ShopHealth Magazine • March 2020

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VOLUME 2, ISSUE 3

LEAVE THE BROKEN SYSTEM BEHIND HOW THE FREE MARKET CAN HELP YOU:

• GIVE EMPLOYEES A RAISE • INCREASE BENEFITS • LOWER HEALTHCARE COSTS

MORE TRANSPARENCY, LESS GOVERNMENT

INDIANA & THE FIGHT TO LOWER HEALTHCARE COSTS

THE HSA & DPC PARADOX

P. 6

P. 16

P. 20



VOLUME 2, ISSUE 3

CO N T E N TS A premier educational asset and tool designed for employers and patients as Buyers of healthcare in the free market movement.

2 Free Market Minute Megan Freedman

3 The Value of the Free Market to Self-funded Employers 4 Healthcare Americana Podcast Partners with FMMA 6 Healthcare – More Transparency, Less Government James Dunavant

Jay Kempton, Jr. Dr. Keith Smith

When they met, the founders of the FMMA had something in common; a crisis of faith in the U.S. healthcare system and, within it, their ability to provide not just greater value in benefits, but better health care for patients. Our Mission: To promote, educate and support the Healthcare Revolution, which will bring about true healthcare reform, based upon Buyers and Sellers working together in a mutually beneficial way, without the interference of the government or valueless third parties.

10 Never Fear the Balance Bill

The Keys to a Successful Reference Based Pricing Model Megan Freedman

Roundtable Should Demand 14 Business Health Care Price Transparency Cynthia A. Fisher

16 Indiana and the Fight to Lower Health Care Costs Jordan Roberts

20 The HSA & DPC Paradox:

Could 2020 be the Year an Unstoppable Force Meets an Immovable Object? Keven Brady, Esq. & John Shearer, JD, MHA

22 Local Chapter Updates 25 Local Chapter Directory

Online at www.FMMA.org ShopHealth | Vol. 2 | Issue 3

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free market

MINUTE PUBLISHER Cathy Payne cpayne@ushealthmedia.com EDITORIAL MANAGER Megan Freedman support@FMMA.org

BY MEGAN FREEDMAN

THE GOAL OF THIS PUBLICATION AND THE FREE MARKET MEDICAL ASSOCIATION IS TO EXPOSE THE CORRUPTION, EDUCATE YOU ON WHAT YOU CAN DO TO PROTECT YOUR PLAN, AND INTRODUCE YOU TO THE GOOD GUYS IN HEALTHCARE.

GRAPHICS / PRODUCTION / WRITING Ann Marie Kennon Elysia Wright Davis SENIOR MARKETING DIRECTOR Ben Daniel ADMINISTRATION / ACCOUNTS RECEIVABLE Debbie Tolliver dtolliver@ushealthmedia.com CIRCULATION Tom Higgs circulation@ushealthmedia.com CONTRIBUTING WRITERS James Dunavant, Cynthia A. Fisher, Jordan Roberts, Kevin Brady, John Shearer ShopHealth Magazine welcomes FMMA members to submit articles, information, opinions, or ideas that enhance the mission of this publication. Please submit contributions to info@USHealthMedia.com or megan@FMMA.org. For information about becoming a member of the Free Market Medical Association, visit: FMMA.org.

ShopHealth Magazine © 2020 Published quarterly by Fidelis Publishing Group, LLC P.O.. Box 217 • Jarrell, TX 76537 No part of this publication may be reproduced, translated, stored in a database or retrieval system or transmitted in any form by electronic, mechanical, photocopying, recording or other means, except as expressly permitted by the publisher. For permission contact Publisher@USHealthMedia.com. POSTMASTER: Send address changes to: ShopHealth Magazine Subscriptions. P.O. Box 217, Jarrell, TX 76537

As you may have noticed, Free MarFinally, the dates and location of the ket Healthcare Solutions has changed 2020 Annual Conference have been its name! announced! The conference will be held at the Hilton Dallas/Plano Granite In our efforts to promote shopping Park in Plano, TX on April 30 – May 2, for healthcare services, the FMMA 2020. Register online at fmma.org. founders believe that ShopHealth is an appropriate name for this publication because it was created for the exclusive benefit of consumers and employers as Buyers of healthcare. That’s what the FMMA is all about, encouraging consumers to shop!

With the continued FMMA growth, we have been able to create more learning opportunities for our members! The FMMA recently partnered with Freedom Healthworks to make Healthcare Americana the official podcast of the FMMA. Every other week, a different FMMA member will be featured on this podcast. Executive Director James Dunavant has created a ShopHealth blog to keep members up-to-date with information about the association and pertinent topics. Make sure to visit the Events section of the FMMA website for current and future webinar presentations.

Don’t Miss These Upcoming Opportunities! You don’t want to miss these educational opportunities. To learn more, visit FMMA.org. • Official FMMA podcast in partnership with Freedom Healthworks’ Healthcare Americana. • New ShopHealth blog • 2020 FMMA Annual Conference - April 30 - May 2, 2020 at the Hilton Dallas/Plano Granite Park.

Articles and written content are the property of Fidelis Publishing Group, LLC, or are used with permission of the contributing authors as noted in the publication. Photos and graphics not otherwise credited are property of Fidelis Publishing Group, LLC. The information in this publication cannot and does not constitute medical or legal advice. Information herein is provided for general information and educational purposes only and is not a substitute for physician or attorney advice. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of Fidelis Publishing Group, LLC.

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Megan Freedman has worked with self-funded benefit plans since 2005. For the past 12 years, she has worked with The Kempton Group serving as the Vice President of Corporate Communications. Ms. Freedman has extensive experience not only in employee benefits, but also marketing, sales, account management, executive support, and member services. Ms. Freedman has been featured on Kevin Price’s Pricing in Business Radio show and writes and co-authors many articles, white papers, and educational materials. She is licensed in Life, Health, and AD&D in Oklahoma and Texas.

ShopHealth | Vol. 2 | Issue 3


the

VALUE

3

OF THE FREE MARKET

T H E V A L U E O F T H E F R E E M A R K E T TO S E L F - F U N D E D E M P LOY E R S

to Self-funded

EMPLOYERS

T

he free market movement in healthcare is vital to fixing the problems with our country’s current care delivery system. The Free Market Medical Association was founded based on three pillars: Price, Value, and Equality. These pillars are essential to the long-term success of self-funded health plans. Healthcare transparency provides you and your employees with the information and the incentive to choose health care providers based on value. Value is not just about price; but rather price and quality. Your employees are inundated with media, advertising, and hype that incorrectly informs them that valuable healthcare has to be expensive; the highest quality will cost more. However, the quality of healthcare is not related to the price in the way consumers are taught to shop for other goods and services. Better quality care is almost always a lower price. High quality and low complication rates combined with efficiency enables these providers to charge far less than a low value choice.

Why is the Free Market important to you? For a self-funded employer, being part of the free market movement is very important to the long term success of your Plan. • Competition in health care delivery is the key to sustaining affordable, quality benefits for your employees.

◦ Transparency in healthcare is crucial to fulfilling the fiduciary responsibility of being self-funded and using health plan dollars to only pay for reasonable costs. ◦ Complying with the fiduciary responsibilities outlined in ERISA is becoming a hot topic for the DOL. Plan Administrators must pay special attention to how Plan assets are being spent. • The FMMA connects you with free market physicians and facilities who have embraced bundled, cash based pricing and understand that your Plan’s success is an essential part of keeping the local community strong. • The FMMA helps you find brokers/consultants and other vendor services who believe transparency is important to your Plan and understand that transparency is important in their business as well. • Finding the right facilitators or vendors can greatly impact your plan. The FMMA educates employers on how to find vendors that can have a good impact. ◦ For example, what value do your current vendors provide? In what way, and how much, do they get paid? Have they embraced the free market and advise you to use plan assets in the most prudent way? Do they understand that network/PPO discounts have no real world value? These questions are important and circle back to being a responsible fiduciary of your Plan.

• As a Plan Fiduciary under ERISA, it is important for you to be part of the free market movement. ShopHealth | Vol. 2 | Issue 3

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FREE MARKET MEDICAL ASSOCIATION ANNOUNCES PARTNERSHIP WITH FREEDOM HEALTHWORKS

H E A LT H C A R E A M E R I C A N A P O D C A S T

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reedom Healthworks and the Free Market Medical Association are excited to announce their new strategic partnership. Freedom Healthworks and the FMMA share common goals of promoting the free market in healthcare, restoring the doctor-patient relationship, and shining a light on the value of direct care. The natural alignment of missions and focus led to this strategic partnership, enabling both organizations to share resources, increase the value to members, and spread the message to a wider audience.

HEALTHCARE AMERICANA PODCAST Freedom Healthworks’ weekly podcast Healthcare Americana is now the official podcast of the FMMA. Every other week, Healthcare Americana will feature an FMMA member. These episodes will highlight the valuable stories, experiences, and strategies of self-funded employers, direct care physicians, independent surgery centers, and free market advocates. To listen to the podcasts online or add to your favorite podcast app, visit HealthcareAmericana.com.

TELL YOUR STORY! Freedom Healthworks and the FMMA are

eager to promote positive change and move the shared mission forward with a little help from our great partners. If you are interested in participating in the Healthcare Americana podcast, please reach out to support@fmma.org.

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by james dunavant

HEALTHCARE

MORE TRANSPARENCY LESS GOVERNMENT

FMMA Executive Director

H E A LT H C A R E : M O R E T R A N S PA R E N C Y, L E S S G O V E R N M E N T

JAMES DUNAVANT

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T

here is a growing public awareness that many of the national problems with healthcare result from a lack of price and quality transparency. President Trump has rightly brought more attention to this problem through recent executive orders and proposed rules to require hospitals and insurers to disclose negotiated “deals” which have traditionally been hidden from individuals and employers. This lack of transparency has no doubt created perverse incentives and cover for healthcare providers to increase cost and enrich the crony hospital systems and big insurance companies. Before we rely too heavily on the federal government to “fix” this mess, let’s not forget that government intervention and regulation in healthcare created this anti-free market phenomenon in the first place. First and foremost, transparency in healthcare is primarily a problem because the majority of consumers of healthcare goods and services rarely CARE about the cost as long as someone else is paying the bill. Our predominantly “fee-for-service” model and third-party payment system are the direct consequence of a long history of government interventions in the market, including employer tax exemptions, Medicare, Medicaid, HMOs, PPOs, ACOs, and all the resulting regulations that have emerged in their wake. The government 6

has intervened to limit the supply of market-based medical services (licensing laws, patent laws, certificate-of-need laws) while artificially stimulating demand (subsidies, tax exemptions, welfare payments). As the 20th century economist Ludwig von Mises said, “Economic interventionism is a self-defeating policy. The individual measures that it applies do not achieve the results sought. They bring about a state of affairs, which—from the viewpoint of its advocates themselves—is much more undesirable than the previous state they intended to alter.” Each government intervention has created more perverse incentives and opportunities for non-transparent interlopers, driving up the cost of healthcare while increasing the profits of the politically-connected. As a result, opportunistic politicians and their economically illiterate constituents call for more government intervention to solve the problems that well-intentioned or outright unscrupulous lawmakers and their corporate lobbyists caused in the first place. The current “private insurance” system that Medicare-for-All advocates want to abolish is actually more of an inefficient government-created and regulated payment system that has little resemblance to true insurance that offers real value for consumers interested in risk management in the midst of economic uncertainty. The issue of transparency has only begun to reach public ShopHealth | Vol. 2 | Issue 3


JAMES DUNAVANT

sign their financial life away to any hospital or healthcare provider who is not willing to guarantee an honest and transparent price. There is one thing the public should demand from government aside from letting this growing free market in healthcare work unhampered by more economic interference. We could start by demanding transparency from government itself in its own purchase of healthcare. There 7 are currently more than 20 million federal, state, and local government employees who are all receiving health benefits. This means that our federal and state tax dollars are subsidizing countless government contracts with hospitals and insurers that are not transparent to the public. Most of these hospital systems are designated as “non-profit” under the guise of providing a public benefit. These very profitable tax-exempt organizations should be held to the same standards of open records law as public universities. It sounds like a criminal heist for government agencies to disregard price and quality in contracting healthcare services and funnel taxpayer money to tax-exempt hospitals while these same hospitals are suing taxpayers who cannot afford the inflated bills the hospital is charging them. Demanding transparency in this area while seeking the services of true free market, price and quality transparent providers will revolutionize healthcare and help us avoid the disaster that will result from more government control of healthcare.

H E A LT H C A R E : M O R E T R A N S PA R E N C Y, L E S S G O V E R N M E N T

scrutiny because individuals and employers have seen their healthcare premiums, deductibles, and other out-ofpocket expenses skyrocket thanks to the latest iteration of government intervention in the form of the Affordable Care Act. So what is the best way out of this abominable mess? One thing is certain. More than 50 years of increasing government control over healthcare markets has been a miserable failure and has created the most expensive healthcare system in the world. Asking the state (i.e. taxpayers) to pay for more of the same is the definition of insanity and will only result in fiscal bankruptcy while effectively transforming physicians into government employees with as much incentive to provide quality service as the clerk at your local DMV. Fortunately, there is a growing segment of the healthcare economy that is operating according to consumer-centric market principles, disproving the narrative that increasing healthcare costs are a result of “greedy capitalism”. This marketplace is comprised of buyers who do care about cost and quality, including cash-paying individuals and members of health-share associations, individuals with high-deductible plans, and employers with self-funded health plans. Real “transparency” is the natural result of voluntary exchange between willing buyers and sellers of healthcare goods and services. Entrepreneurial “sellers” must evaluate the market and develop a cost structure that results in a price that will attract customers. The “buyers” in a free market always look for value (price and quality) when making purchasing decisions. This market-based system is working efficiently in the Direct Primary Care movement and a growing number of facilities that offer a fully-transparent bundled pricing structure. Consumers and employers can and should increase pressure on hospitals and insurance carriers to be more transparent. The free market approach to doing this effectively is to make a concerted effort to only do business with transparent providers of healthcare. Experts and patient advocates like Dr. Marty Makary have recently given sound advice that patients should outright refuse to

James Dunavant serves as the Executive Director for the FMMA. Mr. Dunavant possesses more than ten years of success in academic fundraising and managing comprehensive capital campaigns for private and public institutions. His extensive experience includes event management, corporate and foundation relations, and prospect management. Prior to his work in institutional development, Mr. Dunavant spent nearly ten years in the book industry managing major business to business client relationships and marketing programs across higher education and international markets.

ShopHealth | Vol. 2 | Issue 3

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BE IN THE KNOW Find the value of your plan as a % of Medicare

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NEVER FEAR THE BALANCE BILL

â–

MEGAN FREEDMAN

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Never Fear the Balance Bill THE KEYS TO A SUCCESSFUL REFERENCE BASED PRICING MODEL By Megan Freedman

Many self-funded employers in the U.S. are intrigued by the idea of the free market movement but have not attempted to implement any direct contracts with free market friendly physicians and surgery centers. There are many reasons for this hesitation, including the belief that a carrier is the only viable TPA option, or that network discounts will save them money. However, many employers believe that the only way to be able to direct contract is to not have a network at all. Often, these employers are uncomfortable with the idea of their employees facing possible balance billing. Rental networks that will allow an employer to direct contract do exist, but they may not be available in the employer’s area or are not the solution the employer desires. Luckily, there are new out-of-the box solutions and vendors that can help ease this transition non-traditional reimbursement strategies work effectively, while reducing balance billing concerns. 10

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Keys to a Successful RBP Centered Plan Design There are specific strategies that will bolster the success of any benefit design that incorporates RBP. It is important to keep in mind that having this type of plan design is not a “set it and forget it” strategy.

The keys to a successful RBP + Free Market benefit plan are: Incenting utilization of free market providers at an enhanced benefit tier. A 100% benefit tier is an incentive that patients are reluctant to pass up. Utilization of this benefit tier eliminates ALL possibility of balance billing. This is the “easy button” for participants and is also the best value in terms of cost and quality. Accuracy in Payment. Using the most recent Medicare fee schedule reduces the chances of balance billing. One important question to ask a potential RBP repricing vendor is how frequently their Medicare fee schedules are updated. Participant Education. Educating participants on their benefits and offering them talking points to discuss costs with their physician helps them feel in control of where they seek care. It is important to combine guidance about how their benefits work with education about self-funding. High claims also impact the participants in terms of salaries, raises, premium contributions, bonus potential, etc. Provider Education. Reaching out to providers in the local community to discuss fair and reasonable reimbursements opens the door to a cooperative relationship. Skipping this step can often lead to an antagonistic view of the plan by providers. Some may be opposed to any reimburseShopHealth | Vol. 2 | Issue 3

Patient Advocacy. When a balance bill does happen, having a robust patient advocacy program in place significantly reduces these bills and can lead to direct contracting options.

Networks Don’t Protect from ALL Balance Bills... Another important fact to keep in mind, is that the providers who are most likely to balance bill participants are rarely contracted with any network. The services that are the most likely to generate a balance bill include air ambulance services, emergency room physician charges, and anesthesia. Outrage over “Surprise Bills” tied to these services has led to legislative efforts in many states to make balance billing illegal, even becoming a topic of discussion in Congress.

AIR AMBULANCE

$50,000.00 $40,000.00

$48,410.00

$30,000.00 $20,000.00

$10,673.78

$10,000.00

$8,894.82

$0.00

TOTAL PLAN LIMIT MEDICARE BILLED 120% OF MEDICARE ALLOWED AVERAGE BILLED CHARGE FOR OUT-OF-NETWORK AIR AMBULANCE VERSUS MEDICARE AVERAGE PAYMENT

The True Impact of Balance Billing The anxiety around employees being terrorized by overzealous provider collections for every single medical service they get has been overstated. Outside of the specific services listed above, and a few other less common services, balance billing is not that common when the reimbursement is reasonable. When a reasonable RBP reimbursement is offered, such as an amount over the provider’s current Medicare rate, the actual number of balance bills is quite low. FMMA member Payer Compass, a reimbursement technology company, shows a balance bill rate of less than ► 11

MEGAN FREEDMAN

1 1

Reference Based Pricing (RBP) is not new. In fact, references are used to determine the reasonableness of a charge by many plans. Reference prices can include things like a purchased reasonable and customary list, Medicare, an online retailer price, and other resources such as the FMMA ShopHealth Marketplace. Combining a Medicare Plus reference based pricing strategy with an enhanced free market benefit tier is an innovative approach that has not yet gained widespread recognition. This strategy effectively combines the best of both worlds, offering true plan savings, and cost containment, while having an “easy button” for participants (which is also the best deal and quality!).

ment that is not tied to a percentage off billed charges but being able to share this knowledge prior to a claim occurring allows the employer and their participants to take appropriate steps.

NEVER FEAR THE BALANCE BILL

A New Look at Reference Based Pricing Options


NEVER FEAR THE BALANCE BILL

â–

MEGAN FREEDMAN

1% of processed claims. FMMA members are seeing similar results. A member TPA, The Kempton Group, reports a balance bill rate of 0.378% for 2019, with less than 10 providers refusing to negotiate below billed charges. A 6,000 life self-funded plan reports similar results with a balance bill rate of 0.74%, with only 2 providers refusing to negotiate further. In both examples, the average payment accepted was 12 165% of the provider’s Medicare reimbursement. As a comparison, network contracted rates for hospital systems typically range from 200% - 2,000% percent above the Medicare reimbursement. An additional benefit to consider when making the decision to move to an RBP reimbursement model is participant motivation. Empowering participants to make choices based on the aspects that are most important to them is a strong motivator. Removing in-network restrictions, which often rewards participants for choosing a lesser value provider, encourages more in-depth education about cost and quality.

140 LIFE SELF-FUNDED EMPLOYER $2,500.000 $2,127,258

$2,000,000 $1,213,117

$1,500,000

$1,018,709

$1,000,000 $500,000 $0.00

PPO ALLOWED AMOUNT

PPO ALLOWED % OF MEDICARE

MEDICARE PLUS AVERAGE ACCEPTED

MEDICARE PLUS SAVINGS EXAMPLE

LEARN MORE: If the idea of implementing this kind of program seems overwhelming, or you have specific questions on how it can work, there are FMMA members who can help. A program created from a collaborative partnership between Payer Compass and The Phia Group, combines RBP reimbursement technology with participant education, advocacy, and legal support. Either of these members would be more than happy to talk to you about adding an RBP solution to your plan.

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D A V I D C O N TO R N O

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14

BUSINESS ROUNDTABLE

CYNTHIA A. FISHER

To reduce health care costs, private sector employers must demand that health care providers reveal their hidden pricing – all of it.

B U S I N E S S R O U N DTA B L E S H O U L D D E M A N D H E A LT H C A R E P R I C E T R A N S PA R E N C Y

Should Demand Health Care Price Transparency

By Cynthia A. Fisher

FOUNDER AND BOARD MEMBER, PATIENT RIGHTS ADVOCATE

In October, Massachusetts Sen. Elizabeth Warren sent a letter to JP Morgan Chase CEO Jamie Dimon asking him how he plans to implement the Business Roundtable’s (BRT) new “stakeholder” mission. The BRT, which Dimon chairs, recently announced it is extending the focus of corporations from shareholders to employees, customers, suppliers and communities. Warren, a Democratic presidential candidate, asked that Dimon endorse her Accountable Capitalism Act, which places a slew of new corporate governance regulations on businesses. Originally published in U.S. News & World Report. Reprinted with permission. 14

While we think Warren's legislation is flawed, her underlying request for tangible examples of the BRT's updated corporate vision is welcome. Instead of playing more politics, however, the BRT should leverage its 181 members, who collectively employ 15 million workers, to fix the biggest problem facing American businesses and the public: health care costs. According to a new report by Kaiser Health, the average employer-provided health care costs exceeded $20,000 per family this year – 54 percent more than in 2009. The U.S. now spends nearly 20% of its GDP on healthcare, about double the developed-world average. BRT members collectively spend hundreds of billions of dollars on employee health care expenses each year. Businesses nationwide spend nearly $1 trillion on health care to cover 181 million Americans. To have the biggest impact on reducing health care prices, the BRT must require price transparency from health care providers, insurance companies and third-party administrators (TPAs). The Trump Administration recently issued an executive order requiring hospitals and insurers to reveal their hidden prices. But for this information to be transparent, widely available and patient-friendly, private sector employers must demand it. Real price transparency, which can be achieved through existing laws, is the easiest and least controversial fix to the country's health ShopHealth | Vol. 2 | Issue 3


CYNTHIA A. FISHER

Due to a lack of price transparency, health care is the only industry where there is a massive divergence of prices for the same service. On a recent episode of the HBO show "Real Time," host Bill Maher highlighted how the cost of a knee replacement can vary from $17,000 to $61,000 in the same 15 city. Dr. Keith Smith, who runs the price transparent Surgery Center of Oklahoma, highlights the story of a Georgia woman whose local hospital quoted her $40,000 for a procedure that was listed for $3,600 on the surgery center's website. The patient used this online price as negotiating leverage with her hospital, which actually matched it. Reducing health care costs by demanding real price transparency would help each of the BRT's stakeholders. Employees would benefit ■

airfare has also vastly increased access to air travel. Transparent prices in health care would similarly increase health care access because patients wouldn't avoid the doctor due to cost uncertainty. To achieve price transparency system-wide, BRT employers must first demand that their TPAs provide their secretive claims information and negotiated rates with providers. This includes disclosing their fees, rebates, brokers and even hidden compensation. By understanding this data, employers can avoid price gougers and have the pricing information necessary to steer their employees to low-cost providers. Employers must also ensure that their TPAs don't sign contracts with hospital systems that forbid the construction of a benefit design that in-

To have the biggest impact on reducing health care prices, the BRT must require price transparency from health care providers, insurance companies and third-party administrators (TPAs). and employers could then shop for the best quality of care at the lowest possible price. Widely available posted prices would also eliminate the surprise billing scourge. Consider what transparent prices have done for air travel. Since President Jimmy Carter deregulated the airlines in 1978, secretive pricing collusion has given way to widely available prices. Plane ticket prices, adjusted for inflation, have fallen by roughly 50 percent since then, while airline safety and quality have improved. Cheaper

corporates low-cost providers. Instead, contracts should allow for employer steering to such providers through employee incentives like no copay, no deductible and cash bonuses. Some innovative employers already have reduced their cost of care by 30% to 50% by directly contracting with price transparent primary care providers, surgical centers, hospitals and telemedicine providers. The savings mean these employers are often able to offer these services to their employees for free.

from lower health care prices and faster wage growth. Shareholders would benefit from lower employee health care costs and higher profits. And customers, suppliers and communities would enjoy the externality of easily understood healthcare prices and healthcare price deflation. For transparent prices to prevail against the vested interests profiting from the opaque status quo, the BRT CEOs can lead the way, providing tangible evidence of its expanded mission.

Cynthia A. Fisher is a life sciences entrepreneur, independent investor, and corporate board director. She founded WaterRev, LLC to invest in novel technologies that enable sustainable practices in water use. She serves on the public company boards of The Boston Beer Company (SAM) and Easterly Government Properties, Inc. (DEA). Cynthia is best known for her pioneering work as Founder and CEO of ViaCord, Inc., a leading umbilical cord blood stem cell banking service which she started in 1993. In 2000, she co-founded and was President of the cellular medicines company, ViaCell, Inc. (VIAC) Previously to founding ViaCord, Cynthia ran the Blood Bank Division of Haemonetics Corporation, a medical equipment manufacturer. She began her career in sales at IBM focusing on healthcare IT, insurance, and defense industries. Cynthia holds an MBA from Harvard Business School, as well as an Honorary Doctorate of Science and BS in Biophysics from Ursinus College.

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B U S I N E S S R O U N DTA B L E S H O U L D D E M A N D H E A LT H C A R E P R I C E T R A N S PA R E N C Y

care cost crisis. Absent such transparency, businesses and their employees are blind to real health care prices. This leaves them with no negotiating leverage, essentially requiring them to pay with a blank check. This can change. The BRT CEOs' market clout gives them an unprecedented opportunity to take control of their health care expenses through transparent prices, which will spur competition and choice. By requiring that hospitals, providers, TPAs, insurers and drug-makers reveal their secret negotiated rates for in-network, out-of-network and cash prices, real prices can be posted online and accessed before treatment. Such radical price transparency would lead to vigorous competition across state lines and create a free market in health care. Employees


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I N D I A N A A N D T H E F I G H T TO LO W E R H E A LT H C A R E C O S T S

JORDAN ROBERTS

and the Fight to Lower Health Care Costs

W

By Jordan Roberts

HEALTH POLICY ANALYST, JOHN LOCKE FOUNDATION

e know the lack of price transparency in health care is a significant problem. Health care isn’t purchased like any other product. In most cases, patients outsource consumer power to insurance companies and rely on them to obtain enough in-network providers, handle billing claims, and pay for the cost of the care. Not many people, including those who are involved in the care delivery process, know the final prices. But some self-insured plans are taking it a step further in by demanding that claims data, and therefore transparent pricing, be available to them. A recent article in Health Affairs article looks at how Indiana business leaders have attempted to tackle this problem: In 2016, the Employers’ Forum of Indiana (Forum), an employer-led multistakeholder coalition aiming to improve the value employers and patients receive for their health care expenditures, initiated a collaboration with the RAND Corporation to create a hospital price transparency study using claims data from self-insured employers in Indiana. This study, published in September 2017, was the first to publicly report relative hospital prices by hospital name. It found that, across 120 Indiana hospi-

tals, prices negotiated for employers in Indiana averaged 272 percent of what Medicare would have paid for the exact same services at the same hospitals over the period 2013–16. The Forum used these results to educate employers, build consensus, and demand better value from insurance carriers and hospitals. Self-insured employers are the owner of their claims data. They pay an insurance company to complete claims, but all of the data should belong to the employer to monitor cost variation and tie overall costs to health outcomes. The authors go on to describe how more price transparency among providers can help employers take back control of their plans: The pricing information generated from these studies gave self-insured employers unprecedented insight into the actual contracting outcomes between their carriers and hospitals. Since Medicare prices have already been adjusted for geographic variations in the standard of living, employers can compare the relative prices with local, regional, and national relative price benchmarks and monitor the trends over time. These insights allow employers to assess whether their negotiated prices are

Originally published by the John Locke Foundation. Reprinted with permission. 16

ShopHealth | Vol. 2 | Issue 3


reasonable and how effectively their insurance carriers negotiated with providers, which further empower employers to apply downward pressure on their insurance carriers to negotiate more effectively. This example from Indiana shows how employers can and should demand more price transparency when paying claims. It also shows how employers can use claims data to better direct patients to low cost, high-quality providers. The crucial part of the Employers’ Forum is these employers took control to lower costs themselves without any government regulations or mandates. Private actors have much more power than they think. John Locke Foundation’s readers may be familiar with some of these concepts from the battle over the State Health Plan between State Treasurer Dale Folwell and the state’s hospital lobby. Given that hospitals are charging private employers 2.7 times more than Medicare, it’s no surprise that Folwell struggled to get claims data from the state’s hospitals. The issues described above are precisely the issues that the Folwell attempted to work out with the hospitals before ShopHealth | Vol. 2 | Issue 3

changing to reference-based pricing. The North Carolina State Health Plan is a taxpayer-funded, self-insured plan. That means that the taxpayers of North Carolina are providing the majority of funding for health plan claims. Folwell asked for claims data to evaluate price variation across the state to get a better idea of what claims actually cost, rather than what the third-party administrator told the state it cost. The reason for this was because the State Health Plan was paying out substantially more each year than what it was taking in. This is not a sustainable path. When employers take back control of their employer plans, several options can be used to save money and still provide the same care that employees are used to. Consider direct primary care, for example. Large self-funded plans have started to realize the benefits of utilizing a direct primary care physician, such as Union County, in North Carolina. Traditionally, there was only a consumer-driven health plan. However, Union County offered a new direct primary care plan to employees. The county contracted with a ►

Health care isn’t purchased like any other product. In most cases, patients outsource consumer power to insurance companies and rely on them to obtain enough in-network providers, handle billing claims, and pay for the cost of the care. Not many people, including those who are involved in the care delivery process, know the final prices.

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I N D I A N A A N D T H E F I G H T TO LO W E R H E A LT H C A R E C O S T S

JORDAN ROBERTS

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DPC doctor who set up a clinic near the government offices. The results speak for themselves. Similarly, telemedicine could be incorporated into employer plans. Telemedicine visits or other forms of care at a distance over telecommunications could be easy ways to cut down on unnecessary visits or help better catch symptoms of illnesses earlier. Compared to an average of $114 for an in-office visit, a patient can connect with a physician through telemedicine for $38. Employers are facing tough decisions on how to rein in costs. Yearly premiums for a family plan in 2019 rose 5 percent from the previous year, topping $20,000. This is a problem because not only are the costs of plans rising for employees, but employers also have fewer dollars to allocate to wage raises. The majority of Americans have health insurance and receive coverage as part of a benefits package from their employer. As of 2018, 55.1 percent of Americans had employer-sponsored coverage. Yet, these employers and employees have had to grapple with rising health care costs year after year. In the wake of this, employers are taking back control of their employer plans and looking for any way to cut costs while also providing similar levels of benefits. Sixty-one percent of individuals with employer-sponsored coverage are enrolled in a self-insured plan. Self-insured plans are well suited to use different tools to cut costs. Price transparency is going to be crucial, and as we saw in Indiana, private businesses have the power to make changes on their own. There are also tools such as direct primary care and telemedicine, which employers can use to lower costs. Employers, specifically those who offer a self-funded plan, have the power and several tools to make meaningful cost reductions in employer plans while not sacrificing any of the quality employees expect.

I N D I A N A A N D T H E F I G H T TO LO W E R H E A LT H C A R E C O S T S

JORDAN ROBERTS

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Jordan Roberts joined the Locke Foundation in the summer of 2018 as Health Care Policy Analyst. He analyzes state and national health policy issues with an eye toward removing government barriers and instead infusing health care with free-market solutions that encourage competition, expand access to quality care, and lower costs. Jordan is a Charlotte native. He holds two Political Science degrees from Appalachian State University: a B.S. in American Government and an M.A. in American Politics.

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ShopHealth | Vol. 2 | Issue 3


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www.PhiladelphiaAmericanLife.com 19


THE HSA AND DPC PARADOX:

Could 2020 be the Year an Unstoppable Force Meets an Immovable Object?

T H E H S A A N D D P C PA R A D O X

K E V I N B R A DY, E S Q & J O H N S H E A R E R , J D , M H A

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By Kevin Brady, Esq. & John Shearer, JD, MHA

H

ere at Phia, we are not Physicists, Philosophers, nor Physicians. Fortunately for you, that fact hasn’t stopped us from questioning two of life’s great paradoxes. The first question often heard pondered aloud: what would happen if an unstoppable force met an immovable object? The second: what would happen if patients could use their Health Savings Account (HSA) funds to pay for Direct Primary Care (DPC)? Health Savings Accounts are an increasingly popular option that allows individuals to contribute funds to their HSA on a pre-tax basis, thereby reducing their taxable income. HSA contributions can then be used to cover “qualified medical expenses,” as defined in Internal Revenue Code § 213(d). DPC, on the other hand, is a form of capitated health care where individuals, or sometimes employers or health plans, pay a periodic fee (typically monthly) to a provider for access to designated services without fee-for-service billing. A DPC program increases the accessibility of healthcare by making the delivery of services simpler for both the patient and the provider while also eliminating the administrative burdens associated with fee-for-service arrangements. DPC has become an especially attractive option for individuals and employers as healthcare costs

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continue to rise with unpredictable fluctuations in pricing. Independent of one another, HSAs and DPC have become unstoppable forces in the health care industry. Unwittingly, these unstoppable forces when brought together, somehow create an immovable object. Rooted firmly in the pathway of the potentially exponential growth of both HSAs and DPC are the IRS regulations restricting the use of HSAs in conjunction with DPC programs. Under the IRS rules, an individual with an HSA-eligible High Deductible Health Plan (HDHP) is not only (generally) unable to use their HSA funds to pay for DPC as a qualified medical expense, but they also risk forfeiting their HSA eligibility if they participate in a DPC program. While the current guidance to determine whether periodic fee payments equate to a qualified medical expense is sparse, it is generally accepted that these fees would not meet the definition under IRC § 213(d). Currently, in order to offer DPC in a compliant manner, the service must be provided within a group health plan coupled with co-pays and related fee-for-service arrangements. To do otherwise would likely create an “other” plan (e.g. disqualifying coverage) thereby threatening an individual’s HSA-eligible status as they would no longer be covered by only a qualified HDHP. This current dichotomy is clearly counterintuitive given the spirit of DPC. ShopHealth | Vol. 2 | Issue 3


ShopHealth | Vol. 2 | Issue 3

Kevin Brady, Esq. joined the Phia Group Consulting team as an attorney in the summer of 2019. As a member of the consulting team, Kevin works on general consulting, plan document compliance, contract gap reviews, and general compliance issues. Kevin attended Oakland University in Rochester, Michigan graduating with his B.A. in History. He earned his Juris Doctor from Michigan State University College of Law in East Lansing, Michigan. While at MSU, Kevin was a member of the Journal of Business and Securities Law and worked in the MSU College of Law Immigration Clinic. After law school, Kevin worked as an attorney representing several healthcare providers in the Midwest. He is currently licensed to practice law in the State of Michigan.

K E V I N B R A DY, E S Q & J O H N S H E A R E R , J D , M H A

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John Shearer, Esq. joined The Phia Group, LLC as an Attorney in the summer of 2019. John is a member of the Phia Group Consulting team, providing consultative services to clients including employers, third-party administrators, brokers, and vendors on matters pertaining to plan administration, plan document review, contract review, and regulatory compliance with state and federal laws including but not limited to ERISA, ACA, HIPAA, COBRA, and FMLA. John earned his law degree from the University of Kentucky College of Law where he was an Appalachian Law Fellowship recipient concentrating in health law. While in law school, John earned a Master of Health Administration from the University of Kentucky College of Public Health. He also holds a Bachelor of Science in Economics and a Bachelor of Business Administration from the University of Kentucky Gatton College of Business and Economics. Prior to joining the Phia Group, John served as General Counsel and Director of Human Resources for a large Emergency Medical Services provider in Kentucky. John also has experience as an Administrative Summer Fellow in Ambulatory Medicine and as a Law Clerk in the Risk Management Office at the University of Kentucky Chandler Medical Center. He is licensed to practice in the Commonwealth of Kentucky.

T H E H S A A N D D P C PA R A D O X

The crux of the issue here is that in practice, a standard DPC program and an HSA-eligible HDHP complement one another incredibly well. A DPC program can provide the basic care that individuals will likely require on a regular or frequent basis; and the more unpredictable (and costly) services that fall outside of the DPC program (emergency room, specialist visits, etc.) can be covered under a plan with low monthly premiums, such as under an HSA-eligible HDHP. Using both of these benefits in conjunction empowers individuals to better utilize the marketplace and receive the care they need while also keeping healthcare costs low. It also provides individuals with a tangible tax benefit, protections in the event they require higher-cost services, and ensures a consistent relationship with a primary care physician. Even though an HSA-eligible HDHP/DPC combination could be an appealing option for healthcare consumers across the country, the regulatory environment as it stands today simply hasn’t allowed for it. In order for individuals to take full advantage of the tax benefits available with an HSA in conjunction with the predictable costs and arguably better care of a DPC program, this immovable object must first be overcome. The guidance on this issue must be clarified either through legislation in Congress or in the alternative, through the regulatory process. Luckily, hope is on the horizon. As it stands today, there are currently three bills in Congress that seek to expand the use of HSAs. Two pieces of legislation have been introduced in the House of Representatives (The Health Savings Account Expansion Act of 2019 and the Primary Care Enhancement Act of 2019) along with legislation in the Senate (The Health Savings Act of 2019). While the nuances of the bills are somewhat different, they include revisions to the Internal Revenue Code that would allow individuals with HSAs to participate in DPC programs and include the periodic fee payments as a qualified medical expense. The executive branch has also become proactive in paving the way for HSA and DPC expansion. In June of 2019, President Trump issued an Executive Order directing the Secretary of the Treasury to issue regulations that would clarify the issue as to whether periodic payment fees under a DPC program will be considered a qualified medical expense for HSAs. Given the previous failure of similar bills and the current legislative environment in Congress, it seems most likely that the guidance and clarification needed to solve this paradox will be the result of the Executive Order and the resulting final regulations. Like the unstoppable force that meets an immovable object, the HSA/DPC paradox may not be solved as soon as we like. The good news is that the forces are in motion to finally provide the desperately needed guidance on this issue. When this happens, how it comes to be, and what it will look like when all is said and done, are all questions that we will continue to ponder until the next paradox strikes a chord.

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LOCAL CHAPTER NEWS

IF IT AIN’T… actually, it IS

BROKEN

C H A P T E R U P D AT E S

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Do you like “The Resident” television show? Last month, over 100 Texas and Oklahoma chapter members had the opportunity to meet the man who, literally, wrote the book. The Austin Chapter of the Free Market Medical Association hosted surgical oncologist, author, and leading health expert Dr. Marty Makary as the featured speaker at their third annual Speaker Series event on February 28. Dr. Makary explained the vital role the free market plays in building a better healthcare system. The Fox TV series is based on Dr. Makary’s book Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health

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DR. MARTY MAKARY HEADLINES AUSTIN CHAPTER ANNUAL SPEAKER SERIES Care, and he has recently published another, The Price We Pay - What Broke American Healthcare and How to Fix It, which is sweeping the nation by storm. The free event was sponsored by Sedera Medical Cost Sharing, Texas Medical Management, and J&H Insurance Services and was directed toward self-funded employers; physicians, DPCs, and specialists; third-party administrators, brokers, and other healthcare industry stakeholders. Free market advocates are aware that Americans are losing trust in their healthcare systems, and sometimes even their doctors, Dr. Makary is serious about changing the way Americans think about value-driven healthcare in the market on all levels by driving down the cost of health care and promoting price transparency. Not only is he an advisor to multibillion-dollar companies and leading

health expert, Dr. Makary has met personally with President Trump about the recent executive order on price transparency. He has had many televised appearances in national news media and has contributed to hundreds of publications, The Wall Street Journal and TIME among them, on how the cost of medical care is affecting our everyday lives and how we can solve the healthcare crisis.

ShopHealth | Vol. 2 | Issue 3


elopment announce their collaboration

in healthcare starts in the room between the doctor and the pati

n Antonio. The founder of the San

Clinic in San Antonio. Mr. Poncelet,

apter of FMMA as Co-Chair. Since

bring together business owners,

y in healthcare in the city.

Dr. Moczygemba is privileged to be able to fill the needs o

NEW FMMA CHAPTER Primary Care model. Direct Med Clinic provides access to qu SAN ANTONIO, TX

struggle with access to healthcare due to high premiums or ded

San Antonio, Texas Direct Med Clinic and Shankx Web Development announce their collaboration to bring e the leading contribution of bankruptcy

the Free Market Medical Association (FMMA) to San Antonio. The founder of the San Antonio chapter, Dr. kruptcy due to illness or medical bills.

Direct Med Clinic needs of joins large 23 employer Moczygemba, is owner of Direct Med Clinic in San Antonio. Mr. Poncelet, CEO ofaddresses Shankx Webthe Development, the San Antonio chapter of FMMA as Co-Chair. Since November the allows San Antonio FMMA meets quarterly to services,2019, which Direct Med Clinic to impact the popul bring together business owners, providers and facilities that see the value of price transparency in healthcare in midsize employers, we provide affordable access to care thr the city. Results of a national study shows medical debt continues to be the leading contribution of bankruptcy in the ore the American values of free and Med Clinic also contracts directly with small employers who v United States. 500,000 Americans per year declare bankruptcy due to illness or medical bills. Bringing healthcare and services by providing a free market to millions of Americans without making it accessible and affordable is not a solution to the healthcare crisis. afford insurance. The Free Market Medical Association (FMMA) seeks to restore the American values of free and unrestricted market between the buyer and the seller of goods and services by providing a free market network to San Antonio. ors, physicians aiming to grow their For more information about Direct Med Clinic, please visit d San Antonio FMMA assists patients seeking free market doctors, physicians aiming to grow their Direct Primary affordable, accessible health care for Care practice, and employers seeking quality affordable, accessible health care for their employees without the 2486. fear of costs.

zygemba,

. He has

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d largest

ough his

C H A P T E R U P D AT E S

g it accessible and affordable is not a

ABOUT DIRECT MED CLINIC

About Shankx Web Development ABOUT SHANKX WEB DEVELOPMENT

Before training in Family Practice Although Direct Primary Although Direct Primary Care is Care is on in the Navy, Roger Moczygemba, one of the best innovative healthsolutions providebetter better healthcare MD, graduated from Texas A&M care solutions to to provide Health Science Center. He has healthcare services to still businesses, individuals, it is relatively new. A worked in Family Practice, Occupafamilies and individuals, it is still tional Medicine, and Urgent Care relatively As a result, people Directnew. Primary Care model will n for 25 years. He was a pioneer in unfamiliar with the Direct Primary the telemedicine industry as the Through advanced content and digita Care model will not understand president and lead physician in one the value it offers. Through adDevelopment and Consulting stimula of the nation’s first and largest televanced content and digital marketmedicine companies. His innovative ing strategies, Shankx Web Develeducation. drive continues through his demonstrated commitment to opment and Consulting stimulates awareness and interest the affordable care of his patients. Dr. Moczygemba feels through education. that value in healthcare starts in the room between the Shankx Web Development and Consulting is meeting doctor and the patient. Shankx Web andindustry Consulting isintelmeeting the nee the needs of Development this rapidly evolving by using Dr. Moczygemba is privileged to be able to fill the needs ligent solutions to effectively maintain SEO and websites. using intelligent solutions to effectively maintain SEO and of his community through the Direct Primary Care model. by Regular social media posts made throughout the month Direct Med Clinic provides access to quality primary care by Shankx Web Development increase awareness of free made throughout the month by Shankx Web Development and wellness who struggle with access to healthcare due to market efforts and support resources available to the high premiums or deductibles. efforts and support resources available to the people of San An people of San Antonio. Direct Med Clinic addresses the needs of large employ For more information about Shankx Web Developers through economical onsite clinic services, which allows ment, visit shankxwebdev.com or call 210-806-6642. Direct Med Clinic to impact the population health of their employees. For midsize employers, we provide affordable San Antonio FMMA assists patients seeking free access to care through our “near site” model. Direct Med market doctors, physicians aiming to grow their Clinic also contracts directly with small employers who Direct Primary Care practice, and employers seeking value their employees but who cannot afford insurance. quality affordable, accessible health care for their For more information about Direct Med Clinic, please employees without the fear of costs. visit directmedclinic.com or call 210-405-2486. ShopHealth | Vol. 2 | Issue 3

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PILLARS PRICE

24

OF THE FMMA

• PRICE is NOT a product. CARE is the product. • Selling access to pricing is anti-free-market. • Vendors and third parties whose compensation is based on selling “savings” or “access” are not the solution.

FMMA PILLARS

Percentage-based payment models incentivize price gouging and pricing games. Compensation based on a percentage of savings, claims or premiums where the third party WINS when the cost is high, puts the vendor at odds with the best interest of their clients. • VALUE is established when the buyer and seller agree on a FULLY DISCLOSED, mutually beneficial price for care. • If a vendor adds or changes that price in ANY WAY, those amounts should be truthfully disclosed. • Vendors and third parties whose compensation is based on selling “savings” or “access” are not the solution. Value is based on Price and Quality. A consumer cannot determine the VALUE of the purchasing choices they make without price HONESTY. In an open free market, consumers would be able to readily access the information to choose healthcare providers based on Value.

VALUE

EQUALITY

• PRICE EQUALITY is the basis of a free market. • Cash is king. • Any willing buyer should be offered the same price regardless of any factor.

In an open and honest free market, cash is always king. Enhanced discounts for guaranteed bodies through the door, increases costs for patients based on factors they cannot control; such as one insurance v. another, these are all symptoms of a broken system. In a free market system, a competitive price can be knowable, publishable and complete regardless of the patient, the health plan, the employer, or any other factor.

WHY BE INVOLVED IN A LOCAL FMMA CHAPTER? Local chapters of the Free Market Medical Association connect you with like-minded employers, physicians, facilities, industry experts, and experts in your own community. Local chapter groups help facilitate and implement strategies, ideals, and goals important to you. Bringing buyers and sellers of health care goods and services together to strategize, identify, and implement solutions is ground-breaking and paradigm shifting. For too long, third party vendors have kept two of the biggest stakeholders in our healthcare system apart— the providers, and the employers. Both sides recognize that the only way for providers to provide the highest value, and employers to offer comprehensive benefits without runaway healthcare costs, is to work together to advocate for change. Your local chapter connects you with free marketfriendly providers who have embraced transparent pricing and quality. FMMA member physicians and facilities understand helping your business succeed is 24

an essential part of keeping the local community strong, and helps them succeed! What should you expect? Amazing conversation, new friends, expanded resources, and maybe some answers and solutions. Your chapter may meet monthly over lunch at a local business, or may choose to meet regularly by video chat or conference call, and only meet in person every quarter. Each local chapter has its own schedule and topics based on what is best for the participating members, but the relationships formed are beneficial across the board. Don’t have a local chapter in your area? You can start one! Starting a local chapter is easier than you think— simply talk to the FMMA staff, fill out some paperwork, then invite anyone you know to sit down and have a conversation. Chapters grow steadily over time as attendees invite someone they know to the next meeting. The FMMA currently has 26 local chapters, and more than 300 members in 33 states. You may have free market warriors in your own back yard! Join the FMMA and support or start a local chapter.

FMMA.org/local-chapters/ ShopHealth | Vol. 2 | Issue 3


free market medical association

CHAPTER DIRECTORY

To learn more about FMMA Local Chapters, visit FMMA.org/ Local-chapters

F M M A C H A P T E R D I R E C TO R Y

25

ARIZONA

Timothy Spooner Dr. Kendrick Johnson arizona@fmma.org

CALIFORNIA

SAN FRANCISCO BAY AREA CHAPTER Dr. Richard Fox Dr. Beth Haynes sanfrancisco@fmma.org

CAROLINAS

ILLINOIS

Colleen Ingraham illinois@fmma.org illinoisFMMA

MASSACHUSETTS

Dr. Jeffrey Gold Matthew Painten massachusetts@fmma.org massachusettsFMMA

NORTH AND SOUTH CHAPTER MICHIGAN Cristy Gupton Theresa McIntosh carolinas@fmma.org Dr. Roland Tindle michigan@fmma.org COLORADO michigan fmma Brian Perry colorado@fmma.org Colorado FMMA

FLORIDA

FLORIDA CHAPTER Chris Markford florida@fmma.org FLORIDA SW CHAPTER Dr. Raymond Kordonowy Dr. Sunil Lalla floridasw@fmma.org flswFMMA

GEORGIA

Dr. Avinesh Bhar georgia@fmma.org georgiaFMMA

ShopHealth | Vol. 2 | Issue 3

MINNESOTA

Merlin Brown, MD Tyler Lowthian minnesota@fmma.org mnFMMA

MISSOURI

Dr. Joseph Costello missouri@fmma.org missouriFMMA

MONTANA

Dr. Kathleen Brown Jack Brown montana@fmma.org

NEBRASKA

NEBRASKA CHAPTER Pete Larson nebraska@fmma.org nebraskaFMMA

OKLAHOMA

OKLAHOMA CITY (FOUNDING) CHAPTER Angie McKinney okc@fmma.org oklahoma fmma TULSA CHAPTER Paul Mackey tulsa@fmma.org tulsaFMMA

OHIO

Dr. Louis Flaspohler ohio@fmma.org

OREGON

Dr. Donna Givens oregon@fmma.org oregonFMMA

PENNSYLVANIA

Tom Yakopin pennsylvania@fmma.org

TEXAS

AMARILLO CHAPTER Deeter Prater Josh Butler amarillo@fmma.org AUSTIN CHAPTER Sean Kelley austin@fmma.org Austin.FMMA DALLAS CHAPTER Bret Brummitt dallas@fmma.org HOUSTON CHAPTER Dr. Bhavana Rao houston@fmma.org houFMMA SAN ANTONIO CHAPTER Dr. Roger Moczygemba Shankar Poncelet sanantonio@fmma.org

VIRGINIA

VIRGINIA CHAPTER Dr. Jordan Hackworth virginia@fmma.orgÂ

WISCONSIN

WISCONSIN CHAPTER Dr. Brian Erdmann wisconsin@fmma.org 25


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