Battered Physician Syndrome- Time To Opt Out of Government-run Medicine

Physicians devote our lives to serving others. We endure a rite of passage known to rare few. We work undeterred for the good of each individual patient, together in trust, making many personal sacrifices by choice. I have utmost respect for my colleagues, unified in the Hippocratic Oath, equipped with hard-earned knowledge, skills, wisdom, and experience to do what was once unfathomable- until now.

External philosophical and political forces are preying on our intrinsic enduring calling to serve others. These forces intentionally manipulate, extort, and oppress us as a means to achieve fundamental transformation of the United States of America. These forces are succeeding using predictable tactics including creating crisis and dividing us into groups, one against another and against ourselves. We are told the quality of medicine we are providing is bad, that we are bad, and that government must fix our patients, our profession, and us. I call B.S.

We have been lied about, lied to, denigrated, and subjected to abusive measures resulting in a growing phenomenon that could rightly be called Battered Physician Syndrome. This syndrome is deadly for physicians, patients, the profession of medicine, and individual liberty. It is the physician’s responsibility to recognize and develop resistance to this syndrome.

Battered Spouse Syndrome is defined as “A pattern of signs and symptoms, such as fear and a perceived inability to escape, appearing in those who are physically and mentally abused over an extended period by a spouse or dominant individual.”

Battered Physician Syndrome could be defined similarly as “A pattern of signs and symptoms such as fear and a perceived inability to escape, appearing in doctors who are physically and mentally abused over an extended period of time by demands and constraints of their profession or dominant individuals and groups seeking to malign and control them.”

Under the expanding umbrella of government-run medicine in an entrenched entitlement state, physicians are barraged with constant undeserved defamation and increasingly impossible physical, regulatory, and financial demands. Verbal and nonverbal threats of physical, financial, legal, and professional harm, if not ruin, are constantly unleashed on us from the Administrative Branch of the Federal government via the Department of Health and Human Service’s CMS, the Treasury’s IRS, the D.O.J., and more. Groups like the AMA, our specialty societies, big hospital, big pharma, big insurance, IT, and other special interests emboldened and enabled by a biased, weak press aid and abet the annihilation of American medicine. The constant mistreatment causes physicians to increasingly complain of symptoms consistent with chronic physical and emotional abuse. I see this in my physician patients, my physician friends, and my physician family members. I see this in myself. Physicians show signs of physical assault including overt manifestations of sleep deprivation, malnourishment, and lack of exercise. Many suffer with actual physical disease such as cancer, high blood pressure, and stress related conditions. Signs of depression are common. Physician burnout and a stunning physician suicide rate are only recently acknowledged by our peers.

In spite of this, many physicians continue to comply with the oppressors’ usurious demands, whether it be from fear of losing our certification, licensure, patients, income, or right to practice our trade at all or from the feeling of being trapped with no other way out to care for our patients and provide for our families. Other physicians are leaving the profession, and worse, they are discouraging the best and brightest from pursuing a career in medicine.

April 16th Obama signed H.R.2, known as the “DocFix,” into law. This law further deconstructs the private practice of medicine and destroys physicians’ autonomy to practice patient-centered medicine. Government bureaucrats and committees will call the shots for Medicare patients. The law actually creates Alternative Payment Models (APMs) and a Merit-based Incentive Payment System (MIPS) which require physicians to follow a government rubric on which we will be graded in grade school fashion. Physicians, now defined as “eligible providers”, will get grades from 0-100 as determined by the Secretary of Health and Human Services. The grade for doing what the Secretary prescribes is called the Composite Performance Score. The score is publically posted on the Physician Compare Internet Website of CMS, and the Secretary of HHS assigns each physician a payment adjustment factor based on this score. The payment adjustment factor will be positive, 0, or negative. Based on how well a doctor “performs” for the Secretary, the pay could be adjusted 9% up or 9% down, meaning the Secretary’s most compliant doctors will be paid 18% more than those who don’t perfectly make her wishes our commands. What will doctors put up with, and what will we do or not do for patients in order to be paid 18% more than those government deems “less quality” doctors and to avoid public humiliation on the government website? This is indeed chronic and continued abuse taken too a higher, institutionalized level.

That Battered Physician Syndrome shares features with Battered Spouse Syndrome begs the question- is the propagation of this phenomenon in medicine related to the growing number of women in medicine? Are we more likely to submit to authoritarian domination thus allowing it to proliferate unrestrained in a dark, deafening silence until it’s too late?

Just as many spouses stay in the abusive marriage, will doctors stay in this abusive relationship? We must end this cycle before it ends us. We should apply lessons learned from battered spouses to battered physicians. Physicians must move beyond the stages of denial and guilt to enlightenment and responsibility. This abuse is happening. We are not bad, and we do not deserve this. We must make a choice; we can stay forever trapped in this dysfunctional system enabling and feeding it, or we can say “no more” and get out. It is not easy. We will have to forge a new path and start over from scratch, but we can do it right this time for the good of our patients, our profession, our nation, and our souls. They can take away everything, but our minds and hearts they cannot steal. Our skills, knowledge, experience, and code of ethics they cannot take away. They do not possess what they peddle to our patients. We must opt out of government run medicine. It is time to take responsibility. It’s our choice. Make it.

They Fell for the Fix: Short Term Doc Fix a Trade-Off For Patient-Physician Autonomy

The march toward socialized medicine progressed from a marathon to a sprint when the House of Representatives passed H.R.2, the fatefully named “Doc Fix” bill, with overwhelming bipartisan support, and the Senate approved it 92-8. The 8 Senators who did not vote for this bill deserve credit. Two, Senators Ted Cruz and Marco Rubio, are running for President and deserve our support.

As groups professing to represent doctors, like the AMA (led by CEO Dr. James Madara who is a close pal and Chicago hospital board crony of Michelle Obama and Valerie Jarrett) and Doctors For America (formerly known as Doctors For Obama), “high-five,” I remain stunned that physician Congressmen and those who were elected on their pledge to repeal Obamacare supported this bill. Politicians sold out to specialty hospitals, IT, and other special interests.

That many of my colleagues naively embraced such transformative legislation without reading it and that groups professing to represent doctors, like the TMA and our specialty organizations, effectively campaigned for its passage in the Senate is disturbing. That President Obama is chomping at the bit to sign it is disturbing too.

Truth is, the hyped SGR/Doc Fix is little more than a diversion to distract physicians from the meat of the bill that forever puts a stake in the heart of the patient-physician relationship. The SGR fix becomes irrelevant in short order when “Alternative Payment Models” go into effect.

The “Doc Fix “ neuters the profession of medicine and transforms us from healers to heelers getting paid for doing what the Secretary of Health and Human Services says, not for what we do for our patients.

This usurpation of physician autonomy is achieved through seven major initiatives: Alternative Payment Models, Merit-Based Incentive Payment System, Composite Physician Performance Score posted on the public Physician Compare Website, redefining the patient-physician relationship, requiring that physicians have a government issued National Provider Identifier (NPI) to file claims for items and services for their patients, requiring that prescriptions have a valid NPI in order to be covered, and in the ultimate coup-the HHS Secretary is granted the power to determine whose NPI is valid.

Sec.101 (e), Promoting Alternative Payment Models, warrants intense scrutiny. Six months after the law is enacted, the Comptroller General appoints the Physician-Focused Payment Model Technical Advisory Committee. Medicare physicians will not be paid directly for services provided to patients but will be compensated by unproven Alternative Payment Models concocted by this Committee.

By 2016, the Secretary shall establish criteria for physician payment models, including specialist physicians, and establish incentive payments for participating in such models where payment is made not to individual doctors but to “an eligible alternative payment entity” in a lump sum on an annual basis on a capitated basis.

By 2021 this Medicare incentive plan is expanded to include the “Combination All-Payer and Medicare Payment Threshold Option.” Translation: all 3rd party payers will be included in the government run alternative payment model in a mere six years.

Under APMs, money can only be paid to “eligible alternative payment entities” that collect patient data and do required reporting on performance category measures determined by the HHS Secretary, use certified Electronic Health Records (EHR) technology, and participate in an entity that is a medical home.

The Secretary determines whether an “eligible professional” (new definition of physician inclusive of everyone from a Physician Assistant and Nurse Practitioner to a nurse midwife and dietician) is a “qualifying Alternative Payment Model participant” who can participate in Eligible Alternative Payment Entities that are paid only for services based on the Secretary’s quality measures. There is no administrative or judicial review. By 2016, this will apply this to Medicare Advantage.

The Merit-Based Incentive Program will replace EHR Meaningful Use and PQRS penalties. Physicians will instead be given a Composite Performance Score from 0-100, which will be posted publically on The Physician Compare Internet website. The Secretary will have final say on measures and scoring, so it boils down to who complies with her requirements and implements them to her satisfaction per this rubric:

1.Quality-30%

2.Resource Use 30%

3.Clinical Practice Improvement 15% (new word for maintaining certification (MOC))

4.Meaningful Use EHR 25%

A physician who does not do what the Secretary requires, including completely divulging their patient medical records, scores a 0 and a horrible public listing. A physician, who perfectly complies with everything the Secretary prescribes, gets a 100 and a great public score on Physician Compare.

Based on their Composite Performance Score, doctors are given a “payment adjustment factor.” It can be positive, 0, or negative. Doctors who follow the rubric can receive up to a 10% bonus. Proponents of H.R.2 assert that it removes current penalties, but are a “Negative payment adjustment factor” and a humiliating public listing on Physician Internet Compare not penalties?

Physicians must grant full disclosure of confidential patient information via interoperable Electronic Health Records to HHS, which can then sell this patient data to Qualified Data Entities. Authorized users of this data, who have full access to patients’ private medical records, are: a provider of services, a supplier, an employer, a health insurance issuer, a medical society or hospital association, or any entity that is approved by the Secretary, as determined by the Secretary. Doctors are expected to compromise patient confidentiality and the Hippocratic Oath.

An audacious section is found on page 111 (3): “HHS Secretary shall develop patient relationship categories and codes that define and distinguish the relationship and responsibility of a physician or applicable practitioner with a patient at the time of furnishing an item or service.” One year after the enactment of the law, the Secretary will post the categories on the CMS website. Category 3 of five possible government-fabricated patient–physician relationships is billed when a physician or practitioner “furnishes items and services to the patient on a continuing basis during an acute episode of care, but in a supportive rather than a lead role”; this insanity is better suited for the Academy Awards.

After the HHS Secretary literally redefines the patient-physician relationship, she then requires the physician have a valid National Provider Identifier (NPI) to submit a claim for items or services.

In 2018, a claim submitted by a physician or applicable practitioner must include a care episode and patient condition code and classification, a patient relationship code and classification code, AND per (4)(B) page 115, the NPI of the ordering physician or applicable practitioner.

The Doc Fix goes further to extinguish the private practice of medicine. In anticipation of physicians choosing patients and principle over money and politics and opting out of Medicare, the “Doc Fix “ adds Section 507(4) which establishes that a valid NPI is required on pharmacy claims and then gives the Secretary power to determine whose NPI is valid.

This bill gives the HHS Secretary the power to selectively validate or invalidate a physician’s ability to prescribe medications, items, or services for Medicare patients, and soon all patients as the features of this bill set in. So, if I like my patients, I can’t keep my patients.

I cannot ethically comply with this “Doc Fix”. I will not violate the Hippocratic Oath nor the confidentiality of thousands of patient-physician relationships in which I have been engaged for over 20 years. Thus, I will opt out of Medicare on October 1, 2015. Each physician must make this decision for him or herself.

Apparently, however, many of my colleagues embrace the prospect of receiving their Composite Performance Scores for following marching orders from the Secretary of HHS and seeing them publically posted on the Physician Compare website of CMS. Maybe they want to post their scores on the walls of their offices with their diplomas, residency certificates, board certifications, and state licenses- who needs those silly outmoded things anymore when now they get this. Maybe they’ll wear color coded coats or have a scarlet letter grade monogrammed on their lapels to display their scores for easy public profiling. Is there anything they won’t do? They fell for it, but I didn’t and neither did the 8 Senators that voted against it. Maybe, Senators Cruz and Rubio are the only hope left in America for those like me.

The “Doc Fix” is a call for any physician with a mind, conscience, or regard for the patient and Hippocratic Oath to opt out of Medicare. America’s doctors are being used as pawns if not weapons. If we do not resist, we are to blame.

Whose profession is next?

Kristin S. Held, MD

Don’t Fall for the Fix: Short Term SGR Fix a Trade-Off For Patient-Physician Autonomy

On March 26th, the march toward single-payer medicine progressed from a marathon to a sprint when the House of Representatives passed H.R.2, the fatefully named “Doc Fix” bill, with overwhelming bipartisan support.

The “Doc Fix” is Obamacare on steroids. I remain stunned that physician Congressmen and those who were elected on their pledge to repeal Obamacare supported this bill. Politicians sold out to specialty hospitals, IT, and other special interests.

That many of my colleagues naively embrace such transformative legislation without reading it and that groups professing to represent doctors, like the AMA, are effectively campaigning for its passage in the Senate is disturbing.

Truth is, the hyped SGR/Doc Fix is little more than a diversion to distract physicians from the meat of the bill that forever puts a stake in the heart of the patient-physician relationship. The SGR fix becomes irrelevant in short order when “Alternative Payment Models” go into effect.

The “Doc Fix “ neuters the profession of medicine and transforms us from healers to heelers getting paid for doing what the Secretary of Health and Human Services says, not for what we do for our patients.

This usurpation of physician autonomy is achieved through seven major initiatives: Alternative Payment Models, Merit-Based Incentive Payment System, Composite Physician Performance Score posted on the public Physician Compare Website, redefining the patient-physician relationship, requiring that physicians have a government issued National Provider Identifier (NPI) to file claims for items and services for their patients, requiring that prescriptions have a valid NPI in order to be covered, and in the ultimate coup-the HHS Secretary is granted the power to determine whose NPI is valid.

Sec.101 (e), Promoting Alternative Payment Models, warrants intense scrutiny. Six months after the law is enacted, the Comptroller General appoints the Physician-Focused Payment Model Technical Advisory Committee. Medicare physicians will not be paid directly for services provided to patients but will be compensated by unproven Alternative Payment Models concocted by this Committee.

By 2016, the Secretary shall establish criteria for physician payment models, including specialist physicians, and establish incentive payments for participating in such models where payment is made not to individual doctors but to “an eligible alternative payment entity” in a lump sum on an annual basis on a capitated basis.

By 2021 this Medicare incentive plan is expanded to include the “Combination All-Payer and Medicare Payment Threshold Option.” Translation: all 3rd party payers will be included in the government run alternative payment model in a mere six years.

Under APMs, money can only be paid to “eligible alternative payment entities” that collect patient data and do required reporting on performance category measures determined by the HHS Secretary, use certified Electronic Health Records (EHR) technology, and participate in an entity that is a medical home.

The Secretary determines whether an “eligible professional” (new definition of physician inclusive of everyone from a Physician Assistant and Nurse Practitioner to a nurse midwife and dietician) is a “qualifying Alternative Payment Model participant” who can participate in Eligible Alternative Payment Entities that are paid only for services based on the Secretary’s quality measures. There is no administrative or judicial review. By 2016, this will apply this to Medicare Advantage.

The Merit-Based Incentive Program will replace EHR Meaningful Use and PQRS penalties. Physicians will instead be given a Composite Performance Score from 0-100, which will be posted publically on The Physician Compare Internet website. The Secretary will have final say on measures and scoring, so it boils down to who complies with her requirements and implements them to her satisfaction per this rubric:

1.Quality-30%

2.Resource Use 30%

3.Clinical Practice Improvement 15% (new word for maintaining certification (MOC))

4.Meaningful Use EHR 25%

A physician who does not do what the Secretary requires, including completely divulging their patient medical records, scores a 0 and a horrible public listing. A physician, who perfectly complies with everything the Secretary prescribes, gets a 100 and a great public score on Physician Compare.

Based on their Composite Performance Score, doctors are given a “payment adjustment factor.” It can be positive, 0, or negative. Doctors who follow the rubric can receive up to a 10% bonus. Proponents of H.R.2 assert that it removes current penalties, but are a “Negative payment adjustment factor” and a humiliating public listing on Physician Internet Compare not penalties?

Physicians must grant full disclosure of confidential patient information via interoperable Electronic Health Records to HHS, which can then sell this patient data to Qualified Data Entities. Authorized users of this data, who have full access to patients’ private medical records, are: a provider of services, a supplier, an employer, a health insurance issuer, a medical society or hospital association, or any entity that is approved by the Secretary, as determined by the Secretary. Doctors are expected to compromise patient confidentiality and the Hippocratic Oath.

An audacious section is found on page 111 (3): “HHS Secretary shall develop patient relationship categories and codes that define and distinguish the relationship and responsibility of a physician or applicable practitioner with a patient at the time of furnishing an item or service.” One year after the enactment of the law, the Secretary will post the categories on the CMS website. Category 3 of five possible government-fabricated patient–physician relationships is billed when a physician or practitioner “furnishes items and services to the patient on a continuing basis during an acute episode of care, but in a supportive rather than a lead role”; this insanity is better suited for the Academy Awards.

After the HHS Secretary literally redefines the patient-physician relationship, she then requires the physician have a valid National Provider Identifier (NPI) to submit a claim for items or services.

In 2018, a claim submitted by a physician or applicable practitioner must include a care episode and patient condition code and classification, a patient relationship code and classification code, AND per (4)(B) page 115, the NPI of the ordering physician or applicable practitioner.

The Doc Fix goes further to extinguish the private practice of medicine. In anticipation of physicians choosing patients and principle over money and politics and opting out of Medicare, the “Doc Fix “ adds Section 507(4) which establishes that a valid NPI is required on pharmacy claims and then gives the Secretary power to determine whose NPI is valid.

This bill gives the HHS Secretary the power to selectively validate or invalidate a physician’s ability to prescribe medications, items, or services for Medicare patients, and soon all patients as the features of this bill set in. So, if I like my patients, I can’t keep my patients.

I cannot ethically comply with this “Doc Fix”. I will not violate the Hippocratic Oath nor the confidentiality of thousands of patient-physician relationships in which I have been engaged for over 20 years. Thus, if the Senate passes this bill in this form, I will opt out of Medicare on October 1, 2015. Each physician must make this decision for him or herself.

The “Doc Fix” is a call for any physician with a mind, conscience, or regard for the patient and Hippocratic oath to opt out of Medicare. America’s doctors are being used as pawns if not weapons. If we do not resist, we are to blame.

Kristin S. Held, MD

National Physician Coalition For Freedom In Medicine

Response to TMA President Dr. King Regarding His Campaign for H.R.2

Dear Dr. King,

I was stunned when I received your TMA alert instructing Texas physicians to contact Senator Cruz and tell him to support H.R.2 using your talking points. Have you completely read H.R.2 yourself? Where did you get your talking points? Whose interests do you represent? How did you conclude you as the leader of TMA should back H.R.2?

Like you, I have long held Dr. Burgess in highest regard. His goal of repealing SGR is laudable, but the associated side effects of this proposed SGR cure are worse than the disease. H.R.2 was exposed to far too much outside contamination, whether that be from specialty hospitals, IT, or other special interests, such that the intended SGR fix becomes irrelevant in short order when the Alternative Payment Models ushered in by H.R.2 take effect. Secretary Burwell is targeting 85% of Medicare to be delivered by such models by 2018, less than 3 years from now, at which time the SGR becomes immaterial even if still in place. H.R.2 is the fast track for Secretary Burwell’s agenda.

The proposed legislation that accompanies the SGR repeal puts physicians who honor the Hippocratic oath and the confidentiality of the patient-physician relationship in an ethically untenable position when it monetarily incentivizes us using the Merit-based Incentive Payment System based on a Composite Physician Scoring System that requires we engage in Meaningful Use EHR, that includes full disclosure of the private medical record containing private patient information to authorized users of the data including a provider of services, a supplier, an employer, a health insurance issuer, a medical society or hospital association, or any entity that is approved by the Secretary, as determined by the Secretary. If we refuse to do this we get a 0 on the Meaningful Use EHR component (25%) of our Composite Physician Score which will negatively impact our public listing on the Physician Internet Compare website of CMS and earn us a “negative payment adjustment factor” as the Secretary determines.

Did you ever imagine you would be President of the Texas Medical Society instructing the physicians of Texas to violate our Hippocratic Oaths, disclose confidential patient information, be scored like grade-schoolers by a government rubric that rewards us for doing what the Secretary of Health and Human Services, a non-medical political appointee, says, penalizes us for resisting, and then publically lists this for all to see under the guise that it informs patients which of us are better quality doctors? I doubt this is what you foresaw when you matriculated at the esteemed Baylor Medical School.

Let’s evaluate your talking points on why you say we must get Senator Cruz to vote for H.R.2 one by one:

  1. It repeals the SGR immediately, stopping the 21-percent cut in physicians’ Medicare payments.

While HR2 repeals the SGR, the SGR payment conversion factor is actually just phased out and replaced by a far worse system of new conversion factors based on Alternative Payment Models (APMs) which are projected by the HHS Secretary to apply to 85% of Medicare Payments in a mere 3 years and fully replace the SGR by 2026.That means SGR wouldn’t have mattered anyway. They used it to give us something worse. We traded the pill for the suppository. Under APM’s physicians are no longer paid directly for their work but only through an “eligible alternative payment entity” in a lump sum on an annual basis on a capitated basis. In order to be paid by CMS under APM’s, money can only be paid to eligible alternative payment entities, not individual physicians, and only to entities that collect patient data and do reporting on performance category measures ultimately determined by the Secretary, use Meaningful Use EHR, and participate in a medical home. Sorry, but through this bill we are selling out our patients and principle for the long haul for the lure of short them money. A year extension of the SGR is better than this bill with its baggage that smothers physician autonomy and the private practice of medicine.

  1. It guarantees small, but real, increases in payment rates for the next five years.

This relates to what I just said. The Secretary of HHS wants APMs to cover 30% in a year, 50% next year, 85% in 3 years, and 100% in 10 years. So the claim of guaranteed small payment increases is about as true as “if you like your plan, you can keep your plan. If you like your doctor…. Not one dime… “ and so on.

  1. It rolls the Physician Quality Reporting System (PQRS), Meaningful Use (MU), and Value-Based Payment Modifier (VBM) into one, simpler quality reporting system, boosting possible bonuses and chopping the size of possible penalties.

This statement is deceptive. HR2 creates the new Merit-based Incentive Payment System. It is anything but simple. It is onerous and oppressive. The Merit-Based Incentive Program will replace EHR Meaningful Use and PQRS penalties. Physicians will instead be given a Composite Performance Score from 0-100, which will be posted publically on The Physician Compare Internet website of CMS. The Secretary will have final say on measures and scoring, so it boils down to who complies with her requirements and implements them to her satisfaction per this rubric:

1.Quality-30%

2.Resource Use 30%

3.Clinical Practice Improvement 15% (new word for maintaining certification (MOC))

4.Meaningful Use EHR 25%

A physician who does not do what the Secretary requires, including completely divulging their private patient medical records, scores a 0 and a horrible public listing. A physician, who perfectly complies with everything the Secretary prescribes, gets a 100 and a great public score on Physician Internet Compare.

Based on their Composite Performance Score, doctors are given what the Secretary determines as their “payment adjustment factor.” It can be positive, 0, or negative. Doctors who do everything the Secretary says can receive up to a 10% bonus. Proponents of the “Doc Fix “ assert that it removes current penalties, but are a “Negative payment adjustment factor” and a humiliating public listing on Physician Internet Compare not penalties?

  1. It eliminates the need for physicians who choose to opt out of Medicare to have to renew their status every two years.

Yes, I do like SEC.106 that allows indefinite, continuing automatic extension of opt out election for physicians who choose to “Opt out” of Medicare, so that we no longer have to re-opt out every 2 years as presently required. Many physicians will be forced to opt out of Medicare on October 1, 2015 when ICD10 is required to even file claims with CMS, and this will be important. (On a related note, as President of TMA, how many Texas physicians are not doing ICD10, and have you evaluated the impact on Texas’ patients when thousands of physicians will be forced out of Medicare and Medicaid because they can no longer file a claim with CMS? Please, let us know the expected public health impact and proposed remedies for this looming phenomenon.)

While the indefinite opt-out of SEC 106 is good, Section 507 is very troubling in this regard under current Administration behavior patterns. SEC.507 (4)(B)(i) gives HHS Secretary Burwell the power to determine whose National Provider Identifier (NPI) is valid. I can easily envision her invalidating NPIs for physicians who will opt out October 1,2015, effectively neutering us, because per this Bill, SEC.507 (4) Section 1860D of the SSA is amended to require a valid NPI on Pharmacy Claims. Thus, those of us who opt out, will see patients directly and prescribe indicated medications only to have the claim denied at point of service to the patient (507(4)(B)(ii), because the Secretary deemed our NPI invalid. She can selectively punish physicians with an opt out status or other selective condition and make it impossible for us to practice our profession, because of changes to the law in this bill. This and other features of the bill present serious potential traps that could result in restraint of trade for physicians

  1. It protects state liability reforms and ensures that the care standards and guidelines in the Affordable Care Act, Medicare, or Medicaid statutes cannot be used to create new causes of legal action against physicians.

This is most certainly necessary if H.R.2 becomes law, because physicans will be lumped in a group called “eligible providers” which includes everyone from a PA, NP, and CRNA to a nurse midwife, clinical psychologist, and registered dietician. A most audacious section is found on page 111 (3): The “HHS Secretary shall develop patient relationship categories and codes that define and distinguish the relationship and responsibility of a physician or applicable practitioner with a patient at the time of furnishing an item or service.” One year after the enactment of the law, the Secretary will post the categories on the CMS website. Category 3 of the five possible government-fabricated patient–physician relationships is billed when a physician or practitioner “furnishes items and services to the patient on a continuing basis during an acute episode of care, but in a supportive rather than a lead role”; this insanity is better suited for the Academy Awards.

After the HHS Secretary literally redefines the patient-physician relationship, she then requires the physician have a valid National Provider Identifier (NPI) to submit a claim for items or services.

In 2018, a claim submitted by a physician or applicable practitioner must include a care episode and patient condition code and classification, a patient relationship code and classification code, AND per (4)(B) page 115, the NPI of the ordering physician or applicable practitioner.

Physicians who attempt to practice under these untested practice models will no doubt need extra legal protection.

And finally, in response to your letter as a whole,

Dear Dr. Held:

The Internet trolls are pumping our U.S. senators full of misstatements, distortions, and outright lies about the bill to repeal Medicare’s Sustainable Growth Rate (SGR) formula. Texas physicians need to step up, now, to counter that barrage of deception.

It’s time for Texas physicians like you and me to respond, to make sure we don’t waste this opportunity to eliminate the SGR. Please contact Sen. Ted Cruz today, and let him know that SGR repeal is vital to Texas medicine. Let Senator Cruz know that Texas physicians expect him to be a leader on SGR repeal.

You might be surprised to know that many of the “internet trolls” you so unprofessionally refer to are actually your colleagues, fellow TMA members, fellow doctors who like you have traversed a rite of passage known only to those of us who have endured what it takes to be called physician, love our patients and profession, and honor the Hippocratic Oath. Many of us are AOA, full clinical professors, physicians and surgeons who take care of thousands of Texas’ patients, sons and fathers, daughters and mothers of American physicians like yourself, who live a life in service of others. Many of us actually read bills before they are passed, and yes, many of us call on our elected representatives to do what we elected them to do, not only “pumping them” with information on the internet but also “barraging them” with our physical presence in their offices in Washington D.C. to share absolute truth.

I write this letter to counter your barrage of deception. Please contact me to discuss the truths and realities of this bill- once you’ve actually read it.

H.R.2 is a call for any physician with a mind, conscience, or regard for the patient, the Hippocratic Oath, and the profession of medicine to contact their Senators to modify H.R.2 or vote no in this form. America’s doctors are being used as pawns if not weapons. If we do not resist, we are to blame.

Sincerely,

Kristin S. Held, M.D.

San Antonio, Texas

Here is the email below. Use the contact info they provide to ask Senator Cruz to Vote NO
Texas Medical Association
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TELL SENATOR CRUZ: TAKE THE LEAD
ON SGR REPEAL
April 8, 2015
Dear Dr. Held:
The Internet trolls are pumping our U.S. senators full of misstatements, distortions, and outright lies about the bill to repeal Medicare’s Sustainable Growth Rate (SGR) formula. Texas physicians need to step up, now, to counter that barrage of deception.
It’s time for Texas physicians like you and me to respond, to make sure we don’t waste this opportunity to eliminate the SGR. Please contact Sen. Ted Cruz today, and let him know that SGR repeal is vital to Texas medicine. Let Senator Cruz know that Texas physicians expect him to be a leader on SGR repeal.
Once the Senate convenes at 2 pm (ET) next Monday, senators will have just 34 hours to take up and pass HR 2, the Medicare Access and CHIP Reauthorization Act, before the 21-percent Medicare cuts kick in for real. At the end of those 34 hours, the Centers for Medicare & Medicaid Services will no longer hold claims for services provided after April 1, and physicians will begin to see the SGR-mandated cut in our Medicare payments.
We’re grateful for the House of Representatives’ overwhelming approval of the bill — authored by Rep. Michael Burgess, MD (R-Lewisville) — and for the support we’ve seen from Senate Majority Whip John Cornyn of Texas. But we need to make sure our other senator, Senator Cruz, hears from Texas physicians why the SGR must go and go now.
Five key FACTS about HR 2:
It repeals the SGR immediately, stopping the 21-percent cut in physicians’ Medicare payments.
It guarantees small, but real, increases in payment rates for the next five years.
It rolls the Physician Quality Reporting System (PQRS), Meaningful Use (MU), and Value-Based Payment Modifier (VBM) into one, simpler quality reporting system, boosting possible bonuses and chopping the size of possible penalties.
It eliminates the need for physicians who choose to opt out of Medicare to have to renew their status every two years.
It protects state liability reforms and ensures that the care standards and guidelines in the Affordable Care Act, Medicare, or Medicaid statutes cannot be used to create new causes of legal action against physicians.
Please contact Senator Cruz today. Ask him to be a leader in support of HR 2. Use these talking points.
Get in touch with him by:
Calling his Capitol office at (202) 224-5922.
Using the TMA Grassroots Hotline to send an urgent email.
Contacting him directly through his own Twitter account or Facebook page.
Sending a personalized #FixMedicareNow tweet directed at Senator Cruz.
I’m counting on your help.

Sincerely,

Austin I. King, MD
President
Texas Medical Association

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Stupid and Stupider: The SGR “Doc Fix”- Starring The House and The Doctors

Infamous MIT economist Jonathan Gruber, PhD worked intimately with fellow Obamacare architects to intentionally make the law tortuously difficult to understand in order to get it passed at any cost. In Gruber’s own words, the law was designed to take advantage of the “stupidity of the American people.”

Translation: they deliberately deceived us, and we were easily duped.

We fell for the tricks and lies like Eve for the Forbidden Fruit. Now, we live outside the garden of legislative honesty and integrity under the harsh new reality of the paradoxically named Affordable Care Act. Reality proves the promises were false. You can’t keep your health plan, you can’t keep your doctor, your premiums and deductibles are skyrocketing, as are your denials and restrictions, and it costs incalculably more than “not one dime” in new taxes. Will we ever learn?

We, those of us in working the medical trenches, know first hand that Obamacare is deeply flawed and unworkable. They, those who deny this, admit it in their ongoing propaganda efforts to deceive us about how well the law is playing out and their nonstop unilateral, if not unconstitutional, administrative changes to the law.

Yes, it has boiled down to “We vs. They” – We, the People, vs. They, who want to fundamentally transform the confidential patient-physician relationship, defile the sacred Hippocratic Oath, and take 100% control of every medical dollar and decision in the ultimate game of life and death.

Their game plan is predictable, replete with end-arounds, trick plays, thrown games, and house rules. Their strategy is irrational. They ignore real solutions offered by actual doctors and instead contrive unproven systems offered by partisan ideological bureaucrats. They passed it, without reading it, so we could see what’s in it. But do we see? Have we looked this time? Or are we really just stupid?

The march toward single-payer medicine progressed from a marathon to a sprint on March 26th when the House of Representatives passed H.R.2 http://t.co/36ZIYHjxzE the fatefully named “Doc Fix” or “SGR” bill, with overwhelming bipartisan support. Boehner and his Republican House rejoiced and gloated as President Obama and Nancy Pelosi beamed and smirked. President Obama is “looking forward to signing a good bill in this area” according to White House chief economist Jason Furman who touts that “the SGR is going to offer us even more tools to expand the same types of new payment models that we put in place in the Affordable Care Act.” I read it, and I agree. The “Doc Fix” is Obamacare on steroids and amphetamines.

Fortuitously, the day the “Doc Fix” passed the House, I was on Capitol Hill as a member of the National Physician Council on Health Care Policy and the National Physicians Coalition for Freedom in Medicine to present a patient-centered rescue and reform solution for legislators to consider in anticipation of the Supreme Court ruling in the King vs. Burwell case in June. My friend, Dr. Z, a physician leader and patient-loving colleague who has fought with me for patients in this government war on Hippocratic medicine, was crying. I discovered that there had been significant compromises and add-ons to the “Doc Fix bill, “ but that now it would pass. I cried for the first time in this six-year assault on the American patient, violated and betrayed. I downloaded the bill and read it, knowing the hard call I must make.

The hyped SGR fix is a hoax, a diversion to distract my fellow physicians from the meat of the bill that forever puts a stake in the heart of the patient-physician relationship. The SGR fix becomes irrelevant when the “Alternative Payment Models” put forth in the bill go into effect. It’s frightening to realize that my gullible colleagues would embrace such radically transformational healthcare law without reading or understanding it. What if they approached medical literature in this fashion? Or what if there’s no limit to what they’ll do to keep getting their check from CMS? Is Hippocrates dead by the hand that bears the pen that signs his check?

The Doc Fix neuters the profession of medicine and transforms us from healers to heelers getting paid by doing exactly what HHS Secretary says, “Mother May I?”- doctor edition. Before you castigate me, read it yourself.

  1. 101 (e) Promoting Alternative Payment Models. – This section warrants intent scrutiny. Six months after the law is enacted, an 11 member Committee (the Physician-Focused Payment Model Technical Advisory Committee) is appointed by the Comptroller General of the United States. Physicians who accept Medicare will be paid not for the services they provide but by new, unproven Alternative Payment Models. The Secretary shall fund the committee with $5,000,000 per year starting 2015 and each subsequent year with money taken for Medicare. By November 1,2016, the Secretary shall establish criteria for physician payment models, including specialist physicians (Sec.101 (e)(2)) and establish incentive payments for participating in such models (z) based on care episode and patient condition codes and classification codes where payment is made to “an eligible alternative payment entity” (no longer directly to the doctor) in a lump sum on an annual basis on a capitated basis, and “The Secretary shall establish policies to implement this…”

By 2021 and 2022 this Medicare incentive plan is expanded to include the (ii) Combination All-Payer and Medicare Payment Threshold Option. Translation: all 3rd party payers, including all private insurance, is included in the government run alternative payment model. (The VA is excluded). In order to be paid: 1.the money can only go to eligible alternative payment entities, not individual physicians. 2. Money will only be paid to entities that a.) collect patient data and do required reporting on performance category measures determined ultimately by the HHS Secretary, b.)use HHS Secretary certified Electronic Health Records (EHR) technology, and c.) the eligible professional(physician) participates in an entity that is a medical home, or “bears more than nominal financial risk” if actual expenses exceed expected expenses. The Secretary herself determines whether an eligible professional (Obamacare Newspeak for physician and inclusive of everyone from a midwife to dietician by 2017) is a qualifying Alternative Payment Model participant “as the Secretary determines appropriate.”

  1. Money will not be paid to individual physicians-only to Eligible Alternative Payment Entities who are required to use HHS certified EHR technology, pays only for services based on Secretary’s quality measures, or is a Medical Home (1115A(c)). Further government control is found Per (4): There is no administrative or judicial review for any of this.
  2. Not later than July 1,2016, HHS Secretary will apply all this to Medicare Advantage.
  3. A Merit-Based Incentive Program will replace the current EHR Meaningful Use and PQRS penalties. Physicians will be given a Composite Performance Score from 0-100, which will be posted publically on The Physician Compare site on the CMS website, and is based on the following:

1.Quality-30%

2.Resource Use 30%

3.Clinical Practice Improvement 15% (Newspeak new word for MOC)

4.Meaningful Use EHR 25%

The HHS Sec will have final say on measures and scoring, so it all boils down to who complies with her requirements and implements them to her satisfaction.

A physician (now lumped in as “Eligible Professional”) who does not do what the Secretary requires, including completely surrendering the private patient medical records to her, scores a 0 and a horrible public listing.

A physician (eligible professional) who totally complies and does everything the Secretary says, gets a 100 and a great public score on the Physician Compare website.

Based on this score, doctors are given what the Secretary determines as their “payment adjustment factor.” It can be positive, 0, or negative. A doctor can receive up to a 10% bonus for doing everything the HHS Secretary says. While the supporters of the “Doc Fix “ proclaim that it takes away penalties, is a “Negative payment adjustment factor” and a humiliating public listing for not following government marching orders NOT A PENALTY?

This is undeniably the fast track to single-payer, government –run medicine. Physicians must allow full disclosure of confidential patient information to the government in interoperable Electronic Health Records. HHS can then sell this data on Medicare patients to Qualified Data Entities. Soon this will include Medicaid, SCHIP, and private insurance patients as well. Authorized users of this data who will have full access to patients’ private medical records are: a provider of services, a supplier, an employer, a health insurance issuer, a medical society or hospital association, or any entity that is approved by the Secretary, as determined by the Secretary.

This Doc Fix is something I cannot ethically comply with. I will not violate the Hippocratic Oath I took nor the confidentiality and sanctity of thousands of patient-physician relationships I have been engaged in for the past 25 years. This I will not do, and government cannot compel my services nor force me to do it.

Thus, if the Senate passes this bill in this form, I will opt out of Medicare on October 1, 2015. Each physician must make this decision for him or herself. Our great tradition of innovative, pioneering, and life–saving medicine based on sound, proven, peer-reviewed, and published scientific data cannot be replaced by untested, unproven models based on ICD10 billing data and reporting on interoperable EHR that doesn’t even exist as mandated by a non-medical, political, partisan, appointed bureaucrat HHS Secretary. I will not betray my patients or profession in the fashion that our elected officials have betrayed us by irresponsibly passing laws they haven’t read, that they change on a whim, that waste money and lives, and destroy our blessing of liberty.

The politicians sold out to the specialty hospital lobbyists and IT. What will doctors do?

The Doc Fix goes further to seal our fate and end the private practice of medicine in America as we know it. In anticipation of physicians like me choosing patients and principle over money and politics, the “Doc Fix “ adds Section 507(4) which requires that a valid NPI (National Provider Identifier) is required on pharmacy claims and then gives the HHS Secretary power to determine whose NPI is valid. This bill effectively gives the HHS Secretary the power to selectively validate or invalidate a physician’s ability to prescribe medications for Medicare patients, and all patients soon as the features of this bill set in. So, if I like my patients, I can’t keep my patients.

I remain stunned that this bill was supported and passed by physician Congressmen and those who were elected on their pledge to repeal Obamacare. Haven’t they learned? Didn’t they read it to see what was in it? Did they just sell us out? Or are they just stupid?

And our physician groups that are aggressively supporting this? And individual physicians blindly in support? We must fight this government takeover of our profession for the sake of humanity, the sick, suffering, frail, disabled, premature, elderly… the weakest of us all, our fellow man, and our patients. We’re the last bastions of hope. By God, we need doctors of character and courage back in the game. America’s doctors are being used as pawns if not weapons. If we do not resist, we are to blame. The “Doc Fix” is a call for any physician with a mind, conscience, or regard for the patient and Hippocratic oath to opt out of Medicare. My contemporaries are weak, easily intimidated, easily duped, and most easily bribed.

And sadly, apparently, we’re just stupider. Gruber was right. Stupid and Stupider