Letter to my patients- 4 months working directly for you, not third party entities

February 29, 2016

Dear Esteemed Patient,

Innumerable things in Obamacare and the Medicare Access and CHIP Reauthorization Act of 2015  (MACRA)  place me in an ethically untenable situation such that I cannot go along with it any longer if I honor my commitment to serve you, my patient, not your insurance company or government agency. Accordingly, on October 1st, 2015, I terminated all agreements with 3rd party entities including Medicare and now solely enter into agreements directly with you, my patient. I work with you and for you. My pet peeve is when people say: “she doesn’t take insurance.” I look at it this way- I take YOU! I will do what’s best for YOU and help YOU use your insurance. I am delighted to see all patients regardless of insurance status. My staff and I will help you understand your insurance and help you file with your insurer for “out of network” benefits for my services if you so desire. You and I can discuss any and all aspects of your care. You will be pleased to find my fees transparent and affordable.

With today’s exorbitant copays, deductibles, and premiums, many patients find my new practice model more convenient, more affordable, and less restrictive than “in network” third party contracted models.  This includes Medicare patients. Many Medicare patients are delighted to find that when they see me, an “opted-out” or “private-contracted” physician, their secondary or supplemental insurance will cover anywhere from 20% up to even  %100 of the cost of my services in some cases. Even when it comes time for surgery, the cost for state of the art laser assisted cataract surgery and premium intraocular lenses may be less in my practice than in others that contract with Medicare. Each day we see patients with insurance whose copay is higher than the cost of my exam, depending on the nature of your visit. In some cases it costs you less not to file with your insurance than to use it.  I appreciate the opportunity to care for you and recognize you have made a choice to stay in my care. Thank you.

Now, time for a little history lesson. 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 past 50 years, the federal government has broken this promise time and time again. The government takeover of medicine progressed 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, enacting two hidden parts -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.” In 2010, the “Patient Protection and Affordable Care Act”, Obamacare, became law. Last year, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) became law.


MACRA was publicized as the permanent “Doc-fix” rescinding the feared, but never implemented, SGR cuts, but in reality it expedites the transformation of patient-centered private practice medicine to single payer, government run, socialized medicine. MACRA establishes 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 implement and comply with government metrics. 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 Physician Composite Score, which is posted on the government website, physicians are paid more, the same, or less depending on how well they report their patients’ data per the Secretary’s mandates and metrics. This is the antithesis of what was promised when Medicare and Medicaid were enacted in 1965. Under the guise of lessening the burden on physicians, the Secretary of HHS is applying the quality metrics to all third party payers, private as well as government, facilitating transformation to single payer. 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.

Serving as another person’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. I have devoted my life to acquiring skills, knowledge, experience, and wisdom while continuing to bring state of the art, innovative medical and surgical advances to my patients.

One thing I will not do, is violate my patients’ trust. I will not violate the Hippocratic Oath to my patients and profession as is required by the new payment models in Obamacare and MACRA. My life’s work will not boil down to cookbook compliance and data entry – doing what a politician wants instead of what my patient needs- to avoid being penalized or to get a bigger bonus from the government or insurance company. This is the ultimate conflict of interest.

I am beyond thankful for you cherished patients who have chosen to stay in my care. I have shed many a tear over those who have not. But, each of you- some of whom I have cared for over 20 years-will get personalized, state of the art, highest  quality, affordable care directly from me with no delays or denials from 3rd party interlopers into your medical care and without me having to divulge your personal information to strangers. I am no longer booked 3 months out- you can see me today! I am enjoying more quality time with my patients- those of you who choose to see me because you 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. We will be the paradigm shift. We will forge a new and better way. I look forward to going down that path with you.


Kristin S. Held, M.D.


5 thoughts on “Letter to my patients- 4 months working directly for you, not third party entities

  1. Been following your essays and wanted you to know of my deepest admiration. If I were in TX, I’d move my medical care to you in an instant.
    Confident you know about Pamela Wible’s initiatives and you’ve availed yourself of the concierge model literature.
    Wishing you great success and fulfillment!

    • Thank you so much for engaging and taking the time to respond! Yes, I follow Pam and regard her and her efforts most highly. I pray we can forge this path for patients to choose care when government says NO. I wish you did live in Texas! I have a slot for you tomorrow!

      • And thank you. Sheepishly, I have to admit I just discovered the “notifications” tab on my wordpress account and so am only now replying. (Oh, the learning curve …) We’ll move forward, trying to provide exellent care and escape the indentured servitude imposed by payors and bureaucrats.

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