. Several articles describe a single payer system. David Dvorak, M.D., from the Physicians for National Healthcare Program (PNHP) advocates a Medicare for all program. The article by Carrie Terrell, M.D., from the University of Minnesota, relates how a single payer system would work ideally in an OB-Gyn setting, while an article co-authored by David Racer and Lee Beecher, M.D.

By Robert R. Neal, Jr., M.D. Member, MetroDoctors Editorial Board

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The Journal of the Twin Cities Medical Society

advocates against a single payer system and emphasizes patient choices.

Tyler Winkelman, M.D., a TCMS policy committee member who is now doing a fellowship at the Robert Wood Johnson scholarship program at the University of Michigan, provides an article outlining Minnesota’s health care reform experience and its problems and future possibilities. The editors had hoped to provide some discussion of a national health care reform plan that that would reform the ACA utilizing the private sector, but, it seems, that it’s not the time politically for one to surface.

We have a good article updating the MNsure program by Kathryn Duevel, M.D. Included is information on the MN Healthcare Financing Task Force, the future of MNsure and its financing. It is rewarding to note that over 500,000 Minnesotans have obtained health insurance coverage through MNsure. We asked the MN Department of Human Services for a discussion of state managed health care contracts. Assistant Commissioner Nathan Morocco provides a good discussion of how competitive bidding has progressed since it was put into law in 2011. Specific issues raised by individual counties are discussed as well as quality of care improvements. Marv Segal provides another excellent Luminary story featuring Frank Indihar, M.D. Many of our articles deal with payment/insurance reform which is only part of health care reform. Reform must also address patient care issues like better outcomes, more individual patient responsibility, safer care, less hospitalization, efficiency of the health care team and the two biggies: promoting better nutrition and regular exercise. Integration of providers was covered nicely in our May-June 2015 issue on Chronic Diseases.

Hopefully, after the next election, bipartisan support can produce a modified ACA or an alternative that will provide good health care for all Americans.

November/December 2015

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President’s Message

Reflections KENNETH N. KEPHART, M.D.

THIS ISSUE OF METRO DOCTORS FOCUSES ON HEALTH CARE REFORM. I don’t know

exactly what the rest of the journal articles say about reform but here is my two cents worth. The major area of wasted money, in my opinion, is going to the many insurance companies that fight for market share, complicate and add unnecessary expense to our business offices and confuse patients. I believe we could simplify things and save about 10-15 percent of total health care dollars going to administration of the many different plans by reducing plan types to three or four different ones modeled after the current bronze, silver, gold plans offered in the exchange. We would still have multiple payers like now, federal [Medicare/Medicaid], state [Medicaid/MinnesotaCare], employers, and individual self-coverage. I would keep the individual mandate but drop the employer mandate and encourage employers with tax breaks to continue to make defined contributions for employees to purchase their insurance on the exchange.

On the health care delivery side, I favor competition and a level playing field that allows independent groups to fairly compete on cost and quality with equal pay for equal services. To safely risk share they need to be allowed to participate in networks or ACOs. The elephant in the room is the hospital. Hospitals are quickly moving from a profit [or margin] center to an expense center. Much of the work they used to do can now be done more efficiently and with equal quality outside the hospital. Currently to “feed the beast” hospitals, having purchased primary care and specialty practices, are now focusing on “leakage” which is another way of saying you shouldn’t refer patients outside your system. This becomes problematic for us when best care of patient may not be in our system. Like I said at the beginning this is just my two cents worth and that may be all it’s worth.

This is my last President’s message article. I have enjoyed having the opportunity to share my thoughts. I feel it has been a good, productive year for TCMS, not due to me in particular but to the excellent leadership of our CEO Sue Schettle and her talented staff along with the many individual contributions of you, our members. Early in the year the board reviewed our Strategic Plan. The board felt we needed to continue our long-standing work on improving the health of our community with our Honoring Choices ACP program and our E-Cig education initiative. We also added decreasing health care disparity in children age 0-5 as a new initiative. There may be potential opportunity to partner with Minneapolis Mayor Betsy Hodges’ initiative, Cradle to K Cabinet. We will be exploring that in the coming year. I won’t elaborate on all the activities in our Honoring Choices Minnesota, advance care planning program, please go to its website: honoringchoices.org to see them for yourself. One accomplishment however does deserve special mention. Through the leadership of Sue and our legislative lobbyist, Messerli and Kramer, we did introduce a bill to fund expansion of ACP planning to outstate communities. We were successful in getting a bill passed authorizing the Minnesota Department of Health to fund a two-year grant for a program like ours to provide technical assistance to outstate communities who want to establish ACP programs in their communities. As we go to press we are awaiting news as to whether we received this grant. We are beginning talks with the Minnesota Hospital Association to collaborate with them as we go outstate with this program. Another notable activity was sponsoring the Healthiest State Summit, reclaiming Minnesota’s #1 health ranking. Nancy Bauer, our long-time managing editor of this journal, was the one who suggested this after a report by America’s Health Rankings (https://www.apha.org/ publications-and-periodicals/reports-and-issue-briefs/americas-health-rankings) described us as slipping to number six. Find the proceedings of this summit on our website: www.metrodoctors.com.

Lastly, I want to address my biggest concern for the future — physician membership. Our numbers continue to decline. I understand some of the reasons. I am at a loss as to solutions. I know I am preaching to the choir if you are reading this but please do two things: 1. Think of one idea to improve our value to members and send it to us; 2. Contact one colleague who is not a member and ask them to join. Thank you.

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November/December 2015

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

MMA Annual Conference

Several TCMS physicians played a key role in the recent MMA Annual Conference.

Passing the President’s Medallion was outgoing President Donald Jacobs, M.D. (right) to incoming President Dave Thorson, M.D. (left). Ken Kephart, M.D. served as moderator for the breakout session on “End-of-Life Issues” and Laurie Drill-Mellum, M.D., MPH, was the featured speaker on “Who Heals the Healer? Resiliency Building Tips for Those Who Care for Others.”

TCMS Executive Committee

Work continues on finalizing the details of the five-year strategic plan with approval by the TCMS board slated for November. Specific areas of focus include: Public and Community Health (specifically health equity and health disparities that affect children); Public Policy Advocacy and Physician Advocacy (with a more focused emphasis on wellness).

The Nominating Committee will be presenting a slate of candidates for the TCMS Board of Directors at the November 2015 meeting. A lot of interest has been expressed by medical students in joining our committees and taskforces in addition to the Board of Directors.

Healthiest State Summit

The final report of the proceedings of the Healthiest State Summit is available and can be downloaded from the TCMS website, www.metrodoctors. com. Contact Nancy Bauer at nbauer@

MetroDoctors

metrodoctors.com if you would like to receive a paper copy.

TCMS Foundation

The fall meeting of the TCMS Foundation was held on September 16. One of the unique functions of the Board is the annual selection of the Charles Bolles Bolles-Rogers Award recipient.

David Dries, M.D., a surgeon, trauma and critical care specialist and researcher at Regions Hospital was selected. Dr. Dries will be officially recognized with the award at a meeting of the Regions Hospital Medical Staff in November.

Congratulations to Medical Student Matthew P. Donoghue, recipient of the TCMSF Scholarship Award (formerly Thomas P. Cook Scholarship). This award is administered through the University of Minnesota Foundation.

Senior Physicians Association

Two meetings of the Senior Physicians Association were held this fall. On September 15 Lynn Blewett, Ph.D., provided an informative presentation on “Health Reform — Comparing the U.S. to Other Countries,” and on October 20, Dimple Patel, M.S. spoke on the U of M Medical School Admission Process.

Physician Advocacy Network (PAN)

Ellie Parker, Physician Advocacy Network (PAN) program coordinator, continues her work providing education throughout the state on E-Cigarettes and other tobacco products, training nearly 400 physicians and health care providers to date. Drs. Stuart Hanson, Peter Dehnel and Richard Woellner have assisted her in several of these trainings.

In addition she is supervising a study of U of M medical students to assess their attitudes, beliefs and knowledge about

The Journal of the Twin Cities Medical Society

e-cigs. Results will be used when considering future curriculum. This study, which is the first of its kind in the U.S., is a collaboration between the UMN Medical School and TCMS. Please connect with Ellie if you have an interest in becoming trained on e-cig advocacy or if you are interested in local policy work related to e-cigarettes and other new tobacco. eparker@metrodoctors.com.

Honoring Choices Minnesota

Honoring Choices Minnesota continues to expand with 12 states now licensing the name and educating their communities on advance care planning.

I am pleased to announce a couple of staffing changes. Karen Peterson has been promoted from Director of Program Operations to Executive Director, and Barbara Greene is changing her status from a full-time employee to an on-call consultant, continuing to work on multicultural outreach activities. At the time I am writing this we are also hopeful that we will receive a grant to support two additional staff members who will help us to expand the ACP reach throughout Minnesota. Look for two new faces to appear in the next issue of MetroDoctors (fingers crossed).

This Thanksgiving, remember to take time to “Have the Conversation.”

November/December 2015

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Health Care Reform

Single Payer Systems Around the World

T

he term “single payer” often gets a bad rap for being a form of strictly-defined socialized medicine.

But there are many variations of single payer health care each with a different mix of public and private financing leading to a more fluid definition of single payer. Socialized medicine is one variation of single payer where both the financing and health care delivery system are publicly organized and financed. England’s National Health Service is the closest to a single payer system but even then, there is a growing role for supplementary private insurance. In this article I present an overview of four types of government-organized health care systems, the U.S. health care system and comment on the role of public and private finance components. I include a discussion of Vermont’s efforts to design and implement a single payer system and the reasons for its recent retreat. I highlight the pros and cons of a single payer system and convey that there are many variations of the single payer financing model and different paths to universal coverage.

What is a Single Payer System?

Single payer health care systems are noted by the concentration of public financing at the federal level. Funds are generated by general income and other taxes, and private insurance is limited. Under a single payer system, providers can be either public or private as well as profit or notfor-profit. There is a core set of benefits that are guaranteed, but not all benefits are covered (e.g. dental, vision, and alternative medicine). Universal coverage is a

By Lynn A. Blewett, Ph.D.

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November/December 2015

core principle in single payer systems, and out-of-pocket costs are strictly limited.

Patients are often able to select their own primary care provider, but there is often a gatekeeper for specialists and tertiary care.

Universal Coverage Models Across the Globe

I present here four types of universal coverage models often thought of as single payer: Canada, England, Norway and Germany. All models include a dominate role for the government, both in collecting revenue to finance the health care system and in organizing and paying providers.

Yet each system varies by the role public sector financing and supplemental private financing. Even in England, with the most single “payerness,” the public sector finances just 84 percent of total health care spending. Information presented here is based on these systems and comes from the Commonwealth Fund’s 2014 International Profiles of Health Care System.1

The first universal coverage model is England’s National Health Services (NHS). The NHS is funded by general tax revenue with employment-related insurance contributions (a payroll tax), provides universal coverage and free care at point of service. The NHS pays the salaries of medical providers who are considered government employees. An estimated 11 percent of the population purchase supplemental private coverage for better access to care. Even with its single payer model, public financing accounted for 84 percent of health spending with the remaining financed by out-of-pocket spending and supplemental private insurance. Health care spending accounted for 9.3 percent of the GDP in 2012 representing $3,289 per capita.

The second model is Canada’s health care system, which offers publicly-sponsored comprehensive insurance delivered by private providers. The system is financed by general tax revenue and sales taxes. Funding is allocated to the 10 provinces and three territories that insure its residents, negotiate provider’s fees and hospital global budgets, and pay for services. Three provinces (British Columbia, Alberta and Ontario) charge an additional monthly premium. Public financing makes up an estimated 70 percent of total health expenditures in 2012. An estimated 30 percent comes from supplemental insurance policies often sponsored by employers. In 2012, health care spending accounted for 10.9 percent of the GDP representing $4,602 per capita.

The third system is the German social insurance model. This model is organized by the federal government but

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fully financed through mandated employer and employee contributions. Individuals must join one of the 131 competing “sickness funds” or health insurance pools that negotiate with regional provider associations for provider fees and reimbursement rates. The federal government sets rules for financing and contribution rates and subsidizes insurance for the unemployed.

Employers must participate in the health system and all citizens are required to sign up for coverage. Those who can afford it, about 11 percent of the population, are able to opt out and purchase comparable private coverage. In 2012, health care spending accounted for 11.3 percent of the GDP, representing $4,811 per capita.

Norway’s National Health Care system is a national health care system organized and financed at the federal level through general tax revenue. Funding is allocated to Regional Health Authorities and municipalities who organize the service delivery system. The 428 municipalities are responsible for providing primary care and coverage is universal. An estimated 7 percent purchase additional private insurance generally purchased by their employer to increase access to care. Public financing makes up 85 percent of 2013 expenditures and in 2012, health care spending accounted for 9.3 percent of the GDP representing $6,140 per capita.2 U.S. Health Care System

The U.S. is the only high-income country that does not provide universal health care.

The U.S. has a multi-payer health care system with a mix of public and private programs. In 2013, 54 percent of Americans were covered by private plans (either employer-sponsored plans or purchased in the individual market); 31 percent were enrolled in public programs (primarily Medicaid and Medicare); and the remaining 16 percent were uninsured.3 Interestingly, the mix of public and private financing is more evenly distributed with the private sector paying 52 percent of health care spending and the public contributing 48 percent. In 2012, total health care spending accounted for 16.9 percent of the GDP representing $8,745 per capita.

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Update on Vermont’s Single Payer Proposal

The state of Vermont has considered adopting a state-based single payer health care system, Vermont’s Green Mountain Care. The plan was presented in 2010, when Peter Shumlin (D) campaigned on a single payer platform and was elected governor of Vermont. Legislation passed in the spring of 2011 with significant support within the state.4 Many in the health policy arena thought Vermont was one of the few states that could accomplish the adoption of a single payer model. This was partly due to the state’s size; at 626,000 residents, Vermont is a fairly low population state. Also, Vermont has one dominant private payer BCBS-VT and one of the lowest rates of uninsured in the country (8 percent in 2013). Finally, Vermont has a history of progressive social policies, voting patterns and political leadership, all which make the state a likely candidate for success.

The objective of Green Mountain Care was to provide comprehensive, affordable, high-quality, publicly-financed health care coverage for all Vermont residents regardless of income, assets, health status, or availability of other health coverage. The plan included financial incentives for residents to avoid preventable health conditions, promote health, and avoid unnecessary emergency room visits. The plan also included global payments to providers, population health strategies to improve health, and a reduction in administrative costs. The program was to be financed by new state and local taxes, federal funding through waiver from Medicaid and Medicare, and potential new funding through ACA subsidies.

However, despite the strong beginning, the Governor announced in 2015, that the single payer option would be placed on hold for the foreseeable future.

While several studies had been released over the past five years, the most recent study conducted by Governor Shumlin’s staff found that the model would increase taxes by 11.5 percent for employers and up to 9.5 percent for individuals. Not surprisingly, public support for Green Mountain

The Journal of the Twin Cities Medical Society

Care has deteriorated, with a recent poll finding just 40 percent in support, 39 percent in opposition and 21 percent undecided.5 Pros and Cons of a Single Payer System

Arguments can be made for and against a more concentrated government-centered health care system. On the pro side, a single payer model provides universal coverage and funding established through a broadbased and possibly fair general revenue tax. Also, a centralized system enhances the ability of the government to control costs through either global budgets like the Canadian system or through fee schedules that limit payments to providers. The government can also develop and implement systems to negotiate and set prices for prescription drugs and limit promotional advertising. Next, with only one payer and a streamlined financing system, there are limited administrative costs—-a substantial issue in the U.S. multi-payer system, with for-profit health care adding return to investors as another cost driver. Finally, all the developed countries including the ones reviewed here provide for universal coverage and access to needed care — something that a multi-payer system could do but, at least in the U.S., does not.

On the con side, it would be difficult to establish and collect the level of taxes required to support a publicly-funded single payer system in the U.S. In general, the citizens of the U.S. are typically not in favor of tax increases or expanded government control — something inherent in any single payer model. There is also some concern about a health care system funded entirely from taxes when the economy is facing a downturn, leaving less public revenue for publicly supported programs and more competition among publicly-funded programs for scarce public resources. This becomes an issue when the health care system must rely on decisions from legislative bodies and the complexities of the legislative budget process. In addition, the concern providers currently (Continued on page 8)

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Health Care Reform Single Payer Systems Around the World (Continued from page 7)

express regarding the low payment rates and bureaucracy of the Medicare and Medicaid programs would only increase under a single payer system.

Conclusion

Countries around the world each have a unique health care system and a distinct view of the role of government in providing health and social services. England has come closest to a true single payer model of central public financing of universal coverage. And while most of the high-income countries have a larger public role in the financing of health care than the U.S., they do vary along a scale of “single-payerness” and the growing role of private supplementary insurance. There are common components across systems, including how systems are financed, how providers are

paid, and the quality of care. Interestingly, most people believe their health system needs fundamental reform, which provides indication of how difficult it is to get it right when talking about something as personal as health care. And the limits of this article preclude me from comparing systems on quality and access measures.

The U.S. has embarked on health reform but has stopped short of universal coverage. But, given the flexibility provided in the Affordable Care Act for 2017, now might be the time for states, including Vermont, to think about new opportunities to expand coverage and new ways to finance care.

Lynn Blewett, Ph.D. is Professor of Health Policy at the University of Minnesota, School of Public Health, Division of Health Policy and Management. She is also Director of the State Health Access Data Assistance Center (SHADAC) a research and policy center focusing on access and coverage and

health care reform. Professor Blewett teaches Comparative International Health Systems at the School of Public Health. She can be reached at: blewe001@umn.edu.

Endnotes 1.

Mossialos, E., Wenzel, M., Osborn, R., & Anderson, C. (Eds.) “2014 International Profiles of Health Care Systems.” (2015). Accessed at http://www.commonwealthfund.org/~/media/ files/publications/fund-report/2015/jan/1802_ mossialos_intl_profiles_2014_v7.pdf?la=en.

2.

Glied, S. (2009). “Single Payer as a Financing Mechanism.” Journal of Health Politics, Policy and Law, 34 (4): 593-615.

3.

Kaiser Family Foundation, State Health Fact.

Health Insurance Coverage of the Total Population (2013). Available at: http://kff.org/other/ state-indicator/total-population/ Accessed September 25, 2015.

4.

Kliff, S. “Forget Obamacare: Vermont wants to bring single payer to America.” (2014). Accessed at http://www.vox.com/2014/4/9/5557696/ forget-obamacare-vermont-wants-to-bringsingle-payer-to-america.

5.

McDonough, J. “The Demise of Vermont’s Single-Payer Plan.” N Engl J Med 2015; 372:1584-1585 April 23, 2015DOI: 10.1056/ NEJMp1501050.

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Why the ACA is Good for Minnesota and America

T

he most important thing for Minnesotans to know about the Affordable Care Act (ACA) is that it is achieving its most important goal — helping to ensure more individuals have access to high-quality, affordable health insurance. I voted for the ACA and continue to support its implementation.

This law remains an important first step in transforming our health care system so that it works better for all Minnesota families. It is not perfect, but it provided a path forward to helping to ensure that our health care system serves the needs of all Americans.

During debate on the ACA, I worked with Minnesota doctors leading up to my vote in support of the ACA and continued to do so after it was passed in order to ensure that the law works to serve Minnesotans as effectively as possible.

Even before the ACA was enacted, Minnesota had one of the lowest uninsured rates in the nation. But the law has helped us reach even more individuals and ensure they have access to health coverage.

Since the ACA has been implemented, Minnesota has continued to see our uninsured rate continue to fall. In September, the U.S. Census Bureau reported that Minnesota had one of the lowest uninsured rates in the nation, only 5.9 percent.

Ensuring more Minnesotans have access to comprehensive health coverage is a great first step, but we still have work to do.

Too many Minnesotans are still unaware of all the consumer protections, coverage options, and resources provided to them under the ACA. As a health care

By Congresswoman Betty McCollum MetroDoctors

community and as a state, we must do a better job of reaching all Minnesota families to ensure everyone is aware of all tools, protections, and resources available through the ACA. Better outreach will help us continue to lower the number of uninsured Minnesotans even further — and make the ACA as successful as possible.

Additionally, we must do more to ensure that doctors are rewarded and not punished for providing high-quality health care to their patients. One thing that I heard from the medical community during the ACA debate was the need to fix Medicare’s geographic disparities. Under Medicare’s flawed reimbursement system, Minnesota doctors and health care providers are punished for providing highquality, efficient care. I remain committed to fixing this inequity so that Minnesota doctors are rewarded, not punished for the care they provide.

The ACA has been tremendously successful, but there is still more that we must do to ensure that our system of health care delivery works for everyone — from patients to providers. We must get health care costs under control, and there is no silver bullet or easy solution. I think a first step to bend the health care cost curve should start with a conversation about how we pay for health care. Starting with Medicare, we must transition away from paying for the quantity of care provided and instead reward physicians for delivering high-quality care.

Minnesota has always been a national leader on addressing this issue and I think the nation could learn from what we are doing to improve our state’s health care

The Journal of the Twin Cities Medical Society

system. A large credit for that success can be attributed to our willingness as a state to bring together all the various stakeholders for a collaborative and inclusive conversation. Both as a State Representative and in Congress, I have been able to bring different stakeholder groups — including physicians, nurses, physician assistants, hospitals, community health centers, mental health providers, and patient advocacy groups — to the table around a shared goal.

Hearing from all perspectives provides me with the information I need to understand the different impacts and helps ensure that we can reach our goal together.

The Minnesota medical community knows the successes and shortcomings of (Continued on page 10)

November/December 2015

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Health Care Reform

Saint Therese Rehab

Strengthening. Therapeutic. Results.

Why the ACA is Good for Minnesota (Continued from page 9)

our health care system as well as anyone.

They are working within this system every day and know what we can do to improve it. It is my hope that our doctors, as well as other health care providers in Minnesota, know that they are a valuable voice in our public policy discussion around health care. In order to further improve our system of care, we must have input from all sides at the table and the medical community is a valuable voice within that discussion.

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Congresswoman Betty McCollum is serving her eighth term in the U.S. House of Representatives, representing Minnesota’s Fourth District. Education, health care and investments in transportation infrastructure are her top policy priorities. She is a champion for universal health coverage for all Americans.

Rep. McCollum is a member of the House Appropriations Committee where she serves as the ranking Democrat on the Interior-Environment Subcommittee and as a member of the Defense Subcommittee.

Visit TCMS at www.metrodoctors.com

With just one click you will find information on the latest TCMS news, events and legislative issues; Board and committee actions; past issues of MetroDoctors; and new career opportunities!

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November/December 2015

MetroDoctors

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A Health Care System that Works for Patients

W

hen the President signed the Affordable Care Act into law, he promised that it would “lower costs for families and for businesses and for the federal government.” He said that the core principle he was striving for was that “everybody should have some basic security when it comes to their health care.” Unfortunately, the more we learn about the President’s health care law, the more the facts show that it’s hurting more people than it’s helping.

Instead of feeling secure, Minnesotans are concerned, upset, and confused. Instead of getting what the President promised, patients are paying more, losing access to the doctors they had and liked, and suffering from fewer health plan choices. Companies are being forced to scale back hours with more part-time jobs, and fewer full-time jobs. In the medical device industry, more than 39,000 jobs have been lost either from people being laid off or hiring being differed.

The health care law is also putting pressure on family doctors and health care systems to consolidate. In 2007, 60 percent of cardiology practices were physicianowned. In 2012 that number was down to 35 percent. There were more than 95 hospital mergers every year from 2012-2014.

In 2005, there were only 50 mergers and in 2006 there were just 56. More hospital mergers means fewer choices and higher prices for patients.

There are some good things in the health care law that enjoy bipartisan support. There is unanimous support for children being able to stay on their parent’s insurance until they turn 26. There is also broad bipartisan support for ensuring coverage for patients with pre-existing conditions and closing the Medicare donut hole. Unfortunately, these

By Congressman Erik Paulsen MetroDoctors

bright spots don’t change the fact that the health care law did not address the most pressing problem in our health care system: rising costs.

The reality is Americans needed real health care reform before President Obama signed his health care law — and they still do now. We need to work together in a bipartisan manner to create a health care system that protects the doctor-patient relationship, reduces costs, encourages quality, and ensures access for individuals, employees and families.

Congress showed this is possible last March when it permanently repealed the Sustainable Growth Rate. Doctors used to face the annual threat of a massive cut to payments for treating Medicare patients. Instead of coming up with a long-term solution, Congress usually enacted temporary patches and budget gimmicks that merely raised costs and increased the chance that seniors would lose access to the doctors they know and like. This time, we enacted a permanent solution that ends the uncertainty for doctors, rewards quality, and ensures Medicare is protected for future generations. This law is the first major entitlement reform in more than 20 years, proving that Republicans and

The Journal of the Twin Cities Medical Society

Democrats can come together to get important solutions passed.

We must continue to build off of this successful effort to achieve broader reforms for our health care system. There are four areas I am focusing on to improve quality of care, reduce costs, and create a system that works for everyone.

First, we need to address the real drivers of costs to our health care system — patients with multiple chronic conditions. Too often the debate about the future of Medicare is presented as the false choice of slashing benefits or cutting payments to doctors. Medicare in 2015 is very different than it was in 1965, as 68 percent of beneficiaries have two or more chronic conditions and they account for ninety-three percent of all Medicare costs.

According to the CDC, 75 percent of our nation’s health care dollars go to treat chronic diseases. This includes patients with diabetes, hypertension, heart disease, kidney disease, arthritis, Alzheimer’s and much more. Many of these patients have multiple doctors and specialists that they see and the care for all of these conditions overlaps. Many people with multiple chronic diseases take 10 or more prescription drugs. This can increase to 20 or more for older, more complicated cases.

Although doctors are well-intentioned, the system doesn’t allow them to effectively talk to each other and share information about the patient. This often leaves patients as their own health care coordinator.

Last Congress, I introduced the Better Care Lower Cost Act. This bipartisan bill would allow health practices and plans to create coordinated teams of nurses, doctors, physician assistants, pharmacists, etc. to provide fully-integrated care for seniors with multiple chronic conditions. By modernizing the Medicare payment system to pay for results not just activity, incentivizing people (Continued on page 12) November/December 2015

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Health Care Reform A Health Care System That Works for Patients (Continued from page 11)

to take care of themselves, and removing barriers to innovation we can ensure seniors get the right care at the right time. Our bill would also allow providers to take advantage of health technology and telehealth to break down geographic barriers to bring the chronic care management skills and experience of high quality providers to the most rural and underserved parts of the country.

We can create a better delivery system and this bipartisan legislation shows that with a little collaboration and cooperation, we can find solutions to ensure that current and future beneficiaries have the best care possible.

The second step we can take to improve our health care system is to help patients that are at risk for developing chronic conditions by empowering employers to offer wellness programs. Fifty percent of the health care costs for employers are driven by only five percent of the employees. Many of these costs are preventable, yet less than 30 percent of employees get annual preventive care.

Wellness programs help employers and employees reign in these costs and improve

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health outcome by utilizing health screenings, incorporating disease management into employee health plans, and increasing health premiums or changing employer contributions to employees that engage in unhealthy behaviors like smoking or not taking control of their chronic conditions.

Unfortunately, these programs are now under attack by excessive regulations and limitations. As co-chair of the Congressional Wellness Caucus, I have seen firsthand how these programs can successfully tackle chronic conditions and incentivize employees to make healthy lifestyle decisions. We need to remove hurdles to implementing these programs and encourage employers to find innovative ways to help their employees and reduce costs.

The third important tool for improving our health care system is empowering patients as consumers. Every Congress, I introduce legislation to expand the use of consumer directed health accounts, including Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs), and Health Reimbursement Arrangements (HRAs).

Currently, these accounts are available to a limited number of Americans and there

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November/December 2015

are too many barriers to using them. These accounts help patients keep their own health care dollars and save for when they need them most. They can encourage patients to be wise consumers by not over utilizing the system and shopping around for the best price, like they do in every other sector of the economy. We can reduce costs and empower patients by expanding these accounts, removing the barriers, and increasing price transparency within the health care system.

An informed and active consumer will lead to better health care and lower prices.

Finally, we need to break down the regulatory barriers that force doctors to spend more time doing paperwork than taking care of patients. Too often, Washington tries to tell doctors how to do their job rather than paying them if they achieve a good outcome.

Even when doctors do everything right, they have to be worried whether or not a trial lawyer is going to take advantage of patients and bring a lawsuit against the doctor. Seventyfive percent of physicians face a malpractice claim throughout their careers, leading to defensive medicine that costs more money and does not improve outcomes. Sadly, less than 30 percent of dollars spent by doctors and hospitals for malpractice insurance goes to injured patients or their families.

We need a system that allows physicians to focus on innovation, quality, and patient outcomes instead of having to worry about the arbitrary regulations of Washington bureaucrats and whether or not they will get sued. I have cosponsored the Saving Lives, Saving Costs Act to enact common-sense medical liability reform that could reduce health care spending by billions of dollars, improve care for patients, and allow doctors to do what they do best… practice medicine.

These are just some of the many common-sense actions we can take to improve health care in the United States. By working together and listening to providers and patients, we can enact real health care reform that lowers costs, increases access, and improves quality.

Congressman Erik Paulsen represents Minnesota’s Third Congressional District. He is a champion of small business and advocate of free enterprise, entrepreneurship, and innovation, serves on the House Ways and Means Committee, the bicameral Joint Economic Committee, and is co-chair of the Congressional Medical Technology Caucus.

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The Journal of the Twin Cities Medical Society

Colleague Interview: A Conversation with Stephen T. Parente, Ph.D., MPH, MS

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TEPHEN T. PARENTE, Ph.D., MPH, MS is the Minnesota Insurance Industry Chair of Health Finance in the Carlson School of Management, Associate Dean of MBA Programs and the Director of the Medical Industry Leadership Institute at the University of Minnesota.

As a Professor in the Finance Department, he specializes in health economics, information technology, and health insurance. Dr. Parente has been the principal investigator on large funded-studies regarding consumer directed health plans, health information technology and health policy micro-simulation. He is currently on the Governing Chair of the Health Care Cost Institute. He is the Founding Director of the Medical Valuation Laboratory, a nine college interdisciplinary effort to accelerate medical innovation from scientists, clinicians and entrepreneurs. Dr. Parente was a health policy advisor for the McCain 2008 Presidential Campaign and served as Legislative Fellow in the office of Senator John D. Rockefeller IV (DWV) in 1992/93. He has a doctorate from Johns Hopkins University.

What is the public health policy impact on an individual health care delivery model, and perhaps the impact on an individual’s health status?

Public health’s greatest public policy achievements were realized in vaccine use and popularizing wide-spread hygienic conditions.

Today, public health’s tools are largely embedded in patient and population education on good health habits that will enhance an individual’s health status. The challenge is that education works best if the patient is willing to make a major lifestyle change. Often lifestyle changes in today’s modern world are more expensive than the status quo. For example, eating healthy food is a more expensive choice than high calorie fast food. Taking a long walk every day for low impact exercise may be too expensive in work hours lost for part-time workers holding down two jobs.

Please comment on cost/benefit for non-physician health care services...i.e. nurse practitioners, medical social workers, psychologists, chemical dependency counselors, etc.

All of these non-physician health services have documented health care costs now through insurance claims data representing their utilization. However, there are substantial challenges to measuring the costs and benefits of these specialties. Measuring costs is fairly straightforward. Measuring benefits is more complicated because MetroDoctors

The Journal of the Twin Cities Medical Society

a true cost benefit relationship requires the monetization of the benefits to a currency unit like dollars. While some benefits are easy to measure, such as fewer missed paychecks from an illness, there are more intangible benefits that are complex to measure.

For now, we do not have sufficient data to talk beyond very general outcomes such as suicide prevention, ER visit avoidance, inpatient mortality reductions in work days missed. Even with these metrics it is challenging to put a monetary value on them.

What is the impact of electronic health care, e.g. email office visit, remote IT Intensive Care or Emergency Care delivery? Are medical schools adjusting their curricula to train on new ways of delivering care?

Electronic health care is becoming increasingly transformative.

However, it remains a largely cash-based system and not many insurers are paying directly for it outside a handful of demonstrations. Part of the concern is that Medicare does not reimburse for these visits yet and Medicare is generally considered an important bell-weather for a major change such as this.

Medical schools do not focus on the business of health care unless it is tied to a specific medical specialty practice that they are exposed to in a residency program. Residents with exposure (Continued on page 14)

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Health Care Reform Colleague Interview (Continued from page 13)

to care systems where new technologies like zipnosis are used will get good exposure. Fortunately most of the mobile health technology platforms of the last five years or less have fairly intuitive designs for iPad or tablet use. This is a major advantage since the interface is common in consumer goods now and simply needs the provider to understand and utilize the context of transaction from a mobile health application.

How has the distribution of care delivery assets (people and technology) been influenced by payment mechanisms?

Payment incentives have had a huge impact ever since the advent of Diagnosis Related Groups (DRGs) in 1983 for all of Medicare.

The resulting prospective payment system where hospital stays were no longer paid by day, but by admission created the incentive to move care out of the inpatient setting to the outpatient setting for less complicated cases.

Today, Medicare and private insurers drive to pay for population health management though ACO and Medical Home contracts are forcing health care providers to think more like insurers and consider a total cost of care model. This requires providers to develop comprehensive health care tracking systems

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for more complicated chronic condition management. It certainly has accelerated the use of electronic health records to aid in care management.

Where the next revolution in payment mechanism will come is hard to predict. Increasingly, consumers are buying care with out-of-pocket costs through larger copays or high deductibles.

This too will change care assets as consumers will have greater incentive than ever before to shop for non-emergency care based on published ranges of health care price for paid services and quality metrics. Tools like guroo.com that show ranges of dollars paid for common medical procedures that are two fold will lead the consumer to consider active price negotiation when possible with providers. The proliferation of HSAs will also aid the cause of transparency as consumers have bigger wallets for care with accumulated assets in their HSA accounts.

Please provide a summary of Medical Banking, and its influence (if any) on the Minnesota Medical community.

The goal of medical banking is to enhance financial transactions for health care with information on the patient’s condition, treatment outcome, and drug adherence. This would fit a person’s desire to maximize their health and their wealth jointly. If we consider economist Michael Grossman’s 1972 landmark household

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production function specification, where medical care and other factors affect the production of health, medical banking explicitly makes it possible to collect the data necessary for a household production model to become a day-to-day reality and a part of the current financial transaction system in health care markets.

The fusion of credit card payments for health care services through HSA accounts as well as health insurer identity cards were to be the signature technologies of medical banking as envisioned in 2009 on the eve of health reform. There have been Minnesota start-ups such as eBenX focused in this space but a basic compatibility issue remains between insurers’ proprietary data systems, bank transaction systems and electronic health records. More recently, the fusion of health and wealth management through mobile computing such as the Apple Watch combined with Apple Pay creates a more seamless transaction network for medical payment and health monitoring than ever before.

Do narrow networks truly provide higher value medical care?

Narrow networks have the capability to provide high quality care if the care system used has a strong track record of excellence. For example, all of the major care systems in the Twin Cities have substantial health care quality scores on Medicare’s Hospital Compare web site. As a result, if one of the care systems is the exclusive focus of a narrow network contract, there should be no question that they can provide high value care. If they can and become ‘focused factories’ on certain common medical conditions, they could shield sufficient internal cost savings to be able to lower contracted premiums to consumers without compromising quality.

With health care reform, would the fee-for-service model be retained?

Yes. It is the core reimbursement system for high deductible health plans, and the growth of those types of plans has only accelerated following the passage of the Affordable Care Act.

Are quality assurance conclusions drawn from billing/Medicare data valid assessments of the medical care delivered?

As with most economists’ answers, it is prefaced with ‘it depends.’

In this case it truly does depend on the type of metric you are using. For example, the readmission rate metric is entirely based on claims data and gives a pretty robust reflection on quality of care coordination. In addition, the claims data is used for risk adjustment to account for the fact that some patient care is more complicated for some than others.

There are other ideal measures for quality of care that we just can’t access from claims data. The biggest gap is that we can accurately measure whether the patient has gotten better or not simply by looking at the absence of later billing data. Perhaps MetroDoctors

The Journal of the Twin Cities Medical Society

the patient has no billing data because they are healed and doing great and won’t need care for another decade. However, no billing data for a period of time could suggest a patient is having trouble accessing the health care system for follow-up care and stay on the periphery of receiving adequate care to prevent additional illness or maintain a certain level of health.

I contend that when billing data is combined (securely) with other data sources showing physical activity and mobility it will help to considerably reduce the noise to signal ratio that is very common in the use of claims data as a ubiquitous quality care measurement tool.

Please comment on health care disparity.

Health care disparities are highly correlated with socioeconomic conditions of certain regions in the U.S. with high poverty. Some of the disparities can be attributed to an inadequate supply of providers — though this could be a reflection of the wealth of an area. Some disparities are driven by different demands from different sub-populations.

A recent Kaiser Health study showed progress in health disparities throughout the nation but that much work remained to be completed. In many cases the health of all populations improved, but the percent of change gap between the best and worst ends of the population distribution for change in health status remained stubbornly similar.

Describe the impact of the FDA on new medication or treatment pipelines; the good and the bad.

The FDA’s primary role is to officially opine on the safety and efficacy of a new medical technology. While the process used by the FDA is slow, significant investments over the last 10 years have rectified a situation that could have been worse.

It is important to understand that the FDA is now more reasonable a place to test safety and efficacy than other nations’ similar regulatory bodies. European CE mark is often seen as a faster way to market, but increasingly they are seeking just an onerous clinical trial data as the FDA. Furthermore, China’s process is increasingly tied to the FDA procedure rigor and offers little rapid turnaround in the future.

The good news is the FDA remains vigilant and effective in safeguarding populations from an adverse outcome of new medical technologies. The bad news is that the review process is still quite onerous and could be the leading deterrent for producing lifesaving next stage genetic technology and personalized medicine solutions.

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Health Care Reform

Single Payer Momentum Builds with PNHP

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he 23-year-old young man sitting before me in the emergency department looked ill. Febrile to 101 degrees, he held out his swollen right forearm, revealing a painful abscess the size of a golf ball on its undersurface. A large patch of warmth and redness tracked aggressively beyond his elbow to his upper arm. His symptoms had been progressing for nearly a week.

I noticed several puncture marks on the tense skin surface overlying the abscess.

“That’s where I tried to lance it with a needle to get the pus out,” he admitted sheepishly. “It didn’t work.” The reason he waited for days to seek care, remaining at home as his symptoms progressed: a $3,000 deductible required by his insurance plan. “I just don’t have that kind of money,” he explained.

I suspect most Minnesota physicians have their own stories of patients delaying or forgoing medical care due to unaffordability. A May 2015 Commonwealth Fund study found that 44 percent of privately insured adults don’t get needed care when they’re sick, due to high cost-sharing required by private insurance plans.1 Physicians for a National Health Program (PNHP) is a physician organization that finds such a situation untenable. It believes that a civilized country as wealthy as the United States should be able to find a way to guarantee quality health care for its citizens. It argues that the fragmentation and patchwork inefficiencies of the U.S. health care system have led to decades of skyrocketing costs and corporate

By Dave Dvorak, M.D., MPH

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profiteering at the expense of patients, who continue to struggle with access and unaffordable health care bills.

With over 20,000 members nationally and state chapters across the country (including here in Minnesota), PNHP advocates for a fundamental change in the way we pay for health care. Known as single payer reform, it would create a unified, publicly financed system — while keeping the delivery of health care largely private, as it is now. Such reform, PNHP maintains, would soundly achieve the efficiencies necessary to provide affordable and equitable health coverage for all Americans.

The problem, as PNHP sees it, certainly isn’t a lack of national spending on health care — at 17 percent of our GDP, the U.S. spends twice as much per capita as other industrialized countries.2 Rather, it’s how we spend our health care dollars.

The organization cites a New England Journal of Medicine study showing that a

staggering 31 percent of U.S. health care spending goes to administrative overhead rather than to actual health care.3 In large part, this tremendous inefficiency is rooted in our multi-payer system, with hundreds of profit-driven private insurance companies duplicating the services of one another. As businesses motivated by profit, private insurance companies naturally have incentive to deny or create barriers to coverage, all the while diverting policyholder premiums to advertising, marketing, underwriting, lobbying, exorbitant executive salaries and investor profits — administrative functions wholly unrelated to patient care.

Meanwhile, physicians grapple with the wasted time and frustrations of practicing in a complicated maze of insurance plans, in which every patient has differing coverage. This necessitates significant billing staff labor and huge hospital billing departments. An increasing share of the physician workday is spent seeking prior authorization from insurance companies in order to treat their patients appropriately.

A 2011 Health Affairs study found that interaction with private insurance companies costs the average U.S. physician nearly $83,000 per year.4 While the reforms of the Affordable Care Act (ACA) have enabled millions of previously uninsured Americans to obtain coverage, such coverage increasingly is proving to be sorely lacking. Ultra-high deductibles — as high as $7,500 — required to be paid before insurance kicks in make patients reluctant to seek needed care, and vulnerable to financial ruin when they do. A July 2015 Minneapolis StarTribune article portrays the aggressive manner in

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which the state’s major hospital systems are pursuing patients for unpaid deductibles through debt collectors and lawsuits.5 Not surprisingly, unaffordable health bills are the leading cause of bankruptcy for American families, accounting for 62 percent of U.S. bankruptcies.6 PNHP backs single payer health reform as the most sensible and equitable solution to our current dysfunctional system. Single payer is universal health care that is publicly funded, yet privately delivered. It preserves our current, largely private health care delivery system, maintaining market-based competition where it matters — among providers. But it replaces our dizzying labyrinth of private insurance plans with a single, unified public financing stream. Individuals pay a premium into the fund according to ability to pay — meanwhile shedding the premiums paid to private insurance companies, as well as deductibles, copays and coinsurance.

The chief strength of single payer lies in its efficiency. It streamlines payment for health services and products by establishing uniform, transparent pricing. It replaces the costly, cumbersome practice of itemized hospital billing with global annual budgeting, removing layers of hospital administrators and bloated billing departments. It provides for bulk purchasing and the ability to negotiate fair prices for prescription medications and medical supplies.

Evidence-based in its approach, PNHP points to multiple studies showing that by capturing the massive waste in the health system and redirecting it to actual health care, single payer can achieve truly universal coverage while reining in health care inflation3,7,8,9 — something no other type of proposed reform has shown the ability to do. The organization maintains that single payer would guarantee health security for all citizens, removing crippling out-of-pocket copays and deductibles.

As single payer reform at the national level appears unlikely in the current political climate, many state PNHP chapters have focused their efforts on state level reform. The ACA’s Section 1332 State MetroDoctors

Innovation Waiver will allow individual states, beginning in 2017, to apply for federal waivers to implement their own innovative health care systems. However, the state must demonstrate that it can cover at least as many residents as are currently covered by the ACA without adding to the federal deficit.

As such, the Minnesota chapter of PNHP (PNHP-Minnesota) is enthusiastically backing single payer reform in Minnesota. The organization points to a 2012 study by the Lewin Group as evidence of the economic feasibility of single payer in Minnesota. The analysis found that a Minnesota single payer system would be able to provide comprehensive health and dental coverage to every Minnesotan while saving the state more than $5 billion per year in health spending over its first 10 years.9 The median-income Minnesota family would save an average of $3,512 per year on health care. Notably, the savings in the model came primarily from administrative waste reduction and bulk purchasing; provider compensation remained unchanged.

PNHP-Minnesota engages in education and advocacy, providing speakers to hospitals, clinics, medical schools and residencies, churches and community groups.

More than 1,000 Minnesota physicians, medical students and health care professionals have signed the PNHP resolution in support of single payer reform (http:// tinyurl.com/q2czr8k). Also backing single payer is the Minnesota Nurses Association (MNA), a union of 20,000 Minnesota nurses. Over the past year, MNA and PNHP-Minnesota have joined forces in hosting educational seminars throughout the state to continue to build support for single payer among medical professionals.

Making single payer health care a reality in Minnesota will require widespread popular support among citizens and medical professionals — as well as the political will of legislators — to counter the natural opposition of profit-driven corporate interests. Legislation authored by Sen. John Marty (DFL-Roseville) would establish universal health care in Minnesota based upon single payer principles. Known as the

The Journal of the Twin Cities Medical Society

Minnesota Health Plan, it would replace the current inefficient patchwork of private and public health plans with a single statewide fund that would cover the health needs of all Minnesotans.

The fight for a more sensible, equitable and efficient health system continues.

Physicians and health care professionals interested in learning more about single payer reform should visit the PNHPMinnesota website at PNHPminnesota. org.

Dave Dvorak, M.D., MPH has practiced emergency medicine in the Twin Cities for 21 years. He is a member of the Minnesota chapter of Physicians for a National Health Program.

References 1.

The Commonwealth Fund Biennial Health Insurance Survey. “The problem of underinsurance and how rising deductibles will make it worse.” May 2015. Availble at: http://www. commonwealthfund.org/publications/issuebriefs/2015/may/problem-of-underinsurance.

2.

The World Bank. Health expenditure, total (% of GDP). 2012. Available at: http://data. worldbank.org/indicator/ SH.XPD.TOTL.ZS. 3.

Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. NEJM. 2003. 349: 768-775.

4.

D. Morra, S. Nicholson, W. Levinson et al. U.S. Physician Practices Spend Nearly Four Times as Much Money Interacting with Health Plans and Payers Than Do Their Canadian Counterparts.

Health Affairs Web First, Aug. 3, 2011.

5.

Howatt, Glen. StarTribune, July 26, 2015,“More in Minnesota have health coverage but still can’t afford to be sick.” Available at http:// www.startribune.com/more-minnesotanshave-health-coverage-but-still-can-t-affordto-get-sick/318545021/.

6.

Himmelstein DU, Thorne D, Warren E, et al.

Medical bankruptcy in the United States, 2007: results of a national study. American Journal of Medicine. 2009. Available at: http://www. amjmed.com/article/S0002-9343(09)00404-5/ abstract.

7.

Gerald Friedman, Ph.D., Department of Economics, University of MassachusettsAmherst.

Available at: http://www.pnhp.org/sites/ default/files/Funding%20HR%20676_Friedman_7.31.13_proofed.pdf.

8.

Woolhandler, S. Cutting health costs by reducing the bureaucracy. NY Times. Nov. 20, 2011. Available at: http://www.nytimes. com/2011/11/21/opinion/cutting-health-costsby-reducing-the-bureaucracy.html.

9.

Sheils J, Cole M. Cost and economic impact analysis of a single-payer plan in Minnesota.

2012. Available at: http://growthandjustice. org/images/uploads/LEWIN.Final_Report_ FINAL_D.

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Health Care Reform

The Patient—Honoring Choices

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ow are patients going to retain choice in medical decisions and over the quality of their own care? Which ‘system’ of care and payment processes best meets the needs of individual patients?

The Twin Cities Medical Society expended time, resources, and intellectual power in promoting individual choice for “comprehensive advance care planning program[s].”1 This important program expresses a key feature that should be of first priority in all health care reform efforts. Did the sentiment of honoring patient choice match the Congressional bill authors’ intent in the Affordable Care Act (ACA)?

Thanks to ACA’s expansion of Medicaid, governments are at least modestly reimbursing medical facilities for a good number of low-income individuals for whom charity care had previously been the norm. Add to that, reimbursements are now paid on behalf of some number of the middle-income patients who had previously gone uninsured. Concerning both low- and middle-income patients, however, the ACA’s solutions fall woefully short of the primary question — does the patient maintain choice?

Recently, the Minnesota Department of Human Services eliminated UCare as a Medicaid provider. DHS’ decision took choice away from 360,000 individuals, a great number of whom belong to immigrant communities. Those UCare enrollees are losing access to their preferred

By Dave Racer, MLitt and Lee Beecher, M.D., DLFAPA, FASAM

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physicians. UCare has been very popular among immigrant groups who want to maintain access to culturally sensitive physicians. Clearly, these individuals have lost choice in the new, Minnesota/ACA world.

The Physicians Foundation’s 2014 survey of physicians found Dave Racer, MLitt Lee Beecher, M.D., DLFAPA, FASAM that “… 38 percent of physicians either do still be affordable because federal taxnot see Medicaid patients or limit the payers will pay an increased share of the number of Medicaid patients they see.”2 premium. The health plans that patients Low-income individuals on Medicaid may are choosing, however, often have high now be enrolled in a health plan, but still deductibles and out-of-pocket expenses. may lack access to ambulatory care.

The effect of the expensive ACA health The challenges faced by middle-inplans means most individuals covered by come individuals going forward, however, non-government health plans face potenare also very formidable. Health insurance tially unaffordable health care. Insurance premiums paid during 2014 and 2015 carriers will collect expensive premiums spiked higher each year. Now, in 2016 from individuals who will seldom use their enrollees face 14-49 percent premium ininsurance for medical care. creases on plans offered by BlueCross Blue Patients have only a handful of insurShield of MN, HealthPartners, Medica, ance companies from which to choose.

PreferredOne and UCare. There are really The ACA’s mandatory benefits and onerno other choices for patients who purchase ous regulations have managed to reduce their own insurance. competition among health plans, except “Mark Dayton blamed health plans on price and networks. for the rate increases, saying that if they The ACA promotes consolidation make coverage unaffordable Americans of physician, hospital, clinic, and afwill demand ‘that they be removed as the filiated practices into large provider sysproviders of health insurance.’”3 Insurance tems. These voracious systems, expanding companies blame the high cost of care, and through mergers and acquisitions strive to the rapid increase in high cost claims as a increase their market share, while consignresult of the ACA. ing enrollees to a network of providers MNsure’s interim CEO Allison who have signed employment contracts O’Toole claims the new premiums will MetroDoctors

The Journal of the Twin Cities Medical Society

or agree to participate in restricted provider networks. Although the ACA often denotes physicians as key members of a clinical health care team, all “providers” are under the close scrutiny of data collectors and number crunchers (be these in-house or external) who ultimately must bend to state and federal rules and officials.

The new mega-models are built on common goals — to capture as many patients as possible for as long as possible, and capture the dollars that follow the patients. Do these organizations offer patients more choice over their own health care? Can patients choose from among a variety of physicians, facilities, products, services, and prescription medicines, or are they captured by the system that holds their “membership?”

Some contend that patients retain choice because they are free to go outside of their network, HMO, or ACO any time they wish. When a majority of medical professionals work for a small number of large provider systems, however, it provides limited choices. True, federal law allows Medicare fee-for-service recipients to go to any willing provider, yet the trend toward merging providers and payers into restrictive systems is quickly becoming the new norm. Patients are then strapped with exorbitant out-of-network cost-sharing.

In reality, except for wealthy individuals, the patient in these large systems are its captive.

Recent data suggests that ACOs are not delivering hoped-for cost reductions.4 As the government further reforms ACOs, will patients retain much or any real choice about who cares for them and what care they receive?

The ACA needs major reform and there will be a rigorous debate during this election cycle. As a high priority for voters, Minnesota and congressional policymakers need to empower patients and families with real choices in a real health care marketplace.

Here are three priority questions: 1. What reforms would give Minnesota health care consumers and taxpayers easy access to prices and details of coverage so citizens can shop for health MetroDoctors

care services and third party coverage (cost and coverage transparency)?

2. Which health care funding systems best respect the needs of individual patients in Minnesota? How do proposed state and federal reforms engage patients and their families to have “skin in the game” in managing their own health care?

3. How can we assure that Minnesota taxpayers and policymakers are able to evaluate the performance and administrative costs of public managed care systems?

Without reform, the ACA will lead to a federal government-run system that over time, will evolve into the “single payer” system embraced by so many. We contend this will produce yet another mistaken answer to a complex problem. Already, the ACA has established government hegemony over what goes on in the exam room and overtly influences a physician’s clinical recommendations and decisions.

Would more government oversight improve patient care and create more choices?

Physicians who chafe at government and Third Party Payer control of bedside care surely cannot believe that governments will somehow more efficiently and effectively run the whole system. Medicare and the VA system are single payer entitlement payment systems, but they too cry out for reform.

The California OneCare Coalition, which passed single payer more than once, although vetoed by its governor, showed tremendous faith in government. One Care adherents’ asserted physicians would love it. Doctors, OneCare claimed, will no longer have to deal with insurance carriers and other types of reimbursement systems, fighting for peanuts from all the payers.

Instead, OneCare asserted that physicians would be happy with their contracts negotiated with government’s health care system managers. Is this a desirable future for Minnesota’s physicians? Hopefully not.

We believe that whatever systems American policymakers enact, the best of them will engage patients and physicians in partnership for better health care outcomes — ultimately honoring the wishes

The Journal of the Twin Cities Medical Society

and needs of the patient. Health Savings Accounts (HSA) are a good way for patients and families to fuse health care decisions with value and methods of payment.

The HSA mitigates first dollar care costs before the high deductible insurance kicks in. Patients who pay part of the bill out of his or her pocket are empowered to ask, “Is this necessary?” and “How much does this cost?” Then the vital physicianpatient dialogue bears fruit and patients have choices.

Dave Racer, MLitt, received his Master of Letters Degree from Oxford Graduate School in 2009. He is a writer, researcher, publisher, speaker, and teacher. Dave is a member of the National Association of Health Underwriters (NAHU) and its Minnesota Chapter (MAHU) and is a Board Member of the Minnesota Physician-Patient Alliance. He can be reached at: dgracer@comcast.net.

Lee H. Beecher, M.D., DLFAPA, FASAM is president of the Minnesota Physician-Patient Alliance www.physician-patient.org. A psychiatrist, he closed his private practice in 2014 after 42 years. Dr. Beecher served on the MetroDoctors Editorial Board from 2006 to 2014. He can be reached at leebeecher@ aol.com.

Footnotes: 1.

Honoring Choices Minnesota Executive Summary. Twin Cities Medical Society. Minneapolis, MN. Retrieved 10/1/2015. http://www.metrodoctors.com/dev/.

2.

Miller, P. (2014) 2014 Survey of America’s Physicians. The Physicians Foundation, by Merritt Hawkins. Boston, MA. September 2014. P 9.

3.

Snowbeck, C. (2105) Regulators approve premium jumps averaging as much as 49 percent for some in Minnesota. The Star Tribune.

Minneapolis, MN. 10/1/2015. Retrieved on 10/2/2105. http://www.startribune.com/regulators-approve-premium-jumps-averaging-asmuch-as-49-percent-in-minnesota/330275391/.

4.

Rau, J.; Gold, J. (2015) Medicare Yet To Save Money Through Heralded Medical Payment Model. Kaiser Health News. Menlo Park, CA. 9/14/2015. Retrieved on 10/2/2015. http:// khn.org/news/medicare-yet-to-save-moneythrough-heralded-medical-payment-model/.

November/December 2015

19

Health Care Reform

Health Care Reform in Minnesota: Progress, Problems and Possibilities Introduction

Minnesota was a national leader in health reform long before debate surrounding the Affordable Care Act (ACA) swept the nation. Minnesota has historically had more affordable health care with lower uninsured rates and higher quality when compared to national trends.1,2,3 With passage of the ACA, Minnesota has taken advantage of several of its provisions to continue to improve access to care. This article will provide a general overview of how Minnesota’s health care system has utilized the ACA as a catalyst for reform, the problems that remain despite reform, and possible solutions to address lingering post-reform issues.

Health Care Reform Progress in Minnesota

While the ACA contains a number of provisions that address cost and quality issues to varying degrees, its primary goal was clearly to expand health insurance to uninsured Americans. It has been extremely successful in this sense; the uninsured rates across the United States and in Minnesota have reached historic lows.4,5 Approximately 135,000 Minnesotans gained insurance coverage in 2014, bringing the state’s uninsured rate for adults ages 18-64 down from 10.7 percent in 2013 to 6.7 percent by the end of 2014.

These rates have decreased due to three tools available through the Affordable Care Act: Medicaid Expansion for individuals/ families up to 133 percent of the Federal Poverty Level (FPL), Health Insurance Marketplaces with subsidies available for individuals/families between 133 and 400

By Tyler Winkelman, M.D.

20

November/December 2015

available through the ACA to expand community health centers,9,10 expand home nursing programs,11 and implement health care innovation pilot programs across the state to improve population health.12,13 One of the programs partially funded through the State Innovation Model (SIM) grant, Hennepin Health, has gained national attention by integrating medical, behavioral, and social services to reduce hospital use and increase primary care utilization.14,15 Hennepin Health was one of 15 communities selected to test an Accountable Communities for Health model through the SIM grant. percent FPL, and the Individual Mandate.6 In addition, states were given the option of designing their own health insurance program, termed the Basic Health Plan, for those between 133 percent and 200 percent FPL. Minnesota has been the only state to implement the Basic Health Program, which replaced MinnesotaCare earlier this year.7 Rolling MinnesotaCare into the Basic Health Program will increase the amount covered by the federal government from 45 percent to 95 percent. Minnesota also established its own state-based exchange, known as MNsure, and expanded its Medicaid program. The federal government finances 100 percent of the cost for persons newly eligible for Medicaid until 2017, saving the state up to one billion dolllars.8 This contribution declines to 90 percent of the cost by 2020 and beyond, but is still much greater than the 50 percent federal contribution for those eligible for Medicaid prior to expansion.

In addition, Minnesota has received millions of dollars in federal money

Health Reform and Lingering Problems

In 2012, the United States Supreme Court ruled that individual states could choose not to expand Medicaid without losing current federal funding for existing Medicaid programs.16 As of August 2015, 20 states had chosen to not expand Medicaid, resulting in much higher uninsured rates in non-expansion states.17 Despite the ACA’s gains in health insurance, 29 million people remain uninsured in the United States, including a quarter of poor Americans.18 Over 200,000 people remain uninsured in Minnesota even though Minnesota has implemented every major initiative available through the ACA. While the remaining uninsured is of concern, there is also growing concern regarding the increasing prevalence of underinsurance. The Commonwealth Foundation reported earlier this year that approximately 31 million people in the United States are underinsured partly due to the rise of high-deductible health plans.19 The ACA creates new avenues to obtain health insurance, but does not

MetroDoctors

The Journal of the Twin Cities Medical Society

guarantee that a plan will be affordable in the event of illness.

Another important limitation of the ACA is the scope of its public health efforts. Medical care accounts for only 10-30 percent of health care outcomes,20 leading the Institute of Medicine to conclude: …improving the clinical care delivery system’s efficiency and effectiveness will probably have only modest effects on the health of the population overall in the absence of an ecologic, population-based approach to health improvement.21 Therefore, the ACA created a mandatory funding stream, known as the Prevention and Public Health Fund, to address public health initiatives for the first time in the nation’s history. It was supposed to provide two billion dollars per year for prevention and wellness but Congress has already cut the intended investment by more than 50 percent. Furthermore, its funding pales in comparison to the nearly five hundred billion federal dollars spent on Medicaid alone in 2014.

Why might public health funding be important to Minnesotans? Although Minnesota is a national leader in access to quality health care, its health equity track record has been poor. The 2014 National Healthcare Quality & Disparities Report ranked Minnesota in the nation’s worst quartile for racial/ethnic disparities.22 And the statewide 2014 Health Equity of Care Report showed that disparities exist by race, ethnicity, and language for asthma care, colon cancer screening, diabetes care, and vascular care.23 Few believe health insurance expansion alone can improve these documented disparities.

Possibilities for Future Reform

How could Minnesota extend coverage to the remaining uninsured? Several possibilities exist. The Minnesota Health Care Financing Task Force was recently convened after a bill from the 2015 legislature and will submit a final report in January of 2016 outlining potential strategies to “increase access and improve the quality of health care for Minnesotans.”24 Section 1332 of the ACA is one tool that will be evaluated by the task force. Starting in 2017, Section 1332 (also known as the MetroDoctors

Wyden Waiver) would allow state governments to waive a number of the key provisions within the ACA if they implement an alternative health reform plan that is deficit neutral and provides coverage that is at least as comprehensive and affordable as the coverage that would have been obtained without the waiver.25 Provisions that can be modified include the individual mandate, essential health benefits, health insurance exchanges (ie. MNSure), and marketplace subsidies. Section 1332 provides states with a range of options from increasing public health insurance options for higher income households to increasing private health insurance for lower income households. Such flexibility may allow states to implement reform measures that are less politically divisive.

The waiver can also be merged with existing waiver processes for Medicare, Medicaid, and CHIP programs to coordinate benefits across publicly-financed health care programs.

Using a section 1332 waiver, Minnesota could choose to establish a ‘public option.’ A public option would allow the state government to offer a public health insurance plan on MNsure. For instance, the state could allow those younger than 65 to purchase a Medicare plan on MNsure.

Minnesota could also choose to extend income eligibility for the Basic Health Program beyond 200 percent of the federal poverty level. The public option was a contentious point during the debate leading up to passage of the ACA, although a majority of physicians supported the idea.26 Whether these options would be less expensive than commercially available plans or increase insurance coverage in Minnesota is unclear in the absence of a concrete proposal.

Others in Minnesota support the creation of a single payer system. The plan being proposed in Minnesota and supported by Physicians for a National Health Program Minnesota is known as the Minnesota Health Plan.27,28 The Plan would utilize waivers, including Section 1332, to cover all Minnesotans with a single, statewide plan and would be financed through a progressive income tax on individuals and businesses. The health care delivery system would remain in the private sector,

The Journal of the Twin Cities Medical Society

but health insurance would be run through a newly developed state agency. Savings of 12 percent to 33 percent per year are estimated by 2023.29 Minnesota is leading the nation to address social determinants of health through work supported by a State Innovation Model grant. Fifteen communities have been selected to test novel models of health care, termed Accountable Communities for Health. These communities will be funded for two years with the goal of establishing partnerships between the health care delivery system and community organizations to improve population health. However, population health benefits are unlikely to accrue in only two years.

Therefore, success will, in part, depend on whether future funding will be available for these communities. Stringent measurement of population-based interventions can be challenging, but will be essential if the state hopes to scale successful pilot programs to decrease statewide health disparities.

Conclusion

Minnesota has long been a leader in access to high quality health care. By utilizing provisions within the Affordable Care Act such as Medicaid expansion, health insurance exchanges, and the Basic Health Program, Minnesota has brought its uninsured rate to historic lows. However, hundreds of thousands remain uninsured and even more remain underinsured. A number of possibilities exist for improving upon recent health reform initiatives and may be discussed in the Health Care Financing Task Force’s report due early next year. Regardless of whether Minnesota utilizes a Section 1332 waiver to expand access to care, we are likely to see little improvement in health disparities if the state and federal government continue to underinvest in public health initiatives.

Tyler Winkelman, M.D. completed residency training in Internal Medicine & Pediatrics at the University of Minnesota in 2015. He is a Robert Wood Johnson Clinical Scholar at the University of Michigan, where he is studying the health effects of social policy, health care reform, and the physician role (Continued on page 22)

November/December 2015

21

Health Care Reform Health Care Reform in Minnesota (Continued from page 21)

in advocacy. He can be reached at: tywink@ med.umich.edu.

References 1.

The Henry J. Kaiser Family Foundation. Health Insurance Coverage of the Total Population. (http://kff.org/other/state-indicator/totalpopulation/). Accessed August 23, 2015.

2.

The Commonwealth Fund. Aiming HigherResults from a Scorecard on State Health System Performance, 2014. (http://www. commonwealthfund.org/~/media/files/ publications/fund-report/2014/apr/1743_ radley_aiming_higher_2014_state_scorecard_corrected_62314.pdf). Published May 2014. Accessed August 23, 2015.

3.

The Commonwealth Fund. Commonwealth Fund Scorecard on State Health System Performance, 2014. (http://www.commonwealthfund.org/~/media/files/publications/ fund-report/2014/apr/state_profiles_2014_ all_states.pdf). Published May 2014. Accessed August 23, 2015.

4.

Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA. 2015;314:366-374.

5.

Minnesota Department of Health – Health Economics Program. Assessing the Affordable Care Act in Minnesota: More Adults in Minnesota Have Health Insurance – Challenges Persist with Satisfaction and Understanding Coverage. (http://www.health.state.mn.us/ divs/hpsc/hep/publications/coverage/HRMSIssueBrief2014.pdf). Published December 2014.

Accessed August 23, 2015.

6.

7.

8.

9.

10.

11.

12.

13.

Blumenthal D, Collins SR. Health care coverage under the Affordable Care Act – a progress report. N Engl J Med. 2014;371:275-281.

Medicaid.gov. Basic Health Program. (http:// www.medicaid.gov/basic-health-program/ basic-health-program.html). Accessed August 23, 2015.

Minnesota Budget Project. Covering More Minnesotans Through Medicaid Would Improve Health Outcomes and Reduce State Costs. (http://www.mnbudgetproject.org/research-analysis/economic-security/health-care/ covering-more-minnesotans-through-medicaid-would-improve-health-outcomes-andreduce-state-costs). Published January 2013.

Accessed August 24, 2015.

Browning D. Community health clinics in Minnesota get a $3.6 million booster. Star Tribune. (http://www.startribune.com/communityhealth-clinics-in-minnesota-get-a-3-6-millionbooster/274974521/). Published September 13, 2014. Accessed August 23, 2015.

Health Resources and Services Administration.

Health Center Quality Improvement FY 2015 Grant Awards. (http://www.hrsa.gov/about/ news/2014tables/qualityimprovement/awards. aspx?state=mn&). Accessed August 23, 2015.

Minnesota Department of Health. Family Home Visiting Program. (http://www.health. state.mn.us/divs/opa/2014fhvrpt.pdf). Published March 2014. Accessed August 23, 2015.

Minnesota Department of Health. Community Transformation Grant. (http://www.health. state.mn.us/divs/oshii/ctg.html). Accessed August 23. 2015.

Health Reform Minnesota. Minnesota accountable health model - State Innovation Model grant. (http://www.dhs.state.mn.us/ main/idcplg?IdcService=GET_DYNAMIC_CON

14.

15.

16.

17.

18.

19.

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22.

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24.

25.

26.

27.

28.

29.

Your Link to Mental Health Resources

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VERSION&RevisionSelectionMethod=Latest Released&dDocName=SIM_Home). Accessed August 23, 2015.

Tavernise S. Health care systems try to cut costs by aiding the poor and troubled. New York Times. (http://www.nytimes.com/2015/03/23/ health/taming-health-costs-by-keeping-highmaintenance-patients-out-of-the-hospital. html?_r=0). Published March 22, 2015. Accessed August 24, 2015.

Sandberg SF, Erikson C, Owen R, et al. Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population. Health Affairs. 2014;33:1975-1984.

The Henry J. Kaiser Family Foundation. A guide to the Supreme Court’s decision on the ACA’s Medicaid expansion. (https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8347. pdf). Published August 2012. Accessed August 23, 2015.

The Henry J. Kaiser Family Foundation. The coverage gap: uninsured poor adults in states that do not expand Medicaid – an update. (http://kff.org/health-reform/issue-brief/thecoverage-gap-uninsured-poor-adults-in-statesthat-do-not-expand-medicaid-an-update/).

Published April 2015. Accessed August 24, 2015.

Cohen RA, Martinez ME. Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, JanuaryMarch 2015. (http://www.cdc.gov/nchs/data/ nhis/earlyrelease/insur201503.pdf). Published March 2015. Accessed August 23, 2015.

The Commonwealth Fund. The problem of underinsurance and how rising deductibles will make it worse. (http://www.commonwealthfund.org/publications/issue-briefs/2015/may/ problem-of-underinsurance). Published May 2015. Accessed August 23, 2015.

Health Policy Brief: The Relative Contribution of Multiple Determinants to Health Outcomes.

Health Affairs. August 21, 2014.

IOM (Institute of Medicine). 2011. For the Public’s Health: The Role of Measurement in Action and Accountability. Washington, DC: The National Academies Press.

Agency for Healthcare Research & Quality.

2014 National Healthcare Quality & Disparities Report. (http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/index.html). Published May 2015. Accessed August 26, 2015.

MN Community Measurement. 2014 health equity of care report. (http://mncm.org/reportsand-websites/reports-and-data/). Published January 2015. Accessed August 23, 2015.

Minnesota Health Care Financing Task Force.

About the task force. (http://mn.gov/dhs/hcftf/ about/). Published August 2015. Accessed August 24, 2015.

McDonough JE. Wyden’s waiver: state innovation on steroids. Journal of Health Politics, Policy and Law. 2014;39(4):1-13.

Keyhani S, Federman A. Doctors on Coverage – Physicians’ Views on a New Public Insurance Option and Medicare Expansion. N Engl J Med. 2009;361:e24.

MNHealthPlan. (http://mnhealthplan.org/).

Access August 26, 2015.

PNHP Minnesota. (http://pnhpminnesota.org/).

Accessed August 24, 2015.

Growth & Justice. Beyond the Affordable Care Act: an economic analysis of a unified system of health care in Minnesota. (http:// growthandjustice.org/publication/BeyondACA.pdf). Published March 2012. Accessed August 26, 2015.

MetroDoctors

The Journal of the Twin Cities Medical Society

What is Single Payer

and Why Should Obstetrician-Gynecologists Care?

H

aving a baby in Minnesota is a pretty good deal. Many pregnant women have health insurance.

Most pregnant women who are not already insured are eligible for medical assistance (MA). The majority of the visits and tests during pregnancy are covered by insurers in a package which includes routine prenatal care, delivery, and post-partum care for up to six weeks. Yet, insured women are becoming more concerned about potential charges, more commonly asking “will this be covered?” and finding themselves with large unpaid medical bills. Given Minnesota is enrolled in the Affordable Care Act (ACA) and continues to support Medical Assistance why are women focusing more on coverage, medical bills, and policies than on their health and pregnancies? Additionally, why is the United States ranked 28th(1) for maternal mortality and falling if we are insuring more women?

Despite ACA and excellent medical assistance women are still underinsured in Minnesota. Women seeking pregnancy and gynecological care with good insurance have high deductibles commonly in the thousands of dollars. For many women the understanding is employment equals benefits equals health insurance. The summation of the deductible along with copays for visits (clinic, Labor and Delivery, ER, OR, lab, and ultrasound) results in out-of-pocket costs which are insurmountable and lead to feelings of betrayal and mistrust of the insurance system or her employer. Many women assume if they pay their monthly premium everything else should be covered. Even our more savvy

By Carrie Ann Terrell, M.D., FACOG

MetroDoctors

patients do not understand which visits, tests, procedures will be covered or at what percentage. Insurance companies compete by avoiding unprofitable patients and shifting costs to patients or providers. This system avoids caring for the sickest patients and creates huge administrative costs.

Meanwhile, health insurance CEOs are financially rewarded for generating profits which do not increase the wellness of our communities.

How often have we heard a middleaged patient, a friend, a coworker exclaim she is simply retaining a job until she qualifies for Medicare? How many of these patients put off visits, cancer screenings, wellness exams until Medicare “kicks in?”

A single payer program is essentially Medicare for all. The program would provide universal comprehensive coverage with free choice of providers and no direct charges to patients. A public agency would manage the plan and budget. Insurance company profits and multimillion dollar company executive bonuses would be eradicated. Mandatory referrals and pre-authorization for medications would

The Journal of the Twin Cities Medical Society

vanish. Improved access, the ability to obtain and monitor outcomes in a systematic way, and the ability to provide evidencebased care uniformly would improve the health of our populations. There would be no confusion as to when or if a visit, lab, medicine, or surgery would be paid for. The funding would be accomplished by taxes. Note these taxes are in lieu of premiums, co-pays, and deductibles. The Lewin Group recently studied the economic feasibility of a Minnesota single payer system. It found that such a system could provide comprehensive health and (Continued on page 24)

November/December 2015

23

Health Care Reform What is Single Payer (Continued from page 23)

dental coverage to every Minnesotan while saving the state an extraordinary $189.5 billion in health spending over 10 years.

The median-income Minnesota family would save an average of $3,512 per year on health care.(2) Daily, I am saddened and frustrated with our current processes and systems.

I envision a world wherein women can get the care they need when they need it without concern for cost. I desire a system in which the money invested in health care or insurance actually benefits patients. The U.S. spends 25-31 percent of our health care dollars on administrative costs.(3,6) This is more than Canada (12 percent), Netherlands (20 percent), or England (16 percent).(6) We spend half to three quarters of this money on administration of health care and the rest on administration of insurance.(3) Administration of health care includes: running our practices/clinics/ hospitals, paying executives to help us run our businesses, and dealing with various insurance companies. According to a study published in 2010 by Dante Morra1 and Sean Nicholson “We estimated physician practices in Ontario spent $22,205 per physician per year interacting with Canada’s single payer agency — just 27 percent of the $82,975 per physician per year spent in the United States.”(4) The money spent on the administration of insurance includes: health insurers’ advertisements, lobbyists, eight-figure executive salaries and six-figure bonuses and profits for the investors in those companies.

As physicians we feel a lot of pressure to do our part to decrease the costs of medicine. We receive grades from our community (MN Community Measurement), the government (Meaningful Use), and insurance companies on how well we prescribe generic medications, integrate technology into patient care, the ordering of expensive tests, and our patients’ lab values. While I do my best to limit excessive testing or prescribing I cannot have my practice do away with coders, billers, administrators who translate my clinical work into claims. I have no input into 24

November/December 2015

how many insurance companies exist or the rules for submitting claims. I am asked to focus on certain measures to elevate my practice’s tier within insurance companies.

As an academician I fully appreciate and am eager to participate in programs which will improve the health of my patients or reduce unnecessary costs. Society and government do not and legally cannot put the same obligations onto insurance companies. We do not expect Medica, Blue Cross, HealthPartners to decrease their costs to patients or improve the health of their customers. And how can they? Citing Morral and Nicholson again, “U.S. senior administrators also spent more time per physician than those in Ontario, mostly on overseeing claims and billing tasks. Very little time was spent in Ontario or in the United States on submitting quality data to payers or reviewing data on quality.”(4) So, we spend time and money dealing with insurance companies while trying to take care of patients and they spend time and money accepting, rejecting and negotiating our claims.

It’s not difficult to imagine how much more effective my care could be and how much safer, healthier, happier my patients would be if we spent a fraction of the money earned by insurance companies on actual health care. I realize my view and expectations of a single payer universal health care system are probably oversimplified and even naïve. I understand any proposed plan may increase taxes for some, even me, while lowering out-of-pocket costs for most Minnesota families. Currently, Governor Dayton has created the Minnesota Health Care Financing Task Force to evaluate and make recommendations for how Minnesota can increase access to care and the health of its citizens.

Our country started Medicare 50 years ago with the same objectives. It has been wildly successful for our population over age 65 and has increased coverage to younger individuals over time: In the 1970s we added long-term disability and end-stage renal disease. In the 1980s we added hospice care. In the 90s and 00s prescription drug coverage and those affected with ALS.(5) These Medicare expansions demonstrate

that we see value in universal health coverage for many U.S. citizens. I am confident Minnesota could create a system which is fiscally responsible and able to fulfill all Minnesotans’ health needs.

As a physician, I believe in good health and good health care for all our community members. As an OB/Gyn physician, I believe in good health and health care for our women. I believe providing women with attainable, equitable health results in healthier families and societies. We’ve been told over and over our current system is not sustainable. We know our outcomes are not improving. We know our patients are dissatisfied with their current costs and coverage. We know insurance executives earn a salary much greater than ours. We know our hospitals barely stay afloat and cannot invest in basic infrastructure. We know something has to change. Let’s do it the right way. Let’s change it for the better.

Carrie Ann Terrell, M.D., FACOG, Assistant Professor and Division Director General OB-GYN at the University of Minnesota.

She can be reached at (612) 273-7111.

References: 1.

Nicholas J Kassebaum, M.D. et al Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 The Lancet Volume 384, Issue 9947, 13–19 September 2014, Pages 980–1004.

2.

Cost and Economic Impact Analysis of a SinglePayer Plan in Minnesota; Prepared for: Growth & Justice Submitted by: John Sheils and Megan Cole – The Lewin Group.

3.

Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., and David U. Himmelstein, M.D. Costs of Health Care Administration in the United States and Canada. N Engl J Med 2003;349:768-75.

4.

Dante Morra, Sean Nicholson, Wendy Levinson, David N. Gans, Terry Hammons and Lawrence P. Casalino U.S. Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers Health Aff August 2011 10.1377/hlthaff.2010.0893.

5.

Thomas R Oliver, Philip R Lee, and Helene L Lipton A Political History of Medicare and Prescription Drug Coverage Milbank Q. 2004 Jun; 82(2): 283–354.doi: 10.1111/j.0887378X.2004.00311.x PMCID: PMC2690175.

6.

D. U. Himmelstein, M. Jun, R. Busse et al., “A Comparison of Hospital Administrative Costs in Eight Nations: U.S. Costs Exceed All Others by Far,” Health Affairs, Sept. 2014 33(9):1586–94.

MetroDoctors

The Journal of the Twin Cities Medical Society

Understanding MNsure Today

W

hen I was appointed to the MNsure Board of Directors in April of 2013, I was excited to be part of this new and innovative approach to improving access to health insurance in Minnesota. MNsure has been through tremendous changes since it opened for enrollment in October 2013.

In the beginning, the IT problems were very visible, but great progress has been made. Both the website and the business of the organization are functioning at a significantly higher level. The basic processes for eligibility and enrollment are working.

Further improvements have been added on time and as scheduled to be ready for open enrollment. There is more rigorous testing before additions are made so we have increased confidence as new functions are added. As with any IT system, there will be continual improvements and enhancements. We’re focused on the immediate needs of a better experience for open enrollment as well as defining a positive and productive long-term strategy.

Our first priority is to have a robust and stable IT system that can deliver a quality experience for consumers and for our industry, government and community partners. With the progress made in IT and business practices, we can now begin to address more consumer needs, health care delivery reform issues and other longterm goals. Projects currently underway were chosen for their impact and the ability to be implemented without distracting from our established immediate IT priorities. These projects include improving

By Kathryn Duevel, M.D. MetroDoctors

transparency of the enrollment and business structure, a consumer decision tool to allow Minnesotans to better understand their overall health insurance costs and a request for the health plans to include innovative products to address the needs we heard from stakeholder interviews.

The initial IT struggle was not the only controversy surrounding MNsure.

This year there were questions about insurance rates, governance, scope of work and funding.

MNsure plays no role in the rate determining process. This process occurs in the Departments of Commerce and Health. We won’t know what the rates will actually be until they are released in October. As rates increase, more people become eligible for tax subsidies and other financial assistance. If rates increase, checking prices on the MNsure website will be even more important, since only policies bought through the online marketplace are eligible for financial assistance.

During the 2015 legislative session there were two proposals to change Minnesota’s Health insurance marketplace.

This created some confusion over the future of MNsure. One proposal dissolved the current state-based exchange and replaced it with Healthcare.gov. The other kept the state-based exchange model but dissolved the current board of directors, creating a more traditional state agency with accountability directly to the governor through the CEO, similar to the role of a commissioner of a state agency.

Neither proposal was adopted and the discussion concluded with the formation of the Minnesota Health Care Financing Task Force to address MNsure’s future as

The Journal of the Twin Cities Medical Society

part of a more comprehensive discussion of health care delivery in Minnesota. The discussion will include financing, affordability, program alignment and transformation of our health care delivery system among others. MNsure’s interim CEO is a member of the task force. MNsure is ready to provide any information that the task force requests directly from MNsure staff or from background research and documents. The task force began meeting in August. Their report is due to be given to Governor Dayton on January 15, 2016.

MNsure’s operating budget and revenue sources are frequently discussed topics. MNsure operated with three streams of revenue for the first three years: 1. A 3.5 percent premium withhold on policies sold through the exchange.

(Continued on page 26)

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Health Care Reform Understanding MNsure Today (Continued from page 25)

MNsure estimates enrollments to project income and create a projected budget.

2. An allocation from DHS to reimburse MNsure for the IT work done for DHS. The larger than expected enrollment in public programs has resulted in a proportionately higher contribution from this allocation.

3. Center for Consumer Information and Insurance Oversight (CIIO) establishment grants that will end in FY2016.

MNsure’s budget is and always has been balanced. There are no plans to go to the legislature to ask for more funding at this time. Instead, MNsure is focused on increasing the number of people buying on the exchange. A great shopping experience is the most effective marketing tool. Focusing on this benefits consumers and increasing the number of consumers buying insurance through MNsure makes the exchange more financially sustainable.

Outreach and enrollment assistance are key to increase enrollment and to reach the remaining uninsured. Educating consumers about the need for insurance, how to get insurance and how to use it are increasingly important functions of our partners who provide these services.

So what does this mean to practicing physicians and our communities? The most frequent questions asked by my colleagues fall into three categories: 1. Access to insurance In spite of what you may hear, at this point the vast majority of people who come to MNsure.org can sign up for insurance with little difficulty. More than 500,000 Minnesotans have obtained health insurance coverage through MNsure since the October 2013 launch. Some IT problems still exist but they are being solved daily.

Real problems arise for families with complex insurance needs. These cases need personal attention and often involve help from county staff or a MNsure certified navigator or broker.

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You can safely encourage your patients to sign up for insurance through MNsure, or get free, in-person enrollment help from one of the hundreds of navigators or brokers across the state. If you are dealing with a complicated family structure, the family will probably do better with assistance than trying to sign up online without help.

2. Affordability and appropriateness of the policy for a patient MNsure is the entry point for Minnesotans to get insurance through public programs and private plans. We need to find better ways to make plans affordable so that the insurance is usable to those barely above the income thresholds for public programs. The MNsure board made two recommendations that begin to help. First is a consumer decision tool on the website so patients can make better-informed choices. Instead of a choice based on premium alone, a decision should include information on cost sharing and how they will use their insurance. The second recommendation is a letter sent to health plan companies asking for innovative products to address affordability and other consumer needs.

We hope to see new products in this category for the 2017 plan year.

While we expect those recommendations to assist consumers, a current valuable resource is our network of outreach and education community partners. As our uninsured rate drops, educating consumers to evaluate plans based on their needs and how to use the benefits they have in their plans becomes an increasing role for these organizations.

plan offerings are under review by the Department of Commerce. MNsure has no input into those processes.

MNsure can set additional standards that will apply only to plans offered through MNsure. Currently, all plans approved at Commerce are accepted but MNsure has the authority to add additional criteria. As more data about quality ratings and network adequacy become available, patients can use these criteria to choose their health plan. In the future, MNsure may elect to use these criteria and others to improve the quality of insurance products offered.

The future of MNsure is on solid ground. While the exchange and the business have had serious challenges, every year and every day we are improving. Importantly, we have seen the rate of uninsured Minnesotans drop. We want to be the catalyst for development of new and innovative ideas in health care insurance.

After two challenging years, MNsure is beginning to look ahead to the positive contributions we can make in addressing our state’s health care needs with a robust and stable health insurance exchange in place.

Dr. Kathryn Duevel attended the University of Minnesota where she received her BS and MD degrees. She is board certified in OBGYN and practiced for 21 years at ACMC in Willmar, MN. She completed an MS in Health Care Delivery Science from Dartmouth College in 2013. Her interests include women’s health policy, international medicine, innovation in health care delivery and policy surrounding disparities and access to health care. She was appointed to the MNsure Board of Directors in 2013, where she currently serves as Vice Chair. She can be contacted at: kmduevel@yahoo.com.

3. Empowerment of physicians to provide the right care While MNsure can affect policy around quality of insurance plans offered on the marketplace, adequacy of plan coverage is decided by the Department of Health, while the rates and financial soundness of the MetroDoctors

The Journal of the Twin Cities Medical Society

Competitive Bidding for State Managed Care Contracts Benefits Patients, Taxpayers

F

or more than a decade, “reduce health care costs” was the refrain that echoed throughout human services, and government generally. This often meant choosing between low-income people and taxpayers, presenting policymakers with the difficult choice of providing the basic care and benefits people needed, or reining in runaway health care costs — never both together.

Until four years ago. That’s when the Minnesota Department of Human Services (DHS) rejected this false choice and developed a new and better way to purchase health care for low-income Minnesotans: competitive bidding for state managed care contracts.

This new process has saved taxpayer dollars and improved the quality of health care for enrollees.

Before 2011, managed care contracting was done on a non-competitive basis.

Generally state business was given to health plans (managed care organizations) that met certain requirements. They were paid rates that rose every year based on medical inflation, to the tune of about 6 percent a year.

The plans competed with each other to get enrollees to sign up, but they had few incentives built into these contracts and little encouragement to innovate on cost, quality or service delivery. The introduction of competitive bidding presented managed care organizations with an opportunity to revisit their business practices and find new ways to deliver better quality care at lower prices.

A pilot program approved by the Legislature in 2011 allowed DHS to negotiate better health care benefits and get the best possible deal for taxpayers. Because of the

By Nathan Moracco, Assistant Commissioner MetroDoctors

program’s success in the Twin Cities metro area in 2011 (for 2012 managed care contracts) and in 27 counties in 2013 (for 2014 managed care contracts), in 2014 the Legislature directed DHS to expand competitive bidding statewide.

DHS did that this year, for the first time, with significant results for people enrolled in public health care programs and taxpayers. Statewide competitive bidding for the 2016 managed care contracts will result in taxpayer savings of $450 million next year alone. Because of competitive bidding and other reforms since 2011, we will save taxpayers an estimated $1.65 billion by 2016. More than that, hundreds of thousands of Minnesotans will receive better quality health care. That’s just the kind of reform Minnesotans expect, and deserve.

Change of this magnitude did not happen without help from communities around the state. DHS asked for and received significant input as we developed the request for proposals (RFP) for the 2016 managed care contracts. DHS staff met with more than 15 advocacy organizations, including doctors and clinics, stakeholder groups and tribes,

The Journal of the Twin Cities Medical Society

counties and health plans and county-based purchasing plans under current contracts.

We received more than 30 responses to our request for comments on this process.

All of this feedback went into constructing the final request for proposals. For example, we heard concerns from providers about the length of time it took for claims to be paid, so we asked responders about their claims payment process and how long it took them to process claims. Overall, we believe the request for proposals reflected the concerns and priorities of a wide range of state, local and advocacy interests.

DHS also asked counties to develop questions focused on specific issues in their communities. These questions, which were scored by county human services agencies, represented 20 percent of the overall score for health plans, and nearly 40 percent of the overall score for county based purchasers.

Questions developed by counties addressed issues such as how responders are reducing barriers associated with racial and/or ethnic disparities, how they are addressing the lack of transportation services in rural areas and how they will expand their provider networks in key areas such as interpreter services.

While historically quality of care for enrollees in public programs has lagged behind quality for other enrollees, over the last year there has been significant improvement in key categories, such as optimal diabetes and vascular care. According to Minnesota Community Measurement’s most recent Minnesota Health Disparities report, the rate of optimal care received by patients with vascular disease increased by 8.5 percent, while the rate of optimal care received by patients with disabilities rose 6.7 percent.

(Continued on page 28)

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Health Care Reform Competitive Bidding (Continued from page 27)

Transitions and large changes are never easy. But competition allows us to push health plans to improve quality and access to care, and to improve in areas where they fall short, such as mental health care and dental care for children. Using competition to drive better care and better results for the people we serve is the best way to ensure those improvements become reality.

While the number of public health care program enrollees transitioning plans is larger than in previous years, the annual health plan selection process is not new to enrollees. Many of them have selected health plans during previous selection periods, and are familiar with the process. For the large majority of public health care program enrollees who are not receiving ongoing treatment, we anticipate that there will be little change in their health care experience.

DHS created an external stakeholder work group to help us during this year’s annual health plan selection process, to help ensure smooth and seamless movement between plans for our enrollees. This group

includes representatives from health plans, counties, the mental health community, community organizations, limited English proficiency communities and other advocacy organizations. It is advising DHS on critical operational and communications issues during the transition, such as data transfers between health plans to support continuity of care and identification of key providers as health plans develop and implement public information campaigns aimed at specific communities.

For people enrolled in the Medical Assistance and MinnesotaCare programs, and the providers who serve them, the most important thing to know is that no one will lose coverage or benefits.

Enrollees will have until Dec. 11, 2015, to choose a health plan during the annual health plan selection period. If an enrollee doesn’t proactively pick a health plan, for whatever reason, he or she will automatically be placed in a health plan with coverage beginning on Jan. 1, 2016. If he or she wants to choose a different health plan, for whatever reason, he or she will have 60 days starting Jan. 1, 2016, to change plans.

All health plans serving the Medical Assistance and MinnesotaCare programs must provide all services covered under the contract, without delay, once a person is enrolled and coverage begins. Coverage for doctor visits, hospital care, mental health care, prescription drugs and other services does not change when a person enrolled in one of these programs switches health plans.

There may be some differences from plan to plan in the network of health care providers they may use or in coverage of specific prescription drugs, but benefits will stay the same.

Because of our state’s strong network adequacy requirements, most enrollees will not have to change providers. For those who will have to change providers, we will have transition plans, and no one will have to change providers where continuity is essential to their care. State law specifically addresses continuity of care for circumstances including previously authorized services, pregnancy, chemical dependency services, mental health services and prescription drugs.

Now that statewide bidding is nearly complete, we know that providers around the state are ready to step in and serve the state’s health care program enrollees. For those enrollees changing doctors, it’s vitally important that providers help welcome their new clients and provide assistance with transitioning their medical care.

The goal of competitive bidding is to improve the quality of health care for the hundreds of thousands of Minnesotans we serve in the Medical Assistance and MinnesotaCare programs, and to do so at significant savings to taxpayers. By those measures, our competitive bidding reforms have been a resounding success.

Nathan Moracco has served as Assistant Commissioner for Health Care at DHS since December 2013. Prior to his current position, he served as Acting Deputy Assistant Commissioner for the Health Care Administration.

Prior to coming to DHS, Moracco served as Director of the Employee Insurance Division within Minnesota Management & Budget for more than a decade. Assistant Commissioner Nathan Moracco can be reached at nathan. moracco@state.mn.us or (651) 431-5929.

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MetroDoctors

The Journal of the Twin Cities Medical Society

In Memoriam JAMES G. ANDERSEN, M.D. passed away on August 27, 2015 in Winnetka, IL. Dr. Andersen was a staff sergeant for three years with the USMC during WWII. He received his medical degree from Harvard Medical School in 1952, followed by an internship and residency from the University of Minnesota. Dr. Andersen is a co-founder of Emergency Physicians Professional Association (EPPA). Dr. Andersen became a member of the medical society in 1960.

WILLIAM R. HILGEDICK, M.D. passed away on August 14, 2015. Dr. Hilgedick received his medical degree at the University of Minnesota. He was a partner at Columbia Park Medical Group. Dr. Hilgedick served as Captain in the U.S. Army Medical Corps in Taiwan. He joined the medical society in 1961.

ROBERT D. LETSON, M.D. passed away on September 13, 2015. Dr. Letson received his medical degree at the University of Minnesota in 1952 and completed an internship at Minneapolis General Hospital. He practiced family medicine in Glenwood, MN for 10 years including serving two years in the U.S. Army Medical Corp in France. Dr. Letson continued his education with an Ophthalmology residency at the University of Minnesota and fellowship at the University of Oregon and Institute of Visual Sciences in San Francisco, CA. In 1967 he received a faculty appointment at the University of Minnesota and is known as the “Father of Pediatric Ophthalmology.� Dr. Letson joined the medical society in 1954.

GREGORY A. SCHISSEL, M.D. passed away on August 23, 2015. He served in WWII as an Army Air Force B17 pilot. He earned his medical degree from the University of Minnesota and practiced family medicine with his partners at Crystal Doctors Park. In 1972 Dr. Schissel joined the U.S. Foreign Service in Liberia and South Africa. He returned to Minnesota to complete his medical career. He joined the medical society in 1953.

ARTHUR E. SETHRE, M.D. passed away on August 30, 2015. He graduated from the University of Minnesota Medical School and practiced family medicine in Fergus Falls for several years. In 1970 Dr. Sethre returned to St. Paul joining the medical department at 3M. He became a member of the medical society in 1955.

MetroDoctors

The Journal of the Twin Cities Medical Society

November/December 2015

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New Members Blanche M. Chavers, M.D. University of Minnesota Division of Pediatric Nephrology Pediatrics, Pediatric Nephrology Thomas E. Christenson, M.D. Ear, Nose & Throat Specialty Care of Minnesota, PA General Surgery, OtolaryngologyHead & Neck Surgery Brooke Ayoka Cuningham, M.D. UMN Family Medicine & Community Health Internal Medicine William J. Garvis, M.D. Ear, Nose & Throat Specialty Care of Minnesota, PA Otolaryngology, Neurotology

CAREER OPPORTUNITIES

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November/December 2015

Tamiko R. Morgan, M.D. Hennepin County Medical Center Pediatrics

Michael B. Johnson, M.D. Ear, Nose & Throat Specialty Care of Minnesota, PA General Surgery, OtolaryngologyHead & Neck Surgery

Michael Barclay Pitt, M.D. University of Minnesota Department of Pediatrics Pediatrics

Nissim Khabi, M.D. Ear, Nose & Throat Specialty Care of Minnesota, PA Otolaryngology

Steven R. Vincent, M.D. People’s Center Family Medicine

John Kvasnicka, M.D. HealthEast Internal Medicine

Larry A. Zieske, M.D. Ear, Nose & Throat Specialty Care of Minnesota, PA Otolaryngology

Michele Montejo Loor, M.D. University of Minnesota Department of Surgery Surgery, Surgical Critical Care

See Additional Career Opportunities on page 31.

MetroDoctors

The Journal of the Twin Cities Medical Society

CAREER OPPORTUNITIES

Please also visit www.metrodoctors.com

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November/December 2015

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

FRANK J. INDIHAR, M.D. THE SAGES TAUGHT: “I have learned much wisdom from my

teachers, more from my colleagues and the most from my students.”

Those thoughts are echoed by our Luminary, who — when asked what part of his splendidly diverse career provided him with the most gratification — answered, “Mentoring — it gave me the greatest joy of all!” More about that later . . .

Dr. Frank Indihar was born in Gilbert, MN and educated at our U of M where he earned B.S. and M.D. degrees and completed internal medicine training at its affiliated program.

His residency was interrupted by two years of Army service in Vietnam and Washington, D.C., having then been honored with a Bronze Star, and he returned to serve as Chief Resident at the Minneapolis V.A. Hospital.

Frank’s St. Paul private practice of internal and pulmonary medicine numbered nearly 30 years. During that period, he found the time to also become deeply involved and play leadership roles in the MN Society of Internal Medicine, the Allina Physicians Council, the MN Academy of Medicine, the MMA and our Ramsey/Twin Cities Medical Societies from which he led and chaired our Minnesota AMA Delegation from 2002-2008.

Dr. Indihar spent decades on the adjunct faculty of his alma mater, attaining the academic title of Professor which accompanied his Fellowship in the American College of Physicians and an MBA earned relatively late in his career.

Among his most pleasant professional activities were those connected to the Bethesda Rehabilitation Hospital, where he founded and medically directed the Prolonged Respiratory Care Unit and later became the facility’s overall CEO. Both his administrative and clinical talents were valued facets as he made decisions relating to resource allocation, health care policy and quality of care. When Frank was asked how he summons the energy to engage in and balance so many pursuits, he modestly replied, “I guess that is fueled by my passion for medicine and all that it entails.”

Dr. Indihar and his wife, Dr. Anita Pampusch, have partnered through the years to contribute greatly to civic aspects of our community through their interest and dedicated service to organizations including the Minnesota Symphony and Opera Associations, St. Catherine and St. Thomas Universities, Walker Art Center, the Minneapolis Institute of Art and the Bush Foundation.

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Frank has authored 20+ medical literature publications on topics ranging from trigeminal neuralgia to managed care and hypersensitivity pneumonitis, and has lectured from Guatemala to Rochester and to our Twin Cities professional audiences regarding respiratory subjects.

A few words on perhaps his favorite activity are in order . . . For many years, Dr. Frank spent countless hours mentoring medical students.

He has continued those personal developmental transmissions with many of them long after they graduated — believing that “there are few relationships more pure and important than that of a mentor/mentee.” A thankful mentee has related some of the motivating principles taught to him by our Luminary, and they speak for themselves: “No one is a better advocate than oneself, but it should be done in a way that simultaneously elevates others;” “Appreciate art and use it as a lens to understand other cultures;” “The future of medicine belongs to the passionate;” “Make good friends part of your family;” “Sincerity and concern for others is something to be practiced and perfected.”

The following is a statement by a protégé of Dr. Indihar that is reflective of the abundant benefits he has imparted to his students: “ . . . he leads by example and in doing so, exemplifies the very best parts of medicine and the human connection.”

We agree!!

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

Please join us in welcoming…

Phillip Keith, MD

Jozef Lazar, MD

Jessica Morrell, MD

Lydia Turnbull, MD

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