Don’t Surrender

flying cadeuciiIndependent physicians are at the beginning of a challenging movement as we fight to stay relevant and solvent during the transition of health care from independence to “regulation without representation”.   In 1773, British Parliament passed the Tea Act with the objective to help the struggling British East India Company survive. Opposition to the Act resulted in the return of delivered tea back to Britain.  Boston left the ships carrying tea in port and on December 16, 1773, colonists in disguise swarmed aboard three tea-laden ships and dumped their cargo into the harbor.  The seeds were planted for the Revolutionary War. 

Physicians in private practice are facing a war of our own, and make no mistake; we are battling for our freedom and our livelihoods.  Insurance companies and government control of health care has become “regulation without representation.”  Lofty guidelines are being imposed, while administrators, insurance executives, and policy consultants are wedged firmly between doctors and patients.  Ironically, when it comes to taking responsibility for a life, the physician is standing there all alone.  How dare we ask a fee-for-the-service we have rendered?  That would be ‘fiscally wasteful’ according to health policy pundits who know nothing of service-oriented occupations.  This is my call to action. 

Where is all the money going?  CEO’s of healthcare insurance companies are making millions. High level CMS employees undoubtedly have higher incomes than primary care physicians.  I do not hear cries of ‘fiscal waste’ when it comes to paying these non-essential members of the health care team.  They are middleman sucking the life out of patients and physicians. The CEO in this story is on the Forbes top 10 list for compensation.  In one year he made $102 million, which amounts to approximately $280,000 a day. Where is the outcry from the media and public?  They jumped all over Mylan when they started charging $600 for an Epi-pen two-pack.  How many Epi-Pens could this guy buy per day with $280,000? 

The majority of physicians are beholden to third party payers, who decide what our work is worth, like modern day indentured servitude.  Instead of having conversations with patients, our time is spent buried in absurd paperwork, endless forms, and questionnaires to accommodate federal requirements instituted by elected officials while industry insiders are controlling the puppet strings.  Physician lobbying groups, such as the American College of Physicians, keep telling us to “roll over and play dead” because they are profiting regardless. 

While they may not be drinking tea, the business of healthcare is certainly having a party at the expense of physicians, patients, and taxpayers.  It is time the party comes to an end.  Physicians are being held accountable for outcomes yet have no influence on how we care for our patients in our own offices.  Medicare beneficiaries are forbidden from entering private contracts with their long-term physicians (DPC); the only way out is physicians must say no to Medicare and some private insurances. 

Last year, a large insurance company and I did not quite see eye to eye.  Family X already had two children for whom I provided medical care.  Their newborn was assigned to an adult nephrologist two counties away by mistake (I hope), so it seemed reasonable to provide necessary primary care for their third child.  This infant had a respiratory arrest at her two week appointment.  I resuscitated the baby and paramedics transported the infant to the children’s hospital for PICU care.  Imagine my surprise 2 months later when a “take-back” was initiated on the payment for this patient encounter after initially being compensated.  Dr. W in the appeal resolutions department told me to “lose his phone number”; he thought a few hundred dollars was too costly for just saving a human life.  Believe it or not, Dr. W was a pediatrician in private practice before “if you can’t beat them, join them” took hold. 

Ultimately, I had no choice but to bill the family for provided services (at a considerable discount) as cash pay and they obliged.  A threatening letter arrived a few days later from Mr. CEO that balance billing was illegal and there would be serious consequences if I insisted on any monetary payment for my work.  This by definition is worse than indentured servitude.  Balance billing is charging a patient the difference between what health insurance reimburses and the provider charged.   The fact I was not paid by his company nullifies his entire accusation. 

I fired off a response humbly suggesting he focus more on placating his stockholders, while leaving the work of saving lives to me.  Our practice cut ties with this company, notified patients it was no longer accepted in our practice, and most families changed their insurance plans.  You would think my David and Goliath-esque tale ends here; however our local federally subsidized Community Health Center is the only place accepting this exchange plan (for reasons that should be obvious at this point.)  There is no pediatrician available.  The tables turned toward negotiation. 

Local insurance representatives inquired why patients were being turned away.  Never having signed a contract, I made it abundantly clear they had no control over anything.  If I did not receive back pay, there would be no further deliberations. Suddenly, ‘take-backs’ were being halted and back payments were being reversed from over a year before.  When a high level executive called to ask if I would reconsider accepting their patients, it dawned on me that physicians may hold more cards than we realize. 

Health policy experts and insurance executives are NOT physicians and they require our expertise; they have not foreseen the complications that will arise when supply does not meet demand.  Physicians are fed up with data collection requirements, cumbersome electronic record systems, and outcome measures that mean next to nothing.  The time has come to throw proverbial tea chests into the Harbor and refuse to comply with the regulations being enforced up on us.  “No Regulation without Representation” should be our battle cry.  My practice is terminating another insurance contract this week.  If we make smart business decisions, refuse to follow the rules while managing to survive long enough, we can win this war.  Patients deserve better.  Physicians deserve better. 

Acquiescent physicians have already been driven out of independence.  Those of us who remain are smart, resilient, capable, and now we must be resolute in our refusal to comply. We know how to provide extraordinary care, which is why our doors are still open.   My office is overwhelmed by patients clamoring for a living, breathing physician who listens, makes eye contact, and is not attached to a computer.  We must never give up, we must continue to argue, irritate, and aggravate healthcare bureaucrats at every turn, like those brave individuals who boldly tossed tea into the Boston Harbor many years ago.  Defiance will inspire progress. Do not surrender at any cost.   

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31 replies »

  1. “For example, why not place a “care coordinator” in each small rural area to help patients get better access? In our town multiple physicians could share that one person and those with chronic illness can get some extra help. That would save money, resources, physicians time, and taxpayers money. These are real solutions for real problems.”

    Why wait for the government, especially in rural and small towns. Why can’t the local docs hire a co-ordinator or link computers with patients records. You complain about the government but want the government to take action.

  2. Look, a little oversight is fine, if it makes common sense and actually improves quality of the care being provided. I have written multiple posts on THCB about building better metrics. https://thehealthcareblog.com/blog/2016/08/16/building-better-metrics-invest-in-good-primary-care-and-get-what-you-pay-for/. I am not unwilling to work with the government if it is for the benefit of the people.
    I (and many others) happen to disagree about what oversight is best and my larger point is we are physicians in actual practices who are out on the front lines. We KNOW what makes care better.
    For example, why not place a “care coordinator” in each small rural area to help patients get better access? In our town multiple physicians could share that one person and those with chronic illness can get some extra help. That would save money, resources, physicians time, and taxpayers money. These are real solutions for real problems.

  3. Peter, I don’t have any problem with what you did, but what would have happened if your health were such that you couldn’t fly to India and the costs were above your means? Would you force them to let you die? If after the hospitalization you were doing perfectly fine but had to remain on dialysis for a limited time and you didn’t have the money, would you permit someone else to pay for you for that limited period of time?

    Single pay means one entity pays all the bills. Do you have an idea of which model you would like to be under? Do you realize that Medicare uses BC/BS or other insurance companies to pay the bills and even provide U/R? Do you realize that Medicare rations as well? If Medicare funding fell below Medicaid funding (That was Obama’s intention, at least the numbers pointed to that result.) would you be happy with Medicare?

    When you were on BC/BS and became dissatisfied were you on an HMO, Hybrid, in Manged Care or was it a risk-based indemnity? I’d like to know what made you so unhappy though I can easily figure out many reasons for your dissatisfaction where I would easily agree with you, but I still would like to know why.

  4. “You took the route of no insurance, but what if the government forced you to pay for that insurance anyway?”

    If the government did truly single pay coverage with everyone paying through taxes (even Trump) then I would gladly pay. My income did not qualify for an ACA subsidy and I became Medicare age before I had to pay any premium, but for those who do qualify they are signing up. However, the enforcement of the mandate is weak.

    I gladly pay my Medicare premium. I’ve had no problems as I did with BCBS private.

    No one’s going to bail me out, they never have. When I needed hip surgery as private pay I went to India and a very qualified doc for less than a 1/3 (including airfare & hotel) of what this system wanted.

  5. Thanks for that advice. I googled his name and I would be embarrassed if that were me. One article said it all in a few words “one of the most shameless mop up artists”

  6. You took the route of no insurance, but what if the government forced you to pay for that insurance anyway? Would you then forgo use of that insurance? The answer for most is no. They would use Medicare especially since Medicare permits so much usage. You might supplement that with completely private care, but I feel sure most would use Medicare. What does the doctor do with his patients that are on Medicare when he no longer takes insurance? It is pitiful, but those patients then have to pay cash and can no longer keep their doctor without such payment.

    Should you have a catastrophic event are you able to pay for that high-level care that can reach the stratosphere or are you dependent upon the rest of us and our tax dollars to bail you out?

  7. At one time I planned to be the last standing physician that didn’t accept Medicare in my area (a time when the patient was sent the Medicare check), but eventually I succumbed. I was, however, able to refuse all HMO’s.

    Later I considered cash, but that meant leaving patients I had treated for decades along with a lack of coverage so I remained chained to Medicare and insurance. My compensation did not lead to significant complaints . I did complain about how these huge organizations maltreated my patients. On occasion I got into fights with those at a very high level who threatened to throw me off their panels. One of those discussions was a doozie. The man was way at the top and thought he was God. I threatened to sue the company and him personally. He finally had to be controlled and the conversation was shifted to the UR director (an M.D.) of all 50 states. I was never bothered by that company again.

    Faced with well thought out resistance you will prevail though the scammers will leave with tens of millions of dollars sucked out of patient care.

  8. Don’t worry, we’re going to have “teams” and PAs and NPs. Who needs docs?

  9. I can understand complaints against large institutions (CMS/insurance) as we all have experienced it in some form. I also support PCPs getting higher pay (at the expense of specialists), but the complainers here seem to want it both ways – payments without oversight.

    Again, no one, not even the “evil” government, is forcing you to be in Medicare or insurance. Go cash, you’ll be able to lower your prices, reduce your staff, and free yourself to practice medicine the way you want, except for professional oversight – if you even want that.

    I was insured with BCBS once until they screwed with a small claim. I then went with self pay and self insurance – never looked back. Isn’t America great.

  10. Allan – I am so sorry to hear about your miserable experience. If it is not Medicare, it will the State Board of Health, a large insurer, or whoever else wants a piece. Don’t forget my painfully terrible experience with the Office of Civil Rights about medical records fees found on my blog.
    You are correct about taking the higher road and it is important to be careful as to how things are done. IMO, things should be done proactively, within legal boundaries.

    For instance, each contract we terminated (two so far) have notified patients 3-4 months ahead of time and we still work to make sure every one of my patients (who wants to) is able to switch insurances so as not to abandon patients unnecessarily. These details are very important to be successful in the long run.

    Remember, once the British were on our soil, we used our own tactics to win the Revolutionary War and I absolutely believe “all is fair in war.” Thank you for sharing your story.

  11. If you ever take a vacation out to the Pacific Northwest, we need to have coffee and commiserate. I am so sorry you are burned out. I will say an occasional win here and there against the “big guys” does keep me in the fight! Glad I could inspire you a bit.

    I am part of one of the Transformation of Care Grants and the insurance company awarded the grant cannot figure out how to make patient panel lists accurate. They literally have been stumped by my simple question (and a few others) for the last 30 days.

    The HEDIS measures pediatricians are rated on all over the country have been written so they are impossible to achieve yet no one paid attention to their mistake until now. I have spent hours on the phone trying to help them make sense of the most basic things in health care but the largest problem is these are people have never worked in a medical office so they are missing the BIG PICTURE.

    My response to the recent MACRA rule release is to allow some of us in small practices to be a control group and continue to practice as we do now, but it is falling on deaf ears.
    Oh, and yes, I know Mr. Slavitts shady background quite well. The fox has been running loose in the hen house.

  12. You are always an inspiration Mommy Doc.
    Today I lost a battle with CMS. I wanted to see my QRUR (the output for PQRS, VBM, etc) because my registry asked to see it. After essentially 3 hours on the phone from QualityNet, CMS, my bank, Experian, all multiples times,filling out multiple forms, repeating all my IDs and faxing a copy of my passport and 2 bank statements to CMS, I am still unable to download or review it. Yet CMS finds it perfectly appropriate to post that some pharma company paid $3 for a lunch once for me in 2015. CMS literally sucked the life out of me.
    And this is how we are supposed to review our MACRA progress. Good luck everyone.

    Since I was on with the QPP folks at CMS, I got different answers for the same questions from 3 different people. Classic.

    So today, I literally wanted to quit and the whole way home, planned my early retirement. I do this too often. Would be very fair to say, I am completely burned out by all this reporting for dollars and attesting and nonsense.

    I think I might find solace in just forgetting all of it, no matter how much they want to entice me with limited options. Its just not worth it. And for those that want some eye opening reading, google Andy Slavitt and how he defrauded MDs, patients for hundreds of millions and got his company fined $350M. This is our supposed fearless listening leader. Be wary.

  13. Ma’am, let’s just agree to disagree. Whether or not Medicare patients can find primary care physicians in the coming years will tell us who was correct.

  14. “you feel quite self-important.” I don’t think Dr. Al-Agba’s statement was one of self-importance. She is describing what she sees so her title M.D. has importance. She wants open dialog and wants to let the listener know where she is coming from. Yet the kind doctor told you that use of her first name was fine as well. It sounds like you own the problem and it has to do with your ego, not hers.

    “The private PCP is a small business, no more threatened than any other small business. How many small businesses have been destroyed by Big Box Home Improvement and Walmart.”

    One who understands the basics behind healthcare policy would immediately recognize the falsity of the above statement. I hope you realize that the rules and regulations set forth by government don’t target the small business because it is a small business. In fact, regarding Walmart, not infrequently, government will impose all sorts of regulations to keep Walmart out. The rules and regulations being promoted by government many of which are untested or represent prior failures force the private PCP to close. That is a big difference.

  15. “You obviously do not like physicians and seem like an unhappy woman in general.”

    You a assume a lot with no information. Why do you think I’m a women, especially when my name is Peter – sorry, that’s Mr. Peter to you.

  16. Miss Peter- I say accuracy, you say self-importance. You obviously do not like physicians and seem like an unhappy woman in general. I do hope you find much happiness as you coast into your golden years.

  17. “First and foremost, it is Dr. Al-Agba if you are going to use a title.”

    For someone who claims not to be “super formal” you feel quite self important.

    I’d like a link to some studies of all these doc suicides as a little Goggling showed it highest in medical students. Dentists have a high rate as well, but I never hear much griping from them.

    My entire life of 65+ years I have heard much griping by docs. A profession usually respected (apparently not as much as nurses), certainly well paid, and for the most part shielded from economic downturn. I don’t think anything will make docs happy.

  18. First and foremost, it is Dr. Al-Agba if you are going to use a title. Niran is fine as I am not super formal, even with my patients. I may seem like I have balls of steel, yet I do not actually have them on my anatomical form. Hope that issue is now clear.

    Ok there is no trapped in the system for me, but many others are frustrated to the point of retirement or suicide as they see no way out. I am letting them know with fortitude, we can overcome.

    The sole reason I do not go off the grid is that small children with respiratory arrests (and others) need a pediatrician. Both the wealthy, the poor, and everyone in between. I care deeply for my patients and am fighting for them as well as for physicians.

  19. “it dawned on me that physicians may hold more cards than we realize. ”

    We do, but we have to be very careful how these types of things are done. If we remember the Tea Party, we remember that we took the higher road. Later we paid for the tea that was dumped. We have to do things within the law and maintain our dignity and professionality, but that can only occur with physicians thinking in a non-specific proactive fashion rather than after the fact because the government can and has used RICO.

    Medicare is as bad or worse an offender than the big insurers and in the past broke a lot of rules intentionally. Years ago they wanted to intimidate physicians so they started doing extensive auditing (6 mo). I was one of the unfortunates to be audited and within ten days had to pay a lot of money to Medicare before any audit was done. I will skip a lot of the nauseating detail that demonstrates the piggishness and stupidity of those that regulate us.

    I felt that my charts were totally in order. My attorney agreed but told me to settle at 60/40 because otherwise I would be hounded for years. (He made no money giving me this good advice.) The settlement was made and 2 years later Medicare opted to unilaterally void the contract settlement. I spoke to the attorney representing Medicare and he admitted it was illegal, but those were his orders. My attorney told me I would win, but actually lose because of my legal costs that would not be returned.

    I ended up accepting the second audit of the charts which was to my benefit since I could prove that almost every last item I did was according to medical necessity and the law. Medicare had to return their 39.9+% plus my 60% which once again I had to pay. There were recent federal rulings that saved me a lot of money.

    The first rule had to do with notification. Medicare apparently changed the rules of payment on a number of lab tests, but intentionally kept those changes secret. They then went after the physicians that broke this secret rule. The federal courts ruled Medicare could not fine physicians unless they were previously informed in writing.

    The second ruling if true came after my audit. The courts imposed a type of parity. If Medicare audited and over billing was noted the physician had to pay the fines and costs. If however, underbilling was found Medicare had to return funds. The attorney and I found a lot of underbilling so if the second ruling existed at the time Medicare would have had to pay me a lot of money.

    I had a case similar to yours. An HMO patient picking up his wife from my office had a cardiac arrest in my office and the HMO refused to pay because I didn’t have a contract with any HMO”s and I didn’t call for advance approval.

  20. I can’t understand this, “I’m trapped in the system” POV. There is a solution – go cash only and off the grid. Mr. AL-AGBA, why don’t you do that?

    The private PCP is a small business, no more threatened than any other small business. How many small businesses have been destroyed by Big Box Home Improvement and Walmart.

  21. I do not plan on giving up. I anticipate being the last independent clinic standing.

  22. Dr. Nelson- how unfortunate. That is my birthday. I will be thinking of you and your colleagues. We have never had a nurse, but if we did, we wouldn’t be able to afford it either. These are sad times.

  23. Niran,

    Given the degree of professional burn-out among my own colleagues and the financial needs of young physicians, there will soon be essentially no Primary Physicians in private group practice.

    The future of our nation’s healthcare industry will become increasingly buffeted by the complexity of payment processes, meaningless EMR systems, rationing and the absence of any connection to solving the under-served needs within every community.

    Please don’t give up!


  24. The paradigm paralysis of our nation’s healthcare industry is generally unyielding. It is good to acknowledge the isolated examples of retrenchment. The fundamental problem for our nation’s healthcare industry is that it is paralyzed by the codependent relationship between the payers of healthcare and the portion of our nation’s healthcare devoted to Complex Healthcare Needs, principally the University based healthcare institutions. This is now severely aggravated by the lack of increased funding of post-graduate medical education by Medicare, for about 4 years now. This has occurred in-spite of the medical school increasing enrollment. Currently, there are medical students who will not match with a residency within the USA. This has all occurred while Congress has become paralyzed by the politics of “Obamacare.” My oh my! By the way, the Medicare contribution to post-graduate medical education includes no requirements or inducements to train adequate numbers of Primary Physicians. What a mess!

    And now, my colleagues and I are closing our practice on 10-31-2016, two weeks from tomorrow. After 41 years, we couldn’t afford to have a qualified BSN nurse answer the phone. Having survived the HMO capitation years, we learned that the only way to offer accessible and efficient healthcare was to have a great nurse answer the office phone.

  25. Thank you for your support gentlemen. Our fortitude is our greatest strength. It is time to use it!
    Medical societies are full of physicians who were not good enough to make it out on the front lines. Of course they are being led by the nose. That does not mean independent docs must follow.

  26. “Stop punishing doctors, the sick, the elderly, and the poor.”
    Thanks for doing what the scoundrals in the medical societies would never do.