The Scarlet Zero- MACRA’s MIPS Completes Government Takeover of Medicine

When Medicare and Medicaid were created, the government promised not to interfere in the practice of medicine whatsoever. President Lyndon Johnson signed the Act into law on July 30, 1965, ironically in Independence, MO. The Act established Medicare, a health insurance program for the elderly, and Medicaid, a health insurance program for the poor.


Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer, or employee, or any institution, agency or person providing health care services… or to exercise any supervision or control over the administration or operation of any such [health-care] institution, agency, or person. Section 1801, Medicare Act, 1965


Fifty years later, in flagrant violation of this prohibition clause, stands the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), replete with the Merit-Based Incentive Payment System (MIPS). MIPS is a rubric the federal government uses to grade physicians and assign each a score of 0 to 100. The Composite Performance Score (CPS) is used to financially incentivize or penalize physicians, and then the scores are posted on a public website for all to see. I contend MIPS constitutes deliberate government extortion of our nation’s physician, and at the core lies the ultimate conflict of interest- the very lives and well-being of America’s patients vs. the money and power of the medico-industrial complex run by a small group of insider elites, implemented and micro managed by entrenched, faceless deep state bureaucrats. At the heart of the matter, begs the question of physicians, who do you serve? Are you a physician in the tradition of Hippocrates, who believed the physician works on behalf of the patient, not for the good of the state, or are you a physician like Plato, who urged that doctors refrain from curing the weak and infirm to improve society? Do you serve the patient or the state?


I further contend that implementing and complying with MIPS is ethically untenable for those who sacrifice and devote our lives to serving patients, and that physicians who do engage in MIPS either don’t understand it or are forsaking their virtue and morality under threat of bankruptcy and continued abuse from an over-aggressive government no longer controlled by the people but by a powerful cartel of self-serving third party bosses.


MIPS consists of four categories upon which physician are graded: quality (outcomes), advancing care information, improvement activities, and cost. Earning a high score often requires doing what government says instead of what is best for the patient. Doing what is best for the patient often results in a low score, loss of income, and public humiliation on the public website.


  1. While this sounds great, the “quality indicators” and “outcome measures” chosen may be harmful for patients or deter physicians from taking on the most difficult and challenging patients. For example, one measure of outcome is how many patients under a physicians’ care achieve a blood glucose level under a certain number. One of my patients told me she has passed out twice, sustaining injuries, since her PA put her on two diabetic medications to get her blood sugar below the government number. Imagine if she had been driving or been alone at home in her bathtub. She stopped taking the medications and has yet to return to her physician for care. Since I have refused to participate in MIPS and the likes, I am “out of network” for all insurance plans including Medicare and Medicaid. Ironically, I am seeing an influx of patients with what I call “3rd world cataracts” seeking my care. One that comes to mind could see light only when he sought my care. He is 60 years old with severe cardiovascular disease that presents a higher than normal surgical risk, but his quality of life is unnecessarily negatively impacted because he can only see light, not even hand motion. I did what was best for the patient, operated on him, and he is now 20/20. The surgery was more difficult, because in the government medicine shuffle with the risk of a poor outcome, he had been avoided by several surgeons trying to play the MIPS game to the point his cataracts were like granite rocks floating in bags of milk, making visibility and removal difficult. The physicians earning the highest “quality” or “outcomes” score might be inflicting undue danger on their patients or avoiding the most difficult, sickest, weakest patients altogether.
  2. Advancing Care Information (ACI). This used to be called “Meaningful Use Electronic Health Records”, but Advancing Care Information sounds so much friendlier that MACRA changed the term in Orwellian fashion. MACRA sets law and rules in motion that mandate that government have full, unblocked access to patients’ records, including their protected health information (PHI) without their permission. PHI includes all personal identifying data including all demographics and all medical history, past and present, including all medications ever taken. This is not just a violation of the Hippocratic Oath and sacrosanct patient-physician relationship, but this is a blatant violation of the 4th Amendment. Government will gather all data, not just MIPS data, on all patients, not just Medicare patients, and from all insurers- commercial too, not just Medicare. This data will be sold by government to entities the federal government itself chooses. On a personal note, when I was hospitalized after breast cancer surgery in 2012, an elderly male patient’s medication list was errantly entered into my electronic health record. Had I not been a physician, the error could have gone unnoticed, and I could have been severely injured if not killed. EHR’s have been implemented at warp speed without proper testing. Those seeking high MIPS scores facilitate this, thus, endangering patients and violating their rights. I believe it is my duty to keep my patients’ private information from government not transmit it to government.
  3. Improvement Activities. This is a sneaky one. This is a category where government hopes to, in their own words, “drive physician behavior,” like by having us engage in “education” activities that government deems important- like learning about the emerging “palliative care” movement, replete with educational material glorifying “aid in dying”- formerly know as “physician assisted suicide,” the little sister of euthanasia. This also links the Maintenance of Certification (MOC) issue to government scoring, and financial penalty or reward, and is the mechanism for control of physicians by hospitals, insurance companies, and groups working toward nationalized, if not international, medical licensure.
  4. Formerly known as Resource Use, this category is beyond worrisome. The sample grade chart itself shows that physicians who spend the most on their patients get 0 to 2 points while those that spend the least get 8 to 10 points. In other words, doctors get more money for withholding care and resources from patients and are penalized for delivering care and resources. Need I say more?


There can be no denying, MIPS is a top down, command and control grading system based on perverse incentives whereby government rewards physicians who do government bidding and penalizes physicians who serve their patients first. MIPS is more like a Marxist grading system used by China on their citizens than a grading system imposed on America’s physicians. Don’t shrug and think this doesn’t affect you. To make matters worse, government has redefined the definition of physician to include everyone from audiologists, dieticians, and speech pathologists to Nurse practitioners, Physicians Assistants, Nurse Midwives, clinical nurse specialists, psychologists, and so on. We are all now lumped into a group called “Eligible Clinicians” or “Eligible Professionals”- that subjects virtually everyone at all associated with health care to MACRA and its perverse MIPS. Read the law for yourself.


In the fifty years since Government vowed not to interfere with medicine whatsoever, government has completely taken us over. It is no wonder physician suicide is epidemic and life expectancy in the US is not increasing, but declining for the first time in history. Ask yourself; do you serve the patient or the state? Do not violate your oath, your ethics, and your conscience to get a higher Composite Performance Score and a positive payment modifier- AKA a payoff. I don’t know whether this is extortion, bribery or both, but I do know- I won’t do it. And neither should you. If physicians would not comply, this perverse system would die. Patients can help by understanding what is going on and realizing that physicians with the highest scores may not necessarily have their best interests in mind, while those of us who refuse to play this most dangerous game wear our Scarlet Zeroes proudly and deserve a second look rather than a premeditated shun.


Insane Healthcare Laws Like MACRA Must Be Dethroned Not Enshrined

The more I read federal healthcare law and the rules promulgated thereof, the more I realize how insane the law is and how bizarre it is that we the people dutifully implement and comply with the insanity. I first read the Medicare Access and CHIP Reauthorization Act (MACRA) just after the House of Representatives passed it in March of 2015. I tried to alert the public and stop the Senate from passing it. Only eight Senators had the wisdom and fortitude to vote against it. I then read and dissented to the proposed MACRA rule and went so far as to travel to DC to personally meet with then head of CMS (formerly Executive VP of United Optum), Andy Slavitt, to point out the dangers and suggest solutions. While professing to listen, hear, and modify the rule accordingly, the CMS bureaucrats made revisions to the proposed rule that did virtually nothing but provide lip service to the people and cover to the most egregious, transformational law in US history.


MACRA’s Merit Based Incentive Payment System (MIPS) is a top down totalitarian, Chinese-government-style rubric crafted by progressive politicians of both parties and applied by progressive bureaucrats of the deep state to all physicians and patients of America in a one-size-fits-all fashion. It is the template for the transformation to socialized medicine, replete with assigning scores from 0 to 100 in grade-school and Communist-China fashion to individual Americans in association with monetary rewards and penalties based on how obediently “eligible professionals” dole out limited amounts of government approved medical goods and services to “beneficiaries.”


CMS acknowledged per the government’s own analysis, that MACRA will harm small medical practices and put them out of business in short order. The infamous Table 64 from the original proposed rule projected that 87% of “Eligible Clinicians” who are solo practitioners will receive a negative payment adjustment, as will 70% of those in practices of two to nine physicians. Combined, 73% of physicians in practices with fewer that 25 physicians and 60% of all eligible clinicians in groups of less than 100 will be penalized with a cut in payments. Loss of these practices will shatter care. According to the Texas Medical Association (TMA), more than 60% of Texas physicians practice in groups of one to three. These patients will lose their doctors and access to medical care under MACRA MIPS.


In response, CMS created exemptions for small practices from MIPS and self-congratulated shamelessly. The current 2017 MIPS policy allows exclusions for individual MIPS eligible physicians or groups with less than or equal to $30,000 in Part B allowed charges OR less than or equal to 100 Part B beneficiaries for the year. The proposed 2018 rule increases the threshold for exclusion from MIPS to less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries. Before they hurt their backs patting them, let’s see what they have in fact done.


For my medical surgical practice of ophthalmology, the one-size-fits-all law is a nightmare, and the exemption from it is a farce. A typical ophthalmology practice is composed of largely Medicare aged patients, because most medical conditions that require eye surgery and ophthalmologic evaluation and treatment occur in patients 65 and older. Cataract, glaucoma, age-related macular degeneration, retinal detachment, diabetic retinopathy, complications of cardiovascular disease, and other potentially blinding diseases occur in the Medicare age population. Most people fear blindness more than death. Ophthalmologists work to prevent and treat blindness in this increasing segment of the population. According to the AARP Fact Sheet: “Currently, 44 million beneficiaries—some 15% of the U.S. population– are enrolled in the Medicare program. Enrollment is expected to rise to 79 million by 2030.” Using the 2017 CMS MIPS exclusion, I can only see only 2 Medicare patients per week over the course of the year if I want to avoid the MIPS monetary penalty and stay in business. I cannot perform even one cataract operation per week on a Medicare patient if I want to avoid penalty. The 2018 proposal does little to improve on this- I could see 4 Medicare patients per week but not operate on even 2 Medicare patients each week if I choose to avoid MIPS participation. According to Richard Lindstrom, M.D. in the March 2015 Review of Ophthalmology , Thoughts on Cataract Surgery: 2015 (the same month MACRA was passed in the House): “Cataract surgery is the most common procedure performed by the ophthalmic surgeon. This year 3.6 million cataract procedures will be performed in the United States… In the United States, there are approximately 18,000 ophthalmologists, of whom 9,000 perform cataract surgery regularly. Thus, a typical surgeon might anticipate a surgical volume of about 400 eyes per year. “ Under current MACRA law, a surgeon who does even 10% of what is truly needed currently will be penalized. The insanity is blinding, literally. Who needs to see when they’re 65 or older anyway? What Health and Human Services Secretary Price should do is advise CMS to exempt all practices with less than 10 physicians from MACRA MIPS altogether and allow Medicare beneficiaries to see private-contracted Medicare physicians if they so choose, but this is not what is proposed.


I am dumbfounded that MACRA is law and more so that physicians implement and comply. Of serious concern, is that MACRA’s “All-Payer Model” rolls out in 2018, a few short months from now. This new government payment model subjects all payers, commercial insurance companies and Medicare and Medicaid, and all patients, those with commercial insurance and those with Medicare and Medicaid, to this flawed template for government command and control of their medical care- AKA socialized medicine and its inherent rationing of care. Thus far, I see little difference in how this is being handled under GOP control from the handling under Democrat control. The government agencies’ focus is on making it easier for physicians to comply not making it actually work. That physicians acquiesce, albeit begrudgingly, is tragic.


If we would refuse to comply with such insanity, the law would fail. But as a profession, we are too busy to pay attention or too weak to do anything but run for the cooler corner of the hot box. Because of such totalitarian laws (which completely violate what was set forth when Medicare and Medicaid were created), I can no longer ethically enter into any agreements with 3rd party- commercial or government insurers. My agreement is solely with my patient. Heartbreakingly, national healthcare law is making it increasingly difficult for patients to see physicians like me who won’t play the game and facilitate the fundamental transformation to socialized medicine. I pray Americans, particularly our physicians, will wake up and stand up. I am discouraged, but surrender is not an option. So, I keep reading the ludicrous laws they pass and the ridiculous rules they write and trying to forge ways to practice Hippocratic medicine in spite of them . Insanity reigns. We must dethrone it.


Start by commenting to CMS on the proposed MACRA rule changes by tomorrow.


Independence Day Plea: Repeal Obamacare Root and Branch, Peanut Butter and Baby Oil.

My daughter returned from a Fourth of July Weekend whirlwind boat ride with a huge tangled mess smack dab in the front of her hair. She snapped me a picture of the knot and asked for my advice. I told her to cut her losses and cut it out. She decided to sleep on it and see if it might be better in the morning. Of course, the knot was still there- worse, entangling more strands and then increasing clumps of her hair. I, a surgeon, proceeded with knot dissection and disentanglement using fine instruments and detangler, persisted momentarily, then called for the scissors. This was met with shrill cries of resistance, and we were immediately joined by two more of my daughters who flew down the stairs in response to the cries for help. One added peanut butter, the other added baby oil, each professing it was a guaranteed fix, and I left the room thinking only of the mess I would have to clean up. At which time, I realized we were enacting a real life metaphor for the huge tangled up mess that is healthcare law in America in 2017.


In 1942, Congress passed the Stabilization Act to control wages in the workforce. Because government restricted employers from paying workers more, employers could not attract nor compete for the best workers. But American ingenuity prevailed and a way around this progressive Congressional Act was forged. If they couldn’t increase wages, they’d offer benefits-and make them tax exempt to boot- a “win, win” for all- as another strand was added to the government knot. This is how tax exemption for employer based health insurance was spawned. Individual Americans who wield relatively no power and money are still subject to taxation of money they use to buy individually purchased health insurance. Think of the unintended consequences. Now, if you leave or lose your job, you lose your health insurance. This contributes to the pre-existing problem. Also, businesses are looking to cut expenses every year, so they may change insurance companies every year; this too is expensive, inefficient, and wasteful. Individuals who purchase their own plans bear the financial burden for this mess and pay taxes on top.


Then in 1965, President Johnson signed Medicare (medical care for the elderly) and Medicaid (a safety net for the poor) into law Title XVIII of the Social Security Act replete with Sec. 1801. PROHIBITION AGAINST ANY FEDERAL INTERFERENCE.


“Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.”


After you clean up the coffee you just spewed, flash forward through ERISA, HIPAA, the HITECH (The Health Information Technology for Economic and Clinical Health Act) and CER (Comparative Effectiveness Research-now called Patient centered outcomes research) parts of the American Reinvestment and Recovery Act of 2009, and myriads of acts, laws, rules, and regulations culminating in the “Affordable Care Act” and the supreme tyrannical Act of all time- the Medicare Access and CHIP Reauthorization Act of 2015… Trillions of dollars intertwined with innumerable third, fourth, and higher order intermediaries, politicians, bureaucrats, administrators, physicians and patients has resulted in a giant hairball of epic proportion.


All the detangler, peanut butter, and baby oil in the world applied by all the sisters with all the best intentions and promises cannot fix this. It is time for the scissors! Congress must enact the complete repeal of the Patient Protection and Affordable Care Act. Fixing it only twists and tangles it more. Why should the American people spend over $3 TRILLION annually to make matters progressively worse? I bet half the people in DC don’t even know the difference between Medicare and Medicaid. I know they haven’t read these absurd, if not diabolical, laws.


People say- “But what if the insurance companies fail?” REALLY? Does any sane adult with any speck of reason seriously think these mega insurance companies with billions in profits run by CEO’s making hundreds of millions will fail without the government teat to suck on? Quite the contrary, I venture to say, unleashed from the government constraints a plethora of amazing, innovative, inexpensive medical insurance plans could be devised on a weekend corporate brainstorming retreat and on the market in three months. I’ll host it at my office. No one will die. No one will go without care. These shrill cries for help must just stop.


I pray that just as the American people rallied to elect a majority in the House, Senate, and White House based on their promises to “Repeal Obamacare root and branch,” we will rally once again and descend on the offices, phone lines, emails, and Facebook pages of those we elected and demand accountability and action. There is NOTHING a single Democrat will support now. So proceed with full repeal effective December 31, 2017. Then continue to repeal more, most importantly MACRA. Do this in fewer than 1500 words. The word count of the Declaration of Independence itself is 1458- including the names of the 56 signers.


Then do just a few things. 1.) If we profess that we want everyone “covered,” we must practice what we preach and extend the tax exemption to individually purchased plans. 2.) Free insurance companies to innovate and sell a robust offering of insurance plans of all shapes and sizes, predominantly composed of low premium, high deductible major catastrophic plans 3.) Empower Americans to put tax-exempt dollars into large Health Savings Accounts to use prudently at their discretion for medical expenses, including meeting their deductibles should a medical crisis occur. 4.) Allow free market competition to commence with transparent disclosure of the cost of medical goods and services across the board from doctors offices, operating rooms and hospitals to labs, imaging, and pharmacy. 5.) Allow these free market forces to operate across state lines. 6.) The truly sick and disabled do not need “insurance”; they need actual medical care. For this establish high risk pools at the state level and allow true charity care 7.) Return Medicaid to its intended purpose, a safety net for the poor, not a flawed plan for single payer, socialized medicine, “Medicaid for ALL.” 8.) Allow seniors the choice to go on Medicare or keep their individually owned tax-exempt plans purchasing insurance they have chosen using their HSAs dollars which have grown through their lives of individually responsible savings. 9.) Enforce the 4th Amendment and restrict government and government authorized data collectors from unfettered access to patients’ medical records without their consent. 10.) Use government grants for credible, meaningful medical research and innovation and quality medical education, not progressive indoctrination.

It’s time for the scissors, America. Cut the knot out. Then start with a fresh cut (actually massive cutting). Restore America to a land of personal and individual liberty, opportunity, and freedom of human minds and spirits of an exceptional people gifted by God and endowed with inalienable rights. Unless we do this, we will have to continue to be on defense, trying to pass laws to grant us back our rights from government and to protect us from progressive government command and control, peanut butter and oil.



The Forgotten Patient- Powerful, Patient, Not Forgotten

Reality check- the Democrats are pursuing single payer government run socialized medicine and proposed the Expanded and Improved Medicare for All Act (H.R.676 introduced in the House 01/24/2017 by Rep. John Conyers, Jr. (D- MI- 13)). Ironically, the Republicans won control of the White House and maintain control of House and Senate, largely on campaign promises to repeal and replace Obamacare, but have all but reneged on their vows, in effect, spitting on the Constitution and those who elected them.


I am a physician and patient who read and understands the healthcare laws, most notably the paradoxically named and failing Affordable Care Act and the totalitarian-style Medicare Access and CHIP Reauthorization Act (MACRA), that was appallingly sponsored and continues to be supported by Representative Michael Burgess, M.D. (R-TX- 26). Over the last 8 years, I traveled to the Swamp too numerous to count times and engaged with physicians, patients, economists, and politicians across the country to attempt to craft policy that solves the healthcare debacle. What have I learned?


  1. The problems are increasing exponentially in direct proportion to the increasing intrusion of government and third party special interests into the patient- physician relationship.


  1. Most Americans, including patients, physicians, and politicians, do not understand the complex, perverse system of pay to play schemes driven by taxation and subsidy games using money taken and redistributed from working Americans- the forgotten patients- to politicians and special interest elites.


  1. Most plans are schemes to fund and preserve the current dysfunctional system, replete with perverse incentives and cronyism, rather than addressing core problems that would actually bring down cost.


  1. Propaganda is rampant, replete with lies, and disseminated using advertising dollars siphoned from tax dollars taken from the forgotten patients, who the elites seek to milk and manipulate.


  1. The lefties who seek socialized medicine are vicious and aggressively attack freedom-loving, Constitution-abiding Americans who beg to differ.


  1. The lefties have infiltrated our medical education system and use tax dollars to train a new breed of “providers,” indoctrinated with ideology that undermines the patient-physician relationship and Hippocratic Oath and fosters adherence to a command and control, top-down system of government guidelines, data collection and reporting, scoring by government rubric, and payment based on compliance with government bidding. A growing number of “providers” are not doctors but are granted increasing scope of power by government fiat.


  1. Third party special interests, particularly insurance corporations, hospital associations, pharmaceutical companies, pharmacy benefit management companies, health information technology companies, and even national and specialty medical societies and boards, comprise an enormous multi-trillion dollar medico-industrial complex that feeds itself from the very lifeblood of the forgotten patients, extorting the patient-physician relationship. They have very little regard for patients, who they view as the widgets- more of inconvenient annoyances on the way to big money.


  1. Physicians and patients have very limited means to influence the current mess. Why? Because with respect to those in #7, we have no money to buy-off politicians. Every time I ask, “What can we do? How can we get them to listen to us and implement our plans?”- I’m told, “Donate money. You physicians are too tight. You don’t donate enough money.”


  1. The vast majority of physicians loves our patients, works our tails off for them, but feels trapped in the dysfunctional, unethical system that takes advantage of our core devotion to our patients and intentionally demeans and demonizes us as a profession. We must rise above “Battered Physician Syndrome” to save our patients, or we share the blame in their pain and suffering. We must be healers and problem solvers not victims, enablers, accomplices, or useful idiots.


  1. While physicians do not have the money to effect policy change compared to the third party parasites, we do hold the power. Without us, they milk and sell nothing but false promises, sickness, and death. They will be exposed eventually but only after immense suffering becomes glaringly apparent. Can we ethically sit by and watch this happen?


  1. There is a small but loud and growing segment of physicians seeking universal, government-run medicine. Many of these left-leaning, if not socialist doctors, work in academic medicine, employed positions, within the third party bowels of the medico-industrial complex, or even within the government bureaucracy, where they have access to the big money and power to promote and implement their antithetical agenda- again using the forgotten patients’ tax dollars. They must be engaged and exposed for what they are.


  1. There is a small but powerful group of lawmakers who give me hope. They are true statesmen, who stand on their principle, their word, and the Constitution- not their next campaign. This group starts with the Freedom Caucus, epitomized by Congressman Mark Meadows (R- NC- 11), and ends with a handful of Senators like Ted Cruz, Mike Lee, Rand Paul, M.D., and John Barrasso, M.D., with a few other patriots scattered in between.


  1. The individual States have a lot to lose and are under brutal assault by the powerful, rich and greedy medico-industrial complex players. Bold Governors such as Greg Abbott of Texas play a huge role in preventing a plan such as the Democrat’s Medicare for All from usurping the 10th Amendment and becoming law of the land.


  1. The forgotten patient holds all the power and must once again stand strong, as in the last election, and demand those elected fulfill their promises or suffer the consequences.


I pray for the United States of America, her forgotten patients, her physicians, her Governors and State legislatures, her principled Congressmen such as those in the Freedom Caucus and those on the Senate committee working to repeal Obamacare and end the institutionalized corruption, our Supreme Court Justices, and our President. We must all stand strong together in our pursuit of good and Truth, shielded by the armor of God from the unconstitutional forces that seek to control us. While we don’t have the money or media on our side, we have ultimate power that will surely overcome. We must be brave and bold. We must never give up. We must use our power, patient but not forgotten. We must drain the swamp or drown in it.





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 “leadership” 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 under 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 $1.3 Billion to $17.7 Billion between 1990 and 1992 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” before they can start. 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 Obamacar 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.

It gets worse. The body shop was able to fix your car for $10,000.00, so they make a profit, but their scheme allows them to collect $40,000.00 from you and the insurance company (the allowable) to increase their profit while also reporting a loss of $60,0000.00 (because the “bill” was $100,000.00) to the government. Because of the reported loss, the body shop gets a subsidy and maintains a nonprofit status avoiding taxes. The insurance company still makes a profit and gets government subsidies as well. The government via weak politicians is redistributing taxpayers’ money to benefit the very interests that then hold them hostage. Patients pay and lose inside and out. 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 pools 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 implore him to stand firm on his pledge to repeal Obamacare and drain the swamp. 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.




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.



Kristin S. Held, M.D.

San Antonio, Texas