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 XVII SEC.1801. Over the ensuing 50 years, physicians and patients have done nothing but lose yardage in the ultimate game of life. The filthy rich, loaded-bench, goliath government offense relentlessly works the ball, trick plays, mid-game rule changes and all, toward their goal as our scrawny, dilapidated defense is blind-sided and beaten back time and time again. It’s 4th and nowhere to go as our backsides ram into the goalpost, which feels colder and harder, like the headstone of American medicine that it is.
Team Goliath’s offense surged when President George Bush signed the Omnibus Reconciliation Act of 1989, enacting a physician payment schedule based on the resource-based relative value scale (RBRVS). Medicare RBRVS was implemented in 1992 establishing its infamous Relative Value Units (RVUs), which Medicare uses to decide how much it will reimburse physicians for their services. The AMA/ Specialty Society cheerleaders eagerly set up their Relative Value Scale Update Committee (RUC).
Team Patient-Physician mustered a defense and The Health Security Act of 1993, otherwise known as Hillarycare, failed to become law. The progressives countered back with a vengeance under President Bill Clinton with the 1996 Health Insurance and Accountability Act (HIPAA) and the Medicare Sustainable Growth Rate ( SGR) via the Balanced Budget Act of 1997 empowering Congress to control payments to physicians.
President Barack Obama signed the American Reinvestment and Recovery Act of 2009 into law, thus enacting two hidden parts that furthered the statists’ assault on medicine-the Health Information Technology for Economic and Clinical Health Act (HITECH) to “promote the adoption of meaningful use of health information technology” and Comparative Effectiveness Research (CER) described by the government’s Agency for Healthcare Quality and Research (AHRQ) as “designed to inform health-care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options.”
They threw the long bomb in 2010, the biggest end-around, trick play in American history- the passage of the “Patient Protection and Affordable Care Act”, Obamacare. The goal line stand has since been a blood bath with team Goliath changing the rules every down and playing dirty.
The ultimate trick play was the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)- sponsored by Rep. Michael Burgess, (R-TX-26 and an M.D., no less). MACRA was hailed as the permanent “Doc-fix” rescinding the feared, but never implemented, SGR cuts, but in reality it jettisoned the Goliaths to the win establishing Alternative Payment Models (APMs), Merit-Based Incentive Plans (MIP’s), and Composite Performance Scores whereby government now completely determines how physicians are paid and penalized, and this is based on how well physicians do what Goliath says. Physicians will literally be scored from 0 to 100 based on metrics established by the Secretary of Health and Human Services (a non-doctor, presidential appointee). Based on the score, which is posted on the government website, physicians are either rewarded, neutralized, or penalized monetarily based on how well they report their patients’ data in the name of quality metrics per the Secretary’s command. This is the antithesis of what was promised when Medicare and Medicaid were enacted in 1965. To their credit and a testament to their courage and actual reading of the law, Senators Ted Cruz and Marco Rubio were two of only eight Senators to vote against MACRA.
The CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) (Draft) is up on the CMS website awaiting comments by March 1st. It is a 61 page pathetic gameplan. They think they’ve got the win, that we’re in left field, and that this measure development plan will fly by without negative comments. Under the guise of lessening the burden on physicians, HHS will be applying all their metrics to all third party payers, private as well as government, in a legendary coup, punching it in for single payer.
But do they really have this in the bag? In their haughty haste, we must force a fumble, overtime, and ultimately a win for the patients.
The 50 year sustained defense has not worked. Our only option for survival is to mount an aggressive offense, and the two minute warning has almost ticked off . Not only have big government medicine proponents expanded their offense to include organized medicine, which profits bigtime, but they have gone to the States.
Here’s what they’re doing, and here’s what we must do. Physicians like me( who cannot ethically practice under MACRA, effectively droning away as an arm of big insurance, my services compelled by big government who says “do what we say to get pay or else”, at the expense of the best interests, privacy, and dignity of patients) have said NO MORE! Growing numbers of us are severing all agreements with insurance companies including Medicare and Medicaid. They cannot provide what they promise without physicians. So, they are trying to end our ability to practice outside their grip.
- Direct Patient Care is the way we must go. Physicians like me set up fair, transparent fees and provide the best care directly to the patients outside the payoffs, waste, redundancy, restrictions, and regulations of the government-insurance cabal. Per Obamacare, patients are mandated to buy policies from companies who get billions of dollars from the patients and government subsidies. In the ultimate conflict of interests, the insurance companies (which are beholden to shareholders to profit) keep the cash by denying and delaying the care. Establishing restricted networks, called “in-network”, helps them do this covertly. While they deny they are rationing or withholding care, if they have too many patients and not enough doctors, the line is long, and the money goes out much slower, AKA they keep it. It’s like putting only one cashier at the return counter the day after Christmas. Patients can, however, choose to see “out of network” doctors like me and get the care they want and need expediently. To the surprise of most, my fees are often lower than their copays and allowables making it cheaper (including surgery) NOT to use their in network insurance with its associated exorbitant premiums, deductibles, and cost sharing which has exploded under Obamacare. Historically, patients then file with their insurance company for services from “out of network providers” and receive a check back from their insurer. To get around this, big insurance has set up separate deductibles for out of network doctors, decreased the amount they will cover, and in the case of Texas’ Obamacare Exchange plans (which Texas refused to set up, but the feds came in and did it against the will of the state) no out of network providers are covered at all. Team Goliath has gone full frontal now going to states like New Jersey and Florida and introducing bills to ban out of network billing altogether. Fortunately, these bills were defeated by the vigilant few. Physician groups like the Association of American Physicians and Surgeons (AAPS) through diligent work of expert counsel, Andy Schlafly, have been instrumental fending off such law. But defense is wearing down and Goliath has the momentum and the money.
We must mount an offense. In stark contrast to the big cabal quest to ban all out of network billing, we should propose legislation to Ban Restricted Networks!
- Hawaii recently introduced a bill to require physicians to see Medicare patients as a condition of getting a license to practice medicine in the state. This amounts to extortion, restraint of trade, theft of intellectual property, if not violation of the 13th Amendment in my mind. Sneeky players like the Federation of State Medical Boards (FSMB) and their pal Interstate Compact are going state to state under the guise of helping physicians get licensed in more than one state. Physicians are in reality licensed by their respective states. Maneuvers by the FSMB in effect usurp the state’s power of physician licensure and are potentially a stealth move toward national licensure.
We must go state by state and prohibit the FSMB and other such self-serving groups from trumping individual states, and we must prohibit individual states from compelling our services and linking our ability to obtain a license to practice medicine to requirements that amount to indentured servitude. We must pass legislation that affirms that licensure cannot be linked to compulsion of service to government, insurance, or other 3rd party entity.
- Groups such as the American Board of Internal Medicine (ABIM) are linking our hard earned, once lifetime specialty board certification to passing recurring tests they create and from which they then profit hundreds of millions of dollars. In epic irony, the ABIM head is actually named Rich Baron, M.D. Further, these physician-government colluders attempt to propagandize and indoctrinate us with what they want us to “study and pass.” MACRA makes MOC requirements part of the physicians’ Composite Performance Score, and the very people who develop the metrics, like Christine Cassel, M.D., head of National Quality Forum(NQF) are the very ones who profit from the MOC testing (Cassel is former ABIM head too). They charge us thousands of dollars to take their tests, AKA regurgitate government metrics and agenda items, and then score us-paying us more for doing their bidding and penalizing us if we don’t. Further, many hospitals require the sham maintenance of certification for us to obtain or retain hospital privileges.
We must create and support alternative boards composed of non-profiteering physicians with integrity, in stark contrast to the profiteers of the ABIM. Such exists in the National Board of Physicians and Surgeons led by Dr. Teirstein; we must sanction this. Most importantly, we must reassert that board certification is a lifetime achievement and remove maintenance of Certification (MOC) once and for all, especially from the auspices of the ABIM, bureaucrats associated with MACRA, quality metrics, and the ACA, and hospital credentialing boards. Join the AAPS with its proven record of fighting for the private practice of medicine and call out the AMA and other quasi-government groups who sell us out. Educate ourselves about corrupt and incestuous relationships of physicians like Christine Cassell, MD former head of both ABIM and NQF who plays a huge role in determining quality metrics- and then makes millions in cash and shares in companies for testing us on them.
- All patients and physicians must go on the CMS website and comment on the CMS Quality Measure development Plan by March 1st to stop the complete government control of patients’ medical care.
This is just a start, but we must do this. All of it. The clock is running out. Goliath is cocky and corrupt. We must find a way to get our patients and the practice of American medicine into overtime. Get off the bench. Suit up (and it will take literal lawsuits at the local and state levels and all the way to the Supreme Court, no doubt)! It’s time for offense in the ultimate game of our lives.