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 Response Page - Magnan  Interview -      

These comments are responses to the questions listed below,
which were generated in regard to the
Sanne Magnan Interview of

The Questions:

Minnesota Dept. of Health Commissioner  Sanne Magnan says we're spending too much on health care and receiving too little in return. Unless changes occur, spending on health care in Minnesota will double in the next eight years. New measurements will soon make it possible to compare health care providers based on quality and cost. Consumers should be given incentives to choose value-based health insurance. Physicians and other providers should be held accountable for outcomes and cost.  For the complete interview summary see:

Response Summary:  Readers have been asked to rate, on a scale of (0) most disagreement, to (5) neutral, to (10) most agreement, the following points discussed by Commissioner Magnan. Average response ratings shown below are simply the mean of all readersí zero-to-ten responses to the ideas proposed and should not be considered an accurate reflection of a scientifically structured poll.

1. Health care assumptions (8.8 average response)  It is not necessarily true that more service or more expenses assure better health care.

2. Comparing quality and cost (6.2 average response)  A new developing system enabling consumers to compare quality and cost of different providers will significantly help Minnesota restrain its rapidly escalating health care expenses.

3. Incentives to consumers  (7.3 average response)  State and local government and private health plans should offer  incentives for consumers to choose providers based on cost and quality.

4. Accountability (7.5 average response)  Physicians and other providers should be held accountable for outcomes and cost, instead of only being paid for patient visits, tests, procedures and hospitalizations.

5. Specialists (7.1 average response)  Relatively less compensation should be given to specialists and relatively more to primary care physicians.


 Response Distribution:

Agree Strongly

Agree Moderately


Disagree Moderately

Disagree Strongly

Total Responses

1. Health care assumptions







2. Comparing quality and cost







3. Incentives to consumers







4. Accountability







5. Specialists







Individual Responses:

Ray Ayote  (10)  (7.5)  (10)  (10)  (10)

Polly Bergerson  (10)  (5)  (5)  (10)  (10)

W.D. (Bill) Hamm  (10)  (2.5)  (0)  (7.5)  (2.5)

1. Health care assumptions.  Depends on your definition of "health care". Like most folks in the bottom 62% (not rich or middle class), we are looking for a system that is: (1) designed to be in my best interest first and foremost, (2) designed to protect from tort and encourage personal improvement in the professionals within our medical system. (3) (would) give none of my money to either insurance companies or new governmental bureaucracies.  None of the proposals and schemes so far put in our faces by these arrogant elitist politicians comes even close to these three simple objectives. 

2. Comparing quality and cost.  This nonsense does nothing to, first, help improve or police doctor or professional ranks; second, such figures will favor doctors who are smart enough to cherry pick which patients they take, forcing other doctors to take on riskier patients thus skewing the figures.

3. Incentives to consumers.  Quality health care, from the patient point of view, should be what is driving the system, not profit, not what protects the institution. Your ridiculous incentives do nothing to change the way the existing system thinks of us, as the person receiving health care rather than the allocation of resources.

4. Accountability.  The whole system should be built around patient driven outcomes defined by patients. Then and only then can doctors and professionals as well as processes be evaluated from the proper perspective.

Robert Freeman  (10)  (7.5)  (10)  (10)  (10)

1. Health care assumptions.  Study after study has proved this to be the case.  However our system provides an incentive to do more, not less.  Imagine what contracts would look like if we paid lawyers by the word.  That is the system we have for health care.

2. Comparing quality and cost.  If implemented correctly.  We also need to reform the way in which we pay for health care.  Since the government pays for about half of medical care, it needs to lead by example.

4. Accountability.  With the proviso that providers are not good at managing risk - but they are very good at providing care.

Peter Hennessey  (7.5)  (2.5)  (7.5)  (0)  (2.5)

1. Health care assumptions.  This is true; it depends on external factors: (1) how sick the patient is, (2) how willing the patient is to follow his doctor's instructions. (3) how up-to-date the doctor is, (4) how much time the doctor has to spend with the patient to get all the facts and form the correct diagnosis, then explain all the details and treatment options to the patient, at the patientís level of understanding.  There is nothing the third party payer can do about (1) or (2), licensing bodies take care of (3), and third party payers with their decreasing reimbursements are working directly against everybody's interests in (4).

2. Comparing quality and cost.  Short of weeding out incompetent providers, which is a function of licensing bodies, there is nothing the third party payers can do except tinker with the reimbursement rates, and thereby make the problems worse. All this talk about quality and cost is good-sounding nonsense that neither the patient nor the third party payer can possibly define and quantify to everyone's satisfaction. The doctor-patient relationship is unique to each paring of a specific doctor to a specific patient, even if it were possible to assume that every patient's illness and the course of that illness is precisely identical. For a variety of reasons, a specific doctor and a specific patient may assign a different degree of severity to the patient's condition, and the patient might prefer a different course of treatment. There is no amount of standardization and the consequent imposition of certain treatments and the prohibition of others that can force every patient, every illness and every treatment into a satisfactory cost-benefit model.

3. Incentives to consumers.  Having disposed of the notion that cost and quality are factors that a patient or even a panel of "experts" can possibly determine with any level of authority and credibility, the only thing left is the patient's freedom to choose his own doctor. Sorry, but even health care is a human activity that is governed by the rules of the free market, no matter how it is distorted by the efforts of third party payers to standardize everything. At some point you have to admit that the patient must be left free to choose -- choose to admit he has a problem, choose to admit that the problem is severe enough to seek help, choose to admit that he is happy with his doctor, choose to admit that the treatment is something he can tolerate and follow. There is nothing that any third party payer can do about this, except refuse to pay because the patient does not follow the standards they seek to impose on everybody.

4. Accountability.  There is no way the doctor can be held accountable for outcomes (with the obvious exception of criminal behavior). Everyone does not have the same illness, to the same degree, under the same living, exercise, nutritional and other conditions. Everyone does not respond equally well to the same treatment. Some respond to no known treatment. On the other hand, the doctor's effort to help the patient takes time, and the treatment involves the use of medicines and equipment that cost money to buy. How else will you reimburse the doctor if not on the basis of service provided? So if the patient has terminal cancer and dies, the doctor and hospital get nothing because the outcome is the obvious failure to save him? If the treatment extends your life, by how long must your life be extended in order for the third party payer to reimburse the doctor? We all die, eventually; is that too an outcome that the doctor is responsible for, and therefore the third party payer will never pay him for anything? What kind of society are you building where the doctors are turned into slaves?

Bob White  (10)  (7.5)  (10)  (7.5)  (10)

Ray Schmitz  (10)  (10)  (10)  (7.5)  (10)

2. Comparing quality and cost.  I asked that my employer require on the self-insurance plan that the cost of overhead be included in the information provided on a claim, this was rejected as "not cost effective".  I suggest this is the kind of info that would lead to lower cost.

Dave Broden  (10)  (5)  (10)  (7.5)  (5)

1. Health care assumptions.  Agree, There is far too much focus on cost vs. value and outcome. This is a broad problem of management thinking not just related to health care. System thinking must be on what needs to be done and how it should be done and then how does it get done in the best way not how do you do something within a cost level--the bucket will always be full if cost is the starting point.

2. Comparing quality and cost.  This is a great approach. The measure of success will be on how it is done, implemented, and what is the result.

3. Incentives to consumers.  The concern here is to establish measurable metrics that are common and applied to all in the same way. This will be the hard part.

4. Accountability.  Agree-- there may need to be a reasonable mix on this to cover some areas but the idea must be the primary focus in the future.

Rick Bishop  (7)  (7)  (7)  (10)  (10)

Austin Chapman  (8)  (4)  (4)  (6)  (8)

4. Accountability. How does one "hold accountable" physicians and providers for outcomes?     5. How?

Ralph Brauer  (0)  (0)  (0)  (0)  (0)

I rated these all a zero because they show a total lack of understanding of the systemic implications of these proposals and the health care system.  As a newly released study shows a relatively small number of high-cost patients are a problem for the system in part because the reasons for their high costs are unpredictable--serious heart attacks, infections that do not react to antibiotics, strokes, serious accidents. This interview shows why you need to get off this "accountability" kick and get some systemic understanding.  The statistical premise behind all these remarks is essentially indefensible and a great example of not understanding systemic feedbacks.  They are based on the notion that simple linear, spreadsheet databases without feedback loops will help define health care, but as my surgeon father used to say when asked by patients about their chances of surviving a particular procedure, "There are no statistics in individual cases." Health care professionals know high-risk and high-cost cases when they see them so this system would encourage them to pass them on to someone else for fear that one bad result (and in a high risk field like brain surgery that oftens means death or life in a nursing home) will skew their performance ratings. Say I am rated on ten patients and eight of them have good outcomes (say the systems ratings give me an average of 8 for all of them) but then I have two complex cases that cost more money and more time and each has a less than favorable outcome earning me a two on the ratings list. My overall score now drops from 8 to 6.4.  On the other hand what if I had a choice of taking a low risk patient over a high risk one--one that might earn me a ten. My rating goes up to 8.4--a difference of two full points based on which patients happen to walk in the door that day. Obviously the incentives for clinics, hospitals and physicians are to not treat such risky patients. Any industry actuary can tell you these are the elderly and the poor and people in high-risk occupations (police, fire, farmers).  So this plan would not just encourage but reward discrimination against these groups. Now what are the systemic consequences of this? First the ratings systems become totally skewed, since the "best" clinics and physicians are not really the best at treating people but the best at not treating (i.e. avoiding) them.  Steering consumers to such physicians and clinics only sets up a nice negative reinforcing feedback. Second this shift in the system to primary care physicians is also misguided. Again it encourages less care for the seriously ill. Primary care people are fine for treating routine cases but even the best of them know their limitations and the importance of calling in an outside expert. By reducing the incentive to do this you risk mistreatment, which in the long run will cost money. Curiously we built a model of a typical nursing staffing system that shows just such results when an anomaly or a high risk patient can throw an entire floor into what we term a death spiral. Curiously this bizarre plan reminds me of No Child Left Behind with its emphasis on test scores. On a moral level on has to ask what is this country coming to? On an intellectual level one has to ask don't these people understand how real systems work? In fact don't they even understand statistics?

Amy Wilde  (10)  (8)  (8)  (9)  (10)

We need to serious look at how other civilized nations pay for health care. They are more successful at it than the U.S. Our health reform did not go far enough. Recent "gouging" by health insurers using the reform bill as an excuse demonstrates how essential the "public option" was to making the whole scheme work. The individual mandate penalty is too low to be very effective.  Some type of uniform, "single payer" system will eventually be needed to make any real headway at cutting administrative costs.

Connie Morrison  (8)  (10)  (10)  (10)  (3)

Alan Miller  (9)  (2)  (8)  (3)  (0)

By getting lobbyists and insurance companies completely out of health care, where their commitment is to the bottom line, dollars and profit, we could join every other civilized nation by offering health care to every citizen.  Health care is a matter of right, not a method for some to enrich themselves while others go wanting, to the point of death in some instances.  When we choose greed over need, there is something radically wrong with our priorities. 

Chuck Lutz   (10)  (8)  (9)  (8)  (10)

Vici & Seiki Oshiro  (10)  (10)  (10)  (10)  (10)

Donald H. Anderson  (8)  (5)  (5)  (10)  (8)

The biggest problem is the individual cost of health plans and differences in getting compatibility of services between the various plans.

William Kuisle  (10)  (10)  (8)  (9)  (9)

Nancy Jost  (-)  (-)  (-)  (-)  (-)

SHIP is a great program that starts too late; it should include early childhood when many of lifeís trajectories begin.  The research through the ACE Study and many other bodies of research show that if we start in elementary school in changing behaviors we are starting too late.  In rural Minnesota we have a shortage of dentists and an even greater shortage of those who will see people on MN health care programs and we had what we thought was a great, innovative solution to this problem (see below).

October 11, 2010
DHS takes away critical program from the very children it seeks to help.
Recently the Minnesota Department of Human Services (DHS) eliminated a dental care program that benefited thousands of children in the state. The Collaborative Oral Health Practice Model was developed so young children from lower income families could be seen by a highly trained dental hygienist outside the traditional dentist office setting in order to meet their Head Start enrollment requirement of having a dental exam. DHSís reasoning behind eliminating this program? All children deserve to see a dentist. True, but typically it is very difficult for children covered by Medical Assistance and Minnesota Care to find a dentist willing to honor their insurance, this includes a majority of children enrolled in Head Start.
The Early Childhood Dental Network (ECDN) of west central
Minnesota is a group of over 40 agencies and individuals working to improve childrenís oral health and access to dental care for low-income children. The ECDN works with a nonprofit dental clinic to provide mobile outreach clinics, using this same Collaborative Oral Health Practice Model, for children in areas where dental care for low-income families is limited. Dental hygienists went to an environment where the children were at ease, cleaned the childís teeth, performed an assessment, connected the most critical cases with the dentist and educated the rest of the children and parents on the importance of dental care and seeking an exam. Whether in the classroom or outreach clinic, this model worked!
The ECDN agrees wholeheartedly with the Stateís rationale that all children deserve to see a dentist, no matter their familiesí income. Yet, low reimbursement rates from the State, higher administrative costs and the multiple barriers faced by some families have discouraged private dentists from treating our youngest, poorest children. The result is far fewer children, especially low-income children, receiving the dental care they so desperately need.  The current dental care system cannot deliver.
This letter is not about the importance of receiving regular oral health exams by a qualified dentist.  Everyone agrees this is important.  This letter is about thousands of children that, because of the Stateís recent decision, will not have access to ANY form of dental care. We live in an area of the state where public transportation is limited, wages are low, families are struggling to make ends meet, and a visit to the dentistís office is considered a luxury.  Dentists are few, and those who accept Medical Assistance and Minnesota Care insurances are even fewer. The reality is the Collaborative Oral Health Practice Model makes sense.
It is time for our residents and communities to react. Commissioner Cal Ludeman from the Minnesota Department of Human Services and our local legislators need to hear about the day-to-day challenges that real families face in finding affordable dental care for their children.  The ECDN understands that times are tough and days are busy, but please consider sending our state leaders a note to let them know your support for the Collaborative Oral Health Practice Model, or any challenges your family may face accessing oral health care in west central Minnesota.


The Civic Caucus   is a non-partisan, tax-exempt educational organization.   The Core participants include persons of varying political persuasions, reflecting years of leadership in politics and business. Click here  to see a short personal background of each.

   Verne C. Johnson, chair;  David Broden, Charles Clay, Marianne Curry, Bill Frenzel, Paul Gilje,  Jim Hetland,  Marina Lyon, Joe Mansky, John Mooty,  Jim Olson,  and Wayne Popham 

The Civic Caucus, 01-01-2008
8301 Creekside Circle #920,   Bloomington, MN 55437.
Verne C. Johnson, chair, 952-835-4549,       Paul A. Gilje, coordinator, 952-890-5220.

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