November Advocacy Champion

Robert Koshnick, MD

Retired Family Physician
Detroit Lakes, MN

1.     Why is being an advocate so important to you?

I was the physician representative for the fourteen counties of northwestern Minnesota’s MIN-DAK Health Systems, the Certificate of Need (CON) agency covering our region. Our small clinic wanted to expand but we lacked the resources to go through the CON process. We joined with the Dakota Clinic, now part of Essentia Health, in Fargo, which set off a merger mania in Northwestern Minnesota between our clinic and the Fargo Clinic (now Sanford) which eliminated most independent clinics in the area.

I have been philosophically opposed to CON laws ever since. CON laws reduce competition that leads to higher prices and less competition in providing quality. North Dakota abandoned the CON process in 1984. Minnesota moved it to the Minnesota Department of Health (MDH). I introduced a resolution at the MN Academy of Family Physicians’ (MAFP) 2023 House of Delegates to eliminate MDH certification of medical care capital expenditures. It was referred to the MAFP board for action. The MDH needs to get out of the CON process to reestablish a medical marketplace to replace the top-down planning process we now have.

Another driving motivation for being an advocate is that one of my clinic partners committed suicide after being served malpractice papers. She and her husband had children the same age as ours who were in the same school classes. The malpractice lawyer had sued others in our clinic for the same family. The suit later went to trial and the plaintiffs lost, but that did not bring back their mother and wife.

My partner and mentor, the late Dr. James Knapp, pushed through a proposal to set up an MMA malpractice company, the MMIC. He served as chairman of the board and then president of the MMA. Our clinic became MMIC policy number 1 in recognition of Detroit Lakes role in its establishment. MMIC defended doctors when there was no malpractice, which cut down on frivolous lawsuits. The MMIC allowed physicians to have a role in settling lawsuits. St. Paul Companies had 80 percent of the malpractice coverage in Minnesota before the MMIC was set up but got out of the malpractice insurance business soon afterwards.  I pushed collaborative legal reform for years and then Communication AND Optimal Resolution (CANDOR) but to no avail until this year. I am extremely gratified that the legislature passed a CANDOR enabling law this year.

Medicare payments in Northwestern Minnesota had the third lowest of 87 payment regions (now 112). I saw older patients with multiple problems in part because I was certified in geriatrics and followed many patients in our area three nursing homes. Our clinic reimbursement was based on the dollars that we brought into the clinic ledgers. I wanted to change that.

Congress starting around 2000 allowed non-tax-paying hospitals to charge provider-based billing. That meant they could bring in about 50 percent more dollars for the same services as a tax-paying clinic could. The competing clinic in our area merged with a non-tax-paying hospital system. It seemed so unfair to me that they could recruit physicians away from us since they could offer higher salaries because of those advantages. When we did the math, it meant then (2008) another million dollars coming into our town and over $4 million for the clinic in Fargo by not paying taxes and being able to charge provider-based billing. So, we merged with Essentia Health. We went from having monthly physician owner meetings engaged in the practice to almost complete disengagement with clinic affairs overnight.

Medical education needs to start to include business training in their curriculum in medical schools and residencies. Physicians can only be employees unless they are trained to have some level of competency in running their own businesses. High levels of burnout and dissatisfaction with medical care careers will continue if physicians do not learn how to establish direct care practices for their patients where they have some ability to maintain personal autonomy. This is the way to avoid dual allegiance to the corporation that pays them and their professional obligation of practicing for the sole benefit of their patients.

I am concerned that managed care organizations are fighting personal medical care choice. The office of the Inspector General of the Department of Health and Human Services published a July 2023 report that there were high rates of prior authorization denials and limited state oversight. Managed care organizations are dependent on the cash cow of 340B pharmacy benefits where they buy drugs at 20 to 50 percent discounts and resell them at retail prices. The legislature tried to do the right thing by passing bills in both the MN House and Senate to allow medical assistance enrollees to opt out of managed care enrollment. Enormous political pressure was applied by managed care organizations, forcing the legislature to cut it out of the final omnibus bill in the conference committee. This locks Medicaid patients to limited choice with narrow provider systems and access to care concerns.

2.     What health-care related issue(s) have you advocated for over the past year?

We now have corporate medicine that dominates health care in the state that rakes off an exorbitant amount of health care dollars without any improvement in people’s health outcomes. I am not happy with the healthcare system we have at all so I have a plethora of things that I would like to change.

When I retired in 2018, I immediately sat down and wrote out a 553-page book I called NIMBLE Communitarian principles that I had self-published in 2019. (NIMBLE stood for Nourish Character, Intake Wisely, Maintain Health, Be Responsible, and Energize Community). I was given three author copies. I gave one copy to my wife and two to knowledgeable friends. They told me I should rewrite the book. I did, and published Patient-Directed NIMBLE Healthcare in 2020 with some light editing. After I published it, my wife read it and said that I needed to have better editing. So, in 2022 edited by Dave Racer of Alethos Press, I published Empower-Patient Accounts Empower Patients!  

I have written many MAFP and MMA resolutions, books, and articles to address various issues throughout the years. In the last year Minnesota Physician published my piece entitled “Mending a Racquet” suggesting that rather than paying ninety percent of health care through third party payers we should pay directly for most medical care except major medical expenses. The January/February edition of Minnesota Medicine published Empower-Patient Accounts. I suggested we could directly fund individual medical care (Empower-Patient) accounts rather than fund third party payers. I advocated for direct primary care, a direct relationship between patients and their physicians without the corporate overhang.

The May edition of Health Care News published my commentary on “Expand Personal Health Options” in which I suggested funding empower-patient accounts and health savings accounts for people. Health Care News published a commentary titled “Restoring the Patient-Physician Relationship Is the Key to Fixing Health Care” in which I argued for restoration of the corporate practice of medicine laws to undo the corporatization of medical care that has added so much unnecessary cost and regulation to medical care in the U.S.  I have submitted another article that I hope will be published in Health Care News in January titled “Use Tax Credits to Address Medical Care Costs.” The AMA in 1998 and again in 2014, John McCain’s 2008 health care platform, The Hoover Institution 2023 “Choices for All,” and Representative Pete Sessions’ 2023 Health Care Fairness for All are other examples of organizations and people pushing to use medical care tax credits, as we do with childcare, work, food, housing and more recently education tax credits to meet people’s needs.

My basic idea is to take the premium tax credits of the ACA and give them to people instead of third parties, thus cutting out the cost of middle vendors and the regulatory maze that has made medicine in general so miserable. Primary care particularly has become an intolerable nightmare. The joy of medical practice has dissipated through bureaucratic mandates, administrative constrictions on physician autonomy and the imposition of attention to corporate profits to maintain employment. Independent practice of medicine has become almost impossible in the present third-party payer regulatory environment. The physician-patient relationship has been replaced by a corporate employee/customer interaction that neither physicians nor their patients like.

3.  What advice would you offer to others who are interested in advocacy?

Start by being active in one’s specialty organization. I was on the board of the MN Academy of Family Physicians for the first of three time-limited board terms within a couple of years in practice, headed the local Heart-of-Lakes chapter most of my career, was on several and chaired one MAFP committee through the years, and continue in retirement to be on the MAFP legislative committee. Author resolutions on issues that concern you. Many of my resolutions have been adopted at the MAFP state level and several at the AAFP national level, including one many years ago on moving cannabis to a schedule II classification and most recently one on Self-Directed Medical Care (2/2022).

On the state level work through the MMA.  The MMA has never been as successful as this year when the legislature passed four of the five legislative priorities: the creation of a statewide registry for POLST forms, Communication and Optimal Resolution (CANDOR) enabling legislation, extending coverage for audio-only telehealth services, and offering recuperative care coverage for those experiencing homelessness. Those represent a small part of the MMA success this year in which over twenty health care related bills passed, most if not all of which the MMA supported after several major bills were amended. An updated All-Payer Claims Database will likely lend itself to propose greater primary care delivery system funding. The most important legislation affecting physicians in 2023 was prohibiting non-compete clauses in employment agreements after July 1^st, 2023.  Non-compete clauses effectively made physicians indentured employees of the corporations that employed them.

I have been honored to be the chair of the MMA policy committee, which I will term limit out of this year after being on it for six years. Our top three issues were improved professional satisfaction and wellbeing, private equity and their effects on health care, and transgender healthcare access/protection. The first issue was rerouted to another committee, but we were able to add five of our policy committee members to it. Private equity is pushing into Minnesota medical care, further disempowering both the patients and the physicians of the state. We passed a policy position out of our committee recommending collecting better information on the activities of private equity in the state. The issue of transgender healthcare access/protection is on our agenda for our last meeting of the year.

I have worked with the MMA staffer Adrian Uphoff and Dr. Najaha Musse, who practices in a direct primary care setting, on a policy position in support of DPC as a qualified medical expense and not insurance. We submitted a policy position with the support of the MAFP that will be considered soon by the MMA board, and if approved will be put up on the PULSE for approval by the MMA membership. The three of us are also planning on working to update the MMA policy position on health savings accounts to be more in line with the AMA’s policy supporting them. My wish and hope are that despite all odds the MMA will tackle promoting a stronger corporate practice of medicine law in Minnesota to further empower the autonomy of our physicians.

The MMA has the staff and the resources to accomplish successful advocacy on a statewide level much more than specialty physician organizations. Volunteer for and be active on committees. Run for the board. The policy committee has openings for forty people but just over half the positions are filled and only roughly a third of that number show up for meetings.

I personally have been active in several independent advocacy organizations. I am very concerned about medical record privacy. HIPPA passed nationally in 1996 opened medical records, a prime target for hackers in recent years, to over 2.2 million businesses and took away the need to get people’s consent for sharing medical records. The government has access to all our electronic medical records. The Citizen’s Council for Health Freedom based out of St. Paul works on this nationally and is worth supporting. We need to restore the need for people’s consent to share their medical records and/or give people electronic possession of their records so people can decide who they want to give access to them. 

I am also a member of an online medical discussion group, the MN Physician-Patient Alliance (physician-patient.org) of just under a hundred people, half physicians and half lay people. We bounce around ideas that favor patient empowerment. That is open to anyone interested in on-line discussion with no fees.