Minnesotans Choose Health Insurance Online by Advocates for Better Health

It’s time to make a difference. September 8–10, 2013 http://www.mayo.edu/transform/

Contents VOLUME 15, NO. 4

Index to Advertisers

In thIs Issue

J U LY / A U G U S T 2 0 1 3

The Coming Health Insurance Exchange: MNsure By Peter Dehnel, M.D.

PresIdent’s Message

Informed, Empowered, Rewarded By Edwin N. Bogonko, M.D.

tCMs In aCtIon

By Sue Schettle, CEO

6 Page 6

heaLth InsuranCe eXChange

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Colleague Interview: A Conversation With: Roger G. Kathol, M.D.

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Health Insurance Exchange—A National Perspective By Nathan Mussell, J.D., and David Asp, J.D.

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Profiling MNsure: How Minnesota’s Health Insurance Marketplace Came to Be By April Todd-Malmlov

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Back to the Future: An Employer Perspective on the Minnesota Health Insurance Exchange By Carolyn Pare

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How Will MNsure, 2014 Health Insurance Reforms Affect Your Patients? It Depends. By Julie Brunner, J.D.

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Health Exchange: Helping Consumers Keep Their Dollars—and Their Doctor By Representative Joe Atkins

Page 27

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High Risk Insurance Pool Prepares for Transition as Healthcare Reform is Implemented By Karen Einisman

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Exchange: For the Better? By Dave Racer, MLitt

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A Historic Legislative Session By Nathan Mussell, J.D.

TCMS Caucus Meets—The Discussion Continues

Honoring Choices Minnesota Summer Highlights

In Memoriam

New Members/Career Opportunities

LuMInary of twIn CItIes MedICIne

Carolyn Adair Johnson, M.D. Page 32 MetroDoctors

8 Things Physicians Need to Know about MNsure

The Journal of the Twin Cities Medical Society

It’s all about the health insurance exchange — national and local perspectives. Articles begin on page 6.

July/August 2013

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio 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.

July/August Index to Advertisers

TCMS Officers

President: Edwin N. Bogonko, M.D. President-elect: Lisa R. Mattson, M.D. Secretary: Carolyn McClain, M.D. Treasurer: Kenneth N. Kephart, M.D. Past President: Peter J. Dehnel, M.D.

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TCMS Executive Staff

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Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Communications and IT Coordinator (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com Terri Traudt, Project Director, Honoring Choices MN (612) 362-3706 ttraudt@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

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The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

The Coming Health Insurance Exchange:

MNsure WELCOME TO THE RAPIDLY EvOLvING WORLD of health care insurance and the purchasing of health insurance policies by individuals and employees of eligible small businesses. This issue of MetroDoctors is compiled to help physicians in Minnesota be better prepared for the coming new reality that we will face as the Minnesota-based health insurance exchange — MNsure — comes online on October 1, 2013. The better informed that we as physicians can be, the better resource that we can serve for our patients and families as they work to navigate their new online choices for insurance coverage that will take effect on January 1, 2014. As many people know, the state-based insurance exchanges are a mandated provision of the 2010 Affordable Care Act. The 50 states and Washington, D.C. have an option of creating their own exchange, such as Minnesota, choose to have the federal government create one for the state, or have a “hybrid” federal-state program. There is not an option, as some Twin Cities physicians have suggested, of not having an insurance exchange for the state. In addition, the policies that are available on the exchange are required to have an extensive list of covered services, known as the 10 categories of essential health benefits. Many of these services are in the preventive category and will be available to subscribers of that plan at little or no out-of-pocket cost to themselves at the time they receive the service. As an Editorial Board and TCMS staff, we have worked to provide a diversity of positions and opinions that will hopefully serve to inform you, the reader, more fully about the exchange. It is very likely, as mentioned before, that physicians will be in a position to help guide their patients and families to an insurance choice that meets their needs and helps to maintain your availability as a clinic and network choice for them. Dr. Roger Kathol provides a physician perspective through our “Colleague Interview” format and discusses MNsure in the context of other aspects of national and state-based health care reform. David Asp and Nate Mussell from Lockridge Grindal Nauen, PLLP, give a national view in which the Minnesota effort is evolving. Dave Racer highlights his concerns from a consumer viewpoint. April Todd-Malmlov is the current executive director of MNsure, providing critical information on the direction the development effort is heading. Carolyn Pare is CEO of the

By Peter Dehnel, M.D. Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

Minnesota Healthcare Action Group and provides both a present view of the employer’s position in the insurance exchange as well as its connection to past efforts through BHCAG (Buyers Health Care Action Group). Julie Brunner, executive director of the Minnesota Council of Health Plans, summarizes how health care insurers are approaching the development of the exchange. How the Minnesota Legislature navigated the legislative challenges needed to create MNsure is retold by Rep. Joe Atkins, chair of the House Commerce Committee. Finally, Karen Einisman conveys how the Minnesota-based, high risk insurance plan known as MCHA (Minnesota Comprehensive Health Association) will be incorporated into MNsure. This edition of MetroDoctors will be rounded out by two additional articles. A succinct “2013 Legislative Wrap-up” is provided by Nate Mussell of Lockridge Grindal, Nauen, providing an overview of this year’s very active legislative season. Finally, Dr. Marv Segal highlights another memorable and influential physician — Dr. Carolyn Johnson — in the continuing series “Luminary of Twin Cities Medicine.” As stated before, one of the purposes of this edition is to help physicians better prepare for the coming changes in health insurance that will be implicit in the launching of MNsure on October 1, 2013. The purchased plans will take effect January 1, 2014. Many people associated with the development of MNsure acknowledge that with the tight time lines and deadlines imposed, there will be changes and adjustments that will need to be made even after the process goes “live” on October 1. The real opportunity for physicians and clinics is to stay informed and knowledgeable of the evolving program so that they can be an essential resource for their patients and families who will be applying for the first time for a policy online. That is where working collaboratively with other physicians through an organization like TCMS will likely be an essential process going forward. Other options and alternatives that you see as solutions would be great to hear about. I hope you enjoy this edition of MetroDoctors and find it helpful and applicable to your practice or professional setting. Your feedback is always appreciated. July/August 2013

President’s Message

Informed, Empowered, Rewarded EDwiN N. BOGONkO, M.D.

Dear colleagues,

e just survived a bizarre end to the winter and still not sure what season we really are in. As one would say, whoever was in charge of the weather last year needs to get their job back. Anyway, the year is half over and as we reflect, a few important developments. This summer, the MMA will again present its ongoing desire for sweeping governance changes that will no doubt alter the way we set and articulate policy around issues important to Minnesota physicians. The TCMS board has dedicated an incredible amount of time and energy on this issue as reflected by our previous issue of MetroDoctors. Please do your part and consider attending the annual meeting and contribute to this important discussion. In this issue, the new paradigm of health insurance exchanges is profiled. In our state, MNsure has finally taken shape and we are just beginning to understand what it will bring to the health care landscape in Minnesota. Many questions await — will it result in widening coverage as touted? Will final premiums be out of reach for those that it is intended to cover? Are employers going to be mandated to provide certain levels of coverage when employees can’t afford the basic premium costs or will they opt to be fined in default? Are physicians going to receive less reimbursement without recourse? If there are increases in the insured, is there going to be an access crunch? We all know of the national shortage of primary care providers. As physicians, we need to pay attention to this whole debate about financing health care and MNsure’s attempt to bring an open health insurance marketplace. Please read widely and stay informed. We hope that this current issue of MetroDoctors lays the foundation that informs our participation in serving our patients. The exchange starts providing health coverage to individuals on January 1, 2014. Every year, the Health and Human Services budget gets considerable attention as our legislators near the end of session. Through concerted advocacy, TCMS continues to engage leaders at the capitol and during this financial cycle, we were delighted that the final budget included a full restoration of the Medical Education and Research Costs (MERC) program funding — essential to help train health care providers throughout the state. Additionally, a long-awaited across-the-board reimbursement increase was included for physicians and dentists which we hope would mitigate in part against the provider tax. We consider this a key issue for our society as we continue to advocate for health care fund spending to be plowed back into health care activities and medical education. On a more personal note, last month, one my colleagues completed an incredible 30 years of service to St. Francis Regional Medical Center in Shakopee. Dr. Lars Conway will be remembered for his humility and personal engagement with every one of us that shared a mutual patient. Always intent on the welfare of both physician and patient, one can’t help but hope that many of today’s physicians can emulate such humanity. We will miss him but I am sure the plains of Wyoming where he will enjoy the sunset of his career is the perfect backdrop for reflection. Every day, many physicians continue to volunteer their time in service to the profession — we thank them. As a society, we will continue to engage our membership and serve them respectfully. Your participation is much appreciated. Enjoy the summer ahead! 4

July/August 2013

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The Journal of the Twin Cities Medical Society

tCMs In aCtIon SUE A. SChETTLE, CEO

Legislative and Policy Committee

TCMS’ Legislative and Policy Committee had a very successful year with three of the four key areas we focused on this session moving forward. In early 2013 TCMS conducted a survey of our membership asking you to prioritize the top 10 legislative issues that were most important to you. The results of that survey helped the Legislative and Policy Committee focus their efforts on supporting graduate medical education funding, increasing the tobacco tax and increasing physician reimbursement in state public health care programs. All three of these issues were hotly debated but, in the end, moved forward. The fourth area of focus relates to advance practice nurses efforts to expand their scope of practice. This issue will be dealt with in the next legislative session. Watch for more information about this issue in the near future. TCMS will be hosting two Forums in 2013 for our members and others. The first one, related to the Health Insurance Exchange (MNsure), will be held the last week of September, 2013. The goal is to educate our members about the upcoming exchange and provide them with resources and tools to help our members and their patients navigate the exchange. Speakers are being confirmed as I write this article. Please watch for additional information promoted through email. The second forum will be related to mid-level providers (advance practice nurses) and their role and relationship with physicians. Details are still fluid on this Forum. Stay tuned.

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Honoring Choices Minnesota

Honoring Choices Minnesota continues to move ahead full steam. A photo of Kent Wilson, M.D., Edwin Bogonko, M.D. and me was featured in the George Family Foundation annual report. We were able to highlight the successful year that Honoring Choices Minnesota had in 2012, due in part to funding received from the George Foundation. Many community presentations continue to be held by our volunteer Ambassadors (see related article on page 28). A business plan has been developed and will be used as a basis for long-term sustainability planning. Honoring Choices Minnesota staff consultation services continue to be needed. I just returned from a presentation to the Richmond Academy of Medicine in Richmond, Virginia. They are interested in doing an Honoring Choices Minnesota program similar to ours. Discussions continue to evolve in Massachusetts, parts of California, Texas and Florida. It is my pleasure to introduce you to Terri Traudt who recently joined TCMS as a project manager for Honoring Choices Minnesota. Terri will be focusing her time initially on the development of continuing medical education for advance care planning for physicians in Minnesota. Twin Cities Obesity Prevention Coalition

Jennifer Anderson, project coordinator for TCMS’ obesity prevention work continues to make progress introducing healthy eating active living resolutions to metro area communities. Funding for her work concludes at the end of 2013; however, Jennifer is actively applying for additional grants in an effort to continue this good work.

The Journal of the Twin Cities Medical Society

TCMS Caucus

TCMS caucuses were held on Wednesday, June 5, and Monday, June 24 in preparation for the upcoming MMA annual meeting in September. Resolutions discussed by the caucus are available on the TCMS website: www.metrodoctors. com. If you’re interested in serving as a delegate at this year’s MMA Annual Meeting please connect with Andrea Farina at afarina@metrodoctors.com. We need you! Own Your Future

TCMS is a partner of the Own Your Future campaign that is being championed by Lt. Governor Yvonne Prettner Solon and Commissioner of Human Services Lucinda Jesson. Own Your Future helps Minnesota prepare for the dramatic increases in the number of people who will be age 85 and older by the year 2030. The www.mn.gov/ownyourfuture website helps Minnesotans to plan to meet their long-term needs, including how to pay for necessary services using private financing options to pay for increasing expenses. MetroDoctors Survey

Each of you were emailed a readership survey last month. Your feedback is important and will be used to guide the editorial board in continuing to produce a journal that is interesting and engaging to our membership. Please contact Nancy Bauer for another copy of the survey if needed.

July/August 2013

MedicalInsurance Telemedicine Health Care Organizations Exchange

Colleague Interview: A Conversation with Roger G. Kathol, M.D.

oger G. Kathol, M.D., president of Cartesian Solutions, Inc.,™ is a health strategist who assists employers, government agencies, health plans, hospitals and clinics, and care management vendors develop integrated programs for patients with health complexity, many of whom have concurrent general medical and mental disorders. Dr. Kathol received his medical degree from the University of Kansas School of Medicine, Lawrence; and completed a residency at the University of Iowa Hospital. He is board certified in internal medicine, psychiatry, and medical management. Dr. Kathol is an adjunct professor of internal medicine and psychiatry at the University of Minnesota and is a member of the Minnesota Medical Association Board of Trustees representing the Twin Cities Medical Society.

What are the integration implications and positive/ negative effects on the current ACO networks with the exchange program? Will there be real choices? I don’t think the exchange will have a positive or negative effect on ACOs. The exchange is focused on how consumers will purchase health coverage. ACOs focus on how physicians and hospitals are reimbursed. Effective January 2015, the exchange does have the authority to establish specific criteria for selecting qualified health plans that can be offered. To the extent that insurers create products that utilize ACO-type models that otherwise meet all requirements, such as network adequacy, these products could be offered through the exchange. Affordable insurance products will be in high demand, particularly given that individuals with incomes between 138-400 percent of poverty must purchase coverage on the exchange in order to obtain the federal tax credits. And while choice is important — for consumers and physicians — options without meaningful differences can cause confusion. The experience in Massachusetts suggests that people get confused if there are more than four or five options. It is also important that the options don’t create adverse selection. Insurance is about populations sharing risk so that all can buy an affordable product. If increased options create adverse 6

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selection, it becomes bad for all — citizens, patients and doctors. That is when we revert back to a large population of uninsured (non-paying patients) and the use of high cost approaches to “crisis” health.

Will physicians in independent medical practices be required to join an ACO or be providers in a Minnesota health plan network in order to have their services paid for — either to them or directly to the insurance policy owner? There are models that allow physicians in independent practice to continue working alone or in small groups and yet contribute to care for populations of patients. These models, however, will most often impose population-based expectations on the independent practitioners for them to be paid for the care they provide (e.g., follow practitioner communication guidelines, use common electronic health records, access care management for complex patients, maintain prevention measures, employ best practices treatment guidelines, etc.). The practice of medicine is changing. It will endorse and perhaps enhance patient-centeredness (a core of independent practice) but will also have population-based components to improve outcomes for complicated or treatment resistant patients MetroDoctors

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present in any population. Unless independent practitioners embrace these changes, they will find practice during the next 10 years challenging.

How will insurance products be determined and by whom? Will competitive insurance products from companies outside the state of Minnesota be allowed? Or, will only qualifying Minnesota (nonprofit) insurance companies be allowed to participate? Any product offered on the exchange must first be licensed according to Minnesota law. There is nothing in the exchange law that changes the role of the state Department of Commerce to regulate which insurance companies can sell products in Minnesota. It is my understanding that insurance companies will be allowed to offer a wide variety of insurance options inside and outside of the exchange, provided that they meet the federal requirements (i.e., covering essential health benefits and complying with underwriting restrictions). Separate legislation is moving forward to reduce the likelihood that the exchange will suffer from adverse selection (and thus unaffordability). This legislation would create a standard set of rules for insurance products sold inside or outside of the exchange. Its ability to mitigate adverse selection, however, remains to be seen. Hopefully, the Exchange Board will have sufficient power to ensure that adverse selection does not creep in. As far as I know, nothing in the exchange legislation changes Minnesota state law that requires HMOs to be non-profits. Current law allows other insurers to be for-profit. Any insurance company that meets Minnesota licensure requirements can sell insurance in Minnesota if they choose.

In light of the fact that the exchange will be a new exercise for all, it is likely that significant anxiety and frustration will be engendered in potential subscribers who will be doing the “shopping.” Are there plans to help alleviate some of those issues? Is there a penalty for not enrolling? Minnesota is a leader in the development of software that its citizens can use to buy exchange insurance products. Doctors should go to the exchange website and try it out when it opens. Despite what appears to be as good an initial entry point for exchange purchasers as available in any state, there are bound to be glitches. For those who may have trouble navigating the new exchange website there will be assistance — a navigator/broker system is being developed to support those having trouble or deciding on products. At the base of the question is, “Why subject the population to anxiety and frustration with introduction of the exchange?” The answer is that unless something is done to curb medical inflation that is 2+ percent higher than the consumer price index, the U.S. will go bankrupt. You think that the burst housing bubble was MetroDoctors

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bad? Wait until the medical bubble bankrupts the economy. There is not a penalty for failing to use the exchange, but there could be penalties if individuals do not obtain coverage. The ACA individual “mandate” or “penalty” did survive legal challenges. Individuals who fail to obtain qualifying coverage effective January 2014 will face a $95 per adult ($47.50 per child) penalty, up to $285 for a family or 1 percent of family income, whichever is greater. The penalties increase in both 2015 and 2016. To my way of thinking, the penalty is not robust enough to discourage “going without.” Again, insurance is about sharing risk. If a large portion of the population chooses not to buy exchange or non-exchange health insurance and only wants to become insured when the need arises, it defeats the purpose of insurance and creates a scenario for unaffordability. Should we have decided it was not mandatory?

How will physicians get up to speed with knowing enough about the exchange to be of value to their patients who ask them what plan they should sign up for? This is an opportunity for the MMA, TCMS, and other component medical societies to assist their physicians in their understanding of the impact of exchange products on their patients and their practices. Change is happening. Those who do not become informed will suffer, including good doctors who don’t adjust and adapt. The MMA is changing its governance structure to support statewide physician forums on topics of interest and importance. Exchanges are one of the areas in which physician growth could occur at such forums. The forums could be both educational and an opportunity for doctors in Minnesota to suggest exchange enhancements/improvements. Based on forum discussion, the Policy Council could formulate recommendations to a nimble MMA Board for action on behalf of Minnesota doctors and their patients.

In that essential benefit plans among the health plans will essentially be the same, how do you believe that selection decisions will be made by the potential subscribers, i.e. cost alone, additional health plan offered “perks,” other marketing/sales techniques, etc.? The benefits may be similar but the way that they are administered, supported and sold will not be. This is true in the market today and will be after exchanges become a reality. The challenge for doctors and future payers will be to organize delivery approaches of essential benefits in a way that is more efficient and effective. This means changing the way that we set up our clinics and hospitals so that they maximize health and then reorganizing payment approaches so that they foster improved practices. The TCMS (Continued on page 8)

July/August 2013

MedicalInsurance Telemedicine Health Care Organizations Exchange Colleague Interview (Continued from page 7)

Policy Committee document titled “The Twin Cities-Network” is a white paper created by TCMS metro doctors providing concrete thoughts on what this might look like. (www.metrodoctors.com.) Click on Publications Tab.) How to help patients make selections has undergone considerable discussion. As mentioned earlier, there will be a navigator/ broker component to the exchange but little is known yet about how this will roll out. Presumably, this is one area that will be hammered out by the Exchange Board in early days after it is appointed. During deliberation by the Exchange Task Force, two components were considered of importance. First, to make sure that those without insurance or those meeting subsidy guidelines knew that it was available to them. Second, to help all enrolling to understand the different products and which might be best for them. It is still unclear who will fill this role and how the assistance will be given. It does, however, get back to an earlier question. If there are too many products, then it will be confusing for all, including most navigator/brokers.

Will there be health care insurance plans available through the exchange which, coupled with health care savings accounts (HSAs), can be used to cover insurance deductibles or co-payments? The ACA created different cost-sharing options for coverage offered through the exchange. These are the bronze, silver, gold and platinum options. These each have different deductible and co-payment levels. These will be available to use with HSAs.

Will there be insurance products that set an allowable payment for specific physician services based on CPT codes or other descriptors and permit doctors to determine their fees to patients? Not if they are offered through the exchange. Every product offered through the exchange must meet the essential benefit definitions. In addition, any physician that is included as part of a plan’s covered network would be precluded from balance billing patients.

Will MNsure require parity of coverage for mental and substance use disorders on insurance products accepted for MNsure? If so, how will parity be determined? The ACA requires that all exchange and non-exchange insurance products comply with the parity law enacted in 2008. Since all exchange products require having mental health and substance abuse benefits (behavioral health [BH]), they will be included. Perhaps the more important question is how BH benefits will be administered. Today they are paid separately from other 8

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medical benefits, i.e., carve-outs and carve-ins. Unless the approach to BH payment changes, i.e., BHs services delivery paid as a part of medical benefits, then access to BH services may be a benefit in exchange products but that does not mean that they will be generally available. There is nothing in the ACA discussing this issue. This should be an area of concern and action by the Minnesota BH community, however, despite encouragement, I have seen little concerted action by BH constituents. Thus, exchanges may bring little real benefit to patients with BH conditions in terms of access to care. It will also not help primary care settings improve BH in their setting.

How do you envision the exchange impacting health care quality and cost in Minnesota? How will its success be measured, and by whom? Exchanges will substantially increase the number of insured in Minnesota. This is a positive. What is less certain is whether the benefits available through the exchange will improve health and lower cost, as the legislation desires. Of the 50 states, Minnesota is in the top five as far as preparation. It is one of 16-state operated (plus DC) exchange systems that has passed exchange legislation and has many of the core ingredients in process or completed. This is far better (and cheaper) than the states defaulting to the federal system. From a doctor’s perspective, our greatest challenge will be to meet the needs of newly insured patients, who will now have the opportunity to find a primary care physician and to get specialty care without using the ER or hospital. Whether we like the ACA or not, health reform is moving forward. It is time for Minnesota doctors to channel their energy into problem solving the challenges we will face as exchanges are opened, ACOs are developed, and population health unfolds. We, doctors, can be major contributors to effective implementation, whether we like the changes or not. It is no longer a time to fight it. Rather, it is a time to maximize the value that it can bring to Minnesota citizens (our patients).

How will MMA influence MNsure? The MMA has been influencing the development of the exchange since passage of the ACA by ensuring that the voice of physicians is involved in state-level discussions and planning. It can continue to serve members of the MMA, non-member physicians throughout Minnesota, and patients who use our services by being a leader in education about the changes and by informing direction as the ACA matures, exchanges are started, and ACOs are built. In some instances, this will involve mobilizing its member physicians, in others trying to influence health policy. The MMA is transforming its governance structure to be more responsive to its members and health needs in Minnesota. Hopefully, these changes will allow greater contributions to its members and to the health of Minnesotans. MetroDoctors

The Journal of the Twin Cities Medical Society

Health Insurance Exchange — A National Perspective

ne of the hallmark pieces of the Affordable Care Act that passed just over three years ago was the creation of the health insurance exchanges to transform how consumers purchased health insurance. The Affordable Care Act gave states three options to choose from in complying with the requirements for insurance exchanges: (1) create their own exchange; (2) create a state-federal partnership exchange; or (3) use the federal exchange. Throughout the last three years, governors, regulators, and state legislatures have struggled with the significant technological, economic, and policy issues that go into creating an insurance exchange. Twenty-six states have decided not to create their own exchanges, but instead to use the federal-government’s exchange. Seven states opted to participate in a partnership exchange. Minnesota — along with 15 other states and the District of Columbia — opted to establish its own insurance exchange. This article takes a closer look at the implementation of health insurance exchanges by states across the country and, in particular, policy decisions in other states that might inform Minnesota policymakers in the future. State-Based Exchanges: Exchange Models and Premium Costs

States that created their own insurance exchanges each chose to adopt either an “active-purchaser” or a “clearinghouse” By Nathan Mussell, J.D., and David Asp, J.D.

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model. An “active-purchaser” model involves a regulatory entity — in Minnesota’s case, the exchange’s board — that determines which health plans may be offered on the state’s exchange. Advocates of the active-purchaser model argue that the model allows a state exchange to leverage the collective buying power of all exchange enrollees to negotiate with health insurance carriers and ensures a minimum level of quality. By comparison, a “clearinghouse” model permits any plan to be offered on the exchange as long as it meets minimum state and federal requirements. Advocates argue that most states already have laws requiring certain minimum benefits, and that permitting carriers to offer a variety of plans on the exchange increases consumer choices, promotes competition, and thereby decreases costs. Minnesota’s exchange will follow the “clearinghouse” model for one year — until January 2015 — when the exchange board will begin to operate as an “active purchaser.” This “hybrid approach” was, in large part, the result of the short time window between passage of the enacting

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legislation and deadline for health plan certification by the federal government. In the second year, and for each year thereafter, the exchange is expected to use the active-purchaser model. In designing and implementing the exchange, Minnesota worked closely with Maryland, which has adopted a similar transitional model from clearinghouse to active purchaser. Given the short deadlines that many states are working under, particularly those like Minnesota who just passed enabling legislation in the last couple months, many of the states are looking to other similarly situated states for guidance on getting their exchanges operational by January 1, 2014. If Maryland’s model is typical, Minnesotans could see an increase in premium prices for health insurance plans offered on the exchange. According to Kaiser Health News, the average health insurance premium will increase by 25 percent when the exchange goes into effect in October 2013 under the “clearinghouse” model that will operate in Maryland through the (Continued on page 10)

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Medical Telemedicine Health Insurance Care Organizations Exchange A National Perspective (Continued from page 9)

end of 2014. After that — effective January 2015 — it is likely that the costs will increase further as Maryland’s exchange board creates additional requirements for products sold on the exchange. Six other states — California, Massachusetts, New York, Oregon, Rhode Island and Vermont — have opted to use

an active-purchaser model from the beginning. The experiences of these states may foretell the future of Minnesota’s exchange after 2015. In particular, Minnesota’s exchange board can look to determine what, if any, regulatory actions can effectively leverage the state’s buying power to improve the quality or costs of health plans on the state exchange. At the same time, the experiences in

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states opting for clearinghouse models will also show if costs are better with fewer restrictions on what plans may be offered on the health insurance exchange. States using the clearinghouse model include Colorado, Connecticut, Hawaii, Idaho, Maryland, Nevada, Utah and the District of Columbia. What About State-Federal Partnership Exchanges?

For a variety of reasons a number of states elected to operate an exchange in partnership with the federal government. Seven states — Iowa, Illinois, Arkansas, Michigan, West Virginia, New Hampshire, and Delaware — have all reached an agreement with the federal government to operate a partnership exchange. While each of these partnerships will vary in terms of what functions the state maintains versus those left to the federal government, the basis for the partnership exchange is that the state will maintain regulatory authority over their insurance marketplace. The extent of each state’s control of a number of other functions including customer service and reinsurance, varies depending on the framework of the agreement between the federal government and the state. One of the issues that has been raised in partnership states is how, if at all, the partnership arrangement will differ from a state that opted to participate in the federal exchange. Even in partnership states, the federal government will maintain control over the IT and operations of the exchange, in effect performing the same functions as they are under the federal exchange. The partnership model states may very well hold the keys to success or failure of the exchange model in the future depending on which states transition to a state-based exchange and which morph closer to an all federally run exchange. What will the Federal Exchange Look Like?

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The federal exchange is expected to be on the same timeline as the state exchanges with enrollment to the public set to begin this fall on October 1 with the exchange fully operational starting January 1, 2014. Unlike the state-based exchanges, which MetroDoctors

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had to choose between active purchaser or a clearinghouse model, the Department of Health and Human Services has already indicated that the federal exchange will operate as a clearinghouse model, in large part due to the challenges of operating an active-purchaser model in 26 different states. One of the logistical questions with the federal exchange is what type of individuals will participate in the exchange. Unlike state-based exchanges, where states have the ability to regulate their insurance markets both inside and outside the exchange, the federal exchange will only have the ability to regulate products that are sold inside the exchange marketplace. This sets up a possibility for adverse selection as sicker patients find it more advantageous to elect cheaper coverage inside of the federal exchange than outside through a state exchange. An additional concern that came up in Minnesota’s decision to operate a state-based exchange rather than opting

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for the federal exchange, is the limitation that would be placed on the federal government to tailor the exchange to meet a state’s specific insurance needs. Minnesota, for example, has prided itself on rigorous requirements for health plans to offer products to Minnesota consumers. With the federal government operating an exchange for at least half of the states, it will be difficult for the exchange to meet the stricter market requirements of one state over another state. Although many of the states who opted to participate in the federal exchange during the first year are likely to remain in a federal exchange for the near term, some have already indicated their intent to transition to a state-based exchange in the future. What’s Ahead?

There are many unanswered questions about exchange functionality, consumer purchasing and overall access to coverage that are unlikely to be answered until

The Journal of the Twin Cities Medical Society

well after January 1, 2014. Whether an exchange marketplace is ultimately successful and what long-term impacts the exchange concept has on consumers won’t be known for many years. The states and the federal government are jumping into a new world order and the success or failure of the Affordable Care Act is likely to hinge on the insurance exchange model. Nate Mussell is an attorney and lobbyist with Lockridge Grindal Nauen. His work focuses primarily on physician, medical clinic and hospital legal and policy issues at the Capitol. He can be reached at: ncmussell@ locklaw.com. David Asp is an attorney with Lockridge Grindal Nauen practicing primarily in the areas of commercial, health care, and employment litigation. He has particular experience with claims under the Employee Retirement Income Security Act, as well as experience representing health care providers. He can be reached at: dwasp@locklaw.com.

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Profiling MNsure: How Minnesota’s Health Insurance Marketplace Came to Be MNsure, Minnesota’s health insurance exchange, will be a one-stop shop for consumers to search, select and enroll in health insurance. Individuals will enjoy more portability and mobility as a result of consumers making their own decisions about their health insurance needs. The new marketplace will mean that there will be multiple insurers competing in one place whose products will be organized in a standardized manner. Consumers will enjoy a simplified shopping experience and will be able to more easily compare plans. MNsure will also make real-time eligibility determinations for Medicaid and tax credits to lower the cost of premiums for individuals and small businesses. MNsure will also feature useful tools for small businesses. MNsure will have the capability to administer a defined contribution program where small employers will be able to give their employees a defined sum of money toward health insurance and they will be able to shop across all carriers and plans featured on MNsure. Additionally, MNsure will provide a service called premium aggregation which will allow small employers to give MNsure a lump sum for employee health insurance and MNsure will reconcile the financials with the insurance companies based on which employees choose which plans. MNsure will feature robust customer service; there will be various ways consumers can and will interact with MNsure. First, MNsure will have a user-friendly By April Todd-Malmlov

July/August 2013

website where consumers will be able to view, purchase and enroll in health insurance that best fits their individual needs. The website will feature the health insurance products in a standardized, transparent format that will make it easy to compare the insurance products. Second, there will be a call center run by MNsure with highly-trained staff that will be able to answer consumers’ questions or refer them in real time to the appropriate resource. Third, there will be navigators, in-person assisters, and brokers available to consumers and small businesses. These will be trusted community organizations and nonprofits that will contract with MNsure to facilitate and guide consumers through the MNsure enrollment process. Fourth, there will be a streamlined appeals process to resolve issues in the event a consumer feels a specific determination by MNsure requires further review.

It’s anticipated that 1.3 million Minnesotans will get their health care coverage through MNsure. A nationally renowned economist estimates that consumers and small businesses can save as much as 7.5 percent on premiums from increased competition alone through MNsure. Additional savings for individuals and small businesses will come through the availability of tax credits for individuals below 400 percent of the federal poverty level (roughly $90,000 for a family of four) and for small businesses with 25 employees or less making an average wage of $50,000 or less. On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law. Exchanges are one part of the ACA and the primary goal of exchanges is to provide affordable insurance coverage choices for individuals and small employers. States can choose whether or not they want to have a state-based exchange or defer to an exchange operated by the federal government. Minnesota has chosen to operate a state-based exchange for a variety of reasons including the ability to make our own health care decisions at a state level, capitalize on our nation leading health care system and reforms, create a more costeffective exchange, streamline access for public and private coverage making health care simpler for consumers and small businesses, and providing customer service and assistance at a more local level. Other key components of the law include a prohibition on insurers denying individuals coverage based on pre-existing conditions or

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setting premiums based on health status, allowing dependents to remain on their parents insurance until age 26, and reducing the number of factors insurers can use to set premiums for individuals and small businesses. It’s important to note that the policy idea of a health insurance exchange is by no means new or partisan. Massachusetts established an exchange in 2006, the Massachusetts Connector, which was spearheaded by then Republican Governor Mitt Romney working with a Democratic-led Massachusetts legislature. In 2007, the

Human Services Secretary Sebelius to give Minnesota a second chance to apply for an exchange planning grant after previous Governor Pawlenty decided to decline the opportunity to plan for a state-based exchange. On October 31, 2011, Governor Dayton issued Executive Order 11-30, which directed the Minnesota Department of Commerce to “Design and develop a Minnesota health insurance exchange to ensure access to affordable, high-quality health coverage that maximizes consumer choice and minimizes adverse selection.” The

On March 20, 2013, Governor Dayton signed House File 5 into law, establishing MNsure.

Minnesota legislature and Governor Tim Pawlenty also contemplated establishing an exchange in Minnesota long before the passage of the ACA. In fact, the proposal was the subject of final negotiations but ultimately did not pass. After the passage of the ACA, Minnesota engaged in a robust discussion as to whether or not to adopt legislation to establish a state-based exchange or default to a federal exchange. During the 2011 and 2012 legislative sessions a number of bills were introduced on the topic by both Republicans and Democrats, but did not receive serious consideration by the Minnesota Legislature. Governor Dayton was a strong advocate for the establishment of a state-based exchange since he took office in 2011. In February of 2011, Governor Dayton worked with federal Health and

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Dayton Administration also established a Health Insurance Exchange Advisory Task Force made up of stakeholders from around the state representing consumers and industry. The Task Force established work groups on various topics, which met regularly and reported to the Task Force. All told, the Health Insurance Exchange Advisory Task Force and working groups engaged over 300 stakeholders, held dozens of meetings across the state, and spent countless hours on important exchange details. The 2013 legislative session proved to be more receptive to exchange legislation. Federal deadlines required that legislation be passed by March 31, 2013 or Minnesota would default to the federal exchange. This provided for an aggressive timeline for bill passage as the legislation ultimately

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had to pass 18 committees and hearings on the floors of the House and Senate. In the end, the exchange legislation was debated for over 110 hours and over 150 amendments were considered, many of which were included in the final bill. On March 20, 2013, Governor Dayton signed House File 5 into law, establishing MNsure. Most recently, the board members have been appointed by Governor Dayton. MNsure will continue to work to meet its deadlines for a successful launch on October 1 of this year, with policies sold through MNsure effective January 1, 2014. April Todd-Malmlov is the executive director at MNsure, Minnesota’s health insurance marketplace. She comes to this role with over 15 years of experience in the public and private health care sectors. Prior to this role, Ms. Todd-Malmlov served as Minnesota’s State Health Economist and was responsible for monitoring the health care market and informing state health policy related to health care access, cost and quality. Ms. Todd-Malmlov has also served as the director of Competitive Intelligence for UnitedHealthcare and the vice president of Strategic Analysis and Communications for Government Affairs at UnitedHealth Group during the debate and passage of the federal Affordable Care Act. Ms. Todd-Malmlov holds a master’s degree in public health from the University of Minnesota and a bachelor’s degree from Beloit College. She was named one of the top business leaders to watch in 2012 by both the Minneapolis/St. Paul Business Journal and the Star Tribune, and one of the most influential people in the Twin Cities in 2013 by Minnesota Monthly. She can be reached at: (651) 539-1320, or april.todd-malmlov@state.mn.us.

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Back to the Future: An Employer Perspective on the Minnesota health insurance Exchange

n the early 1990s, a group of Minnesota employers stumbled upon a health care model that put the patient and the health care provider at the center of the health care equation. In this model, the employee received a set amount of money with which to purchase health coverage based on cost and quality data, as well as patient evaluation scores. That group of employers was known as the Buyers Health Care Action Group (now called the Minnesota Health Action Group), and that health care model was the groundbreaking ChoicePlus program, which by all accounts, was a predecessor to the current health insurance exchanges. Even back in the ’90s, employers were marching toward an exchange model, where health care decisions were based on cost and value. This is where they felt real change in health care would occur. That employer sentiment remains the same, but the health care model has evolved into what we now know as the health insurance exchange. The public insurance exchange in Minnesota, called MNsure, is one of 17 state-run exchanges that will become available on October 1, and it is expected to attract small employers and individuals first. Minnesota employers, particularly small employers, will be at an advantage when MNsure launches because their needs, in particular, are reflected in the design of the exchange.

By Carolyn Pare

July/August 2013

What Employers Want

Small employers and people who are self employed have historically taken a financial hit when it comes to health benefits. Consider the fact that small employers pay an average of 18 percent more for health coverage due to brokerage fees, adverse selection and fixed administrative costs. Add to this the fact that 50 percent — or 23 million of the 45 million uninsured — are employed by small companies, while 28 percent of people who are self-employed go without insurance, and the need for a more effective model is clear. So, what do employers want in the public exchange? At the end of the day, they want a few things when it comes to buying health benefits for their employees. They want affordability, or at the very least, predictability of cost. They want to feel like they are paying for value. They want competition in the marketplace. And, they want simplicity in administration. There is promise for all these things in a well-constructed public exchange. Advantages of MNsure for Small Employers

As a direct result of the actions of the Buyers Health Care Action Group in 1992, employers in Minnesota, including the State Employee Insurance Group, have already experienced success with tiered health care benefit programs. This is good news for employers. More specifically, Minnesota employers will benefit from

the public exchange in a number of ways: • A guaranteed larger risk pool will reduce the amount of risk that small employers have to take on and manage. • Availability of the SHOP (Small Business Health Options Exchange) feature within MNsure will allow employers to shop for care and choose pricing tiers from which their employees can select coverage (much like defined contribution plans that many employers have already adopted). • Lower administrative expenses for employers, while still allowing them to benefit from the expertise of their insurance agent or broker. Potential Challenges for Employers

While shopping the exchange will likely be very similar to what employers have experienced with defined contribution plans, there are still a number of potential challenges, including:

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Cost uncertainty. While no one can pinpoint the exact cost of shopping the exchange, it’s safe to say that it will be less than the recent cost increases of 100 percent over the past 10 years that some employers have experienced. The cost of insurance is expected to increase, at least initially, within the exchanges. Additional fees will be applied to health insurance providers due to the addition of guarantee issue and mandates that extend coverage to children up to the age of 26. These fees will be passed on to purchasers and consumers, and will show up in reinsurance assessments. In the individual market the government will provide a subsidy which will help low income earners. In the SHOP exchange there is speculation that these tax subsidies won’t be enough. Some experts also are speculating that small business won’t participate as anticipated and the small business exchanges will then fail.

both health plan cost and provider quality. As it currently stands, health insurance is massively complex. Creating an environment that offers some standardization relative to the benefit design and cost will allow employers to make more of an apples-to-apples comparison than they are currently able to do. The exchanges could help with this because the parameters within plans in a given tier will have to be the same. And, the built-in scenarios for needs like diabetes care will illustrate potential out-of-pocket costs to members in a given plan year if they choose a specific plan within the exchange. The Minnesota Health Action Group believes that everyone should have health coverage and access to high-quality health care. But, until we change the way we pay for, and reward care delivery, we won’t change health care. Likewise, the exchange will broaden access and help people get

care that they don’t have, but it’s not going to save health care. To save health care in Minnesota and across the country, we need to stay focused on the central issue of making health care affordable for everyone — regardless of whether you’re an individual or small- or mid-sized employer. To save health care in Minnesota, we need to stay focused on policy not politics. This remains the focus of The Action Group and its member organizations. Carolyn Pare is president and chief executive officer of the Minnesota Health Action Group (formerly Buyers Health Care Action Group), a coalition of private and public health care purchasers representing the interests of the organizations that pay for health care goods and services — those that have the highest stake in ensuring health care dollars are carefully spent. She can be reached at cpare@ mnhealthactiongroup.org.

Value to the Minnesota Health Care Marketplace

If well implemented, the public exchange in Minnesota can provide value to employers, to individuals and to the broader health care marketplace. The exchange has the ability to serve as a vehicle to advance delivery system reforms through quality improvement and increased transparency by promoting value-based purchasing and by providing user-friendly reporting data directly to consumers. The exchange also has the potential to deliver new tools — such as provider directories, consumer decision tools and calculators, and interactive consumer education — that can be leveraged by health care purchasers. What the exchange won’t do, in the first iteration, is support quality care initiatives, because the current framework is built around comparing health plans — not health care providers — based on price. In an ideal future state, the system would allow purchasers to compare

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July/August 2013

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How Will MNsure, 2014 Health Insurance Reforms Affect Your Patients? It Depends.

lthough health care reform is the law of the land, many aspects of the legislation are still in development on both federal and state levels. With Minnesota’s exchange, MNsure, scheduled to open October 2013, most Minnesotans are unaware if or how the exchange and other reforms will affect them. Minnesotans are not alone. A recent Kaiser Health poll found that more than 57 percent of Americans still do not have enough information to know how health reform will affect them. The percentage rises to two-thirds among some of the key groups the law was designed to help: people who are uninsured (67 percent) and those with incomes below $40,000 (68 percent). There is one thing we know for sure: the impact of health care reform in 2014 is personal. It is dependent on an individual’s current health insurance situation. More people will qualify for Medicaid; MinnesotaCare eligibility is changing. People who are currently uninsured may qualify for Medicaid, MinnesotaCare or be eligible for tax credits to help pay their premium. About 38 percent of Minnesotans, those who currently receive coverage through large employers, will likely see minimal change. The impact is substantial on Minnesotans covered by small employers or those who buy insurance on their own. Changes to Insurance Rules

Two components of health care reform that are popular with consumers are the rules that require health plans to cover anyone who applies and pays the premiums By Julie Brunner, J.D.

July/August 2013

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anticipate these new enrollees will have more health care needs. 8 to 11 percent increase on average across the entire individual market to bring deductibles in line with new rules. About 86 percent of people with individual coverage have deductibles that meet the new rules. Of the 14 percent who will see increases, the average increase will be 20 to 66 percent. Individual policies with deductibles between $10,000 and $15,000 will see the largest increase as these policies are no longer allowed. 1 to 2 percent increase is expected on average to add required benefits to current plans that lack coverage for maternity, behavioral health, and pediatric dental/eyeglasses/contacts. -7.5 percent premium decrease is projected due to increased health insurance competition. 10 to 15 percent increase as the state closes the Minnesota Comprehensive Health Association (MCHA), the state’s current high risk pool, and enrollees move into individual market with their choice of coverage.

(guaranteed issue) and the elimination of health history as a part of the calculation to determine the premium (health underwriting). The impact of these changes were outlined in “The Impact of the ACA and Exchange on Minnesota” an analysis conducted at the request of the state. The report showed the following:

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Individual market coverage • 18 percent increase to -7 percent decrease because health history can no longer factor into premiums. The “discount” people received for being relatively healthy will end, as will the “penalty” for being relatively unhealthy. • 15 to 20 percent increase in premiums as new people receive coverage. Because many of these people may not have had coverage before, experts

Small Employer Coverage About 348,000 Minnesotans received their group health care coverage through small employers, defined as fewer than 50 employees. Unlike larger companies, these businesses are not required to offer coverage or pay a penalty in 2014. Tax incentives remain in place for employers with fewer than 25 employees to continue to offer, or begin offering, coverage. Health care reform 2014 will bring the following changes to small group coverage:

•

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Lower deductibles. While most coverage offered by small employers meets new deductible requirements, about 2 percent will see increases between 7 and 15 percent to meet the new requirements. No discounts, penalties for health status. Group premiums will be set based on three components, just like individual coverage: age, location and tobacco use. About 40 percent of Minnesotans working for small organizations are projected to see a premium increase (14 to 26 percent) because the discount goes away. Just more than a quarter of individuals will no longer be penalized, decreasing their premiums 15 percent to 23 percent.

complicated. That’s why the Children’s Defense Fund-Minnesota, Minnesota Chamber of Commerce, the Minnesota Council of Health Plans and others are working to ensure Minnesotans have an easy-to-understand way to get an idea of their personal health care future.

It’s also important to remember that the changes to health insurance were intentional, and the consequences were anticipated. Health care reform was designed to increase eligibility, enhance benefits and change the cost structure. Just like any major change, the imple-

health care reform was designed to increase eligibility, enhance benefits and change the cost structure.

New Taxes, Assessments Increase Premiums

New taxes go live in 2014 and all three taxes are applied to premiums in the small group and individual markets. The taxes fund the: • Expansion of Medicaid and premiums subsidies available to qualifying individuals purchasing coverage through the exchange. This federal tax is about 2 percent. • Federal reinsurance account that will help pay health care costs for individuals with especially high claims. The federal tax is $5.25 per person per month, or about 1.1 percent in 2014, on all health care coverage, including large, self-funded plans. • State’s exchange, MNsure, adds up to a 3.5 percent tax on premiums. It is scheduled to be 1.5 percent in 2014 and up to 3.5 percent in future years. In all, state and federal health care taxes are projected to add more than 10 percent to small group premiums and 13 percent to individual coverage premiums in 2014. Personalized Information Available

As previously stated we know for sure: the impact of health care reform is personal. It is dependent on an individual’s current health insurance situation. Figuring out what change applies to whom is MetroDoctors

The coalition launched myhealthcarefuture.org in April and since then almost 20,000 individuals have logged onto the site to spend a few minutes answering questions that will provide personalized estimates of how health reform changes in 2014 could affect their coverage and premium. Is the user a person who will most likely see little change? Is the user a “winner” as the state’s report outlined and will be eligible for help paying premiums or maybe will receive a 23 percent decrease in premiums because the user’s health is no longer used to help determine premium. What options are open to user’s under age 30? How will the user’s tobacco habit impact his/her premiums in the future? What’s Next for Our Community’s Health Care Future?

It is predicted that the new rate structure will create one time “winners and losers” in terms of the financial impact. However, it is important to take a longer view. Over time, the gap between the two sides will even out. For example, younger people who may pay more in 2014, will, over their lifetime, have better access and more affordable rates.

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mentation of health care reform will take time and tweaking. And while these complex insurance reforms take place, the most difficult work for our entire community remains: providing the best quality care at the lowest possible cost. Julie Brunner, J.D., is the executive director of the Minnesota Council of Health Plans. The Council is active in community health and prevention, health care quality improvement and health care public policy. Members of the Council provide coverage to more than 4.3 million individuals. Before joining the Council in January 2003, Brunner served as the deputy commissioner of the Minnesota Department of Health. Brunner also serves on the board of several nonprofit organizations, including the Amherst Wilder Foundation, The Center for Victims of Torture, Hearth Connection and Portico Healthnet. She can be reached at: (651) 645-0099, or Info@mnhealthplans.org. References: The Impact of the ACA and Exchange on Minnesota: http://mnsure.org/hix/images/Report-GruberGorman-2012-April.pdf. MNsure Report-GruberGormanUpdate-2013-02-28.

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Health Exchange: Helping Consumers Keep Their Dollars — and Their Doctor

or decades, people without health insurance through their employer have been forced to navigate the complicated health insurance marketplace alone. With little buying power or negotiating leverage, and a lack of data to make an informed decision about cost, coverage and networks, consumers have been placed at an enormous disadvantage. While the Internet has simplified the process somewhat, it is still far too difficult — and far too expensive — for many Minnesotans to purchase insurance on their own in the private marketplace. Enter the Health Insurance Exchange. The Minnesota Health Insurance Exchange, now known as “MNsure,” is the most significant health insurance reform Minnesota has seen in 50 years. An exchange is a new online health insurance marketplace where Minnesotans can choose quality, affordable health insurance that meets their needs and fits their budget. For the first time in state history, consumers will soon be on a more level playing field with insurance companies. Health insurers will actually have to compete for consumers’ business. Instead of a federally-operated exchange, which would have been imposed upon us if we took no action, the Minnesota legislature took the opportunity to build a Minnesota-made exchange tailored to meet the needs of our people and our exceptional health care system. As a result, an estimated 1.3 million Minnesotans are

By Representative Joe Atkins

July/August 2013

projected to access high-quality, affordable health insurance using MNsure, including 300,000 uninsured Minnesotans and 155,000 small business employees. By creating our own health insurance exchange based here in Minnesota, consumers are much more likely to be able to choose and keep their preferred physician and network. For Minnesotans who are already purchasing private insurance on their own with a doctor that they like, they can keep their doctor. Their plan doesn’t change. If they choose to buy their insurance through the MNsure exchange — at a more competitive price — they can still keep their doctor. If an individual likes their insurance through HealthPartners, they can keep their doctor by purchasing a HealthPartners plan on MNsure. Just in case Minnesotans are not finding good policies, good prices and good

choices — like the ability to continue to see a trusted physician — on the MNsure exchange, the exchange will be subject to strict oversight. The MNsure board and its operation of the exchange will undergo annual audits by the Legislative Auditor and are subject to independent third-party audits required by the Affordable Care Act. If things aren’t going as planned or if there is impropriety, the legislature will be positioned to make appropriate changes. So, how will the typical consumer find and purchase a health insurance policy on the MNsure exchange? My expectation is that most consumers will seek to do it on their own. There is plenty of motivation. In addition to federal tax credits available only to those who buy their insurance through the exchange, experts predict the average Minnesota family will save $500 annually by purchasing through the exchange. For those who find the online selection and purchasing to be too daunting to do on their own, however, there are other options. The Affordable Care Act requires all state-based exchanges to have a Navigator program. Navigators are entities, not individuals. The intent is to enlist organizations that have “existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or self-employed individuals.” These can include trade and professional organizations, farming organizations, unions, community nonprofits, Chambers of Commerce, and even current

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insurance agencies (who won’t take any compensation from insurance companies for enrolling people in health plans, inside or outside the exchange). Navigator entities will be compensated through grants awarded by the exchange. The exchange legislation requires the Board to establish a navigator program beginning January 1, 2015, along with policies and procedures for in-person assistance, a call center and other customer

customer service or Navigator assistance comes at no cost to them, where many consumers will believe that they have to pay to see a broker or agent. Consumers may also avoid brokers and agents out of a fear of sales pressure, or any of the other numerous reasons that private insurance brokers do not reach certain groups of potential customers. Insurance brokers will continue to play an important role in the health care

Change is never easy, but I’m confident that in a few years, Minnesotans will consider the health insurance exchange a part of the common good of our state, the same way most think of Medicare today.

service provisions that will kick off in 2013. The new law does not change any rules governing the relationship of brokers to insurers or, except for some minor disclosure requirements, to customers. Insurance carriers are required to compensate brokers selling a policy through the exchange on the same terms as the company would compensate a broker making a sale of the same policy outside the exchange. This measure should eliminate adverseselection problems that might be caused by having the exchange pay different compensation from the carrier for the same policies. Many brokers and agents fear that health insurance exchanges with navigator programs and in-person assisters will render them obsolete, or worse, are intended to render them obsolete. Instead, all three — navigators, in-person assisters, and brokers — are sources of consumer information and help getting insurance through the exchange. It’s immediately obvious to the consumer that exchange MetroDoctors

from health care reform expert Dr. Jonathan Gruber at MIT and Bela Gorman of Gorman Actuarial, the same experts who accurately predicted the results of implementing an exchange in Massachusetts in 2006. Individuals in Massachusetts saw premiums drop by 21 percent and families saw a 40 percent decrease, according to a New York Times report. For the rest of the nation, premiums for individuals increased 13 percent and for families by 14 percent over the same period. Change is never easy, but I’m confident that in a few years, Minnesotans will consider the health insurance exchange a part of the common good of our state, the same way most think of Medicare today. Representative Joe Atkins (D-Inver Grove Heights) is the chief author of Minnesota’s Health Insurance Exchange legislation. He can be reached at (651) 296-4192, or rep. Joe.Atkins@house.mn.

industry in helping to match policyholders with the insurance plans that best fit their needs. One big reason: it is explicitly stated in the bill that only a licensed agent or broker may actually select or recommend an insurance policy to a customer. Navigators and others are limited to giving impartial information and providing technical assistance with enrollment. Also, in other states launching small-business exchanges, brokers and agents have overwhelmingly kept their existing customer base, to the detriment of any exchanges that have not allowed brokers to operate freely in the exchange. Through all of this, it bears mentioning that Minnesotans will save an estimated $1 billion by 2016, with the average premium dropping by 30 percent and the average family saving $500 annually. Small businesses — which currently pay 18 percent more on health care than larger businesses — will save up to 7.5 percent on premiums through the exchange by leveraging their buying power. These aren’t my numbers; they come

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High Risk Insurance Pool Prepares for Transition as Healthcare Reform is Implemented

hen federal health insurance reform passed in 2010, the Board of Directors at the Minnesota Comprehensive Health Association (MCHA) knew they had major decisions ahead of them. With the ban on insurance company denials for pre-existing health conditions set to take effect on January 1, 2014, the need for MCHA’s high-risk pool insurance could soon disappear. The board quickly realized that they would need to prepare their enrollees to find and purchase a plan in the new insurance market. Since the first rumblings about reform, MCHA has closely followed its progress in an effort to fully understand how it might affect the risk pool’s 26,000 members. Soon after the Affordable Care Act (ACA) passed and was signed into law, the MCHA board appointed a workgroup to focus on crafting and approving an Enrollee Transition Plan. Once the Plan had Board approval, MCHA staff shared it with the Minnesota Department of Commerce, who regulates the organization and is responsible for determining its future. The two organizations are now in the midst of finalizing how and when MCHA will close its doors, as its members find coverage elsewhere. After a stakeholder and public comment period, which will be conducted this summer, a final Transition Plan should be in place by early fall. MCHA, the Insurance of Last Resort

International tax accountant Julie Larsen came to MCHA after her COBRA ran out By karen Einisman

July/August 2013

in 2000. For most of her career, Larsen had worked for large accounting firms that always offered comprehensive health benefits. But after 20 years, she had decided to go out on her own. Larsen never factored health insurance into the mix when deciding whether or not to start her own business. Had she realized that she might be uninsurable because of an autoimmune disorder that had been inactive for years, she may have made a different decision. Fortunately for Larsen, Minnesota has always been ahead of its time when it comes to health care. In 1976, the Minnesota State Legislature created MCHA, one of the country’s first and largest high-risk health insurance pools, to provide coverage to people with pre-existing conditions that were otherwise uninsurable. Over the years, eligibility grew to include individuals who had exhausted their COBRA; spouses and dependents of employees not offered dependent coverage; employees of companies not offering coverage; people who work part-time or who are self-employed; and individuals who are age 65 or older and not eligible for Medicare. For over 35 years, Minnesotans have turned to MCHA as a result of a number of chronic health conditions from cancer and cardiovascular disease to arthritis and depression. Once people enroll in MCHA, many of them continue to access its coverage, even though they may become eligible for a mainstream plan at some point. A recent study by the University of Minnesota’s State Health Access Data Assistance Center (SHADAC) revealed that 23 percent of MCHA enrollees have purchased the insurance plan for over 10

years. Two-thirds of the risk pool participants have been on the plan for over four years. On the other hand, approximately 35 percent of the MCHA population cycles through MCHA in a given year, as many individuals use the plan as stop-gap insurance during times of unemployment. A large majority, over 80 percent, report being somewhat or very satisfied with their MCHA insurance coverage. Satisfaction may be due, in part, to how MCHA — and its plan administrator, Medica — assists enrollees in managing their chronic and often rare diseases. Members are offered extensive health coaching, medication therapy management and disease management, which often translates into healthier enrollees. According to SHADAC, 20 percent of MCHA members say nothing would make them change plans. Those who would consider transitioning to a new plan consider prescription coverage (73 percent), coverage for a specific service

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(67 percent) and ability to see a specific provider (66 percent) to be the top three features extremely important them. From MCHA to MNsure or the Private Market

When MNsure opens for enrollment on October 1, 2013 (for coverage starting January 1, 2014), it will provide many Minnesotans covered by MCHA with choices for the first time. The marketplace will also mandate a set of essential health benefits, as required by the ACA, eliminate annual and lifetime maximums, provide no cost-sharing for preventive care services and require mental health coverage, among other benefits. For some MCHA members, a plan through MNsure will save them money. As a high-risk pool, MCHA has historically charged higher premiums, up to 125 percent more than the average private market plan. Nearly half of MCHA enrollees will also be eligible for premium subsidies through MNsure in the form of a tax credit. These credits will, most likely, make a plan through MNsure more affordable than an MCHA plan. Enrollees will also have the option of purchasing a plan outside of MNsure through a broker or agent or directly from the insurance carrier. These plans must include the same set of essential health benefits presented inside the online marketplace.

government program staff, advocacy groups and insurance agents to raise awareness among those who may be in closer contact with their members. Some of these groups may be in a position to help MCHA with transitioning members. Many will apply and be awarded federal grants to fund community navigators or in-person assistors, who will be trained by the state to aid in MNsure enrollment over the next few years. Regardless of how long the disenrollment takes, MCHA has one goal in mind: to assist enrollees in finding new coverage and ensure that their care needs are not compromised in any way. “A necessary change in health plan coverage can be a traumatic experience for patients with significant chronic medical conditions,” said Dr. Marvin Segal, MCHA’s longtime medical advisor. “A combination of knowledgeable physician providers working in conjunction with our

caring health plan staff should smooth the pathway through MNsure or the private market to obtain comfortable coverage for this vulnerable population.” Over the many years of MCHA’s existence, it has been a relatively small but very important niche that has served hundreds of thousands of Minnesota residents — a godsend to many who had no other health care coverage available to them. MCHA will eventually close its doors knowing that it has excelled in serving its purpose for the residents of Minnesota. Karen Einisman is currently the Communications Consultant for the Minnesota Comprehensive Health Association (MCHA). Einisman has been working in the field of nonprofit communications for over 17 years, specializing in the areas of public relations, marketing and media advocacy. She can be reached at (952) 593-9609, or karen@ mchamn.com.

Opportunities and Challenges that Lie Ahead

The SHADAC study also showed that 63 percent of MCHA members are somewhat or very unfamiliar with health reform and 83 percent were somewhat or very unfamiliar with potential changes to their insurance coverage. “We have a lack of knowledge about reform among our enrollees,” said Peggy Zimmerman-Belbeck, Director of Operations at MCHA. “MCHA intends on helping to educate and assist them in transitioning to health plans with the same benefits and premium as those without serious health conditions will receive.” In recent months, MCHA has been reaching out to community organizations, MetroDoctors

The Journal of the Twin Cities Medical Society

July/August 2013

MedicalInsurance Telemedicine Health Care Organizations Exchange

Exchange: For the Better?

n March 20, 2013, Governor Mark Dayton signed legislation to establish a Health Insurance Exchange in Minnesota. By this, Governor Dayton joined with 16 other states that prefer a state-run exchange to a federal exchange. The new exchange, now called MNsure, with a $54 million operating budget expects to employ more than 80 workers. Its managers remain confident it will be ready to enroll individuals in MNsure health plans on October 1, 2013, as the Affordable Care Act (ACA) requires. The ACA mandates a Health Insurance Exchange in every state. The law allowed states a limited degree of flexibility to make the exchanges more palatable to local constituents. Thirty-three states, however, decided against creating a statebased exchange. As a result, the federal government is establishing either Federally Facilitated Exchanges or Federal Partnership Exchanges in those 33 states. Minnesota decided soon after the fall 2012 election to create a state exchange. The 2011-2012 GOP legislative majority took no action to create the exchange, but the new 2013 DFL legislative majority pledged to make it happen: They delivered on their promise. Not a single Republican voted for MNsure. The Minnesota Hospital Association supported the bill, and according to their website, preferred a state model to having a federal exchange imposed on them. The Minnesota Medical Association also supported a state-based exchange: “The MMA urges the Legislature By Dave Racer, MLitt.

July/August 2013

to pass enabling legislation this session for a Minnesota-based exchange that meets our state’s needs.”1 Public service unions — AFSCME, SEIU, MAPE, and other unions — strongly favored the new, as did scores of social activist groups. The Minnesota Chamber of Commerce and the National Federation of Independent Businesses in Minnesota strongly opposed MNsure in the form passed by the legislature. The Chamber has 2,300 members — most of the state’s largest employers. NFIB represents 13,000 Minnesota employers — Minnesota’s smallest employees. Together, Chamber and NFIB members employ an estimated 650,000 individuals. How their members interact with MNsure is critical to its success or failure. Insurance carriers and insurance agents fretted about key provisions in the law. Chris Schneeman, chair of the Agent

Coalition for Health Care Reform, said his group strongly opposed MNsure’s highly restrictive conflict of interest provisions. As a result, active insurance industry professionals are prohibited from serving on the seven-person board of directors. MNsure will have the power to choose which Qualified Health Plans to offer and which to reject, “which we strongly opposed,” said Schneeman. “We preferred allowing all Qualified Health Plans offered by willing carriers to be sold at MNsure.” The Agents Coalition quietly supported passage of the law because “we preferred a Minnesota exchange to the federal exchange,” Schneeman said. The Coalition represents more than 2,500 health finance professionals who provide health benefit services and counsel to 2.4 million Minnesotans. MNsure promotes itself as a website where individuals and small businesses can access health coverage. The website, however, also will collect volumes of data about each of the 1.3 million individuals it hopes to enroll. This data will be transmitted to several federal agencies through a data hub — the IRS, immigration services, homeland security, CMS, health and human services, and other federal agencies. Privacy activists fear that the data might be hacked or otherwise compromised and used illegally. The ACA, however, sets strict requirements to protect privacy. Admitting they could not overcome its complexity in time, federal officials have postponed their small business health plan department (CHOP) on the federal exchanges until 2015, a year later than the ACA requires. What about MNsure? April Todd-Malmlov, acting executive director,

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said MNsure will be ready for small business. Bob Paulson, director of MNsure’s individual enrollment cautioned that not all the “bells and whistles” may be ready. How will MNsure affect a physician’s practice? One can only offer educated speculation, given the repeated failures of federal officials to meet ACA deadlines. MNsure must also overcome difficult technical challenges. Public knowledge of MNsure is greatly lacking, and will require a hefty marketing and advertising expenditure. Physicians with independent medical practices may lose patients to MNsure. Unless the physician is in the network offered by the health plan, the patient may seek care elsewhere. Consultants hired by exchange leaders predict the number of uninsured Minnesotans will fall by 298,000 by 2016. “Roughly 46 percent of this population will receive premium tax subsidies through the exchange and 20 percent of this population will receive coverage through a public health insurance program.”2 This suggests about 60,000 Medicaid enrollees and 138,000 enrollees in tax-subsidized commercial plans will be added. MNsure projects more than 75,000 currently uninsured additional enrollees in employer plans.3 The Minnesota Legislature hopes to win a waiver to create a Basic Health Plan under MinnesotaCare, with eligibility to 275 percent of Federal Poverty Guideline income. Physicians express concern about the low reimbursements paid by Medicaid, which might be exacerbated by thousands more MinnesotaCare patients. The 298,000 newly insured individuals will add scheduling stress to the physicians’ practices. MNsure believes small employers will turn to defined contribution plans, giving employees a monthly stipend and letting them choose coverage. Unknown is whether the new MNsure plans will be affordable since these employees will not be able to receive tax subsidies to buy down the premium. The ACA limits deductibles on small group health insurance sold at MNsure — $2,000 for an individual and MetroDoctors

$4,000 for families. The ACA also requires an actuarial value of no less than 60 percent, maximum individual out-of-pocket expense of 9.5 percent of the employee’s salary or wages, and a medical loss ratio of 80 percent (80 cents of each premium dollar must be spent on medical care). These ACA requirements, when taken together, threaten HSA-qualified health plans. Some innovative insurance companies are designing health plans to repay

The Journal of the Twin Cities Medical Society

the patient for money spent on medical services based on a scheduled amount. MNsure will not offer this type of plan. The ACA rollout has been characterized by confusion and missed deadlines. Montana Senator Max Baucus, chief author of the ACA, recently said, “I just see a huge train wreck coming down.”4 David Brooks offered “… that we’re probably in for a few years of shambolic (Continued on page 24)

July/August 2013

Health Insurance Exchange Building a Direct-Pay Independent Practice Thrive, Not Just Survive

Workshop for Physicians, Surgeons, and Other Medical Professionals Saturday, August 10, 2013 – 8:30am-4:00 pm Humphrey School of Public Affairs Conference Center – Minneapolis, MN Register Today: The previous workshop sold out Sponsored by the Association of American Physicians and Surgeons (AAPS) and the Minnesota Physician Patient Alliance (MPPA) To present real-life stories of practicing physicians and surgeons who have transitioned from traditional, third-party paid practices to win freedom to practice with a direct-pay model. To provide tools and guidance for physicians, surgeons, and other medical professionals considering transitioning to a direct-pay practice. Learn first hand from the MDs who are already in Direct Pay Practice:

Jane Orient, MD Tucson, AZ Juliette Madrigal, MD Marble Falls, TX Lee Beecher, MD St Louis Park, MN Susan Wasson, MD Osakis, MN

Chris Foley, MD Minneapolis, MN Robert Sewell, MD Dallas, TX G. Keith Smith, MD Oklahoma City, OK Adam Harris, MD San Antonio, TX

Merlin Brown, MD Edina, MN Gerard Gianoli, MD Baton Rouge, LA James Eelkema, MD Burnsville, MN May be more added

Plus Authors: Lee Kurisko, MD, Ralph Weber, & Dave Racer, MLitt Special Guest: Twila Brase: Citizens’ Council for Health Freedom

For Details & to Register go to: http://tinyurl.com/lajk4uo Or Call Dave Racer at 651.705.8583, Ext. 1 Residents, Interns, & Medical Students Invited to Register for Free

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July/August 2013

Exchange: For the Better? (Continued from page 23)

messiness, during which time everybody will scramble and adjust, and eventually we will settle down to a new normal.”5 Once the insurance carriers file their new ACA-Qualified Health Plans, expected in May, we will know more about the expected premium spike. MNsure will change how hundreds of thousands of Minnesotans receive and pay for medical care. If MNsure is ready and everything works by October 1, and it offers quality affordable health plan choices, it may succeed over time. If (or when) MNsure struggles, it will take a large coalition of stakeholders to convince the legislature to take corrective action. Physicians must be ever-diligent as they observe MNsure’s effects, and create a dialog with stakeholders — patients, health care finance professionals, employers, and medical providers across the spectrum. Dave Racer is an author, publisher, speaker, and radio personality. Among his 34 books, eight deal with health care reform. Dave serves on the board of the Minnesota Physicians and Patients Alliance, and is a member of the National Association of Health Underwriters (NAHU). In Minnesota, Dave serves as the Legislative Research Director for the Minnesota chapter of NAHU, and provides continuing education training for agents across the country. Dave Racer can be reached at: (651) 705-8583, or dgracer@comcast.net. References: 1. Legislative Priorities 2013. Establishing a Minnesota Exchange. Retrieved 4/28/2013. http://www.mnmed.org/Advocacy/LegislativePriorities2013.aspx. 2. Gruber, J.; Gorman, B. (2013) “The Impact of the ACA and Exchange in Minnesota: Updated Estimates. Prepared for State of Minnesota, February 2013.” February, 2013. P 2. 3. Ibid. 4. Pear, R. (2013) “Democratic Senators Tell White House of Concerns About Health Care Law Rollout.” Retrieved 4/26/2013. The New York Times. April 24, 2013. 5. Brooks, D. (2013) “Health Chaos Ahead.” Retrieved 4/26/2013. The New York Times. April 25, 2013. http://www.nytimes. com/2013/04/26/opinion/brooks-health-chaos-ahead.html?hp&_r=1&.

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The Journal of the Twin Cities Medical Society

A Historic Legislative Session

oming out of last November’s elections in which Democrats gained control of both the House and Senate, holding all three bodies for the first time in almost 20 years, capitol watchers knew this was going to be a legislative session where lots of things were thrown at the wall but no one knew what would stick. There was little question that significant new revenue was going to be on the table to help solve the budget issues. It was also apparent that a number of major health care reforms would need to pass as the state prepared for implementation of the Affordable Care Act. In previous years much of the attention on health care centered on the Health and Human Services budget. In 2013, the new legislature wasted little time on an expansion of the Medical Assistance program and continued on a torrid pace over the next two months passing a state-based health insurance exchange and finally into dealing with the ever difficult task of putting together a budget. Budget

Although there was little discussion of it during the last few weeks of session, the state was in fact facing a projected budget shortfall for the upcoming 2014-15 biennium of $627 million. However, with just over two billion dollars in projected new revenue being discussed in the House and Senate tax bill, the deficit was almost an afterthought. Despite an agreement between the House, Senate and Governor’s office that new revenue would be raised for

By Nathan Mussell, J.D.

MetroDoctors

the budget, there was considerable disagreement about how much revenue and where that revenue would come from. In the end, a $2 billion tax bill was agreed upon that included an increase in the top tier income tax and a restructuring of some of the state’s corporate taxes and credits. The item of interest in the tax bill that had the attention throughout the session of those in the physician and provider community was if, and how much, the state would increase the price of tobacco. The final budget agreement increased the cigarette tax by $1.60 per pack, generating almost $430 million. The Health and Human Services budget ran into some bumps along the way as well, largely centered on the budget target. When the House and Senate released their budget targets in late April with a cut of $150 million to the Health and Human Services budget there was an outcry from almost every member of the health care community. The budget target even left House HHS Finance Committee Chairman Rep. Tom Huntley (D–Duluth) contemplating ceding his chairmanship. When the dust finally settled in the last two weeks of session, leadership settled on a $50 million reduction, giving the HHS committee chairs, Sen. Tony Lourey (D–Kerrick) and Rep. Huntley more room to work in satisfying many competing

The Journal of the Twin Cities Medical Society

interests for more money. Unlike in previous years where the concern was how much providers or hospitals would get cut, this year’s budget actually included a long awaited 5 percent across-the-board increase for physicians. Other highlights include over $12 million reinvested in the state’s Medical Education and Research Costs program, a $17.5 million per year investment in the Statewide Health Improvement Program (SHIP), and no change to the provider tax repeal (Sen. Lourey had earlier in session proposed an elimination of the repeal in his budget). Health Insurance Exchange

The first three months of session were largely consumed by countless hearings and many hours spent discussing a statebased health insurance exchange. There was little surprise that Minnesota was going to elect to form our own state-based (Continued on page 26)

July/August 2013

A Historic Legislative Session (Continued from page 25)

exchange rather than take the path other surrounding states had taken in participating in the federal exchange or working in partnership with the federal government on an exchange. The open questions that the legislature had to decide were the governance model, the financing mechanism, and the question of “active purchaser” or “clearinghouse” model. The final legislation that was passed and signed into law in late March created an insurance exchange marketplace with a seven member board called MNsure. The ongoing exchange operations will be paid for by a scaled portion of premium financing projected to cover the $50 million per year cost of the exchange. On the question of “active purchaser” versus “clearinghouse” model, the legislature opted for a hybrid approach in which the

exchange would operate as a clearinghouse model for the first year and then switch to an active purchaser model in subsequent years, giving the seven member board more oversight on exchange products at that time. Passage of the implementing legislation may turn out to be the easiest part of the roll out of the exchange. The potentially more difficult and bumpier road lies ahead when enrollment on the exchange begins in October and the exchange goes live starting January 1, 2014. What Didn’t Happen and a Preview of What’s Ahead

Given how much time was taken up by the insurance exchange debate and the budget process, the legislature largely stayed away from scope of practice issues in the 2013 legislative session. But don’t let the inaction during the 2013 session fool you into thinking scope of practice issues will not

be one of the more contentious issues of the 2014 session. There is an effort ongoing throughout the country to push for independent practice of advanced practice nurses in light of the current physician shortage, the perceived access issues of an aging population and an onslaught of new enrollees in public programs. With both the House and Senate still under DFL control again next session, the legislature is almost assuredly going to see one of the more significant pushes for changes to the current licensure of advanced practice nurses. The physician community should start preparing now for a difficult fight. Nate Mussell is an attorney and lobbyist with Lockridge Grindal Nauen. His work focuses primarily on physician, medical clinic and hospital legal and policy issues at the Capitol. He can be reached at: ncmussell@ locklaw.com.

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!

July/August 2013

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TCMS Caucus Meets— The Discussion Continues

he first meeting of the TCMS Caucus was held on Wednesday, June 5, 2013. Fourteen resolutions were on the table and two hours on the clock. A lively debate ensued with the first resolution and continued with each one thereafter; however, only one-half of the resolutions were heard. After two and one-half hours of discussion, Caucus Chair Michael Michael Tedford, M.D., serves as TCMS Caucus Chair. Tedford, M.D., adjourned the meeting. A second Caucus was scheduled for Monday, June 24, 2013 to complete the review of submitted resolutions and provide Caucus support for forwarding resolutions to the MMA Resolution Review Committee. Not unexpected, much of the testimony centered around the MMA proposed governance changes, noting that many of the delegates remain unclear as to what the exact proposal entails. All delegates are strongly encouraged to familiarize themselves with the proposal in advance of the MMA Annual Meeting and House of Delegates. The report can be found on the MMA website at www.mmaonline.net. Maintaining the physician-patient relationship in MNsure products and policies, and evaluating the impact of SGR on Minnesota physician fee schedules were also passionately discussed. The second Caucus has not been held at the time of this writing. Please refer to the list below of all TCMS submitted resolutions being considered at this time. A final list of resolutions is available on the TCMS website: www.metrodoctors. com. Deadline for subTCMS physicians engage in discussion of mitting resolutions resolutions. MetroDoctors

The Journal of the Twin Cities Medical Society

to the MMA Resolution Review Committee (RRC) is July 12, 2013. The RRC will meet in July and publish their recommendations for House of Delegates consideration by early August. It is imperative that Delegates register their intention to serve at the House of Delegates early — by August 1 if possible. Only registered Delegates will receive the email publication of recommended resolutions. Additional Delegates are still needed. TCMS Resolutions being considered at the time of this writing: • MNsure • Empowering the House of Delegates • Preservation of the House of Delegates • Physicians Not Seeing Medicare Patients Any Longer • Change the Title of CEO to Chief of Staff • MMA President be Chairman of the Board of Trustees • Resolution Background Documents for Reference Committee Members (withdrawn) • Reform the House of Delegate’s Speaker’s Resolution Review Committee Functions • Committee Sunshine Rules • Prohibiting the Ethical Conflict of Global Payment • Reverse FTC and CMS Waivers of Patient Protection Laws • Family Medical Accounts • Disclosure of Payments to Providers Contingent on Volume of Orders for Care • Improving MMA’s Role in Monitoring MN Board of Medical Practice A third TCMS Caucus is scheduled for September 16, 2013, at 6 p.m., at which time all resolutions as recommended by the RRC will be reviewed. This meeting will also take place at Broadway Ridge, 3001 Broadway Street NE, Minneapolis, MN. Please contact TCMS office at (612) 623-2885, or TCMS website for addi- First time Caucus attendee, Doug tional information at www. McMahon, M.D. is greeted by Peter Dehnel, M.D. Medical student Jessica metrodoctors.com. Van Lengerich in the background. July/August 2013

Honoring Choices Minnesota Summer Highlights “Save the Date”...Mark your calendars for the 4th Annual “Sharing the Experience” Conference on Advance Care Planning. Physicians Support Advance Care Planning Media and Community Engagement

Steven Miles, M.D. was a guest presenter on “Ethical Considerations in Advance Care Planning and End of Life Care” at the June 11 HCM Ambassador Continuing Education session. Dr. Miles is professor of Medicine and Bioethics and the Maas Family Endowed Chair in Bioethics at the University of Minnesota Medical School. Kusum Saxena, M.D. also discussed “Hindu Beliefs & Traditions at End of Life” at this Ambassador education session. Dr. Saxena practiced emergency medicine for 25 years at Regions Hospital and served as a clinical associate professor in the Dept. of Emergency Medicine and Family Practice at the University of Minnesota. She is a founding member of the Hindu Temple of Minnesota. Craig Svendsen M.D., Miguel Ruiz M.D. and Mohamed Hagi-Aden M.D. were ACP guests on “Inside Health Care,” a HealthEast sponsored community cable program utilizing 10 cable TV stations. During this June 4 broadcast, Dr. Svendsen gave a rich overview of the HCM initiative. Dr. Ruiz discussed the challenges of ACP for Spanish speaking populations. Dr. Hagi-Aden focused on questions and 28

July/August 2013

concerns of the Somali community around this important health care conversation. The TCMS thanks HealthEast for providing access to this 220,000 metro-wide viewer audience. veronica Svetaz, M.D., host of the Spanish-language cable television program “Nuestra Salud,” featured HCM and advance care planning on four segments of this Latino audience health program. Segments one and two focused on introducing the advance care planning conversation to viewers. Segment three highlighted the importance of completing an HCM health

care directive. Segment four outlined a six-point checklist for family advance care planning. The TCMS thanks Dr. Svetaz and HCMC for providing this culturally-specific ACP program opportunity. “Nuestra Salud” is a partnership between HCMC, Univision and Aqui Para Ti/Here for You. Richard Shank, M.D. has joined HCM as a new Physician Ambassador. Dr. Shank joins the ranks of 60+ community-based Ambassadors who reach diverse audiences on the importance of advance care planning for all Minnesotans.

Thursday, July 18, 2013 — 9:00 a.m.– 4:00 p.m. Mark your calendar today for July’s “Sharing the Experience” Conference! Participants will: • Learn current progress, findings, and best practices from Minnesota’s advance care planning programs • Learn from experts in the field about professional and community perspectives in advance care planning • Be inspired with collective ACP stories and testimonies • Gain additional knowledge on ACP evaluation and outcome measurement • Have the opportunity to develop new professional relationships with other health, human service and community-based professionals • Hear keynotes Penny Wheeler, M.D., CCO, Allina Hospitals and Clinics and Michele Kimball, Director, AARP Minnesota • Plus much more... 2013 Sharing the Experience promises to be a special day of learning and discovery...one you will not want to miss. Register online at www.metrodoctors.com

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In Memoriam EARL HILL, M.D., passed away on April 11, 2013 at the age of 93. Dr. Hill graduated from the University of Minnesota Medical School in 1943. He practiced internal medicine, retiring in 1996. Dr. Hill became a member in 1950.

SIDNEY SHAPIRO, M.D., passed away on April 22, 2013. Dr. Shapiro graduated from the University of Western Ontario Medical School in 1943 completing residencies in psychiatry and neurology. Dr. Shapiro became a member in 1985.

MILES LANE, M.D., passed away at the age of 88 on April 24, 2013. Dr. Lane graduated from the University of Minnesota Medical School in 1959 and practiced family medicine in White Bear Lake. He became a member in 1962.

RUDY TAN, M.D., passed away at the age of 87 on April 5, 2013. Dr. Tan attended the University of Jakarta in 1954,

RICHARD L. MARNACH, M.D., age 58, passed away on Friday, May 3, 2013. Dr. Marnach graduated from the Baylor University School of Medicine in 1985. Dr. Marnach specialized in pediatric anesthesiology. He became a member in 1987.

Career oPPortunItIes

and completed his residency in general surgery in New York. Dr. Tan became a member in 1990. JOSEPH C. vON DRASEK, M.D., passed away at the age of 90 on March 20, 2013. Dr. Von Drasek graduated from the University of Minnesota Medical School and practiced family medicine for 46 years. He became a member in 1959.

see additional Career opportunities on page 30.

JOHN D. PAROD, M.D., age 77, passed away on March 19, 2013. Dr. Parod graduated from the University of Illinois Medical School. He practiced at the Camden Emerson and North Clinic as a family physician. He became a member in 1967. OLIvER PETERSON, M.D., age 90, passed away on April 23, 2013. Dr. Peterson attended the University of Minnesota Medical School practicing general medicine and then as an Ob/Gyn. Dr. Peterson became a member in 1950. SYLvESTER J. SANFILIPPO, M.D., passed away on May 2, 2013 at the age of 87. Dr. Sanfilippo graduated from the University of Rochester Medical School. He practiced pediatrics in Richfield, MN for 26 years. Dr. Sanfilippo became a member in 1962.

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July/August 2013

Career oPPortunItIes

see additional Career opportunities on page 31.

New Members Frederick C. Gramith, M.D. Consulting Radiologists, Ltd. Diagnostic Radiology Sonja M. Green, M.D. Children’s Hospitals and Clinics Pediatrics Nicholas N. Holmes, M.D. St. Croix Orthopaedics, PA Family Medicine, Sports Medicine Anna Karpas, M.D. Children’s Hospitals and Clinics Pediatric Emergency Medicine Elizabeth L. Kennedy, D.O. Ridgeview Excelsior Clinic Family Medicine Brian T. Larkin, M.D. Minneapolis Radiology Associates Diagnostic Radiology, Neuroradiology

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July/August 2013

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Career oPPortunItIes

Please also visit www.metrodoctors.com

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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July/August 2013

LuMInary of Twin Cities Medicine By Marvin S. Segal, M.D.

CAroLyN ADAIr JoHNSoN, M.D. Often, the spotlight of medicine shines most brightly on our most renowned physicians — those with well-known research and academic achievements, multiple subspecialty certifications and past celebrated honors. Not often enough does that spotlight illuminate those in our profession who show up for work each day, go about the multi-tasking business of medicine and diligently care for patients and their families. Carolyn Johnson, M.D. is a St. Paul product. She obtained bachelor degrees at the U of M and was one of but four women to graduate in her medical school class of 1952. There was little doubt that she would follow in her father’s footsteps and pursue a calling in medicine as far back as age seven when he first mentored her in the fine art of tying a surgical suture knot. After an internship at Miller Hospital (a predecessor to current United Hospital), she joined her surgeon father as a family practitioner in his Frogtown neighborhood office. That was the beginning of a varied, full and rich clinical career spanning over 50 years. Dr. Johnson’s interests and expertise were wideranging. She practiced at the time when it was not uncommon for a family doctor to make house calls, assist in the surgical suite and provide obstetrical care in addition to their clinic and hospital responsibilities. Carolyn delivered nearly 6,000 babies, most of them in hospitals; though many were home deliveries done with safely planned specialty back up. She cared for children and adults alike, and in later years she found chronic care of the geriatric population to fit her talents and attention. Dr. Johnson was certified and recertified by the American Board of Family Practice. She taught and supervised medical students and residents for many years in her office and at the hospital as a clinical faculty member through the auspices of her alma mater. Her last academic appointment was that of a full clinical professor of family practice. She served as the medical director of four Ramsey County Chronic Care facilities and was a trustee of the Minnesota Medical Director’s Association. Dr. Johnson’s meaningful volunteer professional activities included positions on multiple Quality Assurance 32

July/August 2013

committees plus additional organizational responsibilities in the realms of pharmacy and therapeutics, ob-gyn and chronic care. She was a member of the Bethesda Hospital Staff Executive Committee and served her colleagues as president of the Ramsey Medical Society Senior Physicians’ Association. Dr. Johnson’s 55+ years as an active member of the American Academy of Family Physicians has been capped with her designation as Life Member by that noble body. Carolyn’s remarkable professional activities were not a deterrent to leading a full family life away from her offices and hospitals. She married her childhood sweetheart, Dr. Clarence Wesenberg (chair of the Department of Educational Psychology at the U of M — now deceased), and together they raised six children. Dr. Johnson admits to juggling and balancing their busy work schedules with that of their home responsibilities and attributes their success in that realm to her husband’s excellent meal planning and cooking skills. In the course of a working day, Dr. Carolyn Johnson frequently cradled a softly cooing newborn in her arms and comforted a frail and wizened elderly patient — all, while still carrying out the many additional tasks of an outstanding family physician. We are proud and pleased to direct our spotlight of medicine on this Luminary, who epitomizes the finest principles of the practice of medicine. 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

things physicians need to know…

MNsure

Minnesota’s HealtH insurance excHange 1

MNsure will be designed similar to popular travel websites such as Travelocity and Expedia to allow easy comparison shopping of insurance products. Users will enter demographic, income and family information and be provided with coverage options that compare premiums, out-of-pocket costs, physician and hospital networks, and measures of insurer service.

MNsure is targeted to individuals purchasing coverage who are not already covered by an employer and to small employers (those with up to 50 employees). It may be expanded to large employers in 2017.

The exchange will determine whether individuals (or small employers) are eligible for tax credits to subsidize the cost of purchasing their insurance coverage. Tax credits are only available for coverage purchased on the exchange.

Users will have help available. There will be a toll-free hotline they can call with questions. And there will be “navigators” who can guide them through the review process.

Each insurance plan option will provide coverage for “essential” services: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including dental and vision care. Although there may be some differences in actual covered services, the real differences between plans will be in the networks of physicians and other providers, premiums and out-of pocket costs.

There will be no fees for individuals to use the insurance exchange. The cost of operating the exchange is financed by an assessment on insurance companies that choose to offer products on the exchange. For some people, it will cost more to purchase insurance on the exchange but they are likely to get better coverage.

Patients will be able to know if their doctor is part of an insurance plan offered on MNsure. The exchange will identify the network of physicians and other providers under contract with each insurance plan.

MNsure opens for enrollment on Oct. 1, 2013 for coverage for Jan. 1, 2014.

The Journal of the Twin Cities Medical Society

July/August 2013

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