Make Insurance Honest Again

A perverse, convoluted system exists in healthcare that enriches third party at the expense of the patient, the taxpayer, and the solvency of the U.S. economy. The scheme uses dishonest manipulation of the cost of providing medical goods and services, discriminatory taxation, selective government subsidy, entitlement programs, and complex laws of command and control that are created by politicians who are bought off by rich and powerful special interest groups.

Republicans campaigned on a pledge to repeal and replace Obamacare. The electorate responded to this promise, and Republicans now control the House, Senate and White House. So, what’s the hold up?

The hold up is that politicians won’t do what they promised the American people, because they succumb to pressure from special interest groups (insurance corporations and hospital associations) that benefit billions upon billions of dollars in a convoluted system of billing, subsidizing, and taxing to the point of insanity. These third party entities feed off a medico-industrial complex that consumes over $3.2 Trillion yearly. They want to keep their hands on this money. Individual patients and doctors have no power or money to influence politicians by comparison. We have lost the forest for the trees. The political forces are evil. They run ads against each other, make up lies about each other, and fund candidates to run against one another, if one doesn’t do what the “leadershop” says- and this is what they do to members of their own party!

In a recent WSJ piece, Daniel Henninger opined that the Freedom Caucus, led by Congressman Mark Meadows, was responsible for fracturing the Republican Party and delaying the leadership’s repeal of Obamacare- except there was never a “Repeal Obamacare” bill. There was only Paul Ryan’s American Healthcare Act (AHCA) bill- put together in conjunction with insurance executives and hospital association lobbyists, behind closed doors with physician Senator Rand Paul outside knocking to no avail, and thrust on the American people with no messaging, in a take it or leave it condescending fashion.

Ryancare, AKA Obamacare 2.0, would have led to another 15 to 20 percent increase in premiums at least according to the Congressional Budget Office, while leaving intact the expansive Obamacare insurance regulations that make insurance so expensive and creating yet another new government subsidy. It took away cuts to Disproportionate Share Hospitals (DSH payments) and granted billions to states, only to then force them to subsidize payments to insurers.

Contrary to Mr. Henninger’s premise, Congress Meadows and the Freedom Caucus should be applauded for refusing to support bad policy and broken promises and refusing to acquiesce to political threats. The so-called moderate “Tuesday Group” should be reprimanded for acquiescing to special interest and political pressure- including abandoning their campaign promises and principles- and deceiving Americans about the actual cost of medical care. But, playing the blame game helps nothing. The goal is to make medical care in America great- exceptional, accessible, and affordable- particularly in catastrophic circumstances. This requires we first make insurance affordable again, and to do this we must make insurance honest again.

One of the biggest deceptions of of all times is that the actual cost of medical care is so unfathomably expensive that no one can afford it without insurance. This myth is perpetuated by the insurance and hospital industries, because it is part of a perverse, convoluted, deceptive business plan. Understanding this scam is essential to calling it out and fixing it. Politicians decry huge hospital bills, and accordingly they claim they must support federal subsidies, Medicaid expansion, and even single payer, government-run medicine, recanting anecdotal tales of medical catastrophes where hospital bills mounted to such enormous sums that the patient would be bankrupt were it not for health insurance regulated and subsidized by the federal government. I recently heard a member of the Republican Tuesday group telling a personal story on Fox News where he tragically lost a child and would have been bankrupted by a million dollar hospital bill were it not for his health insurance, based on this he was unable to support repeal and replace of Obamacare. Let’s be honest, the million dollar “bill” is a scare tactic and a scarce occurrence. The entire system must not be aberrantly manipulated for the benefit of the outlier.

In reality, no one ever pays those huge bills. They are fake- fabricated and inflated to maximize profit for insurance companies and hospitals. A hospital can make the bill be whatever it wants it to be. There is even a term for the inflated bills- called the hospital chargemaster. Dr. Keith Smith at Surgery Center of Oklahoma has done a beautiful job of showing side by side comparisons of the cost of the same operation done in a hospital versus in his outpatient direct pay surgery center. These huge bills are rarely paid. In reality, as Dr. Smith shows over and over, the operation can be done at a fraction of the cost.

The insurance companies negotiate with the hospitals to pay a percentage of the bill or a flat fee for a specific operation. This is called an “allowable.” While the bill is huge, the allowable is drastically less. Further, the insurance company pays only a fraction of the allowable because, on top of the monthly premium, the patient pays a deductible and a percentage of the allowable, called cost-sharing. The insurance company also receives government subsidies.

Why does it behoove hospitals to overbill? By overbilling and then accepting a lower payment (the allowable) from the insurer, the hospital is able to report that it has sustained a loss from providing medical care to the patient, which it calls “uncompensated care.” The hospital then adds up the cost of all the uncompensated care it has provided and reports it to the federal government. The federal government then issues the hospital a check based in the amount of uncompensated care reported. This subsidy is called Disproportionate Share Hospital (DSH) payments. This led to the intentional inflation of bills. The more phantom uncompensated care a hospital reports, the more subsidy money it will get from the government. When this began, DSH payments escalated from $1.7 Billion to $17.3 Billion between 1990 and 1993 alone. Further, because the hospital reports these manufactured phantom losses for providing uncompensated care, they are deemed nonprofit and pay no taxes. This is how nonprofit hospitals become very rich, and this is another reason why they overbill patients. It also serves to scare patients to death when they get their “bill.” The bills are also extremely difficult to understand, as if by design, and they are rarely itemized. This is a sinister “marketing plan.”

My perfectly healthy 22 year old daughter was in a near fatal accident last year. My amazing physician and surgical colleagues saved her life. Her hospital bill for just under one week was just over $100,000.00. The insurance company paid the hospital the allowable- $40,000.00. (The hospital is actually making a profit at this negotiated rate.)The hospital can claim $60,000 in uncompensated care and receive DSH money from the government. The hospital pays no taxes on all this money, because it is deemed nonprofit. My daughter paid her $3,000.00 deductible on top of $1200.00 each month in premiums, for a total of $17,400.00 last year, which means the insurance company actually paid the hospital only $22,600.00 of the $100,000.00 bill. In her prior 22 years of life she never had a claim, so the insurance company is still way ahead. Had we been uninsured, the hospital would have billed us the full $100,000.00, but knowing what I know, I would have tried to negotiate the bill down to the Medicare rate and may have saved more money than the allowable negotiated by my insurance company. An uninsured patient should never just pay the falsely inflated hospital chargemaster bill, nor should the patient be frightened by the bill.

If she had purchased a plan with a lower monthly premium, her deductible and cost-sharing would have been higher. It all comes out about the same. The insurance actuarials and accountants make sure of that. And, under Obamacare, if they’re off, taxpayers will subsidize them. (Recall Obama’s decision to do this using taxpayer money, even though the money is not allocated in the law. A lawsuit is ongoing.)

The billing vs. allowable scheme is also why there is no price transparency. It is nearly impossible to find out the cost of goods and services-except under the new, third party free, direct patient care models. Each insurance company has negotiated a different allowable with each hospital and provider for each patient depending on the benefits of their plan. All that people can see is the inflated chargemaster bill at best.

This is like the federal government forcing you to pay an extra $1200.00 every month for auto insurance in case you wreck your car badly. If you wreck your car, you have no choice, you can only go to one body shop and it takes months to get in and then months for the work to be “prior authorized.” You and your family wait and suffer without your car, but they don’t care. Then the body shop bills you $100,000.00 to fix it, but accepts a $3000.00 payment from you and $37,000.00 from the insurer, for which you have paid $1200.00 per month for years. In fact, if you have paid this premium for just 2 and a half years, you have already paid the entire bill yourself. With Obamacare you are forced to buy the bad wreck insurance and pay every month. Even if you don’t wreck your car, you lose the money at the end of the year. There is a better way!

We must force our politicians to stop selling out to 3rd party parasitic special interest groups like the insurance and hospital lobbies. We must demand partisan players stop threatening one another for standing by their word. We must demand transparent pricing and allow free market competition. We must cut DSH payments for “uncompensated care” to hospitals. We must stop the fraudulent hospital chargemaster overbilling scheme. We must stop subsidizing insurance companies. We must not create a new subsidy that gives money to the States and then requires states to pay the insurance companies. We must stop preferential tax law that taxes working class patients and exempts rich hospitals. We must end the corruption-which can only be construed as theft from America’s patients and taxpayers.

We must allow people to put pre-tax dollars into health savings accounts to save for a catastrophic medical issue, instead of being forced to pay huge premiums to insurance companies, which are lost at the end of every year. Patients will be responsible custodians of their own money. States can establish high risk for the seriously and chronically ill. We must get rid of minimal essential benefits and other regulations on insurers, allowing them to innovate and create a robust offering of plans, and we must allow patients to buy individualized plans that best suit their individual needs. If patients can buy plans they like, pre tax, at a low cost, from an early age, they will build up a safety pot of money in their HSA should a crisis come, and they will have no reason to go without insurance. This will virtually eliminate problems with preexisting conditions and guaranteed issue. We must reform government medicine, Medicare, Medicaid, and the VA , freeing these hundreds of millions of patients to choose doctors, hospitals, and insurance plans they want.

 

Let’s be honest, only by calling out and stopping the inflated billable charge vs. allowable charge/ tax exemption and subsidy scam can we address the core problem- the high cost of care. Only by fixing the corrupt system that incentivizes 3rd party special interest groups to overbill patients can we reclaim money and power from politicians, insurance corporations, and hospitals and return it to the patients. We must demand our politicians stop perpetuating the false system and go forward with an honest transparent system of actual insurance-not prepaid healthcare sold like used cars by members of the mob. We must stand up for the good guys and call baloney on the others. The only person with the position, power, principles and pluck to do this is President Donald J. Trump. We must support him. We must oppose others. The time to repeal Obamacare and make insurance honest again is now.

TEXAS!Say NO To Interstate Medical Licensure Compact Bill in Texas, HB3040 and SB315

April 5, 2017

 

Dear Senators and Representatives of Texas,

 

The Federation of State Medical Boards (FSMB) posts its address as 400 Fuller Wiser Road Euless, TX 76039 and 1300 Connecticut Avenue, NW Suite 500 Washington, D.C. 20036. This Federation states its purpose as protecting the public through licensure and regulation and makes its money through licensure and regulation of medical professionals. Currently, physicians receive their license to practice medicine from the State of Texas. The regulation and discipline of physicians is under the auspices of the Texas Medical Board (TMB). The FSMB has been aggressively pursuing Texas, through the TMB, to join the Interstate Medical Licensure Compact designed by the FSMB, and if HB3040 and SB315 pass, Texas will become a part of this alliance. Reportedly, there is a lot of power behind these bills, including the support of the TMA.

 

Interestingly, Humayun Chaudhry, D.O. a former New York Health Commissioner and President/CEO of the FSMB, is now the Chair of the International Association of Medical Regulatory Authorities (IAMRA). According to Dr. Chaudhry, IAMRA was put together by the FSMB in the 1990’s, so everyone around the world can share “best practices” and “continued competence of physicians.” Describing themselves as “globally inclusive”, they even have a working group currently working on finding the best way to exchange information about physicians among medical regulatory authorities internationally. Dr. Chaudhry boasts of IAMRA’s regulation authorities in 46 countries and even says they are pursuing associating with China, among other such countries. The FSMB is also proud of its journal, The Journal of Medical Regulation, its pursuit of Maintenance of Licensure efforts, and its services including credentialing, regulating, and disciplinary alert services of and about physicians (all of which make lots of money for this private entity and its leaders-on the backs of the patients and physicians of Texas.) The FSMB is certified by the National Committee for Quality Assurance (NCQA), a powerful agency intertwined in the Affordable Care Act, and is affiliated with largely progressive, left-leaning, federal government-centric/loving entities and people- and if Dr. Chaudhry’s dream comes true as he articulates, soon it will be associated with China.

 

Dear Texas, my beloved Lone Star State, what in the world are we doing affiliating with such an entity. Please, maintain our sovereignty and retain the power to license, regulate, and discipline our State’s physicians solely to the State of Texas. Do not relinquish or diminish this critical power by affiliating with and empowering such a private, non-profit organization. There is absolutely nothing to gain from this alliance and everything to lose. When the number of patients needing medical care and the cost of providing medical care is skyrocketing amidst a looming and growing physician shortage, why would we complicate the process and inflate the cost of physician licensure? What do we have to gain by comingling with other states and countries as envisioned by the FSMB visionary and now IAMRA Chair, Dr. Chaudhry. I encourage you to investigate the finances and conflicts of interests of such groups, their stakeholders, and more importantly, the associated moral hazard. I for one, as a Texas physician, will need more than a little guarantee of protection of my right of conscience and protection from the corporate and global practice of medicine. China, with its one child policy, and the ABIM (American Board of Internal Medicine), with its recent financial indiscretions and physician abuses related to Maintenance of Certification testing-for-profit schemes, serve as prime examples of the slippery slope to which I am referring.

 

I implore our esteemed State legislators to reject siding with the Federation of State Medical Boards. Please, remove any wording related to FSMB, its Interstate Medical Licensure Compact, and the largely unaccountable Interstate Medical Licensure Commission, from HB3040 an SB315. We have done and will continue to do well by the people of Texas without such potentially destructive, abusive, punitive, expensive, and morally hazardous association with the FSMB.

 

Respectfully,

 

Kristin S. Held, M.D.

325 Sonterra Blvd, Suite 100

San Antonio, Texas 78258

 

Urgent Letter to Members of Congress to Implore Them To Reject RINOCARE/Obamacare 2.0.

I will be sending this to Members of Congress tomorrow. Please call or write members of Congress ASAP.

March 21, 2017

 

Dear Congressman/Congresswoman,

 

You were elected on a promise to repeal and replace Obamacare. If you vote “yes” on the GOP healthcare bill Thursday, you will fail to uphold your promise. I have read the bill word for word. Have you read it? I have also read the ACA, MACRA, the MACRA rules, and much more healthcare law ad nauseum word for word. Have you? The AHCA makes horrible things worse. I pray you will stand up for what is right and for what you promised, instead of acquiescing to pressure from those who represent selfish interests against the will of the American people. The bill is clearly written to appease, if not reward, big healthcare insurance executives, big hospital interests, and the Left. Why?

The healthcare debacle is extraordinarily complex; I doubt most politicians even understand a fraction of it. I implore you to pause and seek counsel from physicians and patients like me who live and work in the trenches under the shackles of bad healthcare law. I am sick and tired of hearing about sausage making and half a loaf. I long for strong leaders, statesmen who will do what it takes to achieve the exceptional, the ultimate goal, and honor their word- not settle for 2 steps back, enabling the perpetual tantrum of adolescents who throw stones from safe spaces seeking to destroy what our Founders created, as they wallow in relative truth, suckling on the government teat of dependency.

 

In addition to all the talking points fed to you, here are 3 things I gleaned from reading this bill and prior law for myself that make terrible law worse, that no one is discussing- that you will be responsible for if you vote “yes” instead of innovating, thinking outside the box, and crafting transformative, healing legislation that achieves repeal, as you promised.

 

  1. SEC. 113 Eliminates DSH cuts: The hospital and insurance interests must love this. It will bankrupt us and make healthcare costs explode, as history proved when unlimited DSH payments and financing flexibility increased DSH spending from $1.3 Billion in 1990 to $17.7 Billion in 1992. Thus, DSH cuts were implemented. Eliminating DSH cuts now will accordingly result in a 10-fold increase in government spending if we look at recent history. DSH stands for Disproportionate Share Hospital. Hospitals receive money from the federal government for providing “uncompensated care“ to Medicaid and other underprivileged patients. Such allocation of federal money applies to the cost of inpatient and outpatient care. It financially behooves hospitals and healthcare entities to artificially inflate their bills and then accept a lesser sum of money from an insurance issuer or patient to make the claim that they are providing uncompensated care and justify receiving ever-increasing sums of federal (taxpayer money). This results in the institutionalization of such bogus practices as the Chargemaster bill and lack of transparency. What we need is transparent pricing across the board and a law that fosters price transparency not massive price inflation.

 

  1. SEC. 2203 and 2204 will similarly result in artificially manufactured overbilling, lack of transparency, and increased transfer of taxpayer money to hospitals and insurance companies. Between 2018 and 2026 the federal government will appropriate $100 Billion dollars to the States and require them to pay issuers all claims that exceed $50,000 but do not exceed $350,000. It doesn’t take a genius to foresee the explosion of “bills” that will be miraculously amount to $50,000.01 and require payment from the State using federal (taxpayer) money under the pretense of “market stabilization.” In reality, no one ever pays the “bill.” “Allowables” are negotiated by insurance companies and accepted. This elimination of DSH cuts mentioned above will result in massive skyrocketing of bills, which is incentivized by the repeal of DSH cuts and forced payment of high claims to issuers by States using federal money. The hospitals and insurance companies will gluttonously consume increasing federal funds until they are all gone- and then what. Patients will be left high and dry- broke without care. Again, we need policy that fosters cost transparency and lowest cost to patient, not what this law does. This law rewards what could be construed as collusion and money laundering.

 

  1. Subtitle ___ Remuneration From Certain Insurers- This seems to me to be a bone thrown to insurance executives. (AKA a massive, flagrant personal multimillion-dollar payoff). It terminates the limitation on deduction of remuneration for taxable year exceeding $1 Million for the top 5 earners of publicly held health care insurance corporations, like the CEO, etc. Translation, under this bill, they CAN deduct huge remuneration packages. What do you think? Read it-it takes awhile pulling all the references –section 162(m) of the Internal revenue Code of 1986.

 

 

There is so much more that is bad, but while I have devoted the time to read this, most will not take the time to even read what I’ve written here. This is your job. You ran for it and were elected to do it faithfully. I just want to take care of my patients and have my doctors take care of me without such sinister, wasteful government and special interest intrusion.

 

Please, stop the insanity. Take a deep breath. Do the right thing, and do what you promised. Save the American patient and the United States of America. We can and must do better.

 

Sincerely,

Kristin S. Held, M.D.

San Antonio, Texas

 

Letter to HHS Secretary Price and “Healthcare Insurance” Company CEO Regarding Inept,Dubious Business Practices that Can Be Construed as Violation of False Claims Act, Breach of Contract, and Flagrant Theft of Patients’ and Government Payments to Their Company.

I have yet to receive a response to this letter, and the patient still has not been reimbursed by his insurance issuer (7 months after the surgery); therefore, I am presently redacting the company name. It is one of the big remaining few companies, to whom I have written before. Patients and physicians are acting in good faith. Insurance companies cuddling in bed with big government are preying on our calling and goodwill, as they laugh all the way to the bank operating per a business model that combines the ineptness of the Three Stooges and moral code of a sponge.

March 1, 2017

Dear Secretary Price and Mr. _________,

With continued dismay, I seek your attention to resolve a serious matter where government healthcare law and commercial insurance company practice collide once again to harm my patient. Ironically, we have come to the point where the patient, for whom healthcare laws and insurance companies were created, is now the last one helped and first one hurt, as if an annoying afterthought in a convoluted web of third party misplaced priority and moral inversion.

My patient is a 71 year old gentleman who suffered from decreased vision due to cataracts in both eyes. He has had 5 cardiac stents placed and is on blood thinners. I successfully performed laser cataract surgery with placement of a toric intraocular lens in each of his eyes (08/18/2016 and 08/25/2016), and thankfully he now sees 20/20 in each eye without glasses. His suffering has been alleviated, his quality of life improved, and his ability to perform his activities of daily living with continued independence markedly enhanced. Sadly, your health insurance company refuses to cover the cost of my surgical fee in what could potentially be construed as a pattern of misrepresentation and errant billing.

The patient pays for coverage under the _____ Teacher Retirement System of Texas. I am an out of network provider for TRS, and my status with Medicare is classified as “private contracted” or “opted out.” In other words, my agreement is directly with my patient, and I have no agreement with _____. In fact, neither the patient nor I can submit a claim directly to Medicare or a supplement plan. ____, on the other hand, as a commercial replacement plan, has an agreement with my patient who pays monthly premiums for promised coverage. _____ TRS serves as a Medicare replacement plan and has an agreement with CMS for which it accepts federal funds to pay for services for Medicare patients. While I have honored my agreement with my patient, _____ has not upheld its agreement with its client or the federal government; in other words, _____ is breaching its contract with its client and the federal government. _____’s stated negotiated amount of coverage for the surgeon fee for cataract surgery is $618.81. _____ refuses to reimburse their client (my patient) for this amount for each eye. Initially, _____, made a mistake and processed the claim as if I was an “in network” surgeon. Subsequently, (after the patient has already had the operation and come out of pocket) _____ is refusing to reimburse the patient. _____’s own Benefit Detail states 100% coverage for “in network” and “out of network” specialists. The patient opted for _____ as a replacement plan in lieu of traditional Medicare but is now denied reimbursement for services received from an “out of network” provider. One must ask: What has the patient been paying his monthly premiums for, and what has _____ been doing with the money it receives from the federal government?

Neither commercial insurers nor Medicare covers laser use during cataract surgery or toric intraocular lenses. Intraoperative use of such advanced technology is an instance where balance billing is the correct, legal standard of practice and billing. Had my patient gone to a “participating” Medicare surgeon, the overall fees would have been dramatically higher. As a third party free surgeon, my fees are transparent and significantly lower, saving the patient and the healthcare system at large a substantial amount of money. The patient should be commended for using such a practice- not denied coverage. _____ must reimburse the patient the negotiated $618.81 per its negotiated rate for each eye for a total of $1237.62 plus the cost of the initial examination and preoperative consultation and measurements ($135.00, $103.42, $79.54 totaling $317.96) for an overall reimbursement due of $1555.58.

The time and resources required by the physician and her staff to help the patient fight for his due from _____ is enormous and usurious. _____ willingly takes money from the patient and federal government but then fails to fulfill its agreements to pay negotiated rates to those whose services they advertise to sell. Such patterns of errant billing and denial of payment suggest either an overall ineptness (further encumbering a flailing healthcare system with 3rd party waste of resources) or a dubious underlying business plan that seeks to profit from an intentionally convoluted, prolonged, and cumbersome process of prior authorization and denial of claims. This could be perceived as a violation of the false claims act, breach of contract, as well as flagrant theft.

I look forward to resolving this issue expediently. The patient must come first. I look forward to positive solutions and clarification under Secretary Price. I await your timely response and reimbursement of your client.

Sincerely,

Kristin S. Held, M.D.

Fight the MAL-bots(Mindless-Alt-Left Bots) or succumb to moral inversion

Like my father before me and two daughters after, I am a physician. We took the Hippocratic Oath. We work to heal our patients and stop their hurting, to help people live longer, better quality lives, to delay death and alleviate suffering when death comes, and to do no harm.

In an extreme state of moral inversion, we are attacked for our beliefs, our defense of the patient-physician relationship, and putting the best interest of the individual patient before the demands of big government. We are increasingly mischaracterized by attackers wearing masks of political correctness, who profess to be tolerant. These hateful, angry agitators seek us out, engage us, and instigate the same nonsensical arguments over and over, as if reading from a list of talking points intended to advance a perverted agenda and drive our behavior. I call the attackers Mindless-Alt-Left bots (MAL-bots). They work to oppress and silence us. They play on our innate calling and exploit the fact that we will are servers, pleasers, and non-confrontational by nature. At first it worked.

MAL-bots seek out doctors who believe in God. They launch into the tired old “how can you call yourself a doctor if you believe in magic not science” mantra and threaten to blacklist us publically, as if that will make us denounce our belief in God and join them in atheism. Early on, I naively thought a MAL-bot who engaged and attacked me for my religious beliefs, was reaching out to learn more about faith, forgiveness, and salvation. I was wrong, and he hurled horrific ad hominen attacks, replete with vile profanity and misogynistic verbal abuse. The interchange is too repugnant to share. In spite of what MAL-bots claim, most physicians do believe in God. Reasoning with such MAL-Bots, however, is futile. The only course of action is disengagement.

The next line of attacks is launched when MAL-bots detect that a physician is pro-life. In spite of what MAL-bots claim, most physicians are pro-life and do not perform abortions. Following a tweet that revealed my pro-life belief, out of the blue, I received a horrible tweet. I was deeply affected by it and ashamed to show anyone, as if I deserved it. But I will not let such abuse silence me any longer. Here is the tweet:nasty-tweet

I replied that I am also vehemently opposed to rape and suggested Fever Phil focus his aggressive efforts on opposing rape of women in the first place in lieu of engaging and attacking women doctors like me. The hypocrisy is stifling.

A third line of attacks comes when I say I put the patient first, defend the sacred patient-physician relationship, and reject the big government takeover of medicine, replete with its mandates, violation of privacy, and deciding who lives and who dies. While I am one of a rare few who actually reads the healthcare laws and their rules-I am often accused by MAL-bots of making them up and called “unorthodox” and “fringe” for wanting to do “all for the patient.” Sadly, movements are underway to get rid of the Hippocratic Oath. Even the AMA is rewriting its code of ethics. On February 13, 2017, two top stories featured in Medscape Business of Medicine (a government subsidized online publication) were “In Defense of Physician-Assisted Dying” and “Is it Time to Retire the Hippocratic Oath?”

A fourth wave of attacks comes when I reject government mandates and oppose physician- assisted-suicide. While I personally receive and recommend vaccinations to patients and family, I believe we must be wary of unchecked government mandate forcing people at threat of retribution, against their will, to receive any and every new vaccine, medication, or treatment a company could possibly produce or a government could possibly order. In ultimate irony, the very MAL-bots who fight for “pro-choice” with a vengeance, claiming to be fighting for women to have control over our bodies, attack me for standing up to government-mandated everything, in favor of patient choice and informed consent. These MAL-bots also fight for physician-assisted-suicide, that is, making it legal for physicians to prescribe lethal doses of medication to their patients to be used to kill themselves (MAL-bots justifying their desire for legalization as “to respect patient choice.”) While physicians, of course, must prescribe patients medications to alleviate their pain and suffering, I choose not to prescribe lethal doses of medications to my patients. (Physician-assisted-suicide is the ultimate defiling of the patient –physician relationship.)

The MAL-bots don’t want you to choose God, life, or what medical treatment you choose to have or not to have as a patient, or to do or not to do as a physician, but they do want you to choose abortion, physician assisted suicide, and to do what big government says- the items on their agenda.

The moral inversion is blinding. There is no morality, common sense, or sanity with the MAL-bots. They are not just wrong; they are evil. Don’t waste time trying to reason with them. Call them out. Play offense. Fight to win for your patients and principles.

Such MAL-bots remind me of what the Democrats are doing to the new Trump administration. They are the same ones who agitate, divide, burn, march, and wear their genitals on their heads. They are not just destructive; they are fools. Trump and his administration must not kowtow to them or be intimidated by them. The American people must pray for our leaders to be be empowered not oppressed, emboldened not silenced. We must stand up together for good, in truth, and in pursuit of life, liberty, sanity, and humanity.

Fix the medical bill mess

We the people of the United States of America desperately need a leader who possesses common sense, business savvy, and commitment to make America great. I’m a patient and physician who lives in the trenches of real life medicine and sees first hand the casualties of the government assault on America’s patients, physicians, the patient- physician relationship, our code of medical ethics, and the U.S. economy. The Affordable Care Act (Obamacare) and the Medicare Access and CHIP Reauthorization Act (MACRA) are massive government redistribution schemes and power grabs that rob patients of their choice of doctors, health plans, and individualized treatment, rob physicians of their autonomy to freely care for patients, and rob taxpayers of $3 Trillion per year, most of which is irresponsibly squandered in a cesspool of administrative incompetence and political pay-to-play, best called money-laundering, as political elites, special interests, and their lobbyists prey on our very lives. Rare few- patients, physicians, politicians, administrators, and bureaucrats included- even understand what is going on. Architects of these laws intentionally made them extremely convoluted in order to “slip one over on us”, the American people who they regard as “stupid,” as espoused by Obamacare architect Jonathan Gruber. Bad law is layered upon bad law and confounded by out-of-control agency rule-making. This must end.

Personally, as a physician, current healthcare law makes it ethically untenable for me to comply and makes it increasingly difficult to even stay in business. I have severed all ties with third party insurance companies and have opted out of Medicare choosing instead to serve my patients directly. At the peak of my career, I could be caring for substantially more patients, but federal laws, rules, and regulations restrict my ability to practice medicine, my life’s calling that required 12 additional years of arduous education and training after high school. What a waste of time, resources, and lives. As a patient, my insurance premiums, deductible, copay, cost sharing and medications are exorbitantly more expensive, while my visits to my doctors (those who have not left medicine altogether) are impersonal, short, and consumed with nonsensical electronic health record data gathering and reporting.

Here is an example of something that can and must be fixed.

A fifty-something year old patient sustained a retinal detachment, which was successfully repaired in a hospital outpatient department. He thought he had signed up for Healthy Indiana, his state’s Obamacare plan, but can’t find any information from anyone about his benefits or status, much less has he been able to communicate with anyone. So, the hospital deemed him uninsured, sent him a bill, and gave him a 40% “self-pay” discount. The bill he received from the hospital outpatient surgical facility alone was $103,336.96, which was discounted $41,334.18, for an adjusted payment of $62,002.18. This is beyond outrageous. That the hospital accounting department sent this to the patient with so many obvious mistakes and inflated charges is evidence of a systemic lack of understanding and rampant incompetence.

I volunteered to review the bill for the patient. First off, the patient was charged for 54 half hours of surgery ($74,844.00) instead of 5.4 half hours ($7,484.40)- accounting for an overcharge of $67,359.60. This correction immediately brought the bill down to $35,977.36, which leaves the patient responsible for $21,586.42 after the 40% discount is applied. In addition to the hospital’s facility fee, the surgeon billed $2739.93, and the anesthesiologist billed $2565.00. All in, the patient now owes $26,891.35. Medicare would have paid around $2000.00 to an Ambulatory Surgery Center facility, and commercial insurance allowables vary from $2000.00 to $4000.00.

Had the patient had his retinal detachment surgery performed at an ambulatory surgery center instead of a hospital outpatient department, the facility would have accepted an insurance allowable of between $1800.00 and $4000.00 ( a private physician can negotiate even lower transparent fees for uninsured patients or patients whose deductibles are prohibitively costly) while a retina surgeon would charge $1800.00 and an anesthesiologist around $1500.00, for a total of between $5000.00 to $7000.00- 20-25% of the cost in this case.

A few charges stand out on the itemized hospital bill and exemplify more of what is wrong with the system. Povidine-Iodine 5% solution is used to clean the eye prior to surgery. The hospital charged $1502.64 for a 30 ml bottle of this, times 2 bottles, totaling $3005.28; we purchase this exact product in this size for $6.05 at our Ambulatory Surgical Center (ASC), times 2, for a total of $12.10. The hospital charged $688.40 for a 3 ml bottle of Moxifloxacin ophthalmic eyedrops, (times 2 bottles for a total of $1376.80) which we purchase for $149.00 at our ASC. Every item on the hospital bill is usuriously inflated in this fashion.

Why does the hospital artificially inflate the bill to this extent and then accept a fraction from the self-pay patient, an insurance company allowable, or Medicare allowable? ($30,000 compared to somewhere between $2000 and $4000.) Because, in effect, they are fabricating losses, which they can then report to the government as having provided a vast amount of uncompensated care, for which they receive credit, and maintain a non-profit status. In this case alone, if the patient ultimately pays $4000 instead of the $35,977.36, the hospital will report that it provided $31,997.36 in uncompensated care, will stay non-profit and pay no tax. And then there’s the hospital-big insurance-big pharma cartel, that inflates prices to line each of their own respective pockets.

I suggest this “self-pay” patient aggressively pursue his status with Healthy Indiana- if he has been paying premiums, the insurer must deliver. If it turns out he does not have benefits (the ineptness of the exchanges, enrolling, and staying enrolled, is another story), he should negotiate with the hospital and his doctors. Perhaps $3000.00 would satisfy the hospital, $1800.00 for the surgeon, and $1200.00 for the anesthesiologist for a total of $6000.00- a far cry from $26,891.35.

This convoluted system can and must be fixed. We must educate ourselves about the way insurance works and the way the “bill” relates to the “allowable” or discounted rate. Then we must make wise choices. Choose facilities and doctors who have transparent, fair, reasonable fees and work with them directly, outside of 3rd party agreements. Change the perverse tax code that rewards hospitals with a nonprofit status for alarming and abusing patients with falsely inflated bills. Fix bad policy that allows hospitals to be paid more than ASC’s for doing the same work. Be your own best advocate. Read and understand medical bills and address problems with your physicians.

Fixing the mess starts with electing leaders who have common sense and business sense, and who understand healthcare law and will work tirelessly to repeal and replace Obamacare and repeal MACRA. Yes, we can fix this. And we must. Vote accordingly.

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Third Party Free, But Still Having to Fight For My Patients. UGH.

August 26, 2016

Dear Aetna Claims Department,

I do not have a provider agreement with you. Our agreement was severed in 2014 after a prolonged period of your company refusing to honor my request to terminate this relationship. I continue to see my patients who purchase coverage from you. They pay me at the time I provide their care, and then they submit claims to you for my services as an out of network provider. This is the second time you have sent me a check. I am concerned about the competency and accuracy of your claim processing. If this is happening to my patients and me, what does this mean for your entire client population?

The last time this happened, I returned the check you issued to me to you, and you then appropriately issued a check to the patient, who is your client with whom you have a contractual agreement. Sadly, I have no way to confirm the patient ever received the check from you. Often patients and physicians just give up during a prolonged, convoluted, and inaccurate claims process, which makes us wonder, is this accidental error or part of a business model?

This time, the patient is due $73.14 from you, but you sent the check to me. I am sympathetic to the patient that is due the money and harmed by the delay. So, I will write the patient a check and deposit the check you erroneously sent me. This time you have no way to know if I in turn forwarded the payment to your client, my patient. Fortunately, the patient-physician relationship is based on trust, personal communication, and competency. As a physician, I serve my patient first. That is my business model. The check will be sent to the patient today accompanied by a copy of this letter.

I will keep documentation of all this, because I do not trust that it will be accurately depicted on your end, and I need to protect my patient and my practice from you trying to claw back the payment in the future or accuse my practice of fraud- as the burden of proof falls on the physician now.

The amount of money misallocated by your company is something that may need to be investigated and improved upon. Perhaps, it is the insurance company that needs the quality/value rubric set forth by government’s MACRA, not the physician. Perhaps our patients would be better served if we worked together for the patient, not for the government.

We can and must do better.

Sincerely,

Kristin S. Held, M.D.