Letter my remaining private insurance patients will receive as I am forced to forced terminate all 3rd party agreements as of October 1- the day HHS mandates ICD-10 implementation

September 13, 2015

Dear Cherished Patient,

I most humbly request you take a few minutes to read my heartfelt letter to you. Whether I have cared for you for the past 20 years or you are new to the practice, I want you to understand that I value our relationship most highly and regard my service to you as your physician and surgeon as a privilege and a blessing. I honor the Hippocratic Oath and will treat you individually to the very best of my ability with dignity and privacy.

In 1965, President Lyndon Johnson signed the Social Security Act Amendments into law creating Medicare and Medicaid with the promise that the federal government would not interfere in any way with the practice of medicine whatsoever including compensation, administration, or operation of any institution, agency, or person per Title XVIII SEC.1801. In 2010, President Obama signed the Affordable Care Act with the promise, ”If you like your doctor, you can keep your doctor. Period.”

Tragically, over the past 50 years, the government’s pledge to not interfere with the practice of medicine has been broken. The law has been unheeded and continuously altered, such that the practice of medicine in the United States has been fundamentally transformed, commandeered, and all but lost. Your right to keep your doctor has been lost as well. My right to freely practice medicine has been lost as well.

October 1, 2015, the Department of Health and Human Services of the Executive Branch of the United States federal government requires that in order to bill for services physicians must implement ICD-10, the 10th revision of the International Classification of Diseases and Related Health Problems, a medical cataloging system of the World Health Organization that includes 141,000 diagnosis and procedure codes including W56.22 Struck by Orca, initial encounter, V91.07 Burn due to water-skis on fire, V97.33 Sucked into jet engine, X52 Prolonged stay in weightless environment, V95.40 Unspecified Spacecraft accident injuring occupant, and even VO6.00xA for when Grandma gets run over by a reindeer. The costs of ICD-10 implementation are staggering, far outweigh any perceived benefit, and are a vital factor separating financial sustainability from bankruptcy for private medical practices going forward. ICD-10 implementation was fought vehemently and delayed 2 years, but ultimately, money from lobbyists representing hospitals, IT (American Health Information Management Association), and other special interests bought votes and trumped the best interests of America’s patients and physicians. ICD-10 is required for all health care providers, billing agencies, clearinghouses, and payors that transmit patient data electronically (all HIPAA covered entities), not just Medicare and Medicaid.

Government is now virtually extorting physicians in unprecedented fashion. If physicians do not precisely follow government rubrics and implement and comply with everything the Secretary of Health and Human Services says, we are penalized. I am not implementing ICD-10, because it is nonsensical and doing so does not serve my patients first and is not the best utilization of resources. If I implement this nonsensical, wasteful system, what won’t I do? This is my line in the sand. Therefore, as of October 1st, I will be unable to submit claims for my services to you to your insurance company, because they will be rejected. I will be forced to terminate my agreement as an “in network” provider with your insurance company.

Just as government has broken its pledge not to interfere with the practice of medicine, it has broken its promise to you, the patient. On April 16,2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and soon government will be implementing Alternate Payment Models and Merit-Based Incentive Plans for physicians that are perversely incentivized, such that doctors who follow marching orders from the Secretary of HHS (a non-doctor appointed bureaucrat) will be rewarded monetarily and with a high, publically posted “Composite Performance Score”; those who do not do her bidding so well will be penalized. Further, if less money is spent on patients, more money is retained to profit the entities that ultimately pay, and thus control, physicians. Initially this will apply to Medicare patients but will be expanded to include all third party insurers. Think about it- we now have a system whereby you are forced to buy what amounts to prepaid “healthcare” from an “insurance” company that profits by restricting and denying the very care they are paid to provide. You have to pay them. They keep more money when they provide you less care.

Government has betrayed us, but we must not betray one another. The preeminent, inviolable relationship that must be preserved exists between patient and doctor. The insurance company-customer and government-subject relationships are secondary by great orders of magnitude. I am asking you to continue in my care. I will provide you with a transparent fee schedule that is fair, reasonable, and in many cases less than Medicare. My services may cost less than those of your hairdresser, mechanic, or any other professional with whom you do business.

Of utmost importance is your understanding of the convoluted healthcare system in which we are forced to live. Education and communication are critical for us going forward. Our premiums, deductibles, and copays have sky-rocketed. Our access to and networks of hospitals, doctors, and medications have been severely restricted. You will be pleasantly surprised, and in the long run you will be better served by staying in my care- outside of the restrictions and wastefulness of your insurance plan. For example, if your copay is $70.00, it costs you only $15 more to stay with me for your follow up exams. If your deductible is $5000.00, and your insurance company has negotiated “allowables” with surgery centers for cataract surgery or other operations, you will find my fees to be lower and you will save money to the tune of thousands of dollars. You will spend more using your insurance in many cases. Most importantly, you will not be subjected to what I call the “insurance shuffle” where each year you will have to start from scratch with a new “in network” insurance doctor du jour who knows nothing about you or your medical history and will spend but a few impersonal, data-collection-focused minutes with you. If you stay in my care, you can remain confident and comfortable in an ongoing, lifelong patient-physician relationship of mutual trust and respect. There is unquantifiable value in the patient-physician relationship that is focused on what is best for the individual patient as opposed to dealing with a third party controlled doctor who must enter meaningless data into government mandated electronic medical records that will be shared with “authorized users” who will have full access to patients’ private medical records. Guess who will have acces to your “confidential records”- “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 of Health and Human Services as determined by the Secretary.” I will put you and your well-being first, in place of nonsensical, if not harmful, government rubrics that serve the collective good and political ruling class at your expense. I will keep your personal medical information confidential and share it with no one without your consent. I will not violate my pledge to you. Please, stand with me.

If you chose to stay with me, you can personally file a claim with your insurance company for my services as an “out of network” provider. You, an individual patient, are not mandated to use ICD-10 codes. You are paying the insurance company; the company must deliver what it promised to provide. If you like your doctor, you apparently must now fight to keep you doctor. I pray you will. If you leave, I pray you will come back.

My choice is to violate my code of ethics and implement government–mandated ICD-10 and all other subsequent diktat or to terminate agreements with insurance companies and serve my patients first. I cannot continue to enable this perverse, wasteful, dysfunctional system. I pray you will work with me in a new paradigm-shifting, alternate universe where you have an actual doctor and actual medical care in lieu of government-mandated “insurance” that comes with neither. Enclosed you will find my fees. My staff and I are available to answer your questions and address your concerns. I appreciate your time and consideration of this critical matter.

Warmest Regards,

Kristin S. Held, MD


21 thoughts on “Letter my remaining private insurance patients will receive as I am forced to forced terminate all 3rd party agreements as of October 1- the day HHS mandates ICD-10 implementation

  1. Congratulations. I wish you were closer. Integrity and professionalism are rare qualities. To find both in one physician is truly a find. Your patients would be fools to leave you, but patients being the sheep that they are may ignore the handwriting on the wall, as they might have to actually take responsibility for their own health. I wish you the very best. Anyone that can read…anyone that stays with you, is blessed with a partner in their healthcare.
    Please let me know how this unfolds.
    SDFluger, DDS

  2. Pingback: Government All Up In Our Healthcare: A Doctor Is Forced To “Fire” Her Patients | Bydio

  3. So… tips on this from an insider… this doctor is suffering from a problem common in the medical community. It’s called fear of change. ICD-10 has been around since 1993. It’s almost as old as I am. Yes, some of the diagnoses are silly, but currently, with ICD-9, one must specify what length and type of watercraft a patient fell from in a boating accident. This isn’t new. It’s going to be a big change, but it IS beneficial for medical professionals like me, who don’t see the patient, to get the most accurate and specific diagnosis possible. Especially when you consider that my field (the lab) is the basis for 70-80% of all diagnoses.

    I won’t argue the ACA or anything like that (that verdict is still up in the air), but if you can’t be bothered to keep up with your education and submit the proper diagnosis, you probably shouldn’t be practicing medicine anyhow.

    TL;DR: Doctor is stuck in the past, refuses to accept change, change helps patient.

    • Dear Med Tech,
      This is as far from the truth as possible. I have the most innovative, state of the art technology and am an early adopter of everything that serves the patient best and first. From laser cataract surgery to LASIK etc, I have embraced positive change! On the other hand , I vehemently resist BAD change. ICD-10 has been around and is old news not even compatible with evolving EHR technology. ICD-11 is just around the corner and is adaptable to current IT. IN other countries ICD-10 is used for epidemiology BUT NOT linked to billing. The ICD-10 does not servethe patient first and is not the best use of resources. It wastes billions of tax payer dollars and was pushed through by IT and specialty lobbyists essentially buying votes. It makes huge $ for special interest and does not benefit the patient. If I do this -is there any limit to what I will not do and what government cannot make me do. Drs are doing this because if we do not we cannot bill for our services. I appreciate you commenting, so I can respond. I recommend you study the history of ICD codes and the history of the government takeover of the practice of medicine over the past 50 years since creation of Medicare and Medicaid. It is far easier for me to just do it. Again- if I do this, is there anything I will or won’t do to get paid by 3rd party. At that point I am no longer practicing Hippocratic medicine which is focused on the patient and patient-physician relationship. If hospitals want to use ICD10 or whatever, so be it. But-forcing a profession to do it “or Else” is not a reason.You are a tech. I am a surgeon. WE are insiders, but we are different. If you like ICD10-go for it. Just don’t force it on me and my patients.I “keep up with my education” and am cutting edge. I have also read ,helped tweet,and reported on the entire ACA and have read and repprted on the entire MACRA. That’s why I know what’s going on, where this is headed, and why I will not enable or facilitate the destruction of physician autonomy and the patient-doctor relationship. Maybe it is other doctors who just do whatever a corrupt government says that “shouldn’t be practicing medicine anyhow.” I suggest you read up on it.

      • Well said. Physicians are being dumbed down to not think in terms of advocating for patients, but rather assimilate into the (increasing) rules of factory-line medicine. The real innovators are disrupting this and getting back to patient advocacy. We are the farthest from fearful of change, we are creating change.

      • Dear Dr. Held,
        Thank you. Thank you for straight-talking. Thank you for taking a stand. Thank you for not leaving this profession but, instead, finding a way to keep doing the great work you do.

        MedTech- You are not helping anyone. You are using your clinical role to lay claim to ‘insider knowledge’ about physicians. This undermines our profession, the integrity of the physician patient relationship and the health care continuum in general.
        I have the utmost respect for all healthcare providers and workers, particularly when people function at the top of their game within the realm of their area of expertise. My mother ran a large microbiology lab for 30 years and, in that time, I learned much from many laboratory experts.
        Do not get on this physician’s forum and lambaste her for what is a national crisis.
        Healthcare is unduly costly, complicated, barrier laden and unsustainable. Until you are 40 years old with $200K in debt, 12 hour work days, the threat of lawsuits, an EMR and computer that doesn’t work worth a damn, office managers who won’t provide pens and medtechs who bad mouth the role you play behind the scenes, keep your mouth shut.

      • Dear Dr. Gunther,
        Thank you for taking the time to read the letter and commentary.Your reply is spot on and well articulated.Physicians must stand up for our patients and profession.No one else can do this for us. Have you read my article in the Journal of American Physicians and Surgeons- Abuse of Physicians: Battered Physician Syndrome. I will link it in a reply. I would be interested in your opinion.
        Best Regards,

    • Dear Med Tech,

      “Change helps [a] patient” is a slogan at best, for it does not identify what change and what benefits to that change there might be. Having looked into the “codes” game just a little, what is certain is that the art of diagnosis is not about jargon and bookkeeping, but about caring. “Submit” a “proper diagnosis” coming from a technician aimed at a physician is hubris. If patients wished to seek care from a med tech, then they would do so. But there is a reason why medical technicians are not physicians because — wait for it — they aren’t qualified. Hubris does not make a convincing argument in any field. After all, to address your slogan, “change helps patient,” death is a change, but no patient I know seeks that readily. A “common problem” in the medical field is that non-physicians think themselves equal to physicians….

      This from a PhD who has seen many decades of life and trusts a physician far more than a medical technician.

  4. Thank you for the link to the article about Battered Physician Syndrome. Yes and yes.
    Dr. Pamela Wibble is doing great work in this space right now, as well. She is speaking out about physician suicide and physician abuse, particularly as pertains to what happens during our training. She will be speaking at the national TED talks this fall.
    We need to get back to being colleagues who mentor each other, lift each other up, support each other. Our well-being matters and it matters because we make less errors, think clearer and support our patients, ourselves and our loved ones better when we are supported.
    I will NOT consent to nor participate in physician-bashing. We have a culture that does not like/trust anyone with credentials because they have oft been abused. But there are many, many, many devoted, hard-working physicians with integrity who have the skills and desire to help others. And their voice needs heard and regarded.
    I am so very appreciative of your VOICE.

  5. A note to all doctors – there are many of us potential patients out here who wish there were more of you doing what the Oklahoma Surgery Center and individual physicians such as Dr. Held are doing; providing patients with a cost effective way to know charges up front, to pay reasonable sums for care, to pay for the doctor to actually spend time with the patient instead of the software, and to pay without insurance. For years we’ve fought insurance companies to have them uphold their side of the insurance contract. Obamacare made everything worse, and with the sky high premiums, deductible and copays it’s no longer insurance for any but the most catastrophic illnesses/accidents. Please, ask your fellow doctors to follow in your footsteps and let’s act together to stop the federal takeover of healthcare. Just say no to federal mandates and opt out of Obamacare. Your patients will be better off for it.

    • Tom- Search under terms such as “ideal medical care” and “direct primary care”. There is a movement afoot of physicians, like Dr. Held, who are trying to make things better… for everyone.

      Best of luck.

  6. I’m a conservative-a former medical coder, now in administration, and your claims of being overburdened by ICD-10 make no sense to me. How is it that small practices in my rural area can afford to change with little difficulty, yet you can’t do the same with your practice? Maybe you made a poor choice of IT software provider in the past? There really should be little preventing you from doing this.

    The training on the new system isn’t cumbersome. The index referencing methodology in ICD-10 is virtually identical to ICD-9. There are very few rules changes/additions, and most of those pertain to hospital coding.

    ICD-10 will help us more clearly identify diagnoses and inpatient procedures, allowing us far more comprehensive data for researching and trending purposes than ever before. It begins to catch us up with the rest of the developed world in the area of data (they are all on ICD-11 by now). All that you posted are a few ridiculous-sounding external cause codes, and nothing with the other 79,000+ codes that are clearly useful.

    I fear you are achieving nothing but spreading misinformation and claims of government overreach that are not substantiated. Experts in clinical information have been trying to implement ICD-10 since the early 90’s. The ACA had nothing to do with it. It’s about time the US caught up with the rest of the civilized world in this area.

    • Dear Jennifer,
      Thank you for taking the time to read and reply to the letter to my patients. Many small practices you refer to (those with 10 staff or less who don’t electronically file) are exempt from the ICD-10 mandate. ICD-10 is the straw that broke my “camel’s back.” Why should we squander billions on ICD-10 (which was created pre-EHR, pre-SNOMED era) when ICD-11 is almost here.You are right ICD-10 has been around for yearend years- why adopt it now? Because the AHIM, IT, and specialty hospitals… want it and will make tons of money off it.But let’s go back-ICD-10 is a World Health Organization Classification system that has been around since the early 1900’s for cataloging disease. The USA is the only country that links ICD codes to billing. And we are thinly country that uses all the codes. Most use a fraction. Physicians would definitely have a different perspective on this than coders and administrators. I would love to discuss this entire topic with you, but my daughter was in a horrible accident this weaker and I am replying from her bedside in the Trauma ICU. Yes, I could do it. But I ask myself-does this serve patients first, and is this the best utilization of resources? The answer is no to both. Let’s talk later.At some point, just gotta say not to insanity. ICD-10 in the USA is used to get paid. This year is a grace period. Claims by its proponents that it will be used for research…are not being truthful.What people code to get paid is not what represents anything upon which any research should be based- except research on how to code to get paid.Praying form baby girl now. Gotta go.

  7. Doctor Kris
    I am so excited to have heard about you today from a facebook physicians group
    I had to google your name to find you

    I m not sure how I can follow a no insurance policy like you
    Please let me know how I can reach you

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