Brave New Practice

The implementation of Obamacare and its “Fast Pass to Single Payer” companion law, MACRA, is disrupting the patient-physician relationship and the practice of medicine in the United States. We need a way to practice medicine outside this government domain.

My father is a retired neurosurgeon who inspired me to pursue a life in medicine, which he regards as the most noble profession. He taught me to honor the tradition, serve the sick, and advance the field. He taught me to study hard, work hard, and care for patients, each one to the best of my ability with deep commitment and compassion. Work toward perfection; there is no room for errors. Listen to them, examine them, and treat them according to the Oath of Hippocrates. Serving as another’s physician is a humbling experience that is a privilege, a blessing, and a lifelong responsibility. The relationship is based on mutual trust. It is dignified, private, sacred and inviolable. My father was a leader in his field, a teacher, an innovator, courageous, principled, and a hero in my mind. He taught me to be a strong individual, an innovator, an independent critical thinker, a problem solver, an ethical and moral person. He taught me the importance of truth and trust. I wanted to follow in his footsteps since I was a little girl in third grade and recognized I had the wherewithal to do so when I received both the academic award for the highest grades and the “R” award for responsibility in the fifth grade. I mustered the courage and pursued my calling.

I am a surgeon now. I built a practice of which I am proud. I have worked so hard that some days I would get tightness in my neck and could hardly breathe. At times, I regarded sleeping and eating as inconvenient intrusions into my schedule, especially when my four precious daughters were little girls. When I delivered each of my 4 babies, when I broke my leg and had two operations, and when I had breast cancer and had 3 operations, I never missed more than two weeks of work. I have worked two weeks overdue, two weeks after a C-section, two weeks after 8 screws and a plate, and two weeks after a mastectomy. I have worked in early labor, drains under my dress, in a cast, and from a wheelchair. I worked when my daughter was in the ICU. I do this, because it is my obligation to my patients and my profession. I love my patients. I think about them all the time, especially when they are not feeling well or something is not quite right. I became skilled, experienced, wise, and efficient while continuing to bring state of the art, innovative medical and surgical advances to my patients.

One thing I will not do, though, is violate my patients’ trust. I will not violate the oath to my patients and profession as is required by the new payment models in Obamacare and MACRA. These new models require me to submit government required “quality metric” data via interoperable electronic health records to virtually anyone the Secretary of Health and Human Services deems appropriate. MACRA literally creates a grading system from 0 to 100 for physicians, called the Composite Performance Score, which will be posted on the CMS website and will be used to monetarily reward, neutralize, or penalize physicians based on their score. The Secretary of HHS, a non-doctor political appointee, will literally choose and approve the so called quality metrics and other measures on which physicians will be graded. Those who best comply with what the HHS Secretary deems important will be paid more, while non-implementers and non-compliers will be paid less. My life’s work will not boil down to cookbook compliance and data entry just so I can earn a good grade from a Washington politician or grovel for a few more crumbs. Innumerable things in Obamacare and MACRA place me in an ethically untenable situation such that I cannot implement nor comply. I have written about this extensively at .  Accordingly, on October 1st, 2015, I terminated all agreements with 3rd party including Medicare and now solely enter into agreements directly with my patients.

I am beyond thankful for those cherished patients who have chosen to stay in my care. I have shed many a tear over those who have not. Today I saw 32 patients instead of 50. Thursday I will operate on 6 patients instead of 10. But, each patient- some of whom I have cared for over 20 years-will get personalized, state of the art, quality, affordable care directly from me with no delays or denials from 3rd party interlopers into their medical care and without me having to hand over their personal information to 3rd party medical record voyeurs! I pray I will be able to build this direct patient care model  and stay in business in Ophthalmology, a surgical specialty where most of my surgical patients are of Medicare age. You see, I also have a young associate with whom I share 9 employees who depend on me for their jobs and a landlord who depends on the rent from my office space and so on.

I find it ironic, that at the pinnacle of my career when I am most proficient and efficient, when there is a shortage of doctors, and when patients are going without care, that because of the healthcare “law of the land”, I am seeing  25% less patients, doing 30% less surgery, and down-sizing. I am no longer booked 3 months out- you can see me today! But, I love it even more! I am enjoying more quality time with my patients, who choose to see me because they see value in our relationship over settling for a stranger on some insurance company’s list of “in network providers.” I will not seek an alternate career or retire early as are many of my colleagues. Instead, I’m working with like-minded colleagues to create an “alternate universe” where patients and doctors work directly with one another with mutual trust and confidentiality without 3rd party interference. I will be the paradigm shift. I will forge a new and better way.

My 2 oldest daughters are in medicine as well- third generation physicians. The oldest is a resident, and the second is a 3rd year medical student. While most physicians now discourage their family and friends from going into medicine, I am quite the opposite. I encourage the best and brightest to study hard, work hard, and pursue the humbling, blessed life in the noblest profession. God knows, we need good doctors.

I advise them to honor the Hippocratic Oath, serve their patients solely, and to never enter into 3rd party agreements with government or other 3rd party entities. Most of all, I could not bear to watch my extraordinary daughters squander their brilliant minds, hard earned skills, and beautiful souls clicking away on some lame government mandated EHR, their services compelled, reduced to mindless drones, implementing insanity and complying out of fear, thus enabling the demise of Hippocratic medicine and the rise of team based, population based health rationing replete with the politicization, if not weaponization, of medicine. That a partisan bureaucrat who may know nothing about medicine will give them a grade on how well they do her bidding, which determines their pay, is beyond distressing.  My comfort lies in the knowing that having traversed the rite of passage known only to those of us who have earned the title physician, we possess a shared, sacred knowledge that cannot be stripped from us. This we must hold dear. Together we will work together, ever vigilant, fighting to preserve our ability and autonomy to practice patient centered medicine in the United States of America- even if we must practice in an alternate universe. This is not easy, but nothing worth fighting for ever is. It starts here and now with me- in my brave new practice.


6 thoughts on “Brave New Practice

  1. I am proud to know you Kris and applaud your efforts. I am convinced you will continue to be a successful healer because you have A Surgeon’s Heart.

  2. Oh, how I wish more Dr’s were like you. How I wish the AMA could get behind this. I have a wonderful Dr who post Obama Care is truly distressed at how he had to change his practice. He is like-minded with you, and I know it pains him. 2 of my regular Dr’s have decided to retire early. It is truly a sad state of affairs that this is happening. I now see Dr on avg for 7-10 minutes tops. I don’t know what the answer is. Repeal and replace. The government and political appointees need to get OUT of my personal healthcare. It truly is a shame.

  3. Now if we could convince patients to stop paying insurance companies for nothing. The insurance companues are getting rich on the backs of the American people/patients and denying us the medical care our doctors recommend. Think about paying $300.00 a month premium, having to meet a $5,000.00 deductible, and then not being approved for the care our doctors recommend. Or worse, our doctors not recommending the care we need to save the insurance company money. There is something very wrong here! Both doctors and oatients should divorce the government and the insurance companies. Yes, it’s time fir a Brave New Practice.

  4. I am with you, Dr. Held. I am also an ophthalmologist who dis-enrolled from Medicare Jan.1 and am now out of all insurance “networks.” No more begging insurance hacks for “prior approval” for meds and procedures. Total dedication to the interests of my patients. If the public only knew what we know about the cancerous effects of federal government intrusion into American medicine.

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