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 Response Page - McClure  Interview -      

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


Walt McClure, an original market reformer in health care, describes Minnesota's position at the cusp of national leadership in health care system reform. The requisite elements are in place for the state to lead in this reform effort: the ability to systematically measure health outcomes and costs, and a system offering incentives for choosing those health care providers that deliver better outcomes at a lower cost.  

A name suggested for this strategy is Informed Consumer Choice. No other state is in such an advanced stage of progress on this strategy as Minnesota. Now the task is to get the elements of the strategy operating maximally and meshing as part of an integrated policy. State leadership, both public and private, is required to complete this job. The role of a health insurance exchange is discussed.

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 McClure. Average response ratings shown below are simply the mean of all readers’ zero-to-ten responses to the ideas proposed and should not be considered an accurate reflection of a scientifically structured poll.

  1. Expansion increases urgency. (9.4 average response) Controlling health care costs without endangering quality becomes more urgent as the federal Affordable Care Act extends health care access to millions of people.
  2. Structure rewards costly services. (7.3 average response) As structured today health care incentives strongly reward more costly doctors, hospitals and other providers, irrespective of quality.
  3. Consumers unaware of providers' efficiency. (8.3 average response) Some providers obtain top quality outcomes while charging less per patient. Other providers with the worst outcomes charge more. Yet the general public doesn't know which providers fall in which categories.
  4. Minnesota can lead with good data. (7.5 average response) Minnesota is well equipped to be a national leader in changing incentives because reliable information on provider-by-provider quality and cost now is being gathered in the state.
  5. Plans should encourage better choices. (7.4 average response) Insurance plans should be changed so that members of the public have incentives to select doctors, hospitals and other providers who produce higher quality at lower prices.
  6. Add incentives to state's exchange. (7.8 average response) Incentives to reward quality and cost effectiveness should be built into Minnesota's health insurance exchange, the Affordable Care Act online marketplace being developed to help individuals select from among competing health insurance plans.
  7. No need for new incentives. (0.6 average response) There's no need to change incentives for choosing health care providers or health insurance.

Response Distribution:

Strongly disagree

Moderately disagree


Moderately agree

Strongly agree

Total Responses

1. Expansion increases urgency.







2. Structure rewards costly services.







3. Consumers unaware of providers' efficiency.







4. Minnesota can lead with good data.







5. Plans should encourage better choices.







6. Add incentives to state's exchange.







7. No need for new incentives.







Individual Responses:

Bert LeMunyon (10) (7.5) (7.5) (5) (10) (5) (2.5)

6. Add incentives to state's exchange. The Affordable Care Act needs to be replaced with a plan that will provide quality care at an affordable cost without trying to be all things to all people.

David G. Dillon (10) (10) (10) (0) (0) (0) (0)

1. Expansion increases urgency. So true. As the Affordable Care act was sold as "reform" when it was really about expansion, the need to do something about costs is more critical than ever.

2. Structure rewards costly services. Again, so true. We have much to learn from a Minnesota invented success story company, Minute Clinic. Their former CEO, Michael Howe, was formerly the CEO of Arby's. Fast Food has a great deal to teach health care about efficiency and quality.

3. Consumers unaware of providers' efficiency. More truth. Then again, why would a consumer care what the costs are if they aren't the ones paying?

4. Minnesota can lead with good data. I wish this were true. Given the systems and the incentives, the chance of measuring quality or cost in a useful way is nearly zero.

5. Plans should encourage better choices. It's not a matter of changing the insurance. It's a matter of who buys the insurance. Today the insurance is bought by someone other than the person using it. Companies buy insurance because it is tax deductible for them but not income for employees. Individuals can't deduct this cost from their tax burden. If individual consumers could get back to being in charge of this purchase, quality and price would be re-introduced into this important part of our economy.

6. Add incentives to state's exchange. Good luck. Just more (meaningless) measurement and fiddling from the government trying to fix a broken market with band aid interventions.

Jean Chaput (10) (7.5) (7.5) (5) (5) (7.5) (0)

1. Expansion increases urgency. Quality is problematic since it is always evolving and is delayed in its recognition especially by the public.

2. Structure rewards costly services. Selection of a provider is driven by word of mouth with little or no regard for cost so the incentive is for patient satisfaction with little regard to cost. If the cost in some facilities is increased because of research and development, won't there be an advantage for places not so engaged?

3. Consumers unaware of providers' efficiency. The public may not know, but individual patients with identified issues get help from friends, doctors and other health care providers in choosing a doctor or a hospital.

4. Minnesota can lead with good data. It is too soon to declare victory. It is enough that we are moving in the right direction.

5. Plans should encourage better choices. What would the proposed change look like? Usually the price to the patient is the incentive and this takes away from the concept of insurance coverage.

6. Add incentives to state's exchange. Competing plans suggests differences in coverage at the choice of subscribers. This may lead to the flip side of cherry picking.

Craig Brenden (10) (0) (10) (7.5) (10) (10) (0)

RC Angevine (10) (7.5) (7.5) (7.5) (10) (10) (0)

Ray Ayotte (10) (7.5) (10) (10) (10) (10) (0)

Chris Brazelton (10) (10) (10) (10) (10) (10) (0)

6. Add incentives to state's exchange. This interview and the information provided are so important; I hope that Civic Caucus can take additional steps to disseminate this far and wide.

7. No need for new incentives. Some will demonize those who are working to fix our broken system, calling them socialists and condemning our efforts as coming from a "nanny state". Nonpartisan leadership is required to integrate the puzzle pieces. As long as profit and creation of wealth are primary goals within our healthcare system, quality is, at best, in 3rd place.

Robert Freeman (10) (7.5) (7.5) (10) (2.5) (5) (2.5)

2. Structure rewards costly services. This seems to be a matter of culture - in certain areas of the country doctors are more likely to order tests, etc., as was clear from the Gawande article.

5. Plans should encourage better choices. Insurance companies will change by themselves if there is good, reliable cost and quality information and consumers want it. Having the state try (to) do this is foolish.

6. Add incentives to state's exchange. This is silent on the possibility of a robust private marketplace outside of the Exchange. Again it is something the private market is better poised to do than state government.

7. No need for new incentives. Better transparency and more information is always helpful. We should be cautious about the state intervening in the relationship between customers, brokers and health plans though.

Ralph Brauer (7.5) (5) (5) (5) (0) (2.5) (2.5)

2. Structure rewards costly services. There are no data or studies cited in this interview to justify such a broad sweeping statement. Which brings me to a pet peeve about these interviews: the interview team allows too many people to get away with unsupported (nonsense) like this. When stuff like this gets published some people assume it is true. Others of us assume it is just (nonsense) because the person being interviewed has no evidence. Please don't allow this sophomoric behavior to (continue).

3. Consumers unaware of providers' efficiency. See above.

4. Minnesota can lead with good data. Much of this information is looking at the wrong variables. Health care is unique statistically because 99% of outcomes can be OK but some bad screw-ups can really alter the financial picture. Also all hospitals and physicians are not the same. Fairview Southdale would not even admit the patients that show up at Hennepin County.

5. Plans should encourage better choices. No. Patients should be allowed to choose their own physicians period. As a disabled person I am tired of being jacked around by HMOs and their stupid rules. Get rid of the HMOs and their high administrative costs and allow patients to make the choices, not some bureaucrat.

6. Add incentives to state's exchange. This--and the subsequent discussion are too vague to give an answer. What is quality? What is cost effectiveness? This is not an idle question. Is quality doing the best we can for every patient or for a majority of them? From a systems perspective there are several feedbacks between quality and cost that need to be considered. How do you lower cost without lowering quality? Currently the HMOs and their silly rules require a physician to spend no more than 15 minutes with each patient. Ridiculous. Some take five minutes (or should be there are at all); other(s) take an hour. Which brings up a point not raised in this discussion--patient responsibility. A couch potato should not be allowed to demand the same level of health care resources as people who exercise and eat right.

7. No need for new incentives. Cost effectiveness is in the eye of the beholder. In the name of cost effectiveness my HMO almost killed me and cost themselves close to a million dollars in costs caused by their own stupid rules and medical decisions made by bureaucrats. Finally (as) my surgeon father used to say--statistics are meaningless in individual cases. By that he meant Patient A could miraculously recover due to nothing done by the system while Patient B could prove resistant to the most exotic treatments. Because of this, some of us are advocating systems-based approaches such as system dynamics modeling in place of the linear, primitive spreadsheet data currently being used.

Peter Hennessey (0) (0) (0) (0) (0) (0) (0)

1. Expansion increases urgency. Who is going to control costs? How? Everything that is wrong in this industry is a direct consequence of government action. Buy the way, Obamacare does not extend coverage to more people. All it does is what it is designed to do: destroy the private health insurance and the private health care industries, increase the size of government and reduce the size of the private sector which pays all the bills for everybody, even government.

2. Structure rewards costly services. The pitiful reimbursement rates under Medicare, also being applied in the general population and more of same coming under Obamacare, cast serious doubts on this assertion.

3. Consumers unaware of providers' efficiency. You have no way to know this, let alone be able to communicate it to normal people. Death rates are high in the ER, trauma, cancer and geriatric centers. So...? Does that make those doctors look incompetent?

4. Minnesota can lead with good data. Even assuming that experts devise ways to measure each other's performance and competence, how will normal people come to understand let alone use the data intelligently?

5. Plans should encourage better choices. Who would change the insurance plans? Hint: ever hear of competition? First of all, government must rescind all the politically inspired mandates, which today drastically distort the market. Let insurers, doctors and patients find the ways they can work with each other.

6. Add incentives to state's exchange. The only thing states should do is seek exemptions from, or outright defy, Obamacare, which is the federal government's effort to destroy the private health insurance and the private health care industries. Nothing in Obamacare is about increasing competition in the private health insurance market.

7. No need for new incentives. Yes there is. You could take government out of the private market. Nothing In the Constitution permits the government to be in the heath care or in the insurance business, to name just two. You could try the free market for a change. You could let individuals face up to their own responsibilities and make their own decisions, like adults. You want to find ways to measure performance? Great. You want to collect data? Great. You want to sell it or give it to people? Great. You want to make sure they actually understand it? Great. Encourage them to use it? Great. Your job is done. There is no room for government in any of this. Not in a free country.

Amy Lange (10) (2.5) (2.5) (2.5) (0) (5) (0)

2. Structure rewards costly services. Incentives reward more intervention but don't necessarily reward more costly providers. Our opaque pricing system is largely to blame for high prices- there is not set prices for anything, every payer negotiates a different payment structure- consolidated provider groups and out of network providers negotiate high prices. This adds tremendous administrative waste to our system. Yes, there are a lot of perverse incentives in our system- the incentive to do more intervention whether or not it is more beneficial than conservative treatment, the incentive for insurance companies to cherry pick, etc. But generalizations such as the one above also mask how complex health care is, how limited quality measurements are and how there are perverse incentives in measurements too.

3. Consumers unaware of providers' efficiency. Some providers also have much harder patient populations (poverty, transportation problems, language barriers, housing etc. have huge impact on outcomes- and so you can't always compare outcomes for Dr. X of patients with condition Y to outcomes of Dr. Z of patients with condition Y. Most of our health care spending goes to a very small percentage of people with very complex health care problems (often overlaid with psycho-social or demographic complications). Getting the general population to shop on the basis of "quality" and "cost" will not make a dent. This is a solution in search of a problem.

4. Minnesota can lead with good data. Most doctors want to practice high quality care. In many cases we don't have evidence-based research to guide clinical decision-making. We should focus more on (finding) ways to avoid error and promoting collaboration on clinical pathways (where Minnesota is a leader). These "market based reforms" are another false solution. We need single-payer unified, rational health care system with tax based financing. It would save (a) significant amount of money and guarantee affordable universal coverage.

5. Plans should encourage better choices. This will just lead to adverse selection. It always does. We need to get rid of insurance companies having any role in basic health care coverage.

6. Add incentives to state's exchange. All this sounds good, but I have seen no economic data to show that it works. I have seen economic data and research suggesting that attempts to change incentives (Like P4P) just lead to up-coding and hence more resources from high need patients to lower need patients. The only thing that works to save money is single-payer.

7. No need for new incentives. See answers above

Scott Halstead (10) (10) (10) (10) (10) (10) (0)

7. No need for new incentives. We need to reward individuals that choose have a healthy lifestyle. Employers, Medicare and Health Insurance providers need to structure premiums, Medicare fees, copayments, coinsurance, fitness programs and any incentives to reward controllable healthy lifestyle. Health Care providers need to ensure their health insurance providers have an adequate supply of quality providers. There should be consideration for retraining doctors, hospital administrators and staff and other health care providers that need to improve their quality and cost. How do you accomplish this in rural settings with very few providers? Great interview, and Minnesota keep on progressing!

Don Anderson (10) (7.5) (10) (10) (10) (10) (0)

1. Expansion increases urgency. Controlling health costs is just as important as quality. You shouldn't have to sacrifice one-for-the other.

3. Consumers unaware of providers' efficiency. These providers, both in quality and outcome, deserve to be known by the public.

5. Plans should encourage better choices. Does these mean, between plans. If your plan doesn't have the best providers, how do you switch between doctors in different plans who might be better in the area of expertise you are seeking then the corresponding doctor in your plan?

David Broden (10) (5) (7.5) (10) (7.5) (10) (2.5)

1. Expansion increases urgency. Focus on cost will shift attention away from the skill and excellence unless specific incentives and rationale is given to maintain quality. Metrics only will not do this but can be helpful. Quality must be divided into two parts--quality meaning doing it right and quality meaning applying new techniques and treatments. How these two play in the cost control world will be the decider if cost control works and can be managed.

2. Structure rewards costly services. While this is likely correct in some instances it is one of those slogans that in itself is damaging and must be addressed in a positive way not stressing the high cost but managing the high cost.

3. Consumers unaware of providers' efficiency. Again a broad statement that can be misunderstood. The ACA and other controls should monitor and address this issue. The public also has a responsibility to check on the selection of providers and that is where the heath exchanges either by the providers or public if correctly done can be helpful.

4. Minnesota can lead with good data. Minnesota has been and continues to be a leader. The question is, will the ACA result in Minnesota information being compromised to a lower level to comply with federal standards, or will Minnesota be able to maintain leadership and an independent approach. We need to be careful that the federal program does not level the playing field and thus lower Minnesota capability.

5. Plans should encourage better choices. Question to ask is "is this not what we have today if we ask the right question?" Also why do we always focus on higher quality at lower cost. Why not be realistic and state (that) increased quality and capability … will cost somewhat more. We should not get into a" must be lower cost" mode.

6. Add incentives to state's exchange. The approach seems to be moving in this direction. Just need to ensure that we are not constrained by federal limits to the scope of the program that we establish.

7. No need for new incentives. Question always to ask-- is the system really not working or is it not being communicated and applied effectively?

Donald Mark Ritchie (na) (na) (na) (na) (na) (na) (na)

Wow, pretty interesting stuff.

Tim Hall (na) (na) (na) (na) (na) (na) (na)

In the Untied States we have four workers to every one patient compared to Australia and Canada. Their health care is also paid for by a national sales tax. In the Obama plan anyone who is supposed to pay for it has an exemption. In Croatia they have a national health care plan that costs 50 dollars and has no mandate to buy it. All have a basic heath care plan but you can also pay for additional insurance. The European Union isn't stupid enough to have a health plan run by them for every country. Governor Carlson has already set up the framework for a state plan with private companies with Minnesota Care. Neither party will ask for productivity studies to find out who the nonessential people working in health care are. For a state plan to work they would have to be fazed out as they retire.

Tort reform is the most important, though. Without it in some cases we are paying doctors to do nothing. They are scared to death to do anything but run tests. If they try to do anything and something goes wrong then they get sued. That is why John Edwards sued doctors delivering babies. They have to be delivered. Doctors can't keep the baby in there until they retire.

If we can put together a state plan that includes senior citizens, and people in the military we can get rid of any Federal health care plan. These are our citizens, our state, our responsibility.

John Milton (10) (10) (10) (8) (10) (10) (0)

Alan Miller (10) (8) (9) (9) (9) (9) (2)

Charles Lutz (10) (9) (9) (10) (9) (10) (1)

Robert J. Brown (na) (10) (10) (na) (10) (8) (0)

Wayne Jennings (10) (8) (10) (10) (10) (10) (1)

Sage comments by McClure, who has devoted a lifetime of study to issues of health care. We’d all like to know who are the best providers for a given medical procedure and at reasonable costs. I hear some people cross the border to Mexico or India for health operations because they are reputed to be excellent and much cheaper. It galls me to see some health organizations with executives on multimillion-dollar salaries. It’s troubling to see so much of health costs eaten by paper work and bureaucracies. Harrah for Walt and the good progress he reports.

Greer Lockhart (10) (10) (10) (10) (10) (10) (0)

Tom Swain (10) (7) (10) (8) (10) (10) (0)

Al Quie (10) (10) (10) (10) (10) (9) (0)


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,  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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