Time to stand against obstructionist insurance company nonsense- real life insanity from the trenches

Insanity reigns, and we must dethrone it. Today, a precious new patient sought my care. She is 28 and was perfectly healthy until 10 days ago when she developed a headache and then rather suddenly started to lose vision in her left eye. She was scared and waited a day or so hoping things would get better, but they’re not, they’re worsening. She confided in her mom who brought her in to see me, based on the recommendations of friends. I’m an M.D., a board certified ophthalmologist, having completed 4 years of college, 4 years of medical school, an internship in internal medicine, a three year residency in ophthalmology and ophthalmic surgery, 5 years on faculty as an attending physician at the medical school, and 23 years in private practice.


The patient and I engaged in a patient-physician relationship, and I obtained her medical history and examined her. This dear patient needs an immediate work up to make a definitive diagnosis, so that appropriate treatment can be implemented before she loses her vision or worse. She is worried, and so are her mom and I. According to standard practice, I arranged for her to have an immediate MRI scan of her brain. This is where the obstruction to her care began. The obstructionist is Blue Cross Blue Shield (BCBS), her “insurance company.”


BCBS will not authorize her MRI, because she is an HMO patient and has not seen her assigned “PCP” (primary care physician). If you have a BCBS HMO plan, you must see your PCP before BCBS will cover anything- even if deemed indicated by a board certified specialist. Your designated PCP is your gatekeeper, and there are no exceptions. She has not seen her PCP since having the BCBS HMO policy, because she is 28 and healthy. Apparently BCBS randomly assigned her a PCP, but the physician listed could not be located today, and no one was “on call” for her. In fact, the number listed seemed to be out of business. It just rang and then disconnected time after time. Sadly, there is a scarcity of PCP’s, and it can take months for a patient to get an appointment. Often, PCPs listed by the insurance companies are not actually “in network”, not accepting new patients, not in town anymore, not even in business, or not even practicing medicine anymore. My staff spent hours today trying to ascertain this PCP’s status and obtain authorization for the MRI, to no avail. I called and spent over an hour on hold and talking to various levels of BCBS employees working my way up the ladder through non medical personnel to finally speak to a nurse (God forbid I should get to speak to an actual physician colleague), who tried to get her manager to approve my patient’s MRI. This was all a massive waste of time as BCBS was unyielding. I was told all the usual things, sorry, this is policy, there’s nothing we can do, and even “maybe next time she won’t get the HMO plan.” I was informed all our conversations were being recorded for quality purposes, and I was glad. No one would believe the irrational nonsense I had to endure at the hand of these non-physician BCBS obstructionists without the recordings to prove it. At the end of the day, in spite of my pleas and appeals for rational behavior and ethical care, BCBS said NO, AKA- patient be damned, and screw you while you’re at it.


My patient can go to the emergency room tonight, and get the MRI at thousands upon thousands of dollars extra and hours upon hours of waiting and NOT seeing a specialist, and that will be covered. What a waste of valuable resources and abuse of the patient. The MRI I, a specialist, scheduled for this afternoon will not be covered. Further, BCBS negotiated a fee for the MRI of over $4000.00. The patient’s deductible is high. She will have to pay thousands. Ironically, I am an “out of network” physician. I will not enter into agreements with “insurance companies.” I only enter into agreements directly with my patients. I negotiated directly with a local imaging center a fee for the MRI at a fraction of the cost- $350.00. Much to my surprise, the radiologists’ practice has just been purchased by a 3rd party venture capitalist group, and the fee has increased to $550.00 and growing. Still, $550.00 is much less than the $4000.00 BCBS negotiated. This is all one big hot mess.


My patient went home with her mom. She is worried sick and asked me for sedatives to get her through the night. I refused, tried to reassure her, and gave her marching orders. If she suddenly gets worse, she will got to the E.R. BCBS will pay thousands of dollars extra, but the MRI will get done, and she will get actual medical care. It’s all a crapshoot now. God willing, she will make it through the night, and I will literally beg a colleague who is listed as a BCBS “in-network” provider to see her tomorrow to sign off on my (the specialist to whom he would have sent her in the first place) orders for the MRI. We’re hoping it helps that her mom went to high school with him, and I can name drop that to get her in before a few months. Then BCBS will hopefully authorize the MRI. It will most likely cost the patient significantly more money, but will at least “apply to her deductible.” Again, this is all convoluted, irrational, and unethical.


I am fed up. I can’t play this game. Patients will be harmed, and no doubt patients will die needlessly, because of insurance “policy.” For the second year in a row, the life expectancy in the USA has gone down- what does that tell you about the corporate practice of medicine? I accused BCBS of malpractice and the unethical obstruction of indicated patient care. I can’t sleep, because I am worried about my patient and angry that the tail is wagging the dog in the name of “universal coverage,” which is a scam, garbage, especially if you bought the HMO plan. And just know this, the ACA, MACRA, and the cascade of failed federal “healthcare” laws, rules, and regulations are all part of a top-down, government scheme for HMO’s on steroids, now called ACO’s (accountable care organizations) or APMs (alternative payment models). It is one giant insane mess. This mess benefits the insurance companies and the central planners. I will continue my fight for this patient in a few short hours. I pray she will get through this ordeal- a medical fiasco, pot stirred and fire stoked by BCBS, and its unethical, rigid, nonsensical, wasteful policies.


I call on my physician colleagues to refuse to put up with this anymore. They can’t do it without our consent. I call on my patient colleagues (we are all patients, I have cancer among other things- how about you?) to demand the insurance companies deliver. We are paying these companies thousands upon thousands at the individual and family levels and hundreds of billions at the national level to do what- obstruct, delay, deny, ration our care for their bottom line? Just think of the money from interest alone they make on a month of delays and denials. This insanity must stop. If all physicians would give the few remaining insurance companies a 90 day without cause severance notification tomorrow this would end in short order. Patients must stand up to the insurance companies too. Patients must read the fine print and know what they have signed up for and agreed to. Lawsuits against the obstructionist, rationing insurance companies will be essential. The time is now.


MedPAC is Right That MIPS is Wrong- The Patient is Best Served by Merit-Based Incentive Payment System Repeal

*Accepted for publication in the Journal of American Physicians and Surgeons

The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997, whose members are appointed by the Comptroller General, which is required by law to review Medicare payment policies and to make recommendations to Congress.[i] At its January 2018 meeting, MedPAC voted 14 to 2 to repeal the Merit-based Incentive Payment System (MIPS),[ii] which was created in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). [iii]



MACRA repealed the sustainable growth rate (SGR), established statutory payment update rates, created an incentive for advanced alternative payment model (A-APM) participation, and created MIPS[iv]– a government program for grading individual physicians with a composite performance score between 0 and 100, and then either penalizing or rewarding that physician with a negative or positive payment adjustment based on his or her score. The composite performance score (CPS) is determined by the sum of each individual provider’s weighted grades in four performance categories as set forth by a complex, untested, and flawed federal government rubric. The CPS is then posted on the Centers for Medicare and Medicaid Services (CMS) physician compare public website.


MACRA also expanded the definition of physician by creating the term MIPS Eligible Clinicians and utilizing the term Eligible Professional; thus, the law and its Merit-based Incentive Payment System apply not only to physicians, but to physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, nurse midwifes, physical therapists, occupational therapists, audiologists, speech pathologists, clinical social workers, dieticians and nutritional specialists, and so on, as well.[v] In the MACRA rule-making process, the Center for Medicare and Medicaid Services (CMS) granted itself immense power and expanded its authority, including the potential “to expand the definition of MIPS eligible clinician to include additional eligible clinicians through rulemaking in the future.”[vi] In other words, the federal government could subject anyone and everyone to their social engineering scheme.


Social engineering report cards of this sort have been seen in recent years in China, for example, as a way to harness big data and score its people on their behavior. China’s personal social credit score was recently tested on 89 million Communist Party members on their performance in 136 performance categories. Those with good behavior according to the collected data will be rewarded while those who fall short of the Party’s expectations will be denied basic freedoms like loans or travel.[vii]


MACRA, via its ensuing rule, rebranded key terminology[viii] to make it appear more palatable and vastly expanded the federal government’s control over patient care and the patient-physician relationship. The stated goal is to drive physician behavior. Government seeks to move physicians away from a fee-for-service payment model, and to instead drive physicians to alternative payment models (APMs) they claim reward what government perceives as value-based care and require providers to assume significant financial risk. The federal government calls their healthcare version of a U.S. social engineering plan the Quality Payment Program (QPP).  Lawmakers believe they can drive physician behavior by incentivizing or penalizing physicians monetarily and psychologically via threat of public shaming on the CMS Physician Compare website, where each “eligible professional’s” government compliance score is posted for all to see.


Fortunately, MedPAC ultimately concluded that MIPS cannot succeed. In MedPAC’s own words:  MIPS replicates flaws of prior value-based purchasing programs. MIPS is burdensome and complex. MIPS is costly and wasteful having cost providers $1 Billion in the first year alone just to comply. The reported information is not meaningful. The payment adjustments will be large and arbitrary in later years, and it will not help patients choose clinicians or clinicians improve value.[ix]


MIPS does not promote, create, or reward value. In fact, it may do quite the opposite. A 2017 article in The Annals of Internal Medicine reports that pay-for-performance programs such as the Value-Based Payment Modifier, a predecessor to MIPS, implemented by the Centers for Medicare and Medicaid Services, may actually contribute to healthcare disparities without improving performance.[x] The article concluded that physicians were incentivized to care for lower-risk patients and penalized for serving higher-risk patients. In other words, money was inadvertently shifted away from physicians who treat poorer and sicker patient populations to fund bonuses for physicians treating more affluent, healthier populations.


That MedPAC recommends repealing MIPS is encouraging, but then, MedPAC arbitrarily concocts something to replace MIPS, called the Voluntary Value Program (VVP). The MedPAC commissioners propose to withhold a percentage of all fee schedule payments unless the physician abandons fee for service and joins an APM or “voluntary group” to be assessed at a group level.  Much of the discussion in the transcript of the recent MedPAC meeting revolved around how big the withhold penalty needs to be to force physicians to join advanced alternative payment models, which include an array of Accountable Care Organizations, (ACOs). ACOs are essentially reincarnations of the reviled HMO’s of the 80’s, and 90’s. If MIPS is repealed, MedPAC recommends a 2% across the board withholding from payments to providers, but MedPAC Commissioners discussed withholding everything from 0.5% to 10%.[xi]


This leads us from the struggle for the soul of healthcare to the frontlines of the battle for America’s soul. Who determines and what constitutes value-based medicine? What physician behaviors deserve a high score and high pay, and what behaviors warrant a low score, low pay, and public humiliation? As my dear friend and physician colleague, C.L. Gray, M.D. astutely reminds us, the struggle for the soul of healthcare began with Plato, the ancient Greek philosopher who urged that doctors refrain from curing the weak and infirm to improve society, vs. his contemporary, Hippocrates, who felt physicians worked on behalf of the patient, not the good of the state.[xii] This begs the question, whom do we serve, the patient or the state?


One of the four MIPS performance categories in which physicians are scored is rebranded in the MACRA Rule as Advancing Care Information (ACI), formerly known as meaningful use electronic health record technology (MUEHRT) or certified electronic health record technology (CEHRT). This category is especially disconcerting, as it requires physicians to fully disclose all of our patients’ medical information to government data auditing agencies for surveillance or direct review, including the patients’ protected health information (PHI). PHI includes individually identifiable information including all demographics, all medical history past, present, and future, all medications ever taken, and even genetic information. If the physician does not do this, he or she will receive a score of 0 in the ACI performance category. The MACRA law makes data blocking illegal and demands bidirectional, unfettered access by outside government-created or approved entities to clinicians’ electronic health records- for all patients, not just Medicare patients, for all data, not just MIPS data, and from all insurers, including commercial insurers, not just Medicare. The federal government wants to collect, audit, assess, and sell the patient data and wants to be able to input government treatment guidelines, templates, restrictions, and controls. In effect, the federal government wants to dictate the medical care of the American people. The federal government, through the Office of Civil Rights of the Department of Health and Human Services (HHS), via the Office of the National Coordinator of Health Information Technology, specifically granted itself access to our once sacred, private medical records.



A most dangerous part of the MACRA rule is that the ONC (Office of National Coordinator for HIT) and its ONC-ACB’s (ONC-Authorized Certification Bodies) are granted direct unrestricted access to all individually identifiable protected health information without patients’ authorization under any circumstance. [xiii] MACRA instructs the Secretary of HHS to create 3rd party intermediaries to collect the data and 4th party entities to audit it, potentially including unblocked surveillance on demand and even onsite auditing. [xiv] Further, MACRA requires the data collectors to keep all the data for a minimum of 10 years, if not eternity if government so says.[xv] In this light, engaging with CEHRT may be a violation of our professional code of ethics at best, if not a violation of the 4th Amendment. As such, our ethical duty as Hippocratic physicians is to keep our patients’ data from government, not transmit it to government. We must ask ourselves again, whom do we serve, the patient or the state?


In 2016, after reading MACRA and the proposed MACRA rule and submitting comments, this author personally met with Acting Administrator of CMS, Andy Slavitt, and a group of high ranking CMS officials at CMS headquarters in DC to personally convey concerns about such intrusive, self-granted government data collecting practices. A distinction was ultimately made in the final rule allowing voluntary on-going data surveillance, but ONC direct review of Certified EHR data remains mandatory. This highlights the critical importance of U.S citizens reading word for word not only bills before and after they become laws, but to read and comment on proposed rules, and then read the final rules once they are published. If we do not do this, we will continue to fail to secure our blessings of liberty as instructed in the Preamble to The Constitution of The United States of America.


In recent months and years, we have become privy to abuses of data collection and surveillance of American citizens by federal agencies, the likes of the FBI, CIA, NSA, and IRS as well as the Department of Justice and Department of Defense. Why are we to presume federal agencies within the Department of HHS, such as the Office of the National Coordinator, the CDC, and CMS, will behave any better? And, might our most intimate medical, physical, psychological, and even genetic information be even more vulnerable to EHR-related injury and death, foul play, and public control than our phone conversations, emails, texts, and finances? If they can lose five months of texts and thousands of emails, can they also lose our vital medical information? There is no limit to the potential consequences of such government healthcare malfeasance, should our protected health information remain subject to unblocked, bidirectional, manipulation by soul-less government agents. The risk to our medical data is not only subject to national forces, but international as well. The politicization and weaponization of our very lives is at bay.  The very soul of America is at stake.


Will Congress heed MedPAC’s advice and repeal MIPS? For that matter, will our elected officials honor their word and repeal the Affordable Care Act, root and branch? Or, is the allure of $1.3 trillion per year spent on “healthcare” and the power over each individual American’s life just too hard to resist?



Tragically, as if penned by Shakespeare himself, MACRA, replete with its MIPS and Advancing Care Information performance category, was sponsored by a physician colleague and fellow Texan and passed with broad bipartisan support. Will egos, money from special interests, political pressures, and irrational excuses like, “we’ve invested so much on this, we have to go forward,” rue the day, or will Congress, led by MACRA sponsor Congressman Burgess himself, step up, admit it was a mistake, and repeal MIPS, and all of MACRA for that matter. In other words, will Congress use some common sense, cut our losses, and do the right thing?


The scoring of individual citizens by use of massive government data collection funneled into a complex government grading rubric in order to reward or penalize them monetarily based on the score and to pressure them psychologically by subjecting them to public humiliation by posting the scores on a public website for the stated purpose of driving behavior is something Americans would never dream is part of U.S. federal law. Yet, this social engineering scheme is precisely what is contained in MACRA, and the system is the Merit-Based Incentive Payment System, affably called MIPS. The confiscation, surveillance, and potential manipulation of our medical data as codified by MACRA’s MIPS violates the Constitutional rights of US citizens and places us in harms way. We are heading toward a totalitarian state in short order unless we stand up and fight for our freedoms and liberties. I call on my physician colleagues, with Congressman Burgess, MD, leading the charge, to follow MedPAC’s advice and make MIPS repeal a reality. Through the MACRA rule-making process it became apparent that this law could be too easily and too vastly contorted beyond the sponsors’ intent. Congressman Burgess must ask himself as a physician, whom does MACRA serve, the patient or the state? If he answers honestly, he must next courageously draft the repeal legislation for not just MIPS, but MACRA itself.


[i] Medicare Payment Advisory Commission. USAGov. https://www.usa.gov/federal-agencies/medicare-payment-advisory-commission. Accessed February 18, 2018.


[ii] http://www.medpac.gov/docs/default-source/default-document-library/jan-2018-meeting-transcript.pdf?sfvrsn=0+Page+113-+172.



[iii] Burgess M. Text – H.R.2 – 114th Congress (2015-2016): Medicare Access and CHIP Reauthorization Act of 2015. Congress.gov. https://www.congress.gov/bill/114th-congress/house-bill/2/text. Published April 16, 2015. Accessed February 18, 2018.


[iv] http://www.medpac.gov/docs/default-source/default-document-library/jan-2018-phys-mips-public.pdf?sfvrsn=0.

[v] The Federal Register Proposed Rule Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models A Proposed Rule by the Centers for Medicare and Medicaid Services on 05/09/2016 E.1.a. page 39-40/625.

[vi] Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Federal Register. https://www.federalregister.gov/documents/2016/05/09/2016-10032/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm. Published May 9, 2016. Accessed February 18, 2018. Page 40/625

[vii] Denyer S. China’s plan to organize its society relies on ‘big data’ to rate everyone. The Washington Post. https://www.washingtonpost.com/world/asia_pacific/chinas-plan-to-organize-its-whole-society-around-big-data-a-rating-for-everyone/2016/10/20/1cd0dd9c-9516-11e6-ae9d-0030ac1899cd_story.html. Published October 22, 2016. Accessed February 18, 2018.

[viii]Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models A Rule by the Centers for Medicare and Medicaid Services on 11/01/2016.

[ix] MedPAC Public Meetings, Past Meetings January 11-12, 2018 View Agenda, Briefs, and Presentations, View Transcript  Presentation  Kate Bloniarz, Ariel Winter, and David Glass January 11, 2018, Assessing payment and updating payments: Physician and other health professional services; and Moving beyond the Merit-Based Incetive Payment System (MIPS) Slide 5

[x] Mendelson A, Kondo K, Damberg C, et al. The Effects `qazof Pay-For-Performance Programs on Health, Health Care Use, and Processes of Care: AA Systematic Review. Annals of Inernal Medicine. 2017;166(5):341-353.

[xi] MedPAC Public Meetings, Past Meetings January 11-12, 2018 View Transcript. Pages 113-172.

[xii] Gray CL. Healthcare, The Culture War, and the Future of Freedom. In: The Battle for America’s Soul. Hickory, NC: Eventide Publishing; 2011:27-45.

[xiii]Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Federal Register. https://www.federalregister.gov/documents/2016/05/09/2016-10032/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm. Published May 9, 2016. Accessed February 19, 2018. Page35/625

[xiv]Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models A Rule by the Centers for Medicare and Medicaid Services on 11/01/2016.

[xv] Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Federal Register. https://www.federalregister.gov/documents/2016/05/09/2016-10032/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm.  Page 242/625. Published May 9, 2016. Accessed February 19, 2018.

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.