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:
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