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VOLUME 1, ISSUE 4

Transparency

THE VALUE OF INDEPENDENT FACILITIES

DPCs: Congress and HSA

#PlanHacks

THE CASE FOR HEALTHCARE REIMBURSEMENT ARRANGEMENTS

12 WAYS TO FREE-MARKETIZE YOUR PLAN

DPC and Self-Insured Employers

Green Imaging, PLLC

FREE MARKET IMAGING

COUNTING THE COSTS

ENHANCE YOUR BENEFITS PACKAGE WITH AFFORDABLE IMAGING

• FREE MARKET MYTH V. FACT • PILLARS OF THE FMMA • WHY BE INVOLVED IN YOUR LOCAL FMMA CHAPTER FREE MARKET MINUTE FMMA ANNUAL CONFERENCE

THE VALUE OF THE FREE MARKET TO SELF-FUNDED EMPLOYERS

SHOW ME THE PRICE LIST!

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SOLUTIONS FREE MARKET

HEALTHCARE

VOLUME I, ISSUE 4

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.

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.

ON THE COVER:

Green Imaging, PLLC is providing direct-care radiology via a growing network of providers and physicians to give patients and self-funded employers quality scans at fair prices. p. 20

USHealthMedia.com | Vol. I | Issue 4

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Free Market Minute

”FMMA Annual Conference” • Megan Freedman

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The Value of the Free Market to Self-funded Employers

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2019 FMMA Annual Conference

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Burn the Ships - Going All In! • Speaker Topics and Bios

The Value of Independent Facilities Dr. Richard Kube

Direct Primary Care and Self-insured Employers Counting the Costs • Dr. Robert Nelson

COVER - Free Market Imaging

Enhance your Benefits Package with Affordable Imaging

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Show Me the Price List

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DPC: Congress and HSA

Compliance with CMS Rules Shows Road to Transparency Not Always So Clear • Philip Qualo, J.D.

The Case for Health Reimbursement Arrangements and DPC Dr. Lee Gross

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Free Market Myth v. Fact

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FMMA Local Chapters

Local Chapter Directory • Why Be Involved Online at www.USHealthMedia.com 3


SOLUTIONS FREE MARKET

HEALTHCARE

BETTER BENEFITS LOWER COSTS

PUBLISHER Cathy Payne cpayne@ushealthmedia.com EDITORIAL MANAGER Megan Freedman megan@FMMA.org GRAPHICS / PRODUCTION / WRITING Ann Marie Ludlow aludlow@ushealthmedia.com SENIOR MARKETING DIRECTOR Ben Daniel wbendaniel@ushealthmedia.com ADMINISTRATION / ACCOUNTS RECEIVABLE Debbie Tolliver dtolliver@ushealthmedia.com CIRCULATION Tom Higgs circulation@ushealthmedia.com CONTRIBUTING WRITERS Dr. Richard A. Kube II, Dr. Robert Nelson, Philip Qualo, J.D., Dr. Lee Gross Free Market Healthcare Solutions 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.

FREE MARKET HEALTHCARE SOLUTIONS © 2018 Published bi-monthly 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: Free Market Healthcare Solutions Subscriptions. P.O. Box 217, Jarrell, TX 76537

free market

MINUTE

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.

Do Not Miss the 2019 FMMA Annual Conference! It is exciting to watch how the association has grown and changed since 2014. FMMA’s initial goal was simply to teach others how to replicate the success the Founders had experienced by embracing the free market in healthcare. At that time, a Buyer and Seller working together, without interference, was unheard of, and often it was contractually banned by the establishment. As awareness of the true causes of the broken healthcare system has emerged, greater rumblings about perverse incentives, inflated costs, and the monopolistic control by just a few are getting louder. The theme of the 5th FMMA Annual Conference is Burn the Ships: The Healthcare Free Market New World. This event will be more than informative, more than commiserative; it will provoke you to act and (possibly) instigate an insurrection. Our speakers will help empower you to eliminate the option of retreat by rejecting the system and liberating yourself from the failing healthcare status quo ship. The Keynote Lun-

cheon guest speaker is the ultimate free market defender: The Honorable Dr. Ron Paul. In his presentation Free Market Medical Care and the State, Dr. Paul will provide the insight of a physician and champion of liberty while providing a glimpse of what his ring-side seat in Washington revealed about the machine bent on delivering medical bankruptcy to all but the elite. His unwavering passion will motivate every attendee to wake up and speak out! All of this year’s speakers and panelists will be inspiring and motivating. As you review the full list of speakers and contributors in the conference section of this issue, finding a topic or speaker that is relevant and valuable to you will be easy. As always, the conference will include the Founders’ Panel with Dr. Keith Smith and Jay Kempton presenting “Burning the Ships: Going All In!” One of my favorite authors, Dr. Marty Makary, is a general session speaker. Dr. Makary is the author of Unaccountable, the book that sparked the TV series “The Resident”.

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 is the Executive Director of the Free Market Medical Association. She was recently 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.

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the

VALUE OF THE FREE MARKET

Note: Registration is open now at www.ShopHealth.FMMA.org/ events. More details on page 6.

USHealthMedia.com | Vol. I | Issue 4

MEGAN FREEDMAN

to Self-funded

of the free market movement. ◦◦ Transparency in healthcare is crucial to fulfilling the fiduciary responsibility of being The free market movement in self-funded and using health healthcare is vital to fixing the probplan dollars to only pay for lems with our country’s current care reasonable costs. delivery system. The Free Market ◦◦ Complying with the fiduciary Medical Association was founded responsibilities outlined in based on three pillars: Price, ValERISA is becoming a hot topic ue, and Equality. These pillars are for the DOL. Plan Administraessential to the long-term success of tors must pay special attention self-funded health plans.  to how Plan assets are being Healthcare transparency provides spent. you and your employees with the information and the incentive to • The FMMA connects you with choose health care providers based free market physicians and facilon value. Value is not just about ities who have embraced bunprice; but rather price and quality. dled, cash based pricing and unYour employees are inundated derstand that your Plan’s success with media, advertising, and hype is an essential part of keeping that incorrectly informs them the local community strong. that valuable healthcare has to be • The FMMA helps you find expensive; the highest quality will brokers/consultants and other cost more. However, the quality of vendor services who believe healthcare is not related to the price transparency is important to in the way consumers are taught to your Plan and understand that shop for other goods and services. transparency is important in Better quality care is almost always their business as well. a lower price.  High quality and low • Finding the right facilitators or complication rates combined with vendors can greatly impact your efficiency enables these providers plan. The FMMA educates emto charge far less than a low value ployers on how to find vendors choice. that can have a good impact. Why is the Free Market ◦◦ For example, what value do important to you? your current vendors provide? In what way, and how much, For a self-funded employer, being do they get paid? Have they part of the free market movement embraced the free market and is very important to the long term advise you to use plan assets success of your Plan. in the most prudent way? Do • Competition in health care they understand that network/ delivery is the key to sustaining PPO discounts have no real affordable, quality benefits for world value? These questions your employees. are important and circle back • As a Plan Fiduciary under ERISA, to being a responsible fiduciait is important for you to be part ry of your Plan.

EMPLOYERS

FREE MARKET MINUTE

His presentation is guaranteed to be thought-provoking and engaging. He will also be discussing his newest book The Price We Pay, which will be available for purchase at the conference. Please join us on April 11-13, 2019 at the Hyatt Regency in Dallas, TX. This unique event is sure to motivate the legitimate stakeholders (victims) to fight for change!

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2019 FMMA ANNUAL CONFERENCE

6 BURN THE SHIPS

Burn the Ships: The Free Market Healthcare New World

FMMA ANNUAL CONFERENCE

THE 5TH ANNUAL FREE MARKET MEDICAL ASSOCIATION CONFERENCE IS RIGHT AROUND THE CORNER! YOU WON’T WANT TO MISS THIS AMAZING EVENT APRIL 11-13 AT THE HYATT REGENCY IN DALLAS, TX.

Conference Host JONATHAN SMALL, C.P.A. President Oklahoma Council of Public Affairs

The theme for the 2019 conference is “BURN THE SHIPS!” The Free Market Healthcare New World

As the leaders of this free market movement in healthcare, we must encourage our clients, patients, and the members of our team to reject the Stockholm Syndrome of our current healthcare system. Our mission has changed from just educating and connecting the buyers and sellers to one of revolutionizing the healthcare industry; helping those who are victims of this broken system to reject the fear of letting go of their broken, listing, and sinking ship. The goal of the 2019 conference is to motivate, energize, influence, and empower the current and potential leaders of the free market movement to Burn Your Ships! With a spectacular speaker lineup of innovators and idea generators, this is a must-attend event. Notable speakers include economist and co-author of Primal Prescription, Bob Murphy; Dr. Marty Makary, author of The Price We Pay; and David Contorno, the paradigm-busting benefits innovator and Founder of E Powered Benefit. Everyone will find something of value in one of our eight breakout sessions covering topics like Incorporating the Free Market into your Benefit Plan, HMOs & the Free Market, Pricing of Specialty Care, Lies Employer’s Believe, Creating Bundled Pricing, and more! The conference will close with our Founders’ Panel where Dr. Keith Smith and Jay Kempton will present Burn Your Ships: Going All In! 6

Jonathan Small is President of the Oklahoma Council of Public Affairs, having joined staff in December 2010. Previously, Jonathan was a budget analyst for the Oklahoma Office of State Finance, as a fiscal policy analyst and research analyst for the Oklahoma House of Representatives, and as director of government affairs for the Oklahoma Insurance Department. Small co-authored Economics 101 with Dr. Arthur Laffer and Dr. Wayne Winegarden, and his policy expertise has been referenced by The Oklahoman, the Tulsa World, National Review, the L.A. Times, The Hill, the Wall Street Journal and the Huffington Post. His weekly column “Free Market Friday” is published by the Journal Record and syndicated in 27 markets. A recipient of the American Legislative Exchange Council’s prestigious Private Sector Member of the Year award, Small is nationally recognized for his work to promote free markets, limited government and innovative public policy reforms. Jonathan holds a B.A. in Accounting from the University of Central Oklahoma. USHealthMedia.com | Vol. I | Issue 4


CONFERENCE SPEAKERS

CONFERENCE DETAILS

Where: Hyatt Regency Dallas • 300 Reunion Blvd. E • Dallas, TX 75207 When: April 11-13, 2019 Register: ShopHealth.FMMA.org/events

BURN THE SHIPS

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The FMMA cannot change the broken healthcare system alone. Your support and assistance is needed to create a better system in which you can create or maintain your own successful plan and offer your employees valuable healthcare choices.

FMMA ANNUAL CONFERENCE

Exhibitors: Sponsor and Exhibitors must be FMMA members. Space available on a first come, first served basis. 15 Premium 8x10 booths at entrance • 25 Standard, 6-ft table in adjoining room For questions about the FMMA or the Annual Conference, visit www.fmma.org or email support@fmma.org. Check out upcoming events in your area at www.fmma.org/events and www.fmma.org/local-chapters

Keynote Speaker, April 12 RON PAUL, M.D. Former Congressman and America’s Foremost Advocate for Liberty TOPIC: FREE MARKET MEDICAL CARE AND THE STATE

Dr. Paul delivers a candid look at the dysfunctional American political system. Using anecdotes from his 23 years in Congress, he highlights the need for a limited government and more personal liberties. Dr. Paul captures audiences’ attention by relating the occurrence of current national issues such as debt, privacy, and freedom to the government’s neglect to follow the constitution. His unwavering passion leaves audiences motivated to speak out, wake up, and let politicians know what they want. Since his retirement from Congress, Dr. Paul has continued to work for limited constitutional government through organizations he founded, including the Foundation for Rational Economics and Education (FREE), USHealthMedia.com | Vol. I | Issue 4

Campaign for Liberty, and the Ron Paul Institute for Peace and Prosperity. In addition, Dr. Paul recently launched The Ron Paul Liberty Report, an online network airing original programming on today’s most pertinent issues. Dr. Paul, the author of several best-selling books, most recently released Swords into Plowshares, offering a personal reflection on American’s history of war, foreign intervention, and prospects for peace. While serving in Congress during the late 1970s and early 1980s, Dr. Paul served on the House Banking committee, where he was a strong advocate for sound monetary policy and an outspoken critic of the Federal Reserve’s inflationary measures. He also was a key member of the Gold Commission, advocating a return to a gold standard for our currency. He was an unwavering advocate of pro-

life and pro-family values. In 1984, he voluntarily relinquished his House seat and returned to his medical practice. He returned to Congress in 1997 to represent the 14th district of Texas, serving on the House Financial Services Committee and the Foreign Affairs Committee. Dr. Paul, the author of several best-selling books, most recently released The School Revolution: A New Answer for Our Broken Education System, offering a provocative look at how we need to change the way we think about America’s dysfunctional education system in order to fix it. 7


CONFERENCE SPEAKERS

SPEAKERS & TOPICS

JAY KEMPTON

G. KEITH SMITH, M.D.

FMMA Co-founder President & CEO, The Kempton Group

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In 1992, Joseph “Jay” Kempton started his journey with The Kempton Group, which was founded in 1969 by his father, Wayne Kempton. Mr. Kempton became the President and CEO in 2003 and has diligently worked with Oklahoma employers to ensure their employee benefits fit the needs of our community. In 2011, Mr. Kempton became aware of the free market medical movement in Oklahoma and what it could mean for healthcare in his community. Based on a true belief in transparency, and a genuine desire to change how employers and participants view and purchase healthcare, Mr. Kempton started the Kempton Premier Provider™ program. By partnering with free market minded providers in Oklahoma, Texas, and surrounding states, Mr. Kempton has helped his self-funded clients save millions of dollars in just a few years. Mr. Kempton is one of the founding members of the Free Market Medical Association, a board member of the Society of Professional Benefit Administrators, and a member of the Health Care Administrators Association. Mr. Kempton has a Bachelor of Science degree in Business Administration from Oklahoma State University and is Life, Health, AD&D, and Property and Casualty Insurance licensed in multiple states.

FMMA Co-Founder Managing Partner, Surgery Center of Oklahoma

Dr. Keith Smith is a board certified anesthesiologist in private practice since 1990. In 1997, he co-founded The Surgery Center of Oklahoma, an outpatient surgery center in Oklahoma City. SCO is owned by over 50 of the top physicians and surgeons in central Oklahoma. Dr. Smith serves as the medical director, CEO and managing partner while maintaining an active anesthesia practice. In 2009, Dr. Smith launched a website that displays SCO’s all-inclusive pricing for various surgical procedures. This move garnered national, and even international, attention. Not only do many uninsured or underinsured American patients take advantage of this cash pricing, but many Canadians have traveled to The Surgery Center to receive care. The free market focus of the Surgery Center, the innovator of this free market model in the U.S., has gained the endorsement of policymakers and legislators. Dr. Smith hopes as many facilities as possible will adopt a transparent pricing model, a move he believes will lower costs for all and improve quality of care. Dr. Smith is the co-founder of the Free Market Medical Association. The association provides a platform where buyers, both individuals and employers, who are seeking high quality, affordable healthcare can find free market minded sellers, both physicians and facilities. Dr. Smith and Mr. Kempton will host the Founders’ Panel

Burn the Ships: Going All In!

In this Founders’ Panel, Dr. Keith Smith and Jay Kempton, co-founders of the FMMA, will dispel common myths that keep free market supporters from Going All In and rejecting the healthcare system status quo.

ROBERT P. MURPHY Senior Fellow, Mises Institute & Research Assistant Professor - Free Market Institute at Texas Tech University TOPIC: THEORY AND HISTORY AGREE: GOVERNMENT INTERVENTION IN HEALTH CARE REDUCES QUALITY AND INCREASES COST

Murphy first explains the theory by which free-market medicine should provide better quality at lower prices for patients. He critiques the mainstream economist view (derived from Kenneth Arrow) in which “market failure” allegedly keeps markets from working well in healthcare. He uses numerous examples from U.S. history to illustrate the pattern, including the FDA, medical licensing, the tax code, the ACA, and patterns in medical prices for different payment structures. Robert is a Research Assistant Professor with the Free Market Institute at Texas Tech University. Along with ER doctor Doug McGuff, Murphy is the author of The Primal Prescription: Surviving the “Sick Care” Sinkhole. He earned his B.A. in economics from Hillsdale College and his Ph.D. in economics from New York University. He is currently Senior Economist at the Institute for Energy Research. Dr. Murphy also serves as a senior fellow with the Fraser Institute, a senior fellow with the Mises Institute, and a research fellow at the Independent Institute.

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DAVID CONTORNO Founder and CEO of E Powered Benefits TOPIC: HEALTHCARE STOLE THE AMERICAN DREAM, HERE’S HOW TO TAKE IT BACK

Well over 20% of our GDP goes to Healthcare. Based on the current trends, more than half of Millennials’ lifetime earnings will go to healthcare. The majority of Opioid addicts started with a legitimate prescription, taken as prescribed, and paid for by an employer sponsored health plan. Doctors are the number one suicide rate of any profession. And the average out-of-pocket is 10X the average savings account. If that doesn’t show that healthcare has stolen the American Dream, I don’t know what does. Here’s why we let this happen… and how to take it back.

Twice named Broker of the Year and one of Forbes’ Most Innovative Benefits Leaders, David Contorno’s business model has produced average one-year savings of over 40% along with substantially reduced out of pocket costs for employees.

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CONFERENCE SPEAKERS

SPEAKERS & TOPICS

TOPIC: THE PRICE WE PAY: CUTTING THROUGH THE MONEY GAMES AND RESTORING MEDICINE TO ITS MISSION

Dr. Makary, a surgeon and leading health care expert, reviews the current state of medicine and how to prepare for the future of health care. With regulatory and paperwork burdens crushing doctors, he identifies the disruptors that are saying “no” to the throughput-billing model of practicing medicine and saying “yes” to a more patient-centered, relationshipbased model that embraces technology, lifestyle science, and a competitive marketplace designed to bypass the middlemen and put physicians back in the driver’s seat. He will also discuss his newest book The Price We Pay and the grassroots effort to reform health care. The movement to restore medicine to its mission, Makary argues, is alive and well--a mission that can rebuild the public trust and save our country from the crushing cost of health care. Dr. Makary has been elected to the National Academy of Medicine and named one of America’s 20 most influential people in health care by Health Leaders Magazine. His book, Unaccountable, was turned into the hit TV medical series “The Resident”, and his newest book, The Price We Pay, tells the stories of health care’s disruptive innovators and the new movement to restore medicine to its mission.

ADAM V. RUSSO, ESQ Co-Founder & CEO, The Phia Group, LLC TOPIC: INNOVATIVE OPTIONS FOR 2019: EMPOWERING YOUR BENEFIT PLANS

Healthcare has been and continues to be one of the (if not the) number one issue dominating politics, law, and the economy. Employers are making a conscious decision to familiarize themselves with the legal landscape and various cost drivers tied to health benefits. As a result, employers are demanding more—more options, more results, more information - in their quest to improve benefit offerings while minimizing costs. This presentation is the best first step in your journey to understand the plan types and services that should be offered in 2019, and the steps needed to successfully implement each one.

The Phia Group LLC provides health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. Their overall mission is to reduce plan costs through recovery strategies, innovative technologies, and legal expertise. Russo is also founder and managing partner of The Law Offices of Russo & Minchoff, a full-service law firm with offices in Boston and Braintree, MA. His practice is devoted to employers, plan fiduciaries, third-party administrators and carriers in employment and employee benefits matters nationwide. He frequently speaks and writes on health care and employee benefits at webinars, conferences and seminars across the country.

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R. SCOTT VAUGHN, CPA President & CEO, GlobalHealth TOPIC: HMO & THE FREE MARKET, SERIOUSLY?

The evolving role of innovative health plans in promoting free market principles. Specifically, innovative HMOs have unique capabilities that can help facilitate the move to more efficient delivery of health care services. GlobalHealth is a $275 million health maintenance organization providing affordable health care coverage to over 32,000 Oklahomans.

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Scott has been actively involved in community and civic organizations, most recently co-chairing the Tulsa Area United Way’s Alexis de Tocqueville committee with his wife Kayla. He has also served as the president of the Child Abuse Network, a member of the advisory board for the Salvation Army – Tulsa, and as a member of the advisory board for the Oklahoma State University School of Accounting.

TRACY CREGER Director of Provider Strategies, Licensed Nurse Tracy is licensed in Oklahoma as a Life, Accident and Health Producer. Since joining MedCareOne in 2016, Tracy has developed their bundled transparent program; Evolution, and is working with clients and providers on cost-containment strategies. By providing cost-containment strategies to employers she helps them continue to provide great benefits to their employees which is a win-win for all.

JON WILKERSON Director of Benefits and Retirement

Mr. Wilkerson has worked in the Insurance/ Healthcare realm for over 27 years. He begin his career working for an insurance company auditing outside legal case progression and fees. He then moved on to working in medical underwriting for the same company for several years. He then gained great hands on experience working for a third party administer for over 10 years in claims, client services and account management. In 2009, he became the Director of Benefits & Retirement for Oklahoma County. He soon found out that the County’s health plan had to have innovative direction to remain solvent. The County’s aging population, along with an almost uninsurable stop loss pool, led him to implement direct contracts, innovative preventative screenings, full spectrum mental health care and removing barriers from care. These programs have saved the County and its participants millions of dollars, allowed easy access to high quality care and have saved lives.

Ms. Creger, Mr. Wilkerson & Mr. Hurley will host a panel discussion:

Free Market, An Employer’s Perspective

This discussion will cover the effect of free market from an employer’s perspective; including everything from employee experience to the effect on their total health care spend. 9

2 01 9 F M M A A N N U A L C O N F E R E N C E • S P E A K E R S A N D TO P I C S

MARTIN MAKARY, M.D., M.P.H. New York Times Bestselling Author and Johns Hopkins Surgeon and Professor of Health Policy


CONFERENCE SPEAKERS

SPEAKERS & TOPICS

KATHLEEN BROWN, M.D.

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RICHARD KUBE, M.D.

Independent Physician

Founder/Owner, Prairie Spine

Kathleen is a dermatologist in solo practice. In 1997, she and her husband and young children moved from Maryland to Coos Bay, Oregon, to join a multi-specialty group. In 2011, she founded her own solo, direct pay dermatology practice. Oregon Coast Dermatology operates free from third-party payers. Dr. Brown works directly for patients, by cutting out the middleman, and publicly posting her prices, based on time spent with patients.

Richard A. Kube II, MD, FACSS, FAAOS, CIME is a fellowship-trained spine surgeon and Founder/ Owner of Prairie Spine & Pain Institute, in Peoria, Illinois. He also founded and owns Prairie Surgicare, an AAAHC certified surgical facility.

WILLIAM GRANT, M.D. Orthopaedic Surgeon, Monticello Community Surgery Center

JACK BROWN President, WMI

Dr. Grant is an Orthopaedic Surgeon who coordinated efforts with his physician partners to develop a transparent pricing-based Outpatient Surgery Center within a Certificate of Need state.

Jack Brown studied Engineering at The United States Military at West Point, and Business at The College of William and Mary. Currently he is the President and CEO of WMI; a global data management and application development company. While at The College of William and Mary, Mr. Brown created one the first major oil company gasoline and convenience stores chains for Texaco. Mr. Brown and his wife recently established the Oregon chapter of the Free Market Medical Association.

Dr. Kube & Dr. Grant will host a panel discussion:

Bundles Payment Models in Healthcare: Past, Present & Future

This presentation will describe the market forces encouraging buyers and sellers to create a bundled model, present the considerations for determining the bundled price, and instruct on how to implement bundled pricing into your medical practice.

Dr. Brown & Mr. Brown will host a panel discussion:

Pricing Choices Beyond DPC

The DPC movement is great. This 3rd party free practice model is inspiring many physicians across the country. However, DPC is not a good fit for everyone. Physicians and patients still need more choices. We will explore another highly effective pricing and service model that may be more appropriate for some markets, specialties, physicians and patients.

CHARLES SAUER President & Founder, Market Institute TOPIC: PROFIT MOTIVES IN HEALTHCARE: WHY TO LEAVE D.C. BEHIND AND WHY NOT TO FORGET ABOUT IT The financial dynamics that drive policy creation and cronyism in healthcare are unbeatable with a head-on attack. The only way to win is not to play. Ignoring daily fights that happen on Capitol Hill and focusing on rebuilding the once-free market in healthcare is the only real way to reform the system. But there is never a guarantee Congress will stay out of your way, so we can’t forget it exists. We must continue to tell our stories and defend the freedom that does still exist. In the end, we need to recognize Congress won’t help, we just need to keep them from hurting us. Charles is a policy specialist and writer with more than 15 years in politics. He worked on Capitol Hill; for a Governor on tax, immigration, and labor issues; and was Deputy Legislative Director for an academic think tank focusing on tax, finance, and healthcare. He is also author of Profit Motive: What Drives the Things We Do.

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MICHEAL ACCAD, M.D. TOPIC: THE ETHICS OF FREE MARKET MEDICINE Medical care provided under free market conditions will certainly provide more services at a lower cost, compared to any non-free market alternatives. But there are deeper and more important ethical considerations at play than utilitarian effects. The essence of medical care—understood in its Hippocratic vision—demands that the decisions made by doctors and by patients be free. Any deliberate outside restriction on the freedom of doctors and patients necessarily corrupts the ethics of the doctor-patient relationship, however well-intentioned they may be. This talk will connect the Hippocratic understanding of medicine and the doctor-patient relationship to the workings of the free market. Michel Accad, M.D. practices cardiology and internal medicine in San Francisco and holds a faculty appointment at the University of California San Francisco. He regularly publishes articles in peerreviewed journals of medicine, ethics, and philosophy. He co-hosts The Accad and Koka Report, a podcast program that was recently ranked #1 podcast for healthcare innovators by Forbes magazine online.

USHealthMedia.com | Vol. I | Issue 4


CONFERENCE SPEAKERS

SPEAKERS & TOPICS

ANN RIGGS, D.O. Direct Medical Care Dr. Riggs will highlight her experiences with Direct Primary Care since 2013. She has embodied the spirit of providing patientdriven affordable healthcare that focuses on accessibility, accountability, and affordability to her patients. She not only offers membership options to her patients but also à la carte direct primary care services.

In 2013 Dr. Riggs opened Direct Medical Care and has never looked back. She is more passionate today about delivering patient-driven affordable healthcare than she was when she opened over five years ago.

THE U.S. FAR EXCEEDS ANY NATION IN EXPENDITURES FOR INSURANCE ADMINISTRATION. THE ESSENTIAL MEANS OF COST CONTROL IS DENIAL OF SERVICE AND RATIONING OF CARE VIA EVERINCREASING COMPLEX TREATMENT APPROVAL SYSTEMS, RESULTING IN SPIRALING COSTS. INSURANCE IS DESIGNED TO PROVIDE COVERAGE FOR MEDICAL EMERGENCIES, NOT ROUTINE CARE. INSURANCE HAS NEVER WORKED IN ANY INDUSTRY AS A METHOD OF PROVIDING SERVICES THAT ARE USED ON A ROUTINE BASIS.

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TOPIC: ALL-INCLUSIVE DIRECT PRIMARY CARE


PA R T 4

APPLYING FREE MARKET VALUES TO SPINE AND ORTHOPAEDICS

TRANSPARENCY:

The Value of Independent Facilities

12 DR. RICHARD KUBE

by dr. richard kube

PA R T 4

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T H E V A L U E O F I N D E P E N D E N T FA C I L I T I E S

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The previous articles in this series discussed quality as it relates to service and outcomes. Additionally, different aspects of value, such as full-burdened cost, were covered. Now that the reader has some idea of what to look for, it is time to discuss where to find value. While value can be found in multiple places, most health care consumers do not have the ability to launch a major nationwide search or dig through hundreds of facilities. What follows are some generalizations that can be used to make the search as efficient as possible. With advances in medical technology and techniques, one does not have to go to the major health centers to receive quality service and great value. Many elective surgeries can be, and are, performed regularly in ambulatory settings. As an example, we at Prairie Spine & Pain Institute have been performing spine surgeries; e.g., fusions and disc replacements, in an ambulatory setting for over ten years. These are great options for patients. The facilities are typically smaller and easier to navigate. Extremely ill patients are not treated there, so risks like infection are typically much lower in the ambulatory setting. Another important advantage is that there is typically more surgeon control in the ambulatory facilities. This is true for independent facilities, as well as those

affiliated with hospitals. This allows for more personalized and tailored care, with more decisions being made by medical providers instead of business administrators. Staff is generally constant, so efficiency is improved which helps cost as well as outcomes. There are often better nurse to patient ratios, so nursing staff can be more

meticulous, and patients receive more immediate nursing assistance. Even though ambulatory facilities are delivering more care and often experiencing higher patient satisfaction, the costs are typically much lower than the hospital setting. Greater efficiencies including staffing and resource management are contributing factors. Also, these facilities are specialized, and performing elective scheduled proce-

Richard A. Kube II, MD, FACSS, FAAOS, CIME is a fellowship trained spine surgeon and Founder/Owner of Prairie Spine & Pain Institute, in Peoria, Illinois. He also founded and owns Prairie Surgicare, an AAAHC certified surgical facility. He holds Board Certifications from the American Board of Spine Surgery, American Board of Orthopaedic Surgery and American Board of Independent Medical Examiners. His practice is dedicated to providing comprehensive operative and non-operative treatment for spinal ailments with a special interest in minimally invasive surgical techniques. Dr. Kube is also engaged in active research and education projects. His interests extend into strategic planning and entrepreneurship as he is Advisor to Twisted Sun Innovations, a Hydrogen energy company currently working on renewable energy solutions for the U.S. Department of Defense. Dr. Kube currently serves as clinical faculty at University of Illinois College of Medicine at Peoria.

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Even though ambulatory facilities are delivering more care and often experiencing higher patient satisfaction, the costs are typically much lower than the hospital setting.

EMPLOYER COST Decrease Costs by:

Decrease BeneďŹ t by: Current

14%

DR. RICHARD KUBE â–

T H E V A L U E O F I N D E P E N D E N T FA C I L I T I E S

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local word of mouth and by patient research on the Internet. Therefore, I would encourage you to research local facilities, especially those in an ambulatory setting for elective spine and orthopedic procedures. Certainly, the FMMA website (FMMA.org) is an important resource. Value with a great reputation must be present for these places to survive. Frequently, given the size of ambulatory facilities, discussions can be held with decision makers so that you can really learn about the services provided and those individuals providing the service. Access to decision makers also makes negotiation and contracting a smoother process. Hopefully, this provides insight as to where to get started. Next month we will summarize everything we have shared over the last few issues to provide a playbook for navigating spine and orthopedics in the free market.

PA R T 4

dures allowing them to have predictable cases, thus leading to lower supply costs. Finally, the healthier patient population treated in the ambulatory setting uses fewer resources while in the operating room and prior to discharge. These advantages are passed along to the health care consumer to increase value. In general, these reasons allow independent facilities hold a distinct advantage to provide high quality at lower cost. Additionally, market forces push independent facilities towards creating value. They do not have emergency departments or employed primary physicians funneling patients to them. The independent facilities also do not have the million-dollar advertising budgets of the large hospital systems. Therefore, they must produce a superior experience at a great price to be competitive and to stay in business. The health care consumer is prioritized, so the patient, rather than the insurance carrier, is seen as the customer. These locations are typically driven by

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Providing insight for better decision-making

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DPC AND SELF-INSURED EMPLOYERS: COUNTING THE COSTS

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COUNTING THE COSTS

DR. ROBERT NELSON

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I

by d r . r o b e r t n e l s o n

n the department of economy, an act, a habit, an institution, a law, gives birth not only to an effect, but to a series of effects. Of these effects, the first only is immediate; it manifests itself simultaneously with its cause—it is seen. The others unfold in succession— they are not seen: it is well for us, if they are foreseen. Between a good and a bad economist this constitutes the whole difference—the one takes account of the visible effect; the other takes account both of the effects which are seen, and also of those which it is necessary to foresee. Now this difference is enormous, for it almost always happens that when the immediate consequence is favorable, the ultimate consequences are fatal, and the converse. ~Frederic Bastiat ^ Visit USHealthMedia.com for links to sources, references, and additional information on these topics.

The results of the immediate/ intended effects (the seen) and the subsequent/ unintended effects (the unseen) of U.S. healthcare policy are clearly instantiated by examining the way we use, and misuse, health insurance. Despite the ostensibly good intentions to improve access by expanding coverage for various medical services, the “ultimate consequences are fatal, and the converse.” Our insurance-based third-party payer protocols have pernicious and nefarious economic consequences on our healthcare system. This manifests as rampant healthcare inflation catalyzed by the macroeconomic market distortions of the 3rd party payer effect and perpetuated by the microeconomic price-obscuring distortions of the billing cycle. Stated differently, we have taken the concept of insurance, designed to pay out rare higher-priced claims on unpredictable events, and turned it into a product whose design promotes an incentive for everyone to

use it as often as possible. Insurance is sustainable only when the financial risks of individually rare events are spread over a large population. When it also becomes a funding source for anticipated and affordable events, combined with a perverse incentive to utilize it to the margin, the result is the creation of a perpetual payout fund. The costs of sustaining this model are never satisfied, being squeezed by patients who are chasing the benefits and providers who chase the billing codes for reimbursement. As evidence for the negative consequence of misusing insurance as a pass-through system for virtually every healthcare expense (accelerated by passage of the ACA), we can examine the employer-sponsored group market premiums. From 2007 – 2017 the ^average premium for family coverage increased by 55% and employee contribution rate as a share of premium cost increased by 74% over the same 10-year period; while ^median household income went up by only 3%. To add financial injury to insult, the percentage of employees with an ^out-of-pocket maximum of greater than $3,000 doubled, going from 30% to 60% of employees.

“Eighty-one percent of covered workers have a general annual deductible for single coverage that must be met before most services are paid for by the plan. Among covered workers with a general annual deductible, the average deductible amount for single coverage is $1,505. ~KFF.org

Dr. Robert Nelson received his M.D. degree at the Ohio State University College of Medicine. He is the Founder and Owner of Encompass

Health Direct, in Cumming, Georgia; the publisher and editor of The Sovereign Patient blog; and a founding member and spokesperson for the Georgia chapter of the Free Market Medical Association. Dr. Nelson has spoken about healthcare economics and free market healthcare throughout the country, and has been a guest expert on multiple radio programs.

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USHealthMedia.com | Vol. I | Issue 4

COUNTING THE COSTS

DR. ROBERT NELSON

pocket maximums of $3,000 or more have doubled! Given that household income has barely budged in real dollars since 2002, these increases are clearly not sustainable. By contrast, the auto insurance market (a real indemnity product) ^increased 15 by only 17% from 2007 - 2016, while deductible offering ranges remained stable, averaging $500. The introduction of DPC has deflated these cost escalations considerably. In the individual market, data from several sources bears this out. ^CovenantMD, a Direct Primary Care practice in Lancaster, PA illustrates the potential savings based on a typical family’s utilization. They compared the total costs incurred using a Bronze ACA plan with $6K individual/$12K family deductibles without and with a DPC membership at CovenantMD. Pairing a Bronze Plan with a DPC membership at ^CovenantMD resulted in an out-of-pocket savings of $7,267, even after the cost of the membership was counted. That is a 65% reduction in out-of-pocket costs! ^Zenith Direct Care did a similar analysis for a typical family of five with an 80/20 plan with $3,000 deductible. They compared annual costs for this scenario with a Zenith Direct Care membership plus a Health Cost-share Plan (health-shar■

sequent encounters away from the more expensive insurance-based protocols, Self-insured employers can utilize creative plan designs to cut costs and improve employee satisfaction.  Considering that approximately 65% of 160 million employees who have insurance in the workplace are covered under a self-funded plan, representing over 100 million lives, the aggregate savings can be substantial even after accounting for membership costs. Let’s compare traditional insurance-based coverage for primary care vs a self-funded model with DPC at the hub and count the costs. In broad context, the large volume of ^data from the Qliance experience, and supported by other self-insured employer’s experiences, efficient primary care via the DPC model reduces unnecessary downstream care by approximately 50%, with the resultant cost savings. The caveat being, as we double the number of primary care visits combined with longer visits to adequately address problems, the need for emergent visits, ER visits and specialty intervention drop significantly. Consider that ^between 2002 and 2016, medical costs for a family of four in an employer-sponsored PPO plan increased 180%, with the percentage of employees facing out-of-

PA R T 4

The average deductible for covered workers is higher in small firms than in large firms ($2,120 vs. $1,276) … Over the last five years, however, the percentage of covered workers with a general annual deductible of $1,000 or more for single coverage has grown substantially, increasing from 34% in 2012 to 51% in 2017. Thirty-seven percent of covered workers in small firms are in a plan with a deductible of at least $2,000, compared to 15% for covered workers in large firms. In the ACA individual market insurance exchanges, ^single coverage premiums (unsubsidized) increased by 62% and family coverage premiums increased by 75% just since implementation of ObamaCare! Our third-party payer system has created a dependency paradox; the same funding method that contributes to runaway costs also causes us to be more dependent on it for access. This guarantees that Healthcare will cost significantly more than the sum of its individual parts, and will continue to escalate faster than our ability to pay for it. Even if American doctors took a 50% pay cut and we could eliminate the spend equal to all care during last 12 months of life (retrospective knowledge of course), we would still spend more per capita on healthcare than any other country. All components of healthcare spending add to cost of care. But the overwhelming cost drivers for the U.S. healthcare system are embedded so deeply within the way we access and pay for medical services that we often overlook them, choosing instead to blame the symptoms for the disease rather than the disease for the symptoms. Self-insured employer health plans are in a unique position to break out of this dependency paradox. As discussed in ^part 2 of this series, by contracting with a Direct Primary Care practice and re-routing sub-

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COUNTING THE COSTS

DR. ROBERT NELSON

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ing member). Estimated out-of-pocket costs with the traditional insurance alone was $18,343 compared to $6,160 with the Zenith/HCS combination. A savings of 66%! Next, let’s explore the advantages of utilizing DPC in a self-funded plan in place of insurance-based primary care by looking at lab and pharmaceuticals prices. ^Core Family Practice, a DPC practice in Kennett Square, PA, compared a 90-day supply of four common primary care medications purchased through Aetna’s Mail-order supplier with the prices their members pay for same quantity. The annual cost for the

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Aetna mail-order came to $2,248.68 compared to only $850.80 for the same medications from Core’s generic supplier, which were dispensed in the office. That $1,397.88 savings equates to a 61% reduction in out-of-pocket costs for the married couple! They also looked at the costs of obtaining three sets of commonly ordered lab tests for the same couple. Out-of-pocket costs using their high-deductible plan (QHDHP) was $480 in lab test responsibility. The same tests drawn and paid at time of services to Core FP totaled $63.17 yielding an incredible 87% reduction. A similar level of savings for di-

rect-pay lab tests was noted in ^data published in 2014 by CMT journal comparing lab fees charged to a Direct Pay practice by the lab vs. the CPT billed charges by the lab (assuming patient had no coverage or had not met their deductible). For five common blood tests the savings was 89% by not using insurance, with lab billed charges of approximately $782 compared to a direct pay cost of $80. ^Plum Health, a direct primary care practice in Detroit, shows similarly impressive lab test savings of 87% on six common blood tests; $811 vs $106. The evidence is overwhelming. With DPC at the hub of the benefits package, combined with proper utilization of insurance, Self-insured employers and employees are enjoying undeniable and significant cost savings. Using DPC as a free-market-friendly alternative to traditional insurance-accessed medical care not only saves employers directly on coverage costs, but the model has a huge impact in reducing patients’ out-ofpocket costs incurred from laboratory tests, pharmaceuticals and imaging services. Many Self-insured companies are beginning to discover the value and savings in this approach, while breaking free of the coverage trap and the myth that health insurance equates to health care; and the realization that so-called “access” to inflated pricing and the phony discounts used to fleece the buyer is no longer a conversation they are willing to have. Consider the costs (of continuing the status quo) counted!

USHealthMedia.com | Vol. I | Issue 4


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GREEN IMAGING, PLLC

ENHANCE YOUR BENEFITS PACKAGE WITH FREE MARKET IMAGING

F R E E M A R K E T R A D I O LO G Y

GREEN IMAGING

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B Y A N N M A R I E L U D LO W

Builders will tell you that you can have it good, fast, or

cheap—you can’t have all three. But, as health care consumers, we should insist on having it all; high quality, fast service and low cost—or at least fair—prices. Research data indicate more than half of Americans are actively looking for pricing information before deciding on care. More than half of the nation’s imaging providers have or are developing their own free-standing imaging centers, but are they all the same? Dr. Cristin Dickerson (pictured), founding partner of Green Imaging, PLLC, based in Houston, Texas, saw the proverbial writing on the wall while she was president of a diagnostic clinic and a self-funded employer herself. “We were a multi-specialty group with 50 doctors,” she says. “We had 400 covered lives and we came up with an idea to hold down our costs by incentivizing our employees to use our own medical services. Employees had zero out-of-pocket expenses and their deductible didn’t apply if they used our services. They were subject to their copay and deductible if they went elsewhere. That was my introduction to free market medicine and I have never looked back.” Subsequently, she began to recognize the need for affordable imaging across the city; “There was imaging available in-network, but at freestanding centers attached to hospitals, which meant inflated hospital-contracted prices. There were many other free-standing centers largely operating out-of-network, so, I began contracting with imaging centers in Houston, leasing their unutilized scanner time at a discount.” Dr. Dickerson founded Green Imaging to provide affordable, high-quality medical imaging for uninsured and high deductible patients in Houston, and rapidly expanded the company to provide services throughout Texas. Today, Green Imaging includes a virtual medical imaging network across the United States, owned and operated by board-certified radiologists. “I saw very early the potential for employers to use our network to hold down costs on self-funded plans because I have successfully done the same,” she says. 20

Dickerson says “At first, I felt like I was hitting my head against a wall to get employers to buy in. But, at a benefit conference in 2017, I began talking to Human Resource directors and hearing about so many employees asking, If I can’t afford to use this plan, why do I even have it?—I believe that is when we hit the tipping point; the year it became unsustainable. Employees were paying up to 40 percent of their insurance premiums, and yet were functionally uninsured. Because they were paying so much of their income toward their plan, they had nothing left to pay for care.” The tide turned and she began to contract directly with employers and third-party administrators who began writing Green Imaging into many employer plans. Since then, Green Imaging has had an exciting ride trying to keep up with demand and has added more value to the system by taking steps to take the bureaucracy out of the process as well. “We are trying to consolidate and automate like [The Kempton Group]; we have not quite gotten our contracts down to one page, but we will get there!” As Green Imaging has become sustainable, Dickerson is even more passionate about spreading the word that there are great new non-traditional health care coverage options in emerging free market health care. USHealthMedia.com | Vol. I | Issue 4


GREEN IMAGING ■

The Green Imaging model helps patients make the most informed decisions about MRIs, CTs, and other imaging procedures. Unlike many other imaging facilities, the cash-pay price they provide is the “all in” price. There are no other changes or fees. Patients pay for procedures up front, with no surprise bill after the fact. “Working with creative TPAs enables us to further simplify the work flow by eliminating redundancies. We remove traditional claims and their expense from the process, utilize existing concierge services, when available, to help schedule, and automate the process wherever possible to get the information into the hands of our specialists and our patients. We are continuously developing best practices, making things more efficient and holding down costs.” Green Imaging, PLLC contracts for the idle time on imaging machines in-network, and because technology has progressed, images and scans do not have to be produced and read on-site. “In Texas, our model is to read the studies ourselves, thus assuring consistency and quality. “Nationally we have a different model to assure the same type of quality. We preferentially contract with radiologist-owned imaging centers that are like-minded, which enables us to sustain the kind of relationships we’re used to,” Dickerson says. “We know these radiologists take pride in their work and they understand quality. The benefits are many: fewer middle men involved; the centers are glad to have the business and make use of under-utilized equipment; and help sustain their own centers.”

supporting Direct Primary Care (DPC) and the whole free market system so I am happy to advise employers with employees in a single geographic area to shop for services to make sure they are getting quality images at fair prices. We are a great solution for employers who want a single resource for a wide geographic range of quality imaging. AT the same time, we are not here to compete against independent physicians, we want to bring them business 21 they would not otherwise have.” Green Imaging’s goal is to continue centralizing resources for scheduling and payment. With their services, employers and TPAs have fewer contracts and separate agreements to manage, providing more economy of effort. Dickerson says an educated broker can make the biggest difference. “Brokers and nurse navigators have all the tools to educate consumers and help them make the best decisions. The more they can eliminate the hassles of health care, the more satisfied employees will be with the plan and the better than plan will serve everyone.” The best tool to drive employees to a plan like a Green Imaging “bolt on” is to incentivize the employee with zero out-of-pocket cost, a low copay, or shared savings. F R E E M A R K E T R A D I O LO G Y

How it Works

The Results Consultant-provided analytics on Green Imaging prices in Texas compare well to a typical self-funded health care plan. Their bundled price was about one-third of the average price in a self-funded health care plan. Dickerson says, “I know as we gain traction and expand, we will get that price down further. Our own center in Houston charges $250 for a non-contract MRI. We own that center and we have enough volume to sustain that price. I believe it makes me more credible when I go in to negotiate with a new image center because I own my own facility; I understand their pain and am certain about what I can do for them.”

Looking forward... Dr. Dickerson has plans for a greater national presence, despite the barriers to that growth. “There are carriers who do not want us in their states and, while we also want to support free-standing imaging centers, we are not always the lowest price option. I want to continue USHealthMedia.com | Vol. I | Issue 4

I don’t want to be the cheapest price in town. I want great imaging at a fair price—that is sustainable. If you under price yourself and go with lower quality facilities, that’s not sustainable. Dr. Cristin Dickerson, Green Imaging, PLLC

She is confident that TPAs who are not using Green Imaging may be costing their clients money and headaches. “Part of what we do is contract directly with employers typically reimbursing with reference-based pricing. If you take that RBP insurance card to most of the centers we work with, they will tell you they don’t take that plan.” 21


Summing up...

F R E E M A R K E T R A D I O LO G Y

GREEN IMAGING

Dickerson says she is pleased to note that free market health care is looking over the wall. “However, if things change too quickly, we will not have enough providers and employers, and employees will get frustrated. We need to be intentional and educate physicians and providers about self-funded plans and TPAs first. They need to 22 understand that they are spending 30% of their revenue to collect 70% of what they are contracted to receive from traditional plans in order to understand the benefit of direct contracting and reference based pricing. “We have been working for some time to pull together a multi-specialty network of free market providers here in Houston and we still have work ahead of us. Everyone does contracting differently, but I am at a point where I can mentor people and help bring great physicians into this direct care market.” Dr. Dickerson has been a self-funded employer and understands the needs and challenges they face. She looks forward to working with hospitals, helping them evolve the way they are paid for care over the next decade. “Until something changes in the amount of money hospitals are paid by big insurance, they will be reluctant to adopt something new. But as fewer employees choose or maintain enrollment in traditional plans, hospitals and major medical will feel that pain and start making changes.”

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She adds, “The ultimate test is what do you do with an emergency room visit; how can you make that cost-effective? I know I could go in there and negotiate the bill after the fact. As a physician I have the capability to hold my costs down. But the average employee—negotiating on the back end—cannot. They may be suffering in silence because they aren’t sure exactly what their insurance will cover in the E.R. “As soon as TPAs contract with hospital systems successfully, reasonable rates will be part of the negotiation. For the hospital, it means a lot less bad debt; they will be fairly paid at the end of the month for their services compared to what they have to wrangle out of patients with huge patient responsibility. Simply put, it is a better model.” For now, Green Imaging is enjoying being in this space nearly exclusively. As the first and only physician-owned direct care facility providing these services nationally, they have a great head start and are on the heels of traditional companies. Dickerson’s final word; “We consider ourselves Direct Care Radiologists; we try to be much more available to referring providers; we try to be people who practice good medicine and take the time necessary to provide excellent interpretations. We offer quality at a fair price—not the lowest price—but a fair and sustainable price.”

USHealthMedia.com | Vol. I | Issue 4


SHOW ME THE PRICE LIST!

COMPLIANCE WITH CMS RULES REQUIRING HOSPITALS TO PUBLICLY POST PRICES SHOWS ROAD TO TRANSPARENCY IS NOT ALWAYS SO CLEAR

SHOW ME THE PRICE LIST!

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P H I L I P Q U A LO , J . D .

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by Philip Qualo, J.D. In an effort to empower healthcare consumers and further White House initiatives focused on making patients a priority, the Centers for Medicare and Medicaid Services (CMS) finalized a rule in August 2018 that included a requirement for hospitals to post their price lists online. Specifically, the rule requires hospitals to publicly post their charges online in a machine-readable format on annual basis. The mandate stems from the 2019 Inpatient and Long-Term Care Hospital Prospective Payment System (IPPS/ LTCH PPS) Final Rule. Although this new rule has only been in effect since January 1, 2019, efforts by hospitals to comply with the rule are showing that transparency is not always a synonym for clarity as many healthcare consumers struggle to locate these price lists or even understand them. Although the primary intent of the rule is to encourage patients to make informed decisions about their medical care, price transparency also provides employers and plan sponsors who offer self-funded health coverage with more opportunities to contain costs. It arms self-funded health plans with the information necessary to make cost 24

effective decisions regarding provider requirements and maximum allowable charges. It also provides employers and plan sponsors with the information necessary to implement cost containment incentives that encourage utilization of hospitals that provide quality care at a reasonable price. The transparency rule could help to curb the rapidly rising costs of healthcare services overall. According to the 2018 UnitedHealthcare consumer sentiment survey, patients are price shopping more today for healthcare services than

ever. The survey indicated that thirty-six percent of Americans used the Internet or a mobile app to comparison shop for healthcare during the past year. That is more than double from fourteen percent in 2012 (according to another UnitedHealthcare study). As more consumers are becoming price savvy with their healthcare needs, the requirement to publicly post price lists could encourage hospitals to compete with each other and reconsider their pricing when faced with competitor price lists that offer similar quality services at a lower cost. USHealthMedia.com | Vol. I | Issue 4


You Have the Right to Know the Price

When facing any policy issue, it helps to take a step back and run it through the lens of common-sense. Can you imagine going to the grocery store, getting the groceries you need for the week, but never knowing the price of your items until a week later when the store sends you a bill? Sadly, that’s how health care works every day.

~Seema Verma, Administrator of the Centers for Medicare & Medicaid Services In response, CMS released additional guidance in October 2018 that clarified, among other things, the definition of machine-readable and what items and services furnished at the hospital must be included on the publicized list. CMS opined that price lists must contain the hospital’s standard charges for items and services provided. The guidance also confirmed that hospitals are free to choose how to make the standard charges public on the Internet. In regards to format, CMS advised that hospitals can use whatever format “as USHealthMedia.com | Vol. I | Issue 4

price lists so deep into their website that they only could be located through a Google search. In a review of several hospital price lists that have been posted since January 2019 there appears to be a consistent theme – a lack of organization and the use of diagnostic codes, acronyms and medical terminology only a claims administrator or medical professional would understand. One price list I personally reviewed was hundreds of pages long. In navigating through the novel length price list I conducted a general word search in an attempt to find 25

long as the information represents the hospital’s current standard charges as reflected in its chargemaster.” CMS also defined a machine-readable format as “a digitally accessible document but more narrowly defined to include only formats that can be easily imported/ read into a computer system (e.g., XML, CSV).” The recent guidance from CMS also encouraged hospitals to go beyond the bare minimum requirements of the new rule as it noted that hospitals are not restricted from posting additional quality price transparency information. In fact, the federal agency encouraged hospitals to provide consumer-friendly communication regarding hospital charges; however they did not make this a requirement. As the January 1, 2019 deadline has now passed, the lack of a specific definition of “consumer-friendly” communications has resulted in hospitals demonstrating compliance with the new rule in a non-uniform manner which has created some confusion. For example, some have chosen to prominently display a link to their price lists on their homepage along with contact information for any individuals with questions about the listed prices. Others have done the opposite and buried their

P H I L I P Q U A LO , J . D .

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SHOW ME THE PRICE LIST!

In order to reap these rewards, however, it is imperative that hospitals make good faith efforts to comply with the rule in a manner that furthers the ultimate goal of providing all consumers with more than just a price list, but rather a clear and accurate accounting of true healthcare costs. That said, many healthcare providers have expressed serious concerns about the new rule. According to a recent survey of 150 healthcare participants conducted by PMMC Healthcare Business Insights, approximately 92 percent of healthcare providers are concerned about how their charges will be perceived by the public. Critics of the transparency rule have argued that a lack of specific guidance regarding the location and content of publicly posted lists will allow providers to demonstrate bare minimum compliance with the rule in ways that would undermine the goal of true transparency for the average consumer. For example, the rule does not specifically require that hospitals prominently display their respective price lists in a manner that would promote its availability. Hospitals could potentially post their price lists in a manner that would make the list generally inaccessible to consumers with less than savvy computer skills. The rule has also been criticized for not requiring hospitals to organize the content of price lists to ensure procedures and prices are displayed in easy to understand terms so that the average individual (i.e., one without a background in healthcare) could easily understand.


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27 P H I L I P Q U A LO , J . D .

Therefore, as transparency continues to be molded by CMS, with hospitals and healthcare providers leading the trend, we can expect to see additional requirements, or at minimum a uniform best practices guide, that mandates where the price lists must be posted on a hospital’s website and how the content of the list should be communicated. More importantly, we can expect to see resources and guidance developed to educate healthcare consumers on how to understand and use the information to make the decisions regarding their healthcare. Only when price transparency becomes synonymous with price clarity will the benefits of the newly-effective CMS requirement make a positive impact on healthcare pricing overall.

PHILIP QUALO, J.D., JOINED THE THE PHIA GROUP, LLC IN JUNE 2018. IN HIS CURRENT ROLE AS A COMPLIANCE AND REGULATORY AFFAIRS CONSULTANT, PHILIP PROVIDES CONSULTING SERVICES TO EMPLOYERS, THIRD-PARTY ADMINISTRATORS, BROKERS, AND VENDORS ON AN ARRAY OF TOPICS FOCUSED HUMAN RESOURCE AND EMPLOYEE HEALTH BENEFIT PLAN COMPLIANCE. HE PROACTIVELY MONITORS THE LEGAL AND REGULATORY ENVIRONMENT TO IDENTIFY LEGAL, REGULATORY AND COMPLIANCE-RELATED GAPS AND ADVISES INTERNAL AND EXTERNAL STAKEHOLDERS ON AREAS OF RISKS. HE EARNED HIS J.D. FROM VILLANOVA UNIVERSITY SCHOOL OF LAW AND HIS B.A. IN BOTH PHILOSOPHY AND ENGLISH FROM LOYOLA UNIVERSITY MARYLAND. PHILIP’S PROFESSIONAL EXPERIENCE HAS RANGED FROM PRACTICING EMPLOYMENT LAW, SPECIALIZING IN DISABILITY LITIGATION, TO MANAGING FEDERAL GRANTS AND ADVOCATING FOR UNDERSERVED COMMUNITIES ON BEHALF OF NATIONAL ALLIANCE ON MENTAL ILLNESS (NAMI).

SHOW ME THE PRICE LIST

the price of common procedures in layman’s terms with very little success. The CMS price transparency rule is a shift in the right direction toward empowering self-funded health plans and healthcare consumers with information necessary to make informed decisions. Before we can reap the benefits of this rule price lists need to be more than just “transparent”, they need to be clear, easily accessible and presented in terms that the average American can understand. Without uniform guidance on how to accomplish this, we have only just begun our journey to true price transparency has just begun. As with any new law or regulation, there is sure to be further guidance from CMS as the agency audits compliance with this new rule and responds to requests for additional information.


DPCs: CONGRESS AND HSA BY LEE S. GROSS, M.D. • FOUNDER & SR. VP, EPIPHANY HEALTH • PRESIDENT, DOCS4PATIENTCARE FOUNDATION

T H E C A S E F O R H E A LT H R E I M B U R S E M E N T A R R A N G E M E N T S A N D D P C

DR. LEE GROSS

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The Case for Health Reimbursement Arrangements and DPC The key question here is whether a DPC membership is a health plan or a payment for physician services. ~Dr. Lee Gross

I

n October 2018, the U.S. Departments of the Treasury, Health and Human Services, and Labor issued a proposed regulation that would expand the usability of Health Reimbursement Arrangements (HRAs). The proposed regulation was the final in a series of proposed rules in response to President Trump’s October 2017 Executive Order on “Promoting Healthcare Choice and Competition”. The Treasury Department estimates that 800,000 employers would take advantage of this change, empowering approximately 10 million American workers to have more consumer-driven healthcare choices. The regulation, if finalized, will affect plans beginning January 1, 2020. The proposed regulation would allow employees to use HRAs to purchase individual coverage on a pre-tax basis. This gives an individual the same tax-preferred advantage as the business, while allowing them additional choices beyond the typical single health plan offering of the employer. In addition, the regulation would also allow employers offering traditional employer-sponsored coverage to offer an HRA of up to $1,800 per year to reimburse an employee for certain qualified medical expenses, including certain health plans. This proposed HRA rule creates a particular opportunity for Direct Primary Care (DPC). DPC is a fixedfee arrangement between an individual and a physician for a defined 28

package of healthcare services. The IRS has previously issued an unpopular opinion that DPC is a health plan, disqualifying contributions to a Health Savings Account (HSA). The IRS has never issued any formal guidance on HRAs and DPC, but many have erroneously extrapolated the HSA opinion to include HRAs. The key question here is whether a DPC membership is a health plan or a payment for physician services. While the IRS has opined that DPC was a health plan, 25 states have passed legislation declaring that DPC is NOT a health plan. In this proposed rule, there is an opportunity for clarification. Is DPC a health plan or is it a physician service? It must be one or the other. It can’t be neither. That means that, for the purpose of this rule, the Treasury should pick a bucket to put DPC into. Either it is a qualified medical expense as a physician service or it is a health plan. Either way, it should fall as an HRA eligible expense under one of the newly created designations in the regulation. At Docs 4 Patient Care Foundation, an organization that I am president, we hired the legal firm of Foley Hoag to make the case for DPC to be treated as a qualifying medical expense, in line with the 25 states that have passed legislation. In an 8-page comment letter submitted to the Department of Treasury, we laid out the legal foundation for the IRS determination of DPC as a qualifying medical expense under section

213(d) of the Internal Revenue Code, bolstered by 31 citations including supportive legal rulings for such a determination. The public comment period recently ended. Of all the public comments submitted to Treasury on the proposed regulation, a staggering 92.5% were in support of allowing DPC to be a qualified HRA expense. This is due, in large part, to an advocacy call to action by the Association of American Physicians and Surgeons (AAPS). While there are still efforts underway for a permanent legislative fix for the HRA and HSA issues surrounding DPC, we are hopeful that the Departments will use our legal foundation and the overwhelming public commentary to make the appropriate determination that Direct Primary Care is an eligible physician service to be paid by an HRA under this final rule. We anticipate the final rule to be released sometime this April. If the Trump Administration is truly seeking to promote choice and competition in healthcare, this HRA determination would be an easy consumer-driven way to lower healthcare costs for millions of Americans. USHealthMedia.com | Vol. I | Issue 4


MYTH: MY BROKER ALWAYS HAS MY BEST INTEREST IN MIND. FACT: Your broker, agent, or consultant MAY have your best interest in mind, but not always. Many brokers, agents, and consultants earn the majority of their income from commissions, overrides, and bonuses from third parties that are NOT the employer. In a recent article published by NPR, Insurers Hand Out Cash and Gifts To Sway Brokers Who Sell Employer Health Plans, author Marshall Allen outlines the dirty little secret of the broker world. It is common for brokers to be highly compensated by carriers, earning additional high-dollar bonuses for writing more business. Additionally, if a broker is compensated based upon a percentage of premium, when an employer’s costs increase, the broker gets a raise. Brokers who work in the best interest of the employer do exist. To find them, look at the FMMA member list or at HealthRosetta.org.

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FACT: In reality, the vast majority of the time better quality care is almost always a LOWER price. When an FMMA member facility sets their up-front bundled price, they are incentivized to make sure the patient has few to no complications and is back on their feet as quickly as possible. This is because they have set a single price for all patients, regardless of who they are. This pricing structure drives efficiency. Anyone can lie about quality. Quality metrics often just go to the highest bidder through “best hospital lists.”  But when there›s a financial impact tied to the quality outcome, providers have to be more accountable.

MYTH: I HAVE TO OFFER A QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN WITH AN HSA TO SAVE MONEY FOR MY COMPANY AND MY EMPLOYEES. FACT: There are many types of benefit plan designs that an employer can offer that are not tied to the rules and restrictions placed on HDHPs with HSAs. If any employer wants to lower their actual claims costs, incentivizing employees to use valuable free-market focus providers can drastically impact their plan. When an employer combines an HDHP with free market options, the incentive to use a low cost provider is lost for any claim that is higher than the participant’s deductible and the employer has very few options for true incentives. Additionally, an employer cannot offer Direct Primary Care as a benefit option due to IRS regulations. Instead, consider having a non-qualified plan and offering a Health Reimbursement Account (HRA). Not only does this set-up enable you to incent the use of high value providers, but any funds not spent stay with the employer.

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F R E E M A R K E T M Y T H V. FA C T

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MYTH: YOU GET WHAT YOU PAY FOR. HIGHER QUALITY IS MORE EXPENSIVE.


3

Shop Online for Healthcare with ShopHealth!  Save an average of 50-70% on your care by using the FMMA ShopHealth online marketplace!  Know before you go with bundled, transparent, and up-front pricing.

SHOP TODAY! WWW.FMMA.ORG

 Search and compare procedures, services, locations, physicians, surgeons, imaging providers, or facilities.


RX Costs

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• Encourage employees to “shop” for their prescriptions; costs can vary widely between pharmacies, even with a PBM. • Many PBM contracts make the cost of a drug higher than if it was bought with no contract in place. • If employee pays cash for lower-cost RXs, structure your Plan to reimburse these purchases. • Cover the cost of RXs purchased by the employee from their DPC; generally at wholesale prices. • Check out free market pharmacies.

Durable Medical Equipment • Many pieces of durable medical equipment (crutches, breast pumps, CPAP machines, etc.) can be bought for much less on the open market than through the network. • Incentivize your participants to shop for DME based on price! • Structure your Plan to allow reimbursement if your employee finds their equipment online or through a non-network provider and pay it at 100% (HDHP rules would still apply).

12 Ways to Free-marketize Your Plan Out-of-the Box Tips • Cover over the counter drugs! Often, when commonly used heartburn and allergy drugs go OTC, patients switch to another RX because it’s no longer covered by their health Plan. You can cover these OTC drugs at 100% to lower your RX spend! Why stop covering it when it gets cheaper? (HDHP rules would still apply) • Work directly with high value, low cost lab providers and incentivize your employees to use them. • Place dollar caps or a reference based pricing cap on services that have the most unpredictable, and often incredibly high, cost; such as air and ground ambulance, implantable items, interoperative nerve monitoring, dialysis, and more. If an employee gets balanced billed, you can step in and help negotiate a more reasonable reimbursement. • Many out-of-network physicians and facilities are actually high value! Penalizing patients for using a ‘good guy’ even though they are a better deal is not in your Plan’s best interest. Eliminate out-of-pocket penalties for non-network providers and allow your employees to shop for the best value.

31 PLAN HACKS

#PlanHacks

THE MORE THE HEALTH CARE SYSTEM INCORPORATES FREE-MARKET MECHANISMS, SUCH AS COMPETITION, COST SHARING (COPAYS), TRANSPARENCY, CONSISTENT PRICING FOR ALL GOODS AND SERVICES, CONSUMER CHOICE WITH AN INCENTIVE AND ABILITY TO DISCERN PRICE AND VALUE OF GOODS AND SERVICES AND REJECTION OF GOVERNMENT CONTROL, THE MORE EFFECTIVE THE HEALTH CARE SYSTEM.

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PILLARS OF THE FMMA

FMMA PILLARS

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• PRICE is NOT a product. CARE is the product.

PRICE

• 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.

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.

VALUE

• 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.

• PRICE EQUALITY is the basis of a free market.

EQUALITY

• 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.

TRANSPARENCY PROVIDES SELF-FUNDED EMPLOYERS AND INDIVIDUAL PATIENTS WITH THE INFORMATION AND THE INCENTIVE TO CHOOSE HEALTHCARE PROVIDERS BASED ON VALUE, WHICH INCLUDES PRICE AND QUALITY.

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USHealthMedia.com | Vol. I | 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

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CAROLINAS

MICHIGAN

NORTH AND SOUTH CHAPTER MICHIGAN CHAPTER Dr. Shane Purcell Theresa McIntosh carolinas@fmma.org Dr. Roland Tindle michigan@fmma.org FLORIDA michigan fmma FLORIDA CHAPTER Chris Markford florida@fmma.org

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

GEORGIA

GEORGIA CHAPTER Dr. Robert Nelson georgia@fmma.org georgiaFMMA

ILLINOIS

ILLINOIS CHAPTER Colleen Ingraham illinois@fmma.org illinoisFMMA

MASSACHUSETTS

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

MINNESOTA

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

MISSISSIPPI

MISSISSIPPI CHAPTER Micah Walker, M.D. Becky Russell mississippi@fmma.org

MISSOURI

MISSOURI CHAPTER Dr. Joseph Costello missouri@fmma.org missouriFMMA

NEBRASKA

NEBRASKA CHAPTER Pete Larson nebraska@fmma.org nebraskaFMMA

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OKLAHOMA

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

OHIO

OHIO CHAPTER

Dr. Louis Flaspohler ohio@fmma.org

TEXAS

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

VIRGINIA

OREGON

VIRGINIA CHAPTER Dr. Jordan Hackworth virginia@fmma.orgÂ

PENNSYLVANIA

WISCONSIN CHAPTER Dr. Brian Erdmann wisconsin@fmma.org

OREGON CHAPTER Jack Brown oregon@fmma.org oregonFMMA

WISCONSIN

PENNSYLVANIA CHAPTER Dr. Nicholas Pandelidis pennsylvania@fmma.org 33


WHY BE INVOLVED IN A LOCAL FMMA CHAPTER?

W H Y B E I N V O LV E D

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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 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 20 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/


2019-2020 PUBLICATION SCHEDULE ISSUE DATE

CLOSE DATE

June 2019

May 2, 2019

August 2019

July 11, 2019

October 2019

Sept 13, 2019

December 2019

November 7, 2019

February 2020

January 8, 2020

April 2020

March 7, 2020

June 2020

May 2, 2020

100% C-Level Focused Key information resources from the Free Market Medical Association and Free Market Healthcare Media have combined strength and market knowledge to create the first fully focused and integrated message vehicle for the corner office— Free Market Healthcare Solutions. We target the challenges and opportunities faced by employers in healthcare plans and benefits. Such a full-scale, high-level media focus hasn’t existed until now.

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Free Market Healthcare Solutions’ integrated media platform brings executives the information they need—and your message— in a language they understand. Focus on the right top executives in all the right markets.

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