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 Response Page - Nelson  Interview -      

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

The Questions:

Today's discussion covers a Civic Caucus meeting with Peter Nelson, policy fellow, Center of the American Experiment. Nelson outlines a new state effort to provide health care coverage for single adults in poverty.  The new program is designed to give hospitals incentives to help the targeted population remain in better health, thereby requiring fewer expensive in-hospital services.  

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 Nelson. Average response ratings are shown below.  Note:  these average ratings 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. Fee-for-service (6.8 average response) Because trauma hospitals have automatically received taxpayer-financed fees for services delivered to childless, poverty-level patients, trauma hospitals in Minnesota have had little incentive to try to improve the overall health of that population.

2. Better incentives (8.0 average response) It would be far better--for the health of patients and the finances of health care providers--if providers were rewarded for keeping patients healthier in the first place.

3. Lump sum (6.3 average response) Thus--despite start-up difficulties--a new state program that began in 2010 and that replaces fee-for-service with lump sum payments to trauma hospitals should be continued.

4. Non-metro service (7.0 average response) Residents of non-metro Minnesota should be able to receive service in their own areas and not be forced to come to hospitals in the metro area.

 Response Distribution:

Disagree Strongly

Disagree Moderately


Agree Moderately

Agree Strongly

Total Responses

1. Fee-for-service







2. Better incentives







3. Lump sum







4. Non-metro service







Individual Responses:

Sue Abderholden  (2.5)  (2.5)  (0)  (10)

1. Fee-for-service.  Hospitals are the top tier of our health care system; they are not designed to provide yearlong care  

2. Better incentives.  But not the hospitals - look to community providers  

3. Lump sum.  Not at all. This has been a total disaster for people living with mental illnesses. Now they can't obtain their medications and are in worse shape than before.   

4. Non-metro service.  Absolutely

David Dillon  (10)  (10)  (0)  (0)

3. Lump sum.  Sorry to vote no on this.  It is simply that a conclusion is being asked for without a case being made.  No doubt there is need for reform of the fee-for-service model.  I did read the recap, but it is not possible from that to understand enough about the "start-up difficulties" or the programís performance to agree that it should be continued.   

4. Non-metro service.  Again, sorry to be negative but the case isn't made.  It might well be true.  It likely makes sense in some non-metro areas for some services, but transportation is not automatically bad and tele-medicine is an option.

John Sievert  (0)  (0)  (2.5)  (0)

1. Fee-for-service.  None of this healthcare for the poor will work unless they have some level of skin in the game. In other words, while they can't pay much, they need to pay something so that the patient is incentivized to be healthier.  A hospital cannot force a patient to be healthier if the patient doesn't want to be or won't change their behavior.  Incentivizing the hospital does no good when it's the behavior of the patient that needs to change.  

2. Better incentives.  Same comment: None of this healthcare for the poor will work unless they have some level of skin in the game. In other words, while they can't pay much, they need to pay something so that the patient is incentivized to be healthier.  A hospital cannot force a patient to be healthier if the patient doesn't want to be or won't change their behavior.  Incentivizing the hospital does no good when it's the behavior of the patient that needs to change.  

3. Lump sum.  Who cares?  Same comment applies: None of this healthcare for the poor will work unless they have some level of skin in the game. In other words, while they can't pay much, they need to pay something so that the patient is incentivized to be healthier.  A hospital cannot force a patient to be healthier if the patient doesn't want to be or won't change their behavior.  Incentivizing the hospital does no good when it's the behavior of the patient that needs to change.   

4. Non-metro service.  At some level, yes.  However, it makes no sense to duplicate the state-of-the-art facilities everywhere and then have them be operated at less than full capacity just for convenience.  Part of choosing to live in the beauty of the north woods means inconvenience.

Peter Hennessey  (0)  (0)  (0)  (0)

1. Fee-for-service.  The incentive to improve the service (which is the only thing they really have control over, not the population) can only come from competition, not from guaranteed payments from the government. The only option providers have to try to improve the health of their patients is to harangue them about this or that. That is a good way to lose patients and make them go somewhere else.  

2. Better incentives.  How would providers keep their patients healthier? Short of closing all food stores and restaurants, and forcing everybody to eat at government approved (government run?) soup kitchens, and forcibly feed them whatever government-approved slop is put on their plate, and force them to participate afterwards in some government prescribed exercise regime, there is no way anything can be done to "improve the health of the population." Why? Because as long as people have free will and free choice, some will choose wrong (in the government's estimation) and they will run up their health care costs. The real problem is that health care costs have been universalized, thereby removing any incentive of the individual to take responsibility for his own health.  

3. Lump sum.  The problem still is that government in whatever form is interfering in business and does not allow business to find whatever solution works for them and their customers. You can't prescribe one solution and expect everybody to fit that solution.    The constant theme running through all the programs described in this meeting and all these questions coming from that meeting is that (1) people are too stupid and too irresponsible to face their own life's problems, (2) doctors and hospitals do business in a predatory manner, prescribing and performing unnecessary services only to run up costs, and therefore (3) some do-gooder watch dog government has to step in to save them from the consequences of their stupidity or depravity. But the problem with all these programs is (1) that (they) exist in the first place and (2) they are too complicated and arbitrary in every detail. And they overlook the fact that people are not stupid and they can make choices for themselves, and there is nobody, least of all a nanny state government, who can tell them that their choices are stupid or harmful to the "common good."     The source of all these problems is a political culture of deliberately breeding dependency on all sorts of government programs, in order to replace a culture of individual responsibility.   

4. Non-metro service.  Who forces them to come to metro areas? Who would provide the service in non-metro areas? If the government would allow people to find free enterprise solutions to specifically peculiar market conditions, then the problem would be solved by the people directly affected by the problem and the solutions people may be offering.   Are people not free to choose where they live?   Are providers not free to see, for example, if local clinics or the proverbial country doctor can do most of the job, and refer patients to metro hospitals only in severe cases?

bob white  (10)  (10)  (10)  (10)

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

3. Lump sum.  It needs to be better financed - currently the amount of money is making the system unsustainable.  Early Medicaid enrollment would help enormously with this aim.

Dan McElroy  (2.5)  (10)  (10)  (10)

1. Fee-for-service.  Improving health is instinctive for most care providers.  There haven't been institutional incentives but professional standards do provide incentives.  

3. Lump sum.  There will need to be changes and improvements, but the concept should continue.   

4. Non-metro service.  Poverty is not exclusive to the Metro area.  A dialogue with statewide providers is essential.

Carol Jean Becker  (10)  (10)  (10)  (10)

2. Better incentives.  The problem is that it can't be done by providing services through hospitals but it has to be an insurance-type system - where healthcare providers are responsible for individuals, not populations.

Dave Broden  (2.5)  (10)  (10)  (10)

1. Fee-for-service.  Incentives are established in many ways and this statement is simply a very narrow view of how the medical community evolves improvements. Yes, there was and is perhaps some abuse of the fee for services, and other approaches are better, but a blame statement does not fix the cause. There is a need for incentives in all businesses and services, and when coupled with outcomes benefits do occur.  

2. Better incentives.  This is certainly a key component of the quality of life in any area, state, nation etc. The trick to make this work is how does the message connect to society in all aspects including eating habits, exercise, life style, etc. Some of these that drive health are outside the norm of health care-thus how to impact a society problem. Then the next step is to find a way for effective periodic medical checks for everyone to result in early awareness of health issues. This is the issue of how to connect and communicate--prevention and early awareness is definitely the driver.  

3. Lump sum.  The new approach simplifies the process and offers some level of cost control. The need is, however, to ensure that the lump sum has value and is applied effectively. A good measure of outcomes relative to the entire patient population and to individuals must remain as part of the process. Audits and control must be simple--not add cost--and relate to health care, not administration. How the funds are spent will be also be key. Patient services must be the priority with equipment, capital etc. a limited percentage in some way--such as allocation to this program as %-of-use, etc. Continuing must mean evolving and improving not just the same and adding the annual cost of inflation, etc. Outcomes and fund allocation must be drivers.   

4. Non-metro service.  This is a very key. The health services need is statewide. There must be equal services for all of Minnesota. The capability must be available in regional hospitals across all of Minnesota. The types of services may vary due to specialties but there should be no distinction between what outstate citizens can receive and what the metro citizens receive. The possible bias to metro must be changed.

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

1. Fee-for-service.  Quality of care is the last consideration as is a positive patient outcome. Hospitals, Insurance Companies, and Medical professionals have no incentive to look at these people as anything more than "Pimples on the [backside] of society" and treat them as such. To fix this ridiculous mess we must push the power and control back out to local advisory boards and out of the hands of bureaucratic central control that is increasingly failing us.  

2. Better incentives.  This will never happen under central control by self-serving bureaucrats. While your goal is excellent, it is unachievable under any government-controlled scheme. Only by shifting power and funding away from the hands of bureaucrats and politicians will we ever solve this mess. Cooperative medical structures like those used by the Mondagon Industrial Cooperatives in the Basque region of Spain are a perfect example of how we can all save money by eliminating Government involvement and control.  

3. Lump sum.  Lump sum payments do nothing to undermine the current negative incentives or negative attitudes toward this group of our society. Your dream scheme is just another underfunded and unfullfilled empty promise.   

4. Non-metro service.  This always was a no brainer. Making it harder for these people to receive services equals lower cost to provide them healthcare; seems to be working just the way it was redesigned to me. So much for your system redesign buzzword driven garbage.

Hans Sandbo  (10)  (9)  (10)  (0)

1. Fee-for-service.   Trauma hospitals need to make their own decisions on this, and constraints should not be put on them by society (governments) unless they are able and willing to fund them.  Once the government has made a decision on the funding, trauma hospitals need to live within the dollars funded.  Medical care gets to the basics of life and these types of decisions are best left to the individual and the person supplying medical help.  It is impossible to supply everyone with what they need in medical services.  I might need a heart transplant - if I win the lottery and, there is one available and I can pay for it - so be it, but I should not depend on society to give me that transplant, just because I need one.

2. Better incentives.  In general I feel this is a good idea.   However, it is generally not a good idea to make medical help a profit-and-loss situation for the medical personnel.   However they should be operated on a break-even basis. 

3. Lump sum.  Yes, this puts the decisions on the medical staff where it should be, mistakes and all. 

4. Non-metro service.  This would cost too much. Transportation (not always a helicopter) is available where it is determined by the medical staff that better trauma treatment is needed. 

5. Comment:  Very difficult issue.  Our society has a lot of difficult issues and an educated public is better off because of forums like this.  Thank you all for your time and efforts on this.

Chuck Lutz  (10)  (10)  (10)  (8)

Wayne Jennings  (10)  (10)  (8)  (10)

Itís a complicated area to figure out. Iíd like to see more storefront medical clinics that take the burden off hospitals.

Bright Dornblaser  (10)  (10)  (10)  (10)



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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