Despair and the Bear: The Patients, the Physicians, and the D.C. Cartel

The current state of government medicine is abysmal. The United States government forces us, our entire working lives, to pay them for Medicare and forces us to buy health “insurance” we don’t want. Then they tell us what medications we can and can’t have, what treatment we can or can’t have, and what doctors we can or can’t see.

They lie to us. If we like our health insurance, we can’t keep our health insurance. If we like our doctors, we can’t keep our doctors. And I really like my patients-no… I love them, but I can’t keep them.

I am praying for massive public outcry to replace the passively accepted theft and inhumanity of business as usual in our nation’s capitol. The squandering of 3 Trillion dollars per year on complete and utter dysfunction and insanity called healthcare is criminal.

Below is a patient’s letter that shares just a taste of my daily heartbreak. Notice the word choices of my dear patient: despair and painful stand in stark contrast to trusting and care.

An interesting phenomenon is occurring in me, a new coming of age, if you will. My once dilute tear streams of intimidation and fear have crystallized into solid rock salt streaks on my cheeks, kinda like subtle war paint, symbolic of my growing strength and courage. My sorrow has morphed into determination and laser focus. My mama bear instincts are on fleek.

Attention members of the inside the bubble D.C. cartel:

Hear us, out here! We’re not playing anymore. We, the very good people of the U.S.A, demand you fix your mess. Our eyes are on you, our roar is ferocious, and our bite will be more than you can bear.

Despair patient letter


Dear B____ and J__,

I can’t tell you how much I appreciate your handwritten and heartfelt letter. I was blessed to meet you back in July 1996, 20 years ago, and have had the great privilege and pleasure of serving as your ophthalmologist since this time. I hope you will share my letter far and wide, and particularly with our elected representatives who have so severely let us down.

You must know I traveled to Washington D.C. this week and met face to face with Mr. Andy Slavitt, Acting Administrator of the Center for Medicare and Medicaid Services. I am trying my best to fix this broken system that harms not just seniors, but all patients.

You need to know that I have agonized over changing my Medicare status. My own mom and dad are in your same predicament. You all have paid into Medicare since 1965 on the promise that you would receive medical care. Sadly, Part B Medicare premiums are going up, while access to physicians and ability to obtain needed medications and treatment is going down.

I have read extensively about what is in store for Medicare patients going forward, and I cannot ethically go along with it any longer. This is why I opted-out and continue to privately contract with my Medicare patients. Yes, the “opted–out” status is also called “private contracted” by Medicare.

I am forging a new path to provide top-notch, state of the art care to my patients at a fraction of the cost. I will always be here for you. I have a follow up visit for $45.00 now, should you have a problem and not be able to get in with your Medicare provider. Further, when you need cataract surgery, please consider comparing my fees. You may not know that Medicare does not cover laser assisted cataract surgery, lens implants that correct astigmatism, or multi-focal lens implants that allow you to see distance and near. If you plan on having one of these options, you will find my fees are substantially lower, and you will actually save money returning to my care.

My pledge to you, and all patients, is to fight for a solution that benefits patients, not insurance companies and politicians.

I will forward your records to you. I wish you both the very best. I will be overjoyed to see you any time you need me. Our patient-physician relationship never ends; it’s just taking a little detour. Again, thank you!

Warmest  Regards,

Kristin S. Held, M.D.


The Carrot and The Corn

Just got home from DC where I met with the Acting Administrator of CMS, Center for Medicare and Medicaid Services, and his team, to discuss the MACRA proposed MIPS/APMs rule, because I am fighting for the survival of the American patient. We are all patients. I read the convoluted laws and rules our government is imposing on us. I dissent. I propose solutions. I bought my own ticket, paid for my own hotel and cab rides, and bought my own food. I incurred debt in order to go; my overhead as a solo practitioner is huge, and the day out of the office went straight to the expense column. The income column remained empty.

I live my life grounded in principle and truth. I will fight for what is right. I cannot be bought.

I opened my laptop to report on my meeting and saw the JAMA piece disparaging and degrading physicians, implicating we prescribe drugs for patients because pharmaceutical reps bring us lunch.

My colleague, Dr. Meg Edison, posted an eloquent rebuttal on Facebook. I look forward to thousands of hard-hitting responses from physician colleagues across the country. Mine is not eloquent.

Physicians are a special lot. We are selected for admission into medical school based on flawless character, stellar and rigorous academic achievement, and a multitude of other factors that demonstrate we possess the requisite traits to survive the rite of passage one must endure to become a physician. I have the utmost respect for my colleagues. Throughout our lives, we have proven strong and courageous, trustworthy and honorable. From college and medical school, internship and residency, to fellowship and practice, we sacrifice our personal lives and work undeterred in service of others. Most importantly, we cling to our professional code of ethics and the patient-physician relationship.

In stark contrast, stand the political elite (with rare exception) who operate according to an antithetical code of ethics. Ironically, they are the ones who create and execute the very laws and rules, which they inflict on us, and destroy everything the physician holds dear- our ability to autonomously care for the patient, confidentiality, and freedom to innovate. We are constrained, if not indentured. Oppressed, if not abused. And we take it, our actions implying, “Thank you, sir, may I have another?” The insider elites, on the other hand, project their inherent tendencies to be bought and sold in pursuit of self-gratification onto us. They pass laws such as The Sunshine Act that was enacted along with the Affordable Care Act in 2010.

The DC insiders believe physicians can be bought and sold like they are. The Sunshine Act requires pharmaceutical companies to report to government everything they do with respect to physicians, and this information is posted on a public website. I had fun looking myself up to see what I had eaten for lunch, apparently in criminal fashion, over the past couple years.

Used to be, relationships between physicians and drug developers were collegial, intellectually stimulating and useful, provocative and inspiring. We would interchange ideas. What do patients need? Can they make a drug that cures disease X? Or make injury Y heal faster? Or relieve pain and suffering from condition Z? Or can they make it sting less, taste better, and go down or up easier? What are potential uses of their drugs, and what will make the drugs better? Now, it is a federal crime to even discuss “off-label” uses of drugs. We cannot engage in academic discussion. We cannot interchange ideas. Government says “No!” What a waste. I hate it. I’m bored to tears. Innovation is stifled. I prescribe generics of the same drugs I prescribed 20 years ago, except that they’re vastly more expensive now, and it requires jumping through hoops to get insurance companies and pharmacies to fill my prescriptions, which are now called requests.

Pharmaceutical representatives come to my office rarely now, but usually I’m busy seeing patients. They sometimes bring lunch, so we can talk while we eat between morning and afternoon clinic. Do members of other professions eat? Do other professionals go to lunch together? What about those elite DC lawmakers? Do they eat lunch with anyone ever? Do they “talk”?

Per the Sunshine Act, anything a physician eats must be reported to government to the penny. The elites and their band of merry cronies and enablers now use this information to portray physicians as hungry, cheap-date, sell-outs, who prescribe whatever the drug rep peddles for chips and tea. This is insane.

Recently, I invested in an innovative laser to improve cataract surgery for my patients. The company that developed the laser hosted a physician speaker, who had performed thousands of procedures on the laser, to speak in my hometown. I was exhausted after a long day at work and wanted to see my family but knew it would benefit my patients if I listened to this more experienced surgeon as he related the pearls and pitfalls of this new technology. The talk was at a distant hotel, and dinner was served. I couldn’t resist, I had a few brussel sprouts, a few bites of chicken, and several tastes of a dessert sampler, as the presentation progressed. Then the sign-in sheet was passed, and I was asked for all my demographics, including my medical license number, Medicare NPI, and if I had consumed a meal.

I suddenly felt ill. Dirty. Violated.

Had they filmed me eat? Had I eaten too much? Had I had too much cobbler and not enough sprouts?

I refused to sign. I admit it. It was all just too insane and surreal. Insulting and juvenile.

If they really needed us lowly physicians to attest to whether or not we had “consumed a meal”, in the world of mistrust and malfeasance they had projected on us, and in the vein of the quality measures and MACRA MIPS they had passed to control us, they needed proof positive. A better measure would be not if we consumed the meal, but if and when we actually passed the meal.

In the future, maybe government will amend the Sunshine Act to require all pharmaceutical and device companies to serve at least one food item, which the physician is required to consume, that contains a readily identifiable food product like corn, so the physician can prove positively at the site of production that the food was actually consumed. The transit time would confirm that the food was indeed ingested at the respective company’s event. The physician could then photograph the product using a cell phone and securely transmit the data to an interoperable, bidirectional, unblocked government portal. The physician could then be scored on efficiency and quantity of product transferred. Rapid response would be correlated with rapid transit time, which would be considered a high outcome measure, while high quantity would be regarded as over-utilization of resources and would be scored poorly. An overall composite performance score would be given and publicly posted. Based on the score, the physician would then be rewarded with a positive payment adjustment factor or penalized and have to pay the device company back for the price of the dinner and the speaker’s airfare and meal. Using the government’s “rebranding of key terminology” strategy, this new model is now called the “the carrot and the corn” model, as opposed to the older, unfriendly-sounding “the carrot and the stick” of days gone by.

I feel better now.

If you think I’ve lost it, just read the MACRA law and its proposed rules, you’ll see I’m just applying their law. If you think their law is crazy, go to the CMS website and post your comments by June 27. Fell free to tell them to stick it where the sun don’t shine.





The Physician says: “Save the Patient!” Will the federal government listen?

Monday, June 20, 2016

Dear Mr. Slavitt and Esteemed MACRA Rules Team,

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.

In spite of the federal government’s pledge not to interfere with the practice of medicine, the law has been continuously amended such that it is now in complete violation of Title XVIII SEC. 1801- our profession, the heart and the art of medicine, commandeered, if not lost.

MACRA is the absolute antithesis of what government promised with Medicare. It massively increases government control over patients, physicians, and the practice of medicine, proving once again, a government pledge is fleeting and begs the questions: What is in the MACRA proposed rules? How must the rules be modified to achieve what is best for patients? And what do the rules portend for the next 50 years of medicine in the US?

Tragically, medicine has been politicized. One side says, everyone’s stupid, and no one can be trusted, so promulgate more laws with voluminous rules, and take everything over fast. The other side says, it’s a failure, so don’t try to fix it, let it fail under its own weight and start over.

The physician says, save the patient.

I’m here for the patients, to dissent to flaws in the MACRA rule and to offer solutions for the patients. I’m here to advise you that the code of ethics embraced by the majority of US physicians and our allegiance to our patients and the patient-physician relationship has been vastly underestimated.

I have read MACRA and the MIPS/APM rule word for word. I have read and reported on the Affordable Care Act in its entirety, as well as the HITECH ACT contained in the American Reinvestment and Recovery Act of 2009 and the aspects of the law pertaining to the investment in data infrastructure for comparative effectiveness research (CER).

I have practiced medicine for over twenty years, from academic medicine and resident education to the front lines of patient care in private practice, having transitioned from a participating Medicare provider with in-network agreements with virtually all commercial insurers, to Medicare non-participating with select commercial agreements, to Medicare Opted-Out/private contracted with no in-network agreements whatsoever as of 10/01/2015.

Burgeoning coercive federal healthcare law and increasing 3rd party intrusion into the patient-physician relationship collided head on with my life of service and commitment to my patients, our confidential relationship, the Hippocratic Oath, and medical ethics. I asked myself, if I’ll do this, what won’t I do?

Our specialty and professional societies like the AMA no longer represent the will of the physicians and patients. Once prestigious, revered organizations like the ABIM, under the ABMS, have come under scrutiny for unscrupulous financial activities including a professional testing for profit and MOC scheme that undermines the trust of all physicians across the country. Sky-rocketing costs of premiums, deductibles, copays, and cost-sharing with Obamacare exchange plans and all commercial insurance accompanied by restrictive networks of physicians, poor patient access to care, emergence of 4th party entities like pharmacy benefits management companies requiring prior authorizations, step edits, and quantity limits, denying prescriptions, and exploding drug costs, and routine prior-authorization delays and insurer denials for operations, subjecting patients to prolonged pain and suffering, have become the norm. According to the 2015 National Health Interview Survey published by the CDC, the same number of people remain uninsured now as 10 years ago, but more patients are on Medicaid (government welfare) and fewer on commercial insurance. Medicaid and Medicare are in abysmal financial condition putting the US and its individual states at risk of economic collapse in the not too distant future. Enabling such a dysfunctional system is unethical, if not inhumane.

I seek a better way and work toward that end for my patients.

MACRA was passed with massive bipartisan support as the SGR repeal. In reality, it was a replace bill that we must ensure is an improvement, not a Trojan horse. It sets forth the Merit-Based Incentive Payment System, Alternative Payment Models, and the Composite Performance Score, whereby physicians are scored and incentivized or penalized based on their performance on a complex, experimental government rubric.

A false premise of epic proportion is that a government rubric is necessary to drive physicians toward quality performance. This implies that physicians are not providing high quality, high value care. The truth is we physicians spend our lives training and serving our patients to the very best of our abilities; we do not need a government rubric. We will repudiate the composite performance score.

The MIPS, APMs, and CPS rubric are untested, unproven metastases of underlying medical economic problems born of Medicare, Medicaid, Obamacare, and commercial health insurance. The rules further aggravate the problems by creating layers of new intermediaries with billions of dollars of new expenses, changing the intent of the law, and violating people’s rights. The money does not exist, and the people will resist.

While we approach solutions from different perspectives, we share our common goal. We seek what’s best for the patients.

While it is said, that sadly, people will be hurt in times of change. We cannot settle in haste for a suboptimal rule when the very lives of the American people are at stake. There can be no casualties of change with MACRA.

Thank you for the opportunity to engage in serious discussion at this level. Our time together is brief, but I pray this is the beginning of ongoing dialogue producing meaningful results. I appreciated the opportunity to speak with Jean Moody-Williams prior to the meeting and submit this outline in advance having seen how little time 30 minutes is for such crucial conversation.

I have gone through both the 962 page and 625 versions of the rules. These comments will refer to the 625 page version downloaded from The Federal Register. Here are my dissents and proposed solutions:

1.The entire concept of a MIPS/APMs/CPS, whereby government designs a perpetual rubric for scoring and accordingly incentivizing or penalizing physicians financially in order to drive behavior, is ill-conceived. The US federal government does not possess the authority to drive individual physician behavior by paying out more money or financially penalizing them. This is better called enticement and extortion. The premise that this is needed is false. The composite score must be eliminated.

The core of good medicine is the simple and sacred patient-physician relationship based on mutual trust and communication. As physicians we spend our lives acquiring the knowledge, skills, judgment, wisdom, courage, and moral code to do what we do. We are not selected for acceptance to medical school unless we exhibit flawless character and requisite traits worthy of the position. We do not complete our intense training, best called a rite of passage, until we are 30 years old or beyond. The patient-physician relationship is like no other, from the physician perspective. In fact, it often supersedes one’s relationship with family, including spouse and child in times of greatest need. When on call, in the O.R., when there is a crisis, complication, or emergency, we attend to the patients. Our families know this. This can’t be put in a rubric or IT analytics. It’s about commitment, compassion, trust, responsibility, ownership, and a professional code that cannot be coded by government.

Those of us in the smallest practices have this down to a tee. Our patients have our cell numbers. We live and work in the same communities. Our staffs are well-trained, cross-trained, fully employed, and loyal. We have trimmed our budgets, negotiated lower fees, cut waste, paid off equipment, and make things easy and accessible for our patients. Your rubric is an intrusion, an insult, and a sign of lack of insight into that which you seek to control. I invite you and your staff to visit my office, my staff, and my patients in San Antonio. I would love to show you, first hand, a real life model of quality/value medicine provided with greatest access at a fraction of the cost- and how top down intrusion from government is making it more difficult and more expensive for my patients and me.

2.The MACRA rule will harm small practices and patients and put us out of business in short order. Are we to presume this is the intent of MACRA? Is this the intent of your rule? I think not, but let’s look at your numbers.

Table 64 (on pages 378 and 379/625) projects that 87% of Eligible Clinicians who are solo practitioners will sustain a negative payment adjustment, as will 70% of those in practices of 2 to 9, and 60% of those in practices of 10 to 24. 73% of physicians in practices less than 25 will receive a negative adjustment. 60% of all eligible physicians practice in groups less than 100. Loss of these practices would shatter patient care.

My question is, what are the ramifications of this for each individual state?

According to the best information I could find out from the Texas Medical Association, over 60% of Texas physicians, who engage in patient care, practice in groups of 1-3. Under MIPS, 87% of such practices will be forced out of business. In an economically diverse and geographically vast state such as Texas this law will be devastating to patients. They will lose their doctors and access to care. Lives will be lost.

A July 2015 article from the AMA reveals the majority of America’s physicians still work in small practices- “These data show that the majority 60.7 percent) of physicians were in small practices of 10 or fewer physicians, and that practice size changed very little between 2012 and 2014 in the face of profound structural reforms to health care delivery,” said AMA President-elect Andrew W. Gurman, M.D.

Have you looked at the ramifications of MIPS on a state by state level? I would like to see these numbers.

So, you might say- there is assistance for small practices. Based on 2014, only 63% of small practices were participating in PQRS, and you might predict more will participate and do better participating in MIPS. I contend, fewer of us will participate in MIPS.

Of note from his inaugural address June 17, is that Andy Gurman, M.D., AMA’s new president who is an orthopedic hand surgeon in solo practice, said “I don’t have an EHR,” and he found it easier to forgo the enhanced payments he would get under the federal “meaningful Use” regulations for converting to electronic records. “I just take the penalties,” he said.

While you sell MIPS as less burdensome, in reality, it is intrusive, expensive, and fraught with unlimited potential for mistakes that could harm patients and the practice. Many of such practices are not going to adopt CEHRT. A recent publication showed 2-4% of physicians have had ransomware problems and even more have had data breaches. You are familiar with the arguments against CEHRT- that it is not specialty and practice specific, that it makes one less efficient and distracts from patient-focused care, and so on. I predict fewer will participate in MIPS, and a doctor shortage tsunami is incited under this plan.

If the intent is to drive physician behavior, in other words, if your intent is to end small private practices and drive physicians to large groups, you will fail, because we will not do it. Patients will be harmed. Many like me are not subject to such malevolent manipulation. We will find a way to care for our patients outside the constraints of this rule. (While not the intent, it may be inferred based on your numbers.)

So, you might say there is money and technological assistance to help us participate. We don’t want or need that. It serves no purpose. (From the rule-Technical assistance to MIPS EPs in small practices, rural areas, HPSA’s-practices less than 15 ECs (p 30). The SECRETARY is required to enter into contracts or agreements with appropriate entities (such as quality improvement organizations, regional extension centers, or regional health collaboratives) to offer guidance and assistance to practices of 15 or fewer -a separate guideline coming. Page 30 MIPS and APMs RFI published in Federal Register Oct 1,2015 (80 FR 59102, 59102-59113)

Where is that money coming from? It is better spent on patient care than expanding new classes of intermediaries to extend government reach into the physician’s office. This is a prime example of administrative waste.

You may say, well, the negative adjustment factor is only 4% instead of the 9% cut that was coming with SGR cuts. But that is a partial truth. First, the 4% cut will be imposed on the lowest quartile of compliers, while the best compliers will get an 8.7% positive adjustment and bonus for an overall disparity in pay of 12.7%. This is just for the first year, 2019, based on work done in 2017, just 6 months from now. Each year the penalty and resultant pay disparity will increase, and in a mere 3.5 years the penalty will be 9% compared to the incentive and bonus of 9.9% for a difference of 19%. MIPS will end small practices within the next few years if this rule goes forward as such. Many like me will opt out of Medicare and commercial insurance pursuing successful practice models outside MACRA, and patients will be harmed.

Doctors can care for patients without MACRA; MACRA can’t care for patients without doctors.

My suggestion is, let practices of less than 100 be permitted to choose not to participate in MIPS/APMs and settle for a 0% adjustment factor, in lieu of so much expense and interference. This will save money, resources, and error.

Who do you not trust? The medical schools and residencies that trained us? Physicians as a whole? I trust us, the physicians and patients at the small practice level, more than any other professional entity in the world. The need for MACRA is a false premise. Spend money on patient care not false premise.

Large practices and massive healthcare organizations with inherently more cogs, waste, and potential for problems, such as hospital systems and ACO’s, can remain subject to MACRA/APMs.

3.The ONC and its ONC-ACBs absolutely must not be granted unrestricted access to CEHRT individually identifiable protected health information without patients’ authorization under any circumstance (page 33/625). This constitutes unreasonable search and seizure of patients’ most intimate papers and effects- a violation of one’s most intimate, private information. Knowing a federal government agency has self-appointed itself with such authority makes it a violation of the physicians’ professional code of ethics to even engage in use of CEHRT. Our ethical duty is to keep our patients’ data from government, not transmit it to government. The potential for misuse of such information is unacceptable.

Further, systems do not operationally exist that can secure such information from ransomware insertion and hacking of patients’ demographic data as well as all details of their medical history past, present, and future. Patients’ medical records are not subject to government surveillance, particularly on site for in-the-field surveillance.

What is the annual operating budget of the ONC, and what is the estimated cost of the ongoing CEHRT surveillance and the ONC-ACBs? This must be struck.

Who will bear the ongoing cost of hardware, software, coding updates and upgrades? What is the projected cost of this to all parties? (For example, when will ICD-11 and so forth be implemented?) Who pays for this type of ongoing expense that takes resources from actual patient care?

4.What is the projected cost of the massive expansion of 3rd party intermediaries to collect, analyze, and report patient data including the self-nominated QCDR’s, Health IT vendors, qualified registries, and CMS-approved survey vendors? Who bears this cost burden? The money would be better spent on patient care.

The random CMS audits of such data, including patient medical records, are unacceptable. The last thing we need is layer upon layer of new administrative costs and potential data breeches. The fact that CMS wants the data kept for 10 years at minimum to eternity with 30 day notice is unacceptable. All the surveillance and auditing begs the question-who don’t you trust. Adding new layers of intermediaries adds new layers of mistrust.

5.With regard to the Other-payer and All-payer options- CMS is expanding its scope of power to incorporate commercially insured patients and their data under the agency’s control, not just Medicare. All patients and all insurers are not subject to CMS jurisdiction. This must be delayed.

6.The collection of MIPS and Non-MIPS data by 3rd party intermediaries like the QCDRs and Health IT vendors of All patients and all insurers is beyond overreach and must not be sanctioned. This must be debated at length and defined succinctly.

7.The definition of EC’s and EPs cannot continue to be modified. This changes the scope of power for many and results in overutilization of resources by midlevel clinicians and increased potential risk for patients.

8.The power of the Secretary to reweight categories is risky and should be limited and defined

.9.As far as capitation, if the HMOs failed, as have many of the co-ops and ACO’s, what evidence points toward successful APMs going forward?

10.The operational feasibility by January 1, 2017 is 0 to none. Delay.

11.The public reporting of physicians CPS’s is misleading and oppressive and must be eliminated.

12.According to P28, the Innovation Center works directly with CMS and has collaborated with these federal agencies: CDC, HRSA, AHRQ, ONC, ACL, HUD, ACF, SAMHSA, and “colleagues throughout the federal government” to test new models and execute mandated demonstrations. This is far too much federal agency intrusion and risk for data breech, individual targeting, and worse when considering the army of 90,000 IRS agents. These agencies must be restricted form interfering with the practice of medicine by agency proxy. Patients’ data must be protected from intrusion by so many potential data seekers.

In conclusion, MACRA and its rules create a whole new level of intermediaries with associated expense. The MACRA, MIPS, and CPS rubric are convoluted, subject to change on a whim, expensive, and unnecessary. Application of this theoretical, untested, system to all patients and all insurers to collect all data, MIPS and non-MIPS, using a new level of intermediaries overseen by ONC and CMS without patient or physician authorization is not an acceptable plan. This unnecessarily complicates and increases administrative cost and resource utilization instead of facilitating and improving patients’ care.

Exclude the multitude of federal agencies from interfering in healthcare. Simplify and consolidate government agencies. Encourage individual patient responsibility and transparency. Limit dependency on Medicaid. Medicare must be reformed, but this isn’t the way to success. Instead, uncouple PART A from Social Security, create voucher option for Part B, and allow patients to choose and purchase their own plans if so desired. Allow a voucher for Part B and allow out-of network billing per patient choice.

This MIPS/APMs MACRA rule is not ready for launch in 6 months. The last thing we need is a rerun of the failed launch of 2013. Do not go forward with MACRA, MIPS, or APMS now. Do not allow ONC-ACBs or other entities access to individually identifiable protected health data.

Thank you and I look forward to working together toward healthcare solutions. I have many specific examples from the trenches of real life practice that will save vast amounts of taxpayer money and more importantly, patients’ lives.

Respectfully Submitted,

Kris Held, M.D.














Another Physician Dissent to CMS MACRA Rule

Good afternoon, Ladies and Gentleman,

My name is Dr. Richard Armstrong. I am a general surgeon who has been in practice for 35 years since completing post-graduate training. I have been in the military, in academics, in private practice and now employed. I have watched the development of the federal medical bureaucracy since 1976 and opposed more government intervention then in public in a letter to the Washington post. I did this as an active duty naval officer and received hundreds of letters of support.

In 2009 after President Obama spoke before a joint session of Congress about health care reform, I wrote to him with a simple specific request. I asked him to please speak with the doctors on the front lines, the dedicated physicians and surgeons who care for all of you and your families day and night…24/7. The fellow human beings who are there for you when you need us and who passionately care about our profession and our patients. Of course, my plea went unheeded, so I joined a group of concerned physicians and traveled to Washington to read my letter in public on October 1st, 2009. This was the beginning of a national movement to return the leadership of our proud profession to those who understand what it is to care for individual human beings, one at a time, face to face, with dedication, compassion and excellence. That movement is growing.

I opposed the ACA, not because we didn’t have problems to be solved in American health care, rather because building a much larger and more complex federal bureaucracy is not the way to do it. Bureaucracies grow themselves and in the process they steal valuable resources and more from those who support them…American citizens. The administrative arm of the Executive Branch of our government is given “instructions” from Congress to carry forward. This is how a “small” law like MACRA can turn rapidly into the proposed final rule we are discussing currently, and frankly, it is a mistake.

We understand that the Medicare and Medicaid programs must work to purchase value for those who are accessing the program and we also understand that the underlying flaw in these programs has been present since they passed in 1965. You see, demand for these services will always outstrip the ability of our medical professionals to supply them…always. Congressman Wilbur Mills knew this leading up to the passage of Medicare which is why he opposed it…as a Democrat.

My friends, MACRA, the APMs and the MIPS do not “simplify” things for American patients and their physicians, they make them more complex and more expensive, but the money is spent unseen by the patients and out of their control. We need to end this spiral of building larger and larger complex bureaucracies which is essentially an “inside the beltway” disease. In our banking sector it has destroyed local and community banking. Now in the medical sector we are destroying local and community hospitals and the private practice of medicine, while supporting and encouraging consolidation and corporatization of medicine.

I would assert to you that it is not the federal government who should be defining what quality medical care “looks like”, rather it should be the patients, the consumers of health care services who know quality when they see it who should be the final judge.
We need to move toward more consumer oriented health care for ALL Americans and not fall into the trap of believing that we are somehow “smarter” than the millions of people who access this care daily.

We need to recognize that the complex act of reporting metrics to the federal government and others has not been shown to improve quality as was documented well in the recent “Health Affairs” article from the Weil/Cornell Medical Center which points to the tremendous cost and loss of productivity this process causes for American physicians.

Yes, the SGR was flawed and needed to be reformed. However, what we needed was true simplification and if CMS wanted to collect data, then put a very simple process in place which physician practices can understand and is based on positive incentives which are meaningful and add to the quality care which we work to deliver.

Physicians account for between eight and ten percent of the budget of CMS and yet it appears that we are being singled out for what feels like punishment. My colleague and friend, Dr. Mike Koriwchak is having a constructive and ongoing dialogue with Mr. Slavitt about these important issues. We represent the Docs 4 Patient Care Foundation which has been working tirelessly on behalf of patients and doctors since 2009.

We appreciate the dialogue and respectfully request that this final rule be modified and if possible significantly delayed until American working doctors have a chance to learn what this means for their patients and their future.

Richard A. Armstrong MD FACS
The Docs 4 Patient Care Foundation

My Texas Physician Colleague’s Letter of Dissent to CMS Regarding MACRA Rules

June 15, 2016

My name is Darren Meyer, MD, and I am in a two-physician psychiatric practice in McKinney, Texas. I am currently both a TriCare and a Medicare provider. I have read through much of MACRA and I must say again, as I had posted earlier, that I am not in favor of implementing this Act. A particular concern I have is how quality of care and outcomes are to be measured and reported. Let me share two recent clinical cases to illustrate my belief that the recommended quality measures and reporting mechanisms cannot be relied upon as accurate indicators of quality of care, and should not be used to determine physician reimbursement.

A middle-aged female patient of mine who has been under my care for years returned for a follow-up visit a few weeks ago. She was clearly not feeling well. She had recently had back surgery and had spine films taken the day before. Those x-rays showed bilateral patchy infiltrates as an incidental finding to her intact spinal hardware. Her orthopedic surgeon recommended she take that report to her primary care physician. She was there this morning, and saw the nurse practitioner. The nurse practitioner told her she needed to go to her pulmonologist. She called her pulmonologist, and was told they would get back with her with an appointment time. My patient has limited mobility and is not able to drive. Getting to and from all of these other appointments is extremely difficult for her. I have a nurse who works with me in my office. You should know I had to hire her two years ago to help me keep up with my attempt to be EHR-compliant, an endeavor I soon abandoned as one additional staff member was all we could afford to hire. I had my nurse check my patient’s vital signs, and we found she had a temperature of 100.1°F and an oxygen saturation of 92%. Her son was with her, and we advised them to go to the emergency room. She called the next day to tell me that she had been admitted with bilateral pneumonia, and she thanked me for sending her to the hospital right away. Now keep in mind, I am a psychiatrist. But I have not forgotten my medical training. I know her other physicians practice in large groups and they have marvelous IT staff and they generate very pretty electronic records so I assume they would score quite well in their management of this woman’s case. But I find no means under MACRA for me to receive adequate credit for the time that I spent to listen to her concerns, to perform what was largely a non-psychiatric evaluation, and to make a potentially lifesaving referral. I am the type of physician who will be penalized under MACRA, while the box–checkers will be rewarded.

I had a similar outcome earlier today. There is a gentleman who has seen me for years who has had chronic recurring infections that have not responded to multiple rounds of antibiotics. He has been to an excellent dermatologist and an infectious disease specialist. I have received progress notes from those practitioners. They are clearly computer–generated records, and very likely would pass every MACRA quality review. But it was me, the psychiatrist, who suspected that he had some type of immunodeficiency syndrome and referred him to an immunologist. My suspicions turned out to be correct, and he will likely begin gammaglobulin infusions soon. I don’t find a checkbox under MACRA’s psychiatric quality measures that would credit me for anything other than documenting that he has continued to take his antidepressant medications routinely. And I’m by no means unique. There are thousands of doctors who take the time to listen to their patients, who truly care for them, who try their best to help them, and who are at their wits end with more forms to fill out or reports to file when all they want to do is take better care of their patients, not chase brownie points on an EHR.

So from MACRA, this is what I see in one of the tables:

 28374 Federal Register / Vol. 81, No. 89 / Monday, May 9, 2016 / Proposed Rule


Percent with negative pay adjustment: 68.8%

Percent with positive pay adjustment: 31.1%

Aggregate negative impact: -$29 mil.

Aggregate positive impact: +$8 mil.

At a time when it is clear that mental health services need to be expanded, why are you proposing a net negative reimbursement to psychiatry? According to CMS data as reported in Modern Healthcare, “Among adults aged 18 through 64 with Medicaid coverage, approximately 9.6% have a serious mental illness, 30.5% have any mental illness, and 11.9 % have a substance use disorder.” ( When those adults turn 65, or at an earlier age if they are determined to be disabled, they are all going on Medicare. Who is going to be there to take care of them?

And as reported in Modern Healthcare by Maria Castellucci on June 15, 2016,

“A House committee Wednesday voted unanimously in favor of advancing a sweeping mental health reform bill. The Helping Families in Mental Health Crisis Act passed 53-0 in the House Energy and Commerce Committee and is now going to the full House floor. “

( Again I have the same question: If just as laws are being proposed to expand mental health treatment, why is CMS considering cutting reimbursement to two-thirds of the few psychiatrists who still accept Medicare assignment? And for the third who might receive a small increase, don’t you see that the measures proposed to decide who is rewarded and who is punished are only minimally indicative of what actually happens in real clinical encounters between patients and physicians? You are not collecting meaningful data, and therefore cannot come to accurate conclusions as a basis for payment. You will reward large impersonal corporate practices with the dollars you withhold from physicians like me, who have chosen to spend more time listening and less time typing. That makes no sense and it’s wrong on all counts, so I ask that MACRA not be implemented at all until these and so many other intrinsic flaws are corrected.


Darren Meyer, MD

McKinney, TX

Tearless and Fearless.Surviving the patient breakup. Blue Cross Blue Shield- you got some splainin’ to do!

It’s Friday afternoon. Tears of despair stream down my face. It’s funny, I never cried once throughout my entire breast cancer ordeal, when I was the patient- I guess because I had hope and faith then. For the first time in my professional career, a patient actually hung up on me.

The patient-physician relationship is unique, based on mutual trust and communication. It is like no other. I have countless such patient-physician relationships that span 20 years and four generations of many a family.

I have known the patient that broke up with me for two years, since I removed an advanced cataract from his eye and restored his vision to 20/20. At that time, I had “in-network” agreements with Medicare and Blue Cross/Blue Shield his secondary insurer. I severed all agreements with third party insurers last year. This year I saw him as an “out-of-network” provider. I performed a medically necessary laser procedure to improve his vision in my office in February, saw him in follow-up in March, and he was doing great.

Today he walked into my office angry and accosted my staff about an “Explanation of Benefits” he had gotten from Blue Cross/Blue Shield his secondary insurer. He made a scene in the office in front of my other patients and disparaged 4 wonderful women who work at my front desk. He was fed up and frustrated. He had filed with BCBS for out-of-network benefits with great frustration. Needless to say, after four different rejections and requests for more and different information each time, Blue Cross finally applied $275.00 to his deductible. He still did not understand the process and demanded a refund of $125.00.

Here’s the deal, he paid me a global fee of $400.00 for a complete examination, the laser surgery, and post op care. Had he used an “in-network” doctor and had the laser at an “in-network” facility the negotiated allowable would have been a surgeon’s fee of $275.00 and a facility fee for use of the laser of $700.00. He would have had to come out of pocket $415.00 after all was said and done. I actually saved him $15.00 and provided access and convenience. BCBS paid nothing.

Here’s the first sad part. Had he gone “in-network”, he still would have paid the $415.00, and BCBS would have had to pay the “in-network” facility $595.00. That extra $595.00 goes to a hospital or entity that owns the laser, and the extra expense results in higher premiums and so on for BCBS patients, and in the case of Medicare, it costs the taxpayers. In my situation, I bought the state of the art $25,000 laser and maintain it in my office-a facility I built and own. Yet, I charge no additional facility or laser fee, and it cost BCBS nothing. You would think BCBS would be thanking me for saving them $595.00 and encouraging such responsible business practice. But, then again, this is the age of Obamacare and MACRA.

Second sad part. I spent all afternoon trying to figure this out with BCBS. They will try to figure out their calamity of errs by the 15th via a conference call with multiple involved parties. The EOB they sent the patient told him I was an “in-network provider”. He thinks I deceived him. I have yet to see a copy of that. I notified BCBS in no uncertain terms, I was “out-of –network” last year, trust me. That’s another story in itself.

I called the patient to explain all this, and he said it was just too much of a mess to try to file with BCBS and although he liked me, it was not worth it, even if he saved money himself and saved money from being wasted by the dysfunctional healthcare system. As I tried to explain I was trying to do the responsible thing and create a new way that saved money and was better for patients and our flailing healthcare system, he just said he doesn’t care, he’s done, and hung up on me.

I blame BCBS for abusing my 71 year-old patient. BCBS intruded into a valid patient-physician relationship, undermined, and destroyed it. They lied to my patient. Ironically, I saved them $595.00. But, in reality, they have no idea what’s going on. What is happening to the other millions of patients they “insure?” How much money are they squandering?

My tears have dried up. I realize my breakup won’t be the last. He didn’t value our relationship or me as his physician and what I was trying to do for him- for all patients, for the economic viability of our country. He wants no hassles, at any cost.

What about BCBS? Well, they got some splainin’ to do. We’ll see what they say on the 15th.

Is BCBS really that inept and wasteful? Are they happy to pay off in-network facilities at the expense of patients and physicians? Or, could the patient harassment be intentional to punish the patient for going outside the network? Could this be an attempt to punish me for being “out-of-network” and put me out of business? What if the patient reports the fiasco to the state medical board? Then I will have to defend myself because of BCBS BS. It is becoming risky and hurtful to stay in medicine.

I will cowgirl up and carry on as long as I’m able. I pray for my former patient. I thank God for those who choose to understand the insane system and stay in my care. It will serve them well in the long run. I will fight the intruders in defense of the patient-physician relationship to my last breath- smiling, fearless, and tearless.

Happy Friday.

Daily Dissent 9 to CMS’ MACRA proposed Rule

Friday, June 03, 2016

Daily Dissent 9

Dear Mr. Slavitt, Acting Administrator CMS,

I am pleased to see my comments finally posted on the CMS site. Although I have been submitting them daily for the last 13 days, they were held until yesterday and posted at once. A CMS employee was kind enough to call me at my office yesterday to inform me that my comments could not be posted, because they contained “proprietary information.” I was perplexed by her assertion having painstakingly read the law and rule and citing supporting information verbatim from the proposed rule. Turns out the banned “proprietary information” was simply the name of a government agency official who had targeted individuals based on political preference and the name of a government-contracted ACA economist who had taken advantage of what he called “the lack of economic understanding of the American people” in his economic design. Further, she wanted me to submit all comments in a single attachment and informed me I could get a confirmation email. I told her I believed she was suppressing my speech and that she could redact the “proprietary information” then publish my dissents individually as intended. I informed her I did not want my comments to show up obscurely as a single paper clip icon, but as 8 individual ready-to-read dissents. I further told her, not only do I know about the email confirmation option, but I have screen shot and photographed my 8 confirmation numbers- just to be safe. You see, I have spent countless hours reading the MACRA laws and rules, and I want truth to be told to my fellow Americans, who in recent history have been deceived by what you and your coworkers in the multitude of Executive Branch departments and agencies say is in the laws vs. what truly is in the laws. I would love to name names of government officials who told us things like, “we’ll have to pass the law to see what’s in it” and “if we like our doctors, we can keep our doctors” to factually back up my point, but then this dissent might be withheld from posting on the basis it contains “proprietary information” as well.

The proposed MACRA rule is an assault on the American people. Unless struck down and MACRA repealed, your agency, CMS, will have expanded its powers in unprecedented and unconstitutional fashion. The rule grants CMS access to any and all protected health information of ALL patients in the US without their authorization via a new class of intermediaries that must keep the data for CMS audit for 10 years minimum, if not a lifetime in targeted cases. My 8 prior dissents address this in detail.

The proposed rule defines its All-Payer-Option, which is single-payer, government-run medicine.

The proposed rule incentivizes physicians and hospitals to merge into huge groups, like failed HMO’s of the ‘90s, that must comply with your data reporting, including maintaining interoperable, bidirectional, unblocked certified electronic health records that must be available for surveillance during all relevant times, including on-site inspection.

Physicians will be graded and receive a Composite performance Score from 0-100 for following your top- down rubric in grade school fashion- except that the scores will be publicly posted to intimidate, oppress, and humiliate those of us who will not comply and to glorify those who best do your bidding. Those with the high scores will receive more money from you. Those with the low scores will be penalized monetarily and forced out of business in short order. An example of a Clinical Practice Improvement Activity Measure for which a physician will be rewarded with 20 points by CMS is creating or contributing patient mental health/ behavioral health data to a national, state, or local registry. The potential for malfeasance with government control over such data is chilling. The MACRA plan to bribe, extort, coerce, and punish physicians in order to drive their behavior is more suitable for the Mafia than the US government.

What MACRA and its proposed rule do is require physicians to violate their professional code of ethics, betray their patients, and turn everything over to your agency. And on whose authority do you do this? My allegiance is to my patients, and my job is to keep their private medical information from you not transmit it to you. I will treat them according to my time-honored professional standards not CMS’ global population-based government experimentation.

Finally, I have looked at the projected costs of this fiasco as outlined in your rule. Hundreds of billions of dollars that could be better spent on patients or kept by taxpayers will be squandered on a whole new bureaucratic wasteland of intermediaries leeching off IT and data marketing. Groups like the ONC-ACBs, QCDRs, and Health IT Vendors will siphon hundreds of billions from patient care. And if these bodies and registries are disqualified, the physicians and their groups are left holding the financial burden and assuming the financial risk. Your pet insurance and IT companies stand to make billions at minimal risk. I read one projection that an individual physician could be out $33,000 and a large group up to $6,500,000 per year if the ONC-ACB, QDCR, or other new bureaucratic intermediary they work with is suspended or disqualified. The lobbying efforts (money and power) and incestuous conflict of interest (money and power) at play here is beyond epic.

We really must talk. I will email you this weekend. You have my email and phone number as well. Time is of the essence as is the lifeblood of the USA and her patients. The MACRA rule must go and MACRA must be repealed.


Kris Held, M.D.

Dr. Darren Meyer’s Dissent on the CMS proposed MACRA rule

A courageous Texan physician colleague, Darren Meyer, MD, shared his comments to CMS with me. Please, take heed of his comments and share yours with CMS before the deadline,  June 27, 2016. I personally have submitted a series of 8 Daily Dissents to CMS and have yet to see them posted, while others are posted within a day of submission and since the submission of mine. Please, read my previous posts and take heed of my comments as well. Then post yours. Thank you Dr. Meyer for allowing me to share your comments. You are a blessing to your patients and our profession. Here are Dr. Meyer’s comments:

Darren Meyer, MD

McKinney, Texas

Memorial Day

May 30th, 2016


As I tried for formulate some of my thoughts about why I am opposed to the implementation of the MACRA, my initial thoughts were that the whole idea and the assumptions on which it is based are so demonstrably false that trying to address particular concerns about how this or that item is scored or reported is pointless.

My concerns are based in part on the current situation with the VA’s health system. Despite what may be $65 billion in VA healthcare funding in 2017, tens of thousands of administrative positions, and a massive data collection and reporting system, the VA cannot generate accurate quality data that translates into meaningful benefits for veterans seeking care. Consider the following excerpt from the VA’s investigation of alleged manipulated wait times in the North Florida/South Georgia Veteran’s Health Center. This report was issued in 2008 regarding events from years prior:

“We substantiated the allegation that when schedulers created appointments for some new

patients, the use of non count clinics prevented the patients’ actual waiting time from

being accurately assessed.”


“Although the Director’s Fiscal Year (FY) 2008 Performance

Plan included patient waiting times as a performance measure, it was not a “mission

critical” measure and only accounted for 5 percent of the Director’s rating. Therefore,

the understatement of waiting times that occurred from creating new patient

appointments in non count clinics did not significantly affect his performance appraisal.”

(VA OIG Report No. 08-03327-35 December 4, 2008.)


This points out several systemic flaws in medical performance data collection, reporting, and evaluation:

1) If the people entering the data are not telling the truth, or even just making honest data entry errors, everything that follows is useless. In many systems, employees are pressured to make the numbers look good so their managers look good. It’s human nature, and forced implementation of the MACRA will just create more pressure on the data collectors to enter the “right” data. Even if there is no deliberate manipulation of the data, the volume of data entry the MACRA requires in order to be a compliant, quality provider is so burdensome that it is certain to fall short of the accuracy it will claim to possess.

2) Decisions about what is “mission critical” determine the value of the reports generated. In this example, patient waiting times were not considered critical. I am certain the veterans waiting for care would feel otherwise.

3) How different evaluation criteria are weighed also determines the conclusions one makes, such as the scoring system of bonus points and such built into the MACRA. Again, whoever decides what items count for how much determines the reported outcome more than the real outcome. In the above example, since wait times were given so little value, the Director came out looking like he was doing a great job, when that was not the case. The MACRA is going to do the same thing. And no amount of changing the weighting of this item or that will ever take enough bias out to make the collected data have much relevance to real-world patient care. Patients care about getting well, not getting cut up into data points.

Now recall that this VA investigation and report was back in 2008. Sadly for our veterans, their situation has not changed despite one report and investigation after another. I’ll spare us both the references to all the current challenges veterans face in trying to access healthcare in a timely manner. Veterans Affairs Secretary Bob McDonald himself still brushes off wait times, comparing the “experience” of waiting for health care to Disneyland guests waiting for a ride:

“The days to an appointment is really not what we should be measuring. What we should be measuring is the veteran’s satisfaction,” McDonald said. “What really counts is how does the veteran feel about their encounter with the VA? When you go to Disney, do they measure the number of hours you wait in line? What is important is, what is your satisfaction with the experience.”   Unless a veteran died in line, of course. Then that insignificant 5% of the total score was 100% fatal.


I am concerned that with the further expansion of the Federal government into our healthcare system through the MACRA, everyone’s healthcare is going to end up like the VA healthcare system, where the wait does not matter, and your “experience” only exists as it was administratively recorded, entered, weighed, and scored under an arbitrary accounting system that is almost completely disconnected from the real-life encounters that patients have with their doctor.

One partial solution was to give veterans the option to go outside the VA system for care under The Veterans Access, Choice and Accountability Act of 2014 ( That has proven to be an administrative failure as well. As currently structured, doctors have to file so many forms and requests to receive authorization to provide care, and then another set to get paid, that few participate.

The same 2014 act referenced above also created the Commission on Care “to examine veterans’ access to Department of Veterans Affairs health care and to examine strategically how best to organize the Veterans Health Administration (VHA), locate health resources, and deliver health care to veterans during the next 20 years” ( Their preliminary conclusion? Scrap the whole system over the next 10 to 20 years and transition veteran’s care to the private sector. ( So while there still is a private healthcare sector, and while we still have a chance to not make practicing medicine so much more administratively oppressive, I urge delay in the implantation of the MACRA. As currently written, the MACRA will only serve to accelerate the push of the private healthcare system in America toward a VA-like system, just as the patients trapped in the VA system are trying to get out.

Darren Meyer, MD