Sanford Health Plan President Kirk Zimmer said the company would likely have to recalculate its rates and refile them if the payments are to stop. The 2018 open enrollment period starts Nov. 1.
“Our rates are filed as long as the federal government agrees to continue payment of the cost-sharing reductions,” Zimmer said. “We’re firmly committed to being on the exchange for 2018.”
…Avera Health Plans CEO Debra Muller said she believes the state would provide insurance carriers with an opportunity to adjust their rates if the payments are cut off, but she said they need to be funded for “market stabilization.”
“I think that’s what everybody’s directionally trying to do right now is to figure out how we maintain stability in the individual market going into 2018 without knowing what the federal government is going to decide to do, whether it be President Trump or Congress,” she said [“SD Insurers Urge Trump to Make Health Law Payments,” AP via Pierre Capital Journal, 2017.08.16].
I don’t like agreeing with big insurance companies, but Avera and Sanford are simply confirming what Kaiser Family Foundation reported last week and what the CBO reported Tuesday about the negative impact Trump’s threats may have on insurance premiums. Donald Trump is out to make your health insurance more expensive.
An eager reader shares this letter from Avera Health to its thousands of South Dakota employees urging them to vote No on Initiated Measure 23, the “fair share” union dues measure:
The South Dakota Association of Healthcare Organizations also opposes IM 23, saying that allowing unions to charge non-members for collective bargaining and other services “will hinder health care workforce development.” (Um… how? nurses in Sioux Falls will revolt at fair-share dues, throw away their college educations, and go stock shelves at Hy-Vee? Or they’ll all pack up and go nurse in Minnesota… where Chapter 179A Section 6 Subdivision 3 authorizes fair-share union dues?
Because Avera and Sanford can’t get along, going to the doctor is about to become a bigger pain the keester for thousands of South Dakotans. Sanford is pulling out of the DakotaCare network, meaning that, as of January 1, 2017, folks with DakotaCare (including 12,000+ state employees) will have to put up their own cash to visit Sanford hospitals and clinics.
Right now, DakotaCare and Wellmark are the only health insurance providers that includes the two market-dominating hospital chains, Avera and Sanford, in their coverage networks. Both Avera and Sanford offer additional insurance plans, but Avera’s plans don’t include Sanford providers in their network and vice versa.
Last year, Avera bought DakotaCare. So right now, Avera owns a plan that provides coverage at Sanford facilities. Free-market tension ensued:
Earlier this year, Sanford officials say they approached Avera about extending access to Sanford Health Plans to Avera physicians, a move that would have created a third broad network plan in the state and one that would have put Sanford on an equal footing with Avera’s DakotaCare plan. But Avera countered with a proposal that Sanford buy an equity share in DakotaCare.
Paul Hanson, the executive vice president of Sanford Health, said Sanford balked at Avera’s proposal based on philosophical and regulatory concerns. Hanson said he didn’t think it was realistic for two competing health systems to own an insurance company, and he said the move might have raised anti-trust problems with the two owning a single insurer [Jonathan Ellis, “Sanford to Leave DakotaCare After Negotiations with Avera Fall Through,” that Sioux Falls paper, 2016.08.23].
Hmm… maybe it’s not realistic for any health system in South Dakota’s sparse health care market to own any insurance company. If two oligopolizing health care providers are going to leave us with only one broad health insurance network, the market is failing us. The public option—the recommendation from President Obama and candidate Clinton that we offer Medicare to citizens under 65—is now all the more warranted in underserved South Dakota.
But Sanford is not the biggest employer, or even the biggest health care employer, in South Dakota. The outfit writing the most paychecks in our fair state is Avera. Check out the top ten South Dakota employers listed in the brand-spankin’-new South Dakota Comprehensive Annual Financial Report for FY 2015, released yesterday by our Bureau of Finance and Management:
Avera employs 1 out of 25 South Dakota workers, 61% more than Sanford. Add Rapid City Regional Hospital, and our three biggest health care providers provide 7.7% of South Dakota’s jobs, meaning if no one got sick, our economy would be in deep trouble.
Walmart and Hy-Vee are duking it out for top retail employer in the state, each employing over 5,000 South Dakotans (Hy-Vee! You could top Walmart by bringing a store to Aberdeen!). Wells Fargo sneaks into the tenth spot with 3,520 employees, just under 1% of our workforce required by corporate protocol to shout “Welcome to Wells Fargo!” across the lobby and engage in small talk when they should be attentively counting my deposits.
The remaining four top employers are all government: state, federal, Sioux Falls, and Rapid City. Over 41,000 people, one out of ten South Dakota workers, punch the clock for those top four public employers; according to U.S. Census data from 2014, another 12,000 or so shovel snow, chase bad guys, and otherwise serve the public for other local governments.
The workforce of these top ten employers comprises 20.9% of South Dakota’s workers.
Scroll down a snudge and compare the top employers from 2006:
The top four public employers topped the list in 2006 and employed nearly the same share of working South Dakotans, 10.1%. The feds actually employ fewer South Dakotans now under president Barack Obama than they did under President George W. Bush (Kristi, what’s that you keep saying about protecting businesses from a growing government?).
Citibank has yielded to Wells Fargo, and John Morrell gave up its spot to Hy-Vee (hmm… a shift from production to consumption?). Sanford topped Avera in 2006 by 56%, but over the last decade, Sanford’s workforce has nearly doubled while Avera’s nearly quadrupled. Speaking of market concentration, the top ten employers in 2006 only captured 15.9% of South Dakota’s workforce, compared to 20.9% now. More South Dakotans are now beholden to fewer employers, which deep down in our social fabric means a concentration of money and power in fewer hands. This blog will watch for the 2025 CAFR to see if that trend continues! (Pssst! Dennis! We could check that trend if the state promoted more small organic dairies instead of giant CAFOs!)
A lawsuit filed Friday in federal court implicates Lieutenant Governor Matt Michels, in his role as lawyer for Avera Sacred Heart Hospital in Yankton, in medical malpractice that led to the death of Frances Bockholt. The lawsuit also seeks to overturn the South Dakota medical peer review laws that kept secret the malpractice of orthopedic surgeon Allen A. Sossan.
Five children of Frances Bockholt are suing Avera Sacred Heart Hospital, Lewis & Clark Specialty Hospital, Dr. Soosan (a.k.a. Alan Abdali Soosan), Dr. Don Swift, Dr. Kynan Trial, attorney Michels, and members of the medical executive and peer review committees of Avera and Lewis & Clark. Sossan/Soosan’s malpractice—unnecessary surgeries that contributed to Bockholt’s death in 2011—and his disruptive, violent behavior in the workplace have been documented in the press and established in court.
This new lawsuit alleges that Avera initially refused to give Sossan privileges to perform surgery at the Yankton hospital. Enter Matt Michels:
89. After the Avera Sacred Heart Medical Executive Committee (“MEC”) initially opposed extending Soosan privileges, Defendant Matthew Michels then intervened, acting on his own initiative and at the behest of the administrations of Avera Health and Avera Sacred Heart Health Services.
90. Defendant Michels misled the MEC. Michels falsely advised the MEC that there was insufficient justification to deny Soosan privileges. Defendant Michels further misled the MEC by arguing that failure to vote to extend privileges to Soosan would result in a successful lawsuit by Soosan against the MEC and Avera Sacred Heart Hospital.
91. Defendant Michels knew or should have known that overwhelming evidence existed to deny Soosan privileges.
92. Defendant Michels also knew that other hospitals had refused to extend Soosan privileges without being subject to a lawsuit.
93. Defendant Michels knew that Faith Regional Hospital forced Soosan out without being subject to a lawsuit.
94. In fact, Michels knew Soosan released Avera Sacred Heart Hospital from liability for “acts performed in good faith and without malice in connection with the gathering and release and exchange of information … in addition to any other applicable immunities provided by law for peer review activities.”
95. Nonetheless, Defendant Michels misled the MEC about the threat of a lawsuit to induce the MEC to change its position regarding Soosan and continued to withhold relevant and accurate information from the MEC during Soosan’s tenure [Bockholt et al. v. Sacred Heart et al., Civ 15-4106, complaint, U.S. District Court of South Dakota, filed 2015.06.05].
Why would Michels mislead his hospital’s medical executive board to employ a doctor with such a terrible record? Money. The plaintiffs allege that Avera Sacred Heart was losing money and brought Dr. Sossan on board because his specialty, spine surgery, offers big profits. Michels, the suit contends, “fraudulently induced the MEC into changing its position in order to improve the financial position of Avera Sacred Heart….”
The Bockholt plaintiffs would have a much easier time proving their case if they could access the peer review proceedings that led the two Yankton hospitals to admit Sossan to practice and led the state to license him. However, state law keeps such evidence secret from everyone except doctors defending themselves in court or checking into the decisions relating to their employment:
Proceedings of peer review committees confidential and privileged–Availability to physician subject of proceedings. The proceedings, records, reports, statements, minutes, or any other data whatsoever, of any committee described in § 36-4-42, relating to peer review activities defined in § 36-4-43, are not subject to discovery or disclosure under chapter 15-6 or any other provision of law, and are not admissible as evidence in any action of any kind in any court or arbitration forum, except as hereinafter provided. No person in attendance at any meeting of any committee described in § 36-4-42 is required to testify as to what transpired at such meeting. The prohibition relating to discovery of evidence does not apply to deny a physician access to or use of information upon which a decision regarding the person’s staff privileges or employment was based. The prohibition relating to discovery of evidence does not apply to deny any person or the person’s counsel in the defense of an action against that person access to the materials covered under this section [SDCL 36-4-26.1].
In addition to damages, the Bockholt plaintiffs ask the court to overturn this statute and others related to the peer review process as violations of the rights to a jury trial and due process.
* * *
In other legal notes, the Bockholt complaint contends that Michels and the other “employees, members, shareholders and agents” of Avera and Lewis & Clark are subject to the Hippocratic Oath. I’m not sure that Michels has ever actively recited those words or signed an employment document saying, “Yup, I’ll follow Hippocrates, too,” but I’d be curious to know if courts have previously taken the position that anyone working for or overseeing a hospital is subject to the oath. As we all know, oaths matter.
The complaint also lays out Sossan/Soosan’s sordid history. Before he became a doctor, Alan Abdali Soosan was convicted in 1982 of five counts of forgery, one count of issuing a forged check, and one count of grand theft. In 1983, he was convicted of felony burglary for stealing answers to a biology test at St. Petersburg Junior College. Soosan then took to spelling his name differently, as “Allen Sossan”, without ever legally changing his name. The complaint argues that Sossan/Soosan has thus been committing perjury in various lawsuits and applications for medical licenses in Nebraska, South Dakota, and elsewhere to hide his felony record.
The complaint goes on to discuss allegations that Sossan has falsified medical records, “maimed or mutilated” hundreds of patients with unnecessary surgery, threatened to kill a Yankton nurse anesthetist, and had sex with a medical device salesperson at work. All of those alleged crimes would have been prevented if medical boards and hospitals had held Sossan accountable for perjury and refused to trust him with patients.